sutures newsletter

PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY January 2013 | Archived Issues

Leon Morgenstern, MD: 1919-2012

Leon Morgenstern, MD, a beloved colleague and the founding director of surgery for Cedars-Sinai Medical Center, died Dec. 23 at his home in Malibu at age 93. A surgeon, scholar, humanist, medical researcher and prolific author, he remained active after his retirement and was working in his Cedars-Sinai office as recently as Dec. 21.

Cedars-Sinai is planning a memorial in his honor.

» Read more and see photos from Morgenstern's career


Mark your calendar


Grand rounds

Click here to view a schedule of all upcoming grand rounds.


Surgery scheduling

Click the "read more" for hours and contact information for surgery scheduling.

» Read more

An eventful six months for Department of Surgery

Message from the chair

The first half of fiscal year and academic year 2013 was particularly noteworthy for the Department of Surgery.


» Read more

Cedars-Sinai surgical team expands mission in China

In November 2011, when a pediatric surgery team from Cedars-Sinai traveled to Maria's Big House of Hope, an orphanage in Louyang, China, the focus of the mission was on the children. The future looked bleak for the infants and toddlers, born with anorectal malformations in a culture that believes such birth defects bring a family bad luck. They had all been abandoned by their parents within days of their birth. Last year, following up on the success of that mission, in which 11 children had operations and several were adopted, the Cedars-Sinai team returned to Louyang.

» Read more

Here comes the flu

C-S sees spike in flu cases; new visitor precautions put into place

Cedars-Sinai is experiencing an increase in flu cases, and California public health officials warn that the flu epidemic that has already hit hard in other areas of the nation is headed our way. "The number of positive influenza cases confirmed at Cedars-Sinai has increased substantially in the past two weeks," says Rekha Murthy, MD, director of Hospital Epidemiology at Cedars-Sinai. "We are admitting five to six patients per day with influenza diagnosis and three to four positive for other respiratory viruses."

» Read more

C-S team repeats as surgical Jeopardy champ

Congratulations to Seth Felder, MD, and Doug Liou, MD, for winning surgical Jeopardy at the recent Southern California conference of the American College of Surgeons.



» Read more

Dozens make presentations at Research Day, ACS meeting

Numerous Cedars-Sinai Department of Surgery residents and faculty members made presentations at the medical center's Research Day IV and at the annual meeting of the regional chapter of the American College of Surgeons.

» See a list of the presentations and participants

Articles accepted for publication

Several articles involving members of the Department of Surgery have been accepted for publication.

» Learn more about the articles

Prominent bone cancer surgeons join Orthopaedic Center

Two of Southern California's best-known orthopedic oncologists have joined Cedars-Sinai, enhancing a surgical team that treats some of the most complex and difficult types of cancer. Lawrence R. Menendez, MD, and Daniel C. Allison, MD, FACS, MBA, have partnered with Earl Warren Brien, MD, director of musculoskeletal tumor service at the Cedars-Sinai Orthopaedic Center, to form one of the preeminent orthopedic oncology practices in the western U.S.

» Read more

More doctors, hospitals partner to coordinate care for people with Medicare

Cedars-Sinai has been selected as one of 106 new Accountable Care Organizations in Medicare, ensuring as many as 4 million Medicare beneficiaries across the United States now have access to high-quality, coordinated care, Health and Human Services Secretary Kathleen Sebelius announced Jan. 10.

» Read more

Reversing the trend in APLs

"Accidental Puncture and Laceration" is a patient safety indicator developed by the Agency for Healthcare Research and Quality that is reported on the Centers for Medicare & Medicaid Services website to report adverse events for individual hospitals. The indicator rate is calculated from the hospital's coding of diagnoses and conditions that is based on physician documentation.

» Read more

Patient whiteboards see red ... and yellow and green

Cedars-Sinai is rolling out newly redesigned patient room whiteboards with color-coded sections designed to enhance patient care and help improve patient satisfaction. The boards are being installed in patient rooms across the medical center.



» Read more

Visualizing how colorectal surgical site infections have fallen

New protocols at Cedars-Sinai have significantly reduced the number of surgical site infections among patients who undergo colorectal procedures.

» Read more

FDA lowers recommended dose of zolpidem products

Pharmacy focus

The U.S. Food and Drug Administration is notifying the public of new information about zolpidem, a widely prescribed insomnia drug. FDA recommends that the bedtime dose be lowered because new data show that blood levels in some patients may be high enough the morning after use to impair activities that require alertness, including driving.

» Read more

An eventful six months for Department of Surgery

Message from the chair

The first half of fiscal year and academic year 2013 was particularly noteworthy for the Department of Surgery.

Operative volumes at our main ORs and our outpatient facility surged, with greater than 4 percent increases in case volumes and hours from 2012. The complexity of cases continued to be strong led by the remarkable clinical volume of our world-leading heart transplant service and the strong performance of other service lines to include thoracic surgery, spine surgery, joint replacement and minimally invasive advances in virtually every discipline. For the first time, we performed more than 200 kidney transplants. Indeed, Cedars-Sinai continues to lead all California academic medical centers in virtually every measure of surgical volume and outcomes.

Our post-graduate education programs demonstrated sustained excellence. More than 700 applications were received for our largest residency program (general surgery), representing applications from nearly one-third of all medical students applying across the country. A new program in orthopedic surgery attracted four superb young people. This program joined the urology and cardiothoracic educational programs established in the last several years. Residents and fellows in all fields distinguished themselves with a large number of presentations and awards at national surgical meetings including specialty specific sessions as well as the annual American College of Surgeons Clinical Congress.

Research activities continued at a high level. The Department currently enjoys research funding of nearly $ 10 million and a standing among the top 25 surgery departments in NIH funding. This ranking doesn't include the $4.5 million in other federal funds from the Department of Defense for our "OR of the Future" human factors project. Michael Freeman has been appointed Vice-Chair for Research and is working very closely with Hyung Kim and Ken Catchpole and the research administrative office led by Jesse Null. A record number of external grants have been submitted in the first six months of this year.

The next six months will see many other welcome changes to include the opening of the Advanced Health Sciences Pavilion. This spectacular building will house one large procedural floor (with a second under development) as well as extensive laboratories and outpatient clinics.

Also opening this spring will be the new home for surgical research activities at 825 San Vicente. This unique collaborative space, designed by a nationally recognized architecture firm, will offer top of the line conference and creative space along with a state-of-the-art research simulation space.

With all of these unambiguously positive changes will come a number of bracing challenges to both our academic and clinical enterprises. Our practitioners and hospital will be impacted by continued downward pressure on reimbursement. This is not limited to government payors and includes virtually every private insurer. The still-unresolved fiscal perturbations in Washington leave long-term graduate medical education financing and the NIH budgets both unsettled.

Cedars-Sinai and the Department are currently actively engaged in many process improvements focused on reducing our per unit costs while safeguarding both efficiency and safety. As emphasized by our CEO Tom Priselac, we need to be as passionate about "value" as we are about providing the best outcomes for the patients in our care. The strong current financial position of our institution, coupled with the resolve of all of us to maintain our leadership role, are powerful indicators that Cedars-Sinai can adapt to any challenge. I am optimistic that the talents of our staff and physicians will insure that our Department will continue to be a prominent driver of these efforts.

Bruce L. Gewertz, MD
Surgeon-in-Chief
H and S Nichols Endowed Chair
Vice-President, Interventional Services
Vice-Dean, Academic Affairs
Cedars-Sinai Health System

Cedars-Sinai surgical team expands mission in China

Amberlin and Jace are two of the orphans the Cedars-Sinai team operated on in 2011.

Philip Frykman, MD, (second from right) and others view X-rays.

A laparoscopy draws a crowd.

In November 2011, when a pediatric surgery team from Cedars-Sinai traveled to Maria's Big House of Hope, an orphanage in Louyang, China, the focus of the mission was on the children. The future looked bleak for the infants and toddlers, born with anorectal malformations in a culture that believes such birth defects bring a family bad luck. They had all been abandoned by their parents within days of their birth.

Last year, following up on the success of that mission, in which 11 children had operations and several were adopted, the Cedars-Sinai team returned to Louyang. Led once again by pediatric surgeon Philip Frykman, MD, PhD, the group's mission expanded. They worked with the orphans again, but this time, they also educated the local surgeons about how anorectal malformations can be corrected.

On the 2011 mission, surgeries were conducted in the medical facility at the orphanage. Shiwei Zhai, MD, a local surgeon, scrubbed in on every case.

"This time, we did all of our surgeries at the local hospital, and we had a lot of interaction with the surgeons at that hospital," Frykman said. Surgeries included hernia repairs, anorectal reconstructions, colostomy repairs and several emergencies.

"Dr. Zhai was there again, and he has improved a lot and knows more what to do," Frykman said. "But when you have a city of 6.5 million, you have to have more than just one guy."

From left: Cecilia Lam, MSW, Jennifer Ross, RN, volunteer Sienna Dugan and Ramona Abney, RN

Surgical tech Claire Esguerra

Surgeons from throughout the region came to watch and work with the Cedars-Sinai team. For many, the concept that anorectal malformations can be repaired safely in infancy was a revelation.

"We did some laparoscopic surgeries for some of the more complicated disorders, and the local surgeons were fascinated," Frykman said.

The mission to China is organized by Mending Kids International, a Burbank-based nonprofit that sponsors medical missions throughout the world. The team for the China trip included pediatric anesthesiologist Keith Kimble, MD, several ICU nurses and a number of staff members. In addition to Frykman and Kimble, team members associated with Cedars-Sinai were senior surgical resident Seth Felder, MD; surgical tech Claire Esguerra; nurses Janet Kimble, Jennifer Ross and Ramona Abney; and Cecilia Lam, MSW.

The team performed 13 surgeries in five days, and taught new procedures to the local medical professionals.

Because the conditions the children suffer from are so grave, they can't be considered for adoption until they are completely healed.

"Four children we worked on (in 2011) were adopted, two of them to American families," Frykman said. "After this last mission, there are more on the launch pad. It's very gratifying."

The Cedars-Sinai team on the mission in China

Here comes the flu

C-S sees spike in flu cases; new visitor precautions put into place

Cedars-Sinai is experiencing an increase in flu cases, and California public health officials warn that the flu epidemic that has already hit hard in other areas of the nation is headed our way.

"The number of positive influenza cases confirmed at Cedars-Sinai has increased substantially in the past two weeks," says Rekha Murthy, MD, director of Hospital Epidemiology at Cedars-Sinai. "We are admitting five to six patients per day with influenza diagnosis and three to four positive for other respiratory viruses."

To help prevent the spread of infection and protect our patients, all Cedars-Sinai employees and members of the medical staff are strongly urged to get vaccinated if they have not already done so. This year's vaccine is particularly effective – an estimated 90 percent of all the flu strains circulating in the nation are included in the current vaccine, according to the CDC.

Cedars-Sinai medical staff, including attending physicians, can receive a free vaccination at Employee Health Services, located on the second floor of the Spielberg Building, from 7 a.m. to 4 p.m., Monday through Friday. No appointment is necessary. Flu shot clinics are also being scheduled on campus; watch for further announcements about dates and locations.

Physicians are advised to take note that a number of precautions have been put into place this week to minimize the spread of influenza-like illness at the medical center. These include:

  • Screening visitors with symptoms of influenza-like illness as they arrive (fever and any of the following: cough, shortness of breath, difficulty breathing, muscle aches, sore throat) and keeping them from visiting patients.
  • Pre-emptively place patients with influenza-like illness on Droplet Precautions (employees, medical staff and volunteers must sanitize hands and wear a surgical mask when entering these rooms).
  • In ambulatory care areas such as the ED, provide a disposable surgical mask for patients with influenza-like illness and separate from others where possible.
  • Reminding employees, patients and visitors to observe proper hand hygiene and respiratory/cough etiquette (cough and sneeze into your elbow or a tissue).
  • Urging staff with influenza-like illness to stay home until symptoms subside (usually five to seven days from onset) or absence of fever for 24 hours.

C-S team repeats as surgical Jeopardy champ

Congratulations to Seth Felder, MD, and Doug Liou, MD, for winning surgical Jeopardy at the recent Southern California conference of the American College of Surgeons. They are bringing the trophy back to Cedars-Sinai; this is the first time in the history of the resident Jeopardy competition that a repeat winner has been crowned.

Dozens make presentations at Research Day, ACS meeting

Numerous Cedars-Sinai Department of Surgery residents and faculty members made presentations at the medical center's Research Day IV and at the annual meeting of the regional chapter of the American College of Surgeons.

Presentations at Cedars-Sinai Research Day

The Department of Surgery would like to acknowledge all of those who participated in the Cedars-Sinai Research Day IV on Jan. 11. The following posters were presented:

  • Yelena Bykhovskaya, PhD, Ana Laura Caiado Canedo, Kenneth W. Wright, MD, Yaron S. Rabinowitz, MD. "MIR184 c.57C>T mutation is responsible for congenital cataracts and corneal abnormalities in a five-generation family from Galicia, Spain." Presented by Yelena Bykhovskaya, PhD
  • Valentina R. Minciacchi, Matteo Morello, Mirja Rotinen, Mandana Zandian, Julie Yang, Murali Gururajan, Leland W. K. Chung, Michael R. Freeman, Francesca Demichelis, and Dolores Di Vizio."miRNA profiling of prostate cancer cell-derived oncosomes." Presented by Valentina R. Minciacchi
  • Matteo Morello, Valentina R. Minciacchi, Mirja Rotinen, Mandana Zandian, Chia-Yi Chu, Leland W.K. Chung, Marsha A. Moses, Michael R. Freeman, and Dolores Di Vizio. "A new filtration-based method for high-throughput analysis of tumor-derived large oncosomes." Presented by Matteo Morello, PhD
  • Mirja Rotinen, PhD, Matteo Morello, PhD, Mandana Zandian, MD, Michael R. Freeman, PhD, and Dolores Di Vizio, MD, PhD. "ssDNA and dsDNA can be isolated from tumor-derived large oncosomes." Presented by Mirja Rotinen, PhD
  • Mirja Rotinen, PhD, Samantha Morley, PhD, Matteo Morello, PhD, Julie Yang, Jayoung Kim, PhD, Joaquín Villar, PhD, Dolores Di Vizio, MD, PhD, Ignacio Encío, PhD, and Michael R. Freeman, PhD. "Transcriptional regulation of the mediator of the amoeboid phenotype DIAPH3 in prostate cancer cell lines: potential cross-talk between androgen receptor and NF-kB pathways." Presented by Mirja Rotinen, PhD
  • Sungyong You, PhD, Seok Joong Yun, Hyung L. Kim, MD, Edwin Posadas, MD, Beatrice Knudsen, MD, PhD, Massimo Loda, Michael R. Freeman, PhD, Wun-Jae Kim, and Jayoung Kim, PhD. "An EGFR Subcellular Trafficking Network in Chemoresistant Bladder Cancer." Presented by Sungyong You, PhD
  • Sungyong You, PhD, Jennifer Anger, MD, Tack Lee, Susan Keay, Michael R. Freeman, PhD, and Jayoung Kim, PhD. "A Signaling Networking Evoked by the Interstitial Cystitis-Associated Frizzled 8-Related Antiproliferative Factor." Presented by Sungyong You, PhD
  • Sungyong You, PhD, Samantha Morley, PhD, Dolores Di Vizio, MD, PhD, Jayoung Kim, PhD and Michael R. Freeman, PhD. "Microvesicles Shed from DIAPH3-Silenced, Amoeboid Prostate Cancer Cells Enhance Growth of Other Tumor Cells and Suppress Proliferation of Immune Cells." Presented by Sungyong You, PhD
  • Sungyong You, PhD, Julie Yang, Mirja Rotinen, PhD, Samantha Morley, PhD, Michael R. Freeman, PhD, and Jayoung Kim, PhD. "NFAT5 as a Transcriptional Mediator of Mesenchymal-Amoeboid Transition Induced by DIAPH3 Loss in Prostate Cancer." Presented by Sungyong You, PhD
  • Yanping Wang, Hao Zhang and Hyung L Kim. "CD4 depletion enhances the antitumor effect of mTor inhibition." Presented by Yanping Wang
  • Gordon Wu, MD, Ning-Ning Chai, PhD, Irene Kim, MD, Stanley Jordan, MD, and Andrew Klein, MD. "IL6R Blockage by Therapeutic Antibody Suppresses Donor Specific Antibody Responses in a Mouse Model of Allosensitization." Presented by Gordon Wu, MD
  • Thuy B. Tran, Vijay G. Menon, Douglas Liou, Nicholas N. Nissen. "Surgical Management of Advanced Adrenocortical Carcinoma: AJCC Prognostic Factors." Presented by Douglas Liou, MD
  • Vijay G. Menon, MD, Vichin C. Puri, Oscar Garcia, Alagappan A. Annamalai, MD, Nicholas N. Nissen, MD. "Outcomes of Vascular Resection in Pancreaticoduodenectomy." Presented by Vijay Menon, MD
  • Zorica Buser, PhD, Li Zhao, PhD, Yalda Safai, Linda Kanim, Rick Delamarter, MD, Alexander Rasouli, MD. "Inflammatory response after spinal cord injury in rats is modified by Enbrel." Presented by Zorica Buser, PhD
  • Melodie Metzger, PhD, LEA Kanim, Li Zhao, PhD, Samuel T Robinson, Zorica Buser, PhD, Rick Delamarter, MD. "The Relationship Between Serum Vitamin D levels, Successful Fusion, and Fusion Strength: A Quantitative Analysis." Presented by Melodie Metzger, PhD
  • Samuel T Robinson, Rick B Delamarter, MD, Mark T Svet, Melodie F Metzger, PhD. "Does Sacral Geometry Affect Biomechanical Bahavior and Facet Forces after Total Disc Replacement at the Lumbosacral Junction?" Presented by Samuel Robinson
  • Samuel T Robinson, Mark T Svet, Melodie F Metzger, PhD. "Four-Point Bending in Flexion as a Method for Quantitatively Assessing Spinal Fusions." Presented by Samuel Robinson
  • Mark T Svet, Samuel T Robinson, Rick B Delamarter, MD, FL Acosta, DG Drazin, MD, Melodie F Metzger, PhD. "Biomechanical Analysis of the Effect of Different Instrumentation Techniques on Adjacent Level Stability After Long Segment Instrumentation of the Thoracic Spine." Presented by Mark Svet
  • Shiran Ben-David, Dmitriy Sheyn, PhD, Dan Gazit, PhD, DMD, Zulma Gazit, PhD. "Adipose derived stem cells reprogrammed to iPS cells can be efficiently differentiated back to MSCs using a short exposure to TGFb." Presented by Shiran Ben-David
  • Zorica Buser, PhD, Christopher Buser, PhD, Rick Delamarter, MD. "Differentiation of adipose stem cell constructs for intervertebral disc regeneration." Presented by Zorica Buser, PhD
  • Dmitriy Sheyn, PhD, Wafa Tawackoli, PhD, Deuk Soo Jun, MD, Young Do Koh, PhD, Hyun Bae, MD, Xiaoyu Da, Susan Su, PhD, Zulma Gazit, PhD, Gadi Pelled, PhD, DMD, and Dan Gazit, PhD, DMD. "Systemic treatment for multiple lumbar bone defects using combined human MSCs and PTH therapy." Presented by Dmitriy Sheyn, PhD
  • Susan Su, PhD, Dmitriy Sheyn, PhD, Gadi Pelled, PhD, DMD, Dan Gazit, PhD, DMD, and Zulma Gazit, PhD. "Isolation and characterization of mesenchymal stem cells (MSC) from the temporomandibular joint (TMJ) disc." Presented by Susan Su, PhD
  • Dodanim Talavera, MD, PhD, Soshana P. Svendsen, PhD, Clive N. Svendsen, PhD, Vaithi Arumugaswami, PhD, and Donald Dafoe, MD. "In vitro expansion and characterization of insulin-producing cells derived from human pluripotent stem cells co-cultured with endothelial cells." Presented by Dodanim Talavera, MD, PhD
  • Wafa Tawackoli, PhD, Dmitriy Sheyn, PhD, Xiaoyu Da, Gadi Pelled, PhD, DMD, Dan Gazit, PhD, DMD, and Zulma Gazit, PhD. "PTH treatment enhances mesenchymal stem cell differentiation, improving healing process of calvarial bone allografts." Presented by Wafa Tawackoli, PhD

Presentations at the American College of Surgeons chapter meeting

Several Cedars-Sinai faculty members and residents were scheduled to give presentations at the Annual Scientific Meeting of the Southern California Chapter of the American College of Surgeons, Jan. 18-20 in Santa Barbara.

In the General Surgery sessions:

  • "Surgical Instrument Waste after Elective Major Colorectal Surgery: A Prospective Interventional Pilot Study," Zhaoyi Tang
  • "Will Internet-based Education and Reminders Reach Uninsured Hispanic Women?" Catherine Dang, MD
  • "When It's Not a Spigelian Hernia: Abdominal Cutaneous Nerve Entrapment Syndrome," Shirin Towfigh, MD

In the Breast and Oncologic Surgery session:

  • "Surgical Management of Advanced Adrenocortical Carcinoma: AJCC Prognostic Factors," Thuy B. Tran, MD
  • "Paget's Disease with Parenchymal DCIS: A Worse Prognosis than Paget's Disease Alone," Brandice Durkan, MD

In the HPB Surgery session:

  • "Outcomes of Vascular Resection in Pancreaticoduodenectomy," Vijay G. Menon, MD

In the Colorectal Surgery session:

  • "Routine Elective Colectomy Following CT-Guided Percutaneous Drainage of Diverticular Abcess," Seth Felder, MD

In the Breast Surgery session:

  • "Nipple-Sparing Mastectomy: Mainstream but Not Yet Standard of Care," Armando Giuliano, MD, FACS

In the General Surgery/Hernia session:

  • "The Pediatric Patient," Philip Frykman, MD

In the Trauma Surgery session:

  • "Bicycle Trauma: A Ten-Year Experience," Alexandra Gangi, MD

In the Cardiothoracic and Vascular Surgery session:

  • "Video Assisted Thoracoscopic Surgery (VATS): A Viable Approach for the Treatment of Traumatic Hemothorax," Daniel Shouhed, MD
  • "Midodrine use in the Management of Postoperative High Flow Chylothorax," Douglas Liou, MD

In poster sessions:

  • "Laparoscopic Retrograde Cholecystectomy: Valuable Approach in Patients with Underlying Liver or Pancreatic Disease," Vichin C. Puri, MD
  • "Prospective Evaluation of Current Practices of Venous Thromboembolism Prophylaxis Using Heparin After Elective Intestinal Surgery at an Urban Teaching Hospital," Joseph Wend

What’s new in surgery:

  • Neuroendocrine – Nicholas Nissen, MD

Presiding officers from Cedars-Sinai:

  • Daniel R. Margulies, MD (Acute Care Surgery)
  • Edward Phillips, MD (General Surgery)
  • Farin Amersi, MD (Breast and Oncologic Surgery)

Chair from Cedars-Sinai:

  • Shirin Towfigh, MD (General Surgery/Hernia)

Articles accepted for publication

The following articles involving members of the Department of Surgery have been accepted for publication:

Kim, J. (corresponding author); Keay, S.K.; You, S.; Loda, M.; Freeman, M.R.: "A synthetic form of frizzled 8-associated antiproliferative factor enhances p53 stability through USP2a and MDM2," PLoS ONE, 7(12):e50392. PMID: 23236372 (2012).

You, Y.; Yang, W.; Anger, J.T.; Freeman, M.R.; Kim, J. (corresponding author): "Omics Approaches to understanding interstitial cystitis/painful bladder syndrome/bladder pain syndrome" (in press) International Neurourology Journal, Epub Dec. 31, 2012.

Ruzza, A.; Vespignani, R.; Khoynezhad, A.; Berci, G.; De Robertis, M.; Trento, A.; and Czer, L.S.C.: "Concomitant Dual Intravascular and Subcutaneous Microsurgical Implantation of Xenograft Tissue in a Rodent Model for Evaluation of Structural Degeneration," Transplantation Proceedings.

Prominent bone cancer surgeons join Orthopaedic Center

New cancer surgeons add expertise to treat metastatic bone disease and other complex conditions

Two of Southern California's best-known orthopedic oncologists have joined Cedars-Sinai, enhancing a surgical team that treats some of the most complex and difficult types of cancer.

Lawrence R. Menendez, MD

Daniel C. Allison, MD, FACS, MBA

Earl Warren Brien, MD

Lawrence R. Menendez, MD, and Daniel C. Allison, MD, FACS, MBA, have partnered with Earl Warren Brien, MD, director of musculoskeletal tumor service at the Cedars-Sinai Orthopaedic Center, to form one of the preeminent orthopedic oncology practices in the western U.S.

The surgeons specialize in metastatic bone disease, sarcoma cancers of the bone and soft tissue, invasive skin cancers and melanomas, and complex tumor-like conditions that other hospitals are unable to handle.

"With the joining of these new physicians to the already outstanding program established by Earl Brien, Cedars-Sinai can continue to make meaningful contributions to the treatment of these disorders," said Bruce Gewertz, MD, chair of the Department of Surgery and the H & S Nichols Chair in Surgery.

Menendez and Allison came from USC, where they held leadership positions in orthopedic oncology.

At USC, Menendez served as chief of the Metastatic Bone Clinic, the Multidisciplinary Sarcoma Center and the Center for Orthopaedic Oncology.

His research focuses largely on musculoskeletal tumors. In addition to authoring a book on musculoskeletal tumors for the American Academy of Orthopaedic Surgeons, he co-authored two book chapters, 34 peer-reviewed journal articles and numerous abstracts and presentations.

Menendez is a member of the Los Angeles Surgical Society, the Western Orthopaedic Association, the American Medical Association, the American Academy of Orthopaedic Surgeons, the Musculoskeletal Tumor Society, the American College of Surgeons and the Society of Surgical Oncology.

"We've come to Cedars-Sinai to build something special and important in the field of orthopedic oncology," Menendez said. "This is the place to be if you're an orthopedic oncologist."

Before joining Cedars-Sinai, Allison was assistant chief of the USC Center for Orthopaedic Oncology at the USC Norris Cancer Hospital. He has expertise in musculoskeletal oncology, joint reconstruction and anterior hip replacement. Allison has published extensively in peer reviewed journals and co-authored two book chapters relating to orthopedic surgery, and he has presented numerous papers and abstracts about orthopedic conditions.

"This is a valuable opportunity to become the preeminent center for orthopedic oncology in the western U.S.," said Allison, who is a fellow of the American College of Surgeons and the American Academy of Orthopedic Surgeons, as well as a member of the Musculoskeletal Tumor Society and the California Orthopedic Association.

Menendez and Allison combine forces with Brien, the co-director of Orthopedic Oncology who has published numerous articles, written book chapters and lectured internationally on these subjects. Brien is a diplomate of the National Board of Medical Examiners and the American Board of Orthopaedic Surgery. He also is a member of numerous professional societies, including the American Orthopaedic Association and the Association of Bone and Joint Surgeons.

"This team will offer a level of expertise and specialized care that patients will find few other places," Brien said. "We treat some of the most challenging cases."

More doctors, hospitals partner to coordinate care for people with Medicare

Cedars-Sinai has been selected as one of 106 new Accountable Care Organizations (ACOs) in Medicare, ensuring as many as 4 million Medicare beneficiaries across the United States now have access to high-quality, coordinated care, Health and Human Services (HHS) Secretary Kathleen Sebelius announced Jan. 10.

Doctors and healthcare providers can establish Accountable Care Organizations in order to work together to provide higher-quality care to their patients. Since passage of the Affordable Care Act, more than 250 Accountable Care Organizations have been established. Beneficiaries using ACOs always have the freedom to choose doctors inside or outside of the ACO. Accountable Care Organizations share with Medicare any savings generated from lowering the growth in healthcare costs, while meeting standards for quality of care.

“Accountable Care Organizations save money for Medicare and deliver higher-quality care to people with Medicare,” said Secretary Sebelius. “Thanks to the Affordable Care Act, more doctors and hospitals are working together to give people with Medicare the high-quality care they expect and deserve.”

ACOs must meet quality standards to ensure that savings are achieved through improving care coordination and providing care that is appropriate, safe, and timely. The Centers for Medicare & Medicaid Services (CMS) has established 33 quality measures on care coordination and patient safety, appropriate use of preventive health services, improved care for at-risk populations, and patient and caregiver experience of care. Federal savings from this initiative are up to $940 million over four years.

The new ACOs include a diverse cross-section of physician practices across the country. Roughly half of all ACOs are physician-led organizations that serve fewer than 10,000 beneficiaries. Approximately 20 percent of ACOs include community health centers, rural health centers and critical access hospitals that serve low-income and rural communities.

The group announced Jan . 10 also includes 15 Advance Payment Model ACOs, physician-based or rural providers who would benefit from greater access to capital to invest in staff, electronic health record systems, or other infrastructure required to improve care coordination. Medicare will recoup advance payments over time through future shared savings. In addition to these ACOs, last year CMS launched the Pioneer ACO program for large provider groups able to take greater financial responsibility for the costs and care of their patients over time. In total, Medicare’s ACO partners will serve more than 4 million beneficiaries nationwide.

Also Jan. 10, HHS issued a new report showing Affordable Care Act provisions are already having a substantial effect on reducing the growth rate of Medicare spending. Growth in Medicare spending per beneficiary hit historic lows during the 2010 to 2012 period, according to the report. Projections by both the Office of the Actuary at CMS and by the Congressional Budget Office estimate that Medicare spending per beneficiary will grow at approximately the rate of growth of the economy for the next decade, breaking a decades-old pattern of spending growth outstripping economic growth.

Additional information about the Advance Payment Model is available at http://www.innovations.cms.gov/initiatives/ACO/Advance-Payment/index.html.

The next application period for organizations that wish to participate in the Shared Savings Program beginning in January 2014 is summer 2013. More information about the Shared Savings Program is available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html?redirect=/sharedsavingsprogram/

For a list of the 106 new ACOs announced Jan. 10, visit: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/News.html

Reversing the trend in APLs

"Accidental Puncture and Laceration" is a patient safety indicator developed by the Agency for Healthcare Research and Quality that is reported on the Centers for Medicare & Medicaid Services website to report adverse events for individual hospitals. The indicator rate is calculated from the hospital's coding of diagnoses and conditions that is based on physician documentation.

Historically, Cedars-Sinai's Accidental Puncture and Laceration (APL) rates have been very high compared to other hospitals; upon review, it appears our rates are inflated because our Health Information Management coders are using cues from the operative note, like "injury" or "repair," to assign diagnoses for accidental punctures or lacerations when, in some cases, the involvement of other organs was actually reasonably necessary to accomplish the surgery.

For example, a loop of ileum, completely adherent to the uterus from endometriosis, would be entered while attempting to free it. The gynecologists would dictate that the bowel was inadvertently entered, and it would be reported as an APL. With education of our Ob/Gyn colleagues to document that this was unavoidable and intentional as part of the procedure, the rate has dropped dramatically and more clearly reflects true APLs. As surgeons, we can be more accurate in our dictations. If there are extensive severe adhesions, document that. Think about these two statements, both of the same operation:

"The colonic disease process involved the ureter, which required segmental resection and primary anastomosis over a double J stent."

"In mobilizing the diseased colon, the ureter was also divided, which we fixed."

The second would be coded as an APL, the first would not.

When dictating operative reports, think about how to make it clear to the reader (and coder) what occurred.

Click the link below for a graphic illustrating Cedars-Sinai's rates.

APL Trend Graphic (PDF)

Patient whiteboards see red ... and yellow and green

Cedars-Sinai is rolling out newly redesigned patient room whiteboards with color-coded sections designed to enhance patient care and help improve patient satisfaction.

White Board (PDF)

The boards currently are being installed in patient rooms across the medical center.

The new boards – now referred to as patient care boards – feature special sections on pain management and post-discharge care. Because patients experience and deal with pain differently from each other, the boards are designed with an individual approach in mind. A pain level chart in red, yellow and green allows the nursing team to record and monitor the patient's pain levels throughout the day, with the red section indicating high levels of pain and green indicating mild pain. Another section lists the medications prescribed to alleviate discomfort.

Patient preferences for alternative therapies for pain management, such as music, massage or a favorite pillow, can be listed as a quick reference for caregivers, family members and visitors.

"Our goal is to not only help make our patients feel more comfortable but to also engage them in their own pain management so that they feel more empowered," said Chris Ng, MD, a urologic surgeon and co-chair of the multidisciplinary Pain Management Task Force at Cedars-Sinai. "We also want patients to have appropriate expectations about how much pain they should be experiencing and to understand that while we want to safely minimize their pain, we don't want to over-medicate them."

The new patient care boards also feature a section called "My Road to Wellness," which was successfully piloted on 6NW as a test of change earlier this year.

"On 6NW, we saw a 45 percent reduction in readmissions and a 15 percent increase in patient satisfaction related to satisfaction with discharge instructions following the launch of the 'My Road to Wellness' boards on that unit," said Fozia Ferozali, MSN, EdD, nurse manager for 6NE, 6NW and 6ICU.

"My Road to Wellness" is a guide that helps the nursing staff ensure that patients and any family members understand the six major components of their care plan that will help them continue their recovery after discharge. These components include learning what medicines to take, what to eat, how much activity to do and when to see the doctor.

In patient rooms, the six components are indicated with red tags on the care board. As nurses educate patients on each one, the tags are reversed to a green tag to indicate completion.

"The wellness section encourages patients and family members to ask the healthcare team any questions they might have related to their wellness," Ferozali said. "These patient care boards are no longer just for staff member use. It is a powerful tool for patients to help them become more engaged in their plan of care and learn how to make their wellness path more successful."

Click the image below to see a video about the care boards.

Visualizing how colorectal surgical site infections have fallen

New protocols at Cedars-Sinai have significantly reduced the number of surgical site infections among patients who undergo colorectal procedures.

An article in the December 2012 issue of Sutures described the changes and their effects; within six months, the infection rate fell from a baseline of 15 percent to less than 5 percent. Click the link below to see a graphic showing the rate of surgical site infections among colorectal surgery patients.

Colorectal SSI rate (PDF)

FDA lowers recommended dose of zolpidem products

Pharmacy focus

The U.S. Food and Drug Administration is notifying the public of new information about zolpidem, a widely prescribed insomnia drug. FDA recommends that the bedtime dose be lowered because new data show that blood levels in some patients may be high enough the morning after use to impair activities that require alertness, including driving.

Zolpidem products approved for bedtime use are marketed as generics and under the brand names Ambien, Ambien CR, Edluar and Zolpimist.

Data show the risk for next-morning impairment is highest for patients taking the extended-release forms of these drugs (Ambien CR and generics). Women appear to be more susceptible to this risk because they eliminate zolpidem from their bodies more slowly than men.

The FDA urges health care professionals to caution all patients who use these products about the risks of next-morning impairment for activities that require complete mental alertness. The agency also says:

  • The recommended dose of zolpidem for women should be lowered from 10 mg to 5 mg for immediate-release products (Ambien, Edluar and Zolpimist) and from 12.5 mg to 6.25 mg for extended-release products (Ambien CR).
  • For zolpidem and other insomnia drugs, prescribe the lowest dose that treats the patient's symptoms.
  • Inform patients that impairment from sleep drugs can be present even though the patient feels fully awake.

The recommended doses of Intermezzo, a lower-dose zolpidem product approved for middle-of-the-night awakenings, are not changing.

Click here to read the MedWatch alert, including links to a drug safety communication.