sutures newsletter

PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY July 2016 | Archived Issues

Pharmacy and Therapeutics Committee Approvals

Pharmacy Focus

Highlights of the June meeting of the Pharmacy and Therapeutics Committee are summarized in the PDF link below.

P and T Approvals - June 2016 (PDF)  


Mark Your Calendar


Grand Rounds

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


Education Schedule

Click the PDF link below to see the Department of Surgery's education schedule.

Education Schedule - July 2016 (PDF)


Surgery Scheduling

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

» Read more

Inpatient E-Prescribing of Discharge Meds Starts July 30

Starting July 30, inpatient providers will be able to send most discharge medication orders electronically within CS-Link in a process referred to as e-prescribing. Rather than printing, faxing or writing out a prescription, the order will transmit electronically from CS-Link directly to the patient’s preferred pharmacy.

» Read more

Cancer Survivors Gather to Reconnect, Reflect and Celebrate

Demetra Stalling was one of more than 400 cancer survivors, family guests and physicians who came to reconnect, reflect and celebrate at Cedars-Sinai's annual Cancer Survivors Day luncheon in June. Stalling had more to celebrate than most — she beat cancer twice.

» Read more

Advances in the Treatment of Early Invasive Breast Cancer

As breast cancer patients are achieving longer survival rates, the importance of quality of life has increased and surgeons are faced with trying to balance performing adequate oncologic surgery while maximizing quality of life and minimizing morbidity.

» Read more

Seeing Tumors Through a Machine's Eye

Tumors

Aberrant morphologic features that are caused by genetic and epigenetic changes in cancer cells seen by pathologists can be quantitated by digital image analysis. Analysis of tumors through this technique provides multiple benefits and complements human vision.

» Read more

Nominations Sought for Pioneer in Medicine Award

Members of the medical staff are encouraged to nominate a candidate for the 2016 Pioneer in Medicine award. This award is given to a member of the medical staff who has made clinical and research contributions recognized at Cedars-Sinai and in the national or international medical communities.

» Read more

Campaign Event Highlights Research Breakthroughs

Employees and volunteers across Cedars-Sinai got a glimpse last week of groundbreaking research innovations and discoveries fostered by the Campaign for Cedars-Sinai during a daylong event where senior leaders kicked off the public phase of the fundraising effort. The campaign has an overall goal of raising $600 million by 2018, making it the most ambitious fundraising effort to date.

» Read more

Techstars Couple Targets Hospital Technology

Yosko

Andriana Nikolova, MD, noticed as a student at Harvard Medical School that while there had been advances in medical techniques, the same could not be said for medical technology. Nikolova, now a Cardiology Fellow at Cedars-Sinai, and her husband co-founded a company to improve technology efficiencies at hospitals.

» Read more

Online Courses Now Available For Fluoroscopy Safety

The California law governing the renewal of state Fluoroscopy Operator and Supervisor permits now requires that four out of the 10 hours of continuing education that physicians complete be specific to radiation safety during fluoroscopy.

» Read more

CS-Link Tip: Save Time with Calculator Tab

cs-link logo

When you type "visit diagnosis" in CS-Link, the option for "list" or "calculator" with database matches pops up. You have the option to choose "calculator" or "list." While the "list" may seem short, often it is burdensomely long. Click "calculator" tab and save time.

» Read more

Inpatient E-Prescribing of Discharge Meds Starts July 30

Starting July 30, inpatient providers will be able to send most discharge medication orders electronically within CS-Link in a process referred to as e-prescribing.

Rather than printing, faxing or writing out a prescription, the order will transmit electronically from CS-Link directly to the patient's preferred pharmacy. This capability has been available for some time in the outpatient setting, where it has proven to be efficient and convenient for patients and providers.

Eligible providers, including attendings and residents who have their own medical license, will be able to use the new e-prescribing functionality. Providers with their own Drug Enforcement Administration license (including residents) will also be eligible for e-prescribing of controlled substances.

Physicians who would like to e-prescribe controlled substances must opt in and sign up to obtain a security token, which can be configured on a smartphone. To opt in, please visit the project team during scheduled office hours, which are between Monday, July 18, and Thursday, July 28, from 7-9 a.m. and 4-6 p.m. in the Medical Staff Lounge.

Providers unable to attend the scheduled office hours can contact the help desk after July 18 at 310-423-6428 to initiate the request for a security token.

Contact EIS Physician Leader Shaun Miller, MD, at shaun.miller@cshs.org with any additional questions.

Cancer Survivors Gather to Reconnect, Reflect and Celebrate

CSCancerSurvivorDay

Frank and Shirley La Commare celebrate their victories over cancer. She was diagnosed with stomach cancer more than two decades ago, and he had liver cancer four years ago.

Years ago, Demetra Stalling would not have worn a cranberry blouse accented with colorful spring flowers.

But the 45-year-old health information technician at Cedars-Sinai purposefully chose the eye-catching outfit for the Cancer Survivors Day luncheon on Friday, June 17.

"I used to only wear neutral colors like beige and black," said Stalling, who works in the Health Information Department. "After fighting for my life, the world became more colorful, so I reflect that in what I wear."

CSCancerSurvivorDay

Demetra Stalling smiles at the Cancer Survivors Day luncheon.

Stalling was one of more than 400 survivors, family guests and physicians who gathered at the Sofitel Los Angeles at Beverly Hills to reconnect, reflect and celebrate at the annual Cedars-Sinai event, now in its second decade. The invitation-only lunch is open to cancer survivors from throughout the Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute, including affiliates.

"Managing cancer often can be isolating, and many patients feel lonely and disconnected from their previous identities," said Arash Asher, MD, director of the Cancer Rehabilitation and Survivorship program at the Samuel Oschin Comprehensive Cancer Institute. "Being with people who know exactly what you're going through — the joys, the sorrows — there's something healing and validating about that."

Stalling had more to celebrate than most, even in a room with more than 200 cancer survivors. She has battled the deadly disease twice — once as a teenager and later as a single mother.

When Stalling turned 17, she was rushed to the emergency room with severe shortness of breath. An X-ray revealed a cantaloupe-sized tumor on her lungs; a diagnosis of Hodgkin lymphoma followed. She soon underwent a combination of chemotherapy and radiation therapy.

"I really didn't understand the severity of what was happening," Stalling recalled. "My main concern was that I would be bald for the prom."

In 2011, cancer returned. She was now a single mother of a teenage son and had been working at Cedars-Sinai for three years. A mammogram and biopsy led to a diagnosis of stage III C inflammatory breast cancer caused by the radiation therapy she received as a senior in high school.

"I just felt numb," said Stalling. "All I could think was, 'Not again.'"

Her treatment meant spending three hours every third Friday at the cancer institute being infused with a powerful cocktail of chemotherapy drugs. A severe allergic reaction to her fourth cycle of chemo landed her in the intensive care unit.

After finally completing her chemotherapy, she underwent a double mastectomy; during the surgery, she went into respiratory arrest.

"I was truly being tested," Stalling said. So much so, that after a particularly difficult night, she left a note for her care team that simply read: "I can't do this anymore."

But Stalling persevered. On Valentine's Day 2012, she was declared cancer free. She credits her spirituality and care team at Cedars-Sinai with her hard-fought victory

"I love my care team," said Stalling. "They all are — and will always be — near and dear to my heart."

Advances in the Treatment of Early Invasive Breast Cancer

By Alice Chung, MD, and Armando Giuliano, MD

Of the over 700 newly diagnosed breast cancer cases seen at Cedars-Sinai each year, approximately 500 women have early stage invasive breast cancer. While the five-year overall survival rates for Stage 1 and 2 breast cancer exceed 90 percent, there still remain challenges in the surgical treatment of this disease. As patients are achieving longer survival rates, the importance of quality of life has increased and surgeons are faced with trying to balance performing adequate oncologic surgery while maximizing quality of life and minimizing morbidity. This article discusses several examples of how the Saul and Joyce Brandman Breast Center - A Project of Women's Guild and the Samuel Oschin Comprehensive Cancer Institute are at the forefront of evaluating less invasive procedures to achieve these endpoints.

Breast cancer patients over the age of 70 present unique challenges in treatment, as physicians aim to optimize therapy while accounting for life expectancy, comorbidities and effects of treatment on function. Omission of sentinel node biopsy in this patient population may spare unnecessary morbidity without affecting outcome for women in whom the decision to treat with adjuvant systemic therapy is based upon factors such as age, comorbidities and tumor biology. The group previously demonstrated that omission of sentinel node biopsy in women age 70 and older with early invasive cancer was associated with very low recurrence and breast cancer mortality rates. This preliminary data led to the opening of a prospective clinical trial at Cedars-Sinai investigating the safety and efficacy of omitting sentinel node biopsy in women age 70 and older with clinical T1-2N0 ER+ invasive breast cancer. This trial is a single arm Phase 2 trial that includes women age 70 or older with clinical T1-2N0, ER+ invasive breast cancer planning to undergo breast conserving surgery and hormonal therapy. Recurrence, survival and quality-of-life outcomes will be evaluated over time with the hypothesis that these women can safely avoid axillary surgery without compromising survival.

With advancements in preoperative breast imaging and increasing use of breast MRI, the incidence of diagnosing multiple ipsilateral tumors is rising. Traditionally mastectomy has been the standard of care for patients with multifocal or multicentric breast cancer, although there is a paucity of scientific evidence that supports performing mastectomies in these patients. Breast conserving surgery is associated with improved quality of life and has been shown to be cost effective. The multicenter ACOSOG Z11102 is a study open to accrual at Cedars-Sinai that will prospectively evaluate whether breast conservation is a safe surgical approach for patients with multiple ipsilateral breast cancer. It is a single-arm trial with a primary objective of assessing the local recurrence rate. Secondary objectives include evaluating the rate of conversion to mastectomy due to persistently positive margins, inability to satisfy radiation dose constraints due to volume of boost, or poor cosmesis. Patients are eligibile if they are women older than 40 years old who have two or three foci of biopsy proven breast cancer on preoperative imaging. Foci must include at least one focus of invasive breast carcinoma with another focus of either invasive breast carcinoma or ductal carcinoma in situ. The aim is to provide scientific evidence that breast conservation may be an appropriate surgical option for select women with multicentric breast cancer.

Radiation therapy is typically recommended with breast conserving surgery and standard treatment involves five days of treatment per week for up to six to seven weeks. Traditional radiation therapy for breast cancer may expose healthy organs such as the lung and heart to unnecessary radiation. Intraoperative radiotherapy is a new technology that allows delivery of a single concentrated dose of radiation therapy to the tumor bed intraoperatively (during the lumpectomy procedure) while preserving surrounding healthy tissue, including the lung and heart. This helps to reduce side effects as well as treatment time. Early randomized studies of Intraoperative radiotherapy have shown similar survival rates between patients who received standard external beam radiation and those who received Intraoperative radiotherapy. This technology will be available at Cedars-Sinai soon for the appropriately selected patient and may lead to greater patient satisfaction and reduced costs of treatment.

Treatment options for patients with early breast cancer continue to evolve. The advancements described demonstrate how Cedars-Sinai is leading the pathway to improving quality of life while maintaining excellent survival outcomes.

Seeing Tumors Through a Machine's Eye

By Arkadiusz Gertych, PhD

Tumor cells arise from genetic alterations in cells leading to their abnormal behavior and malignant transformation. Tumors are diagnosed by pathologists through the microscope based on morphologic criteria. Aberrant morphologic features that are caused by genetic and epigenetic changes in cancer cells seen by pathologists can be quantitated by digital image analysis.

Example of a modern image analysis workflow. A machine learning classifier is trained to recognize different components of a tissue. For instance, epithelial cell nuclei (blue), glandular lumen (red), immune cells (green) and other components (no color) can be automatically recognized in a whole histology slide with colon tissue.

  • Analysis of tumors through this technique provides multiple benefits and complements human vision:
  • Digital image analysis yields quantitative data that report on effects of the gene function on cancer cell morphology.
  • It can be used to measure interactions between cells in the tumor microenvironment. It can determine the composition of the tumor heterogeneity.
  • It is objective and can provide an opinion when pathologists disagree.

Yet technologies that enable seeing and distinguishing details of tumors that aren't readily available to an expert's eye need to be developed. Our lab has a longstanding interest in building and validating such technologies for research and pre-clinical utilization.

We recently developed an image analysis technique to analyze biopsy specimens from patients with high-grade prostate cancer who developed metastatic disease or were metastasis free. The pathologist cannot distinguish between the groups, and no pathologic features are available today to identify patients at risk of metastasis. However, our analyses of thousands of cancer cell nuclei revealed significant morphological differences in chromatin structure and cell topology that separate patients with lethal cancers from those with more indolent tumor types. We built a model based on nuclear features to predict the severity of the cancer that possesses accuracy greater than 80 percent.

We also devised a tool to quantitate branching of the vascular tree in clear cell renal cell carcinoma specimens. Some patients diagnosed with this disease receive anti-angiogenic therapy to prevent the spread and recurrence of the tumor, but selecting the most effective drug for a patient is difficult. Utilizing images of renal tumors from Cedars-Sinai and The Cancer Genome Atlas, we identified features of the vascular tree branching that lead to the identification of subjects with different survival characteristics. Future studies will apply this approach to the development of biomarkers for treatment of patients with anti-angiogenic drugs.

Despite significant advances, the field of quantitative image analysis to support pathologists in their daily routines is still in its early days of development. A large number of annotated images (usually whole histology slides — see figure) is required to train and validate single approach, and collecting such data is time-consuming. Even with these hurdles, the field slowly pushes the boundary of science. What's not easily observed by humans but can be seen and quantified through a machine's eye provides an opportunity to vastly increase biomarker discoveries. It also leads to answering exciting algorithmic and healthcare-related questions and to build a modern team science.

Nominations Sought for Pioneer in Medicine Award

Members of the medical staff are encouraged to nominate a candidate for the 2016 Pioneer in Medicine award. This award is given to a member of the medical staff who has made clinical and research contributions recognized at Cedars-Sinai and in the national or international medical communities.

The deadline for nominations is Monday, Aug. 22.

The criteria for candidates for the Pioneer in Medicine award are:

  • The candidate shall have made a major contribution to the medical center.
  • The candidate shall be or have been involved in research.
  • The candidate shall have been published in national or international peer-reviewed journals.
  • The candidate shall be a teacher and positive role model.
  • The candidate shall be an innovator or have changed the medical world around him or her.
  • The candidate shall have made clinical contributions recognized nationally.
  • The candidate shall have been a physician at the medical center during a major part of his or her career.

A committee of the medical staff will select the honoree, and the award will be presented at the annual meeting of the medical staff on Monday, Oct. 17.

To nominate a candidate for the Pioneer in Medicine award, please send a letter to Clement C. Yang, MD, vice chief of staff, with the nominee's qualifications, key contributions and major accomplishments. Include a copy of the nominee's curriculum vitae.

Send nominations and letters of support to clement.yang@cshs.org, or submit printed documents to:

Clement C. Yang, MD
Vice Chief of Staff
Cedars-Sinai Medical Center
8700 Beverly Blvd., Suite 2211
Los Angeles, CA 90048

Campaign Event Highlights Research Breakthroughs

Shlomo Melmed, MD, executive vice president of Academic Affairs and dean of the medical faculty, addresses staff and volunteers last week in Harvey Morse Auditorium at the kickoff for the public phase of the Campaign for Cedars-Sinai.

Employees and volunteers across Cedars-Sinai got a glimpse last week of groundbreaking research innovations and discoveries fostered by the Campaign for Cedars-Sinai during a daylong event where senior leaders kicked off the public phase of the fundraising effort.

The campaign has an overall goal of raising $600 million by 2018, making it the most ambitious fundraising effort to date. It already has collected more than $460 million.

Flora Haus, MSN, RN, an education program coordinator in Nursing Research and Development, listens to a speaker at the event.

"The Campaign for Cedars-Sinai is extraordinary," Thomas M. Priselac, president and CEO, said in a video message played at each of five presentations on July 8 in Harvey Morse Auditorium. "Not only is it the most ambitious fundraising campaign in the history of the institution, but it also focuses on strengthening the partnership between our community philanthropists and you, our staff, and the difference you make every day."

Cedars-Sinai's collective commitment to providing world-class care to patients is critical in raising philanthropic support. Grateful patients compose the majority of Cedars-Sinai's donors. These investments help fund innovative research and technology that lead to groundbreaking advances in patient care.

Speakers at the event outlined the ways that Cedars-Sinai is leading the way in research innovation with new targeted cancer treatments, regenerative medicine testing and understanding the mechanisms for neurodegenerative diseases such as amyotrophic lateral sclerosis or ALS.

"Philanthropy provides great value to this institution," said Linda Burnes Bolton, DrPH, RN, FAAN, health system chief nurse executive, vice president and chief nursing officer. "It has allowed us to expand our staffing from roughly 1,200 nurses to 3,000 nurses and to integrate nursing into all aspects of patient care."

The Campaign for Cedars-Sinai supports interdisciplinary collaboration and research in five areas: disease prevention and control, precision medicine and targeted therapies, aging and longevity, innovations in healthcare and technology, and education and training.

"Through fundraising efforts, researchers at Cedars-Sinai are able to discover breakthrough innovations that have the potential to positively impact the community," Shlomo Melmed, MD, executive vice president of Academic Affairs and dean of the medical faculty, said at the event.

Since its launch on July 1, 2010, the Campaign for Cedars-Sinai has raised most of its funds through major gifts of several thousand dollars or more. The public phase of the campaign, which runs through June 2018, will focus on attracting donors at all levels of support.

"Cedars-Sinai is a world-class healthcare organization in research and teaching, pushing us to the forefront of discoveries," said Arthur J. Ochoa, senior vice president and chief development officer. "Seventy-five percent of our donors are grateful patients, which means grateful patients are the ones helping the institution progress and achieve its goals."

More information about the Campaign for Cedars-Sinai and its fundraising initiatives is available on the Intranet.

Techstars Couple Targets Hospital Technology

Yosko 220px

Yosko co-founders and husband and wife, Javier Otin and Andriana Nikolova, MD.

First, as a student at Harvard Medical School, and later as an internal medicine resident at Brigham and Women's Hospital, Andriana Nikolova, MD, spotted a healthcare paradox.

"On the one hand, there had been so many advances in terms of techniques and medications," said Nikolova. "But in terms of technology, it was like healthcare was stuck in the ‘80s."

Nikolova who started at Harvard in 2007, pointed to pagers, paper print outs, and fax machines as evidence of the technological time warp. She also was puzzled by the way patients were transferred from one care team to another.

"Usually, the daily hand-off of patients just involves one shift talking to the next and maybe scribbling some notes," said Nikolova. "Where's the technology?"

Nikolova is working to bridge the tech gaps as the co-founder and chief executive officer of Yosko, a health-tech startup. The company recently rolled out a mobile care-coordination platform for hospitals that improves team collaboration, transitions of care and efficiency in procedural areas.

"Being a physician and an entrepreneur are intricately connected," said Nikolova, who just completed the first year of her Cardiology Fellowship at the Cedars-Sinai Heart Institute. "In clinical practice, you face the limits of medicine and gaps in care, so you start coming up with ideas to address these problems."

Nikolova who grew up in Yambol, Bulgaria, started the company in 2012 with a Harvard classmate and fellow international student, Javier Otin. From Madrid, Spain, Otin was pursuing a master's degree in information technology.

The business partnership came a year before another partnership between the two – marriage. Nikolova sees the dual relationship as a perfect fit.

"Creating a startup company with a co-founder is like being in a marriage anyway because you spend so much time together and you really need to have a profound connection," said Nikolova.

That connection has taken the couple and their company from Boston to Los Angeles. The coast-to-coast trek was prompted by Nikolova's acceptance into the Cedars-Sinai fellowship – a program that topped her wish list.

"I want to be a cardiologist," she said. "But my long-term vision is to become a heart transplant specialist, and Cedars-Sinai does the most adult heart transplants nationwide. Every single day it's inspiring to interact with the world's leading heart transplant specialists and cardiologists. It's such an honor to be here."

That honor was accompanied by a serendipitous coincidence. When Nikolova was starting her Cardiology Fellowship, Cedars-Sinai launched a new program designed to help health-tech startups grow and achieve marketplace success.

Called Techstars Healthcare Accelerator, in Partnership with Cedars-Sinai, the venture attracted more than 500 applications worldwide, including one submitted by Nikolova and Otin.

They were among the 11 accepted into the 2016 Healthcare Accelerator class that started on March 28 and concluded on June 23.

For Nikolova and Otin, it was time well spent. They introduced their mobile care-coordination platform Yosko Flow Manager – which already is being used by the largest hospital system in New York City – to nearly 100 hospital administrators via a webinar.

The pair also developed a second mobile platform. Dubbed Yosko OR Manager, the platform tracks patients prior to scheduled procedures, with an eye toward ensuring that all pre-procedure tests and documents are completed, thus reducing procedure-day delays and cancellations.

The next step is piloting the platform at Cedars-Sinai.

"A year from now, we hope to be actively marketing both of these products," Nikolova said.

Chances are good that additional innovations will be coming.

"This is a profession where you learn something new from your patients and science almost every day," said Nikolova. "You can't help but be inspired and want to create new products and solutions."

Related articles:

Accelerator Demo Day Draws Hundreds (Cedars-Science, July 7, 2016)

Cedars-Sinai, Techstars Team Up for Innovation (Cedars-Science, Oct. 29, 2015)

Online Courses Now Available For Fluoroscopy Safety

The California law governing the renewal of state Fluoroscopy Operator and Supervisor permits now requires that four out of the 10 hours of continuing education that physicians complete be specific to radiation safety during fluoroscopy.

A new online version of the fluoroscopy safety course already developed by the physics team is now available. Instructions on how to link into the system are below.

The classes are the same as the live classes that have been available since January. If you have already completed one or more of the classes, you do not need to complete them again.

The new system is designed to make it easier to meet the new requirements. You will need your Cedars-Sinai email and network password to sign on to the system.

The classes are targeted to fluoroscopy use, but they will also count toward the 10 units required if you only have a radiographic operator and supervisor permit.

Four online CME courses are available on the Cedars-Sinai CME Portal. These courses will meet the new California requirement for education on radiation safety in the use of digital fluoroscopy and are intended for Cedars-Sinai physicians only.

1. Access the system and log in

  • Access the CME Portal. Select Login to the Portal at the top of the CME Portal menu, then enter your system email and password.
  • System accounts have already been created for members of the Cedars-Sinai Medical Staff using email addresses that are on file with the Medical Staff Office.
  • If you do not know which email was used for the CME Portal system, contact the CME Office. Please do not create a new account.
  • Don't know or remember your password: Click the "Forgot Your Password?" link to have a password reset link sent to the email address on file.

2. Take the course

  1. Click Online Courses from the main menu.
  2. Scroll down or use the search box to locate the course.
  3. Click the Pretest button to begin the course.
  4. After completing the pretest, click the Video button to watch the presentation. When finished, close the video popup window.
  5. Click the Test button to complete the post-test. When finished, close the post-test popup window.
  6. If you do not pass the post-test, you may retake it by clicking the Test button again.

3. Complete the evaluation and access your certificate

  1. After successfully completing the post-test and closing the popup window, select Evaluations & Certificates from the main menu.
  2. Click the Complete Evaluation button for the online course just completed.
  3. Upon completion of the evaluation, the list will move the course to the bottom of the list and instead display a Download Certificate button next to it.
  4. Use the Download Certificate button to view, email or download your certificate; credit will also appear on your Transcript within the system. (Use the Transcript menu item to view a complete transcript of credit in the system.)

For more tips on using the system, click Help from the main CME Portal menu, or click Contact Us to reach a CME staff member by phone or email.

CS-Link Tip: Save Time with Calculator Tab

When you type "visit diagnosis" in CS-Link, the option for "list" or "calculator" with database matches pops up. You have the option to choose "calculator" or "list." While the "list" may seem short, often it is burdensomely long. Click "calculator" tab and save time.

Learn to be more efficient by attending a Physician Efficiency Training session. The classes are held in the Cafeteria Conference Room C. The last July class will take place Wednesday, July 20, from 5-6:30 p.m.

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