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Posts from the ‘Chicago’ Category

This Is Not Your Grandparents’ Back Surgery (article)

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Chicago Health Magazine, Fall 2015 print edition

This Is Not Your Grandparents’ Back Surgery

By Heidi Kiec

Some of you may recall a grandparent or elderly neighbor constantly stooped over and in pain after an open-back spinal surgery. Previously, patients having surgery to treat lumbar stenosis, essentially a spur or bony callus on the spine, had muscles cut and bones and ligaments removed in order for the surgeon to even begin addressing the pathology of the pain. Hospital stays were nearly a week, recovery time could be months, and up to eight-inch scars remained.

“When you remove all that bone and ligament it destabilizes the spine and leads to more degeneration and more chronic back pain and makes it more likely for a subsequent fusion,” says Jonathan Citow, MD, founder of the American Center for Spine and Neurosurgery in Libertyville and the chief of Neurosurgery at Libertyville’s Advocate Condell Medical Center. Luckily, significant advances in robotic technology and three-dimensional image-guidance systems allow today’s neurosurgeons and orthopedic spinal surgeons to perform minimally invasive spinal surgeries with far better results than surgeries in the past.

In the United States, 31 million people experience low-back—or lumbar spine—pain at any given time, and experts estimate that as many as 80 percent of Americans will experience a back problem at some time in their life.

Minimally invasive back surgeries are growing in popularity, especially for pain radiating down the leg (lumbar radicular pain), caused by pressure on the nerve from a herniated disc, a slipped disc (spondylolisthesis), or stenosis. To alleviate a patient’s pain due to compression of a nerve, doctors can perform a minimally invasive decompression surgery such as a microdiscectomy, where only the portion of the herniated disc that is pinching the nerve root is removed; or a laminectomy, in which the roof (lamina) of the vertebrae are trimmed or removed to create space for the nerves leaving the spine.

These surgeries, performed often as outpatient procedures, involve the use of a guide wire inserted through a small incision and placed with the assistance of a fluoroscope, a special type of X-ray machine. A series of tubes are placed over the guide wire to gently spread the muscular fibers and sequentially dilate the tissue down to the vertebrae. Then, the guide wire is removed, a tubular retractor is placed over the tubes, the tubes are removed, and a small microscope is brought into the surgical field to provide visualization for the doctor performing the surgery. Specialized instruments and microsurgical tools are inserted through the same port to perform the surgery. This all happens through an incision that, when healed, resembles a paper cut.

Beejal Amin, MD, a spinal surgeon at Loyola University Medical Center, specializes in minimally invasive spinal surgery. “Patients benefit tremendously due to decreased blood loss, less postoperative pain and shorter recovery time compared to traditional open operations,” he says.

Minimally invasive back surgeries go beyond spinal decompression. Cysts and tumors on the spine can be removed, spinal fusions can be performed, and treatment for deformity corrections, such as scoliosis, are also gaining in popularity.

According to Citow, if a patient is under the care of a surgeon with a good skill set, the risks of minimally invasive back surgery should be far less than the risks of open surgery. The latter risks, which occur in less than 1 percent of cases, include numbness, hemorrhaging, cerebral spinal fluid leakage, infection, nerve root injury, failure to improve and reherniation. But the benefits of minimally invasive surgery are smaller incisions, less anesthesia, shorter hospitalization, less operative trauma to adjacent tissues, faster recovery and less postoperative pain.

“Minimally invasive spinal surgery is not minimally effective,” Amin says.

One rainy day, general practitioner Mathangi Sekharan, MD, slipped and fell and injured her back. Yoga and physical therapy helped reduce her pain at first, but after several years, the pain got worse.

“It got to the point where I had severe leg and back pain, and I couldn’t stand for 10 to 15 seconds to check a patient’s blood pressure,” Sekharan says. “I was in pain all the time.”

She put off having surgery with Citow because she thought it would mean missing too much work. It wasn’t until her 80-year-old mother went to Citow for a minimally invasive hemilaminectomy and started traveling within two months that Sekharan changed her mind. She underwent a right-sided L5/S1 hemilaminectomy with partial discectomy on a Monday, was riding a bike that Friday and returned to work one week after her surgery.

Sekharan and her mother are, literally, walking endorsements for minimally invasive spinal surgery as a transformational approach to alleviating back pain. It’s not your grandparents’ surgery indeed.

End-of-Life Care: The Conversation That Can’t Wait (article)

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Chicago Health Magazine, Fall 2015 print edition

End-of-Life Care: The Conversation That Can’t Wait

By Heidi Kiec

Winston Churchill once said, “Courage is what it takes to stand up and speak; courage is also what it takes to sit down and listen.”

This quote, found in many leadership books, is applicable to a host of situations, but it’s especially relevant to individuals and their loved ones facing end-of-life decisions.

The American Psychological Association defines end-of-life as the time period when healthcare providers expect a patient’s death to occur within six months.

A survey by the Centers for Disease Control and Prevention found that although most Americans would prefer to die at home, only one-third actually do. This number is on the rise, as is the number of patients choosing to die in hospice care, but more can be done to ensure that individuals die according to their wishes. Discussions about those wishes need to happen with doctors and loved ones; however, that’s not always easy.

“It’s almost countercultural to have a conversation and think about preparing for death,” says Dan Ross, certified Jungian psychotherapist and director of clinical services at Heartland Hospice. “We have a deeply embedded cultural attitude that is biased toward the myth of the hero, where death is something to be avoided and battled.”

“Care conversations need to start early but can evolve over time,” says Gordon Wood, MD, associate medical director of Midwest Palliative & Hospice CareCenter, assistant professor of medicine at the Northwestern Feinberg School of Medicine and director of Palliative Medicine and Supportive Care at Northwestern Lake Forest Hospital.

“When people don’t have these conversations in great detail early in the course of their illness, it robs them of the opportunity to work with their medical team to develop a care plan that matches their values and helps them meet their goals. Many patients who don’t have these conversations end up receiving painful, invasive interventions that their families say they wouldn’t have wanted if they had [had] the chance to talk about it ahead of time,” Wood says.

Wood encourages patients diagnosed with a serious illness to find a time when they are still feeling well enough to discuss with their physician and family members their wishes for their future medical care and how they want to live through the remaining time in their life, especially regarding their goals, values, hopes and fears.

It can also be helpful to discuss medical scenarios that may represent an unacceptable quality of life. For example, many ALS patients will eventually have to choose whether they want a feeding tube, and this may represent a quality of life that is acceptable to some patients yet not to others. According to Wood, the only way the medical team knows how to proceed is if patients have expressed their wishes. Dementia, congestive heart failure, cancer and all other serious illnesses come with similar decisions, and these decisions often have to be made when the patients are too sick to communicate their wishes. Wood recommends that patients talk with their doctors early so that when the time comes, the doctors can do everything that individual patient would want and nothing that wasn’t wanted.

A patient’s wishes can be put into writing through advanced directives such as a living will. And a decision-maker who knows these wishes can be named through a Power of Attorney for Healthcare form. But these forms are only helpful if they are readily available and based on careful conversations involving the patient, the individual acting as power of attorney for healthcare and the medical team.

“Advanced directives are not always visible or honored,” Ross says.

Illinois legislation that was passed in August 2014 seeks to change that. A practitioner order for life-sustaining treatment (POLST) is a medical order signed by a physician or other medical practitioner and must be followed. The order indicates the patient’s preferences for end-of-life care and allows specific decisions to be made about resuscitation, ventilators, artificial nutrition, hydration, transfers to hospitals and intensive-care units, and comfort-focused care. The order is portable and follows an individual everywhere.

Since POLST is a signed medical order, a conversation with a medical practitioner is a required part of the process. This communication is extraordinarily beneficial. Studies have found that a person’s level of stress decreases and that that person’s ability to cope with illness increases when options for care are discussed with one’s doctor early on.

Palliative care, designed to treat a patient’s mental, physical and spiritual well-being, should also be discussed with a medical practitioner and loved ones early on. Hospice care, a leading form of palliative care, is often misunderstood by families and individuals who believe that an illness should be fought until the very end, Ross says.

“The mistaken belief is that choosing hospice care means you’re giving up, and that can create conflict within families,” he says.

However, studies have found that patients receiving palliative care have symptoms that are better controlled, lead a better quality of life and may even live longer than patients with similar illnesses not receiving palliative care. Loved ones experience less anxiety, and those appointed as caregivers suffer less posttraumatic stress disorder when palliative care is at hand.

Hospice care is administered wherever the patient lives and may include social workers, spiritual care advisers, hospice aides, volunteers, nutritionists, pharmacists and therapists—including those focused on music and art.

Early and open communication can help patients and their families come to terms with what patients want for their care and how they choose to die.

Patients’ end-of-life wishes are more likely to be met when the goals have previously been discussed.  Those who want a peaceful death at home need to have the courage to speak up. And their loved ones need to have the courage to listen.


 

Resource List

Aid for individuals and families facing end-of-life decisions

 

Cancer Wellness Center
cancerwellness.org

The Center to Advance Palliative Care
getpalliativecare.org

The Conversation Project
theconversationproject.org

Final Roadmap
finalroadmap.com

Illinois Hospice & Palliative Care Organization
il-hpco.org

Midwest Palliative & Hospice CareCenter
carecenter.org

POLST Illinois
polstil.org

Handbook for Mortals: Guidance for People Facing Serious Illness
By Joanne Lynn, Joan Harrold, Janice Lynch Schuster

Peanut Consumption in Infancy Could Prevent Peanut Allergies, Study Finds (article)

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Chicago Health Magazine, online article

Peanut Consumption in Infancy Could Prevent Peanut Allergies, Study Finds

By Heidi Kiec

When it comes to preventing a peanut allergy, it might be best to fight fire with fire. Most young children at high risk of developing a peanut allergy may be able to ward off the allergy by consuming peanut protein starting in infancy, according to the results of a recent study.

Peanut allergy is one of the most common food allergies for children, and it is not usually outgrown. Affecting about 1 to 2 percent of American kids, the allergy is the leading cause of anaphylaxis and death due to food allergy.

The study, published in the New England Journal of Medicine, came up with a very important finding for an at-risk population, notes Scott Sicherer, MD, the immediate past chair of the American Academy of Pediatrics (AAP) Section on Allergy and Immunology.

“The conclusion is that there’s enough evidence to seriously consider earlier feeding of peanut protein in infants who fulfill the (high-risk) criteria,” Sicherer says.

The study, conducted in London by Gideon Lack, MB, BCh, observed participants aged 4 to 11 months old and already deemed high risk for developing a peanut allergy, based on an existing egg allergy, severe eczema or both. At the start of the study, 530 infants tested negative for peanut allergy, while 98 participants had a small allergy to peanuts. The participants were randomly assigned to either regularly consume a food containing peanut protein or to avoid peanuts entirely. These feeding patterns continued until the children turned 5 years old.

The half of the study consuming peanut products were fed at least six grams of peanut protein per week, the equivalent of about 24 peanuts, distributed over three or more meals. The recommended food for participants was Bamba, an Israeli puffed corn and peanut butter snack.

The participants who consumed peanut protein were far less likely to be allergic to peanuts at the age of 5. Of the children in the nonallergic group, only 1.9 percent of those fed peanuts had developed an allergy by the end of the study, compared with 13.7 percent of the children in the group avoiding peanuts. The numbers represent an 86 percent relative reduction in the prevalence of peanut allergy.

And among the participants who began the study with a small allergy, only 10.6 percent of those fed peanuts developed a full-fledged allergy by age 5, whereas 35.3 percent of those avoiding peanuts developed the allergy, representing a 70 percent relative reduction in the prevalence of peanut allergy.

Sicherer believes that this study can help change practice. He notes that prior to this study, the prevailing “knee-jerk reflex for infants who already ate egg and got hives was to avoid peanuts, but this is the complete opposite advice. It’s saying, if you have an egg allergy, I want you to eat peanuts to try [to] protect yourself from developing a peanut allergy, if you’re not already allergic.”

Sicherer warns that children in this study had undergone allergy testing to be sure starting peanut protein was done safely and explains that they ate mushy forms of it—similar to baby food—because whole peanuts and peanut butter are choking hazards to infants.

In 2000, the AAP released guidelines recommending that peanuts be withheld until the age of 3 from children at risk of developing the allergy. In 2008, those guidelines were rescinded, citing a lack of evidence that such delays prevent the development of allergies, but no official recommendation on when to introduce peanuts was put forward by the AAP.

Ruchi Gupta, MD, MPH, associate professor of pediatrics at Northwestern University Feinberg School of Medicine and author of The Food Allergy Experience, appreciates having “evidence that shows it could be beneficial if you introduce (peanuts) early. Pediatricians are already counseling families to introduce foods when they are comfortable. This data supports the potential benefit.

Gupta recommends that any parent who is nervous about introducing peanuts into their high-risk infant’s diet should visit an allergist and get proper testing before starting peanuts.

For parents weary of flip-flopping advice on such important health issues, Gupta considers the results “groundbreaking” and goes on to state, “It’s a very strong study and very well done. What it shows is something that most experts around the country will back. There is additional work to be done, but I don’t think these results will be revoked or changed anytime soon.”