August 2014 Emory Surgery newsletter Department of Surgery of the Emory University School of Medicine


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Emory Medishare's 7th surgery trip to Haiti

Scene from a prior Medishare trip: Dr. Srinivasan performs an ultrasound evaluation with Dr. Viraj Master—a frequent Medishare participant—and then-medical student Lee Hugar.
Scene from a prior Medishare trip: Dr. Srinivasan performs an ultrasound evaluation with Dr. Viraj Master—a frequent Medishare participant—and then-medical student Lee Hugar.

From June 18-July 6, Emory Medishare's faculty surgeons and anesthesiologists; medical students; surgery residents; and mid-level practitioners provided surgical care to residents of Haiti's Plateau Central, the poorest and most medically underserved region in the country. Despite such conditions as oppressive heat, an OR that functioned on a diesel generator, minimal lighting, intermittent power outages, and an autoclave mishap that required surgical instruments to be sterilized off the premises for the first two days of the trip, the team managed to perform 65-to-70 procedures.

"The types of things we take for granted in U.S. hospitals, like ORs with environmental controls, automated scrub sinks, and having enough basic supplies like surgical gloves, are not always the case in a country as impoverished as Haiti," says general surgeon Dr. Jahnavi Srinivasan, who has participated in Emory Medishare's summer trips to Haiti's L'Hôpital Sainte-Thérèse de Hinche since 2010. "It's as if the physical environment consistently conspires against the type of work we do. Compassion for those severely in need is what gets us there, but thinking on our feet and doing our best with not nearly enough is what makes it work."

Born as an affiliate of Project Medishare, a non-profit consortium of U.S. medical schools dedicated to providing comprehensive health and development services in Haiti, Emory Medishare made its first trip to Hinche in 2008. Beyond the objective of providing the highest quality treatment possible to a rural Haitian patient population that has little access to medical care, the heart of Emory Medishare is the interaction between faculty leaders, their resident assistants, and medical students, who receive credit for their involvement as a global surgery elective. Months before they set foot in Haiti, medical students have the responsibility of raising funds to finance the trips, making travel arrangements, recruiting physicians and staff, and stockpiling medical supplies and pharmaceuticals. On the ground, the 3rd and 4th year medical students meet patients at first presentation and diagnosis, follow them to the operating room, observe and assist on procedures, coordinate all facets of postoperative care, and provide for discharge.

Dr. Richard Ricketts performing a procedure with assistance from a medical student.
Dr. Richard Ricketts performs a procedure with assistance from a medical student.

In addition to the medical students and physician staff, the clinical teams include volunteer, Haitian expatriate ICU nurses from Emory University and Grady Memorial hospitals that assist with translating and caring for patients. "The nurses are great liaisons, not only because they speak the language, but because they share a cultural heritage with the patients and the hospital staff," Dr. Srinivasan says. "They are very focused on giving back to their people."

For the first week of the trip, Dr. Srinivasan and the medical students were joined by urologist Dr. Jeff Carney, Medishare-veteran and anesthesiologist Dr. Cinnamon Sullivan, anesthesiology resident Dr. Elizabeth Fuacher, and retired Emory professor and former pediatric surgery chief Dr. Richard Ricketts. "I'm always thinking of how we can involve other specialties in these trips," says Dr. Srinivasan. "Dr. Ricketts made it easy. He approached me at his retirement party and was very emphatic about volunteering. While we've been able to do many of the simple pediatric surgeries over the years, we just aren't used to routinely operating on children. Pediatric surgical care is scarce in Haiti, and Dr. Ricketts is just so fantastic. We were lucky to have him."

In addition to Dr. Carney, the staff for the second week included general surgery resident Dr. Blayne Sayed, general surgeons Dr. Joe Sharma (his third Medishare trip) and Dr. Carla Haack, anesthesiologist Dr. Grant Lynde, and anesthesiology resident Dr. Caitlin Sutton. The third and final week was devoted to surgery follow-up clinic and was supervised by Dr. Barbara Pettitt, director of medical student education for the Department of Surgery, with assistance from Dr. Haack and the 4th year medical students. Approximately 80% of the surgical patients from the prior two weeks returned to the hospital to be seen.

The most common procedures performed during the trip were inguinal hernia tissue repairs, open prostectomies, hydrocele repair, and removal of enlarged lipomas, cysts, benign soft tissue tumors, and other subcutaneous masses.

Dr. Srinivasan's desire to expose medical students and residents to global health issues has remained constant on her Medishare trips, though other motivations have shifted. "When I first started going, I was partially motivated by the idea of placing myself in an environment that would truly test my ability to rise to a challenge. These days, that's just a given. Now—and I believe I can speak for all of my colleagues—our passion is for the Haitian people and knowing that there is a population of patients who will benefit from care that they would be unlikely to receive if not for our us. It's great watching how that realization impacts our students, and it's wonderful to have the opportunity to mentor them through an experience that forms the foundation for a career in global health for many of them."

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Craig Coopersmith
Craig Coopersmith
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Mandy Ford
Mandy Ford

Dr. Coopersmith and Dr. Ford receive multi-PI R01 to study alcoholism and sepsis

Compared to septic patients with no significant history of alcoholism, septic patients with chronic alcohol abuse have increased severity of multiple organ dysfunction and mortality. Dr. Craig Coopersmith, associate director of the Emory Critical Care Center and vice chair of research for the Emory Department of Surgery, and Dr. Mandy Ford, scientific director of the Emory Transplant Center, have received a collaborative R01 from the NIH to study the impact of chronic alcohol abuse on the pathophysiology of sepsis. The team hopes to determine the mechanisms underlying mortality in sepsis following chronic alcohol ingestion with the goal of tailoring an appropriate therapeutic approach for these patients.

This study is in addition to Dr. Coopersmith and Dr. Ford's prior, ongoing R01, which is investigating the effect of pre-existing cancer on sepsis. Both studies benefit from Dr. Coopersmith's experience studying the consequences of and adaptation to sepsis and shock and Dr. Ford's focus on examining pathologic immune responses. For example, Dr. Coopersmith's R01 study "Mechanisms of Intestinal Integrity in Sepsis and Shock" has just been renewed for a third cycle of funding by the NIH, and Dr. Ford is the PI of several studies concerned with T cell activation, programming, and memory generation following transplantation.

The co-PIs have created a murine model that replicates the heightened mortality seen in alcoholic septic patients relative to septic patients with no prolonged alcoholism. While the function and state of the majority of organs are similar between alcohol-fed and water-fed septic mice, the team has found that both gut integrity and components of the immune system are severely dysregulated in the alcohol-fed group. It has become clear that abnormalities in gut integrity and the immune response are exacerbated in alcohol-fed septic mice, and that certain mechanisms appear to be specific to the combination of sepsis and chronic alcohol usage. Specifically, multiple anomalies exist with the combination of chronic alcohol ingestion and sepsis that are absent from either chronic alcohol ingestion or sepsis in isolation.

The new study will seek to understand these mechanisms by examining both gut integrity (apoptosis, permeability, proliferation, and villus length) and the host immune response, with a primary focus on CD4+ T cells and NK cells. The team will examine the crosstalk between the gut and the immune system to determine how shifting gut integrity and altered immune response affect each other in alcohol-fed septic mice. Considering that sepsis affects over 100,000 patients with alcohol use disorders annually and is a very costly, highly lethal disease, gaining an understanding of the physiological interactions underlying mortality in sepsis following chronic alcohol ingestion has significant public health implications.

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Felix Fernandez
Felix Fernandez

Analysis of outcomes for early stage lung cancer surgery could yield better treatment tactics

The Agency for Healthcare Research and Quality (AHRQ) has notified Emory cardiothoracic surgeon-scientist Dr. Felix Fernandez that it will fund his RO1 application "National Longitudinal Outcomes Following Surgical Therapy for Lung Cancer." Dr. Fernandez is the PI of the grant on behalf of the Society of Thoracic Surgeons (STS). The study hopes to identify which patients are at risk for reduced long-term survival following lung cancer surgery and determine the most advantageous surgical strategies for these patients.

"It is well known that lung cancer is the leading cause of cancer mortality in the U.S.," says Dr. Fernandez. "However, the opportunity to lessen that trend is becoming more obtainable because detection of early stage lung cancer is becoming more common. This was demonstrated by recent efforts like the National Lung Screening Trial, which showed that screening heavy smokers with CT scans could reduce lung cancer mortality by 20%. Early detection will allow us to cure more lung cancers with surgery, though we need to understand which procedures will yield the best possibility of non-morbid cures for unique patient types and groups."

The source data for Dr. Fernandez's investigation will be provided by the linkage of the STS General Thoracic Surgery Database (GTSD) with administrative data collected by the Centers for Medicare and Medicaid Services (CMS). The STS-GTSD captures unique patient-level demographic, medical history, treatment, and complication details that are unavailable in other cancer databases, making it perfectly suited for large comparative effectiveness studies of lung cancer surgical strategies, though it is unable to give longitudinal survival data beyond 30 days. This limitation will be resolved by the CMS connection.

"By leveraging two complimentary national datasets to produce a unique cross-linked data infrastructure of individual patient clinical characteristics and longitudinal outcomes that cannot otherwise be replicated, we will identify predictors of long-term outcomes following lung cancer resection, including the optimal strategies with respect to surgical approach and extent of resection," says Dr. Fernandez.

Dr. Fernandez hypothesizes that long-term survival following lung cancer surgery will vary according to individual patient clinical and treatment variables, that such minimally invasive approaches as video assisted thoracic surgery (VATS) and sublobar resections are not inferior in terms of long-term survival compared to more invasive approaches like thoracotomy and lobectomy, and that VATS and sublobar resections are associated with more favorable economic outcomes than the standard methods. These hypotheses will be tested by creating a risk prediction model for long-term survival following lung cancer resection and comparing survival, resource use, and cost according to surgical approach and extent of pulmonary resection.

By establishing those patients at risk for poor long-term survival following lung cancer surgery as well as the most favorable surgical strategies for treating those patients and associated costs, the study results could allow physicians and patients to focus on individual patient characteristics and make better informed treatment decisions, drive quality improvement and value in lung cancer care both nationally and internationally, and guide the development of future prospective trials.

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Welcome our new vascular surgery faculty at Emory Saint Joseph's Hospital

Emory Saint Joseph's Hospital.

The following vascular surgeons are well-established, former members of Emory Specialty Associates based at Emory Saint Joseph’s Hospital. By joining Emory’s division of vascular surgery and endovascular therapy, they have helped create the largest vascular surgery group in Georgia.

By continuing to provide vascular surgical services at Emory Saint Joseph’s, these six surgeons will expand Emory’s patient population and increase the base that can benefit from Emory’s excellence in teaching, research, and clinical care.

Michael Clark
Michael Clark

Michael D. Clark, MD, Assistant Professor of Surgery

Dr. Clark received his MD from the University of Alabama at Birmingham, Class of 1979. After finishing his general surgery residency at the Medical College of Georgia in 1984, he did a peripheral vascular surgical fellowship at Georgia Baptist Medical Center.

Upon completion of his fellowship, Dr. Clark was invited to join the faculty at Georgia Baptist and later served as an assistant clinical professor of the Georgia Baptist/Medical College of Georgia Vascular Fellowship. He joined the Heart and Vascular Institute at Saint Joseph’s in 2001.

Peter H’Doubler
Peter H’Doubler

Peter B. H'Doubler, Jr., MD, Assistant Professor of Surgery

Dr. H’Doubler earned his MD from Harvard Medical School in 1981. He completed his general surgery residency at Massachusetts General Hospital, his vascular surgery clinical fellowship at Emory, and a vascular surgery research fellowship at MGH. He was an assistant professor of surgery at the University of Virginia before moving to Atlanta to begin private practice in 1991.

He served as chief of the vascular surgery section at Saint Joseph’s Hospital from 2000-2004, and was appointed head of vascular services at Saint Joseph’s Heart and Vascular Institute in 2008. Dr. H’Doubler has developed a novel use of the intra-aortic balloon pump as a bridge to heart transplant, and has successfully performed the technique on over 60 patients at Saint Joseph’s.

Charles Lewinstein
Charles Lewinstein

Charles J. Lewinstein, MD, Assistant Professor of Surgery

Dr. Lewinstein originally practiced general and vascular surgery in Laguna Hills, CA. After moving to Atlanta, he began focusing exclusively on vascular surgery. He started practicing at Saint Joseph’s Hospital in 1992. He has served on the board of directors of Saint Joseph’s Heart and Vascular Institute as well as chief of the hospital's section of vascular surgery.

Dr. Lewinstein received his MD from the Keck School of Medicine of USC, completed his general surgery residency at Los Angeles County + USC Medical Center in 1986, and did his vascular surgery fellowship at Baylor College of Medicine from 1986-1987.

Veronica Jones
Mark Mittenthal

Mark J. Mittenthal, MD, Assistant Professor of Surgery

Dr. Mittenthal obtained his MD at Albany Medical College of Union University in 1975 and did his general surgery residency and peripheral vascular surgery fellowship at Emory.

At Northside Hospital, Dr. Mittenthal chaired both the Department of Surgery and the vascular surgery subsection and was medical director of the vascular laboratory. Dr. Mittenthal was also chief of the vascular surgery subsection and directed the vascular laboratory at North Fulton Medical Center. He began practicing at Saint Joseph’s in 2000. Dr. Mittenthal was president of the Atlanta Vascular Society from 2002-2004.

Mark Rheudasil
J. Mark Rheudasil

J. Mark Rheudasil, MD, Assistant Professor of Surgery

Dr. Rheudasil received his MD at the University of Texas Southwestern Medical School at Dallas in 1983 and did his general surgery residency and vascular surgery fellowship at Emory. Upon completion of his postgraduate training, he returned to private practice in Texas.

He began practicing at both Northside and Saint Joseph’s hospitals in 1991, and served as chief of the Department of Surgery at Northside. Dr. Rheudasil has been chief of the Department of Surgery at Saint Joseph’s since 2008, and is the current president of the Atlanta Vascular Society and the Georgia Vascular Society.

Joseph Zarge
Joseph Zarge

Joseph I. Zarge, MD, Assistant Professor of Surgery

Dr. Zarge obtained his MD at Emory University and did his general surgery training at Temple University in Philadelphia. After a year of aneurysm research at Temple, Dr. Zarge completed his vascular surgery fellowship at Loyola University Medical Center in Maywood, IL.

From 1997-2011, Dr. Zarge was in private practice with the Georgia Vascular Clinic, PA. He then joined Saint Joseph’s Hospital Medical Group, which became Emory Specialty Associates in 2012. Along with a robust Atlanta practice, Dr. Zarge sees patients in the North Georgia Mountains in an outreach clinic twice a month. Dr. Zarge has an extensive presentation and publication history, and has been involved in multiple clinical trials involving carotid stenting, aortic aneurysm endografts, lower extremity arterial disease, angiogenesis, and dialysis grafts.

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Upcoming events

Understanding Healthcare in Cameroon: Challenges & Opportunities
Presented by Denis Foretia, MD
– Chief Resident, Department of Surgery, Emory University School of Medicine
7:00 a.m. – 8:00 a.m., Sept. 4, 2014 EUH auditorium
Health Reform – What's Next? 2016 and Beyond: Who Are the New Winners and New Losers?
Presented by Ronald A. Williams
– Former Chairman and CEO, Aetna, Inc.
– President's Management Advisory Board
5:00 p.m. – 6:00 p.m., Sept. 10, 2014 WHSCAB auditorium
Augmenting State Cancer Registry Data for Quality-of-Care Assessment: New Findings and Next Steps in Georgia
Presented by Joseph Lipscomb, PhD
– Professor of Health Policy and Management, Rollins School of Public Health
– Associate Director for Population Sciences, Winship Cancer Institute of Emory University
7:00 a.m. – 8:00 a.m., Sept. 11, 2014 EUH auditorium
Medical Malpractice: Law Enforcing Ethics
Presented by Carl C. Hug, Jr., MD, PhD
– Professor Emeritus, Department of Anesthesiology, Emory University School of Medicine
7:00 a.m. – 8:00 a.m., Sept. 25, 2014 EUH auditorium
Winship Win the Fight 5K Run/Walk
Register here.
Sept. 27, 2014 Emory University's McDonough Field
Department of Surgery Division Chiefs Meeting 5:30 p.m. – 7:00 p.m., Sept. 30, 2014 Surgery Education Office, EUH, H108 & H110
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