Cedars-Sinai Medical Center

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A BI-WEEKLY PUBLICATION FROM THE CEDARS-SINAI CHIEF OF STAFF Aug. 31, 2012 Issue | Archived Issues

Attendings encouraged to apply to Clinical Professorial Series

Attending physicians at Cedars-Sinai who actively participate in the Cedars-Sinai teaching mission are now eligible for appointment in the Clinical Professorial Series. Academic titles are conferred via a peer-review process similar to other institutions of higher learning. The series launched early this year.

» Read more

Arm yourself against the flu

Flu vaccine clinics begin right after Labor Day

Cedars-Sinai will begin offering free flu vaccinations to all employees, including medical staff, beginning Tuesday, Sept. 4, immediately following the Labor Day holiday.

» Read more

Navigating Crimson on your own

New tutorial enables MDs to surf the physician performance site whenever they like

Cedars-Sinai physicians who have undergone a review of their performance with a Crimson adviser can now have access to their own data 24/7.

» Read more

New critical high value for potassium (K)

The serum potassium (K) critical value call back will change from >6.5 to >6.2 next month. The projected go-live date for this change is Wednesday, Sept. 26.

» Read more

In war with 'superbugs,' C-S researchers see immune-boosting vitamin as a new weapon

Cedars-Sinai researchers have found that a common vitamin may have the potential to provide a powerful weapon to fight certain "superbugs," antibiotic-resistant staph infections that health experts see as a threat to public health.

» Read more

Survival statistics show hard fight when malignant brain tumors appear at multiple sites

When aggressive, malignant tumors appear in more than one location in the brain, patient survival tends to be significantly shorter than when the disease starts as a single tumor, even though patients in both groups undergo virtually identical treatments, according to research at Cedars-Sinai Medical Center's Maxine Dunitz Neurosurgical Research Institute.

» Read more

Attendings encouraged to apply to Clinical Professorial Series

Attending physicians at Cedars-Sinai who actively participate in the Cedars-Sinai teaching mission are now eligible for appointment in the Clinical Professorial Series. Academic titles are conferred via a peer-review process similar to other institutions of higher learning. The series launched early this year.

"We are a long-standing academic medical center and teaching hospital, and we have been for years," said William Brien, MD, chair of the inaugural Clinical Academic Promotions and Appointments Council. "Over the years our academic and teaching programs have grown substantially, and in response we have implemented a mechanism to recognize the significant clinical teaching, research and other academic work taking place at Cedars-Sinai."

The clinical professorial series is open to all members of the medical staff. The selection process is open to full-time, part-time and volunteer physicians at the medical center.

Eli M. Baron, MD, a neurosurgeon at the Cedars-Sinai Spine Center, received his clinical professorial appointment on July 3, one of the first physicians in the program. He is now a clinical associate professor of neurosurgery.

"It's an important step because an academic appointment reflects your background and training," Baron said. "Without this on-going peer-reviewed feedback and title, there's no acknowledgement or recognition of the fact that there are differences among various physicians' academic backgrounds."

The review process requires physicians to meet rigorous criteria and undergo review by a committee of peers selected from across campus.

"It's not simply an application," Baron said. "The appointment is a reflection of your background and training, and to receive it is a measure of achievement."

All attending physicians are encouraged to apply for an appointment; please contact Tara O'Shea, director of Academic Human Resources, at (310) 423-5539 or tara.oshea@cshs.org for additional information.

Arm yourself against the flu

Flu vaccine clinics begin right after Labor Day

Cedars-Sinai will begin offering free flu vaccinations to physicians and employees beginning Tuesday, Sept. 4, immediately following the Labor Day holiday.

Flu vaccine clinics will be held on the following dates and locations:

  • Sept. 4
    • HMA lobby from 7:30 a.m. to 3 p.m.
    • Ray Charles Cafeteria Conference Rm B from 4 p.m. to 10 p.m.
  • Sept. 5-7
    • HMA lobby from 7:30 a.m. to 3 p.m.
    • HMCC-3 from 4 p.m. to 10 p.m.
  • Sept. 10
    • HMA lobby from 7:30 a.m. to 3 p.m.
    • HMCC-3 from 4 p.m. to 10 p.m.
  • Sept. 11-12
    • HMA lobby from 7:30 a.m. to 3 p.m.
    • Ray Charles Cafeteria Conference Rm B from 4 p.m. to 10 p.m.
  • Sept. 13
    • HMA lobby from 7:30 a.m. to 3 p.m.
    • HMCC-6 from 4 p.m. to 10 p.m.
  • Sept. 14
    • HMA lobby from 7:30 a.m. to 3 p.m.
    • Ray Charles Cafeteria Conference Rm B from 4 p.m. to 10 p.m.

Everyone is encouraged to get vaccinated to help protect against the flu, as well as to prevent the spread of infection to patients and family members.

"Many healthcare workers believe they 'never get the flu,' but even during a mild flu season, nearly one in four show serologic evidence of exposure to the flu," said Rekha Murthy, MD, hospital epidemiologist. "Because we care for patients who are at high risk of flu complications, it's important that all of us get vaccinated to help prevent the transmission of the flu virus throughout the medical center."

Those who decline to get vaccinated must complete a signed declination form. Declination forms must be hand delivered to Employee Health Service (EHS) or to a Vaccination Team Member during one of the scheduled clinics.

For more information, or to schedule an appointment for a flu vaccination, please call Employee Health Service at ext. 3-3322.

Navigating Crimson on your own

New tutorial enables MDs to surf the physician performance site whenever they like

Cedars-Sinai physicians who have undergone a review of their performance with a Crimson adviser can now have access to their own data 24/7.

Tutorial sessions currently are being offered to assist physicians in navigating the Crimson website and drilling down to information that can help them optimize their outcomes. Crimson is a web-based educational tool that displays clinical performance of individual physicians and groups in an easily understandable way. It allows physicians to look at their own risk-adjusted patient data as well as compare themselves to other groups in their specialty, both within and outside of Cedars-Sinai. The software is used by more than 650 hospitals in the U.S., representing 25 percent of all hospital patients across the nation.

The program is being led by Harry C. Sax, MD, senior physician liaison for Cedars-Sinai Medicine and vice chair of Surgery.

"One of the benefits of Crimson is that physicians now have access to objective, timely information that allows them to monitor how their patients fare relative to other physicians at Cedars-Sinai and national trends. It takes into account the severity of illness and guides the practitioner to areas of opportunity. Further, as we prepare for public reporting of data, doctors will be more aware of how they stand relative to their colleagues," Sax said.

Crimson software integrates data from multiple sources, such as the CS-Link™ patient accounting system and CS-Link EMR, as well as key quality and utilization measures, and presents it in an acuity adjusted manner. The data is then displayed in a dashboard format highlighting physician performance in key metrics compared to local and national benchmarks. Information on individual patients is available to the level of daily charges and resource utilization.

To date, more than 450 Cedars-Sinai physicians have met with their Crimson adviser to review and analyze their data. The feedback suggests a new level of individual empowerment in understanding each provider’s role in the care of our patients, according to Sax.

If you are interested in more information about personal use of Crimson, please contact Elisabeth Hallman, MBA, RN, at elisabeth.hallman@cshs.org or Allyson Lazar at allyson.lazar@cshs.org.

New critical high value for potassium (K)

The serum potassium (K) critical value call back will change from >6.5 to >6.2 next month. The projected go-live date for this change is Wednesday, Sept. 26.

Both federal and California law mandate that clinical laboratories develop and follow written procedures for reporting imminent life-threatening laboratory results or critical values. In addition, clinical laboratories must immediately alert the individual or entity requesting the test, or the individual responsible for utilizing the test results, when a test result from among those defined by the laboratory in conjunction with the Medical Executive Committee indicates an imminent life-threatening condition.

Based on recent physician input, the current upper critical value for potassium is higher than the community standard and, on occasion, a patient may not be treated promptly for unexpectedly high potassium.

A review of the literature was conducted to compare Cedars-Sinai’s practices with the community. Based on an article in the Archives of Pathology and Laboratory Medicine, in a survey of 162 labs, critical value cut-offs for K of 5.9 is at the 5th percentile, 6.0 is median, and 6.5 is 95th percentile. (Arch Pathol Lab Med 2007;131:1769).

“We polled numerous doctors in the Department of Medicine, concentrating on those from the division of Nephrology, who would be most affected by this change,” said Holli M. Mason, MD, associate director of Transfusion Medicine and medical director of the Core Laboratory. “All of the physicians with whom we spoke felt that >6.5 was too high and favored lowering the cut off for a critical value call back.”

While there was some discussion on the best number (many favoring lower) it was generally agreed that a value of 6.3 (>6.2) would sufficiently cover patients in danger of an adverse event, while keeping the calls to a reasonable volume.

This proposed change has been presented to and approved by the Pathology PIC, the Medicine PIC, the CIC, and the Medical Executive Committee. Changes in the Laboratory Information System and standard operating procedures are expected to be completed by Sept. 26, when the new critical value will go into effect.

In war with 'superbugs,' C-S researchers see immune-boosting vitamin as a new weapon

Cedars-Sinai researchers have found that a common vitamin may have the potential to provide a powerful weapon to fight certain "superbugs," antibiotic-resistant staph infections that health experts see as a threat to public health.

The research, published in the September 2012 edition of The Journal of Clinical Investigation, found that high doses of the nicotinamide form of vitamin B3 stimulated a specific gene (CEBPE), enhancing white blood cells' ability to combat staph infections, including methicillin-resistant Staphylococcus aureus or MRSA.

With research ongoing, including possible clinical trials in humans, the scientists caution consumers not to treat a suspected infection by taking vitamin B3. Instead, a physician should be consulted.

"It's critical that we find novel antimicrobial approaches to treat infection and not rely so heavily on antibiotics," said George Liu, MD, PhD, a pediatric infectious disease physician at Cedars-Sinai's Maxine Dunitz Children's Health Center and co-senior author of the study. "That's why this discovery is so exciting. Our research indicates this common vitamin is potentially effective in fighting off and protecting against one of today's most concerning public health threats."

Staph infections commonly cause serious, sometimes life-threatening illness. Health officials fear that indiscriminate use of antibiotics has undercut their effectiveness, leading to the rapid rise and threatening spread of resistant germs.

In laboratory tests with mice and human blood, Cedars-Sinai scientists found that vitamin B3 increased by up to 1,000 fold the ability of the immune system to kill staph bacteria. Beyond its findings related to vitamin B3, the study indicates that similar targeting of the CEBPE gene with other compounds may offer a new immune-boosting strategy to fight bacterial infections.

The researchers have been investigating a rare disease called neutrophil-specific granule deficiency, a hematologic disorder afflicting only a handful of people in the world. Due to a mutation of the gene CEBPE, patients with this disease have significantly weakened immune systems, leaving them prone to severe, chronic and life-threatening infections, including staph. The CEBPE gene regulates several antimicrobial factors in the body.

"Our goal in studying a rare disorder is that it may give us broad insight into the immune mechanisms that protect healthy individuals against staph infections," said Pierre Kyme, PhD, a researcher in the Division of Pediatric Infectious Diseases in the Maxine Dunitz Children's Health Center and the Immunobiology Research Institute, and co-first author of the study with Nils Thoennissen, MD, who is now with the Department of Medicine at University of Muenster in Germany. "We found that if you over-express the gene in normal individuals, the body's immune cells do a better job of fighting off infection."

Kyme and Thoennissen turned to vitamin B3, which has been shown to increase the expression of some other genes in the CEBP family. The results: When studied in human blood, clinical doses of the vitamin appeared to virtually wipe out the staph infection in only a few hours.

Formal testing in clinical trials with patients is called for, based on these outcomes in the laboratory and in laboratory mice studies, said Phillip Koeffler, MD, professor of medicine at Cedars-Sinai and co-senior author of the study.

"There's more research to be done, but we believe that vitamin B3, and other compounds that are able to increase the activity of this particular gene, have the potential to be effective against other antibiotic-resistant bacteria in addition to strains of staph," he said.

Survival statistics show hard fight when malignant brain tumors appear at multiple sites

When aggressive, malignant tumors appear in more than one location in the brain, patient survival tends to be significantly shorter than when the disease starts as a single tumor, even though patients in both groups undergo virtually identical treatments, according to research at Cedars-Sinai Medical Center's Maxine Dunitz Neurosurgical Research Institute.

"We've known that certain independent factors, such as age at diagnosis, amount of residual tumor after surgery, and the patient's functional status are useful in predicting outcomes in patients with glioblastoma multiforme, but multifocal disease at time of onset has rarely been examined in this context. Two small previous studies were contradictory. Our study appears to confirm observations that disease in patients with more than one lesion is particularly challenging and that these patients tend to have worse outcomes. Matched survival analysis demonstrated that multifocal disease is a strong and negative independent prognostic factor," said Chirag G. Patil, MD, director of the Center for Neurosurgical Outcomes Research in the Department of Neurosurgery at Cedars-Sinai.

The researchers compared outcomes of 47 patients who had multiple tumors with 47 who had a single lesion, matching them for age, functional impairment scores, extent of tumor removal and radiation therapy and chemotherapy. Median overall survival for the multifocal group was six months, compared to 11 months for those in the single tumor group.

Patil, first author of an article in the Aug. 24 Journal of Neurosurgery, noted that a comparatively large percentage of tumors in the multifocal group appeared to be "treatment resistant," continuing to grow even after patients underwent radiation therapy.

Unlike earlier studies, nearly all of these patients were diagnosed and treated during the "temozolomide era," beginning in 2005 when this drug joined radiation therapy as the mainstay of glioblastoma treatment. Even so, 11 of the 47 patients in the multifocal group did not receive temozolomide because, the researchers suggest, disease progression is so quick that many patients are unable to start or complete standard therapies.

Patil said researchers believe cells of multifocal tumors may have an increased ability to migrate in the brain and invade normal tissue, leading to more rapid patient decline; recent advances in therapies for glioblastomas have not improved survival in these patients.

"A thorough investigation of the unique biology of these tumors and their invasive and migratory mechanisms is needed so we may develop a new generation of targeted therapies," said Patil, who received a Cedars-Sinai grant that will fund the study of genetic and biological differences between single tumors and those originating at multiple sites.

Glioblastoma multiforme is the most common and aggressive malignant tumor occurring in the brain, and patients typically survive 15 months when undergoing standard treatments. Other single-tumor patients in the larger pool from which those in this study were derived, had median survival of 16 months. The shorter 11-month survival of study patients is believed to result from the matching process: Because many of those with multiple-site tumors could not undergo complete tumor removal, their corresponding single-site patients had tumors with locations or characteristics that made them appropriate for biopsy only.

Citation: Journal of Neurosurgery, Aug. 24, 2012, "Prognosis of Patients with Multifocal Glioblastoma: A Case-Controlled Study."