October 2012 Emory Surgery newsletter Department of Surgery of the Emory University School of Medicine


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Dr. Adams in the OR with his team.
Dr. Adams in the OR with his team.
Dr. Stuart Knechtle
Dr. Knechtle

NIH $20 million transplant grant funds multiple pursuits to advance immunosuppression

Dr. Allan Kirk mentoring a medical student in the lab
Dr. Allan Kirk mentoring a medical student in the lab.

A new $20 million grant from the National Institute of Allergy and Infectious Diseases of the National Institutes of Health will allow Dr. Chris Larsen—chair of the Department of Surgery and principle investigator of this program project grant—and a team of Emory physician/researchers to develop better treatments for organ transplant recipients that help avoid both organ rejection and drug toxicity. While the new grant builds on more than 18 years of pioneering immunology research by Emory scientists, such as the development of the immunosuppressant belatacept by Dr. Larsen, Dr. Thomas Pearson, and other investigators at Emory and Bristol-Myers Squibb, it reflects the fact that significant challenges remain for transplant patients over the long term.

"Improvement in these transplant drugs is still a critical need for avoiding acute and late-stage rejection," says Dr. Larsen. "Ultimately, we want to improve overall health while reducing cost through improved outcomes with fewer drugs."

Belatacept was FDA-approved in 2011 for kidney transplant recipients and is currently being tested in experimental clinical trials for kidney transplant, liver transplant, pancreatic islet transplant, and hand transplant. Although belatacept avoids some of the toxicity of earlier transplant drugs, it is associated with higher rates of reversible acute rejection. And because it is a lifelong therapy, it still includes risks associated with a compromised immune system.

"The most important feature of this award is its support for multiple investigators attacking the problems of immunosuppression from different but complementary angles," says Dr. Allan Kirk, vice chair of research of the Department of Surgery. "The team science approach is the best way to get results to our patients."

In addition to Dr. Kirk and Dr. Larsen, the project leaders include transplantation chief Dr. Stuart Knechtle, recent Department of Surgery transplantation faculty appointee Dr. Andrew Adams, and Dr. Leslie Kean, director of the Pediatric Bone Marrow Transplant Division of the Aflac Cancer Center and Blood Disorders Service, Children’s Healthcare of Atlanta. The teams will work to develop more effective transplant drugs, adjuvant therapies combined with transplant drugs, and strategies to avoid immunosuppressant drugs altogether.

Specific projects will include development of a new generation of costimulation blockers that will safely and more specifically block immune pathways in combination with a new type of antibody therapy; refinement of chimerism-based strategies, which involve combining costimulation blocking drugs with transplant of the donor's bone marrow along with the organ transplant, ideally leading to tolerance without the need for lifelong drug therapy; and development of methods to overcome immune sensitization in patients who have had previous transplants, pregnancies, or blood transfusions and therefore have an increased risk of rejection.

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Jill Binkley guiding a patient through her rehabilitative exercise regimen at TurningPoint
Jill Binkley guiding a patient through her rehabilitative exercise regimen at TurningPoint.

Pilot study hopes to treat possible effects of breast cancer treatment

With funding support from the Avon Foundation, a new pilot study aims to promote monitoring for breast cancer related physical impairments during and after treatment. Principle investigator Dr. Sheryl Gabram, director of the AVON Comprehensive Breast Center, Grady Health System, and surgeon-in-chief of Grady Memorial Hospital, designed the study with Jill Binkley, PT, executive director of TurningPoint Women's Healthcare, a not-for-profit women's rehabilitation center based in Atlanta, and Dr. Winifred Thompson of the Rollins School of Public Health.

"The current model of medical care for women with breast cancer focuses on treatment of the disease, followed by intermittent surveillance to detect recurrence and any other problems patients report," says Dr. Gabram. "While these are extremely critical, most women may have subtle physical impairments as a result of their breast cancer treatment that impact function and quality of life.”

The team's Prospective Surveillance Model (PSM) is the first instance of a dedicated plan for breast cancer patients that guides functional rehabilitation, identifies an individualized rehabilitation prescription, and encourages healthy behaviors during and after cancer treatment. The PSM promotes close monitoring of such common breast cancer-related conditions as shoulder problems, fatigue, weight gain, weakness, lymphedema, and osteoporosis. Ideally, the model will establish a standard practice of early detection of breast cancer treatment impairments through periodic examinations and therapies both during and after cancer treatment, leading to rehabilitative and exercise programs when problems are identified.

"Our research suggests that if feasible, a pre-operative assessment followed by an early postoperative reassessment should take place one-to-two weeks after surgery, and upper-extremity range-of-motion exercises should be initiated within the first month after surgery," says Dr. Gabram. "Being among the first centers to implement this innovative model affords an opportunity to study the true incidence of treatment-related impairments, the feasibility and logistics of implementation, its associated costs, and the degree of patient benefit derived."

The team plans to open the study in November 2012 at the Avon Breast Center at Grady, Winship Cancer Institute, and TurningPoint.

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ETC produces its first app for transplant patients

Frame from ETC's

While kidney transplants give new life to patients with end-stage renal disease, the formidable caveat is that recipients must make a life-long commitment to taking a multitude of medications to sustain tolerance for their new organ. Faced with the esoteric names and complex functions of these drugs, uninformed patients can become skeptical and question the necessity of taking them at all. Failure to do so, however, frequently results in rejection of the new organ.

To address this issue, the Emory Transplant Center (ETC) has developed "Medicines after Kidney Transplant," an iPad app designed to educate patients about their post-kidney-transplant medications. The program acquaints the patient with the basics of immunosuppression, the medicines they'll be taking, and why it is essential to adhere to their medication regimen without skipping doses.

"Drs. Chris Larsen and nephrologist Stephen Pastan worked with Emory pharmacists Sarah Todd and Erika Meredith on the medical content, which I paired with original artwork," says Michael Konomos, biovisualist of the Department of Surgery. "We tested the initial version with patients in the transplant clinic and then redesigned certain components based on their feedback. Generally, we focused on making it easier to use. We're all pretty happy with the current version and agree that it is accessible to all ages and abilities."

The app was added in a pilot capacity to the ETC's post-kidney-transplant protocol in early October. As kidney transplant patients receive their infusion of the recently approved immunosuppressant belatacept, they are given a disinfected iPad with the app preloaded. They can navigate through the program at their own pace as they read captions on-screen or listen to professionally narrated audio.

Future plans for "Medicines after Kidney Transplant" include formal efficacy research and versions in Spanish and for the Web. Complementary applications are in the planning stage, as the ETC explores the newest and most effective electronic tools available to help patients succeed.

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Dr. Timothy Love
Dr. Love
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Patient ward at Soddo
Patient ward at Soddo.

Timothy Love doing his VECD Fogarty Global Health Fellowship at two Ethiopian hospitals

After pursuing an MPH in global health from the Rollins School of Public Health during the first year of his two-year research sabbatical, Emory surgical resident Dr. Timothy Love has embarked on his VECD Fogarty Global Health Fellowship at Soddo Christian Hospital and Myungsung Christian Medical Center (MCM) in Ethiopia. Soddo is located in the southern part of the country, a region where there is limited healthcare available for a population of more than three-million people, while MCM is situated in Addis Abba, Ethiopia's capital city.

The VECD Fogarty Global Health Fellowship is sponsored by the Fogarty International Center of the NIH and features training sites in developing countries that are available through the Vanderbilt-Emory-Cornell-Duke Consortium.

Dr. Love’s research is focused on breast cancer, which represents a non-communicable disease with rising mortality in low- and middle-middle income countries that can be optimally addressed by surgical treatment. His feasibility project will design and implement a multi-level intervention through establishing a formal breast cancer registry, training health workers in clinical breast exams, evaluating post-surgical outcomes, investigating the application of screening/diagnostic ultrasound in individuals with suspicious findings from the clinical exam, and measuring specified clinical endpoints.

Dr. Love's research colleagues for this breast cancer project include Dr. Jon Pollock, assistant program director of the Soddo residency, Emory faculty surgeon, and future coordinator of the Emory surgical resident rotations that will begin at the hospital in July 2013; Dr. Theresa Gillespie, a core member of the Winship Cancer Institute; Dr. Roger Rochat, director of graduate studies, Hubert Department of Global Health Epidemiology, Rollins School of Public Health; and eminent Emory surgical oncologist Dr. William Wood, who is currently serving as PAACS' first academic dean.

In addition to his research, Dr. Love will be supporting the Ethiopian surgical residents enrolled in Soddo's five year surgical residency program, which is sponsored by the Pan African Academy of Christian Surgeons (PAACS).

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Upcoming events

Surgery Faculty Meeting 5:30 - 7:00 p.m., Oct. 30, 2012 TEC, B6300 (please note location change)
Emory Medishare Haiti

Presented by physician and medical student leaders of Emory Medishare Surgery, a cross-national partnership that provides surgical aid to rural communities in Haiti’s Central Plateau.
6:30 - 7:30 a.m., Nov. 1, 2012 EUH Auditorium
Ken Brigham & Michael M.E. Johns sign copies of their new book, Predictive Health: How We Can Reinvent Medicine to Extend Our Best Years 5:00 - 6:30 p.m., Nov. 1, 2012 WHSCAB plaza level
5th Annual Garland Perdue Lectureship

Carotid Stenosis: The Limits of the Endovascular Revolution
Presented by Richard Paul Cambria, MD
Chief, Division of Vascular and Endovascular Surgery; Co-Director, Thoracic Aortic Center; Massachusetts General Hospital
7:00 - 8:00 a.m., Nov. 8, 2012 EUH Auditorium
Surgery Division Chiefs Meeting 5:30 - 7:00 p.m., Nov. 27, 2012 Whitehead Room, EUH
Status of Laparoscopic Surgery for Gastric Cancer

Presented by Nathan Lytle, MD
Clinical instructor, Endosurgery Fellow, Department of Surgery, Emory University School of Medicine
7:00 - 8:00 a.m., Nov. 29, 2012 EUH Auditorium
Symposium on Liver Disease and Transplantation: Multidisciplinary Approach, an ETC and Emory Interventional Radiology CME symposium
Presented by James Spivey, MD, Stuart Knechtle, MD, and Kevin Kim, MD, course directors
8:00 a.m. - 4:30 p.m., Dec. 1, 2012 Atlanta Marriott Buckhead
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