October 2014 Newsletter

Department of Medicine eNewsletter
October 2014
:: Interview
:: Department News
:: Department Events
:: Leadership Council Minutes
Website Updates
Leadership Council
October 2014
Richard Walsh

B. Arafah

K. Armitage

A. Askari

R. Bonomo

R. Chandra

F. Cominelli

F. Creighton

S. Gravenstein

T. Hostetter

D. Hricik

N. Meropol

R. Schilz

D. Simon

R. Walsh

J. Wright



J. Sunshine

S. Mohan

Recorded by:
A. Staruch
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department interview
Kingman Strohl, MD, Director of the Sleep Medicine Program, discusses the newly developed technology for sleep apnea therapy, its unique features and availability to patients and projects the management of the disease in the future.


What are some of the most common issues you run into when you are seeing patients in the sleep clinic?


The most common referral is for obstructive sleep apnea, alone or in combination with insomnia. Obstructive sleep apnea is a condition characterized by repetitive episodes of upper airway obstruction at the level of nasopharynx and oropharynx. These repetitive apneas result in arousals during sleep as well as hypoxia and various cardiovascular problems. There is mild, moderate and severe sleep apnea. The daytime symptoms are generally proportional to those categories and include daytime sleepiness, uncontrolled hypertension, pulmonary hypertension, as well as other cardiovascular complications that surface as sleep apnea becomes more severe and chronically present. There are also problems with neurocognitive performance affecting people's memory and impairing cognition by sleepiness. Sleep apnea is the most common disorder that produces daytime sleepiness and impairs a patient's ability to be active during the day.


Your recent article in the New England Journal of Medicine introducing a surgically implanted upper-airway stimulation device to treat moderate and severe obstructive sleep apnea has generated a lot of interest. How did the idea to treat sleep apnea with upper-airway stimulation originate?


In 1978, I published a paper describing genioglossal EMG activity (the result of XII activation), and how insufficient activity was a cause for obstructive apnea. In the 1980s, along with other colleagues across the world, I did some feasibility studies in animals showing how upper-airway muscles and nerves to these muscles work to keep the airway open. In 1993, here at University Hospitals, we had the first demonstration of hypoglossal nerve stimulation with temporary wires and were able to prevent obstructive apnea from occurring. However, this approach at the time provided only a temporary solution and could not break the apnea.


What are the advantages of the new therapy over continuous positive airway pressure (CPAP) therapy and other treatment options currently being offered?


The most common treatment options for sleep apnea are CPAP, oral appliances and anatomic surgical procedures. The advantage of CPAP is that it addresses sleep apnea in a noninvasive way and is offered as a mask that patients wear when they are asleep. Oral appliances are noninvasive as well and keep the airway open by holding the jaw forward during sleep. Anatomic surgical approaches make the airway larger by removing or altering airway anatomy; however, the results are not as predictable. Our Inspire Upper Airway Stimulation (UAS) technology is offered as a rescue therapy for patients who cannot tolerate other noninvasive approaches or who have failed surgery and CPAP therapy.


Could you tell us more about the new device? Who would be the ideal patient for Inspire UAS therapy?


In the article that was published in January 2014 in the New England Journal of Medicine, we showed the pivotal STAR trial with 12 months follow-up. The device was effective in 70 percent of selected participants. The ideal candidate for Inspire UAS therapy would be a patient who is unable, unwilling or intolerant of CPAP and has moderate to severe sleep apnea (an apnea-hypopnea index of 20-65 per hour). In addition, a patient's body-mass index (BMI) upper limit is 35, and ideally below 32. After these criteria are met, a basic airway anatomy examination is performed by an ENT physician; then, if appropriate, a drug-induced sedation endoscopy (called a DISE) is administered during which the nasopharynx and oropharynx are observed under anesthesia and the manner in which they close is determined (nasopharynx closing as a garage door rather than a camera shutter is believed to be optimal for the device to be effective).


What would you tell a patient who fears surgical implementation of a device and is concerned about the procedure's safety?


The patient has to evaluate how strong those feelings of anxiety are and as physicians we encourage external device-based treatments and lifestyle changes before exploring such rescue therapies.


How big is the device? Is it visible once it is implanted? Do patients experience any discomfort during their daily lives?


It is the size of a cardiac pacemaker and has a wire that goes up toward a patient's jaw to the cranial nerve XII and sensor that goes into the intercostal space and measures the breathing pattern. The stimulation is timed in sequence with the respiratory efforts.


As far as visibility during daily activities, the device is only visible when wearing a halter-top or gym attire. The scars fade over time, placed along the natural lines of the body so that they do not seem obtrusive.


The majority of people who have had the device implanted did not experience any discomfort, though about 10 percent of patients have reported some tongue abrasion due to the nightly tongue stimulation. This occurs when patients have rough or missing teeth and can be fixed by dental work or programming.


What is the accessibility of the device for patients?


The FDA approved the device on April 30, 2014, and we will introduce it to the public in a responsible manner. It requires cooperation between sleep and ENT physicians trained to assess the patient, implant and activate the device. University Hospitals Case Medical Center is one place that offers this new therapy. If the procedure becomes more routine, it will be introduced at many centers. However, at the present time, there is a lot of quality control in place to ensure that implantation training and patient assessment are performed at the highest level and meet the expectations of patients and health care systems. The therapy first became available at medical centers that participated in the original trial and includes University Hospitals, University of Pittsburgh Medical Center and others. We currently have 10 patients who are being evaluated for this therapy.


What has been the feedback from patients so far? How has their quality of life changed after the implementation of the device?


The primary outcome of Inspire UAS therapy here in eight patients is a decline of sleep apnea events per hour and desaturation events per hour. The secondary outcome patients experienced was the reduction of sleepiness and snoring, improving their quality of life and daytime functioning.


What are the plans for the follow-up of current patients, design of future trials and further developments of this therapy?


We are continuing to evaluate the patients who were part in the pivotal STAR trial; the three-year follow-up will be reported analyzing the durability of the new therapy. People who recently received the implanted device are currently enrolled in the trial and will be clinically followed in a national database, and their responses will be monitored.


Our current research focus is the manner in which the new therapy opens the nasopharynx and factors that influence it. This therapy has shown us that the activation of the hypoglossal nerve confirms that one of the pathways for the initiation of sleep apnea is inadequate muscle activity that occurs during sleep. We would like to explore the idea of designing drugs that improve sleep apnea through the activation of the upper-airway muscles. We are witnessing a real change in our approach to sleep apnea and our ability to pharmacologically address the disorder.


In your opinion, what will be the management of sleep apnea in the future?


I believe more high-level rescue therapies will be developed in the future; the hope is that they will be easy to perform and will be rapidly disseminated. It is likely that just like the therapy we developed, new therapies will require cooperation, communication and expertise among different medical specialists to effectively address sleep apnea. As physicians, we will be focused on identifying the therapeutic targets for sleep apnea more precisely for each individual patient.


The department news report

Division of Cardiovascular Medicine

Daniel Simon, MD, became the President of the University Hospitals Harrington Heart & Vascular Institute. In his new role, Dr. Simon will lead multidisciplinary cardiovascular groups delivering care across the system to improve consistency of patient experience and will focus on directing clinical, educational, research and administrative programs to foster regional leadership and enhance the national reputation of the institute. In addition, Dr. Simon will be responsible for monitoring UH Harrington Heart & Vascular Institute's models of care as well as quality and safety standards.


Schedule a clinical appointment with Cardiovascular Medicine physicians





Division of Gastroenterology & Liver Disease

Jeffry Katz, MD,
was awarded a $20,000 grant from the American College of Gastroenterology to study fecal microbial transplant in patients with chronic pouchitis.








Maneesh Dave, MD,
published his research entitled "Differential Coupling of KLF10 to Sin3-HDAC and PCAF Regulates the Inducibility of the FOXP3 Gene" in the American Journal of Physiology - Regulatory, Integrative and Comparative Physiology.







Schedule a clinical appointment with Gastroenterology & Liver Disease physicians




Division of Hematology & Oncology

Neal Meropol, MD,
along with his collegues from the School of Nursing received an R01 grand from the National Institutes of Health/National Institute of Nursing Research to map the complexity of influences on aggressiveness of end-of-life cancer care for patients with advanced cancer.

Evi Stavrou, MD,
was appointed as Co-Chair of the Scientific Subcommittee on Factor XI and the Contact System for the International Society on Thrombosis and Haemostasis (ISTH). The committee issues consensus recommendations on practical matters of research standards, methods and nomenclature. It also provides guidelines that address specific clinical questions and contributes to the development of standards by the World Health Organization.

Schedule a clinical appointment with Hematology & Oncology physicians



department conferences & events

State of the Department of Medicine Address

When: 5:00 p.m. on Monday, November 3

Where: Wolstein Auditorium

Click here to RSVP


Grand Rounds

When: Tuesdays, 12:00 - 1:00 p.m.

Where: Kulas Auditorium, Lakeside, 5th Floor


November 4

"Myths and Dogma in the Practice of Endocrinology" by Armand Krikorian, MD, FACE


November 11

"Lung Cancer" by Afshin Dowlati, MD


November 18

"Lyme Disease and Post-Treatment Lyme Disease Syndrome" by John Aucott, MD


November 25

"Thrombosis - 2014" by Alvin Schmaier, MD


department leadership council minutes

Leadership Council

Dr. Walsh welcomed Jeffrey Sunshine, MD, Chief Medical Information Officer, University Hospitals, who gave a presentation on ambulatory practice enhancement initiatives. Dr. Sunshine reviewed the objectives, planning approach, work flow enhancements and work flow management of this initiative. He reviewed the need for funding, resources, standardization and vendor commitment. Dr. Walsh introduced Sri Madan Mohan, MD, into the discussion of the prototype products being considered for implementation with the EMR. Dr. Walsh thanked Dr. Sunshine for his presentation.


Leadership Council

Dr. Walsh updated council members on the following chair searches: Department of Family Medicine, Search Committee chaired by Michael Konstan, MD; Department of Urology, Search Committee chaired by Cliff Megerian, MD; and Department of Surgery, Search Committee chaired by Warren Selman, MD.



Leadership Council

Dr. Armitage reviewed the intern applicant interview process including the number of applicants invited and scheduled. He distributed a list of recruitment interviewing dates and requested that Division Chiefs encourage their faculty to participate.


Leadership Council

Dr. Bonomo updated the council on a successful year for the medical service at the Louis Stokes Cleveland VA Medical Center. The medical service had over 121,000 patient encounters with net growth of 8 percent. In particular, Dr. Bonomo cited growth in nine of 10 subspecialty services, primary care and the hospitalist service. Dr. Bonomo will be overseeing the recruitment of new full-time faculty members in a variety of areas. He reviewed the need for continued growth in the efficiency of patient care and also in quality care.



Dr. Gravenstein, Interim Division Chief of Geriatrics & Palliative Care, gave an overview of the progress in the division. He has or will be launching eight new clinical programs for Geriatrics, some of which include: a Geriatrics Adult Care for the Elderly Program, a Hanna House Quality Inpatient Program, a Palliative Care Unit, a Urology Screening Program for the Elderly, a Nurse Practitioner Training Program and new initiatives in Geriatrics at UH-affiliated area hospitals. He has recruited five new full-time faculty members and will be initiating a Palliative Care fellowship program after the recruitment of a Palliative Care Section Head.



Leadership Council

Dr. Walsh updated the council on the search for a Chief of Geriatrics & Palliative Care.


Among the nation's leading academic medical centers, University Hospitals Case Medical Center is the primary affiliate of Case Western Reserve University School of Medicine, a nationally recognized leader in medical research and education.