Clinical Advances

New procedures, devices, guidelines
for clinicians
BY ADAR NOVAK



 PET Imaging for Evaluation of Diabetes
 Pancreas Center Offers Innovative Treatments
 Bariatric Surgery for the Younger Set


PET Imaging for Evaluation of Diabetes
Researchers Advance Diabetes Research with Imaging Technique

As diabetes and its effects on patients’ overall health make headlines regularly, Columbia researchers are using an increasingly popular brain imaging technique to facilitate the study, diagnosis, and treatment of diabetes in a noninvasive manner. Using PET imaging technology, Columbia researchers can now measure total beta cell mass to evaluate the disease, rather than rely on the relative imprecision of measuring insulin secretion.
   The technique was developed by principal investigator Paul Harris, Ph.D., research scientist in the Department of Medicine, and researchers from the Department of Radiology, the Naomi Berrie Diabetes Center, and the New York State Psychiatric Institute.
   “So far the only tools we’ve had are those taking measurements of insulin in the blood, and those aren’t very reliably predictive,” Dr. Harris says. “The ability to do these real-time measurements in beta cell mass in patients should make treating diabetes much easier.”
   Dr. Harris and colleagues have been working on the project since 2003, when the National Institute of Diabetes and Digestive and Kidney Diseases was beginning to fund such work. They published the results of their animal version of the study in the June 2006 issue of the Journal of Clinical Investigation.
   The researchers now are closing their first proof of concept trial in human subjects and have plans to explore the value of the technique in monitoring changes in beta cell mass in patients with new onset of type 1 diabetes. They also hope to use the technology to create a test to diagnose children at risk for developing type 1 diabetes and to determine whether new biomedical techniques are effective by sending patients for scans before, during, and after treatment to track changes in beta cell mass that underlie the clinical status of the disease. The PET scanning method also may help researchers analyze the mechanisms by which various bariatric surgery techniques have beneficial effects on type 2 diabetes.
   “Physicians are trying to mostly increase beta cell mass in cases where there is a deficit with new drugs, and this will be a way to tell if these treatments work,” Dr. Harris says.
   Rudolph L. Leibel, M.D., professor of pediatrics and medicine and co-director of the Naomi Berrie Diabetes Center, has been involved with the imaging studies and says the multidisciplinary nature of the effort has been critical to its success. “The rapid transition of this research from proof-of-principle in animals to testing in human subjects reflects the flexibility and range of physical and intellectual resources available at the medical center,” Dr. Leibel says. “This sort of translational effort exemplifies a growing emphasis in biomedical research to accelerate the movement of discoveries in the lab to direct application in patients.”

Pancreas Center Offers Innovative Treatments
Center Offers Hope — and Success — Where It’s Often Lacking

The Pancreas Center, a collaborative effort of several departments and the Herbert Irving Comprehensive Cancer Center, is taking the multidisciplinary model of care to a new level with innovative treatments for such diseases as pancreatitis and pancreatic cancer, one of the most difficult-to-treat cancers.
   “We work hard to completely integrate clinical care with research activities; we want to blur those boundaries as much as possible,” says John Chabot, M.D., associate professor of clinical surgery and the Pancreas Center’s director. “We want our nurses and doctors to be conscious of research efforts and similarly imbue researchers with the knowledge that there are people at the other end of their research and that people’s lives will be influenced by their work.”
   In addition to a robust clinical practice that includes a 19-member staff — five surgeons, two medical oncologists, four gastroenterologists, four nurse practitioners, clinical coordinator, clinical research director, administrative director, and special projects coordinator — the center also pursues several research projects. Among them is the development of a mouse model for spontaneous pancreatic cancer that allows researchers to probe the mechanisms of pancreatic cancer and test new therapies. Other research projects: translational research to minimize what Dr. Chabot calls “the cycle time between good ideas and the application of those discoveries to patients”; the clarification of risk factors for pancreatic cancer patients and their families via genetic markers; and development of safe surveillance and prevention strategies for pancreatic disease.
   “We are highly collaborative,” Dr. Chabot says. “Complex illnesses, such as pancreatic cancer, require people of various specialties to have input, and we have formalized that process with weekly meetings in which we discuss all active patients. The discussion encourages all members of the cross-functional team of physicians and nurses to contribute their thoughts, even if they haven’t met the patient.”
   Dr. Chabot describes the role of the four nurse practitioners as the glue that supports the continuity of the patient experience. “There may be several doctors doing many jobs, but through all of those experiences will be a nurse practitioner, who also serves as an advocate for the patient’s entire family,” he says.
   Columbia has a long history in pancreatic disease treatment. Allen O. Whipple, M.D., former chairman of the Department of Surgery, pioneered one of the most important pancreatic operations in 1935 — the Whipple procedure.
   “The Whipple procedure is one of the biggest and most complicated operations in terms of both its undertaking and associated risk,” Dr. Chabot says. As Columbia surgeons have performed more Whipple procedures and other pancreatic resections, the mortality rate has dropped from 10 percent to under 1 percent over the past two decades. Dr. Chabot attributes that success to a small number of surgeons handling a large number of cases —about 200 pancreatic operations each year.
   Center physicians also use minimal access surgical techniques and advanced endoscopic techniques to address pancreatic tumors as well as other pancreatic problems unrelated to cancer to maintain maximal pancreatic function and improve quality of life. In addition, in a clinical trial coordinated by the Herbert Irving Comprehensive Cancer Center that attempts to shrink inoperable pancreatic tumors with chemotherapy and radiation before attempting surgery, the center has made surgery — the only curative treatment — an option for the 35 percent of patients who previously had been deemed inoperable. Such innovations should go a long way toward changing the fatalistic views of both patients and physicians about the outcome of pancreatic cancer, says Dr. Chabot. This is a difficult task when approximately 34,000 patients are diagnosed — and 33,000 die — from pancreatic cancer each year.
   “Right now, most doctors throw up their hands hopelessly,” Dr. Chabot says. “We need to change that mindset. In our work, we hope to decrease the burden this disease places on society, to prolong the lives of people who have the disease, and make it clear to the world that sometimes this disease can be cured.”

The Pancreas Center at the Herbert Irving Comprehensive Cancer Center can be reached at 212-305-9467.

Bariatric Surgery for the Younger Set
Center Offers Surgical Option for Obese Adolescents and Teens

The multidisciplinary Center for Adolescent Bariatric Surgery at the Morgan Stanley Children’s Hospital is among four U.S. academic medical centers performing gastric banding on adolescents. The procedure — placing an adjustable band around the upper part of the stomach to reduce its capacity — is part of an FDA protocol for teenagers between ages 14 and 17 who have been obese for more than five years, have signed a special consent along with their parents, and have well-documented records of unsuccessful weight loss by other, nonsurgical methods.
   Jeffrey Zitsman, M.D., director of the center, completed the procedure on nearly 40 adolescents since the center opened in 2006. Working with Dr. Zitsman at the center to obtain a complete picture of their young patients’ physical and emotional health are a nurse practitioner who serves as program coordinator, a pediatric endocrinologist, a nutritionist, psychiatrists, a pediatric anesthesiologist, and a variety of pediatric gastroenterologists and pediatric pulmonologists. The center has fielded calls from potential patients from as far away as Florida, California, and Israel.
   It usually takes about three months to evaluate each candidate to be sure they meet NIH criteria for the procedure: a body mass index greater than 40 (or greater than 35 with associated co-morbid conditions, such as type 2 diabetes, hypertension, polycystic ovary syndrome); activity in a monitored weight-loss program for a minimum of six months; and the absence of substance abuse and severe psychiatric abnormality. Patients who have not completed a six-month weight loss program are evaluated for six months. Dr. Zitsman carefully explains at a patient’s first appointment the difference between gastric banding and gastric bypass — an operation that combines the creation of a small stomach pouch to restrict food intake and the construction of bypasses of the duodenum and other segments of the small intestine to cause malabsorption. Gastric banding is the only procedure performed at the center.
   The center also conducts several studies to accompany its surgical program, including one exploring the correlation between weight loss and diabetes and one psychological study involving patients’ self image and quality of life. In addition, Dr. Zitsman says, the center is in the early stages of forming a peer support group at the request of several patients. Though the center’s doctors use markers such as body mass index and percentage weight loss to measure a patient’s postoperative progress, some patients have their own goals in mind and it has been gratifying to see those achieved, Dr. Zitsman says.
   Patients’ families are involved throughout the pre- and postoperative process. “Parents accompany young patients when they see the medical director, psychiatrist, exercise physiologist, and nutritionist,” Dr. Zitsman says. “We look very carefully to make sure the decision to have surgery comes from the patient him- or herself. Some patients are very realistic and are not interested in being thin, but rather, losing enough weight to feel good about themselves or to satisfy some other goal. We’ve found that those who do best after surgery have supportive families and peers.”

The Center for Adolescent Bariatric Surgery can be reached at 212-305-8862.

 

 

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