Medical wonders: The cool, new and unique in Maine medicine

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LEWISTON — Two weeks ago, doctors made a small puncture in Wayne Martin Sr.’s leg and gave him a new heart valve. 

They didn’t have to crack open Martin’s chest to replace the worn-out valve that was making it hard for him to breathe. They didn’t have to slice through the membrane around his heart. And they didn’t have to sew him back together and send him home for three months to fully recover.

Instead, Central Maine Medical Center doctors threaded a new valve through an artery in the 80-year-old great-grandfather’s leg and popped a new valve into place — performing a groundbreaking procedure for people too old, too sick or facing too many complications to survive conventional surgery.

CMMC began doing transcatheter aortic valve replacement, or TAVR, in September. Martin, of Westbrook, was patient No. 16.

Immediately after the two-hour procedure, he woke up without pain. Two days later, he went home. A week later, he was looking forward to driving and was planning to ask his doctor when he could start bowling again.

For the first time in months, he was breathing easy. 

Although it’s in its early days — data is still being gathered on long-term success — TAVR is, to many people, a health-care triumph.

And it isn’t the only medical marvel in Maine.

Pinpoint, “wrap-around” radiation for cancer in the brain and near the spine. Custom-made replacement knees. Research that could lead to growing kidneys in a lab. More.

It’s cool, new or unique, and it’s at a hospital near you.

Computer-guided knee replacement: St. Mary’s Regional Medical Center

For 32 years, orthopedic surgeon Wayne Moody prided himself on getting his cuts right during knee replacement surgery. 

A fraction of an inch made the difference. A little this way and the knee was too loose, wobbly, painful. A little that way and it was too tight, hard to bend, painful. But Moody was so good, patients often chose him to fix other doctors’ mistakes.

He could look at a knee’s network of ligaments and bone and see just where and how much to cut. He didn’t need help from a computer system.

“I’m guilty of being maybe a little too prideful in that way,” Moody said. “I sort of thought that I could do a total knee (replacement) as good as you could do a total knee, I’d done so many of them. I was pretty sure when I made a cut, it was the cut that I wanted it to be. I put the jig on there — I’ve been doing this forever — and I put the saw on there and I make my cut. I was pretty sure they were going to be right on.”

Then he tried ExactechGPS Guided Personalized Surgery. The high-tech computer system maps a patient’s leg from ankle to hip, creating hundreds of data points each nanosecond and telling surgeons where and how much to cut for the best results.

“It was unbelievable. I wasn’t way off (without the technology), but one cut was off 2 degrees, and one cut was off a degree and a half, and one cut was off 2 millimeters or a millimeter and a half. I mean, individually, the cuts were all probably OK,” Moody said. “But they were just OK.”

The Lewiston hospital got the system two years ago. Moody quickly found his cuts went from “OK” to nearly perfect 90 to 95 percent of the time.

“I never looked back,” he said.

Moody and fellow St. Mary’s orthopedic surgeon Mohamed Al-Saied are the only doctors using the system in Maine.

“A perfect cut every time, precise and accurate,” Moody said. “You could not make me not use this. You could not take this away from me now.”

Cost: Two of the systems cost the hospital about $300,000. Although insurance companies aren’t willing to pay separately for the computer-guided system, additional costs are not passed on to patients.

“We charge the same whether we use the GPS or we don’t use the GPS,” Moody said. “We believe it’s worth more, but insurance companies don’t want to pay us more. So we just try to do a better job and make it work.” 

The upsides: The system makes surgery less invasive because doctors no longer have to insert a guide rod through the center of a patient’s leg bone. At St. Mary’s, knee surgery infection rates and pain medicine use are down, and patients are staying in the hospital half a day shorter on average and are reporting easier recoveries.

“We think the GPS is a big part of it,” Moody said.

The downsides: Knee replacement is still significant surgery, with all of the risks associated with it. GPS requires doctors to get new training and to be willing to embrace technology. An extra person is needed in the operating room to help with the system.

Moody believes GPS, or something like it, will be the future, both with new knee replacements and, eventually, revisions.

“Some people don’t believe in this stuff,” Moody said. “They want to have a 3-D printer in the operating room make a knee for them. That’s not going to help us. It’s about how you put it in.”

Custom 3-D printed knees: Eastern Maine Medical Center

Orthopedic surgeon Ian Dickey disagrees that custom-made 3-D-printed knees don’t help in joint replacement.

At Eastern Maine Medical Center in Bangor, he’s been using them for about a year.

“We now finally have a three-dimensional solution, potentially, to what are three-dimensional problems,” Dickey said. 

EMMC is the only hospital in Maine offering the knees — called “3-D printed” because they’re designed by a computer and produced by a special machine that “prints” or manufactures them one by one, using a patient’s anatomy as a kind of blueprint.

Dickey starts with a CT scan of a patient’s hip, knee and ankle to gauge alignment, rotation and joint size. Those images are then sent to a company that uses them to form a mold and create a new knee out of alloys.

The printing process takes six to seven weeks. 

“Practically speaking, what it gets (patients) is a total knee replacement that the alignment, the rotation and fit have gone from a game of inches to a game of millimeters. So it’s more precise,” Dickey said. “The theory is that leads us to have a more accurate, functioning knee.”

Cindy Kenny had her right knee replaced with a custom-made 3-D-printed joint in October. Kenny, 62, of Hampden, had been dealing with knee problems and pain since a car accident in 1998, but she kept putting off surgery. Two relatives had undergone knee replacement surgery years ago and neither procedure went well.

“I was afraid that I’d wind up in a wheelchair or crutches and I didn’t want that,” she said.  

But a 3-D-printed knee, with its precise measurements and custom design, intrigued her. When Dickey said she’d be a good candidate, she decided to take the risk.

A week-and-a-half after surgery, she could move without crutches. A month after, she was walking without pain. 

“It’s totally changed my life completely,” Kenny said.

She’s already considering getting her left knee replaced.

Cost: Custom implants cost $3,900 to $4,500, about the same as traditional implants. That’s parts only, not including surgery.

The upsides: The surgery is faster and can be more accurate. Patients tend to recover more quickly and report easier movement sooner. Because each knee is custom created, there is no inventory — and that means technological improvements and other developments can be made immediately, with the very next knee, rather than waiting for stock to run out before upgrading to the next generation.

The downsides: FDA guidelines don’t allow 3-D-printed knees for patients with very significant deformities. And the implants are so new that there’s no long-term data on them yet. 

Dickey believes 3-D-printed custom implants will be part of the future of joint replacement. Possibly in concert with robotics. Possibly for hip replacement as well as knees. And possibly skipping the mold and printing the alloy directly, cutting the wait time in half.

Special delivery heart valve: Central Maine Medical Center

Wayne Martin Sr. needed heart surgery to replace a failing aortic valve, but he couldn’t have it.

Doctors had cracked open his chest four years ago after a heart attack that was so severe his odds of survival, even with bypass surgery, were 50/50. Martin did survive, and thrive, but the bypass left a major artery too close to his breastbone wall. Doctors worried they could nick that artery — which supplied the blood flow to his heart — if they tried to saw through his breastbone again. Another less invasive procedure wouldn’t work, in part, because there was too much calcification around his aorta.  

That left Martin in a spot tens of thousands of people find themselves in every year: At risk of dying from valve surgery; at risk of dying without it.

“I could have walked down my driveway and dropped dead right there. It was just like a time bomb,” Martin said of his faulty valve.

So before dawn on a recent Tuesday, Martin arrived at the hospital for TAVR.

The FDA approved the first TAVR-placed heart valve in 2011 specifically for people who, like Martin, needed valve replacement to overcome senile aortic valve stenosis — a common, age-related disease in which calcium deposits narrow the valve and lead to a weakened heart — but who couldn’t risk open-heart surgery.

Similar to placing a stent, doctors start at the groin and thread the new valve through the artery to the heart.

“I thought (TAVR) was the greatest thing since sliced bread,” said CMMC cardiothoracic surgeon Paul Weldner, one of Martin’s doctors.

CMMC isn’t the only hospital in Maine to offer TAVR and it wasn’t the first. (Maine Medical Center in Portland started in 2012 and has done about 200 since.) But the procedure is still new and relatively uncommon compared to, say, stents. CMMC brought TAVR to its heart center last fall. 

Martin’s two-hour procedure was successful, but not problem-free: The new valve was not a perfect fit, causing some blood to leak around the edges.

Ultimately, Weldner and interventional cardiologist Andrew Eisenhauer decided to leave the new valve alone. As it works, the skirt on the cow-tissue valve billows out, causing a better seal around the bottom of the valve. And as the valve settles, experience has shown, leaks subside on their own.

Cost: The TAVR valve system costs about $30,000 to $35,000. That doesn’t include the cost of medical personnel, anesthesia or the hospital stay.

The upsides: TAVR can be life-saving. The procedure is about an hour shorter than conventional surgery, so patients spend less time under anesthesia. It takes less time to recuperate from TAVR than from open-heart surgery.

The downsides: So far, it’s only approved for people who can’t undergo conventional surgery without significant risk. Because it’s a new procedure, no one yet knows whether TAVR-placed valves — which must be folded and crimped to fit in the catheter — will last as long as valves placed in a conventional operation.

In the future, TAVR may be approved for people who can safely undergo open-heart surgery but choose the new procedure instead. Patients may be able to skip full anesthesia and undergo TAVR under “conscious sedation” like a colonoscopy — a change that will allow patients to go home sooner. Researchers are also looking into whether TAVR can be used to replace other, more complex heart valves. 

A week after his own procedure, Martin was glad he had it done.

“(Breathing) is no problem now,” he said. “No problem at all.

Cancer-killing pinpoint radiation: MaineGeneral Medical Center

Radiation machines are nothing new.

Machines that can deliver focused radiation on tiny brain tumors and avoid hitting the spinal cord while still targeting the cancer around it? Those are.

Two weeks ago, MaineGeneral’s Harold Alfond Center for Cancer Care in Augusta started using a new TrueBeam radiation system. It is one of three hospitals in Maine using the latest radiation technology; in the past, patients had to travel to Boston for some procedures. 

The machine allows doctors to deliver pinpoint radiation. For people with very small brain tumors — less than 1 centimeter — it means they can get treatment now rather than having to wait for their tumor to grow into a bigger target. For people with tumors near their spine, it means treatment is safer and easier — allowing doctors to avoid the spinal cord rather than risking radiation levels that could leave a patient paralyzed.

Before the new machine, MaineGeneral didn’t do spinal-area radiation at all because doctors didn’t want to take that risk.

“Now we can monitor the patient’s positioning very exactly with what’s called surface mapping,” said radiation oncologist Grenville Jones. “So a laser detects and monitors the contours of the patient’s anatomy. Then we can deliver the radiation and sort of wrap it around the tumor but bend it around the spinal cord.”

For all cancer patients, the machine is more accurate overall.

“We can now have more real-time evaluation of where the patient is on the treatment table and actually intervene if they move out of the threshold of where we want them to be,” Jones said. 

Cost: The new accelerator, software and building renovations to accommodate the new machine cost MaineGeneral about $3.2 million. The hospital hopes to get a second one later this year.

The upsides: The new accelerator can improve safety, cut the risk of complications and get cancer patients the treatment they need faster, closer to home.

The downside: It’s still treating cancers after they occur.

“We like to talk about the new technology and that’s great, but I think what’s most important is that continued awareness that in many states, including Maine, smoking is the biggest risk for patients to develop lung cancer and head and neck (cancers). Smoking can be stopped . . . and we’d have a dramatic reduction in head and neck cancers,” Jones said. “We’re trying to treat it from the technical side, but we’ve got to prevent these things from happening.”

For radiation, Jones believes the future is high-dose, high-intensity, highly targeted treatments that will be done in a fraction of the time. And that can happen with this machine.

“Instead of treating patients over five or six weeks, some of the lung cancer patients we’re treating five treatments over a week-and-a-half,” he said. “That’s where I think the future of this field is going to go, and everybody’s predicting that.”

HD TV . . .  for the colon: Stephens Memorial Hospital

It’s something of an uncomfortable topic. And not much fun as procedures go.

But Stephens Memorial Hospital in Norway hopes its latest technology will make colonoscopies more pleasant.

In December, the hospital started using a new colonovideoscope, complete with bright, HD-quality video so doctors can spot small lesions and polyps that would have been missed during old-style colonoscopies. That has the potential to catch colorectal cancer earlier and, potentially, save lives.

The scope itself is thinner than colonoscopes of old, which is supposed to make the procedure more agreeable.   

And rather than using air to inflate the colon — which leaves patients feeling bloated and unhappy afterward — the new technology uses carbon dioxide, a gas the body absorbs naturally.

“Overall, this is a much more comfortable procedure,” said Tim Ingram, senior director of surgical and ancillary services. 

“More comfortable” means more people are likely to do it. And the more people who undergo a colonoscopy, the more likely doctors are to catch cancer. 

Cost: Stephens is part of a growing number of hospitals getting the new colonovideoscope or something similar. The new equipment cost Stephens nearly $300,000.

The upsides: Patients recover faster and go home sooner; it records on a digital system, so images of the procedure can be embedded in patients’ electronic medical record. 

The downside: It’s still a colonoscopy.

In the future, Ingram predicts, colonoscopy equipment will continue to get more compact.

“I see scopes becoming smaller, thinner, as optics change with technology,” he said. “And, yes, the prep still will be with us, but even those have been reformulated and are a little easier than they used to be.”

Growing kidneys: Maine Medical Center Research Institute’s Center for Molecular Medicine

Unlike the other medical advances in Maine, patients won’t be able to get this one from their local doctor or hospital.

But maybe someday. If Leif Oxburgh has anything to say about it.

Oxburgh, a senior scientist with the Maine Medical Center Research Institute’s Center for Molecular Medicine in Scarborough, is leading scientists in Maine, at Tufts University in Massachusetts and at the University of Texas Southwestern Medical Center in Dallas as they work on creating the first building blocks of a lab-grown kidney.

In September, the National Institutes of Health awarded Oxburgh and his researchers a $6.8 million grant to aid in their work. Oxburgh will spend the next five years leading the research team in Maine and coordinating all four teams.

Each team has its own expertise and will tackle its own, but overlapping, research project — how support cells grow into a kidney, for example, or how other cells give rise to blood vessels. The teams will share their research and collaborate on the overall challenge: creating the building blocks of kidney tissue.

“Yesterday we had a group meeting and I think we were at 16 or 18 people all together, discussing,” Oxburgh said. “When you can get that number of people together into one room focusing on one problem, then you have a real opportunity for synergies, new ideas and discovering things. Getting ideas that you don’t get as an individual.”

The upside: In five to 10 years, such research could provide medical advances, including lab-grown tissue that drug manufacturers could use to better gauge at what dose drugs become toxic to kidneys. In 20 years or so, scientists could be able to rebuild a patient’s kidney tissue or create whole kidneys to help the tens of thousands of people every year who need a transplant but don’t get one.

The downside: You won’t be getting a lab-made kidney for a while. Oxburgh’s teams are working on the cellular level; that’s a long way from an entire organ.

“We want to create a unit of this tissue,” Oxburgh said of his research. “The ultimate organ might contain a million of these units. But we want to create this unit.”

In the future, though, Oxburgh believes it can be done. And he believes his teams will be part of it.

“It’s science fiction, but it’s science fiction more like that you would actually be able go to the moon rather than exploring the outer asteroid belt,” he said. “We can get there.”

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The future of medicine in Maine

What will the coming decades hold for medicine in Maine? Some experts believe genetics will play a big role, leading to customized treatments and medications. Others foresee better diagnostics, with more of them done at home using cellphone apps, remote technology or wireless sensors that send information to the doctor’s office.

Mohsen Shahinpoor, a University of Maine mechanical engineering professor specializing in biomedical engineering, believes health care will see more smart materials and systems, such as artificial muscles made from polymers, which he’s been working on. Or a magnetically controlled device that opens and closes a patient’s urethra to stop incontinence, an invention by one of Shahinpoor’s recently graduated doctoral students who was wooed into a job with pharmaceutical company Pfizer.

“The future is in health engineering,” Shahinpoor said.

But experts also say patients shouldn’t always rush to the latest and greatest medical advancement.

“We need to appropriately counter our fascination with technology with informed decisions about things that are often less expensive, less risky and more safe than the newest thing, the newest shiny bright object,” said Lisa Letourneau, executive director of Maine Quality Counts, a Manchester-based health improvement collaborative.

She’s a fan of “Choosing Wisely,” an effort by an American Board of Internal Medicine foundation to spark conversations about health care. It recommends patients ask five questions before any test, treatment or procedure: Do I really need this? What are the risks? Is there a simpler, safer option? What happens if I don’t do anything? How much does it cost?

“It shouldn’t just be assumed that the next thing is the best thing,” Letourneau said.

For knee replacement, for example, she recommends patients talk to their doctor and consider lifestyle changes — weight loss and exercise — before committing to surgery, no matter how new or cool the surgery might be.

“There is no complication with physical activity and eating healthy,” she said.

Ian Dickey, the orthopedic surgeon using 3-D-printed knees in Bangor, agrees. Although he’s a proponent of this latest technology, he never wants the surgery taken for granted.

It is, he said, still surgery.

“What we don’t want people to do is go, ‘Oh! I’m 40 years old, I’ll get a total knee!'” he said. “This is just a more precise tool in the toolbox.”

Some advances are more than medical tech

New procedures, state-of-the-art technology and cutting-edge research are great, but some health-care advancements in Maine are less about hardware and more about relationships.  

Your nurse is a phone call away

Since November, patients at Franklin Memorial Hospital in Farmington have been able to call their nurse directly rather than asking someone at the main desk to relay their needs.

The old way took time and could be frustrating, requiring the patient to call a main desk secretary, the secretary to page the nurse, the nurse to connect with the patient and then handle the request. 

Today, nurses at FMH carry special cell phones that patients can ring directly from their bedside call system. 

“Now the patient calls the nurse directly and they can have that conversation. ‘So, where are you having that pain? Now, I gave you a dose four hours ago, how’d that work for you?’ And you’re doing all this as you’re walking to the med room,” said Jan Bell, who oversees the nurses who work with patients with medical or surgical problems.

The new $500,000 call system has other features — including a safety system that alerts nurses to a specific room when the patient staying there gets out of bed — but it’s patient-to-nurse call that gets the most attention from patients. It saves time, Bell said. It eliminates frustration. It helps get patients what they need from the medical staff when they need it.  

“Cutting that middle man right out of it,” Bell said.

Pregnancy peers

At Mid Coast Hospital in Brunswick, a program called CenteringPregnancy connects pregnant women not only with medical professionals, but also with other pregnant women.

Rather than going to their prenatal medical appointments alone and taking a birthing class with strangers they’ll only meet once or twice, CenteringPregnancy women — with their partners — spend the last half of their pregnancy gathering together once a week for checkups with the same midwife and staying for an evening discussion.

The women are grouped together by due date — all due within the same month.

“Groups really end up coming together and supporting each other,” said Dalit Wolfe. “It shows in several ways. It shows in increased (prenatal care) compliance. It shows in increased self esteem. . . . It shows in sustained relationships and support.”

Wolfe coordinates the program for Women’s Health Care, Mid Coast Medical Group’s midwifery practice. Last spring, she was also a client.

“It was just phenomenal to hear other people’s questions that you wouldn’t have thought of. And also other people’s discomforts that they’re going through that you think, ‘Oh my god, I thought I was the only one having funny dreams’ or whatever,” said Wolfe, whose baby boy was born in July.

Although other medical groups in Maine offer similar programs, Mid Coast’s recently became the only one in the state to earn site certification from the national Centering Healthcare Institute.

Mid Coast started the 10-week program as a pilot in 2010. Since then, about 400 families have gone through CenteringPregnancy, some of them first-time parents-to-be, others preparing for their second or third child. 

Group members often stay in touch, even after they’ve had their babies.

“People compare at 2 in the morning during your nursing session, ‘Does your baby spit up like this?” Wolfe said. “It ends up becoming life long.”

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