MetroHealth DialogueVolume 4 Issue 2metrohealth.org/dialogue

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New MFM Director Continues MetroHealth’s Outstanding Perinatal CareNationally recognized perinatologist, Edward Chien, MD, MBA, has joined the MetroHealth faculty as Director, Division of Maternal-Fetal Medicine (MFM); Maternal-Fetal Medicine Fellowship Director; and principal investigator of the National Institute of Child Health and Human Development – Maternal-Fetal Medicine Units Research Network at MetroHealth. Dr. Chien joins a team of well-respected, board-certified specialists who have contributed to MetroHealth’s long-standing reputation for outstanding maternal-fetal care.

“MetroHealth’s Division of Maternal-Fetal Medicine provides the highest level of care for high-risk pregnancies,” said Brian M. Mercer, MD, Chair, Department of Obstetrics & Gynecology. “Dr. Chien is well qualified to pick up the torch and carry on MetroHealth’s legacy of providing state-of-the-art care; training future leaders in Ob/Gyn and Maternal- Fetal Medicine; and conducting research that positively impacts clinical practice at a regional and national level.”

Prior to joining MetroHealth, Dr. Chien was Director of the Maternal-Fetal Medicine Fellowship Program at Women & Infants Hospital of Rhode Island/Alpert Medical School of Brown University. His faculty appointments include Assistant Professor at the University of Chicago,

Edward Chien, MD

Akram Boutros, MD, FACHE, new President and Chief Executive Officer at The MetroHealth System, has more than 20 years of leadership experience in large community hospitals, specialty

hospitals and academic medical centers. Most recently, he was President of BusinessFirst Healthcare Solutions, a healthcare advisory firm focused on clinical transformation, operational turnarounds and emerging health delivery and reimbursement models. Dr. Boutros previously served as Executive Vice President and Chief Administrative Officer for St. Francis Hospital - The Heart Center in Roslyn, New York and as Executive Vice President, Chief Medical Officer and Chief Operating Officer at South Nassau Hospital in Oceanside, New York.

An internist, Dr. Boutros attained his Doctor of Medicine at S.U.N.Y. Health Sciences Center at Brooklyn. He is a graduate of Harvard Business School’s Advanced Management Program and is a recognized thought leader in management systems. He is a widely published author on subjects such as trust and innovation. He is a Fellow in the American College of Healthcare Executives and has served on the regional policy board of the American Hospital Association.

“I am energized by the excellent team of clinicians, executives, community leaders, educators and researchers who exhibit an unwavering commitment to MetroHealth,” said Dr. Boutros. “During the next year, I will focus on aligning the various aspects of the organization around a renewed mission and vision."

MetroHealth Names Akram Boutros, MD, FACHE, New President and CEO

2 For more information: metrohealth.org/dialogue

In early April, MetroHealth cardiologists were the first in Northeast Ohio to perform the Lariat procedure, which can help patients with atrial fibrillation (AFib) that are unable to take blood-thinning medications to minimize their stroke risk.

A patient with AFib may have blood pooled in the left atrial appendage of the heart’s top chamber. Previously, if a patient was unable to take blood-thinning medications to reduce

this stroke risk, they would have to undergo open-heart surgery to tie off the appendage and lessen the risk.

“Using the Lariat® Suture Delivery Device, we perform a minimally invasive

procedure to tie off the appendage,” said Ohad Ziv, MD, Director of the Atrial Fibrillation Center. “For people with no other options, this is the solution for potentially saving lives.”

MetroHealth Has the Only Cardiologists in the AreaPerforming the Lariat Procedure for Patients with AFib

Below is a step-by-step description of the Lariat procedure (see illustration above):

■ Two catheters are guided into the body through one small incision in the upper thigh and one just under the rib cage. From each catheter, a wire with tiny magnets at its ends is advanced to the left atrial appendage, one from the inside of the heart and the other from the outside of heart.

■ When the magnets connect, a specialized catheter called the Lariat® Suture Delivery Device can be advanced over the left atrial appendage.

■ After the wires are pulled back, a suture is deployed from the Lariat around the left atrial appendage to tie it off.

■ With the appendage closed, blood cannot enter, and blood clots cannot form, reducing the risk of stroke.

“This is a safe alternative for the thousands of atrial fibrillation patients at risk of stroke who are unable to take blood thinners,” said William Lewis, MD, Chief of Clinical Cardiology.

“The recovery time for this procedure is much less than for open heart surgery,” said Dr. Ziv. “People at risk for falls or bleeding will surely benefit from this procedure.”

Dr. Ziv is accepting referrals for this procedure; call 216-778-BEAT.

Call the Physician Referral Service: 216-957-3222 or 1-866-260-53763

Case Study: Advanced Kidney Cancer Requiring Complex Surgery

The physician:Carvell Nguyen, MD, PhDUrologic Oncology, Division of Urology

The patient:A 70-year-old male presented to his primary care physician at MetroHealth in the fall of 2012 with a seven-month history of constitutional symptoms, including extreme fatigue, loss of appetite and unintentional weight loss of more than 30 pounds. He had a significant smoking history, but was otherwise in good health. He underwent a GI workup to evaluate potential etiologies of his anorexia and cachexia. As part of that evaluation, a CT was obtained which revealed a large, locally advanced tumor of the right kidney with extension into the inferior vena cava (IVC). The patient was then referred to MetroHealth’s Division of Urology. The evaluation:An MRI was performed to further delineate the extent of the tumor and confirmed an 8.9 cm right inferior pole renal cell carcinoma with associated renal vein thrombus extending to the inferior vena cava via two right renal veins with tumor thrombus extending 3.5 cm superiorly within the infrahepatic IVC. There was also an enlarged periaortic lymph node measuring 2.1 cm. The procedure:Because of the potential for thrombus progression and embolization, the patient was expeditiously scheduled for surgery. Urologic surgeon, Carvell Nguyen, MD, PhD, performed an open right radical nephrectomy with IVC thrombectomy and a right-sided retroperitoneal lymph node dissection. The complexity of the tumor and the procedure required specialized equipment and monitoring. To ensure that tumor embolization had not occurred, real-time monitoring of the heart and proximal IVC was performed with intra-operative transesophageal echocardiography by Charles Smith, MD, FRCPC. After an approximately six-hour surgery, the tumor was completely resected as an en bloc specimen consisting of the right kidney, renal veins and caval thrombus.

The result: Pathology revealed a clear cell renal cell carcinoma with negative margins and negative lymph nodes. The patient had a successful postoperative recovery. It became apparent that the patient’s advanced kidney tumor was likely causing his previous constitutional symptoms because of the pronounced improvement in his appetite and energy after surgery. At four weeks post-surgery, the patient reported feeling better than he had in years. With the tumor completely resected, the patient does not require any adjuvant therapy for the renal cell carcinoma. He will be surveilled according to protocol for cancer recurrence.

To contact Dr. Nguyen, or to make a referral,email cnguyen4@metrohealth.org, or call 216-778-4257.

Transverse CT image showing large mass involving the right kidney with extension of tumor thrombus into renal vein and inferior vena cava.

Coronal CT image showing large right renal mass.

Sagittal CT image showing large right renal mass.

4 For more information: metrohealth.org/dialogue

Associate Professor at the University of Vermont and Associate Professor in Obstetrics and Gynecology at Brown University.

Dr. Chien earned his medical degree from the University of Illinois College of Medicine at Chicago, after earning a bachelor’s degree in chemical engineering at the University of Illinois at Urbana-Champaign. He recently completed his healthcare MBA from the George Washington University Graduate School of Business.

Dr. Chien’s academic accomplishments include serving on the editorial board for the American Journal of Physiology-Endocrinology and Metabolism and principal investigator, co-investigator or consultant on many NIH research grants. In addition, Dr. Chien has received numerous teaching and research awards during his academic career. He has a long history of scientific presentations and publications related to his primary research focus regarding the biology of the cervix during pregnancy and its relationship to preterm birth.

By coming to MetroHealth, Dr. Chien joins one of the largest maternal-fetal programs in Ohio – a program that residents across the country seek to be a part of and that offers the only maternal-fetal fellowship in the region. Likewise, MetroHealth perinatologists have played a leading role in improving the health of newborns and pregnant women through revolutionary research, including:

■ Developing standards for the diagnosis and management of gestational diabetes

■ Reducing iatrogenic NICU admission from elective deliveries before 39 weeks gestation

■ Understanding the effects of obesity and sleep-disordered breathing on pregnancy

■ Clarifying the benefit of progesterone therapies to reduce the rate of recurrent preterm birth and risk factors associated with preterm birth

■ Establishing the benefit of magnesium sulfate to prevent cerebral palsy in children born preterm

Further complementing the Maternal-Fetal division’s expertise, MetroHealth’s Fetal Diagnostic Center was enhanced in May.State-of-the-art ultrasound systems now allow for more advanced 3D and 4D imaging, tissue Doppler and fetal cardiography.

“I look forward to building upon the historic research and productivity of MetroHealth’s division of Maternal-Fetal Medicine,” said Dr. Chien. “Ohio has a very strong preterm birth collaborative in place that I want to continue to strengthen. I envision MetroHealth continuing to be a leader in making Ohio – specifically, Cleveland – the center for preterm birth research.”

To make a referral, call 216-778-5498.

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New MFM Director Continues MetroHealth’sOutstanding Perinatal Care

MetroHealth Participates in SyNAPSe Study to Improve TBI RecoveryThe MetroHealth System is one of approximately 100 organizations around the world enrolling patients in a phase 3 clinical trial called SyNAPSe – Study of the Neuroprotective Activity of Progesterone in Severe Traumatic Brain Injuries (TBI).

Progesterone has proven to play a key role in promoting and enhancing repair after TBI. It may decrease post-injury swelling of the brain and improve mental recovery, especially when given quickly after the TBI occurs.

Patients enrolled in the double-blind trial are 16 to 70 years old; have serious closed-head injuries; must begin treatment within eight hours of being injured and have a family member provide informed consent; and must be admitted to a participating medical facility.

Since the study’s inception in 2010, physicians in 21 countries have been comparing severely brain-injured patients who receive an intravenous progesterone infusion to those who receive a placebo infusion. A phase II study of 100 U.S. patients determined that those who received progesterone were half as likely to die than those who received the placebo. In the phase 3 trial, patients who get the progesterone receive it intravenously for five straight days.

“We hope to provide more treatment options for patients who have devastating head injuries,” said Jeffrey Claridge, director of the Division of Trauma, Critical Care, and Burns, who is overseeing the research at MetroHealth. “Trauma is the leading cause of loss of work years and quality of life and head injury is a major cause of that disability.”

The phase 3 trial is expected to end this summer after enrolling 1,180 patients. Results should be available in 2014.

5 Call the Physician Referral Service: 216-957-3222 or 1-866-260-5376

High-Quality Care forAcute Pediatric PatientsAvailable 24/7 at MetroHealthWhen a child is critically sick or injured, time is of the essence. That’s why it is important for referring physicians to consider The MetroHealth System as a first choice for acute pediatric care.

With a dedicated pediatric surgical staff available 24 hours a day, seven days a week, and a state-of the-art Pediatric Intensive Care Unit (PICU), MetroHealth’s team is able to handle a range of illnesses and injuries, including the most critical cases.

An agreement between MetroHealth and Akron Children’s Hospital, the 6th busiest children’s hospital in the country, builds on MetroHealth’s trauma and critical care expertise by increasing staffing at MetroHealth’s PICU and providing constant pediatric surgical coverage, said Daniel J. Lebovitz, MD, PICU Medical Director.

“We care for most of the medical needs of critically ill infants, children and adolescents, so there’s rarely need to transfer patients anywhere else,” Dr. Lebovitz explained. “We are the only pediatric ICU available on the west side of Cleveland. Our location is off the highway and accessible by public transportation, which makes it easier for families to visit their children.”

MetroHealth has pediatric specialists in:❚ critical care ❚ surgery ❚ trauma❚ burns❚ cardiology/cardiac surgery❚ gastroenterology ❚ hematology/oncology❚ neonatology❚ kidney disorders

Robert Parry, MD, FACS, is one of four pediatric general surgeons covering the surgical service from Akron Children’s Hospital. “The full service pediatric surgical skill set is there 24/7. Any pediatric surgical case can be addressed here,”he said. “Trauma cases goes through the trauma system,and we consult on that, depending on the need. We also handle less complex cases, too, like hernias, appendicitisand tumors.”

MetroHealth’s pediatric surgeons are board-certified by the American Board of Surgery in Pediatric Surgery and are specially qualified to treat congenital malformations, neoplasms and inflammatory conditions occurring throughout

childhood. The team treats a range of disorders that are unique to children or that require special expertise.

“The level of expertise we can provide is important to have present when kids are being stabilized,” Dr. Parry said.

Transferring acute pediatric patients requiring rapid transfer is easy to do. Simply call Metro Life Flight (1-800-233-5433) to facilitate auto-launch and auto-acceptance. Auto-launch is the quick and rapid dispatch of an aircraft before collecting additional information, such as patient destination. MetroHealth will automatically accept any pediatric patients 18 and under with acute injuries or those requiring care in the PICU.

Dr. Lebovitz and five other critical care physicians who staff the PICU are available for consultations by calling 216-778-4700.

Pediatric Stress Testing Now Available

MetroHealth’s Division of Pediatric Cardiology now offers stress tests for pediatric patients. Administered by John R. Bockoven, MD, the tests are for patients 13 to 18 years old, but can be offered to younger patients if they’re physically able.

“We can help diagnose exercise-induced arrhythmias, congenital arrhythmic heart disease, and evaluatepost-operative cardiac disease,” Dr. Bockoven said.

Stress tests are offered on Thursday afternoons at MetroHealth’s main campus. Referring physicians should call 216-778-2222 or 216-778-2583 for cardiac consultation.

❚ lung disorders❚ rheumatology❚ adolescent medicine❚ infectious disease❚ genetics❚ endocrinology❚ neurology and neurosurgery❚ dermatology

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Neurological Team Offers 24/7 Care for Patients with Brain Bleeds

Time is brain. That’s why physicians from around the region refer their stroke and aneurysm patients to The MetroHealth System for round-the-clock medical care.

MetroHealth’s neuro-interventional radiologists and neurosurgeons are available 24/7 to treat aneurysm and stroke patients. For patients who need to be referred outside of the hospital system, a 24/7 line in the emergency room triages calls to the appropriate providers. Metro Life Flight transfer is available, and MetroHealth’s Level I Trauma designation means the hospital is capable of handling the most severe cases.

“Having Metro Life Flight capability makes us the perfect place to care of this type of condition, because we are here 24/7 with neurosurgeons and neuro-interventionalists,” Steven Reed, MD, a neuro-interventional radiologist, says. “Being a Level I Trauma Center, we have to have the utmost supply of critical care available. It’s rare that we get surprised with someone’s condition. We have a wealth of resources for aneurysms, strokes and hemorrhages.”

Quick Action Saves Lives

In February, Jackie Lawson, 56, of Amherst, was transferred from Mercy Allen Hospital in Oberlin to MetroHealth via Metro Life Flight after suffering a brain bleed. When she arrived at MetroHealth, she was placed in the care of the neuro-interventional radiology team of Scott Williams, MD, and Dr. Reed. Jackie immediately had an angiogram done by CT, which confirmed that she had a subarachnoid hemorrhage and several aneurysms. (See image at left.)

“We had to make decisions on how to treat and what to treat. Her degree was very severe, and it is hard to say which one may have been the cause of the bleed,” Dr. Reed explained. “In collaboration with Dr. Williams and the neurosurgery team, we found two that had high likelihood of being the offenders.”

The medical team acted quickly and performed coil embolization on the bleeders. (See image below.)

Dr. Reed says the referring physician’s quick action played a large part in Jackie’s good prognosis. “This is an example of how it should work,” he says. “Getting patients to us is very easy. That’s important when minutes matter.”

Today, Jackie is at home with her family after spending 22 days in the Intensive Care Unit at MetroHealth. She will have another surgery to fix the other two aneurysms. For that surgery, she will return to her team at MetroHealth.

“I feel that I got the best treatment in the world, from the doctors, to the nurses, to the people who brought my lunch,” Jackie says. “I would recommend MetroHealth to anyone.”

Noncontrast head CT showing diffuse subarachnoid hemorrhage within the basal cisterns.

Right internal carotid angiogram showing occluded ACOM aneurysm. (Coil mass from previously coiled right PCA aneurysm.)

7 Call the Physician Referral Service: 216-957-3222 or 1-866-260-5376

New Medical StaffMembers at MetroHealth All of MetroHealth's active medical staff are faculty atCase Western Reserve University School of Medicine.

Bulent Yapicilar, MD NeurosurgerySpecialties: Cerebrovascular and Skull-based Neurosurgery

Medical School: University of Hamburg Medical School (Germany)

Residency: University of Arkansas Medical Center, Little Rock, Arkansas

Fellowship: Cornell University Medical College, New York, New York; University of Zurich (Switzerland); University of Texas Health Sciences Center, Houston, Texas

Summer CME:Comprehensive Treatmentof the Aging SpinePresented by MetroHealth Spine Center experts, this free CME course is specifically designed for busy internal and family medicine physicians, orthopaedic surgeons, neurosurgeons and chiropractors. It will provide a comprehensive review of the advances in spine care along with evidence-based treatment options for an aging population. Thursday, August 29, 201311 a.m. - Lunch/RegistrationNoon to 6 p.m. - CME presentation

Holiday Inn - Independence6001 Rockside RoadIndependence, OH 44131

6 CME and Chiropractic CE hours available To register, visitmetrohealth.org/spinecme

For more information,call 216-778-5281.

David S. Rosenbaum, MD, an internationally-recognized cardiologist, scientist and beloved mentor, served as Director of MetroHealth’s Heart & Vascular Center. He was dedicated to training the next generation of physician scientists and improving his knowledge of the intricacies of heart disease. Dr. Rosenbaum authored the only textbook on optical imaging of the heart and developed tools to predict and prevent sudden cardiac death. The David S. Rosenbaum, MD, Endowment honors Dr. Rosenbaum’s distinguished career in treating heart disease, and supports a physician who embraces Dr. Rosenbaum’s commitment to teaching and research that results in breakthrough, life-saving work. For more information, contact Megan Quinn at mquinn@metrohealth.org or 216-778-5178.

Please write to us at our address if you wish to have your name removed from the list to receive fundraising requests supporting The MetroHealth System or The MetroHealth Foundation in the future. In the event that you contact us with this request, all reasonable efforts will be taken to ensure that you will not receive any fundraising communications from us in the future.The MetroHealth Foundation, Inc. . 2500 MetroHealth Drive, Towers 135-A . Cleveland, OH 44109-1998

Edward K.S. Chien, MD, MBADirector, Division of Maternal-Fetal Medicine;Maternal-Fetal Medicine Fellowship Director

Specialties: Ob/Gyn, Maternal-Fetal Medicine

Areas of Interest: Preterm birth

Medical School: University of Illinois College of Medicine in Chicago, Chicago, Illinois

Residency: University of Michigan Medical Center, Ann Arbor, Michigan

Fellowship: University of Chicago Hospitals,Chicago, Illinois

Board certification: American Board of Obstetricsand Gynecology/Maternal-Fetal Medicine

Endowment Honors Extraordinary Cardiologist

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Call the Physician Referral Service: 216-957-3222 or 1-866-260-5376

MetroHealth Fast FactsMetroHealth’s Comprehensive Care Program has been caring for patients with special needs for more than 50 years. It was the first program of its kind in Northeast Ohio to offer a holistic approach to primary care for children and adults with special healthcare needs. Visit metrohealth.org/compcare

For the first time in its history, MetroHealth tracked more than 1 million patient visits in 2012 – the year of its 175th anniversary.

Christine Alexander, MD, Family Medicine physician, shares MetroHealth news and health information Saturdays at 7 a.m. on WTAM 1100. Learn more at metrohealthandyou.org

MetroHealth Breast Center Opening SoonLater this summer, MetroHealth’s West 150th Health & Surgery Center will be home to a comprehensive breast center, certified with the National Accreditation Program for Breast Centers (NAPBC). The Center, conveniently located just off I-71 at the W.150th exit, will feature the following:

■ Minimally invasive breast procedures: diagnostic and selected therapeutic techniques for benign disease

■ On-site surgical and cancer services

■ Advanced technology, including mammography with 3D Breast Tomosynthesis – one of the most powerful diagnostic tools for the early detection of breast cancer

■ A certified breast health patient navigator to help guide patients through the process of care and ensure prompt communications

■ Breast exams for a timely evaluation of breast problems To refer a patient, call 216-957-BRST. MetroHealth staff can assist with precertification. 3D Breast Tomosynthesis Mammography Unit