Medical Update (2001)

Volume1/2001_AutumnMEDICAL G PDATE i Irritable Bowel Syndrome: Varied Treatments Ease Symptoms Autumn 2001 UNIVERSITY OF UTAH HOSPITALS & CLINICS Pulmonary Rehabilitation Program Exercise Reaps Benefits for Lung Disease Patients Like a lot of parents who work 40 hours a week while raising a young family, Lannea Silva needs to catch her breath some-times. But that has never been easy to do. Silva, 24, has cystic fibrosis ( CF), a hereditary chronic illness that causes excess mucus to form in her lungs, turning them into a breeding ground for bacteria and viruses. People with CF often feel short of breath and live with flu- like symptoms that turn everyday tasks into a struggle. There is no cure. " We tend to sit a lot ... just because we don't feel well," Silva said. Silva lives in Tremonton, with her husband, George, and their children, Emily, 3 and Daniel, 4. A few years ago, she could count on little relief from feeling almost constantly tired and sick. But that changed in 1999 when she learned about University of Utah Hospital's Pulmonary Rehabilitation Program. The program helps people with CF and other lung diseases improve their quality of life through some-thing they often avoid- exercise. In the two years she's been in the program, Silva has come to realize the benefits of brisk walking and lifting weights and credits that with helping her fight off infections and spend less time hospitalized. By any measure, that makes her life easier. " I just feel better when I exer-cise," she said. " I seem to have more energy." Doctors long have recom-mended exercise for people with asthma and Chronic Obstructive Pulmonary Disease ( COPD)- the Lannea Silva, right, walks a treadmill in the Pulmonary Rehabilita-tion Program laboratory. Exercise specialist Kathryn Krause tracks Silva's heart rate, oxygen level and other data as she exercises. term for lung diseases that includes emphysema and chronic bronchitis. But encouraging CF patients to exercise is a more recent develop-ment, said Wayne Samuelson, M. D., associate professor of medicine at the University of Utah School of Medicine and the pulmo-nary rehabilitation medical director. Now, when cystic fibrosis patients are hospitalized at the U, as Silva was in late September when she caught a cold, doctors get them into the pulmonary lab as soon as they can exercise. The idea behind the rehabilitation program is pretty simple, according to Samuelson. People with lung disease often are short of breath, which makes them fear exercise. But muscles that aren't regularly exercised use oxygen less efficiently, making it even more strenuous for lung- disease sufferers to be active. The pulmonary program is trying to eliminate this Catch- 22, and for people willing to put in the effort, it almost always succeeds. " But it only works if you exercise consistently," Samuelson said. Right now, about 30 people with lung disease work out on the pulmonary program's treadmills, stationary bicycles, weight machines and other equipment. Everyone entering the program receives a baseline examination from one of the program's three exercise special-ists to determine their current pulmonary function and ideal training level. From that, an individual exercise plan is designed. The program, open only to non-smokers, is divided into three phases: inpatient; outpatient; and self- directed, according to lab coordinator Bill Pazos. Inpatient serves patients who exercise while hospitalized. Outpa-tient teaches people with COPD about their disease and gets them started exercising. This phase lasts a minimum eight weeks; Samuelson recommends 12. Self- directed is for those who have completed the outpatient phase and can exercise without supervision and little monitoring. Pazos likens it to belonging to a health club. By the end of eight weeks in the outpatient phase, the typical patient reports a 20 percent increase in endurance to walk or perform other tasks, Samuelson said. Exercise has been proven to help asthma patients decrease their reliance on medication; people with COPD gain stamina and strength. Although exercise appears to help CF patients clear mucus more effectively from their lungs, it is too soon to say conclusively how they benefit, according to Samuelson. Sam King is no stranger to exercise. The 71- year- old Salt Lake City attorney lived an active life that included daily jogging, hiking in Wyoming's Teton Range when he was 60, and skiing in resorts from Utah to Switzerland. He also smoked two packs of cigarettes a day for 50 years and has emphy-sema. His lung capacity is about 40 percent of what it once was. " I burned the candle at both ends," King said. Last Christmas, after trying " a thousand times," he quit smoking and recently joined the pulmonary program as an outpatient. Initially, with the aid of oxygen, King could University of Utah Hospitals & Clinics toll- free referral and consultation numbers: in Utah 1- 800- 662- 0052 outside Utah 1- 800- 453- 0122 www. med. utah. edu Wayne Samuelson, M. D., medical director of pulmonary rehabilitation, said the goal of the program is to give people with lung disease a better quality of life. exercise for an hour at a time, but already has increased to 90 minutes or longer. The key to more endur-ance for people with lung disease is the ability to exercise in the lab with the aid of oxygen, he said. The oxygen gives them the breath to work harder, which builds stamina. King hopes being better condi-tioned will help him ward off a yearly bout with pneumonia. But he has another goal: He'd like to get in good enough condition to go cross- country skiing with the aid of a portable oxygen canister. Mel Wilhite, 71, wanted just to function better on a daily basis. Wilhite, a former smoker, was diagnosed with COPD four years ago and his life largely had become an either/ or proposition. If he had to go to the bank and grocery store, for example, he went either to the bank or the store- but never both on the same day. Since joining the pulmonary program three years ago, Wilhite, who is in the self- directed phase, has gained stamina and no longer has to restrict his activities to just one a day. The program also has given him the confidence to handle stress better at those times when he runs short of breath- a major improvement in his life, he said. While King and Wilhite exercise regularly in the program laboratory, Silva is on her own unless she is in the hospital. She has been hospital-ized three times since April- a lot by most people's experience. But before April she hadn't been in for eight months, and that's a healthy stretch for her, one she said is a result of the pulmonary rehabilita-tion program. Fewer trips to the hospital. More stamina for life's daily tasks. The ability to go cross- country skiing. The pulmonary rehabilitation program helps people with lung disease spend better time with family and friends and lead more normal lives. That is the program's ultimate goal. " Virtually everyone who partici-pates has a better quality of life," Samuelson said. For more information, call the Pidmonary Rehabilitation Laboratory, 801- 585- 1015. 3 Irritable Bowel Syndrome Varied Treatments Manage Frustrating Condition Irritable Bowel Syndrome ( IBS), which affects 20 percent of the population, can be just a mild annoyance or can cause extreme physical discomfort and psychological distress. " It runs my life, and it ruins my life," is the way Linda Duffy, Salt Lake City, describes the condi-tion, which has affected her career plans, travel and social life. Because its common symptoms include abdomi-nal pain, flatulence, and diarrhea or constipation, and, sometimes, mucus in the stools, IBS was a condition that was not openly discussed until recently. Duffy believes that most physicians, other than gastrointestinal specialists, cannot understand how bad the pain can be. " It's hard explain to someone who hasn't been there, or who doesn't deal regularly with IBS patients, how frustrating the condition is, " she said. According to John C. Fang, M. D., assistant professor of gastroenterology at the University of Utah School of Medicine and director of the endoscopy center, IBS is the chief reason people visit gastroenterologists and is among the top 10 reasons people go see their primary care physicians. IBS is often called a functional disorder because there is no objective sign of disease when the colon is examined. If there is good news associated with IBS, it is that it does not inflame or cause changes in bowel tissue, does not cause intestinal bleeding and does not appear to increase the risk for colon cancer. The main causes of IBS are thought to be due to disorders in the motility or movement of the bowel; hypersensitivity of the bowel; and/ or related psychological dysfunction. " It's probably a combi-nation of all three," Fang believes. The motility of the colon moves the contents slowly back and forth, but mainly toward the On the cover. . . First affected by IBS 27years ago, Linda Duffy has finally succeeded in managing the painful, frustrating condition. John C. Fang, M. D., assistant professor of gastroenterology, believes a combination of factors causes irritable bowel syndrome. ^ KSmmm • H• N• 1M1T1 rectum. This movement results as muscles lining the intestine walls contract and relax. In IBS, the contractions are stronger and last longer than normal, and some IBS patients may actually be able to feel these contractions. Seventy percent of those affected by IBS are women, and the condition is more common in young to middle- aged women. IBS is usually a symptom- based diagnosis, Fang said. More serious organic disease is first excluded through various testing procedures, which may include a sigmoidos-copy or colonoscopy. Physicians then rely on the patient's medical history and a careful detailing of symptoms to make the diagnosis. " We can treat the condition, but it is very difficult to make patients completely symptom- free; we can't cure IBS," said Fang. For some patients, symptoms tend to wax and wane over time and people learn to adjust to their symptoms, he added. Duffy, 47, has had the syndrome since she was 20 and remembers vividly the first time she experi-enced the severe spasms and diarrhea that she has contended with since. She was delivering informa-tion to an athlete being recruited by the college coaching staff she worked for. Her problem was not diagnosed as IBS at that time; colitis, or inflammation of the colon, was the conclusion, and she was given some anti- diarrheal mm • • l i l 11111s' medication and some tranquilizers. Over the years, IBS has been called spastic colon, nervous colon, irritable colon and unstable colon, as well as mucous colitis or nervous colitis. The latter terms may be misleading, causing people to confuse IBS with ulcerative colitis, a more serious condition. Until two years ago, when Duffy made an appointment with Fang, she had tried to find out what the trouble was by talking about it whenever she saw various physicians. Some suggested that stress could have been a factor, but she tends to discount this. " I think I'm just average as far as stress goes; I don't worry or fret too much, so I don't think that's a significant factor." Duffy, who has primarily worked in office and project management and is now an office manager with the tenant finish department at The Gateway, believes IBS has had a profound effect on her career and income. She did not accept work that required a lot of travel or lengthy meetings because of the need to use the bathroom frequently. " It's had a psycho-logically devastating effect because I haven't been able to do what many normal business and social situations require. " I wouldn't carpool or ride with a friend because I might have to cut an evening short, and I'd never go to an event unless a bathroom was easily available." The expense for a number of different prescrip-tion drugs she took over the years also was consid-erable. " Just for fun, I decided to calculate how much I was spending on an over- the- counter anti-diarrheal medication. It averaged out to $ 365 a year." The syndrome is costly, not just because of many medications that patients may try. " The illness results in $ 8 billion in direct costs and $ 25 billion in indirect costs, based on things such as loss of work time," said Fang. Duffy finally decided to seek a specialist's help when an onset of IBS forced her to cancel, at the last minute, a promise to go door- to- door for Rocky Anderson during his Salt Lake City mayoral campaign. Several antidepressants had been prescribed in the past. One " worked like a charm" but just put her out; another exacerbated the condition. Fang suggested amitriptyline-" a very old, safe and cheap" medication. She considers it a " Godsend" and has been taking it once a day, at 7 p. m., for two years. Fang says that one of the most successful treatments is the use of antidepressant drugs, in lower than standard dose, as a gut analgesic and antispasmodic. However, treatment is usually a combination: something dietary, such as more fiber; and a pharmaceutical, based on the primary symptoms such as constipation, diarrhea and pain. He prefers to prescribe simple things- a laxative for constipation or an anti- motility agent for diarrhea. Some patients find relief with mild modifica-tions in their diet. Milk, cheese and certain veg-etables appear to aggravate the syndrome, but this varies greatly and it is hard to generalize about such changes for all patients. Duffy takes a fiber supplement, but can't really pinpoint a single food that causes an IBS episode. Sometimes the diarrhea and spasms come after eating chocolate, sometimes not, so she is careful how much chocolate she eats. She does always avoid ice cream and the greasiest of foods. Duffy now experiences only one or two IBS episodes a month, and says she feels better than she has in years. For more information, call John C. Fang, M. D., 801- 581- 7804. Clinical Studies Ophthalmology: Individuals with moder-ately severe to very severe nonproliferative diabetic retinopathy are being recruited for a three- four year study of an oral medication to reduce the progression of retinopathy. The medication's mode of action is to inhibit neovascularization pathogenesis. Participants will be evaluated at three- month intervals. Call Kim Wagner at 801- 581- 6265. Ophthalmology: Individuals with subfoveal choroidal neovascularization secondary to age- related macular degeneration are being recruited for a two- year study of an anti-angiogenic drug. Participants will receive intravitreal injections of the study drug every six weeks for a minimum of 54 weeks. Call Darek Leyde at 801- 585- 6647. 5 Waiting For a New Heart Circulatory Devices Strengthen Patient for Transplant Nearly 700 World War II model airplanes sit on the shelf waiting to be built. A Provo, Utah, hobbyist waited, too, for a medical rescue of his failing heart that would give him the strength to build them. Mark Hamilton, Ph. D., professor of architec-ture history at Brigham Young University, devel-oped heart disease 10 years ago. For him and thousands of others, heart transplant extends the promise of a return to a healthy and productive life. While he waited, Hamilton was supported on a Left Ventricular Assist Device ( LVAD), a me-chanical support that, as waiting lists grow, is being looked at as a more permanent replacement for patients with failing hearts. On Aug. 2, Hamilton's wait ended and his new life began. After several months on the LVAD, he received a heart transplant at University of Utah Hospital. " The longer patients wait, the worse their heart becomes, and the greater their need for devices to sustain them until a heart becomes available," said James C. Stringham, M. D., assistant professor of cardiothoracic surgery, and surgical director of the University Cardiac Transplant Program at the University of Utah School of Medicine. In the year 2000, 53 percent of those on the waiting list received a transplant, but many patients wait more than two years for a compatible heart. " Many are waiting longer than usual for heart transplants, because donors are in short supply," said Stringham, who is also director of the U's Mechanical Circulatory Support Program. He attributes the dearth of hearts to the fact that fewer families of potential donors are consenting to organ donation than before and that automo-biles are safer today, resulting in fewer fatal accidents that lead to organ donation. Hamilton's heart trouble began in 1992 with a heart attack. Six years later he had another. He underwent coronary bypass surgery to correct the problem, but six months later it failed. At that point, stents were inserted, but lasted only three weeks. By December 2000, Hamilton remembers, " I was so weak I could barely walk." Mark Hamilton enjoys a hobby he began as a college student, collecting, building, and trading model planes. His declining health had kept the usually active university professor, who is approaching his 30t h year of teaching, from hunting and fishing with his sons and sapped his strength. Despite not feeling his best during that period, he still maintained a busy teaching schedule and spent extensive time in New Zealand and San Diego, researching and photographing buildings for two papers he was preparing to publish. He called a hot- line mentioned in a newspaper article about cardiac disease and was directed to check into a hospital immediately. " I'll never forget that telephone call," he said of his conversation with Stephanie V. Moore, M. D., a Salt Lake City cardiolo-gist. " I didn't realize how sick I really was. If we had not done something about it when we did, I wouldn't have had much longer to live." Because of the gravity of his condition, Hamilton was referred to University of Utah Hospital where he was evaluated for transplantation by the cardiothoracic team consisting of Stringham, David A. Bull, M. D., associate professor of cardiothoracic surgery, and Shreekanth V. Karwande, M. D., professor and division chief of cardiothoracic surgery. Three weeks James C. Stringham, M. D., believes future heart support devices may be a substitute for transplants. later, after failing to respond to standard medical therapy, Hamilton received an LVAD. He spent the next three weeks in the hospital getting accus-tomed to the device and regained the strength he had lost in previous months because of his weakened heart. Eighty percent of all heart failure occurs in the left ventricle, a large muscular chamber that pumps oxygenated blood to the body. In the LVAD procedure, surgeons implant the pump- like device in the upper part of the abdomen with one tube surgically attached to the left ventricle pulling blood into the pump. The pump then " bypasses" the weakened ventricle and sends the blood to the aorta. The pump is controlled by a drive- line that is brought out through the skin and connected to a small controller, worn at the waist, that provides power, and regulates and monitors the beat. LVAD patients can resume a somewhat normal lifestyle, which helps them stay active and in better shape as they prepare for a heart transplant. Hamilton said his recovery seemed quick; his body and muscles began feeling stronger after he received his LVAD. Although more than 2000 people in the U. S. receive heart transplants in one of the 261 transplant centers across the country, the demand is double that. As a consequence, the need for LVADs to help buy additional time for potential candidates, also is growing. The number of patients who have had circula-tory support devices implanted at University Hospital has grown since the program began in 1996. The 2001 numbers already have met last year's total which was double the number of those who received devices in 1999. Although mainly used as a bridge to transplant, mechanical devices are being evaluated in clinical trials as a possible permanent replacement to the failing heart, a prospect Stringham sees as a viable option in the next five to 10 years. " Millions of patients with coronary disease could potentially be saved by a mechanical device," he said. " The future is bright." He believes the $ 65,000 pump will prove to be cost- effective as devices become smaller and more durable, and will easily offset the many costs associated with repeated hospital admissions for end- of- life heart failure. Hamilton spent just four months on the LVAD before receiving a heart transplant. Transplants are suitable for only certain kinds of heart disease, and other qualifying factors are considered, including the candidate's age, psycho-logical stability, family support, and severity of illness. Also, all other vital organs- specifically kidneys, liver, and lungs- must be in excellent condition. Hamilton spent a month in the hospital follow-ing the transplant. His three- month evaluation in October showed " no sign of rejection and every-thing seems balanced," he said. He will continue to " guard" his health for the next year with regular check- ups, biopsies, and evaluations. Although Hamilton's heart trouble will put nearly a one- year hold on his teaching, researching, traveling and model plane building, he is looking forward to the future. " I am thrilled to be on my way back," he said. " The most exciting thing is the potential I have to return to do the things I have always done." The father of five and grandfather of six believes his family has been instrumental in his recovery. " They were by my side the entire way. It was probably most difficult on my wife," he said of her constant support. Hamilton can't thank Stringham and the U team enough. " If we were to get rich tomorrow," he added, " I would give i