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					                                                                           Georgetown
                                                 P hysician Update     January/February 2006                                                          Volume 3, Issue 1


                                                                                         GUH Offers
                                                                                         Innovative
                                                                                         Alternative
                                                                                         for Breast
                                                                                         Reconstruction
Photo by Donna Foley




                                                                                         Surgery Uses Patient’s Own
                                                                                         Tissue Rather Than Implants
                       Maurice Nahabedian, MD, uses the DIEP Flap procedure to reconstruct a woman’s breasts from her own abdominal tissue while sparing
                       the abdominal muscles. The procedure requires expertise in microvascular surgery as well as reconstruction techniques.



                       W
                                   ith the arrival of Maurice           Dr. Nahabedian, who is associate          centers for breast and reconstructive
                                   Nahabedian, MD, at George-       professor in the Department of Plastic        surgery in the U.S., and we felt it was
                                   town University Hospital         Surgery at GUH, is the first and only          time to offer this procedure to women
                       in July, the muscle-sparing DIEP Flap        surgeon in Washington, DC to perform          who are interested in breast reconstruc-
                       procedure for autologous breast re-          the DIEP Flap, which requires exper-          tion using their own tissues, rather
                       construction is now available to breast      tise in microvascular surgery as well as      than implants,” says Scott Spear, MD,
                       cancer patients in the Washington met-       reconstructive techniques.                    who is a professor and chairman of
                       ropolitan area.                                  “Georgetown is one of the major                                                continued on page 6




                       Infectious Disease Chief
                                                                                                                               Photo by Donna Foley




                       Reviews Avian Flu
                       F
                                ew people are in as much de-        The only type A subgroups that normal-        infected,
                                mand these days as Princy K.        ly infect humans are H1N1, H1N2, and          although
                                Kumar, MD, Georgetown’s chief       H3N2. “We now know that bird flu can           they tend
                       of Infectious Diseases. And that is in       undergo genetic reassortment and then         to remain
                       the face of a slow-to-start regular flu       infect humans who have no prior im-           healthy.        Princy Kumar, MD, chief
                       season and a threat of an avian influen-      munity, and cause a pandemic similar          H5N1 is         of the Division of Infectious
                       za pandemic that is still not much more      to what happened during the Spanish           believed to     Diseases at Georgetown
                                                                                                                                  University Hospital
                       than a gathering storm. The reason for       flu of 1918,” says Dr Kumar.                   have killed
                       all the attention is that people are eager       Type A in birds mainly affects farm-      140 million birds (some through cull-
                       for details about the avian influenza         yard birds like chickens, ducks and tur-      ing to prevent spread of the virus). An
                       virus known as H5N1.                         keys, which typically become seriously        ability of bird flu to jump from birds
                           H5N1 is a type of influenza A virus.      ill and die. Migratory birds can also be      to humans and other mammals is the
                                                                                                                                                       continued on page 7
    AZYXXI:
                                                                                                      information increases the accuracy of our
                                                                                                      diagnoses,” said Carlos Jamis-Dow, MD,
                                                                                                      radiologist.
                                                                                                          “AZYXXI makes our jobs easier and
    New Clinical Informatics System                                                                   faster,” said Dr. Jamis. “We use the system
                                                                                                      daily. It’s very fast and reliable.”
    Improves Practice of Medicine                                                                         Before the system was available, physi-
                                                                                                      cians sometimes had to spend considerable
                                                                                                      time waiting to locate previous films be-


P
          hysicians at Georgetown University     data together in one location,” explained            cause they hadn’t been returned to the film
          Hospital now have instant access       Furlong. “We can look up a lab value that’s library, or because films were located out-
          to millions of patient records as      up to two years old in a matter of a few             side the facility for those patients who had
part of a unique clinical information sys-       seconds.” The system is user friendly and            not been treated at the hospital recently.
tem that organizes nearly all clinical data      provides sub-                                                                         “We can
into one computer program called AZYXXI          second respons-                                                                    make a compari-
(pronounced “uh-ZIK-see, rhymes with             es to all clinical                                                                son to previous
“Trixie”.) The only clinical informatics sys-    requirements                                                                      films much more
tem of its kind in the nation, AZYXXI was        in as little as                                                                   quickly now, al-
introduced at Georgetown last year. The          one-eighth of a                                                                   though we do not
Azyxxi System was originally developed and       second.                                                                           interpret films
implemented by the Informatics Experts               The dra-                                                                      with AZYXXI,”
and Clinicians in the Department of Emer-        matic change                                                                      explained Dr.
gency Medicine at Washington Hospital            in the avail-                                                                     Jamis. “We can
                                                                                                                                   check to see if an
                                                                  Photo by Donna Foley



Center (like Georgetown, a part of MedStar       ability of this
Health System).                                  data is help-                                                                     abnormality was
    “Physician reaction is incredibly positive   ing to save                                                                       present before,
because of the innumerable benefits that          lives, as well                                                                    such as a tumor
AZYXXI provides,” said Brendan Furlong,          as time and                                                                       or pneumonia.
                                                                       Dr. Brendan Furlong, shown in the Emergency Department      Radiology can
MD, chief of service, Emergency Medicine,        administrative with a patient X-ray supplied via Azyxxi, directed the
who directed the careful diffusion of the        costs. “In the                                                                    also distribute
                                                                       implementation of the Azyxxi system at Georgetown.
technology hospital-wide. “The system            Emergency                                                                         images to clini-
allows us to obtain historical patient data      Department, we don’t always have the                 cians to confirm certain procedures includ-
instantly.” According to Furlong, AZYXXI         luxury of waiting,” said Furlong. “With              ing the correct placement of a chest tube or
acts as a data miner that communicates           the incredible speed of AZYXXI, we can be            central line.”
with many of the different hospital com-         more precise. For example, if a patient has              In August, Georgetown successfully
puter systems and automatically pulls up         an abnormal creatinine, the physician can            launched its Web-based version of AZYXXI.
comprehensive medical information about          find out right away if this is a new problem          Though not quite as fast as the hospital-
individual patients – all with a few com-        or an old problem. We can also avoid the             based system, it can retrieve much of the
puter keystrokes.                                                                          pro-       same information. With online access,
The data include                                                                           cess       physicians can check patient data from
                                                                                                      their offices and even their homes, no mat-
MRIs, CT scans,
X-rays, ultra-
                         AZYXXI is literally changing                                    and
                                                                                        expense       ter what time of day or night. “Geriatric
sounds, echo-          the way medicine is practiced...                                of a huge      physicians are even making house calls
                                                                                                      with laptops and connecting wirelessly to
cardiograms,                                                                          workup
lab results,                                                                        which may         the system to look at labs, x-rays and an-
blood bank information, history and              not be needed depending on the patient’s             giograms from the patient’s home,” said
physical, surgeon’s notes, dictation notes,      history.”                                            Craig Feied, MD, AZYXXI co-founder and
scanned charts and pathology reports, as             In the Intensive Care Unit, AZYXXI has           director, Institute for Medical Informatics,
well as patient demographics and contact         allowed clinicians to stay closer to their           Washington Hospital Center. “These kinds
information.                                     patients -- literally. “With faster access to        of things haven’t been done anywhere in
    The advanced information system liter-       critical patient data, the entire ICU team           the country.”
ally is changing the way medicine is prac-       doesn’t need to walk down to Radiology to                AZYXXI is also facilitating complex
ticed, giving precious time back to physi-       review someone’s films,” said Dr. Furlong.            research and data analysis at Georgetown,
cians while generating less paperwork. The       “They can view them right in the ICU.”               allowing the hospital to quickly spot trends
amount and type of patient data that can be          The difference has been palpable in the and monitor quality of care more efficiently.
retrieved immediately on a single computer       Department of Radiology, too. “We use                    Access to the system is secure, password-
has made it easier for physicians to see and     AZYXXI to access patients’ consultation              protected and is provided only to hospital
treat patients more quickly. “Instead of         notes, surgical descriptions, discharge sum- physicians, private practice physicians who
going to the lab computer to look up test re-    maries, clinical laboratory and pathology            are credentialed at Georgetown, and other
sults and then going to the X-ray computer       results, etc. Interpreting the radiographic          clinical staff including nurses. “There are
to find films, physicians can locate clinical      findings in light of the patient’s clinical                                      continued on page 4

2                                                                                                                    Georgetown Physician Update
  A Range of Solutions




                                                                                                 Photo by Donna Foley
  to Decreasing Mobility
  Georgetown University Hospital’s Joint Restoration
  Center Includes Uncommon Biologic Approach


T
          he first of the baby-boomers turn      few hospitals in the area to embrace this
          60 this year, and as they have        biologic approach for everything ranging
          done throughout their existence,      from torn medial meniscus to chrondoma-
they are changing the face of everything        lacia.
around them, including medicine.                    “Because it’s a more anatomically
    While boomers, as a group, are living       correct repair, the biologic approach
longer, more active lives, their weight-bear-   generally produces more normal results                                  Orthopaedic surgeon Brian Evans, MD, right,
ing joints are paying the price. According      than arthroplasty,” says Dr. Klimkiewicz.                               performs hip replacement surgery.
to the Arthritis Foundation, nearly one in      “As such, it is an especially viable alterna-
three                                                                            tive for                               tic-and-metal combination. The majority
adults     Georgetown tackles knees with                                         younger,                               of hip replacements at the hospital are
                                                                                                                        completed using proven minimally inva-
has been
diag-
           the goal of restoring rather than                                     more active
                                                                                  patients                              sive techniques. Total knee replacements,
nosed      replacing the injured joint.                                           who want                              however, are still most often performed us-
with                                                                              to regain                             ing open surgery, as successful, minimally
arthritis,                                                                        their previ-                          invasive procedures for the knee are still
one of the leading causes of disability in      ous level of physical functioning.”                                     evolving.
the United States today.                           Literature shows that the biologic ap-                                   Despite advances in the field, Dr. Evans
    Georgetown University Hospital’s Joint      proach, introduced a decade ago, is suc-                                is quick to point out that both hip and
Restoration Center is ahead of the curve,       cessful in 70 to 90 percent of cases. But                               knee arthroplasty are life-changing experi-
offering a comprehensive, multidisci-           for patients whose advanced condition                                   ences, and not for every one.
plinary approach to managing disease            makes them poor candidates for the ap-                                      “Ideally, we like to see patients before
and disability of the knees and hips, at all    proach – or if it fails – arthroplasty offers                           their condition deteriorates to the point
stages and for all ages. Under the direction    an effective answer to the unresolved pain                              where arthroplasty is the only option,” he
of Brian Evans, MD, orthopaedic surgeon,        and limited mobility of severe arthritis.                               says. “The comprehensive nature of our
the Joint Restoration Center features the                                                                               service means that we can address almost
complete spectrum of therapies, rang-           Advances in Arthroplasty                                                any ligament, mechanical or biological
ing from the most conservative medical                                                                                  problem through a variety of interven-
management and physical therapy to total        Once the exclusive purview of the old and                               tions, early on.”
joint replacements to revisions of previous     infirm, arthroplasty has become almost
surgeries and implants that failed due to       commonplace within our society, thanks                                  Other Services
subsequent injury or wear-and-tear.             to improvements in techniques and pros-
    What further sets Georgetown apart          thetics. According to the National Center                               Housed in the Department of Orthopaedic
is its dual emphasis on using a biologic        for Health Statistics, about 165,000 hips                               Surgery – which boasts the largest group
approach to knee repair and minimally           and 326,000 knees were replaced in U.S.                                 of sub-specialists in the metropolitan area
invasive techniques for hip replacement         hospitals during 2001 alone. George-                                    – the Joint Restoration Center offers a
whenever possible.                              town’s expertise in total knee replacement                              wide variety of therapies for patients with
                                                recently earned it designation as Top                                   diverse needs and conditions, including
Staving off Knee Replacement                    Provider – one of only 16 hospitals na-                                 complex revision surgeries.
                                                tionwide so honored – by CareScience (a                                     Ironically, as increasing numbers of
John Klimkiewicz, MD, Chief of George-          provider of care management services and                                younger patients seek initial relief from
town’s Division of Sports Medicine, tackles     solutions to hospitals and health systems).                             knee pain through arthroscopy, the more
approximately 40 to 50 knees each year              Georgetown uses the latest materials                                likely they are to develop arthritis in the
with the goal of restoring rather than          – either metal-on-metal or ceramic-on-                                  future. As a result, Georgetown is per-
replacing the injured joint. To do so, he       ceramic – and custom-made implants to                                   forming a rising number of knee revision
transplants living cartilage tissue from the    help prolong the duration of the artificial                              surgeries for failed arthroscopy, as well as
patient or an allograft, effectively rebuild-   joints and reduce the deterioration often                               repairing previous hip replacements due
ing the joint. Georgetown is one of only a      experienced with the more common plas-                                                          continued on page 8

Georgetown Physician Update                                                                                                                                           3
Capsules
Kenneth A. Newkirk, MD                                                                                    Georgetown VIP Health Check
K      enneth A. Newkirk, MD, has re-
       turned to Georgetown University
Hospital, joining the full-time Otolaryn-
                                                                                                          W       ith clear demand for complete wellness checks, performed
                                                                                                                  in one day, Georgetown University Hospital officially in-
                                                                                                          augurated its VIP Health Check Program. Under the medical
gology-Head and Neck Surgery faculty as                                                                   direction of Andrea Singer, MD, the Program was designed to be
assistant professor. Dr. Newkirk is a grad-                                                               convenient for people on a tight schedule – such as corporate lead-
uate of Mount Sinai School of Medicine                                                                    ers or individuals visiting the USA for a short period of time – and




                                                                          Photo courtesy of Dr. Newkirk
and completed his residency training in                                                                   it offers a choice of two complete packages. The Silver Health
Otolaryngology-Head and Neck Surgery                                                                      Check includes a complete physical exam and medical history
at Georgetown University Medical Center                                                                   consultation, comprehensive lab testing, electrocardiogram, chest
in 2001. He completed a National Insti-                                                                   X-ray, ophthalmology assessment and more. The Gold Health
tutes of Health K12 research fellowship                                                                   Check adds an advanced cardiovascular assessment, advanced
at the Lombardi Comprehensive Cancer                                                                      hearing assessment, colonoscopy with possible biopsy, and more.
Center in 2003 and a clinical Head and         Kenneth A. Newkirk, MD                                     Additional tests can be added in consultation with the Health
Neck Surgical Oncology fellowship at the                                                                  Check team. Each package is performed in one or two days. Pay-
M. D. Anderson Cancer Center in Houston, Texas earlier this year.                                         ment for this program is competitively priced, made in advance
    Broadly trained in head and neck surgical oncology, Dr. New-                                          and not reimbursable from insurance companies.
kirk has special clinical interest in cancers of the thyroid, parana-                                          “Georgetown is a natural setting for this kind of program
sal sinuses and larynx. His research involves exploration of the                                          based on our world-renowned physicians and our location here
molecular basis for head and neck cancer.                                                                 in DC. We are close to many corporate headquarters as well as
    Dr. Newkirk has authored and co-authored numerous publica-                                            numerous embassies,” explains Dr. Singer. “And, of course, every
tions including invited chapters, original papers and abstracts/pre-                                      patient at Georgetown is a ‘VIP’ – but we wanted to use that spe-
sentations. He is also a frequent lecturer. His current research                                          cific phrase in our name to attract executives and dignitaries from
includes work on imaging modalities and Parathyroid Adenoma                                               the domestic and international markets to this special program.”
Localization and role of Imaging Studies as Prognostic Determin-                                              The patient care coordinators of the International Services
ates of the role for Neck Dissection.                                                                     department are the backbone of the program. Multilingual and
    Dr. Newkirk is seeing patients with new or suspected tumors                                           experienced in working with the diplomatic community, they
of the head and neck.                                      —D. Foley                                      navigate the scheduling and intensive coordination required for
                                                                                                          the program’s success.
If you have questions or wish to make a referral to Dr. Newkirk,                                              To date, the Health Check program has already exceeded ex-
please call the Department of Otolaryngology-Head and Neck Sur-                                           pectations, serving clients from Washington DC’s corporate leader-
gery at 202-444-8186. Or, call Georgetown Physician Access at                                             ship arena and persons from Germany, Qatar, Congo, Kazakhstan,
202-342-3300 or 1-800-442-4200 outside the DC metro area.                                                 Saudi Arabia, Kuwait and Jordan.                 continued on page 8


    AZYXXI, continued from page 2

many checks and balances in the system to ensure patient confi-                                            speed and reliability,” said Dr. Feied, who was named Microsoft
dentiality is safeguarded and that only people eligible are granted                                       2005 Physician of the Year for his role in developing AZYXXI.
system access,” said Dr. Furlong. “Physicians who want to use                                             The system is installed at the Secretary’s Command Center at
AZYXXI must apply for it and, if approved, must sign a MedStar                                            the US Department of Health and Human Services, and is also
confidentiality agreement and HIPAA privacy statement.”                                                    installed at the DC Department of Health. Both Virginia and
    In addition to the benefits enjoyed by physician users, AZYXXI                                         Maryland used the system for evacuee tracking in the aftermath of
also helps nurses and other hospital staff perform their jobs more                                        Hurricane Katrina.
efficiently and safely. Nurses can track physician orders in real                                             “The future is already here,” said Dr. Feied. “Instant ubiqui-
time and find test results as soon as they are available. Hospital                                         tous access to clinical information is a little bit of the future that
forms are generated very quickly and with more information than                                           we have today and we think everyone will have some day.”
before. “If you need an order sheet or a progress note, it comes
out labeled, bar coded and ready to be scanned,” said Dr. Furlong.                                                                                           — L. Wolfington
    AZYXXI is technically a software program, but it’s much more
than that, according to Dr. Furlong. “The people, the philosophy,                                         To apply for AZYXXI access at the Hospital or on-line, physicians
the hardware, and the system design engineering all come togeth-                                          should call Todd Williams in Patient and Physician Advocacy at
er to present data intuitively to clinicians to facilitate efficient and                                   202-444-3040. Those physicians who have access to the hospital’s
improved patient care.”                                                                                   clinician portal on the Web (www.emedstar.net) can print and
    “AZYXXI helps prevent medical errors because of its unusual                                           download the application and instructions from the site.
4                                                                                                                                                 Georgetown Physician Update
   Multidisciplinary Management
   of Non-Small Cell Lung Cancer
L
         ung cancer is still a scourge, but                                                          of NSCLC. These                                        and less physically challenging for pa-




                                               Photo courtesy of Dr. Marshall
         one that is being vigorously chal-                                                          doctors often treat                                    tients. For use specific to lung cancer (and
         lenged by scientists and clinicians                                                         patients whose lung                                    other soft tissue cancers), CyberKnife®
at Georgetown University Hospital. That                                                              cancer is influenced                                    is used in conjunction with Synchrony
was a prevailing take-home message from                                                              by other conditions,                                   Software, the first technology in the world
a recent symposium featuring doctors                                                                 like chronic obstruc-                                  capable of accurately delivering radiosur-
from Georgetown University and Univer-                                                               tive lung disease, heart                               gery to tumors that are affected by the
sity of Pennsylvania Hospitals. This event                                                           disease, or frailty. The                               respiratory cycle. “Before Synchrony,
revealed the powerful talent and multi-                                                              special needs of these                                 such tumors were, literally, moving tar-
modality approach that is being brought                                                              patients have spawned                                  gets,” explained Dr. Collins. Throughout
to bear in the fight against lung cancer at                                                           the development of                                     the procedure, Synchrony is monitoring
                                               Photo by Donna Foley




GUH.                                                                                                 surgical and medical                                   the target and readjusting its calibrations
    The symposium, hosted by M. Blair                                                                approaches for serving                                 to assure that it is locked on the tumor.
Marshall, MD, Georgetown’s chief of                                                                  them.                                                  Georgetown was the first hospital in the
Thoracic Oncology Surgery, focused on                                                                    These include                                      Mid-Atlantic/Northeast to put the system
advances being made in diagnosis and in                                                              diagnostic tests that                                  to use – with very positive outcomes.
medical and surgical treatment of non-                                                               identify patients who                                      Dr. David Earl-Graef of Georgetown’s
small cell lung cancer (NSCLC). Dr. Mar-                                                             might not previously                                   Department of Radiology discussed
shall is known for her skill in minimally                                                            have been considered                                   another powerful new tool in the arma-
invasive surgical techniques and experi-                                                             good surgical can-                                     mentarium of Georgetown doctors. This
ence in lung volume reduction surgery.                                                               didates; surgical ap-                                  one he hopes will help predict survival
                                                                                                     proaches that preserve                                                         in NSCLC patients.
  HARD FACTS ABOUT                                                                                   lung tissue and mini-                                                          It’s called FDG-PET
                                                                                                     mize damage to sur-                                                            (fluorodeoyglucose-
  LUNG CANCER:
                                                                                                     rounding tissues like                                                          positron emission to-
    Lung cancer is the leading                                                  muscle and bone; re-ordering the timing                                                             mography) and here,
                                                                                                                                     Photo by Donna Foley




  ▲
    cause of cancer deaths.                                                     of chemotherapy and radiation therapy                                                               in simplified terms,
                                                                                in the pre-operative and post-operative                                                             is how it works:
  ▲ Nearly three-quarters of cases                                              periods; and alternatives to older forms of                                                         because tumor
    of NSCLC are diagnosed in                                                   radiation therapy for killing                                                                       cells are very active
    the late stages, Stages III                                                 cancer cells and shrinking                                                                          metabolically, they
    and IV.                                                                     tumors.                                                                                     are hungry for fuel. The
                                                                                    Georgetown Radiation                                                                    fuel is usually glucose, but
  ▲ Overall 5-year survival from                                                Oncologist Brian T. Col-                                                                    the cells will also use FDG.
                                                                                                              Photo by Donna Foley




    NSCLC is 15% of patients.                                                   lins, MD, discussed the use                                                                 Unlike glucose, FDG gets
                                                                                of a new technology called                                                                  trapped within the cancer
                                                                                the CyberKnife®, which is                                                                   cells. Attaching a positron
    NSCLC is one of two types of lung                                           an image-guided high dose                                                                   emitter to FDG causes it to
cancer. It includes squamous cell carci-                                        stereotactic radiosurgery                                                                   light up in PET scans. The
noma, adenocarcinoma, and large cell                                            system, especially useful in cases where                                    more aggressive the tumor, says Dr. Earl-
carcinoma, among others. Although                                               the patient’s lung cancer is inoperable                                     Graef, the higher its contrast against nor-
surgery to remove the cancerous cells is                                        or health makes other types of radiation                                    mal surrounding tissue. With information
the treatment of choice, it is not always an                                    therapy risky. The CyberKnife® uses ad-                                     about the amount of FDG retained by the
option and not usually a cure. Treatment                                        vanced software and technology to make it                                   tumor, the doctors are hoping to improve
options and prognosis depend on the type                                        fast, focused precisely to ablate the tumor,                                                        continued on page 7
and stage of the tumor, its size, and the
patient’s health.                                                               Photos top to bottom: M. Blair Marshall, MD, GUH chief of Thoracic Oncology Surgery; David
    The speakers at this symposium                                              Earl-Graef, MD, chief, Division of Nuclear Medicine at GUH; Charles A. Read, MD, associate
described ways their work contributes                                           professor of medicine and surgery at Georgetown; Shakun Malik, MD, head of the lung cancer
to the multidisciplinary management                                             program at Georgetown’s Lombardi Comprehensive Cancer Center; Brian T. Collins, MD, GUH
                                                                                Radiation Oncologist

Georgetown Physician Update                                                                                                                                                                               5
     DIEP Flap, continued from page 1


     the Department of Plastic Surgery          Flap currently account for fewer than      mastectomy, while about 40 percent of
     at GUH. “The DIEP Flap provides            five percent of breast reconstructions,    patients seek the reconstructive proce-
     good cosmetic results and it spares        since few surgeons are experienced in      dure after mastectomy.
     the rectus abdominis muscle, which         performing the complex procedure.              A three-night hospital stay is typical
     makes it a desirable alternative for       At present, about 75 percent of breast     for both the DIEP Flap and the TRAM
     some women.”                               reconstruc-                                                       Flap procedures,
          The DIEP Flap takes its name          tions involve                                                     since they involve
     from the Deep Inferior Epigastric          implants, while                                                   surgery to two
     Perforator blood vessels, which supply     the TRAM Flap                                                     areas of the body.
     the flap of tissue and skin that’s         procedure is                                                      Implant recon-
     removed from the patient’s abdomen         used for about                                                    struction typically
     during the first part of the surgery.      20 percent of                                                     involves an over-
     In addition to fat tissue and skin, the    breast recon-                                                     night stay for the
     procedure excises the deep inferior        structions. Dr.                                                   first step in the
     epigastric artery and vein together        Nahabedian                                                        process, when tis-
     with their perforators, which pierce       has performed                                                     sue expanders are
     the rectus abdominis muscle to supply      more than 500                                                     inserted beneath
     the overlying fat and skin.                autologous                                                        the skin.
          “To be a candidate for the DIEP       breast recon-                                                          “The hospital
     Flap, a woman must have a certain          structions, in-                                                   stay and recovery
     amount of excess tissue and skin in        cluding about                                                     time are shorter
     the lower abdomen, since the procedure 350 DIEP Flap                      Maurice Nahabedian, MD             for implants be-
     is the equivalent of a tummy               procedures.                                                       cause less surgery
     tuck,” says Dr. Nahabedian.                     “Some women are very averse to        is being performed,” says Dr. Nahabe-
          During the procedure, incisions       having any foreign material put into       dian. “With the DIEP Flap, we want
     are made in the rectus muscle and          their body, so they don’t want implants,” women to refrain from strenuous activ-
     overlying fascia, but the muscle and       says Dr. Nahabedian. “One of the advan- ity for about six weeks — but they can
     fascia are not removed. This reduces       tages of using your own tissue, rather     start driving again when they’re off pain
     the likelihood of post-operative weak-     than implants, for reconstruction is that medicine and have a full range of mo-
     ness and morbidity in the abdominal        it’s as close to mimicking the natural     tion, which is generally about ten days
     region that’s associated                                                                                 after the procedure.”
     with the more widely         “One of the advantages of using your own tissue, rather                              “The success
     performed Transverse         than implants, for reconstruction is that it’s as close to                  rate for the DIEP Flap
     Rectus Abdominis             mimicking the natural breast as you can get...”                             is 98 to 99 percent,
     Musculocutaneous                                                                                         and patient satisfac-
     (TRAM) Flap procedure                                                                                    tion has been very
     for autologous breast reconstruction.      breast as you can get. If you gain or lose high,” says Dr. Nahabedian. “Women
     The TRAM Flap removes part or all          weight, the breast will also gain or lose  can do sit-ups and perform all their
     of the rectus muscle — along with the      weight.”                                   sporting activities after the procedure,
     DIEP vessels, skin and tissue — for trans-      With the DIEP Flap, the transplant- so there’s no compromise in the activi-
     plant to the chest area.                   ed tissue can be used to reconstruct one ties of daily living.”
          “The DIEP Flap is a more compli-      or both breasts, which takes about four
     cated operation than the TRAM Flap,        hours for a single reconstruction and six                                     —H. Daly
     because we’re dissecting out the small     to seven hours for bilateral reconstruc-
     blood vessels from the muscle and reat- tion. The procedure can be performed          For more information, call Georgetown
     taching them to small blood vessels in     in conjunction with a single or bilateral Physician Access at 202-342-3300 or
     the chest area,” says Dr. Nahabedian.      mastectomy, or it can be performed as      1-800-442-4200 outside the DC metro
     “We have to use an operating micro-        an independent procedure.                  areas.
     scope to make the attachments at the            According to Dr. Nahabedian, about
     mastectomy site.”                          60 percent of his patients schedule the
          Dr. Nahabedian estimates that mus- DIEP Flap procedure to be performed
     cle-sparing procedures like the DIEP       when they undergo a single or bilateral


6	                                                                                                           Georgetown	Physician	Update
                                                                                                   NSCLC, continued from page 5
  Avian Flu, continued from page 1

  reason for concern. By early November         in case,’ and particularly Tamiflu. The anti-      their ability to stage cancers and predict
  about 125 cases of the H5N1 flu had            viral should be initiated within 36 hours of      the risk of recurrence.
  been recorded in humans along with 64         onset of flu symptoms to reduce the length             Charles A. Read, MD, associate profes-
  deaths.                                       and severity of illness. However, studies         sor of medicine and surgery at George-
      It is believed that most cases of H5N1    show that giving Tamiflu even sooner,              town, discussed treatment strategies for
  infection in humans are from extremely        within 1 and 1-1/2 hours from the onset of        NSCLC patients with chronic obstructive
  close contact between humans and live         symptoms, has the greatest potential to be        pulmonary disease. Evaluation of lung
  infected fowl. In fact, it’s been most        truly effective.”                                 function is paramount to treatment plan-
  common among people who work — and                Does Dr. Kumar recommend writing              ning for this high-risk group. The goal,
  sometimes even share living and sleeping      prescriptions for patients requesting Tami-       he explained, is to make sure that the
  quarters — with the birds, which shed         flu? “Development of a vaccine against             patients will tolerate radiation therapy or
  virus in their feces. The virus can also      H5N1 is underway. Until it is available,          surgery and have enough remaining lung
  be present in uncooked poultry products       we will be more dependent on oseltamivir
                                                                                                  function to breathe independently. If not,
  and on contaminated surfaces.                 [Tamiflu].” H5N1 virus is resistant to
                                                                                                  they may be candidates for newer forms of
      A major concern is that an avian          another class of anti-viral agents, aman-
  flu pandemic that parallels the flu pan-        tadanes. “However, my personal position is        radiation, such as the CyberKnife® dis-
  demic of 1918, in which an estimated          in agreement with the Infectious Disease          cussed by Dr. Collins.
  20 to 40 million people died, will arise.     Society of America. I do not support in-              Also presenting at the symposium were
  Extrapolating from that, experts are          dividuals stockpiling Tamiflu. This would          John Kucharczuk, MD, of the University
  projecting that 150 million people world-     lead to reduced access for people who             of Pennsylvania, discussing surgery for
  wide could die. The regular seasonal flu       actively require the drug. Furthermore,           IIIB lung cancer, and Shakun Malik,
  is responsible for about 36,000 deaths in     there is a risk of antiviral drug resistance in   MD, head of the lung cancer program at
  the U.S. annually.                            people who use the drug inappropriately.”         Georgetown’s Lombardi Comprehensive
      According to Dr. Kumar, “We don’t             Dr. Richard Waldhorn, former chief            Cancer Center. Dr. Kucharczuk described
  know when a major avian flu will strike,       of the Division of Pulmonary and Critical         cases in which extensive surgery for pa-
  but I do believe that we are due for a        Care Medicine at Georgetown and current           tients with advanced disease, that involved
  severe outbreak. It may not be this year      distinguished scholar of the Center for           other soft tissues and even bone, had suc-
  or next, and it may not even be the cur-      Biosecurity of the University of Pittsburgh       cessfully improved long-term survival and
  rently feared H5N1 bird flu. But, based        Medical Center, added that hospitals must         quality of life. He was careful to point out
  on the history of recurrent major flu          plan for a very large influx of patients in        that this success was based on a very care-
  outbreaks in the past century, we must        the event of a flu pandemic and that “a            ful selection of the patients and intensely
  be prepared. Our major concern about          well-funded and well-designed response            conscientious medical care.
  the H5N1 virus is its impact on the           plan will be key.”                                    Dr. Malik emphasized the importance
  lower respiratory system and pulmonary            Dr. Kumar does, however, suggest that         of careful patient selection, too, but in the
  complications that call for intensive         there are measures one can take to prevent        use of neoadjuvant therapy (chemotherapy
  care,” says Dr. Kumar.                        infection with influenza. One, anyone who          and/or radiation therapy given prior to
      Why so much attention to avian            is eligible for a flu shot should get one.         surgery). She and her colleagues, in an
  influenza now, given that the first case        Two, it is essential to practice good public
                                                                                                  upcoming clinical trial, will be asking the
  of bird-to-human spread of H5N1 was           health measures: wash hands often with
                                                                                                  important question of whether neoadju-
  reported back in 1997? There are sev-         soapy water or with an alcohol-based hand
  eral reasons, Dr. Kumar believes, not         sanitizer; keep hands away from mucous            vant therapy provides survival advantages
  least among them being the specter of         membranes; use a tissue to cover a cough          for patients with NSCLC, and how to
  mass human-to-human transmission,             or sneeze, then toss the tissue in the trash      identify the patients for whom it would be
  although there has been no such sus-          and wash hands. No tissue in sight? Cover         most effective.
  tained transmission to date (only two         your mouth and nose with your sleeve. If              Dr. Marshall agrees with the present-
  probable human-to-human cases). Oth-          you have the flu, help prevent spreading it        ers about patient selection. “We want
  ers are the memory of last season’s flu        by limiting contact with other people.            to improve survival and quality of life
  vaccine shortage; the fact of last fall’s         In preventing bird flu specifically, it is      for a larger number of our patients with
  migratory birds carrying H5N1 to dis-         advisable to avoid close contact with live        NSCLC,” she says. “This will involve a
  tant continents; and the impact on the        poultry, cook poultry thoroughly, and wash        multidisciplinary approach, to increase op-
  American conscience of the failure of         hands and utensils thoroughly after han-          tions for patients who are not candidates
  the response at all levels to the hurricane   dling raw poultry.                                for surgery, which today is the treatment
  Katrina. “These events have raised our                                                          of choice.”
  consciousness.”                                                      —E. Richman, PhD                                   —E. Richman, PhD
      “Supplies of vaccine will be inad-
  equate if there is a flu pandemic,” con-       To contact Dr. Kumar, please call George-         For more information, call Georgetown
  tinued Dr. Kumar. “Patients know this         town Physician Access at 202-342-3300 or          Physician Access at 202-342-3300 or 1-800-
  and are asking for antiviral agents, ‘just    1-800-442-4200 outside the DC metro area.         442-4200 outside the DC metro area.

Georgetown Physician Update                                                                                                                  7
  Joint Restoration, continued from page 3                                             Georgetown Physician Update is an informative bi-
                                                                                       monthly publication containing news of interest
                                                                                     about Georgetown University Hospital for physicians.
to wear-and-tear. The Center’s success      “We have treated patients ranging
                                                                                              Please submit your comments to
rate with revision surgeries is excep-   in age from 17 to 98,” he says. “When        Richard Goldberg, MD, editor, at (202) 444-8645
tional, as it is with other joint proce- your patient experiences persistent pain       or via e-mail at goldberl@gunet.georgetown.edu.
dures.                                                       and a reduction
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Dr. Evans en-
                       Georgetown is one of                  help.”                                Washington, DC 20007


courages physi-        only a few hospitals in —L. Whitlinger                                            Joy Drass, MD
cians to consult       the area to embrace                                                                   President
with the Joint         this biologic approach For more informa-                                       Edmund Cronin, Jr.
Restoration                                                  tion, call George-
Center when
                       for everything                        town Physician
                                                                                                     Chairman of the Board


injections, medi-      ranging from torn                     Access at
                                                                                                   John P. McDaniel, CEO
                                                                                                         MedStar Health
cations, physical      medial meniscus to                     202-342-3300 or
                                                                                                    Richard Goldberg, MD
therapy and            chrondomalacia.                        1-800-442-4200                                   Editor
life-style modifi-                                             outside the DC
cations fail.                                                 metro area.                                 Donna Foley
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                                                                                                              Layout

  VIP Health Check, continued from page 4                                                                     Writers
                                                                                       Helen Daly, Donna Foley, Elaine Richman, PhD,
                                                                                       Ben Waxman, Leslie Whitlinger, Lisa Wolfington

                                                                                                    Editorial Board Members
      In addition, Dr. Singer notes, “We’re delighted that many patients have been          Karen Alcorn            Stephen Epstein, MD
  so pleased with the VIP Health Check that they have chosen to continue their              Julie Andrews            Chris Kalhorn, MD
  follow-up care at Georgetown.”                                                          John Carroll, MD           Princy Kumar, MD
                                                                                        Bruce Davidson, MD           Charles Read, MD
                                                                                         William Davis, MD          Wolfgang Rennert, MD
                                                              —B. Waxman               Steven Davison, MD


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