Oregon Health & Science University

 

About OHSU Connections

OHSU Connections is a quarterly newsletter covering the latest developments and advances in medicine at OHSU for primary care providers. Learn about the many clinical, education and outreach resources available to you and your patients.

Winter 2015 Edition

Clinical Trials

OHSU offers ample opportunity for participation in ongoing research and clinical trials. Our clinical studies would not be possible without the thousands of participants who volunteer each year and the providers who help enroll them.

To sign up one of your patients for an OHSU clinical trial, visit www.ohsu.edu/clinicaltrials.

Continuing Medical Education

Oregon Health & Science University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for medical professionals.

In addition, our traveling continuing medical education (CME) sessions can take place at your clinic, making it convenient for you to meet your professional needs. For information on how to schedule a traveling CME session, contact your provider relations manager. For a complete list of upcoming CME sessions visit www.ohsu.edu/cme.

Upcoming CME Events

4th Annual OHSU Stroke Conference
March 7, 2015
OHSU Collaborative Life Science Building (CLSB), Portland, OR

CME for the Primary Care Physician: What’s New in Lung Cancer Screening, Diagnosis and Treatment
April 29, 2015
Portland, OR

Gastrointestinal Cancer Conference
May 1, 2015
Allison Inn, Newberg, OR

2015 Pediatric Review and Update
October 29-31, 2015
Sentinel Hotel, Portland, OR

37th Annual Salishan Conference: Cardiology for the Primary Care Provider
September 11–13, 2015
Salishan Spa & Golf Resort, Gleneden Beach, OR

4th Annual Clinical Neuroscience on the Oregon Coast: A Symposium for Primary Care Providers
September 18–20, 2015
Salishan Spa & Golf Resort, Gleneden Beach, OR


Familial Hypercholesterolemia

From the OHSU Knight Cardiovascular Institute

Do you have a patient whose cholesterol stays high even with statins? If LDL remains over 190 despite medication, dietary changes and blood pressure control, you may need to consider familial hypercholesterolemia, or FH. This life-threatening genetic syndrome is underdiagnosed, but manageable when identified early.

What is familial hypercholesterolemia?

Familial hypercholesterolemia is a genetic disorder with heterozygous and homozygous forms characterized by high LDL cholesterol from birth. The major risk is very early coronary heart disease and myocardial infarction (the youngest patient with FH-related MI was 6). On average, patients with FH lose 15 to 20 years of life.
FH is not rare. In the United States, between 600,000 and 2 million people have it, and worldwide prevalence ranges from 1 in 200 for the heterozygous form to 1 in 500 for the homozygous form.

Why diagnosing FH is critical

With timely diagnosis, patients with FH can live an essentially normal life span. However, just 45 percent of those with LDL over 190 are diagnosed with FH, even though many have it. Approximately 90 percent of patients with FH go undiagnosed.

For patients with FH, the risk of MI depends on LDL levels, which vary by genotype.


FH Genotype

LDL Without Treatment

Myocardial infarction commonly occurs

Heterozygous (1 in 500 – FH mutation from both parents)

250 to 300

40s and 50s

Homozygous (1 in 200 – FH mutation from one parent)

600 to 700; some patients, 800 to 900

Late 20s to early 30s


How is FH diagnosed?

A lipid panel and family medical history are sufficient for clinical diagnosis. The main characteristics include:

  • High LDL at any age—190 or above
  • Premature CHD—Calcification identified in patients as young as 11
  • Family history of FH or early CHD
  • Tendon xanthomata—Fatty deposits on the tendons
Which patients need screening?

All patients with family history of early CHD or MI and first-degree family members (parents, siblings and children) of patients with FH. The table gives screening recommendations.


Patient Characteristics to Prompt FH Screening

  • Family history of CHD before age 50
  • LDL cholesterol above 190
  • Tendon xanthomata
  • Premature sudden cardiac death in family member
  • Arcus senilis in young patients—These fatty corneal deposits are associated with normal aging, but should raise suspicion of FH in patients from childhood to early middle age.
Treating FH

Nearly 100 percent of FH patients require statins. Generic statins are an excellent way to protect patients who have already had an MI, but patients with FH generally require higher doses of the higher-potency statins. Many FH patients require double or triple combined therapy to bring LDL into a safe range.  

Some primary providers and other non-cardiac specialists are less comfortable with combination therapy regimes for patients already taking high-intensity statins. The OHSU Knight Cardiovascular Institute partners with providers to find the best regimen and assist with management of patients with FH.

New, adjunct and alternative FH therapies

In the last two years, the U.S. Food and Drug Administration has approved two new drugs for homozygous FH: lopitamide (Juxtapid) and mipomersen sodium (Kynamro). OHSU Preventive Cardiology is experienced in prescribing and monitoring these drugs if statin therapy alone is not effective. Patients with LDL above 400 should be evaluated for homozygous FH by a lipid specialist and may be good candidates.
OHSU is also the only Oregon center offering LDL apheresis, an FDA-approved procedure , which we have performed for more than 10 years. Insurance covers the procedure for post-MI patients whose LDL remains above 200 even with medication. Patients with no MI, but an LDL above 300 with medication, also qualify.

For patients who do not respond well or tolerate statins, we support a holistic approach, including alternative and complementary therapies. Supplements and education are always available.
Surgery for drug-resistant FH includes ileal bypass, portacaval anastomosis and liver transplant. OHSU surgeons are experienced in all these procedures.

OHSU clinical trials and FH registry

The Knight Cardiovascular Institute is committed to clinical trials of promising drugs for FH and other lipid disorders. We are one of the few institutions nationwide with a clinical trial and FH registry.

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What’s New in Colorectal Cancer Treatment

From the OHSU Knight Cancer Institute

Colorectal cancer is the third most common cancer in the United States. While surgery is the main treatment for localized colorectal cancer (stages I to III), chemotherapy and radiation also play important roles in treatment for various stages. Neoadjuvant chemotherapy may be used for locally advanced rectal cancer, and both chemotherapy and radiation may be part of initial treatment or therapy for recurrences. The OHSU Knight Cancer Institute offers the most advanced colorectal cancer treatments available in the Pacific Northwest, including some techniques new to the region.

New:Intraoperative electron beam radiotherapy

Intraoperative electron beam radiotherapy, or IOERT, was introduced at OHSU this fall as an adjunct to surgery for patients with advanced rectal cancer. If our multidisciplinary oncology team believes cancer-free surgical margins may be a challenge, IOERT can be a good option.
The OHSU Knight Cancer Institute is one of the few sites nationwide to offer IOERT and the only site in Oregon and Washington. We use the Mobetron system to deliver IOERT to areas that may still harbor tumor cells.

New: Hyperthermic intraperitoneal chemotherapy

In December, a team of nine OHSU Knight Cancer Institute specialists was trained in hyperthermic intraperitoneal chemotherapy, or HIPEC, for patients with advanced colorectal tumors and abdominal metastases. In a procedure called cytoreductive surgery, tumor tissue is excised and heated chemotherapy is administered for 90 minutes before the bowel is reconnected.
HIPEC has been a subject of considerable discussion and some controversy to date. While not every patient with metastatic colorectal cancer is a HIPEC candidate, this treatment shows promise and has improved survival for select patients.

A commitment to multi-specialty care

The OHSU Knight Cancer Institute is committed to multidisciplinary care for colorectal and other GI cancers. Every Thursday, approximately 30 experts attend our gastrointestinal tumor board conference, where we discuss each new case of GI cancer. Attendees include surgical, medical and radiation oncologists, radiation and pathology specialists, genetic counselors and nurses from the clinic and inpatient units. We believe patients, families and referring providers benefit greatly from specialists who work together on each patient’s customized treatment plan.

Minimally invasive treatments

The latest minimally invasive treatments and diagnostic techniques are available at OHSU, including the following.

Transanal endoscopic microsurgery for rectal lesions

Transanal endoscopic microsurgery, or TEM, is an advanced option for precancerous rectal lesions and stage I rectal tumors with favorable prognostic indicators. It offers outstanding tumor visualization, is more precise than a traditional transanal approach and allows the surgeon to resect lesions higher in the rectum.

Endoscopic mucosal resection for polyps

In endoscopic mucosal resection, or EMR, a liquid such as saline is injected under the polyp to lift and separate it from surrounding tissue before resection. This is a leading option for removing large adenomas that can eliminate the need for segmental resection.
EMR is complemented by endoscopic ultrasound, or EUS, for high-definition imaging of the GI tract’s multiple layers. EUS can alert the endoscopist to deeper tumor invasion that contraindicates endoscopic removal.

Endoscopic submucosal dissection—beyond EMR

Endoscopic submucosal dissection, or ESD, is the most advanced technique for removing large polyps or early malignancies from any part of the colon. Rather than removing tumors piecemeal, ESD allows en bloc removal and thus, more complete pathologic evaluation.

Convenient Sunday screening appointments

We are committed to improving colorectal cancer screening rates because colorectal cancer is highly treatable if detected early. We now offer colonoscopy screening appointments the second Sunday of each month. The timing allows patients to prepare at home in greater comfort and avoid missing work. Learn more about second Sunday appointments.

The most experienced screening, diagnosis and treatment

The OHSU colorectal cancer team is your partner for convenient colorectal screening, diagnosis and treatment. We always welcome your questions and the opportunity to consult or offer a second opinion on treatment.

About the OHSU Knight Cancer Institute colorectal cancer team

Our colorectal cancer specialists have extensive knowledge of treatment options for colon and rectal cancers. We work together to offer you and your patients the most comprehensive, multidisciplinary care available, with personalized treatment plans and access to clinical trials.

Contact us

To refer a patient or consult with our team, call the OHSU Physician Consult & Referral Service at 800 245-6478.

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Fetal Echocardiography

From the Fetal Therapy Program at OHSU Doernbecher Children’s Hospital

The risk of congenital heart disease risk is low, but not infinitesimal—one in 100 babies have a heart defect present before birth. While standard prenatal ultrasound can reveal cardiac abnormalities, the basic views of the heart in this screening may also fail to show congenital or structural defects or arrhythmias.

Why fetal echocardiography?

Fetal echocardiography is more sensitive in diagnosing cardiac defects than prenatal ultrasound. This advanced form of screening should be done for fetuses with a higher-than-usual risk of congenital heart disease. Optimal imaging is performed by a pediatric echocardiographer with expertise in fetal imaging, usually between 18-24 weeks. The majority of serious cardiac defects can be identified during this time, though earlier imaging is sometimes indicated for high-risk fetuses.

Indications for fetal echocardiography

Fetal echocardiography is appropriate in the setting of a family history of CHD in a first-degree relative, maternal use of certain medications (ACE inhibitors, retinoic acid and NSAIDS), maternal phenylketonuria or rubella, diabetes mellitus, twins or in vitro fertilization.

Clinical suspicion is another important indication for fetal echo. Concerns about a potential cardiac abnormality or the presence of other extracardiovascular abnormalities (including increased nuchal thickness) found by a primary care provider or OB-GYN warrant a closer look. Examination by a specialist in fetal echocardiography can reveal the cardiac structures in much greater detail than ultrasound. Fetal echo can help reassure parents and provide important information for delivery.

The table gives the major indications for a fetal echocardiogram at a glance.

Reasons for fetal echocardiography referral

  • Family history of congenital heart disease in first-degree relative
  • Certain maternal medications—ACE inhibitors, retinoid acid, NSAIDS in the third trimester
  • Maternal phenylketonuria
  • Maternal rubella
  • Maternal diabetes mellitus—before pregnancy or diagnosed in the first trimester
  • Monochorionic twins
  • Pregnancy conceived by IVF
  • Suspicion of cardiac abnormality
  • Presence of other systemic abnormalities
  • Increased nuchal thickness
  • Fetal hydrops
Does prenatal diagnosis make a difference?

Numerous studies have consistently demonstrated that prenatal diagnosis improves the outcomes for the affected baby. When a cardiac diagnosis is made before birth, those babies have shorter delays from diagnosis to treatment, less multi-organ failure, fewer neurologic events and less pre- and postoperative mortality. Additionally, because of these improved outcomes, prenatal diagnosis has been shown to reduce health care costs significantly.

Ultrasound screening: is it enough?

Based on surgical numbers from OHSU Doernbecher Children’s Hospital, it is estimated that only about 50 percent of congenital heart defects are diagnosed prenatally. This is partly because routine fetal ultrasound requires only three views of the heart to look for signs of congenital heart disease. Studies in the United States and elsewhere show that ultrasonographers trained to perform six views of the fetal heart have a significantly higher ability to detect congenital heart disease. Missed abnormalities typically appear on those non-standard views.

Faculty from the OHSU Doernbecher Fetal Therapy Program offer CME lectures in the community and provide guidance on more detailed imaging techniques.

Benefits of a multi-disciplinary fetal therapy clinic

The OHSU Doernbecher Fetal Therapy Program is the only place in Oregon that brings together maternal-fetal, neonatal and pediatric specialists to plan a coordinated approach for fetal diagnoses after birth. Through OHSU Doernbecher, you and your patients have access to a full range of pediatric subspecialists, including experts from cardiology, urology, surgery, neonatology and more.

We coordinate care for the family’s convenience and comfort. In the fetal therapy clinic, parents consult with their customized multi-specialty team, receive a plan for prenatal monitoring and delivery and have all follow-up appointments coordinated. We present the team’s ideas to the family and referring providers, including diagnostic details, treatment options, what to expect and plans for postnatal pediatric care.

Your partner for fetal screening

Experts recommend fetal echocardiography for patients who are pregnant and have a family history of congenital heart disease or other indications above. If you have concerns about a patient with or without these indications, we encourage you to contact us with questions.

The Fetal Therapy Program at OHSU Doernbecher Children’s Hospital is always available to provide consultation, screening expertise and assistance in planning delivery and neonatal care. Our experienced providers and specialized care coordinator are here to help you meet your patients’ needs.

Contact us

To refer a patient or consult with our team, call the OHSU Physician Consult & Referral Service at 888 346-0644.

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Women and Pituitary Disorders

From the OHSU Northwest Pituitary Center

Pituitary disorders can pose a diagnostic challenge. As with many disorders, it is helpful to know some of the signs and symptoms, and how pituitary disorders may present differently in women and men. For example, menstrual cycle changes and fertility issues can point to a pituitary disorder, and knowing about pituitary issues in pregnancy can aid early diagnosis for potentially high-risk complications.
In this article, based on our own knowledge and a thorough review of the current literature on women and pituitary disorders, we suggest points to consider when evaluating patients. As always, the OHSU Northwest Pituitary Center team is glad to consult with you on diagnostic or treatment concerns.

Menstrual Changes

Amenorrhea, oligomenorrhea and polymenorrhea can signal a pituitary disorder. For example, over half of women with acromegaly have menstrual irregularities, as do more than 70 percent of women with Cushing’s syndrome. Pituitary adenomas, the most common intracranial neoplasm, can often cause irregular menstruation, and prolactinomas are associated with oligo- or amenorrhea and infertility.

Fertility Issues

The most common infertility-related ovulation disorders involve hypothalamus-pituitary-ovarian dysfunction. An hCG test for pregnancy is the first step in evaluation. Additional tests are listed below.

Diagnostic Testing for Secondary Amenorrhea and Infertility
  • Thyroid stimulating hormone and free thyroid hormone (TSH and free T4)
  • Prolactin testing and evaluation
  • Follicle stimulating hormone/Luteinizing hormone (FSH/LH)
  • Estradiol
  • Signs of virilization or hyperandrogenism
Pituitary Disease in Pregnancy

Prolactinomas, the most common pituitary adenomas, occur most often in the peak childbearing years of 25-43. For microprolactinomas (< 1 cm), we recommend clinical examination and visual field testing every 3 months during pregnancy, and every 1 to 2 months for macroprolactinomas (> 1 cm).

Other Pituitary-related Conditions in Pregnancy

Condition Risks, clinical considerations
Acromegaly If untreated, can cause gestational diabetes and hypertension, babies large for gestational age. Requires careful monitoring for both mother and child.
Cushing syndrome Hypertension, diabetes, myopathy, postoperative wound infection and dehiscence, high fetal mortality, premature labor.
Lymphocytic hypophysitis Most cases happen in pregnancy or postpartum (average age of onset 35-38 years). Visual loss, severe headache most common presenting symptoms. May cause potentially fatal central adrenal insufficiency.
Sheehan syndrome Women presenting with history of postpartum hemorrhage, lactation problems and postpartum amenorrhea or oligorrhea should be evaluated.
Diabetes insipidus Postpartum diabetes insipidus is most common with Sheehan syndrome or lymphocytic hypophysitis.

Pituitary Hormone Replacement Issues

Careful testing, dose adjustment and possible endocrinology consult recommended for women:

  • Adding thyroid hormone replacement to growth hormone (GH) therapy
  • Adding estrogen replacement to levothyroxine therapy
  • Adding GH replacement to oral estrogen therapy
  • Treated with testosterone or dehydroepiandrosterone (DHEA) for androgen replacement

From Fleseriu M, Yedinak CG, Brzana J, McCartney S. Pituitary disorders—specific issues for women. In Laws ER, Ezzat S, Asa SL, Rio LM, eds. Pituitary Disorders: Diagnosis and Management. Hoboken, NJ: Wiley, 2013. 167-178.

Your partner for pituitary diagnosis and treatment

For patients with a known or suspected pituitary disorder, diagnosis can be complicated and there may be multiple treatment options, including a combination of treatments. A comprehensive center such as the OHSU Northwest Pituitary Center can help you diagnose and treat patients faster and more effectively for improved quality of life and better outcomes.

About the OHSU Northwest Pituitary Center

We diagnose and treat more patients with pituitary conditions than any other center in the Northwest. Director Maria Fleseriu, M.D., F.A.C.E., is an internationally recognized pituitary expert. Patients can be evaluated at OHSU’s conveniently located Center for Health & Healing in the South Waterfront District of Portland, with most evaluations completed in one day.

Contact us

To refer a patient or consult with our team, call the OHSU Physician Consult & Referral Service at 800 245-6478. For a second opinion on a pituitary issue, contact Maria Fleseriu, M.D., F.A.C.E., at fleseriu@ohsu.edu.

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