One From the Heart, Cover Story, Cedars-Sinai Catalyst
"Believe in what you're supporting, be passionate and follow your heart." Vera Guerin has lived by these words, beginning with her marriage to Paul Guerin -- 40 years ago this July -- despite the vigorous objections of her family.
Theirs was a storybook romance. Vera met Paul at her brother's Bar Mitzvah. Paul was her best friend's date. "Something clicked instantly for both of us," says Paul. "She was beautiful, alive, animated, and gracious. I told my mother that night I'd met the girl I was going to marry." Paul was not Jewish, however, and Vera's parents would not accept the relationship. Paul eventually converted, but the family was still not comfortable. "In Vera's family, no one had ever married outside of their religion," says Paul. "So we eloped to Las Vegas. I was 22 and Vera was 21."
Read complete story (pdf).
On the Road for Children's Health, Cedars-Sinai Catalyst
On a bright spring morning, Heather, a preschool teacher, is filling out forms outside a cheerfully painted RV parked in front of Worthington Elementary School in the community of Inglewood. Her youngest son, Dylan, is in need of medical care. "Dylan just turned four and hasn't seen a doctor in a couple of years," says Heather. "Some things happened in my life that left me without health insurance, so we're getting caught up on all of his immunizations and filling out the medical history forms, so he can go to school."
The RV is actually a custom-built state-of-the-art mobile medical unit, and Dylan is the first patient of the day for the bilingual medical team of health and social service professionals that brings no-cost primacy care to areas of the city where children and adults have the poorest health conditions and the greatest difficulty in accessing care.
Read complete story (pdf).
Breathing New Life into Lung Surgery, Cedars-Sinai Discoveries
To observe a 30-minute "wedge resection" on a middle-aged woman with Robert McKenna, MD and his team is to watch a wonder of surgical efficiency. In the operating room the lights are dimmed, everyone is covered from head to toe in green scrubs, and music is playing on someone's iPod. But there is very little blood and, strangest of all, no one is looking down at the patient, whose draped body is barely visible. Instead, all eyes are up, staring at three large color television screens, focusing on the movement of their instruments inserted through three small incisions in the patient's chest. One is for a tiny video camera used to project magnified pictures of the chest cavity onto a screen, one for an instrument to hold the lung, and one for a "stapler" which removes the lung on both sides so there is no bleeding or air leakage. The patient goes home by the next day.
Read complete story (pdf).
An Ethical Perspective on Surgery, Cedars-Sinai Discoveries
What happens when a nurse and a social worker believe an operation scheduled for an elderly patient is not in the patient's best interest? What if a living donor is unaware of the risks involved in a transplant? What should the medical team do if a son insists on an operation for his mother but her advance directive says no extraordinary measures?
At Cedars-Sinai, assistance is only a phone call away. The Center for Healthcare Ethics, via its Clinical Ethics Consultation Service, tackles such real-life situations on a daily basis. Working with physicians, nurses, patients, families, and others directly involved in patient care decision making, the CECS's primary aim is three fold: identify the relevant issues; help clarify and articulate the values associated with those issues and with the various options under consideration; and facilitate decision making in a manner that respects the beliefs, commitments, and values of the primary decision makers. Far from dictating what is or is not acceptable, clinical ethics consultants foster communication and understanding, thereby helping patients, families, and care providers alike to come to a decision that is ethically acceptable and in the best interest of the patient.
Read complete story (pdf).
Restoring Balance, Cedars-Sinai Discoveries
Not long ago, people who suffered from depression or addiction—alcohol, drugs, food, nicotine—were regarded as individuals who simply lacked the wherewithal to pull themselves together. Today they are recognized and treated as mental disorders caused, just like other serious mental illnesses, by complex imbalances in the brain's chemical activity.
"Fundamental to all brain diseases we treat," says Dr. Mark Hyman Rapaport, chair of the Department of Psychiatry and Behavioral Neurosciences and holder of the Polier Endowed Chair in Schizophrenia and Related Disorders, "is the fact that there is an underlying deregulation of brain circuitry This deregulation can be modified or improved by a variety of different therapeutic approaches that may include drug therapies, somatic (body) therapies, evidence-based psychotherapies, or a combination of these approaches. What we do," he adds, "is translational behavioral neuroscience."
In fact, the Department of Psychiatry and Behavioral Neurosciences is a hotbed of leading-edge basic and clinical research ranging from the impact of substance abuse in pregnant women to innovative methods of treating depression.
"Some places have patients so they can do research; we do research so we can improve patient care," notes Dr. Robert Pechnick, the associate director of Psychiatry Research at Cedars-Sinai.
The burden of substance abuse on the U.S. economy is estimated at a staggering $414 billion annually*, more than heart disease, diabetes and stroke combined. The high relapse rate is the chief reason for this astronomic cost and the major challenge faced in drug abuse treatment. "The addicted brain loses its ability to make normal choices," says Dr. Pechnick. "A smoker, for example, who sees a cup of coffee and immediately craves a cigarette, exemplifies a 'cue-driven relapse.'" Pechnick is currently testing a compound that blocks cravings and relapse. His goal is within reach: to develop a pill that blocks craving.
Stress is the key driver behind relapse. The good news, according to Dr. Pechnick, is that, "Although the addicted brain is different, gene therapy and other new techniques give physicians the possibility of reversing the brain." Pechnick's research—which includes using new tools, such as DNA microarray technology to find biomarkers for stress—is providing the building blocks for improved substance-abuse and depression treatment.
"We are doing clinical research on most of the new drug treatments for alcoholism," says Dr. Jeffery Wilkins, vice chair of the Department of Psychiatry and Behavioral Neurosciences and director of Addiction Psychiatry. Wilkins, who is the holder of the Lincy Foundation/Andrew Heyward-Amy Moynihan Chair in Addiction Medicine, is well known for advanced treatment in "dual diagnosis" patients: individuals who have substance abuse problems in the context of other mental illnesses, such as depression, anxiety disorder, etc.
Recent breakthroughs in medication for alcoholism, cigarette smoking and pain pill addiction are showing great promise. "For 50 years, alcoholism treatment meant you went to Alcoholics Anonymous and might take Antabuse, and that was it," says Dr. Wilkins. "Two new medications have been recently approved by the FDA to parallel new understanding of the neuroscientific basis of alcohol dependence."
"Addiction alters the brain," explains Dr. Wilkins. "This is something that was discovered very recently. It took three to four million years of evolution for the human species to become what it is today. Addiction 'hijacks' that evolution process. Our ability to survive, to use our memory, our ability to integrate emotions, reasoning, judgment, gets harvested away from family, friends, or work and turned towards drugs. It is extraordinary how that happens—and it is being demonstrated in a variety of research models, and definitely in humans."
The areas of the brain that get affected by the addiction process are the prefrontal cortex (responsible for thought, reason and judgment), the basolateral amygdala (emotions), the hippocampus (memory), and the nucleus accumbens, which plays an important role in reward, pleasure, and decisions.
A new medication with which Dr. Wilkins has been working appears to alter that process. "We have a new understanding of the biology of alcoholism," he says, "and we have new treatments." A four-year clinical trial, in which he was one of the national site principal investigators, demonstrated the ability of a long-acting injectable medicine to decrease relapse. This medication was recently approved by the FDA. "People in this study stopped drinking," he says.
Since stress plays such a major role in the wheel of relapse, the Addiction Medicine program is also focused on helping addicted patients de-stress without drugs, teaching them meditation and other relaxation techniques. "People do really well with meditation and relaxation," says Dr. Wilkins. "What is particularly good about these techniques is that, unlike drugs, there are no side effects."
The next step is to further refine and improve user-friendly aspects of these treatments for alcoholism to make them widely used. "There are about 5,500 addiction experts in the country and about half a million medical practitioners," notes Dr. Wilkins. "To treat alcoholism effectively, you need to get the family practitioner, the internist, and ER doctors linked and supported in some way. Our goal is to have doctors at Cedars-Sinai know how to treat alcoholism or at least know how to work with our group. We are training our staff to learn how to evaluate and prevent alcohol or sedative-hypnotic withdrawal. It is an important issue, because we need to be able to see these problems in patients in order to treat them."
In addition to making advances in the treatment of addiction, the Department of Psychiatry and Behavioral Neurosciences is developing research models that look at the impact of maternal substance abuse—from alcohol, stimulants, and tobacco—on the offspring. It is also spearheading programs to help prevention among children in middle school and high school. "If a child doesn't use illicit drugs or isn't trapped by alcoholism before the age of 15," says Dr. Wilkins, "the chances of having adult addiction problems are dramatically decreased."
Depression is a major problem for over half of the patients seeking help at the Department of Psychiatry and Behavioral Neurosciences. Worldwide, major depressive disorder—characterized by sadness, sleeplessness, fatigue, feelings of worthlessness, and other debilitating symptoms—affects more than 320 million people and is the fourth-greatest source of disability, with a high rate of relapse. Depression often co-occurs with other serious illnesses such as heart disease, stroke, diabetes, cancer, and Parkinson's disease. Physicians and scientists are working on a broad array of studies that seek to alleviate depression in innovative ways, primarily because about 50 percent of patients do not respond to existing treatments.
Dr. Mark Hyman Rapaport authored a large-scale investigation published in Neuropsychopharmacology on the need for long-term, continued augmentation therapy in treatment-resistant depression. Augmentation therapy uses two different treatments that may have different mechanisms of action to create a synergistic treatment response. "The theory" says Dr. Rapaport "is that there may be different areas of the brain that require different interventions at different points in time in order to effectively influence behavior."
"What was remarkable with this study was that we found a subset of people who may need a burst of treatment but don't need continued augmentation with a broad spectrum psychotropic drug to make their antidepressant medication work effectively."
Treatment-resistant depression is associated with the risk of increased morbidity and mortality and with a severely decreased quality of life. "It is one of the most pressing public health needs that we face as a society" Dr. Rapaport says. "We are very encouraged by this research, and we hope this study will stimulate other researchers to pursue investigating the need for the continuation of supplemented therapies."
Dr. Rapaport is also pursuing alternative, non-drug treatments for depression. "The mind and body are intimately connected," he notes, "and we need to really understand the impact of nontraditional and traditional approaches on what we do, which is behavioral neuroscience."
He has received National Institutes of Health funding to study the treatment of depression using alternative therapies, such as changing the ratio of Ornega-3 (fish oil) to Omega-6 fatty acids in diet and using St. John's Wort to treat minor depression. He is also investigating the beneficial effects of massage brought about through release of the brain hormone oxytocin.
"We are making real progress," says Dr. Rapaport. "We are beginning to understand the brain. Thanks to genetics, new research models, and new medications, we have a real chance to make a difference in people's outcomes."
*Source: Substance Abuse: The Nation's Number One Health Problem, Prepared by the Schneider Institute for Health Policy, Brandeis University for The Robert Wood Johnson Foundation, 2001
The Battle Against Alzheimer's Disease, Cedars-Sinai Discoveries
There is no gentle way to tell the story: The number of people with Alzheimer's disease (AD) is skyrocketing. At this moment, it afflicts more than 4.5 million people in the United States alone. As baby boomers age, those numbers will swell to somewhere between 11 million and 16 million men and women.
"In many ways, the brain is like a black box, an enigma," says Dr. Robert N. Pechnick, associate director of Psychiatry Research at Cedars-Sinai. "There are no biochemical tests for diagnosing most neuropsychiatric disorders or for predicting treatment response. We know genes are important. We know environment is important. We have a cluster of well-defined symptoms, but that leaves a lot unexplained."
Alzheimer's disease is a progressive brain disorder that gradually destroys a person's memory and ability to learn, reason, make judgments, communicate, and carry out daily activities. As Alzheimer's progresses, individuals may also experience changes in personality and behavior, such as anxiety, suspiciousness, or agitation, as well as delusions or hallucinations. It is the most common form of dementia, yet it manifests itself differently in each patient. It is primarily an age-related disease: one in 10 individuals over 65 and nearly half over 85 have AD or a related memory disorder.
Dr. Pechnick's "black box" view of the brain is particularly apt with Alzheimer's disease. In an autopsy, two important—but, until then, hidden—characteristics of the disease become visible: "plaques" and "tangles," shorthand for protein deposits in or around the neurons. Scientists don't yet know why plaques and tangles are present in excess amounts, but they are beginning to understand the pathways that produce these two different types of proteins. This, in turn, is leading to new treatments to block their accumulation.
Among researchers there is a "spirited debate," says Dr. Robert Cohen, director of Cedars-Sinai's Psychiatric Research Program, chief of research for Memory Disorders, and holder of the Steven C. Gordon Family Foundation Endowed Chair in Memory Disorders. "Which is the real bad guy: plaques or tangles? Some believe that if you get rid of the plaques you have taken care of the problem; others think plaques are only a part of the problem." Dr. Cohen has not taken sides in the debate, but his studies of cerebral spinal fluid suggest that plaque deposits occur earlier than tangles. "Until we can get rid of amyloid plaques in humans, we won't know which treatment approach will really work."
Given that plaques and tangles are impossible to see in living subjects, the holy grail for AD researchers is to find early biomarkers of the disorder. This would allow physicians to detect the disease through a simple test. "Since most of us will get Alzheimer's if we live long enough," Dr. Cohen points out, "the question is not so much who is going to get it, but rather can we predict at what age an individual is likely to develop it?"
Since the seeds of AD may be planted as early as our late teenage years, the potential inherent in early diagnosis is immense. Electromagnetic differences in the brain tell us that individuals in their twenties with a particular gene (APOE-4) activate their brain differently in response to memory tasks—perhaps less efficiently—than those who do not have the gene. "This means that there are differences in the brain well before aging," notes Dr. Cohen. He is preparing a developmental study of people with the APOE to further pursue this tantalizing clue to early signs of vulnerability to AD.
Dr. Cohen's passion for understanding Alzheimer's disease is both professional and deeply personal. In the mid-1990s, he was a scientist with the National Institute of Mental Health (NIMH). For over a decade, much of his research had been focused on Alzheimer's disease. Ten years into his pioneering work, Cohen made a devastating discovery: His father was developing the disease.
"I was the first one to notice the memory problem," he recalls. In common with so many families of those who have the disease, he encountered physicians who failed to make the diagnosis and, when informed, failed to treat him appropriately. "I would say, you have a problem here, you should do x, y and z, and they would say, well, he's 75 years old. Do you expect him to live forever?"
During his father's 10-year decline, Dr. Cohen and his family dealt with a maze of specialists and healthcare providers who did not talk or consult with one another. "I learned what it's like to deal with fragmented treatment systems and, in general, how poor care is for older people."
The experience motivated Dr. Cohen to envision a better system of clinical care for people with memory disorders. It led him to leave the pure research environment of NIMH for Cedars-Sinai, where patients' needs drive the research and where research findings translate quickly into patient care. In Cohen's words, "Patients should lead us to solutions."
Dr. Cohen's early studies helped lay the foundation for effective medications to improve early AD symptoms, and significant progress has been made in the assessment of patients with dementia, as well as in our understanding of the causes of AD.
Dr. Cohen's work employs neuroimaging and genetic tools to look at atrophy of the hippocampus, a key area of the brain for memory function. Although the size of the hippocampus diminishes as we age, the rate of shrinkage is increased in some subjects. Those with a specific gene (a variety of the APOE gene) have an increased risk of developing Alzheimer's. "In patients with Alzheimer's disease, the rate of hippocampal shrinkage is increased," says Cohen. "We are studying this to see if it is an indicator of the beginning stages of the disease. If so, we could use this measure to determine which individuals are at increased risk before the onset of memory problems. We could also determine the effectiveness of treatments in preventing the onset of dementia."
Drs. Cohen and Pechnick—two experts who clearly enjoy brainstorming new ideas and approaches—have been working on an innovative research model for Alzheimer's disease. It is ideal for advancing the development of new vaccines, as well as the impact of stem cells on memory disorders, particularly on the regeneration of brain tissue. They are also working with the Board of Governors Gene Therapeutics Research Institute to devise immune therapies.
Today, Alzheimer's patients and their families find few experts and modest help. Typically, a family goes to their general practitioner who asks a few questions, says "You may have Alzheimer's," prescribes a medication and sends you on your way. There is no full diagnostic workup, little provision of care services, and unclear road maps for patient and family. It is a frightening and disjointed world in which families navigate their way from neurology to psychiatry to skilled nursing strictly on their own.
Cedars-Sinai is responding to this deficit of patient care options by establishing the Integrated Memory Disorders Program. Its mission: to transform antiquated care models by creating an innovative, donor-supported, multi-departmental program in partnership with the Alzheimer's Association of Los Angeles (AALA). Spearheaded by Dr. Cohen and the Department of Psychiatry and Behavioral Neurosciences, it will offer comprehensive care for patients and families dealing with memory disorders, including Alzheimer's, frontotemporal dementias, and vascular dementia. Says Cohen, "Cedars-Sinai was particularly attuned to the need for such a program, because many of the patients that were successfully treated for other illnesses at the Medical Center were now succumbing to these disorders."
Collaboration will take place between the departments of Psychiatry, Imaging, Occupational and Rehabilitation Medicine, Neurosurgery, Medicine, and the Division of Neurology, as well as the Alzheimer's Association.
The Integrated Memory Disorders Program will serve as liaison between patients, families, and a range of inside and outside community services. Best of all, it will combine state-of-the-art clinical care with cutting-edge translational research. Physician-scientists, like Dr. Cohen, will identify, through imaging and other techniques, the causes and risk factors of dementias, then apply their knowledge to patients and develop innovative treatments ranging from drugs and immune system therapies to vaccines and the stem cell regeneration of brain tissue.
"We have an opportunity to create something truly special at Cedars-Sinai," says Dr. Mark Hyman Rapaport, chair of the Department of Psychiatry and Behavioral Neurosciences. "There are a number of different AD programs and scientists in Los Angeles, but they are more focused on research questions than on integrating a comprehensive care program with research.
Peter Braun, executive director of AALA, points out, "With AD there are two clients: the person with the disease and the caregiver. So there are really over 14 million people impacted by AD." In Los Angeles County alone, more than 150,000 are affected.
Ironically, just as Alzheimer's research is on the cusp of dramatic advances, proposed federal funding for AD in fiscal 2007 is being reduced. As reported in the July-August 2006 edition of the AARP Bulletin, proposed funding for Alzheimer's research for 2007 is $645 million, down from $652 million in 2006 and $658 million in 2003. To make the Integrated Memory Disorders Program a reality will require, above all, the generosity of donors. The need is great. The vision is powerful. The potential breakthroughs are hopefully on the horizon.
Is There an EHR in Your Future? You Bet, MedicalLife
"At most hospitals, it happens every day," says Dr. Fausto Meza, 35, a Geriatrics Fellow at the Wright Center for Aging in New York City. "Mrs. Smith, 95, with multiple medical problems, comes to the ER, unable to tell anyone what's wrong with her and what her advance-directives are. Continuity of care is interrupted. She is treated aggressively and sent to the ICU, which she didn't want. But at our clinic the Electronic Health Record (EHR) system tells us that Mrs. Smith is in the ER. I can print out her problem list, medications, health care proxy advance directive and notes from her last visit. ER docs are happy to see us."
That scenario is a snapshot of how things may soon be everywhere. Experts are now predicting that just as (information) technology transformed most other professions during the 1990s, it will significantly change the practice of day-to-day medicine in the coming decade. In the very near future, EHRs will eliminate paper charts, paper files, paper records, paper prescriptions, paper directives and anything else now recorded and transmitted on paper. The long-term goal is even grander: not just stand-alone EHRs in every hospital, clinic and physician's office, but software configured so that data can be shared by everyone in the health care system, including patients. Read complete article.
From Wisconsin to Wall Street
Wisconsin Finance Alumni Make Their Mark, Update
These are boom times on Wall Street. The "financialization" of the American economy during the last 25 years has helped turbojet careers and rewards. It has also transformed a fairly insular world into a broader-based meritocracy. "As Wall Street has become more quantitative," observes Brian Yelvington, MS '01, director of credit arbitrage, Collineo Asset Management, "it's opened up."
"Major firms care about talent," agrees Ted Beck, MBA '76, who spent more than 20 years in senior management positions at Citibank/Citigroup and now heads the National Endowment for Financial Education. "What you bring to the table is what people care about. You're supposed to maximize the performance of the organization. If you are good, you form a whole new network of successful people."
A vital Wisconsin-to-Wall-Street network already exists. It includes a significant number of high-profile Wisconsin business alumni who set their sights on Wall Street during the late '70s, '80s and '90s and today are major players.
"Whether she writes on some aspect of personal finance or a nuance of life as a single, Eleanor brings a fresh dimension to her magazine pieces -- probably because first-rate research is coupled with sensitivity, insight and style. You just want to keep reading. What more could an editor ask for -- except, perhaps, that the writer be easy to work with. And Eleanor is."
Patricia Schiff Estess, Editor
Sylvia Porter's Personal Finance Magazine
When She Earns More Than He, Sylvia Porter's Personal Finance Magazine
"When she earns more than heÖ is it role reversal? Or role confusion? Often, some of both. In such a relationship, not only are traditional sex roles turned upside down, but each partnerís self-image may be shaken as well. Her head says her role as chief breadwinner is something to be proud of, but she may feel exploited when she turns over $100 for her mateís new shoes. His head may tell him that being a sculptor is more important than earning a six-figure income, but his self-worth may wither as he loses financial dominance."
What Am I Going To Be Now That Iíve Grown Up? Sylvia Porter's Personal Finance Magazine
"Once upon a time, a mid-life career change was a mid-life crisis. And by and large it wasnít done. Today, greater numbers of people in a better-educated work force expect more from their jobs than a paycheck. They want it all: both to earn a living and fulfill themselves. Because of these increased expectations, mid-life career changes are on the rise."
Is Rural the Answer For You? New Choices Magazine
"Itís late summer in southwestern Wisconsin. Lois Fields, 65, and I, are standing atop a high, broad ridge. Below, the Kickapoo River winds through a verdant valley: gentle, wooded hills and snug farms stretch tranquilly to the horizon. I see why Mother Earth named this valley one of the 10 best places to live in the U.S., why Lois fell in love with it; why she, while a divorced woman, abandoned a comfortable, administrative job and house in Columbus, Ohio, to move here 14 years ago."
Painting Her Own Canvas, Ageless Magazine
"'This is my latest creation,í says Adrienne Wincor, artist, art-dealer, wife and grandmother. She turns the small smooth head of a woman, chiseled out of Italian agate, from left to right. One cheek is normal, the other sunken, as though a piece has been taken out. It seems a perfect metaphor for Adrienneís life."
The Breast Cancer Controversy, Upstate Magazine
"For many years, like so many women, I didn't want to hear about it.
If a friend of a friend went into the hospital, I shuddered and changed the conversation. I especially did not want a graphic picture of the details.
And the details were easy to avoid. Few women patients wanted to talk about it: surgeons remained discreetly silent, and women's magazine pretended it didn't exist. Editors did not view it as one of your up-beat subjects.
But recently all of this has changed. The topic has replaced natural childbirth as the hottest female medical controversy around, much to the distress of many surgeons who believe such matters should be buried in medical journals, but to the delight of a growing minority who feel that women have a right to know about medical debates that directly affect their bodies and their lives.
It—that dreaded, nameless spector—is breast cancer.
It is the leading cause of cancer deaths in all American women and the primary cause of death among those between the ages of 40 and 44. Last year it struck about 73,000 American females.
What are most women afraid of? The standard method of treating breast cancer—a disfiguring operation known as the radical mastectomy. It often evokes more horror than the consequences of the disease itself.
It is a tragic but true fact that in a society in which breasts are regarded as the keystone of sexual attractiveness, women would often, literally, rather die than have a breast removed.
Dr. W. Bradford Patterson, professor of surgery at the University of Rochester and acting director of the Division of Oncology, recently observed, 'There is no doubt in my mind that women sit at home afraid, have anxiety and don't want to face it. For some people it is important that an option of less mutilating treatment be found.'
And this is what the controversy is all about."
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