sutures newsletter

PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY May 2017 | Archived Issues

Cedars-Sinai, Torrance Memorial Plan Affiliation

A message from Thomas M. Priselac, president and CEO of Cedars-Sinai

Over the past several years, Cedars-Sinai has initiated numerous innovative partnerships, affiliations and other working relationships with a variety of healthcare providers to help enhance access, coordination and quality of care for patients throughout the region. These have taken many different forms, including partnerships with UCLA and Select Medical (California Rehabilitation Institute), primary care and specialty medical groups joining Cedars-Sinai Medical Network, the purchase of Marina Del Rey Hospital, and a variety of other clinical and research relationships with organizations.

I am now pleased to announce plans for a formal affiliation between Cedars-Sinai and Torrance Memorial.

» Read more

Graft Selection for ACL Knee Reconstruction

Anterior cruciate ligament reconstruction is one of the most common orthopedic surgeries performed worldwide. Despite its frequency, several questions surrounding the procedure continue to spark debate, the most controversial being: "Which graft choice is best?"

» Read more

Cedars-Sinai Creates Pulmonary Embolism Team

Cedars-Sinai has created a Pulmonary Embolism Response Team. PERT is a multidisciplinary team including pulmonary, critical care, cardiology, interventional cardiology and cardiothoracic surgery that provides rapid triage and access to state-of-the-art care for intermediate and high-risk pulmonary embolism.

» Read more

Two Minutes With …

Joshua Tseng, MD

This question-and-answer feature will help you get to know some of the faculty in the Cedars-Sinai Department of Surgery. This month's installment features Joshua Tseng, MD.


» Read more

Bones Rebuilt by Gene, Stem Cell Therapies

Endogenous MSCs BMP Ultrasound co

A Cedars-Sinai-led team of investigators has successfully repaired severe limb fractures in laboratory animals with an innovative technique that cues bone to regrow its own tissue. If found to be safe and effective in humans, the pioneering method of combining ultrasound, stem cell and gene therapies could eventually replace grafting as a way to mend severely broken bones. Dan Gazit, PhD, DMD, was the principal investigator and co-senior author of the research study, published in the journal Science Translational Medicine.

» Read more

Healthcare Leaders Share Lessons from Choosing Wisely

Cedars-Sinai and four other large healthcare providers in California gathered last month to highlight their successes implementing the national Choosing Wisely initiative, which aims to reduce inappropriate medical tests and procedures that can do more harm than good. Physicians and other leaders from Cedars-Sinai were joined at an April 28 symposium on the medical center campus by colleagues from Los Angeles County + USC Medical Center, Sharp HealthCare in San Diego, Sutter Health in Northern California and UCLA Health.

» Read more

Hybrid PET-MRI Scanner Now Available for Clinical Studies

PET-MRI scanner co

Cedars-Sinai's PET-MRI scanner, a highly sophisticated diagnostic imaging tool that provides superior image quality and uses low radiation doses, is now licensed for clinical studies. Cedars-Sinai is one of the few medical centers in the United States to be equipped with the hybrid scanner.

» Read more

WannaCry Malware Prompts Call for Vigilance

In wake of the recent WannaCry ransom-malware attack that has infected more than 200,000 computers worldwide, Enterprise Information Services is urging employees to be vigilant when using email. Distinct from other malware, ransomware is a type of malicious software that prevents access to a computer system by encrypting it with a key known only to the hacker. After the system data is encrypted, the ransomware directs the user to pay a ransom to the hacker for the decryption key.

» Read more

FDA Issues Warnings Against Extended Use of General Anesthetic in Young Children

The U.S. Food and Drug Administration (FDA) has updated a warning about the use of general anesthetic and sedation medicines for lengthy periods of time in children younger than 3 years old. The FDA is restricting the use of codeine and tramadol medicines for children. The medicines carry serious risks, including slowed or difficult breathing and death, which appear to be greater in children under 12 years old.

» Read more

FDA Issues Warning Against Canagliflozin

The U.S. Food and Drug Administration is warning Type 2 diabetes patients who take canagliflozin that the medicine can cause an increased risk of leg and foot amputations. Two recent large clinical trials showed that leg and foot amputations occurred about twice as often in patients treated with canagliflozin than in patients treated with a placebo.

» Read more

FDA Eliminates Risk Evaluations for ESA Agents

The U.S. Food and Drug Administration recently eliminated the risk evaluation and mitigation strategy for erythropoiesis-stimulating agents, which includes Epogen®, Procrit® and Aranesp®.

» Read more

Circle of Friends Honorees for April

CoF

The Circle of Friends program honored 208 people in April. Circle of Friends allows grateful patients to make a donation in honor of the physicians, nurses, caregivers and others who have made a difference during their time at Cedars-Sinai.

» Read more

Policy and Procedure Manager Upgrades May 31

A new software upgrade for Cedars-Sinai’s Policy and Procedure Manager software will take effect Wednesday, May 31. Version 9.5 features significant enhancements, including color theme, browser compatibility, searching tools and navigation panel options.

» Read more

CS-Link Tip: Creating SmartPhrases

cs-link logo

On CS-Link™, SmartPhrases spare you the trouble of having to type commonly used phrases over and over again. Creating a SmartPhrase is fairly simple and can be a big timesaver. Start by looking for a big green plus sign on your screen and clicking it.

» Read more

Cedars-Sinai, Torrance Memorial Plan Affiliation

A message from Thomas M. Priselac, president and CEO of Cedars-Sinai

Over the past several years, Cedars-Sinai has initiated numerous innovative partnerships, affiliations and other working relationships with a variety of healthcare providers to help enhance access, coordination and quality of care for patients throughout the region. These have taken many different forms, including partnerships with UCLA and Select Medical (California Rehabilitation Institute), primary care and specialty medical groups joining Cedars-Sinai Medical Network, the purchase of Marina Del Rey Hospital, and a variety of other clinical and research relationships with organizations.

I am now pleased to announce plans for a formal affiliation between Cedars-Sinai and Torrance Memorial.

The proposed affiliation will provide a platform for future collaborations in primary and specialty care, expanded access to the latest clinical trials and an efficient sharing of resources among both institutions.

While the proposed affiliation has been approved by each institution's board of directors, it will soon be submitted for review by various regulatory agencies that approve proposed affiliations of this type. The regulatory approval process is expected to take about six months.

Under the proposed affiliation, each institution will continue to have its employees and own hospital medical staff and related physician organizations, will retain its respective president and board of directors and continue to operate separately, but will affiliate under a new parent organization. The board of the parent organization will be composed of representatives from Cedars-Sinai and Torrance Memorial.

In addition to continuing to serve as president and CEO of Cedars-Sinai, I will serve as the president and CEO of the new parent organization, to be called Cedars-Sinai Health System. Cedars-Sinai Health System will consist of two entities, Cedars-Sinai and Torrance Memorial.

Cedars-Sinai includes the 886-bed Cedars-Sinai Medical Center, the 145-bed Marina Del Rey Hospital, Cedars-Sinai Medical Network (including Cedars-Sinai Medical Group, Cedars-Sinai Health Associates and other groups such as Valley Internal Medicine, California Heart Center, Tower Hematology Oncology, Kerlan-Jobe Institute and The Angeles Clinic and Research Institute), our research and academic enterprise, and our growing network of primary care, urgent care and specialty care centers throughout the Los Angeles region.

Torrance Memorial includes the 470-bed Torrance Memorial Medical Center, a multispecialty physician group (Torrance Memorial Physician Network), an independent physician association (Torrance Health IPA) and an accountable care organization (Torrance Memorial Integrated Physicians), which collectively include more than 500 physicians. Torrance Memorial also has several outpatient centers located throughout the South Bay region.

Along with Cedars-Sinai, Torrance Memorial (founded in 1925) is one of California's longest-serving nonprofit healthcare organizations and has an outstanding track record of providing quality care for the South Bay. In the past several years, Cedars-Sinai has collaborated with Torrance Memorial on a variety of projects such as the establishment of a telestroke program to more quickly diagnose and treat stroke patients and a proposed partnership involving their cancer program. The relationship has been very positive and constructive for both institutions and has enhanced access for patients. While Cedars-Sinai and Torrance Memorial are very different in size and scope of services, both institutions have a longstanding commitment to serving the community.

The proposed affiliation will provide additional ways for all of us at Cedars-Sinai and at Torrance Memorial to fulfill the reason we come to work each day: to continually improve the lives of the people and communities we serve. Thank you for your continued commitment and dedication to our mission.

Graft Selection for ACL Knee Reconstruction

By Melodie Metzger, PhD

Anterior cruciate ligament reconstruction is one of the most common orthopedic surgeries performed worldwide. Despite its frequency, several questions surrounding the procedure continue to spark debate, the most controversial being: "Which graft choice is best?"

The "graft" refers to the new tissue that will be used to reconstruct the patient's torn ligament. The two main options are an autograft, in which new tissue is harvested from the patient's own body, and an allograft, in which the tissue comes from a donor or cadaver.

Each has advantages and disadvantages. For instance, autografts have little to no risk of disease transmission and are more cost-effective, while allografts do not require removal of graft tissue (usually a tendon) from around the patient's knee, reducing surgical time and complications associated with this additional step.

But one potential complication associated with collection of autograft tissue that has not been fully investigated is loss of stability. Hamstring tendons are a popular graft choice that requires removing a patient's own hamstring tendon from the medial portion (inside) of their knee. However, when intact, these medial hamstrings help stabilize the knee by preventing excessive rotation. Other rotational stabilizers, like the medial collateral ligament, are present to help compensate, but an estimated 20 percent of patients injure their medial collateral ligament at the same time they tear their ACL. This presents an interesting clinical question: Should we caution against using hamstring autografts for ACL reconstructions when an MCL injury is present?

To investigate this question, the Orthopaedic Biomechanics Lab at the Cedars-Sinai Orthopaedic Center used a cadaveric knee model. Each knee was subjected to a series of static loads while motion-tracking cameras recorded precise displacements to quantify stability in the knee.

This was repeated for the following clinical scenarios: intact knee, removal of the ACL, removal of the ACL with an MCL injury, and ACL reconstruction with an MCL injury using different graft options, simulated by either applying (i.e., allograft) or removing (i.e., hamstring autograft) a force to the medial hamstrings.

Our results verified that the addition of a partial MCL tear to complete ACL tear significantly decreases rotational stability. In addition, we demonstrated that in the setting of a concurrent MCL tear, ACL reconstruction with the medial hamstrings loaded does not significantly increase rotation compared to intact knees. Conversely, when the hamstrings were unloaded, as would be the case when using a hamstring tendon autograft, there was a significant increase in valgus (knocked knee) rotation (Figure 1).

This research will ultimately help surgeons determine the best graft choice, surgical technique and post-operative bracing for patients with rotationally unstable knees. This work will be presented at the American Orthopaedic Society for Sports Medicine in July and at the Western Orthopaedic Association, where it has been recognized for a Young Investigator Award.

Figure 1. Valgus rotation as a function of knee angle for three of the test conditions, including: Intact with hamstring muscles engaged (Δ), ACL reconstruction with MCL-partial injury with hamstring muscles loaded (◊) and without hamstring muscles loaded (X), which had significantly greater rotation compared to intact across all knee flexion angles (*, p<0.05).

Principal Investigators: Thomas J. Kremen, MD, and Melodie F. Metzger, PhD

Lab: Orthopaedic Biomechanics Laboratory, Cedars-Sinai Orthopaedic Center

This study was funded through a research grant from the Orthopaedic Research and Education Foundation (OREF).

Cedars-Sinai Creates Pulmonary Embolism Team

By Oren Friedman, MD, Vic Tapson, MD, Danny Ramzy, MD, Aaron Weinberg, MD, Suhail Dohad, MD

We are pleased to announce the creation of the Cedars-Sinai Pulmonary Embolism Response Team. PERT is a multidisciplinary team including pulmonary, critical care, cardiology, interventional cardiology and cardiothoracic surgery that provides rapid triage and access to state-of-the-art care for intermediate and high-risk pulmonary embolism (PE).

Options for this deadly disease have increased exponentially in the past several years and include multiple endovascular procedures, cardiac surgery and extracorporeal membrane oxygenation (ECMO). These options are spread between multiple fields and in the absence of a PE team would require several phone calls to different consultants. The concern is that providers will be stuck in a maze of phone calls, which can delay treatment to a sick patient.

With the advent of our team, one phone call provides access to all necessary disciplines. Our members include:

  • Vic Tapson, MD, pulmonary critical care
  • Aaron Weinberg, MD, pulmonary critical care
  • Oren Friedman, MD, pulmonary critical care, cardiac surgery critical care
  • Suhail Dohad, MD, interventional cardiology
  • Danny Ramzy, MD, cardiothoracic surgery
  • David Hildebrandt, BSN, Heart Institute team manager

Providers can dial in to a dedicated phone line (3-CLOT) and will have 24-hour access to the team, including expert interpretation of CT angiography, VQ scan and echocardiography. The team will provide rapid clinical evaluation and triage of high-risk PE patients. The pulmonary critical care fellow or attending will field the call, gather information and begin to offer advice.

In certain scenarios — such as a massive PE (patients with hemodynamic instability) or a clot in transit — cardiac surgery will be involved immediately. The team will also help guide the often precarious decision to use systemic thrombolytics.

For intermediate risk, the team will provide an expert recommendation regarding indications for anticoagulation alone, IVC filter placement and endovascular treatment. Our cardiac surgeon, Ramzy, and our chief interventional cardiologist, Dohad, perform a vast array of endovascular therapy, including:

  • Catheter directed lysis, including ultrasound-assisted, catheter-directed lysis with the EKOS catheter
  • Clot extraction with the FLowTriever® device or the Angiovac® clot retrieval system
  • Surgical embolectomy or veno-arterial ECMO for patients in critical condition. (ECMO has been used at Cedars-Sinai to bridge patients to a variety of definitive treatments.)

In addition to inpatient treatment, our team can also arrange to monitor patients after they leave the hospital. Follow-up management for pulmonary embolism is crucial, as there are many nuances and options for long-term anticoagulation. The rise of direct oral anticoagulants has introduced many more options for long-term care, including low-dose extended anticoagulation.

Patients with abnormal RV function at the outset of their pulmonary embolus are at risk for long-term RV abnormalities and functional limitations. Our outpatient clinic is headed by Tapson, who in addition to having a national reputation in PE is an expert in pulmonary hypertension. The outpatient clinic can also assure the appropriate removal of IVC filters.

The Cedars-Sinai PERT team is a founding member of The National PERT Consortium headed by Massachusetts General Hospital. The PERT consortium hosts annual meetings to discuss leading-edge developments in PE care and provides a forum to collaborate on care and research.

Cedars-Sinai will contribute to the national database and will be able to publish from this database. The PERT consortium newsletter has featured Cedars-Sinai, highlighting our team approach and the availability of multiple modalities of advanced PE care — including our robust cardiac surgery and ECMO program — which have opened the door to aggressive PE treatment not routinely available at many large centers.

Numerous clinical trials and research projects are underway. A few highlights will follow. Data has been assembled on the multisite Optalyse PE trial led by Tapson, investigating numerous alteplase doses for catheter-directed thrombolysis.

Our center is also participating in a trial studying the FlowTriever® clot extraction device, and thrombolysis activatable inhibitor in acute PE. We are also studying portable VQ scans in the ICU, and will embark on a study of noninvasive cardiac output monitoring during acute PE.

Two Minutes With …

This question-and-answer feature will help you get to know some of the faculty in the Cedars-Sinai Department of Surgery.

Joshua Tseng, MD, general surgery resident

Where did you grow up?

I was born in New York City, and spent the next few years in Taipei, Taiwan. I moved to Southern California in fourth grade and lived here since then.

Why did you decide to specialize in surgery?

Operating is the most fun I've ever had.

What is the most rewarding aspect of your job?

Crafting a solution to help others.

What did your parents always tell you that now you have to admit was correct?

There is no such thing as a free lunch.

If you could spend the day doing one thing, what would it be?

I'd spend the day lounging at a poolside in a resort with my wife, Ohmar, and my dog, Potato.

If you were not a physician, what other career would you choose?

I would open an Asian bakery in Westwood and make bank. As a matter of fact, I am still looking for potential business partners.

Bones Rebuilt by Gene, Stem Cell Therapies

An illustration shows the bone-tissue engineering technique developed by Cedars-Sinai investigators. Endogenous MSCs refers to stem cells from a patient's bone. The BMP gene is a gene that promotes bone repair.
Credit: Gazit Group/Cedars-Sinai

A Cedars-Sinai-led team of investigators has successfully repaired severe limb fractures in laboratory animals with an innovative technique that cues bone to regrow its own tissue. If found to be safe and effective in humans, the pioneering method of combining ultrasound, stem cell and gene therapies could eventually replace grafting as a way to mend severely broken bones.

"We are just at the beginning of a revolution in orthopedics," said Dan Gazit, PhD, DMD, co-director of the Skeletal Regeneration and Stem Cell Therapy Program in the Department of Surgery and the Cedars-Sinai Board of Governors Regenerative Medicine Institute. "We're combining an engineering approach with a biological approach to advance regenerative engineering, which we believe is the future of medicine."

Gazit was the principal investigator and co-senior author of the research study, published in the journal Science Translational Medicine.

More than 2 million bone grafts are performed worldwide each year. They are frequently necessitated by severe injuries involving traffic accidents, war or tumor removal. Such injuries can create gaps between the edges of a fracture that are too large for the bone to bridge on its own. The grafts require implanting pieces from either the patient's or a donor's bone into the gap.

"Unfortunately, bone grafts carry disadvantages," said Gazit, a professor of Surgery at Cedars-Sinai. "There are huge unmet needs in skeleton repair."

One problem is that enough healthy bone is not always available for repairs. Surgeries to remove a bone piece, typically from the pelvis, and implant it can lead to prolonged pain and expensive, lengthy hospitalizations. And grafts from donors may not integrate or grow properly, causing the repair to fail.

The new technique developed by the Cedars-Sinai-led team could provide a much-needed alternative to bone grafts.

In their experiment, the investigators constructed a matrix of collagen, a protein the body uses to build bones, and implanted it in the gap between the two sides of a fractured leg bone in laboratory animals. This matrix recruited the fractured leg's stem cells into the gap over two weeks. To initiate the bone repair process, the team delivered a bone-inducing gene directly into the stem cells, using an ultrasound pulse and microbubbles that facilitated the entry of the gene into the cells.

Eight weeks after the surgery, the bone gap was closed and the leg fracture was healed in all the laboratory animals that received the treatment. Tests showed that the bone grown in the gap was as strong as that produced by surgical bone grafts, said Gadi Pelled, PhD, DMD, assistant professor of Surgery at Cedars-Sinai and the study's co-senior author.

"This study is the first to demonstrate that ultrasound-mediated gene delivery to an animal's own stem cells can effectively be used to treat nonhealing bone fractures," Pelled said. "It addresses a major orthopedic unmet need and offers new possibilities for clinical translation."

The study involved six departments at Cedars-Sinai, plus investigators from Hebrew University in Jerusalem; the University of Rochester in Rochester, New York; and the University of California, Davis.

"Our project demonstrates how scientists from diverse disciplines can combine forces to find solutions to today's medical challenges and help develop treatments for the patients of tomorrow," said Bruce Gewertz, MD, surgeon-in-chief and chair of the Cedars-Sinai Department of Surgery.

Research reported in this publication was supported by grants from the California Institute for Regenerative Medicine under award number TR4-06713, the National Institutes of Health under award numbers R01CA112356 and P30AR069655, the IDF Medical Corps and the Milgrom Family.

See an animation video that shows the bone-tissue engineering technique developed by Cedars-Sinai investigators.
Credit: Gazit Group/Cedars-Sinai

Competing interests: Gadi Pelled, Dan Gazit and Zulma Gazit are shareholders in GamlaStem Medical Inc., which did not provide funds for this study. A patent application related to the study's findings is pending.

The IACUC number for animal subjects in research referenced in this article is 4740.

Healthcare Leaders Share Lessons from Choosing Wisely

Cedars-Sinai and four other large healthcare providers in California gathered last month to highlight their successes implementing the national Choosing Wisely initiative, which aims to reduce inappropriate medical tests and procedures that can do more harm than good.

Physicians and other leaders from Cedars-Sinai were joined at an April 28 symposium on the medical center campus by colleagues from Los Angeles County + USC Medical Center, Sharp HealthCare in San Diego, Sutter Health in Northern California and UCLA Health.

Through the national initiative, launched in 2012 by the American Board of Internal Medicine Foundation and Consumer Reports, dozens of medical specialty societies such as the American College of Physicians have identified nearly 500 common medical tests and procedures that may not have clear benefit for patients and sometimes should be avoided.

The effort gives doctors real-time information and sparks important conversations with patients about the appropriateness of certain diagnostic tests and treatments. As a result, patients waste less time undergoing tests that do not improve their care or taking medications that will not help.

Some providers, including Cedars-Sinai, have integrated Choosing Wisely recommendations into their electronic medical records systems. Alerts pop up on physicians’ computer screens during patient visits, asking whether specific choices are necessary given a patient’s medical condition and medications, and in light of recently published studies.

"Physicians, clinicians on the ground, know best where the problems are, where the overuse is," Daniel Wolfson, executive vice president and chief operating officer of the American Board of Internal Medicine Foundation, said at the symposium. "I think that what Cedars-Sinai has done is remarkable. You have been the leader. You have had tremendous success."

Unnecessary medical care rings up an estimated $192 billion in annual healthcare spending, according to the Journal of the American Medical Association.

Surveys conducted by Choosing Wisely found that 64 percent of physicians report the initiative empowered them to reduce use of unnecessary tests and treatments. Nearly 65 percent of emergency room doctors felt more comfortable discussing low-value services with patients, while almost 55 percent said they reduced utilization.

"After decades of discussion and debate, physicians, nurses and others responsible for delivering care at the bedside are demonstrating that we can address this problem of inappropriate care where the harms exceed the benefits," said Scott Weingarten, MD, MPH, chief clinical transformation officer at Cedars-Sinai and one of the symposium’s organizers. "By empowering patients and doctors, we can deliver higher quality care more efficiently, increasing the value of healthcare for those who need it most."

At the symposium, leaders from Cedars-Sinai and the other healthcare providers shared their Choosing Wisely experiences and results. Some highlights:

Cedars-Sinai

  • Integrated nearly 100 recommendations into its electronic health record system more than three years ago.
  • Patients of physicians who followed all the alerts had fewer medical complications and left the hospital sooner.
  • When doctors fully adhered to all the alerts, costs dropped by hundreds of dollars per patient encounter. The health system avoided $6 million in healthcare spending in the first full year of its Choosing Wisely implementation.

Los Angeles County + USC Medical Center and UCLA Health

  • Implemented and evaluated a multidisciplinary quality improvement initiative at the Los Angeles County Department of Health Services to reduce low-value preoperative care such as blood tests and electrocardiograms for cataract surgery patients. Most people don’t need such tests before low-risk surgery unless they have certain health conditions or illnesses.
  • Dramatically reduced preoperative testing, freed up staff and provided six additional months of good vision to patients by shortening the wait time for surgery.

Sharp Rees-Stealy Medical Group in San Diego

  • Distributed wallet cards to patients listing "5 Questions to Ask Your Doctor Before You Get Any Test, Treatment or Procedure."
  • Engaged community skilled nursing homes with Choosing Wisely recommendations.
  • Decreased opioid prescribing by 10 percent in one year. Reduced use of unnecessary cardiac stress testing by about 5 percent.

Sutter Health in Northern California*

  • Addressed more than 130 Choosing Wisely recommendations.
  • Engaged more than 3,000 clinicians, supporting 1 million patients, and saved $66 million since 2010 by eliminating avoidable tests and treatments.
  • Decreased the ordering of repeat labs by 20 percent in three hospitals after six months — a rate that has been maintained for two years.

    *Sutter Health achieved some of these results for efforts prior to adopting Choosing Wisely recommendations.

Hybrid PET-MRI Scanner Now Available for Clinical Studies


The Biomedical Imaging Research Institute's PET-MRI scanner is now licensed for clinical imaging.

Cedars-Sinai's PET-MRI scanner, a highly sophisticated diagnostic imaging tool that provides superior image quality and uses low radiation doses, is now licensed for clinical studies. Cedars-Sinai is one of the few medical centers in the United States to be equipped with the hybrid scanner.

Known as the Siemens Biograph mMR, the molecular imaging system simultaneously acquires PET and MRI scans and has been used in research studies at Cedars-Sinai since 2015. The hybrid device, which is housed at the Biomedical Imaging Research Institute (BIRI), generates images registering and fusing the PET's metabolic data with the MRI's anatomical and tissue-characterization data.

“We're pleased and excited that the PET-MRI scanner is now available for clinical studies," said Alessandro D'Agnolo, MD, BIRI clinical director of PET-MRI and nuclear medicine physician at the S. Mark Taper Foundation Imaging Center. "The ability to fuse exceptional PET and MRI images' data sets can result in more defined diagnoses, particularly in situations where MRI is superior to CT in tissue characterization."

Since both scans are acquired during the same session, patients spend less time undergoing imaging tests and usually experience less stress. The hybrid scanner also reduces radiation exposure by up to two-thirds, something especially beneficial for pediatric patients, said D'Agnolo.

The PET-MRI scanner may be of particular value in oncology, neurology and cardiology, said D'Agnolo.

In oncology, the scanner will improve the ability to evaluate primary and recurrent brain tumors, neck cancers, hepatobiliary cancers, pancreatic cancer, ovarian cancer, uterine cancer, sarcomas and multiple myeloma, added D'Agnolo.

With the newly available PET radiotracers, which are used to acquire PET images, PET-MRI could open new frontiers in detecting neuroendocrine tumors and prostate cancer.

"In neurology, PET-MRI is going to be helpful in workups of patients with dementia and epilepsy, and in the future may completely replace PET-CT scans for these conditions," said D'Agnolo.

In cardiology, the hybrid scanner can supply powerful imaging of the heart and inflammatory processes of the vessels, as well as in sarcoidosis.

PET-MRI scans are only available for nonurgent, outpatient cases. Before referring a patient for a PET-MRI scan, physicians should first contact the BIRI coordinator at 310-423-4075.

WannaCry Malware Prompts Call for Vigilance

In wake of the recent WannaCry ransom-malware attack that has infected more than 200,000 computers worldwide, Enterprise Information Services (EIS) is urging employees to be vigilant when using email.

EIS has issued the following tips to prevent an attack:

  • Be on guard while reviewing emails that originate from outside of Cedars-Sinai (subject now marked with the tag [External]).
  • Forward suspicious emails to spamcheck@cshs.org, then delete.
  • Do not click on attachments or web links in any email whose sender you do not recognize.

Distinct from other malware, ransomware is a type of malicious software that prevents access to a computer system by encrypting it with a key known only to the hacker. After the system data is encrypted, the ransomware directs the user to pay a ransom to the hacker for the decryption key.

WannaCry ransomware-malware started spreading in mid-May and crippled computer networks around the globe. In the United Kingdom, some hospitals had to turn away patients as the malware shut down computer systems.

While Cedars-Sinai deploys sophisticated cybersecurity defenses, attacks remain especially dangerous.

For questions on cybersecurity concerns, email Chris Joerg, chief information security officer, at chris.joerg@CSHS.org, email information.security@cshs.org, or call the EIS Service Desk at 310-423-6428.

FDA Issues Warnings Against Extended Use of General Anesthetic in Young Children

The U.S. Food and Drug Administration (FDA) has updated a warning about the use of general anesthetic and sedation medicines for lengthy periods of time in children younger than 3 years old. The warning states that the use of the drugs for more than three hours can cause widespread loss of nerve cells in the developing brain.

The FDA website has more information.

FDA: Restricting Codeine and Tramadol Medicines in Children and Breastfeeding Women

The FDA is restricting the use of codeine and tramadol medicines for children. The medicines carry serious risks, including slowed or difficult breathing and death, which appear to be greater in children under 12 years old. FDA is also recommending against the use of the medicines for breastfeeding mothers due to possible harm to their infants.

The FDA website has more information.

FDA Issues Warning Against Canagliflozin

The U.S. Food and Drug Administration (FDA) is warning Type 2 diabetes patients who take canagliflozin that the medicine can cause an increased risk of leg and foot amputations.

Two recent large clinical trials showed that leg and foot amputations occurred about twice as often in patients treated with canagliflozin as in patients treated with a placebo.

Patients taking canagliflozin should contact their healthcare provider immediately if new pain, tenderness, sores, ulcers, or infections develop in the legs or feet.

The FDA website has more information.

FDA Eliminates Risk Evaluations for ESA Agents

The U.S. Food and Drug Administration (FDA) recently eliminated the risk evaluation and mitigation strategy (REMS) for erythropoiesis-stimulating agents (ESA), which includes Epogen®, Procrit® and Aranesp®.

Established in 2011, the REMS program was designed to ensure that the benefits of ESA therapy to treat anemia due to myelosuppressive chemotherapy outweighed the risks. After further study, the FDA determined in April that the REMS program is no longer necessary.

The elimination of the ESA Apprise Oncology REMS program means:

  • Prescribers are no longer required to be certified before being able to prescribe ESA for patients with anemia due myelosuppressive chemotherapy.
  • Prescribers are no longer required to complete a Patient and Healthcare Provider Acknowledgement Form for each patient before a new ESA course is initiated.
  • Hospitals are no longer required to be certified before being able to dispense ESA for patients with anemia due myelosuppressive chemotherapy.

Prescribers should continue to follow clinical guidelines and hospital protocols when prescribing ESA.

For more information or questions, please contact Drug Use Policy (grouppharmacydup@cshs.org).

Circle of Friends Honorees for April

The Circle of Friends program honored 208 people in April.

Circle of Friends allows grateful patients to make a donation in honor of the physicians, nurses, caregivers and others who have made a difference during their time at Cedars-Sinai. When a gift is made, the person being honored receives a custom lapel pin and a letter of acknowledgement.

Click here for more information about the program and for a list of past honorees.

  • Rachel Abuav, MD
  • Kenneth Adashek, MD
  • Hamed Afshari, RN
  • Ericson A. Aguilar
  • Michael J. Alexander, MD
  • Ronald M. Andiman, MD
  • Ellen Anifantis, LCSW
  • Christine T. Armbruster, PharmD
  • Claudia Arrue, RN
  • David Austin, MD
  • Esther Baik, MD
  • C. Noel Bairey Merz, MD
  • Mark Bamberger, MD
  • Benjamin Basseri, MD
  • Satinder J. Bhatia, MD
  • Keith L. Black, MD
  • Vivien S. Bonert, MD
  • Catherine E. Boyer, RN
  • Darina Brezhnev, PharmD
  • Earl W. Brien, MD
  • Philip G. Brooks, MD
  • Rebecca S. Brown, MD
  • Matthew H. Bui, MD, PhD
  • Michael A. Bush, MD
  • Ilana Cass, MD
  • David H. Chang, MD
  • Dorrie Chang, MD
  • Kirk Y. Chang, MD
  • Peter Chen, MD
  • Elaina P. Chu, PA
  • Sumeet S. Chugh, MD
  • Jeffrey M. Chung, MD
  • Joshua Chung, MD
  • Hart C. Cohen, MD
  • Steven D. Colquhoun, MD
  • Yvonne M. Concepcion, RN
  • Stephen R. Corday, MD
  • Kenneth A. Corre, MD
  • Alice C. Cruz, MD
  • Ram C. Dandillaya, MD
  • Catherine M. Dang, MD
  • Robert M. Davidson, MD
  • Onika Davis, RN
  • Julie DeMary
  • Alice R. Dick, MD
  • Jack Ditlove, MD
  • Suhail Dohad, MD
  • Cory A. Donovan, MD
  • Cheryl L. Dunnett, MD
  • Hailu Ebba, MD
  • Christine H. Economides, MD
  • Karyn Eilber, MD
  • Yaron Elad, MD
  • Fardad Esmailian, MD
  • Richard Essner, MD
  • Edward J. Feldman, MD
  • Christopher R. Fitzgerald, MD
  • Lauren J. Fitzpatrick
  • Phillip R. Fleshner, MD
  • Charles A. Forscher, MD
  • Alex Foxman, MD
  • David M. Frisch, MD
  • Larry Froch, MD
  • Gerhard J. Fuchs, MD
  • Srinivas Gaddam, MD
  • Ivor L. Geft, MD
  • Jordan L. Geller, MD
  • Sabrina L. Gerber, RN
  • Armando E. Giuliano, MD
  • Neil J. Goldberg, MD
  • David B. Golden, MD
  • Sherry L. Goldman, RN, NP
  • Jeffrey S. Goodman, MD
  • Sarah Gordon-Harper, RN
  • Richard E. Gould, MD
  • Amanda Ruth O. Goyena, RN
  • Stephen L. Graham, MD
  • Leland M. Green, MD
  • Giselle A. Guevara, RN
  • Antoine Hage, MD
  • Matthew Hakimi, MD
  • David S. Hallegua, MD
  • Michele A. Hamilton, MD
  • Bryna J. Harwood, MD
  • Jeffrey S. Helfenstein, MD
  • Heather Henry Barone, BSN, RN-BC, CCRN
  • David M. Hoffman, MD
  • Gary H. Hoffman, MD
  • David D. Hopp, MD
  • Arash A. Horizon, MD
  • Bree Hysjulien
  • Titus Jackson, PA
  • Jay L. Jordan, MD
  • Stanley C. Jordan, MD
  • David Y. Josephson, MD
  • Saibal Kar, MD
  • Beth Y. Karlan, MD
  • Ronald P. Karlsberg, MD
  • Payman Khorrami, MD
  • Terrence T. Kim, MD
  • Michelle M. Kittleson, MD, PhD
  • Robert Klapper, MD
  • Jon A. Kobashigawa, MD
  • Michael A. Kropf, MD
  • Glenda Y. Lam
  • Todd H. Lanman, MD
  • Gary E. Leach, MD
  • Mary Leier, NP
  • Norman E. Lepor, MD
  • Ronald S. Leuchter, MD
  • Michael S. Levine, MD
  • Richard A. Lewis, MD
  • Andrew J. Li, MD
  • Burt Liebross, MD
  • Milton Little, MD
  • Cheryle C. Maano-Requejo
  • Rajendra Makkar, MD
  • Adam N. Mamelak, MD
  • Leticia Martinez
  • Ruchi Mathur, MD
  • David N. Matsumura, MD
  • Philomena McAndrew, MD
  • Robert J. McKenna Jr., MD
  • Gil Y. Melmed, MD, MS
  • Nicolas Melo, MD
  • Leslie Memsic, MD
  • Robert Meth, MD
  • Avinash Mondkar, MD
  • Reanna Moon, RN
  • Beth A. Moore, MD
  • Jaime D. Moriguchi, MD
  • Esther Morrison, RN
  • Ariella A. Morrow, MD
  • Jeannette Moynihan, RN
  • Zuri Murrell, MD
  • Mamoo Nakamura, MD
  • Youram Nassir, MD
  • Ronald B. Natale, MD
  • Ronen Nazarian, MD
  • Christopher S. Ng, MD
  • Nicholas N. Nissen, MD
  • Arshia M. Noori, MD
  • Katayoun Omrani, DDS
  • Guy D. Paiement, MD
  • Alice Peng, MD
  • Brian Perri, DO
  • Tiffany Perry, MD
  • Surasak Phuphanich, MD
  • Nipaporn Pichetshote, MD
  • Mark Pimentel, MD
  • Stephen C. Rabin, MD
  • Edwin O. Ramos
  • Danny Ramzy, MD, PhD
  • Jeffrey Rapp, MD
  • Alexandre Rasouli, MD
  • Robert Richter, MD
  • Sonja Louisa Rosen, MD
  • Fred P. Rosenfelt, MD
  • James Round, RN
  • Jeremy D. Rudnick, MD
  • Ruth "Virginia" Russell, MD
  • Amy S. Rutman, MD
  • Rachelle Sanchez
  • Annette E. Sand, PT
  • Howard M. Sandler, MD, MS
  • Gregory P. Sarna, MD
  • Jay N. Schapira, MD
  • Wouter I. Schievink, MD
  • Michael M. Shehata, MD
  • John L. Sherman, MD
  • Randolph Sherman, MD
  • Chrisandra L. Shufelt, MD, MS
  • Robert J. Siegel, MD
  • Allan W. Silberman, MD, PhD
  • Amanuel Sima, MD
  • Enrique Slodownik, MD
  • Isabelle Soh, MD
  • Karyn Morse Solky, MD
  • Janet Soto
  • Andrew Ira Spitzer, MD
  • Henrietta Stancz-Szeder, MD
  • Jerrold H. Steiner, MD
  • Daniel J. Stone, MD
  • Leslie Stricke, MD
  • Charles D. Swerdlow, MD
  • Nicholas R. Szumski, MD
  • David B. Thordarson, MD
  • Alfredo Trento, MD
  • Alfiya Tuaeva, RN
  • Kathleen Valenton, MD
  • Michael B. Van Scoy-Mosher, MD
  • Eric Vasiliauskas, MD
  • Robert A. Vescio, MD
  • Ronald G. Victor, MD
  • Olga Voroshilovsky, MD
  • Christine S. Walsh, MD
  • Victor Washington, RN
  • Katherine Weber, MD
  • Jonathan M. Weiner, MD
  • Janet Y. White, MD
  • Alyssa Wield, MD
  • Yu-Tung Wong, MD
  • Clement C. Yang, MD
  • Jacqueline E. Yaris, MD
  • Payam R. Yashar, MD
  • Evan M. Zahn, MD
  • Phillip C. Zakowski, MD
  • Zachary Zumsteg, MD

Policy and Procedure Manager Upgrades May 31

A new software upgrade for Cedars-Sinai’s Policy and Procedure Manager software will take effect Wednesday, May 31.

Version 9.5 features significant enhancements, including color theme, browser compatibility, searching tools and navigation panel options.

For more information, email grouppmohelpdesk@cshs.org or call Leslie Aguilar at 323-866-7858.

PPM (PDF)

CS-Link Tip: Creating SmartPhrases

On CS-Link™, SmartPhrases spare you the trouble of having to type commonly used phrases over and over again.

Creating a SmartPhrase is fairly simple and can be a big timesaver. Start by looking for a big green plus sign on your screen and clicking it. The SmartPhrase editor opens with your text and you can make additional edits.

Next, give your SmartPhrase a nickname so it will be easy to retrieve later. Then, click Accept and your SmartPhrase is now stored in CS-Link™. (It will work in both ambulatory and inpatient notes.)