texas medic al center - memorial hermann | houston · pdf file · 2012-12-09texas...

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R M I S C H E R N E U R O S C I E N C E I N S T I T U T E

M E M O R I A L H E R M A N N

J O U R N A LJ O U R N A LJ O U R N A LT E X A S M E D I C A L C E N T E R

Affiliated with The University of Texas Medical School at Houston

IN tHIs Issue

Features

Hypothermia

Lowering the Body Temperature

of Patients May Improve Survival

Rates for Stroke and Other

Neurological Patients

Going Home

Dorothy Malone Regains Her

Independence

Moving toward Improved

Diagnosis and treatment of

Mild tBI

Alex Valadka, M.D., Is Principal

Investigator of a $36.6 Million

Department of Defense Study

News oF Note

Mischer Neuroscience Institute

and UT Welcome New Recruits

MNI’s New Neuro ICU Offers

State-of-the-Art Care in a Healing

Environment

$5 Million Gift Will Fund

Neurosurgical Research and

Training

Memorial Hermann-Texas Medical

Center Gains Quality Leadership

Recognitions

Harold and Diane Farb Fund for

Stroke Research Established,

Caffeinol Study Begins

IN PrINt

Sequencing of TGF-b Pathway

Genes in Familial Cases of

Intracranial Aneurysm

New-Onset Geriatric Epilepsy

Care: Race, Setting of Diagnosis

and Choice of Antiepileptic Drug

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01 M E M O R I A L H E R M A N N - T E X A S M E D I C A L C E N T E R

RAISING THE BARAT MEMORIAL HERMANN, quality and safety are core strategiesthat underscore our commitment to providing optimal clinical outcomesthrough patient-centered care. To deliver on that promise, physiciansand staff here have embraced a culture of accountability and innovation,which has led to a relentless focus on continuous improvement. In 2009, Memorial Hermann was singled out to receive one of the

nation’s most coveted quality and safety awards: the 16th Annual NationalQuality Healthcare Award, presented by the National Quality Forum(NQF) in partnership with Modern Healthcare and the Studer Group.The NQF award follows recognitions of Memorial Hermann-Texas

Medical Center as a leader in quality andperformance by University HealthSystemConsortium and Thomson Reuters, twoprestigious organizations dedicated toimproving patient safety. ThomsonReuters recognized the hospital for thesecond year in a row with the 2007Thomson 100 Top Hospitals® Performance Improvement LeadersAward, based on an examination of more than 2,800 American hospitalsacross a range of clinical, financial, operational and patient safety data.Memorial Hermann-TMC is the only hospital in Texas and one of only 15major academic institutions across the country to be named to the list.We’re proud of these recognitions, which are testimony to the dedication

of our team of physicians and staff and the impact they are having on thelives of our patients.

Dong H. kim, M.D.

DIRECTOR, MISCHER NEUROSCIENCE

INSTITUTE AT MEMORIAL HERMANN

PROFESSOR AND CHAIR,DEPARTMENT OF NEUROSURGERY,THE UNIVERSITY OF TEXAS MEDICAL

SCHOOL AT HOUSTON

James c. Grotta, M.D.

CO-DIRECTOR, MISCHER

NEUROSCIENCE INSTITUTE AT

MEMORIAL HERMANN

PROFESSOR AND CHAIR, DEPARTMENT OF NEUROLOGY

THE UNIVERSITY OF TEXAS MEDICAL

SCHOOL AT HOUSTON

M I S C H E R N E U R O S C I E N C E I N S T I T U T E 02

MeMorIal HerMaNN-texas MeDIcal ceNter was raNkeD No. 6

By tHe uNIversIty HealtHsysteM coNsortIuM oN

tHeIr aNNual lIst oF toP-PerForMING acaDeMIc MeDIcal

ceNters For qualIty aND accouNtaBIlIty.


OWER ING the body temper-ature of patients may be aneffective way to reduce braindamage following stroke and

other types of neurological injury, includingtrauma, says James C. Grotta, M.D., co-director of the Mischer NeuroscienceInstitute, and chair of the department ofNeurology at The University of TexasMedical School at Houston. Dr. Grotta is

principal investigator in a series of Phase Itrials currently under way at MemorialHermann-Texas Medical Center evaluatingnovel approaches, including hypothermia,for treating and preventing acute stroke. Induction of moderate hypothermia (28°C

to 32°C) has been used successfully since the1950s to protect the brain against ischemiaduring open-heart surgery. Based on itsneuro-protective effects, therapeutichypothermia following cardiac arrest wasattempted in the late 1950s, but the practicewas soon abandoned due to problems with itsuse. In 2002, successful clinical trial resultsprompted the Advanced Life Support TaskForce of the American Heart Association’sInternational Liaison Committee onResuscitation (ILCOR) to recommend thatpatients be cooled to 32°C to 34°C for 12 to24 hours following cardiac arrest.At Memorial Hermann-TMC and the UT

HYPOTHERMIA MAYIMPROVE SURVIVAL RATESFOR STROKE AND OTHERNEUROLOGICAL INJURIES

Medical School, hypothermia has been underinvestigation since 2000, even before it wasproven useful in the treatment of cardiacarrest. “Cooling cardiac arrest patients to 33degrees Celsius to reduce brain damage hasbeen proven safe in studies at MemorialHermann-TMC and around the world,” hesays. “It’s effective in reducing the risk of neu-rological damage, it’s approved as a therapy,but unfortunately, it’s also underutilized.” Dr. Grotta and his colleagues are extending

the use of therapeutic hypothermia from car-diac arrest to stroke patients with a five-yeargrant from the National Institute ofNeurological Disorders and Stroke (NINDS) atthe National Institutes of Health (NIH). Thegrant is part of a NINDS program to establish10 national centers focused on the rapiddiagnosis and effective treatment of stroke. Memorial Hermann-TMC’s strong stroke

treatment record made the hospital an ideallocation for trials under the NINDS grant.Teams led by Dr. Grotta, working closelywith the Houston Fire Department and EMS,successfully administer tPA to more than20 percent of patients who present withischemic stroke, far exceeding the nationalaverage of 2 percent. “As part of the clinical trial, we’re testing a

number of different methods for coolingpatients,” says Dr. Grotta, who holds theRoy M. and Phyllis Gough HuffingtonDistinguished Chair in Neurology at the UTMedical School. “It’s much easier to coolcardiac arrest patients because they’reunconscious. But stroke patients are awake,so cooling them and keeping them comfort-able at the same time is a challenge.” Rather than lowering body temperature to

an uncomfortable 33°C, Dr. Grotta and hiscolleagues have evaluated the effects of

For More INForMatIoN aBout

HyPotHerMIa as a treatMeNt For

stroke aND otHer NeuroloGIcal

INJury, e-MaIl Dr. Grotta at

[email protected].

F e a t u r e

Dr. Grotta aND HIs colleaGues are exteNDING tHe use oF tHeraPeutIc

HyPotHerMIa FroM carDIac arrest to stroke PatIeNts wItH a FIve-

year GraNt FroM tHe NatIoNal INstItute oF NeuroloGIcal

DIsorDers aND stroke (NINDs) at tHe NatIoNal INstItutes oF HealtH.

J F S L D OJ F S L D OL


lowering temperature to 35°C and addinglow doses of caffeine and ethanol to supple-ment the effect of cooling. Early research hasshown that hypothermia combined withcaffeinol,a neuroprotective blend of ethanoland caffeine, may protect the brain bylimiting stroke damage more than eithertreatment alone. “Results to date are promising,” he says.

“We’ve treated over 40 patients safely withcaffeinol. Of those, about half have beentreated with the entire combination –caffeine, ethanol and cooling. It’s beendifficult to keep patients comfortable withthe combination, but we’re hoping hypother-mia will eventually be proven as successful intreating stroke patients as it has been in casesof cardiac arrest. Now that we’ve shown thatthe treatment is safe, Phase II research willexamine the effectiveness of caffeinol andhypothermia separately and together.”Dr. Grotta has teamed up with University

of California, San Diego, neurologist PatrickD. Lyden, M.D., who has developed amethod for cooling conscious patients to 33degrees while controlling shivering. The twoneurologists are seeking NIH funding forICTuS-C2, a Phase II treatment selectionstudy of intravenous thrombolysis plushypothermia for acute treatment of ischemicstroke. “Our trial in Houston included about20 patients to demonstrate that it’s feasibleand safe to administer caffeinol and coolingwith tPA,” Dr. Grotta says. “At UC, SanDiego, Dr. Lyden investigated the effects ofcatheter-based cooling in another 40patients.”Hypothermia is also under investigation at

Memorial Hermann-TMC in the treatmentof traumatic brain injury (TBI). In early2008, under the care of Alex Valadka, M.D.,Grammy Award-winning Tejano singerEmilio Navaira was cooled following surgeryfor an acute subdural hematoma. Dr. Valadkais director of neurotrauma at MNI and a pro-fessor in the department of Neurosurgery atthe UT Medical School. Navaira was latertransferred to TIRR Memorial Hermannfor rehabilitation.n

HyPotHerMIa IN stroke treatMeNt: PatIeNt #14

Thirty-eight-year-old Cheryl Sorak was securing her newborn daughter in the rear seat of

the car when she felt something on her leg. “I looked down and realized it was my hand,”

she says. “Then I realized I couldn’t move my left arm.”

Sorak’s first thought was to call her husband. “When I tried to stand up to get my cell

phone, I couldn’t move my left leg. I fell out of the car into the street. Someone stopped

to help. I could hear people talking but I was disoriented. I heard someone say we need

to call 911. The next thing I remember was the paramedics and the ambulance.”

EMS rushed Sorak to the Mischer Neuroscience Institute at Memorial Hermann-Texas

Medical Center, where a medical team led by James C. Grotta, M.D., successfully admin-

isters intravenous tPA to 20 percent of patients who present with ischemic stroke. Sorak

received tPA about 90 minutes after her stroke, well within the three-hour treatment

window. When Dr. Grotta asked if she would participate in a study investigating the

neuro-protective effects of hypothermia, she and her husband agreed.

Funded by a five-year grant from the National Institute of Neurological Disorders and

Stroke (NINDS), the study is one of a series of trials currently under way at Memorial

Hermann-TMC evaluating novel approaches for treating and preventing acute stroke,

including hypothermia alone and in combination with caffeine and ethanol.

Sorak was Patient #14 of the 20 who received the entire combination – caffeine,

ethanol and cooling – in the Phase I trial. “I remember being ridiculously cold,” she says.

“My teeth were chattering. My joints hurt from shaking so much. The treatment seemed to

last an eternity.”

In reality, Sorak was cooled for 24 hours. “After the cooling, I remember a doctor coming

in and asking me to raise my left arm. I was fine.”

By the time she was evaluated for rehabilitation, she had equal strength in both hands.

“I didn’t need rehab,” she says. “I could tell that I had some residual facial sagging and

my speech was a little slurred, but only people who were close to me would have noticed.

After a couple of weeks those signs were gone. I was able to button the 15 tiny snaps on

my daughter’s pajamas and I thought if I could do that, I could do just about anything.

“I don’t know why I had the stroke. I didn’t have high cholesterol or high blood pressure.

I’d just had my baby four months earlier, and I knew I was healthy,” she says. “I have to

thank the paramedics for correctly diagnosing a stroke and taking me to the right hospital

to handle it, which saved time and therefore saved me from a life with disabilities.”

door and when I heard her voice – andknew she was alive – I called 911.”After the ambulance transport and a

long wait in the emergency room ofanother Houston hospital, Porrettocalled Frank Yatsu, M.D., a neurologistaffiliated with Memorial Hermann-Texas Medical Center and professor ofneurology at The University of TexasMedical School at Houston. Dr. Yatsufacilitated Malone’s transfer to theStroke Center at Mischer NeuroscienceInstitute, where she was admitted onApril 8, 2008, under the care of neurolo-gist Nicole Gonzales, M.D., an assistantprofessor of neurology at the UTMedical School. She was diagnosed witha right middle cerebral artery strokesecondary to atrial fibrillation.When Malone was stabilized, she was

transferred to the hospital’s 23-bedinpatient neurorehabilitation unit forcomprehensive care and an aggressiveprogram of physical therapy, occupa-tional therapy and speech/languagepathology. The neurorehabilitation unit’smultidisciplinary team – a physician, nursepractitioner, neuropsychologist, rehabili-tation nurse, case manager and socialworker for each patient – is led byElizabeth Noser, M.D., medical directorof neurorehabilitation for the MemorialHermann system. She and Nneka Ifejika,M.D., directed Malone’s neurorehabili-tative care.“Mrs. Malone came to our service just

four days after her stroke,” says Dr.Ifejika, who is medical director of neu-rorehabilitation at Memorial Hermann-TMC and assistant professor and directorof neurorehabilitation at the UT MedicalSchool, “We believe the sooner you get torehab following a stroke the better. Oncea patient arrives on our unit, we’re veryaggressive with therapy.”During her recovery, Malone benefited

from the Institute's innovative neurore-habilitation technology, including theBioness Foot Drop System. “TheBioness uses mild stimulation to lift thepatient’s foot to aid in walking,” Dr.

O RO T H Y MA L O N E wasdevastated when she suf-fered a stroke in April 2008.“Before my stroke, I walked

on the treadmill every morning for anhour. I worked out with a trainer and liftedweights twice a week. I had a healthy dietand didn’t smoke or drink. I was a veryindependent 78 year old.”

Previously diagnosed with atrial fibril-lation, Malone had tried a variety ofantiarrhythmic medications, includinganticoagulants. When she began havingdizzy spells, she and her children knewsomething was wrong.“I was sitting on the sofa eating break-

fast and watching TV,” recalls Malone,who lives alone. “When I tried to stand up,my knees buckled. Then the phone startedringing. Both of my children call me everyday, and I knew it was one of them.”When her mother didn’t answer the

phone after three calls, Molly Malonedrove to the apartment. “I knew some-thing was wrong,” she says. “On the way,I called a very close friend, Sue Porretto,and asked her to meet me there. Momhad the door dead-bolted, so I couldn’tget in. She heard me pounding on the


GOING HOME: DOROTHY MALONE REGAINS

HER INDEPENDENCEFOLLOWING ACUTE CARE FOR STROKE, A HOUSTON WOMAN BENEFITS FROM

INNOVATIVE NEUROREHABILITATIVE TECHNOLOGY AND INTEGRATED CARE AT

MISCHER NEUROSCIENCE INSTITUTE AND TIRR MEMORIAL HERMANN.

F e a t u r e

“Mrs. MaloNe caMe to our servIce Just Four Days

aFter Her stroke,” says NNeka IFeJIka, M.D. “we BelIeve

tHe sooNer you Get to reHaB FollowING a stroke, tHe

Better. oNce a PatIeNt arrIves oN our uNIt, we’re very

aGGressIve wItH tHeraPy.”

J F S L D OJ F S L D OD

Ifejika says. “With most patients, returnof use occurs in the leg gradually fromthe hip on down. The foot tends to drop,which puts people at risk for falls. Thesystem helps patients regain the use ofthe involved foot faster.” The Bioness Foot Drop System has

three components that communicatewith each other wirelessly. A leg cuff fitsjust below the knee to place stimulationwhere it helps the patient most. The gaitsensor attaches to the patient’s shoe and“tells” the leg cuff whether the heel is onthe ground or in the air. A handheldremote control lets the patient adjust thestimulation levels and on-off controls.Malone’s rehabilitation team also

used the Bioness Hand RehabilitationSystem to speed the return of wristextension. She progressed well, wasdischarged to her home in mid-May andbegan outpatient rehabilitation at TIRRMemorial Hermann Kirby Glen.At Kirby Glen, Malone was one of the

first patients to use the outpatientrehabilitation facility’s Lokomat®, theworld’s first driven-gait orthosis.Designed to benefit patients with neuro-logical movement disorders, the systemconsists of the robotic gait orthosis itselfand the Levi body-weight support systemused in combination with a treadmill.The patient’s legs are guided on thetreadmill according to a preprogrammedphysiological gait pattern, which can beadjusted to accommodate individualneeds and rehabilitation goals.Advantages of Lokomat-based therapyinclude faster progress through longerand more intensive training sessionscompared to manual treadmill training,ease of monitoring and assessment ofpatient walking activity and improvedmotivation through visualized perform-ance feedback. In July, Malone suffered a setback

when she fell at home and injured herleft hand. “We got a call from Mrs.Malone’s daughter saying she was backin the hospital being treated for ahematoma on her involved side,” Dr.

Ifejika says. “Drainage and a skin graftwere required. She became decondi-tioned because of the surgery, and webegan the entire rehabilitation processover again.”Following her discharge from

Memorial Hermann-TMC in August,Malone completed four months of hometherapy. She started back on theLokomat at Kirby Glen in January 2009. “I am determined to regain my

independence,” she says. “My left handis starting to come back. I’m very opti-

mistic that I’m going to regain the use ofmy left arm and leg. The therapists atKirby Glen and my doctors – Dr.Elizabeth Noser, Dr. Nneka Ifejika andDr. Nicole Gonzales – are extraordinary.They are truly healers of the body andthe spirit. “Doctors’ positive attitudes and

enthusiasm are powerfully influencingto a patient,” she adds. “I was blessed tohave doctors whose training and experi-ence were exemplary, and who also hadendless compassion, sensitivity andthoughtfulness. They let me know thatno request or question was too big or toosmall. I could feel them with me everystep of my recovery journey, and they’restill with me today.”

“Because of the length of stay inneurorehabilitation, we develop veryclose relationships with our patients andtheir families,” Dr. Ifejika says. “They’vegone through a devastating event, andwe all work together as a team to helpthem make the transition back to thecommunity. Patients and family membersare an integral part of that team.”Molly Malone, who stayed at the hospital

during her mother’s inpatient rehabilita-tion, considers it a positive experience.“We marveled at all the positive things


Dorothy Malone uses the lokomat to improve her

gait as part of her neurorehabilitation program.

we saw happening around us in theneurorehabilitation unit. There weremany large and small kindnesses thatreally make you want to give back to thathospital. They focused on the entire person– physically, mentally and spiritually –which is how the hospital experienceshould be for everyone. We would havebeen happier not to be there, but weconsider it a fantastic experience.”Dorothy Malone lives at home and

continues to work toward regaining herindependence. A caregiver helps withher daytime needs.n


F THE MORE than 1.5 millionpeople who suffer a traumaticbrain injury each year in theUnited States, as many as 75

percent sustain a concussion, a mildinjury that can lead to long-term or per-manent impairments and disabilities.Mild to severe TBI has also become the

signature injury of military personneldeployed to Iraq and Afghanistan. Now,with funding from the United StatesDepartment of Defense (DOD) throughthe Congressionally Directed MedicalResearch Program (CDMRP), a consortiumof Houston-area physicians and scientistshas undertaken an important newresearch initiative to improve the diagno-sis of mild traumatic brain injury (TBI) anddevelop innovative treatment strategies.The $36.6 million grant to the Mission

Connect Mild TBI Translational ResearchConsortium is funded from August 1,2008, through July 31, 2013. The totalresearch award is $25 million, with anadditional $11.6 million for the indirectcosts of the research effort. The MissionConnect Consortium includes researchteams from participating institutions TheUniversity of Texas Health Science Centerat Houston, The University of TexasMedical Branch at Galveston (UTMB),

MOVING TOWARDIMPROVED DIAGNOSIS AND

TREATMENT OF MILDTRAUMATIC BRAIN INJURY

ALEX VALADKA, M.D., IS PRINCIPAL INVESTIGATOR OF A $36.6 MILLION

DEPARTMENT OF DEFENSE STUDY

Baylor College of Medicine, and RiceUniversity; their clinical affiliatesMemorial Hermann-Texas MedicalCenter, Ben Taub General Hospital andMichael E. DeBakey VA Medical Center;and the Transitional Learning Center inGalveston.“Our goal is to make discoveries that

will ultimately allow us to intervene withthe most effective early therapy before amild traumatic brain injury results in achronic problem,” says Alex Valadka,M.D., director of neurotrauma services atMemorial Hermann-Texas MedicalCenter, vice chair of the department ofNeurosurgery at The University of TexasMedical School at Houston and the con-sortium’s principal investigator. “There isa high prevalence of mild traumatic braininjury in soldiers, and the consortium’swork is driven by that. We believe that the

conclusions of our research will also bene-fit civilians, including athletes, who havesuffered concussions.” The research is being done within the

framework of Mission Connect, a consor-tium established by TIRR Foundation in1997 to facilitate collaborative research toimprove outcomes for patients with brainand spinal cord injuries and neurologicaldisorders. “The institutions that make upMission Connect have a long history ofworking together successfully,” says DongH. Kim, M.D., director of the MischerNeuroscience Institute and chair of thedepartment of Neurosurgery at the UTMedical School. “The consortium is amodel of innovative thinking and closecollaboration. Its existence made us morecompetitive for this grant than any one ofour institutions would have been alone.”Cynthia Adkins, executive director of

TIRR Foundation, under which MissionConnect was founded and is managed,

F e a t u r e

“our Goal Is to Make DIscoverIes tHat wIll ultIMately allow us

to INterveNe wItH tHe Most eFFectIve early tHeraPy BeFore a MIlD

trauMatIc BraIN INJury results IN a cHroNIc ProBleM.”

J F S L D OJ F S L D OO

agrees. “The award of this grant confirmsthe collaborative platform of MissionConnect as a powerful and pivotal force inresearch,” she says. “We were selectedfor the grant based on our 12-year historyof success as a consortium, the outstand-ing researchers who comprise it and theirtrack record of stellar work. Uniting thesescientists in this shared research effortwill accelerate the pace of discovery andwill ultimately provide new diagnosticand treatment models for mild traumaticbrain injury.”

The work of the consortium’s 22 investi-gators is focused on three major goals:developing a laboratory model of mild TBI,improving and refining mild TBI diagnosticcriteria and developing new treatments.“The lab model we’re developing now islaying the groundwork for the methodologywe’ll use to do laboratory research through-out the study,” says Emmy Miller, Ph.D.,R.N., research coordinator for the MissionConnect Mild TBI Translational ResearchConsortium. “For instance, our investigators


are creating a model for head injury causedby a blast, which may be entirely differentfrom traumatic brain injury resulting fromother causes.”Refining the diagnostic criteria for

mild TBI revolves around differentiatingsymptoms of mechanical injury fromthose of post-traumatic stress disorder(PTSD). “The symptoms of PTSD andmild TBI overlap, but a mechanicalinjury to the brain requires one kind oftreatment, and post-traumatic stress dis-order requires another,” Dr. Miller says.

“To better distinguish between the twoconditions, we’re using a comprehensiveset of 21 cognitive and behavioral tests.We’ll also be examining the results ofMRIs and EEGs and following subjectsover a period of six months to definecrucial clinical differences betweenthese conditions.” For clinical trials, the researchers

will recruit patients with mild TBI whoreceive care at Memorial Hermann-TMC and Ben Taub General Hospital.

“This is a well-thought-out, highlyorganized project and we’re excited tobe part of it,” Dr. Miller says. “We haveresearchers doing work at the cellularlevel, the animal level and the humanlevel, and we’re working to develop acreative f low between these threeareas. It’s rewarding for all of us to havean opportunity to address a health issueof significance to our returning servicemen and women, as well as to civiliansrecovering from mild traumatic braininjury.”n

alex valadka, M.D., is the principal investigator

for the Mission connect Mild tBI translational

research consortium study.


scientific publications and contributed tomore than 20 books. To date, his research hasbeen funded by more than $30 million ingrants from the National Institutes of Healthand private foundations.

Imoigele P. aisiku, M.D., joined the MNI asdirector of the Neuro ICU, concurrent with hisappointment as associate professor in thedepartment of Neurosurgery at the UT MedicalSchool. Previously, he was an assistant professorin the department of Anesthesia/Critical Careand co-director of the Neurosurgical ScienceICU at Virginia Commonwealth University.Dr. Aisiku received his doctor of medicine

at the University of Massachusetts School ofMedicine in Worcester. In 2002, he complet-ed a fellowship in critical care at EmoryUniversity School of Medicine. He completeda fellowship in neuroscience critical care atWashington University/Barnes JewishHospital in St. Louis, Missouri, in 2008.He has served as principal investigator or

co-investigator in funded studies of more than$2.9 million, primarily from the NationalInstitutes of Health. His research interestsinclude sickle cell anemia, subarachnoidhemorrhage and traumatic brain injury. Hiswork has been published in the Annals ofEmergency Medicine, Annals of InternalMedicine, Journal of Women’s Health,Journal of Traumaand other publications.

MEMORIAL HERMANN AND UTWELCOME NEW RECRUITS

Melissa thomas, M.D., joins MNI followingcompletion of a fellowship in neurophysi-ology with a focus on epilepsy, at TheUniversity of Texas Medical School atHouston. She is an instructor in neurologyat the UT Medical School.Dr. Thomas received her medical degree

from the University of Louisville Schoolof Medicine in Louisville, Kentucky,followed by an internship in internalmedicine and a residency in neurology atthe UT Medical School.Her clinical interests include epilepsy

and general neurology. Her research isfocused on improving diagnosis and out-comes in candidates for epilepsy surgery.

qi-lin cao, M.D., associate professor of neu-rosurgery, joins the MNI from the KentuckySpinal Cord Injury Research Center and thedepartment of Neurological Surgery at theUniversity of Louisville School of Medicine,where he was an assistant professor. He com-pleted his medical degree at Hunan MedicalUniversity in China in 1990. In 1996, he wasa visiting scholar at the NeurobiologyResearch Laboratory in the department ofOtorhinolaryngology at the University ofFreiburg, Germany, which he followed witha fellowship in psychology at the Universityof Louisville, Kentucky. In 2002, he com-pleted a postdoctoral fellowship at the

SEVEN NEW PHYSICIANS AND A RENOWNED SCIENTIST HAVE JOINED THE

STAFF OF THE MISCHER NEUROSCIENCE INSTITUTE (MNI) AND THE FACULTY

OF THE UNIVERSITY OF TEXAS MEDICAL SCHOOL AT HOUSTON.

N e w s o F N o t e

claudio soto, Ph.D.,professor of neurology anddirector of the Center for NeurodegenerativeDiseases at The University of Texas MedicalSchool at Houston, joined the MNI from TheUniversity of Texas Medical Branch atGalveston (UTMB). At UTMB he was direc-tor of the George and Cynthia MitchellCenter for Neurodegenerative Diseases anda professor in the department of Neurology, thedepartment of Neuroscience and Cell Biologyand the department of Biochemistry andMolecular Biology. He received his Ph.D. inbiochemistry and molecular biology from theUniversity of Chile in 1993 and was a postdoc-toral fellow at the Catholic University of Chileand at the New York University School ofMedicine, where he became an assistant pro-fessor of research in 1995. From 1999 to 2003, Dr. Soto was senior

scientist, chair of the department ofMolecular Neurobiology and senior exec-utive scientific adviser for neurobiologyat Serono International in Geneva,Switzerland. For the past 15 years, he andhis colleagues have engaged in researchinto the molecular basis of neurodegen-erative diseases with a particular focus onAlzheimer’s and prion-related disorders.His work has led to the development ofnovel strategies for the treatment anddiagnosis of these diseases. He haspublished more than 100 peer reviewed

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soto

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cao


Kentucky Spinal Cord Injury ResearchCenter/University of Louisville School ofMedicine.Dr. Cao serves as a reviewer for Brain

Research, Cell Transplantation, ExperimentalNeurology, Glia, Journal of Neurotrauma andStem Cells. His clinical interests includetesting cell-based therapies for spinal cordand brain injury patients in collaborationwith other MNI neurosurgeons. His currentresearch, funded by the National Institutesof Health, is focused on repairing spinal cordinjury using combinatorial strategies,including stem cell transplantation and genetherapy.

albert J. Fenoy, M.D., assistant professorof neurosurgery, comes to the MNI fromthe department of Neurosurgery at theUniversity of Iowa Hospitals and Clinics,where he was a neurosurgery fellow asso-ciate.He received his doctor of medicineat the State University of New York atStony Brook in 2002 and completed hisresidency at the University of Iowa in2008. He completed a fellowship infunctional neurosurgery at the CentreHospitalier Universitaire de Grenoble,France, in December 2008.Dr. Fenoy’s clinical interests include deep

brain stimulation for movement disorderssuch as Parkinson’s disease and tremor andpsychiatric diseases such as obsessive-com-pulsive disorder, in addition to surgery forneck and back pain. His research, which hasbeen published in Clinical Neurosurgery,Journal of Neurosurgery, Brain Research,Pediatric Neurosurgery and Journal ofNeurosurgery: Spine, has focused on the elec-trophysiology and clinical manifestations ofbasal ganglia disease and auditory cortex, aswell as craniocervical junction abnormalities.

Bryan c. oh, M.D., assistant professor ofneurosurgery, received his medical degreein 2001 at Stanford University School ofMedicine. He completed his residency inneurological surgery at the University ofSouthern California Keck School ofMedicine in Los Angeles, followed by afellowship in spine and neurotraumasurgery at the University of SouthernCalifornia/Rancho Los Amigos MedicalCenter. Prior to joining Memorial Hermannand the UT Medical School, he was a clinicalassistant professor in the department ofNeurological Surgery at the University ofSouthern California.Dr. Oh has developed particular expertise

in traumatic brain and spinal cord injuryand an interest in complex spine surgery.His research interests include traumaticbrain injury and neurorestoration. He is anad hoc reviewer for Neurosurgery.

Neurosurgeon william w. ashley Jr., M.D.,

Ph.D., M.B.a., comes to MNI fromChicago where he was a faculty member atthe University of Illinois at Chicago (UIC)department of Neurosurgery. After grad-uating from Stanford University, Dr.Ashley received an M.D. and Ph.D. inphysiology and biophysics at the UICCollege of Medicine. He completed hisneurosurgical residency at Washington

University-St. Louis, followed by a dualfellowship in cerebrovascular andendovascular neurosurgery at UIC. Dr. Ashley specializes in the treatment of

all aspects of cerebrovascular disease usingboth open surgical and endovasculartechniques. His specific areas of expertiseinclude the treatment of cerebralaneurysms, arteriovenous malformations,extracranial carotid disease and intracranialatherosclerosis, including bypass surgery. An assistant professor of neurosurgery

at the UT Medical School, he has publishedextensively. In addition to his clinicalwork, Dr. Ashley is actively involved inbasic science and translational research.His research interests include investigatingthe molecular basis for aneurysm ruptureand cerebral vasospasm, intracranialatherosclerosis and novel neuroprotec-tion paradigms.

suur Biliciler, M.D., assistant professor ofneurology, earned her medical degree atIstanbul University Istanbul Faculty ofMedicine in Turkey in 1998, followed by aresidency in neurology at Istanbul UniversityCerrahpasa Faculty of Medicine. She was alsoa resident in neurology at St. Louis Universityfrom 2002 to 2006. In 2008, she completeda fellowship in neuromuscular diseases atBaylor College of Medicine. A board-certified neurologist, Dr.

Biliciler is a member of the AmericanAcademy of Neurology. Her clinicalinterests are neuromuscular disordersincluding muscular dystrophies; myas-thenia g ravis and inf lammator ymyopathies; hereditary, immune andinflammatory neuropathies; and amy-otrophic lateral sclerosis. Her researchis focused on muscular dystrophies.

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Long-time philanthropists Celia andAlbert J. Weatherhead III recently made a$5 million commitment to the MemorialHermann Foundation to support the workof MNI neurosurgeon P. Roc Chen, M.D.The funds will provide opportunities toadvance medical treatments availablethrough the Mischer NeuroscienceInstitute.Dr. Chen will receive $5 million dis-

bursed over a 10-year period. “Dr.Chen is doing superlative research forthe betterment of mankind,” AlWeatherhead says. “When he makesadvances, the world advances. It’sthrilling to know that we’re helpinghim move forward with his researchand improve the clinical care deliveredin our community.” The couple madethe gift through the WeatherheadFoundation, which was established in1953 by Albert J. Weatherhead, Jr.Dr. Chen will use a portion of the grant

to fund new technology development,cerebrovascular and stroke research and

advanced training ofyoung surgeons incerebrovascular neu-rosurgery. “We aretruly fortunate tobenefit from thislevel of generosity,”he says. “I look for-ward to using theresources made avail-able by this gift toadvance the field ofneurosurgery.”

An assistant professor in the departmentof Neurosurgery at The University of TexasMedical School at Houston, Dr. Chen isthe director of cerebrovascular andendovascular neurosurgery. He is one ofthe few surgeons accomplished at bothcatheter-based minimally invasive therapyand open microsurgery to treat complexcerebrovascular diseases.


N e w s o F N o t e

MNI receIves $5 MIllIoN GIFt to

FuND NeurosurGIcal researcH

aND traINING

Designed with input from physicians, nurses,patients and family members, MischerNeuroscience Institute’s new $13.5 millionNeuro Intensive Care Unit includes 32private rooms in a 34,500-square-footspace built for efficiency of flow for bothstaff and equipment. Each room is uniquein layout, ranging in size from just under300 square feet to well over 400 square feet.“By investing in a truly state-of-the-art

neuroscience ICU, Memorial Hermann ismaking a strong statement about the level ofcare we want for southeast Texas and thesurrounding regions,” says Dong H. Kim,M.D., director of the Mischer NeuroscienceInstitute and professor and chair of thedepartment of Neurosurgery at TheUniversity of Texas Medical School atHouston. “Our new neuro ICU is designedto support the needs of our patients duringthe most acute phase of their hospitaliza-tion, accommodate the needs of our teamsof surgeons, intensivists, fellows and

residents, and integrateteaching and researchspace in support of ourcombined academic andclinical missions.”The new unit houses

critical diagnostic andsupport equipment,including a mobile CT,ventilators, blood gasanalyzer and PACSradiographic viewingrooms, within the unitto ensure faster resultsand improved patientcare. All rooms aredesigned with break-away glass doors and vir-tual 360-degree viewsfrom the floor to ensure

ease of patient monitoring. Consultationrooms allow for private conferences withfamily members and consulting physicians. Special isolation rooms were incorporated

into the design of the unit, and include ananteroom that separates the patient careenvironment from shared spaces to main-tain a safe and infection-free environment.The waiting area was designed for the com-fort of families who spend long hours in theICU and includes a coffee bar, dedicatedattendant and spacious work carrels. “We’re proud of the new unit and look

forward to working with the philanthropiccommunity to further develop the MischerNeuroscience Institute, which waslaunched by a gift from the Walter Mischer,Sr. family,” says Amanda Spielman, chief ofhospital operations. “Continued expansionis part of our larger mission to raise the barin neuroscience and ensure that our com-munity is served by first-rate clinical pro-grams based on breakthrough research.”

NEW NEURO ICU OFFERSSTATE-OF-THE-ART CARE INA HEALING ENVIRONMENT

ribbon cutting for the new Neuro Icu (from left) Dr. larry kaiser, President,

ut Health science center at Houston; Dr. Dong kim; Dr. James Grotta; Gerald

Bennett, chairman, Memorial Hermann Healthcare system Board; chuck

stokes, Memorial Hermann chief operating officer; walt Mischer; Paula

Mischer; Juanita romans, ceo, Memorial Hermann-tMc; leila Mischer

P. roc chen, M.D.


UNIVERSITY HEALTHSYSTEM CONSORTIUM(UHC) and Thomson Reuters, two presti-gious organizations dedicated to improvingpatient safety, have recognized MemorialHermann-Texas Medical Center as a leaderin quality and performance.UHC, a national alliance of nearly 300

academic medical centers and affiliatedhospitals, ranked the hospital No. 6 on itsannual list of top-performing academicmedical centers for quality and accounta-bility. Over the past three years, MemorialHermann-TMC’s ranking has risen signif-icantly, from last year’s No. 16 and the pre-vious year’s No. 34.To generate the listing, UHC assesses

Houston philanthropist Diane Lokey Farbrecently made a $500,000 gift to theMemorial Hermann Foundation in memoryof her husband Harold Farb and in supportof research directed by stroke expert JamesC. Grotta, M.D. The gift has establishedthe Harold and Diane Farb Fund forStroke Research within the MischerNeuroscience Institute.“During my husband’s lifetime, we shared

the utmost respect for Dr. Grotta, and weappreciated the importance of the advance-ments he has made in stroke management,”said Diane Farb, in making the gift. Her generosity is funding further

research to study the efficacy of caffeinol, apromising treatment for stroke discoveredin the UT laboratory of Dr. Grotta andJarek Aronowski, Ph.D., professor ofneurology at The University of TexasMedical School at Houston. “Our goal is toprovide the data needed to gain FDAapproval of caffeinol as an effective treat-ment for stroke patients worldwide,” saysDr. Grotta, who is co-director of the

Mischer Neuroscience Institute, and chairof the department of Neurology at the UTMedical School. Early studies of caffeinol,a neuroprotective blend of ethanol andcaffeine, suggestthat it may protectthe brain by limitingdamage caused by astroke.“We’ve tested caf-

feinol in our ownanimal model andhave studied itseffects on strokepatients alone and incombination withtPA and hypothermia,with good results,”he says. “Our nextstep is to continue our work here at UT andproduce the same positive results in otherlaboratories around the country.” The Harold and Diane Farb Fund for

Stroke Research is supporting preclinicalstudies at the UT Medical School, theUniversity of Miami School of Medicine,the University of Massachusetts MedicalSchool in Worcester and the University ofKansas Medical Center in Kansas City,

where lab research is focused on testingcaffeinol in older animals with transientand permanent arterial occlusion. “Wefeel that it’s important to show that a

neuroprotec t ivedrug such as caffeinolis effective in olderanimals, includingprimates, that resultsare consistent inindependent labora-tories and that we’recertain about thetime window ofeffect,” Dr. Grottasays. “We also wantto examine theresults with varioustypes of strokes before

proceeding to clinical trials. It’s possiblethat caffeinol might be effective for bothischemic and hemorrhagic strokes.”Based on the results of preclinical studies,

Dr. Grotta and his team will seek fundingfor a randomized clinical trial of intra-venous caffeinol versus placebo for twohours starting immediately upon patientarrival in the emergency departments ofmultiple major American centers. n

organizational performance across abroad spectrum of high-priority dimen-sions of patient care. The 2008 rankingcovers mortality, effectiveness, safety,equity and patient-centeredness usingmeasures developed by national organiza-tions and the federal government.Thomson Reuters, formerly known as

Thomson Corporation, recognized thehospital for the second year in a row as aperformance improvement leader withthe 2007 Thomson 100 Top Hospitals®

Performance Improvement LeadersAward. Memorial Hermann-TMC had tomeet highly selective award criteria tobe named among the nation’s top 100performance improvement leaders.Hospitals on the list were recognized asachieving the following gains from 2002to 2006: having fewer patients deaths,

MeMorIal HerMaNN-texas MeDIcal

ceNter GaINs qualIty leaDersHIP

recoGNItIoNs

complications, and adverse safety eventsthan expected; increasing expenses only2.5 percent on average, compared with a17.4 percent increase among peer hospi-tals over the five-year period; increasingprofit margin from less than 1 percent to6.9 percent; and reducing average lengthof stay by nearly a day, despite greaterpatient acuity.The award is given based on the

Thomson Reuters 100 Top HospitalsPerformance Improvement Leadersstudy, which examines the performanceof more than 2,800 American hospitalsacross a range of clinical, financial,operational and patient safety data.Memorial Hermann-TMC is the onlyhospital in Texas and one of only 15major academic institutions across thecountry to be named to the list.

N e w s o F N o t e

HarolD aND DIaNe FarB FuND For

stroke researcH estaBlIsHeD,

caFFeINol stuDy BeGINs

Diane lokey Farb and James c. Grotta, M.D.


Teresa Santiago-Sim, Ph.D.; Sumy Mathew-Joseph, Ph.D.; Hariyadarshi Pannu, Ph.D.; Dianna M.Milewicz, M.D., Ph.D.; Christine E. Seidman, M.D.; J.G. Seidman, Ph.D.; Dong H. Kim, M.D.

aBstract

BackGrouND aND PurPose. Familial aggregation of intracranial aneurysms (IA)strongly suggests a genetic contribution to pathogenesis. However, genetic risk factorshave yet to be defined. For families affected by aortic aneurysms, specific gene variantshave been identified, many affecting the receptors to transforming growth factor-beta(TGF-b). In recent work, we found that aortic and intracranial aneurysms may share acommon genetic basis in some families. We hypothesized, therefore, that mutations inTGF-b receptors might also play a role in IA pathogenesis.

MetHoDs. To identify genetic variants in TGF-b and its receptors, TGFB1, TGFBR1,TGFBR2, ACVR1, TGFBR3 and ENG were directly sequenced in 44 unrelated patientswith familial IA. Novel variants were confirmed by restriction digestion analyses, andallele frequencies were analyzed in cases versus individuals without known intracranialdisease. Similarly, allele frequencies of a subset of known SNPs in each gene were alsoanalyzed for association with IA.

results. No mutations were found in TGFB1, TGFBR1, TGFBR2 or ACVR1. Novelvariants identified in ENG (p.A60E) and TGFBR3 (p.W112R) were not detected in atleast 892 reference chromosomes. ENG p.A60E showed significant association withfamilial IA in case-control studies (P = 0.0080). No association with IA could be found forany of the known polymorphisms tested.

coNclusIoNs. Mutations in TGF-b receptor genes are not a major cause of IA.However, we identified rare variants in ENG and TGFBR3 that may be important for IApathogenesis in a subset of families.

STROKE, 2009, 40:00-00DOI: 10.1161/STROKEAHA.108540245

SEQUENCING OF TGF-B PATHWAY GENES INFAMILIAL CASES OF INTRACRANIAL ANEURYSM

From the Department of Genetics, HarvardMedical School, Boston, MA 02115, U.S.A.(T.S.S., S.M.J., J.G.S., C.E.S.); Department ofInternal Medicine and Institute of MolecularMedicine, The University of Texas HealthScience Center at Houston, Houston, TX 77030,U.S.A. (H.P., D.M.M.); Department ofPathology, Brigham and Women’s Hospital,Boston, MA 02115, U.S.A. (C.E.S.); andDepartment of Neurosurgery, The University ofTexas Medical School at Houston, Houston, TX77030, U.S.A (D.H.K.).

I N P r I N t


Omotola A. Hope, John E. Zeber, Nancy R. Kressin, Barbara G. Bokhour, Anne C. VanCott, Joyce A.

Cramer, Megan E. Amuan, Janice E. Knoefel and Mary Jo Pugh

aBstract

PurPose.There is a growing movement to assess the quality of care provided to patientsin the United States, but few studies have examined initial care for epilepsy patients. Weexamined the relationships among patient race, setting of initial diagnosis and initialtreatment for older veterans newly diagnosed with epilepsy.

MetHoDs. We used Department of Veterans Affairs (VA) inpatient, outpatient, pharmacyand Medicare data (1999-2004) to identify patients 66 years and older with new-onsetepilepsy. High-quality care was defined as avoiding a suboptimal agent (phenytoin,phenobarbital, primidone) as defined by experts. Predictors included demographicand clinical characteristics, and the context of the initial seizure diagnosis including thesetting (e.g., emergency, neurology, hospital, primary care). We used mixed-effectsmultivariable logistic regression modeling to identify predictors of initial seizure diag-nosis in a neurology setting, and receipt of a suboptimal AED.

results. Of 9,682 patients, 27% were initially diagnosed in neurology and 70%received a suboptimal AED. Blacks and Hispanics were less likely to be diagnosed inneurology clinics (black OR = 0.7 95% CI 0.6-0.8; Hispanic OR = 0.6 95% CI 0.5-0.9).Diagnosis in a non-neurology setting increased the likelihood of receiving a suboptimalagent (e.g., Emergency Department OR = 2.3 95% CI 2.0-2.7). After controlling forneurology diagnosis, black race was independently associated with an increased risk ofreceiving a suboptimal agent.

DIscussIoN. We demonstrated that differences in quality of care exist for both clinicalsetting of initial diagnosis and race. We discussed possible causes and implications ofthese findings.

EPILEPSIA, **(*):1–9, 2008 DOI: 10.1111/J.1528-1167.2008.01892.X

NEW-ONSET GERIATRIC EPILEPSY CARE: RACE, SETTING OF DIAGNOSIS AND CHOICEOF ANTIEPILEPTIC DRUG.

Department of Neurology, University of TexasHealth Science Center at Houston, Houston,Texas, U.S.A.; Veterans Affairs HSR&D, SouthTexas Veterans Health Care System (VER-DICT), San Antonio, Texas, U.S.A.;Department of Psychiatry, University of TexasHealth Science Center at San Antonio, SanAntonio, Texas, U.S.A.; Center for HealthQuality, Outcomes and Economic Research,Edith Nourse Rogers Memorial Hospital,Bedford, Massachusetts, U.S.A.; Section ofGeneral Internal Medicine, Boston UniversitySchool of Medicine, Boston, Massachusetts,U.S.A.; Boston University School of PublicHealth, Boston, Massachusetts, U.S.A.;Neurology Division, VA Pittsburgh HealthcareSystem, Pittsburgh, Pennsylvania, U.S.A.;Department of Neurology, University ofPittsburgh, Pittsburgh, Pennsylvania, U.S.A.;Department of Psychiatry, Yale University, NewHaven, Connecticut, U.S.A.; Epilepsy TherapyProject, Orange, Connecticut, U.S.A.; NewMexico Veterans Healthcare System, MedicineService, Albuquerque, New Mexico, U.S.A.;University of New Mexico Departments ofInternal Medicine and Neurology, Albuquerque,New Mexico, U.S.A.; and Department ofGeneral Medicine, University of Texas HealthScience Center at San Antonio, San Antonio,Texas, U.S.A.

I N P r I N t

Nonprofit Org.U.S. POSTAGE

PAIDPermit No. 3156Houston, TX

Memorial Hermann Healthcare System

7737 Southwest Freeway,

Houston, TX 77074

memorialhermann.org

713.222.CARE

4402528

Physician services provided by UT Physicians.

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