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A BI-WEEKLY PUBLICATION FROM THE CEDARS-SINAI CHIEF OF STAFF July 28, 2017 | Archived Issues

CS Takes Infection Fight to Nursing Homes

Cedars-Sinai is fighting infections in a new way, by battling them in local skilled nursing facilities before they reach the hospital. The organization is working with eight local nursing homes to ensure patients are getting the appropriate antibiotic at the right time to prevent infections and the spread of drug-resistant bacteria.

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Paul Rubenstein, MD: 1931-2017

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Paul Rubenstein, MD, a longtime physician executive whose vision and drive helped transform Cedars-Sinai from a community hospital into a major academic health system, has died. He was 86. Rubenstein, who oversaw a dramatic expansion of clinical services and research from the late 1960s to the early 1980s, died of congestive heart failure July 4 at a nursing home in Northern California.

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Department of Neurology Named MDA Care Center

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The Department of Neurology was recently designated as an MDA Care Center by the Muscular Dystrophy Association, a leading organization in the fight to cure muscle-debilitating diseases.

» Read more

Changing Attitudes on Pelvic Floor Disorders

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More than one-third of women in the U.S. may have a weakened or damaged pelvic floor, a sling-like group of muscles and tissues that supports the reproductive, bowel and urinary organs in the pelvis. Many of these women don't know their condition has a medical name — pelvic floor disorder — and often can be treated. What they do know is how their symptoms make them feel, including shame and embarrassment. Jennifer Anger, MD, MPH, is out to change these attitudes.

» Read more

Carew Inspires Fellow Transplant Patients

Carew and Kobashigawa co

Baseball Hall of Famer Rod Carew spoke to transplant patients, their family members, physicians, nurses and other caregivers at the 24th annual Heart and Lung Transplant picnic. The 18-time All-Star received a new heart and kidney at Cedars-Sinai in December. He shared details about his recovery and about meeting his donor’s family.

» Read more

Cancer Survivor Credits Cedars-Sinai Vaccine

Mary Wong Lee and her husband Ed co

This story is part of an occasional series highlighting the #CedarsGratitude effort. Share why you are grateful for Cedars-Sinai.

Every day is a gift. No one knows that better than Mary Wong Lee. When she was diagnosed with a walnut-sized brain tumor, she believed she had only months to live. That was a decade ago. Mary, now 65, still values every moment she has to share with her sons and her husband.

» Read more

Sand 'N' Snore Set for Sept. 8

Sand 'N' Snore

Sand 'N' Snore is just around the corner. The dinner, sleepover and breakfast starts Friday, Sept. 8, at the Jonathan Beach Club in Santa Monica. Those who don't want to sleep on the sand are welcome to enjoy dinner and the evening with colleagues and their families.

» Read more

Pharmacy and Therapeutics Product Updates

See product information updates for July from Pharmacy and Therapeutics.

» Read more

CS-Link Tip: Online CME Training

cs-link logo

CS-Link™ can help save time, eliminate unnecessary clicks and reduce typing time. HealthStream also offers physician efficiency training modules for continuing medical education credit. There are 22 modules that last 15 minutes each.

» Read more

CS Takes Infection Fight to Nursing Homes

Cedars-Sinai is fighting infections in a new way, by battling them in local skilled nursing facilities before they reach the hospital.

The organization is working with eight local nursing homes to ensure patients are getting the appropriate antibiotic at the right time to prevent infections and the spread of drug-resistant bacteria.

"When it comes to infections and bacteria, they don’t know boundaries. They don’t respect the walls of the hospital," said Rekha Murthy, vice president of Medical Affairs and associate chief medical officer, who established the initiative in 2015. "We will not win the war against these serious infections unless we combat them with prevention and control measures across the healthcare continuum."

Cedars-Sinai frequently discharges patients who need extra care to nursing homes. Many of these patients are elderly and often in need of help after a hip replacement, pneumonia or other major illness.

But sometimes these patients are readmitted to the hospital after developing an infection. Cedars-Sinai wants to avoid readmissions by helping the nursing homes correctly diagnose and treat infections for which antibiotics are often improperly prescribed.

Improper use of antibiotics is a national problem for healthcare providers. As many as 70 percent of U.S. nursing home residents get antibiotics each year, and up to 75 percent of those drugs are prescribed incorrectly, according to the Centers for Disease Control and Prevention (CDC). The CDC estimates that more than 2 million illnesses and 23,000 deaths each year are related to antibiotic resistance.

Since implementing the program a year ago in collaboration with the Enhanced Care Program, Cedars-Sinai has seen a 20 percent reduction in the number of days patients are treated with antibiotics at three of the facilities reporting back data. The facilities also have seen a 41 percent reduction in the number of days patients are treated with a fluoroquinolone, a group of antibiotics that can have serious side effects and can promote antibiotic resistance. The program has been rolling out in phases and will eventually capture data from the other nursing homes.

"Antibiotics are the only class of drug that becomes less effective the longer it’s available," said Jonathan Grein, MD, medical director of the Department of Hospital Epidemiology and infection control officer. "These facilities we’re partnering with really want to do the right thing and work in the best interest of the patients. Sometimes they don’t have the resources or expertise to go it on their own."

Cedars-Sinai developed a tool to help staff at nursing homes assess whether a patient has an infection and to spur a conversation with a doctor. The hospital has provided recommendations to each facility about which antibiotics work best on the strain of bacteria most often found in that specific nursing home.

The new tactic has been used initially to identify and properly treat urinary tract infections (UTIs). Elderly nursing home patients often have a high prevalence of UTI-causing bacteria in their urine, even though the patients may not be ill.

In such situations, doctors will sometimes prescribe antibiotics in an effort to be safe, but doing so can put a patient at unnecessary risk of getting Clostridium difficile. The bacterium causes inflammation of the colon, which can lead to other illnesses and even death.

"Stewardship involves routinely looking at the risks versus the benefits of using antibiotics in every patient," said Hali Yang, PharmD, the antimicrobial stewardship pharmacist who helped implement the project.

Cedars-Sinai’s Enhanced Care Program, which already had been working closely with nursing homes, helped make the project possible. The program supports attending physicians at skilled nursing facilities by partnering them with a team of nurse practitioners who frequently visit patients at the facilities.

Soon after Murthy launched the project in 2015, the Centers for Medicare & Medicaid Services and the California Department of Public Health announced new regulations requiring nursing homes to operate their own antimicrobial stewardship programs by 2017. The new regulation is a daunting prospect for many facilities, which often have high staff turnover and usually lack full-time pharmacy and infectious disease specialists who can create and run such a program.

"Without Cedars-Sinai, we’d still be struggling with that," said Eldon Teper, executive director of The Rehabilitation Centre of Beverly Hills, one of the skilled nursing facilities involved in the project. "They’ve been tremendously helpful."

Paul Rubenstein, MD: 1931-2017

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Paul Rubenstein, MD

Paul Rubenstein, MD, a longtime physician executive whose vision and drive helped transform Cedars-Sinai from a community hospital into a major academic health system, has died. He was 86.

Rubenstein, who oversaw a dramatic expansion of clinical services and research from the late 1960s to the early 1980s, died of congestive heart failure July 4 at a nursing home in Northern California.

"Paul Rubenstein's leadership came at a crucial time in Cedars-Sinai's history and helped make it the dynamic institution it is today," said Thomas M. Priselac, president and CEO of Cedars-Sinai.

The son of a real estate developer, Rubenstein was born May 3, 1931, in Milwaukee, and later moved to Phoenix. After completing undergraduate studies at Harvard University, he earned his medical degree in 1957 from the Washington University School of Medicine in St. Louis. Months later, he arrived at Cedars of Lebanon Hospital, one of Cedars-Sinai's precursors, for an internship and a three-year residency in medicine.

Over the next three decades, Rubenstein would serve in a number of leadership roles with Cedars of Lebanon and its successor, Cedars-Sinai, culminating in his appointment as vice president of professional services, a position he held for nearly two decades. He played an instrumental role in planning for the new Cedars-Sinai Medical Center, which opened in 1976 following the merger of Cedars of Lebanon and Mount Sinai hospitals.

"He always enjoyed pushing envelopes and being a visionary," said Michael Langberg, MD, senior vice president of Medical Affairs and chief medical officer at Cedars-Sinai, who worked with Rubenstein for several years. "He remarked once that most physicians take care of one patient at a time. In his job, he felt he was caring for hundreds of patients at a time, impacting the lives of thousands of people he knew he would never meet."

In 1998, the Paul Rubenstein, MD, Prize for Excellence in Resident Research was created to recognize outstanding Cedars-Sinai trainees. The prize is sponsored by the Burns and Allen Research Institute and the Cedars-Sinai Clinical and Translational Research Center. Rubenstein was the first director of the research institute.

Rubenstein in 1955 married Maxine Kessler, a graduate of Beverly Hills High School and the University of Southern California. The couple, who later divorced, had three children—Daniel, Peter and Anthony.

"My dad really had two families," recalled Anthony Rubenstein, the youngest of the three children, who now lives in Philadelphia. "He had ours when we were growing up and he had Cedars-Sinai. He was completely dedicated to the institution."

Rubenstein is survived by his son, Anthony, who requests that, in lieu of flowers, donations be made to the Paul Rubenstein, MD, Prize for Excellence in Resident Research, c/o Academic Affairs, 8700 Beverly Blvd., NT2004, Los Angeles, CA 90048.

Department of Neurology Named MDA Care Center

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Robert Baloh, MD, PhD

The Department of Neurology was recently designated as an MDA Care Center by the Muscular Dystrophy Association, a leading organization in the fight to cure muscle-debilitating diseases.

Cedars-Sinai joins more than 150 top hospitals and healthcare facilities in the United States and in Puerto Rico that provide highly specialized care and access to clinical trials for a variety of neuromuscular diseases such as amyotrophic lateral sclerosis, inherited neuropathy, myasthenia gravis and muscular dystrophy.

"To achieve this designation is truly an honor," said Robert Baloh, MD, PhD, vice chair for Research and director of Neuromuscular Medicine in the Department of Neurology. "This recognition tells patients we are on the forefront for offering the highest quality of comprehensive care from a wide variety of top healthcare specialists."

Baloh said the designation will help strengthen his team’s collaboration with the Cedars-Sinai Heart Institute, which provides cardiac care for patients with muscular dystrophy and assists with experimental treatment protocols.

As part of the designation, the department will receive financial support from the MDA to continue its work diagnosing, treating and researching diseases that impair the functioning of the muscles and nerves.

The MDA Care Center is on the sixth floor in the Advanced Health Sciences Pavilion.

For more information, call 310-423-5700.

Changing Attitudes on Pelvic Floor Disorders

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Jennifer Anger, MD, MPH

More than one-third of women in the U.S. may have a weakened or damaged pelvic floor, a sling-like group of muscles and tissues that supports the reproductive, bowel and urinary organs in the pelvis. Many of these women don't know their condition has a medical name — pelvic floor disorder — and often can be treated.

What they do know is how their symptoms, which can include leaking urine or stool, make them feel. Ashamed. Embarrassed. Too mortified to tell a soul, particularly a physician.

Jennifer Anger, MD, MPH, associate professor in the Cedars-Sinai Department of Surgery, believes a sea change in attitudes toward pelvic floor disorders is long overdue.  "We really need to remove shame from the equation," she said. "Many women with these disorders find it very difficult to talk about any problems in the pelvic area, and that difficulty creates a barrier to accessing care."

Anger shared her observations and research findings on pelvic floor disorders at a lecture in a bimonthly series sponsored by the Barbra Streisand Women's Heart Center at the Cedars-Sinai Heart Institute, the Faculty Development Office and the Department of Obstetrics and Gynecology. The series, "Sex & Gender Medicine Lunch & Learn," was launched to increase awareness that biological and behavioral differences between men and women require gender-specific approaches to diagnosing and treating diseases.

In women, the pelvic floor supports organs that include the bladder, cervix, rectum, urethra, uterus and vagina. Its structure can be weakened or damaged through childbirth or routine heavy lifting as well as by obesity, aging or other conditions.

The shame that many sufferers feel stems from the resulting symptoms, which can include:

  • Bladder issues: A sudden, urgent need to urinate; urine leakage triggered by coughing, laughing or sneezing; painful urination; or incomplete emptying of the bladder.
  • Bowel incontinence: Leaking of liquid or solid stool.
  • Pelvic organ prolapse: If weakened pelvic muscles and tissues give way, one or more pelvic organs may descend into the vagina or press against the vaginal wall. The most common prolapse occurs when an unsupported bladder bulges into the vagina or through the vaginal opening.

"Prolapse is particularly confusing because women don't know what's happening when they feel a vaginal bulge," Anger said.

In 2016, Anger helped direct a multicenter study of women with pelvic organ prolapse. Patients in focus groups expressed fear, depression and shame, she said. Some patients mistook their symptoms for cancer, stopped socializing or said they felt like "freaks."

Educating women about pelvic floor disorder symptoms and available treatments — which include physical therapy, medication and surgery — may improve patients' ability to discuss their disorder and seek medical advice, Anger suggested.

Sarah Kilpatrick, MD, PhD, chair of the Cedars-Sinai Department of Obstetrics and Gynecology and associate dean for Faculty Development, who moderated the session, said physicians have a key role to play in this effort.

"There needs to be better education of primary care and OB-GYN physicians so they understand that asking about these conditions should be a normal part of taking a medical history," said Kilpatrick, a professor of Obstetrics and Gynecology. "If the practitioner is comfortable, then it's easier for the patient."

Carew Inspires Fellow Transplant Patients

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Baseball Hall of Famer Rod Carew jokes with Jon Kobashigawa, MD, director of the Cedars-Sinai Heart Transplant program, during a talk to patients and medical staff at the recent 24th annual Heart and Lung Transplant picnic.

The softball game between Cedars-Sinai transplant patients and medical staff at the 24th annual Heart and Lung Transplant picnic earlier this month ended in a tie. That might be as close to victory as the physicians, nurses and other caregivers are going to get for a while.

This year, Baseball Hall of Famer Rod Carew, who in December underwent a heart and kidney transplant at Cedars-Sinai, was supposed to suit up with patients. A last-minute phone call spared the healthcare staff an almost certain loss at the hands of one of the greatest hitters in baseball history.

Carew had to leave the weekend event earlier than expected to catch a flight to Miami so he could participate in a pre-game ceremony honoring Latin-American born players at the Major League Baseball All-Star game on July 11.

"I was really looking forward to playing in the [softball] game," said Carew, who was born in Panama, and was an 18-time All-Star and seven-time batting champion. "I was supposed to be the ringer."

Instead of raising his lifetime batting average that day, Carew instead raised the spirits of the hundreds of patients, family members and staff gathered at Rancho Park after sharing details about his recovery and about meeting his donor’s family. Before the softball game, he explained why he felt compelled to attend.

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Carew said he is feeling very good and continues to get stronger after his heart and kidney transplant surgery more than seven months ago at Cedars-Sinai.

"I wanted to be here today to be with the people who had been through what I have been through," said Carew. "Just to see their smiling faces and understanding what folks here have gone through, and continue to go through, because I feel it."

The former professional athlete, who freely gave out warm embraces and firm handshakes, swapped health stories with fellow transplant patients. While back to an active routine that includes a special cardio workout three times a week, Carew said he is still working to improve his balance. But overall, he said he feels good and continues to get stronger.

He offered a special note of gratitude for his caregivers at Cedars-Sinai, which performs more adult heart transplants than any other U.S. medical center. In 2016, Cedars-Sinai surgeons completed 122 adult heart transplants. Carew was No. 119.

"I had a great experience with the doctors, the nurses and the hospital," said Carew, 71, who was accompanied by his wife, Rhonda. "They’ve given me a second chance at living. I want to tell you that life is good."

The hopeful and upbeat day was a long way from where Carew was almost two years ago. After a devastating heart attack, he was fighting for his life. And for one of the rare times in the champion’s life, he was losing.

It began early one morning in October 2015 on a golf course near his home in Orange County. He began experiencing chest pains after hitting a ball off the first tee. Somehow, he managed to drive the golf cart back to the clubhouse. Once there, he fell to the floor.

A physician later told Carew that if he would have had his heart attack farther away from the clubhouse — on the second or third tee — he probably wouldn’t have survived.

"I don’t know how I’m alive today," said Carew, who as a former athlete always kept himself in excellent physical condition. "I had no signs, no signs whatsoever. One minute I was feeling good, the next ..."

The next 15 months were a blur of physician and hospital visits, and personal struggle. He said he spent 160 days in eight different hospitals and underwent two major surgeries before the transplant.

"I cried many a night and morning," he said.

On Dec. 16, he received a new heart and kidney at Cedars-Sinai.

"The doctors tell me that I have a roaring heart now," said Carew.

In an unusual turn, Carew had an emotional meeting with the family of his donor earlier this year. The family had figured out from news reports, later confirming with the organ donor company, that Carew was the recipient of their son’s heart.

Usually, families wait at least a year before coming together, but the donor family, said Carew, was very insistent.

Rod and Rhonda Carew made the short journey to the donor’s family’s Southern California home.

"The first time I went there, his mom put her head on my chest to hear the heartbeat," he said. "She was in tears. I was almost in tears, too. But I decided to be strong for her and me.

"It was a great day," continued Carew. "They are a great family. I couldn’t have asked for a better family to donate their son’s heart."

At the softball game, Jon Kobashigawa, MD, director of the Cedars-Sinai Transplant Program, praised Carew as a wonderful ambassador for the transplant program.

"Rod looks very fit and is an inspiration to others here," said Kobashigawa. "He truly represents the spirit of heart transplantation and what it means to family and friends to get back to a great quality of life."

For only the second time in the history of the patient-staff softball game, this year’s contest was a tie. Patients have won 17 games and healthcare professionals have won five.

Next year, Carew promised to play.

"We’ll have a good chance of winning," he said with a smile.

Cancer Survivor Credits Cedars-Sinai Vaccine

Mary Wong Lee and her husband Ed 480px

Mary Wong Lee and her husband, Ed

This story is part of an occasional series highlighting the #CedarsGratitude effort. Share why you are grateful for Cedars-Sinai.

Every day is a gift. No one knows that better than Mary Wong Lee.

When she was diagnosed with a walnut-sized brain tumor, she believed she had only months to live. That was a decade ago. Mary, now 65, still values every moment she has to share with her sons and her husband.

She had an aggressive, rapidly growing form of brain cancer called glioblastoma. She agreed to try an investigative therapy — a vaccine, developed at Cedars-Sinai that activated her immune system to fight the cancer. She credits the vaccine with saving her life.

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Mary enjoys golfing with her family.

Mary is not alone. The response to the vaccine and associated treatment has been promising, according to neurologists at Cedars-Sinai.

When Mary received her diagnosis, she was devastated. "I was thinking my kids were still in college, I hadn’t seen them graduate from college, or see them get married," she said. "There’s no doubt in my mind the vaccine worked."

Mary initially went to the doctor because sudden migraines left her unable to speak, interfered with her ability to write and turned her thinking cloudy. Her family physician wept when he delivered the news of her diagnosis and what it most likely meant: She would have 15 to 18 months to live.

They went to Keith L. Black, MD, chair of the Department of Neurosurgery and director of the Maxine Dunitz Neurological Institute, and weighed their treatment options. Standard chemotherapy and radiation therapy alone were unlikely to have favorable outcomes.

Mary qualified for what was then an early clinical trial for a brain cancer vaccine. The clinical trial’s purpose was to assess the safety and effectiveness of an investigational vaccine to fight brain cancer.

A patient’s own tumor cells are used to create a targeted immunotherapy, conditioning the immune system to recognize the cancer cells as invaders and attack.

Mary was one of the first patients to receive this treatment. She also underwent chemotherapy, radiation and surgery to remove the tumor. Typically, fewer than 3 percent of people diagnosed with glioblastoma live five years.

"I’ve been working with this cancer for over 30 years, and we did a lot of different studies, a lot of different treatments," Black said. "You just don’t see those types of responses."

Cedars-Sinai has been studying these vaccines for more than 15 years and is home to the largest brain cancer vaccine clinical trials in the United States. The vaccine used to treat Mary is now in its third phase, when larger numbers of patients are given an investigational treatment to validate its effectiveness.

"Survival has doubled or tripled for some patients," said John S. Yu, MD, vice chair of Neurosurgical Oncology in the Department of Neurosurgery. "Even those with the most devastating disease, with the research we’re doing, we may offer hope for living longer."

Mary remains grateful for the vaccine. It’s given her countless moments of happiness and meaningful milestones: a chance to see Kevin graduate from college. Wiping away a tear at the wedding of her oldest son, Michael. Kissing her grandson Connor’s forehead when he was just a newborn and clapping over his first birthday cake. Sharing the pleasures of grandparenthood with her husband, Ed.

"I didn’t expect to be here this long, and I’m sure I would tell everybody the same thing," Mary said. "It doesn’t mean your life is going to be short. It can be done."

Financial disclosure: John S. Yu, MD, who has a leadership role in the Neurological Institute, serves as a board member for ImmunoCellular Therapeutics Ltd., which sponsors the Phase III trial. However, Yu is not an investigator on the brain vaccine trials. In addition, Cedars-Sinai has a financial interest in this study, as the institution is a minor shareholder of ImmunoCellular's stock.


#CedarsGratitude

In July 2010, Cedars-Sinai launched The Campaign for Cedars-Sinai — the organization’s most ambitious fundraising effort to date with a goal of raising $600 million by June 2018 to help build and advance its research, academic and patient care programs. The Gratitude effort aims to bolster contributions in the campaign’s final months by highlighting stories of gratitude from patients, families, donors and employees.

Help us spread the word! Use #CedarsGratitude and share why you are grateful for Cedars-Sinai. About 75 percent of Cedars-Sinai's donors are grateful patients. Showing your support for Cedars-Sinai through social networks is a powerful way to spread the word about Cedars-Sinai's mission to provide excellent patient care and discover lifesaving treatments.

To learn more about The Campaign for Cedars-Sinai and how you can help, visit giving.cedars-sinai.edu.

To learn more about the Gratitude effort or to share your story, visit the #CedarsGratitude giving page.

Sand 'N' Snore Set for Sept. 8

A photo from a previous Sand 'N' Snore.

Sand 'N' Snore is just around the corner.

The dinner, sleepover and breakfast starts Friday, Sept. 8, at the Jonathan Beach Club in Santa Monica. Those who don't want to sleep on the sand are welcome to enjoy dinner and the evening with colleagues and their families. There's a limit of one tent per physician.

Tickets for the whole event are $65 per adult and $45 for each child age 3-11. Tickets for Friday's dinner only are $50 per adult and $25 for each child 3-11.

To reserve a place, contact Cheryl Verne, in the office of Marjorie Santore Besson, at 310-423-2681 or cheryl.verne@cshs.org.

Pharmacy and Therapeutics Product Updates

Product information updates for July from Pharmacy and Therapeutics are summarized in the PDF link below.

P and T Committee Approvals - July 2017  

CS-Link Tip: Online CME Training

CS-Link™ can help save time, eliminate unnecessary clicks and reduce typing time.

HealthStream also offers physician efficiency training modules for continuing medical education credit. There are 22 modules that last 15 minutes each. They include topics such as "In Basket Quick Actions," "Smart Blocks in Progress Notes" and "SmartList Editor."

To take advantage, log into HealthStream and search the catalog using keywords: PET CME. Select the module you want to view, then click "Enroll."

CSLink tip- Physician Efficiency Training  

If you have questions, contact groupeisphysicians@cshs.org.