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Report
In This Issue:
ST. JOSepH MeDICAL Chronic Hip Pain: Referrals and Remedies ..............2
CHD Risk Factors and Treatment
Recommendations Unique to Women ......................3
Breast Cancer Prevention Using
Raloxifene and Tamoxifen ...........................................4
Management of Thyroid Disease ...............................5
Referring Patients for Bariatric Surgery...................6
In The News ...................................................................7
Educational Opportunities..........................................8
Winter/Spring 2011 By Physicians for Physicians
A Breakthrough in Lung Cancer Screening
This past November, the National Cancer Benign nodule (i.e., granuloma with no further work-up)
Institute (NCI) halted the National Lung Indeterminate nodules (follow with serial CT scans every six
Screening Trial (NLST) early to release to 12 months for two years)
a profoundly favorable outcome. We now Highly suspicious nodules (consider for surgical resection
have definitive data on how to best reduce a or biopsy)
person’s chances of dying from lung cancer,
Cases are discussed at our weekly Thoracic Oncology Tumor
which is the number one cancer killer in the
Board and are reviewed by our radiologists, thoracic surgeons,
Dan Vu, MD U.S., claiming more lives than breast, prostate,
Cardiothoracic Radiologist pulmonologists, medical oncologists, radiation oncologists and
Orange, CA colon, liver and kidney cancers combined.
pathologist. The Tumor Board then renders its recommenda-
The NLST was a well-designed, randomized study comparing tions to the patient’s referring physician. Careful evaluation of
effectiveness of low-dose helical CT vs. standard chest X-ray on lung nodules detected by CT screening led to cancer findings
lung cancer mortality rates in 53,000 asymptomatic current or in all surgeries performed. Best of all, more than 80% of lung
former heavy smokers from 33 academic institutions. The end cancers were detected in the earliest stages and the majority of
point of the study was death, eliminating lead time bias. Partici- patients are cured. Nationally, just 16.4% of lung cancer cases are
pants receiving low-dose helical CT scans had a prodigious 20% discovered in an early, localized stage.
lower risk of dying from lung cancer than participants receiving
This stage shift is critical. The national five-year survival rate for
standard chest X-rays.
localized lung cancer is 80%, compared to less than 5% for lung
At St. Joseph Hospital we have offered a low-dose helical CT cancers which have spread. Given these facts, all patients meet-
screening program since 2004, and we are elated with NLST ing the above screening criteria should be considered for referral
findings confirming our own findings from screening close to to CT screening as well as a smoking cessation program such as
600 patients. St. Joseph Hospital has a successful lung cancer the one St. Joseph Hospital offers.
screening program due to strict criteria:
50 years of age or older
Current or former smokers Case Study
High quality study (performed on a 64-slice helical CT scanner)
A 64-year-old female smoker was referred by her primary care
Accurate radiologist interpretation physician for CT lung screening. The original screening CT found
Low dose CT technique (our screening CT radiation dose is a 2.1mm non-calcified lung nodule and a one-year follow-up scan
lower than that used in the NLST, with a radiation dose 1/5 was recommended. A repeat scan 14 months later showed the
of a standard chest CT) nodule increased to 5mm, and the patient was referred to a thoracic
surgeon. Since the nodule was too small, the surgeon recom-
Multi-specialty review of all possible causes
mended a repeat CT and she was re-scanned in four months. The
Low cost ($125, currently not reimbursed by insurances)
nodule grew to 6.65mm. The patient underwent surgical resection,
was found to have Stage IA lung cancer and was cured.
As with any screening program false positives are a concern,
and many patients do have benign lung nodules. We carefully
analyze all nodules and place them into three categories:
sjo.org/medicalreport
Orthopedic Report
Chronic Hip Pain: Case Study
Referrals and Remedies A 17-year-old high school basketball player was referred to my
office with progressive left hip pain localized to the groin area.
Over the years she had intermittent, mild symptoms. In a recent
When a patient presents with the nonspecific
BMX bike accident she landed on her left hip. Her brother has a
complaint of hip pain, several etiologies may be history of developmental dysplasia of the hip. She described
to blame. Common non-traumatic causes range popping and catching sensations in her hip with certain move-
from bursitis to arthritis, tendonitis, labral tears ments. The patient had not had any physical therapy, medications
and osteonecrosis. Not uncommonly, patients or cortisone injections for pain. Examination revealed normal gait
pattern. There was pain with abduction and external rotation of her
with osteoarthritis in the lumbar spine (L2-3)
hip and significant pain on resisted hip flexion. Bone architecture
may have pain referred to the hip.
appeared normal on X-ray. Clinical evaluation included evidence of
Ayaz Biviji, MD likely left iliopsoas tendonitis with associated snapping hip
Orthopedic Surgeon To assist in discovery of the underlying cause,
Orange, CA syndrome, and differential diagnosis of an anterior labral tear. MR
I recommend that the physician order weight- arthrogram revealed normal labrum and strain of the musculoten-
bearing X-rays to appreciate the extent and subtleties of the condition dinous junction. Radiology provided a sheath injection which gave
or to rule out arthritis. Although some patients will request MRI temporary relief and confirmed the source of pain. With continued
perceiving that it is superior to X-ray, these images may not be helpful symptoms, the patient was referred to physical therapy for hip
for issues such as arthritis and may not be necessary. Also, there are flexor stretching; however, symptoms persisted. She underwent
hip arthroscopy with a rapid recovery and successful outcome.
certain conditions for which an MR arthrogram is more useful than
a standard MRI. If considering an MRI, I suggest referring to an
orthopaedic specialist to determine the best imaging studies.
insidious or
Based on diagnostic results, most primary care doctors formulate a spontaneous onset
plan that for the majority of diagnoses begins with conservative, Systemic symptoms Age >65; limited, painful Anterior Hip
("red flags") or history of range of motion; or
progressive therapeutic measures: inflammatory arthritis history of cancer. trauma. Pain Algorithm
corticosteroid use, or
alcohol abuse
Anti-inflammatories
Order CBC, ESR, or CRP;
Corticosteroids consider arthrocentesis
and appropriate Order x-ray study Osteoarthritis
Low impact exercise imaging study
Physical therapy
inflammatory or NSAIDs, analgesics,
Avascular necrosis,
infectious arthritis,
If pain is unresolved after six weeks, a referral should be made to an osteomyelitis
tumor, or fracture activity modification,
physical therapy, walking
orthopaedic specialist. support, consider
intra-auricular injection
Initiate referral and or specialty referral
appropriate treatment
Patients referred to an orthopaedic surgeon’s office sometimes
assume that a hip replacement procedure is inevitable. Traditional hip Overuse or
sports-related injury
replacement has been an effective mainstay of surgical intervention,
and newer materials have improved implant durability. At the same Clicking or snapping of Suspected stress Pain with resisted
hip joint fractures (athletes or muscle testing, and
time, however, the advent of hip arthroscopy has benefited a number those with osteoporosis) muscle tenderness
of younger patients in my practice with labral tears, early stage
Thomas test and Hip flexor muscle strain/
arthritis or femoroacetabular impingement. Hip resurfacing has been snapping hip maneuver
MRI
tendonitis
an effective alternative to hip replacement in select cases, particularly
in my younger patients seeking to continue a very active lifestyle stress fracture
confirmed: non-weight-
Activity modification,
physical therapy, consider
lliopsoas Labral
including higher impact activities. bursitis tear bearing status
for patient, referral
MRI or referral if
treatment fails
With viable, long-term options to alleviate suffering and restore Activity modification,
buRsiTis
Consider bursal injection
Consider diagnostic
intra-articular injection,
function, it is no longer advisable for patients to “wait as long as they physical therapy, NSAIDs or surgical referral MRI arthography, or
TEAR
referral
can stand the pain.”
CBC, complete blood count; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; Thomas Test:
the contralateral hip is flexed and the symptomatic hip is moved from full flexion to full extension.
A deep click palpated may indicate a labral tear. Source: The Journal of Family Practice, August 2003
2 | St. Joseph Medical Report
Cardiology Report
CHD Risk Factors and Treatment Recommendations
Unique to Women
Cardiovascular Disease (CVD) claims more statin and antiplatelet therapy and less revascularization, and
lives in women than all other causes of death later suffer higher morbidity and mortality.
combined. Despite overall decline in mortality
Many women present with nonspecific ST changes on their ECG
rates for coronary heart disease (CHD) over
and report no regular physical activity, making the exercise
the past decade, the gender gap in mortality
treadmill test less optimal for them. With abnormal ECG, either
continues to widen. Manifestation of CHD
myocardial perfusion imaging or stress echocardiography can be
is about 10 years later for women than men
used to assess ischemia. Pharmacologic testing is appropriate for
Shalizeh Shookoh, MD
Cardiologist
and myocardial infarction (MI) is about 20
women who cannot exercise or present with left bundle branch
Orange, CA years later, explaining women’s greater life
block. Evaluation of coronary artery calcification (CAC) should
expectancy. However, the consequences of
be reserved for women with intermediate risk and atypical or no
premature coronary disease are worse in women. Therefore, it
symptoms.
is crucial to risk stratify and treat women with coronary risk
factors as aggressively as is done for men. In treating women’s risk factors, these recommendations
Some cardiac risk factors have a higher impact on women, should be considered:
Menopausal hormone therapy for cardioprotection is a
such as:
class III recommendation (not useful/possibly harmful) by
Diabetes with CHD risk increasing three- to seven-fold the 2007 Evidence-Based Guidelines for Cardiovascular
compared to non-diabetic women Disease Prevention in Women.
Smoking, putting women at risk for MI 19 years earlier than Antioxidant vitamins and folic acid with or without vitamin B6
their nonsmoking counterparts and B12 supplementation are class III recommendations.
Low HDL and high triglycerides being stronger risk factors in Low–dose aspirin is recommended in women younger than
65+ women compared to same-age men. 65 if there is benefit for ischemic stroke prevention, and
There are also gender differences in symptoms and presentation. women 65 and older if blood pressure is controlled. In both
Although chest pain remains the most common presentation cases, the benefit has to outweigh the risks of GI bleeding
of CHD in women, these patients can present with shortness and hemorrhagic stroke. Aspirin is recommended in high-risk
of breath, GERD symptoms and unusual fatigue. More women women regardless of age.
Diabetic women with blood pressure higher than 130/80mm Hg
present with angina than MI and sudden death, which are seen
more in men. At the time of their presentation of angina, women should be treated with appropriate antihypertensives.
LDL goals for diabetic women are <100 mg/dl or, if possible,
tend to be older, afflicted with diabetes, hypertension and/or
heart failure. Women usually receive less diagnostic testing, less <70 mg/dl in very high-risk patients.
Case Study
A 67-year-old, active woman presented to back if symptoms recurred. Less than a year lesion in the proximal left anterior descending
the office following chest burning and nausea later, her concerned internist referred her artery that was treated with a drug-eluting
that had happened twice while resting. back to the office after a third episode while stent.
Episodes lasted 5-10 minutes. The patient standing in a line. This time, she also report-
attributed her symptoms to indigestion as ed shortness of breath with burning that This case emphasizes how women can present
both episodes occurred after having a spe- spread in her chest. Her risk factors were differently and have normal tests despite
cific medication and coffee. She underwent age and hyperlipidemia. Due to her persis- presence of CHD.
a stress echocardiography, which did not tent symptoms she was referred for coronary
show any ischemia and was told to report angiography. The procedure revealed a tight
sjo.org/medicalreport
Breast Cancer Report
Breast Cancer Prevention Using Raloxifene and Tamoxifen
In women with increased risk for breast Important details:
cancer, tamoxifen and raloxifene reduce the Raloxifene is less effective than tamoxifen in preventing
incidence of the disease by nearly half. non-invasive breast cancer.
Despite these remarkable findings, few women Only tamoxifen is approved in premenopausal women.
are offered an opportunity to address breast Raloxifene is generally considered a better choice given
cancer prevention using oral prophylactics. tamoxifen’s risk profile involving a slight increase of serious
The “low and slow” uptake of tamoxifen and side effects in postmenopausal women, such as deep vein
Lawrence D. Wagman, MD
raloxifene as breast cancer prevention drugs thrombosis (DVT), arterial blood clots, pulmonary embolism,
Breast Surgeon and
Surgical Oncologist may be due to perceptions that toxicities cataracts and uterine cancer.
Executive Medical Director,
The Center for Cancer associated with the drugs are worse than they There are scenarios when tamoxifen is considered reasonable
Prevention and Treatment
Orange, CA are, and that the risk of developing breast can- or preferred, such as in post-hysterectomy women.
cer is lower than it is. Currently, tamoxifen as a generic drug is also less expensive
than raloxifene (Evista).
Both raloxifene and tamoxifen are selective estrogen receptor Both drugs are in widespread use to prevent and treat
modulators (SERMs). Tamoxifen’s role in breast cancer prevention osteoporosis. In prescribing an anti-osteoporotic drug,
came as an unexpected finding in a clinical trial treating breast physicians may want to consider prescribing a SERM for
cancer patients. Similarly, raloxifene’s breast cancer prevention its added, cancer-prevention benefit.
benefits were discovered serendipitously in the mid 1990s through
Raloxifene and tamoxifen are viable, proactive alternatives to dras-
clinical trials studying the drug’s effectiveness in preventing and
tic measures such as prophylactic mastectomy or oophorectomy.
treating osteoporosis in post-menopausal women. A series of clinical
With one in eight women in the United States developing invasive
trials to define the benefit followed:
breast cancer in her lifetime, conversations with high-risk patients
The randomized Breast Cancer Prevention Trial (BCPT), part on these drugs’ benefits and risks are warranted.
of the National Surgical Adjuvant Breast and Bowel Project
See also: cancer.gov; sjo.org/breast
(NSABP), began in 1992 to determine if tamoxifen (vs. placebo)
could reduce the incidence in women who were at high risk for de- P-2 STAR
veloping breast cancer. By 1997, more than 13,000 pre- and post-
350 312
menopausal women had participated in the study. Data showed
300
the results of tamoxifen treatment to be "highly significant," with
250
a 45 percent reduction in the number of invasive breast cancers
200
163 168
seen across all age groups.
150
100
In 1999 a follow-up to the BCPT called the Study of Tamoxifen
50
and Raloxifene (STAR) trial involved more than 19,000 post-
0
menopausal women at increased risk of developing breast can- Gail Model TAM Raloxifene
cer. The women were randomly assigned to receive tamoxifen or Projection
raloxifene. The results, published in 2006, demonstrated that the Source: STAR Trial. This graph shows the number of cancers predicted in the women who participated
in the STAR trial based on the Gail Model risk calculation (312 cancers) compared to the actual results
drugs were equally effective in reducing breast cancer risk. of 163 breast cancers for women on tamoxifen (TAM) and 168 breast cancers for women on raloxifene.
Case Study had a hysterectomy at age 52 for benign 2.2 times higher than the average risk. Her
An executive went to her primary care phy- indications, is active and a non-smoker. physician discussed with her the benefits of
sician for her yearly mammogram. During She began menstruating before age 11, has raloxifene to prevent breast cancer and she
their visit her doctor used the Gail Model never had a child, and has had one biopsy for
began taking 60 mg per day, anticipating
for risk calculation (found at www.cancer. atypical hyperplasia. Her risk profile calcu- usage for the next five years.
gov/bcrisktool). The patient has no history lation revealed a 4% chance of developing
of breast cancer, is post-menopausal, white, breast cancer in the next five years, which is
4 | St. Joseph Medical Report
Thyroid Report
Management of Thyroid Disease
In recent years, the detection and treatment In this new decade, preoperative evaluation of thyroid nodules
of thyroid cancers has swelled to become will be further enhanced by genetic profiling to ascertain high
about 50 percent of my endocrinology prac- probability of thyroid carcinomas. Chromosome abnormalities
tice. It’s a trend that reflects national statis- within the biopsy sample will help us differentiate which areas to
tics on the rate of thyroid cancer diagnosis, leave in or remove. Our practice has been among the top interna-
which is twice as high as it was 20 years ago tional research sites in volume contributing to a ribonucleic acid
and one of the few cancers increasing in fre- (RNA) study of thyroid nodule aspirates.
Herbert I. Rettinger, MD
Endocrinologist
quency. At first glance, this seems to indicate
Orange, CA
an epidemic, but in reality, today’s general
practitioners, obstetrician/gynecologists and nurse practitioners Case Studies
are doing a great job in performing neck exams and finding pal- A very nervous 27-year-old female was referred to my office
pable nodules. Incidental findings have risen with increased use with a partially solid, partially cystic 2.1cm thyroid nodule
of ultrasound, CT and MRI scans. and pain with swallowing. As a teenager she had been treated
for Hodgkin’s disease with radiation and chemotherapy. The
Twenty years ago, before the advent of ultrasound biopsy evalua- patient had positive antibodies indicating underlying autoim-
tions, the finding of a nodule frequently led to surgical interven- mune thyroid disease. An ultrasound-guided fine needle aspi-
rate was performed in my office. Once the fluid was removed,
tion, even though as many as 95% turned out to be benign, hy-
the pain dissipated. She left our office relieved, with a simple
perplastic lesions. Today we are able to reassure patients that the
BAND-AID® on her neck, and drove herself home. Pathology
vast majority of thyroid nodules are benign, and the malignant was fortunately negative and she will be followed by serial
neoplasms found usually present at much earlier stages. office ultrasounds. Similar scenarios play out regularly on
numerous other patients each week and many unnecessary
Nearly half of the nodules detected by ultrasound have escaped surgeries are avoided.
discovery on clinical examination. Ultrasound-guided fine-
needle aspiration (FNA) is the most effective method available
to distinguish between benign and malignant thyroid nodules,
with nearly 95% accuracy. Only those lesions with clearly malig-
nant or suspicious characteristics are removed.
Patient with thyroid nodule
Algorithm for
Thyroid Nodules FNA: fine needle aspiration; N: normal;
TSH: thyroid-stimulating hormone (thyrotropin);
TSH US-FNA: ultrasound-guided fine-needle
aspiration.
Abridged and modified from: Castro, MR,
Gharib, H. Pract 2003; 9:128.
TSH-N or TSH -
Ultrasound Radioisotope scan
to assess need for FNA and ultrasound (RAIU)
Cold Hot
Doesn't meet Meets
criteria criteria Observation
Treatment in overt
hyperthyroidism and
selected cases of
Fine needle aspiration subclinical
Monitor hyperthyroidism
sjo.org/medicalreport
Bariatric Report
Referring Patients for Bariatric Surgery
Primary physicians are increasingly discuss- Other barriers to bariatric surgery referral include:
ing bariatric surgery with their patients for
Age – We’ve treated patients as young as 20 who have an accept-
sustained, substantial weight loss and lessen-
able degree of maturity. Recently I’ve seen a trend toward more
ing of co-morbidities. They realize the uphill
older-adult referrals and have operated on patients in their early
battle obese patients face with non-surgical
70s. These cases require an even more critical eye on the risk/ben-
weight loss, and confidence in the procedure
efit ratio. Another consideration with elderly patients is that habits
itself is heightened. At bariatric surgery Cen-
are deeply ingrained and harder to change.
ters of Excellence, such as the one at St. Joseph
Jeffrey Johnsrud, MD
Bariatric Surgeon
Hospital, surgeons predominantly perform Financial Burden – For patients with a legitimate need for sur-
Orange, CA gastric banding which is much safer, easier to gical weight loss, most insurance plans including Medicare now
tolerate and affords faster recoveries than ear- provide coverage.
lier bariatric procedures.
Co-morbidities increasing surgical risk – Risks of obesity often
Once you have exhausted all other weight loss possibilities it’s time outweigh surgical risk. A study in a 2006 New England Journal of
for a frank discussion with your patient about this option. Psycho- Medicine concluded that mortality among morbidly obese patients
social determinants are key: who defer surgical intervention is 10 times the expected rate.
Does the patient have a thorough awareness of weight and its
Lectures where your patients can learn more about our bariatric
related issues? program are held each month at St. Joseph Hospital. For details
Is the patient’s motivation for weight loss strong?
please call 714-771-8298 or visit sjo.org/bariatric.
Does he/she have the emotional skills to stay with
the program? INCREASING PREVALENCE OF EXTREME OBESITY
Some providers’ advertisements for weight loss surgery that would 1000% BMI*>30
BMI*>35
have us believe changes happen overnight do patients a disservice. 900%
Percentage Increase (Baseline 1986)
BMI*>40
BMI*>45
800%
I tell patients to consider surgical weight loss as a two-year project
BMI*>50
700%
requiring seven days a week with no holidays. The cravings, habits 600%
* BMI: Body Mass Index
and social aspects of losing weight do not change with surgery. Our 500%
program’s robust non-surgical aspects - a psychiatric evaluation, 400%
pre- and post- operative dietary counseling, a safe and progressive 300%
activity plan tailored by an exercise physiologist and ongoing sup- 200%
100%
port group meetings - are critical to their success. 0%
1987 1989 1991 1993 1995 1997 1999 2001 2003 2005
Sturm R. Public Health. 2007;121(7):492-496
Case Study her PCP and sees a cardiologist for a stress schedule of eating every three hours. There-
Janet is in her early 40s, 5’4” and weighs echocardiogram. Pre-operative classes are after she settles into a one-to-two pound
270 pounds. Her BMI is 43. She has Type 2 scheduled with the athletic trainer and dieti- per week weight loss. After four months
Diabetes, takes two blood pressure medi- tian. Two weeks prior to surgery she begins Janet has lost 55 pounds, and at one year
cations, and has aching knees limiting her a liquid protein diet. I perform laparoscopic her weight has dropped below 200 pounds.
mobility. A single mother working to sup- banding and she returns home the same day. In the ensuing year she loses another 40
port her family, Janet is struggling to keep pounds and is nearing her weight loss goal.
After the first month she’s lost 20 pounds. With improved glycemic and blood pressure
up with her children. After attending our
Janet describes her food regimen as more control, Janet no longer requires medication.
monthly lecture, Janet decides to take the
troublesome than expected, but follows our She reports an increased energy level and
next step and visits me for a surgical consult.
advice on food choices, portion control, and a better quality of life.
She undergoes an exhaustive work-up by
6 | St. Joseph Medical Report
In The News
A New Leader at Clinical Institute: The Future New Biospecimen Repository
St. Joseph Hospital of Medicine Is Here The Center for Cancer Prevention and
Treatment at St. Joseph Hospital has be-
Steven C. Moreau joined St. Joseph Hos- Through the Clinical Institute at SJO,
come the first community hospital in
pital (SJO) in December 2010 as President numerous evidence-based practice guide-
Orange County to open a Biospecimen
and Chief Executive Officer (CEO). Steve’s lines have been developed and are having
Repository. After three years of planning
career in healthcare leadership spans 35 a profoundly positive impact on patient
and with generous contributions from
years. Most recently he served as Presi- care. This past year the Clinical Institute
the community, the Biospecimen Reposi-
dent and CEO of San Antonio Community developed 31 order sets that contributed to:
tory went online January 1, 2011. The re-
Hospital in Upland, CA. Prior to that he
A sustained patient satisfaction at pository will freeze and store cancerous
was Senior Vice President and Chief Oper-
end of life increase from 83.73% in and surrounding healthy tissue and blood
ating Officer of Hoag Hospital for 14 years.
2008 to 99% in March 2010 samples for a variety of cancers.
Steve remarked, "It's important that our
Decrease in observed/expected
physicians thrive and we must partner with “We are excited to provide an evidence-
mortality from 0.72 in FY 2009 to based biobanking resource for research-
them in this endeavor."
0.68 in FY 2010 ers that will spur development of new
Laborist Program Flourishing A 50% reduction in stable psych/
therapies to treat and cure cancer,” stated
chemical dependency/detox patients' Pathology Program Director Aaron Sas-
Since its inception in January 2010, the
time in Emergency Department soon. “We serve a population with greater
St. Joseph Hospital Laborist program has
delivered favorable outcomes. Approxi- diversity than is found in most academic
In its third year, the physician-led Clini-
mately 5,000 babies are born each year at centers, enabling us to procure a wider
cal Institute has grown to 275 members
St. Joseph Hospital, which includes a sub- range of specimens.”
in 42 specialties, according to Clinical
stantial number of high-risk deliveries. The Institute Medical Director Alejandro St. Joseph Hospital is one of just 30
Laborist program helps ensure timely care Ramirez, MD. For more information, centers in the nation and the only
in emergencies, while the patient’s doctor is visit ClinicalInstitute.org. hospital in California selected by the
en route. Laborist coverage on the Mother- National Cancer Institute (NCI) to par-
Baby Unit is currently available holidays, Latest Surgical Robot Acquired ticipate in its Community Cancer Centers
weekends and week nights. Program (NCCCP). The Center modeled its
In January St. Joseph Hospital acquired
“We’re one of the few hospitals in the state a DaVinci Surgical SI System. Medical biospecimen repository after NCI best
with a laborist program, but it’s quickly Director of the Robotics and Minimally practices.
becoming the standard of care,” states La- Invasive Surgery Program Ashok Kar, “We hope to share this remarkable
borist Medical Director G. Lara Bhatnagar, MD, shared, “St. Joseph Hospital was the resource of biomedical information and
MD. “Our benchmarks show it decreases first community hospital to acquire the tissue specimens with cancer research
risks. We’ve had positive feedback from robot in Southern California in 2003 for investigators locally, regionally and
patients, who feel safe having access to a minimally invasive procedures. With the nationwide for insights into the risk,
qualified obstetrician when their doctor advent of newer technologies and proce- prevention and treatment of cancer,”
isn’t available. We still respect the family’s dures it became essential to obtain the said Lawrence D. Wagman, MD, Execu-
birth plan and their doctor is still in charge. newest generation robot, which allows us to tive Medical Director of The Center for
Obstetricians signing out to the laborist maintain our leadership role in Robotics." Cancer Prevention and Treatment.
like the convenience and stress relief.”
Steven C. Moreau G. Lara Bhatnagar, MD Alejandro Ramirez, MD Ashok Kar, MD Aaron Sassoon, MD Lawrence D. Wagman, MD
President and CEO Obstetrics/Gynecology Anesthesiology Urology Pathology Breast and Surgical
St. Joseph Hospital Oncology
sjo.org/medicalreport
Non-Profit
U.S. Postage
PAiD
Santa Ana, CA
Permit No. 1536
1100 W. Stewart Dr., Orange, CA 92868
sjo.org/physician
For more information about St. Joseph Hospital or to
learn more about the following areas please contact:
Raymond Casciari, MD
Chief Medical Officer Educational Opportunities
714-771-8011 Presented by St. Joseph Hospital
Raymond.Casciari@stjoe.org
Primary Care Physicians are invited to attend:
Kelleen Corfield
Saturday, March 19, 2011
Director of Business Development
Management of Rhinosinusitis,
714-347-7940
Snoring and Sleep Apnea
Kelleen.Corfield@stjoe.org
At the Westin South Coast Plaza, Costa Mesa
Jennifer Kovac
Saturday, May 14, 2011
Physician Relations Specialist
Melanoma Symposium
714-347-7939
At the Balboa Bay Club and Resort, Newport Beach
Jennifer.Kovac@stjoe.org
To register or for more information, please call
Lynn Warrick
1-866-714-1777. You may also register online at
Physician Relations Specialist
sjo.org/PhysicianEd.
714-347-7942
Lynn.Warrick@stjoe.org
EDITORIAl BOARD
Obtain St. Joseph Hospital referral forms Anesthesiology Ophthalmology Surgery - Bariatric
Alejandro Ramirez, MD Timothy You, MD and General
Facilitate physician-to-physician meetings Jeffrey Johnsrud, MD
Cardiology Orthopedic Surgery Eric Pham, MD
Update physician bio information on the Thomas C. Kim, MD Paul Beck, MD
Ayaz Biviji, MD Surgical Oncology
St. Joseph Hospital (sjo.org) website Chief Medical Officer Lawrence D. Wagman, MD
Raymond Casciari, MD Orthopedic Surgery
Receive brochures for specific services Spine Surgery - Vascular
Family Practice Jack Chen, MD Jeffrey Ballard, MD
Lawrence Ehrlich, DO Jeffrey Deckey, MD
Send questions or suggestions
Hematology/Oncology Otorhinolaryngology
Register for new physician orientation and Cindy Tran, DO Robert del Junco, MD
Internal Medicine
tour of hospital D. Sajee Lekawa, MD
Pediatrics
Connie Bartlett, DO
Interventional Surgery - Colorectal
Radiology and General
Mahmood Razavi, MD George Moro, MD
