Team WorkIn medicine, partnerships involving doctors from different hospital systems are rare, especially when those physicians are located in other cities.
“Either egos get in the way or the hospital systems can’t financially come together, or whatever reason. There are always barriers,” says Dr. John Kryger, medical director of pediatric urology at Children’s Hospital of Wisconsin. Bucking the trend, a unique collaboration between Children’s Hospital of Wisconsin and children’s hospitals in Boston and Philadelphia has had tremendous success in addressing bladder exstrophy, a rare, complex birth defect in the lower abdominal wall where pelvic organs herniate out of the pelvis.
“We agreed that every time one of our institutions does a bladder exstrophy repair, we will all work together,” says Kryger, clad in scrubs after performing a late-afternoon surgery. “You achieve the collective wisdom of master surgeons from three of the country’s best pediatric medical centers.”
Children’s Hospital of Wisconsin has been at the forefront of bladder exstrophy repair. Kryger’s predecessor, Dr. Michael Mitchell, pioneered the contemporary surgery. “The repairs used to be done in stages and involved multiple surgeries. Dr. Mitchell realized that a one-stage surgery in early infancy would allow everything to develop better if simultaneously repaired,” says Kryger. “The outcomes would be better with fewer complications.”
The multi-hospital team performs bladder exstrophy surgeries as many as four times per month, often doing more than one procedure during each gathering. In addition to Kryger, the Children’s Hospital of Wisconsin team also includes Dr. Elizabeth Roth and Dr. Travis Groth. Although technically retired, Mitchell still is on hand during these operations, serving as the team’s coach.
Kryger is convinced that this collaboration can be an example for other specialties. “We think it’s a model that others can learn from, whether it’s pediatric general surgery or neurosurgery,” Kryger says.
Cancer Assassin CellsBret Carroll’s cancer was killing him.
Diagnosed in 2011 with mantle cell lymphoma, which attacks the immune system, he endured years of grueling treatments: chemotherapy, stem cell transplants, various medications. He beat his initial prognosis of two years to live, but the cancer kept returning. “My condition was going downhill quickly,” says Carroll, 52, of Grand Chute. “Things were really ugly.”
Near death last fall, he agreed to be the first patient in a clinical trial at the Froedtert & the Medical College of Wisconsin Clinical Cancer Center, where doctors have beaten his cancer into remission using an experimental version of an immunology treatment called chimeric antigen receptor (CAR) T-cell therapy.
“He almost certainly would have passed away. He was literally in the ICU dying from this disease,” exclaims Dr. Parameswaran Hari, chief of hematology and oncology.
CAR T-cells are specialized immune cells that are collected from a patient and genetically reprogrammed to recognize targets on a cancer cell, then put back into the body in a form of active immunity. CAR T-cell therapy targeting a single receptor on cancer cells has been available in the United States for about ve years.
“We actually took a major step beyond that. Our CAR T-cells can recognize two targets on the patient’s cancer cells and we actually make the cells in a desktop machine right here,” Hari explains.
“If you hit the cancer cell in more than one direction, you can get a better response,” says Dr. Nirav Shah, a hematologist/oncologist at Froedtert & the Medical College who is directing the clinical trial. It takes about two weeks for the device developed by Germany-based Miltenyi Biotec and Lentigen Technologies to modify the T-cells.
CAR T-cells so far have been used to treat advanced blood cancers, and the therapy is approved for adults with advanced lymphomas and children with acute lymphoblastic leukemia. Tens of thousands of Americans are diagnosed with those cancers every year. The trial’s goal is to improve outcomes for patients who, like Carroll, had exhausted all other options.
The CAR T-cell therapy can cause side effects. “When the T-cells are working it’s almost like having an infection,” Shah says. “Some people can get fevers and feel very fatigued. That is something that we are cognizant of when we are treating our patients.”
Carroll began the treatment in October 2017 and saw near-immediate results. “I quickly bounced back physically,” Carroll says. “I felt so much better.” A few weeks later, the cancer was undetectable in tests and has remained so ever since.
Carroll, who is retired from the Navy and now works for FedEx, has been performing administrative duties while undergoing treatment and monitoring but hopes to return to his usual job as a pilot. He hesitates to claim that he is cured but admits “it’s looking good.”
The trial remains in very early stages, but as many as 20 patients are expected to eventually take part. Plans call for a similar clinical trial for pediatric and young adolescent patients at Children’s Hospital of Wisconsin.
“This is really changing the natural history of the disease,” Shah says. “Patients, like Mr. Carroll, who had failed everything else, would not be alive without these treatments. The fact that he’s been in remission for a year is incredible.”
Beating the BurnKeeping stomach acid where it belongs can be tough.
When medications don’t yield results, invasive and complicated surgery may be needed to prevent the heartburn and regurgitation of fluid into the mouth common with gastroesophageal reflux disease.
“Most patients I see for surgery are having issues with waking up at night having fluid in their throat,” says Dr. Manfred Chiang, a surgeon at Ascension’s Elmbrook campus. “They are aspirating or choking. They have bad sinus issues and acid on their teeth causing erosion.”
Chiang says he’s the only physician in the Milwaukee area offering an innovative nonsurgical option: transoral incisionless fundoplication, or TIF.
The procedure, performed through the mouth, involves wrapping the upper portion of the stomach around the lower esophagus, preventing stomach acid from moving into the esophagus.
“There are no cuts in the abdomen and it can be done as an outpatient procedure,” Chiang explains during a break from seeing patients at an Ascension clinic in Brookfield.
Chiang estimates he has performed the procedure about 50 times since 2009. Cost has been a hindrance to patients, but some insurance providers in Wisconsin began covering the procedure earlier this year.
It’s an alternative to more invasive procedures and extended use of prescription medications, particularly proton pump inhibitors that Chiang notes have elicited concerns recently over their long-term use.
True BloodMario Higgins has rare blood.
But he didn’t know it until a few years ago when an ambitious screening program launched by the BloodCenter of Wisconsin identified his precious blood type. A regular donor since he was a teenager, the 50-year-old Milwaukee resident is now called on even more by the BloodCenter to help patients with the same rare blood.
“There are other people like me out there who need blood,” Higgins says. “I know I can help.”
Because of donors like Higgins, the BloodCenter has developed into a leading provider of rare and uncommon blood, filling needs across the United States and Canada under the leadership of Greg Denomme, senior director of immunohematology and innovation.
Denomme came to the BloodCenter in 2009 to lead a program to find people with precious rare blood types using mass-scale genotyping of regular donors’ blood.
“We typed some 25,000 blood donors in six months,” Denomme recalls. “This had never been done before. From that, we had a database in which we could look for rare blood types.”
Many are familiar with the eight basic blood types: A, AB, B and O, each of which can be positive or negative. “But there are about 350 antigens, and you could be rare for one of these rare antigens,” Denomme explains.
Higgins is O-positive and is missing a protein in his blood, something that affects some African Americans and people from the Caribbean and Asia. The mutation possibly developed as the body’s way to fight o malaria.
Like Higgins, Sarah Gross, 40, of Waukesha, was “completely unaware” of her extremely rare blood type – O-negative and Vel-negative, meaning that she lacks a specific antigen on the surface of her red blood cells – until she began treatments for acute lymphoblastic leukemia after her diagnosis in December 2017. Gross, whose blood type shows up in about 1 of every 75,000 blood donors, received a bone marrow transplant this summer and has received multiple transfusions of blood, most of which came from rare donors. She also donated some of her own blood to fi ll her needs.
“I’m so grateful for the rare donor program because sometimes you can’t get blood right away,” Gross says.
Guiding LightIn shoulder replacement surgery, as in real estate, it’s location, location, location. Placing and aligning the implant is highly critical to its overall longevity and function.
“One of the most difficult issues is getting the socket piece in place. You can’t see a lot because of the muscles in the shoulder,” says Rick Papandrea, a surgeon at Orthopaedic Associates of Wisconsin in Pewaukee, which co-manages ProHealth Care’s orthopedic services.
Earlier this year, Papandrea began using innovative new technology that pairs surgeons with an advanced computer system to improve accuracy and precision in shoulder replacement surgeries. Among the features is a pre-operative tool that helps surgeons understand their patients’ shoulder anatomy while planning the surgery through a virtual, three-dimensional simulation.
During the surgery, an infrared camera and active tracker technology work together to monitor the position and mechanical alignment of the joint replacement.
“Now you can see through everything and place implants precisely,” Papandrea says. “In some cases, it saves time and minimizes the amount of bone that we need to cut through.” He adds that the procedure may be safer, too.
“We think it will lead to better short-term outcomes and, more important, good longer-term outcomes,” Papandrea says.
Trial BalloonClark Cooley walks a mile or two every day, even in the bitter cold of winter, to get his exercise. He travels different routes and rarely ever stops along the way. “I’ve got to keep moving,” Cooley says.
But one day, the 85-year-old Mequon resident began experiencing excruciating pain in his lower legs during his strolls, often forcing him to rest, even after trekking short distances, until the pain subsided.
The problem lingered for months before tests revealed that Cooley had calcium buildup in the arteries of both legs. Typically, the treatment would require the placement of stents in the legs or surgery to repair blood vessels and retain blood flow, with recovery lasting weeks.
But fortunately for Cooley, a new, minimally invasive surgical procedure is available at Ascension Columbia St. Mary’s Hospital in Milwaukee. Lithoplasty utilizes sonic sound waves emitted from an angioplasty balloon to break up the calcium. The recovery for Cooley was nearly immediate.
“I felt better almost right away,” Cooley says. “I was a little bit sore right after the surgery, but it was gone the next day.”
Columbia St. Mary’s was approached about a year ago to be a trial site for the calcium-disrupting device, which has Food and Drug Administration approval but is not yet widely utilized in the United States, explains Dr. Erik Stilp, an interventional cardiologist who performed the procedure on Cooley. Ascension is now one of just two health systems in Wisconsin using the device and offering the procedure.
“If it gets to the point where a person’s lifestyle and daily function is limited, then we think about offering this treatment,” says Stilp, who has successfully treated 15 patients with it. “We will push the limits of the device and find the patients that we think it’s best suited for.”
Six months after the procedure, Cooley’s troublesome lower-leg pain hasn’t returned. “I haven’t had any problems at all, and it was much better than having a stent put in,” says Cooley. “I’m able to do more walking, which has allowed me to lose weight.”
Take A Deep BreathIf you think aromatherapy is simply an indulgence that you tack onto a spa treatment, think again.
Health care professionals are increasingly turning to essential oils to treat conditions ranging from headaches to insect bites, and lavender is already widely used to alleviate anxiety, depression and grief, as well as to treat sleep problems.
And now, a new clinical trial at Aurora Health Care’s Neuroscience Innovation Institute in Milwaukee is using lavender aromatherapy to help relax patients undergoing brain surgery while awake.
Aurora neurosurgeon Dr. Richard Rovin says lavender has been proven to work in pre-operative settings. “But we hadn’t looked at it during surgery as a way to comfort the patient and reduce anxiety,” he says. “We are really thrilled with the effect it is having.”
Rovin is working with members of the Aurora’s Integrative Medicine Team to direct the trial, which includes 30 patients. It’s going well enough that Aurora likely will continue to offer aromatherapy in all awake brain surgeries when the trial concludes, Rovin says.
The lavender is offered to patients in an inhaler every 30 minutes, if they feel a need for it, during awake surgeries to remove brain tumors, in addition to the local anesthetic and mild intravenous fluid for sedation. Keeping the patient awake allows for communication, which makes the surgeries much safer, Rovin says. “I can identify any subtle changes in the patient, since we are getting constant feedback from them. We can operate with more confidence.”
A Joint EffortSurgeon brothers Mark and Matthew Wichman are offering treatments in a new frontier of orthopedics: treating arthritis and joint pain using the power of stem cell therapy. The goal is to avoid or delay surgery to replace the joint.
“We are both seeing some patients that feel this is the holy grail, to restore their anatomy instead of reconstructing it,” Mark Wichman says.
The brothers are part of the Aurora Health Care Sports Health team that is treating patients with an injection of their own stem cells to alleviate arthritis in the shoulder, hip and knee as well as tendon injuries, chronic tendinitis and to promote healing in ligament reconstruction. “I tend to use it for patients for whom I don’t have a better conventional treatment,” Mark says.
The lack of evidence-based data and long-term studies about the effectiveness of this type of stem-cell therapy prevents it from being a front-line treatment, Mark explains, though patient demand is strong. The treatment provides quick but typically not permanent relief; Mark says he won’t inject the same joint with stem cells more than once in a year.
These treatments, which aren’t covered by insurance, are unique to the Aurora team in the Milwaukee area, according to the Wichmans.
The brothers prefer to use bone marrow drawn from the stem-cell-rich iliac crest on the hip bone. “That’s the uncomfortable part. It’s a big needle,” Matthew says.
The bone marrow is then put in a centrifuge for about 20 minutes as it is spun into a solution that is injected at the trouble spot. “Most patients say they haven’t felt this good in a long time,” Matthew says.