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  Almost ready for prime time
Water for the world
Lowance center offers new immunity deal
Fundraising report: How we did in FY '04

New faces in high places

Women test new gel to fight HIV
Computer screening saves lives
Targeting hard-to-treat tumors
Almost ready for prime time
By Pam Auchmutey

The second phase of the Emory Electronic Medical Record (EeMR) will soon go live with a cast of thousands, as more than 7,000 physicians, nurses, pharmacists, therapists, nutritionists, unit clerks, schedulers, administrative staff, and others begin using the new software applications that will support it.
     Phase II is a major milestone for EeMR, a 10-year, $50 million project that will transform care delivery throughout the Emory Healthcare (EHC) system. In 2002, Phase I included the installation of the system’s technical infrastructure and hardware, as well as the Enterprise Master Patient Index, software that tracks each patient using a unique internal identifier number. This index reduces registration errors and eliminates the need to re-enter the same patient information in different care settings and is also used for PACS, the radiology picture archival and communications system used to store and display medical images electronically.
     Rollout of the new programs in two-week phases began in late January, starting at Wesley Woods Hospital, then moving to Emory Crawford Long Hospital, followed by Emory University Hospital. The Emory Clinic began gradually implementing the programs, a section at a time, in February. Most users are receiving two hours of classroom instruction beforehand, while physicians are being trained individually.
     “The size of this is incredible to me,” says Anne Nelson, director of organizational development and learning services for EHC. Nelson is the team leader responsible for planning educational content. Implementation of Phase II required the scheduling of nearly 900 separate training classes.
     EHC employees can rest assured that the instruction will not end there. As the software programs go live, 500 ACEs—employees trained as Application Content Experts—will be available during each shift to answer questions and troubleshoot problems.
     During Phase II, EeMR’s designers will launch updated versions of existing software, including PowerChart (inpatient results), PowerOrders (a physician/clinician order management system), PharmNet (hospital-based pharmacy), and Charge Services (hospital billing). New applications include PowerChart Office (an outpatient version of PowerChart) and CV Net (a scheduling system for hospital cardiology services). Emory University Hospital also will go live with FirstNet (emergency department tracking and documentation), which has been in use at Crawford Long since 2002, when it was installed as part of Phase I. Cerner Corporation, a longtime EHC partner, is providing the software.
     All of these foundation applications will support Phase III, the point when total transformation of patient encounters will begin. The integrated information systems will lead to a
safer health care environment, administrators say.
     Slated to begin in 2006, Phase III will include new technology and processes such as computer-based physician order entry (CPOE), which will enable hospital and clinic physicians to enter orders in a computer terminal in or near exam rooms and at the patient bedside.
     Not only will CPOE help eliminate imprecise and incomplete communication among doctors, nurses, and pharmacists, but it will also provide real-time decision support to help reduce adverse drug events and other errors. Organizations such as the Leapfrog Group and the Institute of Medicine advocate using CPOE to minimize medical errors, the fourth leading cause of death in the United States.
     “The transition will be challenging—not just learning the new technology but using it as a tool to change our processes so that we can do our work more effectively and safely,” says William Bornstein, chief quality officer and medical director, information services, for EHC. “The real payback will be improvement in the quality, safety, and satisfaction of all involved—our clinicians and our patients. Those are the major goals.”
     In addition to charting clinical data, EeMR will capture and document insurance information and other data, thus eliminating the manual paperwork that occupies a great deal of doctors’ and nurses’ time.
     “We’re not looking for this system to provide help with the brilliant stuff,” says Bornstein, who is an adviser to Leapfrog. “Those are the things only our providers can do. But it can off-load tasks that can be distracting—things like multiple documentation requirements and managed care formularies—and leave more time for the deep thinking that is required for high-quality patient care, more time for physicians to focus on the patient.”
     For now, EHC staff and patients will live in a hybrid world of paper and electronic records. The use of paper will diminish as use of the electronic record grows—a transition projected to last until 2012. Ultimately, every patient and EHC worker will feel the impact of EeMR.
     “This is the biggest challenge our organization has ever had,” says Kate Smith, EeMR project director. “It’s going to affect everybody in our health care system.”

Pam Auchmutey is senior associate director of Health Sciences Publications, and the editor of Emory Nursing magazine.

Water for the world
By Diane Blanks

Today, it is estimated that nearly 2 billion people worldwide lack access to safe drinking water, and more than 1 million people die each year of water-transmitted diseases.
     Retired public health professor
Eugene Gangarosa, who has devoted much of his career to safe-water projects, hopes a recent gift to the Rollins School of Public Health (RSPH) will help change those dire statistics. Gangarosa and his wife, Rose, have pledged $2 million to establish the Eugene J. Gangarosa Chair in Global Safe Water and made a planned gift of another $2 million to establish the Rose Salamone Gangarosa Chair in Environmental Health, a position focusing on improving sanitation in the developing world.
     “United Nations Secretary-General Kofi Annan has pinned the world’s hope for global development and stability on access to fresh water and sanitation,” Gangarosa notes.
     The problem is not that the world doesn’t understand the causes of waterborne illness, he believes, but that many approaches have not included practical “point-of-use” strategies to improve access to cleanwater at the individual level.
     In many areas of the world, simple, low-tech, low-cost solutions can make a major difference, Gangarosa says. For example, many families without running water must travel long distances to communal wells. But the water, often carried in open containers, is contaminated during transport back to the home.
     During the 1980s, however, the Centers for Disease Control and Prevention developed a special, narrow-mouth, 20-liter jug that enabled users to treat water with chlorine at the source and then safely transport it. In countries that field-tested the jugs, incidence of waterborne diseases was reduced by 50%. The system is now in use in countries throughout the developing world.
     Gangarosa began his public health career in 1959 as one of the first doctors working on the international fight against cholera. At the time, data from the World Health Organization indicated that waterborne diseases annually killed almost 5 million people.
     Now, thanks to the development of effective medical treatment, the mortality
for cholera is almost zero, but getting treatment and prevention efforts to those who need it is still a worldwide challenge.
     A medical doctor with a master’s degree in microbiology, Gangarosa has worked around the globe in a number of different roles. But the issue of safe water was never far from his mind.
     The couple also has funded a safe-water endowment at the CDC through the CDC Foundation and established a family foundation that contributes to a number of international safe-water initiatives.
     With their current gifts, the Gangarosas hope to encourage future public health leaders to continue to find practical but innovative ways to address this global emergency.
     Their efforts to foster global safe water and sanitation are, Gangarosa says, “drops of water in an ocean of need,” but ones that they hope will grow and expand over time.

Diane Blanks is an editor in Health Sciences Development.

Lowance center offers new immunity deal

Why do some healthy 40-year-olds have immune systems that look like that of an 80-year-old? And how does this influence their risk of developing cancer, heart disease, or Alzheimer’s later in life?

These are some of the questions under the microscope at the new Kathleen B. and Mason I. Lowance Center for Human Immunology at the School of Medicine. Married scientists Cornelia Weyand and Jörg Goronzy, who collaborate on research in this area, recently moved from the Mayo Clinic to Emory to lead the effort.
     The multidisciplinary center, which opened in May, is dedicated to improving treatment of autoimmune diseases and researching the ways that the immune system influences development of chronic disease.
     “We are seeing a paradigm shift in modern medicine,” says Weyand, the first David C. Lowance Chair in Human Immunology at Emory. “Traditionally, medicine has been organized around organ systems. But it’s become increasingly clear that diseases in many different organs share common principles of how tissue functions fail. Medical specialties of the future will center on such common biologic pathways.”
     The best example, right now, is cancer research and treatment that focus more on how cells in general turn malignant, and less on the specific organ systems involved.
     “The same will eventually be true of many other diseases,” she says.
     Scientists are just beginning to understand the role that the immune system, in particular the inflammatory response, plays in diseases not previously considered immune-related. Although most people think of it as the body’s primary defense against infection, changes in the immune system actually cause or exacerbate many medical conditions.
     “For instance, the inflammatory response prompted by the buildup of plaque in coronary arteries promotes the life-threatening blockages or tears that we associate with heart attacks,” Weyand explains.
     “The immune system causes disease when it fails to protect us against cancer and infections and, equally important, by driving inflammation, which we are beginning to realize, is pivotal not only in rheumatologic and allergic diseases but in other chronic diseases as well,” adds Goronzy, the new Mason I. Lowance Chair in Human Immunology. “We must develop the tools to measure the functionality of the immune system in those who are healthy and in those who become sick when the system fails.”
     “The body’s immune response capabilities change throughout a person’s life and diminish significantly after age 40,” Weyand explains. The new center will study the ways that aging affects immune system function and examine the role inflammation plays in the development of heart disease.
     “The center will also serve as a force for integrating immunology research with existing medical disciplines and helping Emory chart the course for modern medicine in the 21st century,” Goronzy adds.
     “In the future, medical research will look very different from today, and the leadership at Emory is active in guiding and shaping this process,” he explains. “Recognizing genetic and environmental risk factors and developing the instruments, such as bioinformatics, to quantify complex processes will be key for the delivery of high-quality health care and for disease prevention. Diseases do not adhere to our current specialty designations, and they don’t read medical textbooks. Every leading medical center will need integrated platforms to share information along new clinical pathways.”

  Grateful patients offer ongoing tribute

Mason I. Lowance, who graduated from Emory University School of Medicine in 1927, practiced allergy and internal medicine for 50 years. Among his notable patients were Goodrich White, former president of Emory, and Atlanta mayors William B. Hartsfield and Ivan Allen Jr.
     When the highly respected allergist retired in 1979, gifts from many of his grateful patients and their friends provided seed money that eventually grew into the $12 million endowment that now funds the Lowance Center for Immunology and the Lowance chairs.
     “My father was an allergist when very little was known about the immune system,” says David Lowance, a renal specialist for whom one of the Lowance chairs is named. “We requested that the term “immunology” describe the center to connote a desire to elucidate and discover basic underlying mechanisms of immune disorders, whether they be clinically expressed as allergy, transplant rejection, cancer, rheumatoid arthritis, or the many other diseases we now know to be related to disorders of the immune system.”


Fundraising report: How we did in FY '04

The Woodruff Health Sciences Center closed a banner year for fund-raising in fiscal year 2004, raising just over $61 million in total gifts to the schools of medicine, nursing, and public health, the Yerkes National Primate Research Center, and Emory Hospitals.
     “We continue to see substantial giving from a growing list of donors who have faith in the work we do in the health sciences,” says Phil Hills, Emory’s vice president fordevelopment in the health sciences. “In just the past five years, we have seen our annual totals go from about $15 million to more than $61 million, excluding the Woodruff Foundation gifts.”
     Faculty have been important to this success. Increased faculty involvement has allowed development professionals to seek support from more sources for new programs and research and has helped Emory better communicate its vision for making people healthy, Hills says.
     In 2004, fund-raisers were particularly successful in securing endowment gifts to provide ongoing support for education and research in medicine and public health. Last year, a record 10 chairs and professorships in the health sciences were endowed with gifts of $1 million or more, which will allow those positions to receive continued support as endowment funds generate their own income.
     “Endowment gifts are particularly important because they provide a stable source of income over time to support the faculty in research, teaching, and patient care,” Hills adds. “As we continue to see health care income diminish due to declining reimbursements, this support will be more important than ever.”

Gifts of $1 million or more to the health sciences in fiscal 2004 included the following:

Rollins Chair in Pain

Mason Chair in Pediatric
Liver Transplantation

George Brumley Chair in

Kamal Mansour Professorship in Surgery

Eugene J. Gangarosa Chair
in Global Safe Water

Rose Salamone Gangarosa
Chair in Environmental Health

Radiation Oncology
Professorship in Medical Physics

Radiation Oncology
Professorship in Cancer Biology

Michael and Laura Baur
Professorship in Orthopaedics

R. Harold Harrison Professorship in Orthopaedics

Avon Cancer Patient Navigation Program

Joe Craver Cardiothoracic
Surgery Fund

Mason Trust Gift to
Transplantation Clinic

AFLAC support to Pediatric

Georgia Cancer Coalition
Patient Navigation Match

Glenn Family Breast Cancer
Equipment Research Fund


In the Spotlight

The Emory Children’s Center moved into a new home this winter. Construction of the $42 million facility was made possible by donations from the Woodruff Foundation, AFLAC, the Francis Wood Wilson Foundation, and the Family of the late George Brumley, a former chair of the department of pediatrics, among others.
New faces in high places

This year, the School of Medicine welcomed new leadership in two key specialties: a veteran researcher and teacher in pediatrics and an imaging specialist with an interest in improving work environments as the new head of radiology.
     In August, internationally recognized pediatrician and neonatal researcher Barbara Stoll, a member of the pediatric faculty since 1986, was named chair of the Department of Pediatrics and medical director of Children’s Healthcare of Atlanta at Egleston.
     The joint appointment, which marks the first time an Emory pediatrics chair has also been the medical director at the hospital, will serve to further cement the close relationship between the two institutions, Stoll says.
     “In my mind, it is extremely important that the Emory chair has a leadership role at Children’s,” she adds. “It says that Emory is committed to Children’s and that Children’s is committed to Emory. The relationship is more than a collaboration—it is a partnership in every sense of the word.”
     In addition to the new position, Stoll presided over the opening of a new $42 million, 153,000-square-foot pediatrics building, featuring space for state-of-the-art research laboratories and expanded room for clinical care and medical education.
     “The new building represents an extraordinary opportunity and also a responsibility,” Stoll continues. “The first challenge is to fill our research laboratories with creative, productive, cutting-edge investigators who will work on important areas to prevent and treat
childhood disease.”
     The department is also working to design and implement the “ideal patient encounter,” she adds. Woodruff Health Sciences Center CEO Michael Johns challenged the department last year to develop a model for delivering the highest-quality patient care and service to children and their families through the Emory Children’s Center, its affiliated pediatric multispecialty practice.
     Across the Emory campus, the Department of Radiology welcomed new chair and former Harvard Medical School professor
Sanjay Saini.
     Saini, a specialist in gastrointestinal radiology and liver imaging, served on the Harvard faculty for 23 years, also holding concurrentpositions as head of computed tomography and vice chair of radiology for health systems
affairs at Massachusetts General Hospital.
     Radiology is increasingly important in the delivery of health care, Saini says. Where x-rays and CT scans used to be used exclusively for diagnostic purposes, imaging is now more integrated into health care delivery, with a wide array of imaging services used to guide treatment.
     The challenge for Emory and other centers will be to find better ways to integrate radiology services at the point of patient care.
    “In the past, when we wanted an image, we used to send the patient to radiology,” Saini says. “Now we are moving toward having imaging technology at the bedside and available immediately in the emergency room and other places.”
     Another challenge will be to develop efficient operational models that will allow such advanced imaging technology, though it is very costly, to be available across the entire Emory system to serve the largest number of patients.
     “We don’t want to have high-quality imaging just at Emory University Hospital or at the clinic, but at Crawford Long and other facilities across our coverage area,” he states.
     Saini also holds a joint appointment at the Goizueta Business School and hopes to focus some efforts there on developing new models for efficient health care delivery.
     “Emory already has a strong tradition in radiology,” Saini says. “In this specialty, traditional morphologic imaging is now being complemented by advances in functional and molecular imaging. By delivering radiologic services at the time of clinical care, radiologists are becoming increasingly central to the practice of high-quality, cost-effective medicine.”

Women test new gel to fight HIV

Believing an HIV vaccine is still
years away from the market, many public health experts are placing more emphasis on finding new treatments and technologies to prevent the spread of infections.
     One option, topical microbicide gels that kill the virus on contact, may hold particular promise for protecting women, says Frances H. Priddy, director of the Emory Vaccine Center’s Hope Clinic in Decatur.
     “Both biologically and socially, women have been shown to be more vulnerable to infection with HIV,” she says. “Due to some features of our anatomy, we are more likely to contract the virus from male partners than they are from us. And women in many cultures lack bargaining power in relationships to negotiate condom use.”
     The clinic recently received a five-year, $2.2 million grant from the Centers for Disease Control and Prevention to evaluate the safety and acceptability of the vaginal use of topical microbicides in both healthy women and women already infected with HIV. Recent research with primates has shown some topical agents to be effective in preventing transmission of the simian form of the virus.
     Opened in 2001, the Hope Clinic is a community-based, nonprofit research clinic dedicated to finding new ways to prevent HIV and other diseases of global concern. Several clinical trials of different HIV vaccines are currently under way there. And in January, the clinic began enrolling volunteers in a Phase 1 study of UC-781, an antiviral agent in the same category as the AIDS drug nevirapine.
     The early studies will focus on discovering any side effects or adverse reactions the agents may cause, such as rashes or irritation of the application site, and on the attitudes of male partners of the women toward their use of the gel.
      “Although we are not going to test it on the partners and we don’t want them exposed to it at this early stage, we do want to know what they think about it, since partner attitudes will likely influence its use in women,” she says.
     Because this is a Phase 1 study, the clinic will recruit mostly healthy volunteers but also plans to include a small number of HIV-positive women to determine whether use of the gel will reduce viral loads in the vaginal tract, which might mean the agent could reduce the potential for infected people to spread the virus to uninfected contacts.
     The CDC is contracting with other sites to study microbicides in men, but they have asked the Hope Clinic to focus on women volunteers for its studies, says Priddy.
     “Until we have a vaccine that we can administer to everyone, it would be better if we could give people, particularly women, anoption besides condoms,” she adds. “In many other countries, and in some populations in the United States, women don’t feel able to ask their partner to use a condom. A microbicide could put protection entirely in their hands. They could decide to use protection, and their partner might not necessarily have to know about it.”
      This is not the first time
that scientists have attempted to use topical agents to combat HIV, she notes. For years, clinicians knew that the spermicide nonoxynol-9 had antiviral properties, and labstudies showed that it was effective in inactivating HIV.
     However, clinical studies among commercial sex workers—who used the agent several times a day—showed that users actually contracted HIV at higher rates than non-users. Nonoxynol-9 used that frequently caused skin breakdown that made the women more vulnerable to infection, not less.
     “That is why these trials in healthy volunteers at low risk are so important,” Priddy emphasizes. “We don’t want to promote something that will actually have the result of leaving them more susceptible than they were before."

Computer screening saves lives

Patients seeking care in the emergency room at Grady Memorial Hospital are also being screened for signs of depression, domestic violence, and post-traumatic stress disorder (PTSD) under an innovative research program conducted by a member of Emory’s
emergency medicine faculty.
     Debra Houry, an
assistant professor of emergency medicine, is conducting research on the incidence of PTSD and depression among victims and perpetrators of domestic violence by
using an interactive computer kiosk stationed in the hospital’s emergency department (ED).
     Participants in the study receive needed referrals and information if their computer evaluation shows they are at risk for domestic violence, suicide, or PTSD.
     Two days a week, all ED patients between the ages of 18 and 55 are approached by a research assistant and asked if they want to participate in a voluntary study by answering a computerized questionnaire at the kiosk.
     Based on their answers, Houry and her colleagues are able to offer information about services that can help, arrange for confidential follow-up visits, or—in the case of patients whose evaluation indicates suicidal ideation or intent—arrange immediate treatment.
     Too often, people in abusive situations are too ashamed or
fearful to openly seek help, Houry says. One of the good things
about the kiosk project is that it can screen people who are in
the ED seeking care for another problem and offer them
immediate assistance.
     “In terms of domestic violence, many patients did not realize they were victims until we told them that being beaten is not normal relationship behavior,” she says. “A lot of them now are taking more ownership and feel more empowered, and that is something I am very pleased with.”
     Signs of abuse, depression, and anxiety disorders might not be evident to a busy emergency physician, especially if the patient is seeking treatment for an unrelated problem. The kiosk program makes use of the downtime the patient or family member must spend in the waiting room to collect additional information.
     With the person’s consent, the information collected by the computer program can then be shared with his or her treating physician.
     Houry’s research using the kiosk program is part of a $1.6 million study funded by a three-year grant from the Centers for Disease Control and Prevention and a five-year grant from the National Institute of Mental Health. The CDC portion of the grant is for research to find safe ways to screen for domestic violence and to follow up with reported victims, and the NIMH portion is dedicated to studying the possible relationship between mental illness and domestic violence.
     With just over a year’s worth of data collected, Houry says she has noticed a significant correlation between domestic violence and suicidality, PTSD, and symptoms of depression.
     Of the patients enrolled in the study so far, 38% were victims of domestic violence, with 39% of men reporting themselves as victims. Twenty-nine percent of men in the study reported being perpetrators. Of all patients, 27% experienced moderate to severe depression, 15% reported having moderate to severe PTSD symptoms, and 7.5% were suicidal.
     “In general, we have observed significant amounts of depression and post-traumatic stress disorder among our patients here at Grady. I think a lot of that has to do with the ongoing challenges they have on a daily basis, with poverty and being surrounded by violence much of the time,” Houry says. “But the incidence of depression and suicidality have been much higher in both victims and perpetrators of domestic violence when compared with the rest of our patient population.”
     Since the beginning of the kiosk program, Houry notes that several female patients have left violent relationships, more than 50% have developed safety plans, and almost all have kept and used the resource lists they received when they were screened.
     “With just our preliminary data, we are finding that we are making a big difference in people’s lives.”


Emory University researchers attracted $351.5 million in external research funding in fiscal year 2004, leading Georgia’s research institutions in funding, and increasing research awards by approximately 10% over fiscal year 2003. Emory’s Woodruff Health Sciences Center (WHSC) received more than 93% of the total, at $328.9 million. Federal funding was responsible for 71.3% of WHSC funding, with fund-ing from the NIH making up 62.5% of the WHSC total and 87.7% of its federal funding.

has been awarded a total of $6.3 million in grants from the Centers for Disease Control and Prevention to establish programs at a new Cancer Prevention Research Center. Three-quarters of a million Georgians are expected to benefit from this major new public health initiative aimed at reducing high cancer rates through education programs that target smoking, obesity, and lack of physical fitness. The center will focus its efforts on improving the health of residents in the 33 counties of southwest Georgia. The core grant of $3.8 million supports a partnership of the Woodruff Health Sciences Center and the Southwest Georgia Cancer Coalition. In addition, a five-year grant of $1.6 million will aid Emory’s effort to be part of a Cancer Prevention and Control Research Network, and a three-year grant of $900,000 will be used to improve quality of life for men with localized prostate cancer.

  Gastrointestinal surgeons at Emory Crawford Long Hospital and Emory University Hospital are among the first in the world to treat patients suffering from gastroesophageal reflux disease (GERD) with a simple, outpatient endoscopic procedure that takes less than an hour. Undergoing the new procedure does not complicate future surgery for patients who do not experience relief but provides another treatment option for patients who would not do well with traditional surgery or those who want an intermediate option between medication and surgery.

New treatments for devastating illnesses such as cancer, HIV, Alzheimer’s, and cardiovascular disease could reach patients sooner thanks to the new Venture Lab program in Emory University’s Office of Technology Transfer. Venture Lab will identify potentially marketable Emory Research discoveries in their early stages and help find the funding necessary to bring the technologies to market.

The President’s Emergency Plan for AIDS Relief (PEPFAR) has given a $12 million grant to transfusion
medicine experts at Emory University, the American Association of Blood Banks, and the American Red Cross to improve the safety of blood transfusion in the African countries of Kenya, South Africa, Mozambique, and Ghana. The goal is to significantly decrease the incidence of HIV transmitted through transfusion and to ameliorate the devastating personal, social, economic, and political effects of HIV in those nations.

Emory University Hospital (EUH) has been recognized as a National Research Corporation (NRC) Consumer Choice Award winner for the seventh year in a row. EUH is the only hospital in Atlanta and one of only two in Georgia to be honored this year. Consumer Choice Awards recognize those hospitals that are named by health care consumers as having the highest quality and image in 154 markets throughout the country.
  EMORY HEALTHCARE'S  information technology department has been recognized for an innovative project that connects hundreds of computer servers and thousands of desktops into one large virtual pool of memory. A report detailing the design has been accepted into the global Archives of the Computerworld Honors Collection. Computerworld is a weekly magazine described as “the voice of IT management” for Fortune 1000 companies.


Targeting hard-to-treat tumors

Patients receiving radiation
at Emory’s Winship Cancer Institute are the first in the nation treated with new technology that allows doctors to use real-time images to directly target certain tumors while leaving nearby healthy tissue untouched.
     Last June, the medical school’s Department of Radiation Oncology became the first department in the United States to use the new On-Board Imager (OBI), developed by Varian Medical Systems, to treat patients with brain tumors as well as head, neck, and prostate cancer. Emory is also the first center in the world to combine use of the OBI and Varian’s new medical linear accelerator to perform new procedures in stereotactic radiosurgery.
     The OBI allows medical personnel to visualize tumors at the time of treatment, repositioning patients on the table, if necessary, to precisely direct the radiation beam.
     Use of the imager represents the “next wave of treatment delivery options in this field,” says Timothy Fox, the department’s chief medical physicist.
     State-of-the-art, image-guided radiation therapy (IGRT) uses techniques like three-dimensional CT scans and intensity-modulated radiation therapy (IMRT) to target tumors once thought untreatable.
The 3-D scans provide high-quality images of the tumors and surrounding normal tissue, and IMRT allows oncologists to create treatment plans that vary the intensity of radiation to match the exact shape of tumors and avoid high doses to other critical areas of the body.
     Without OBI, however, treatment plans are often executed based on information obtained in CT scans taken days before treatment, though specialists know that some tumors often change position on a daily basis, Fox says.
     Traditionally, clinicians must also rely on external skin marks with laser systems to guide patient positioning the actual day of treatment. Patient placement is determined by aligning the treatment beam with the external marks and comparing with the older CT scan.
     Using the OBI, two x-ray images are taken of the patient’s treatment area shortly before radiation is initiated. Aided by a computer, these images are either manually or automatically matched with the reference images from treatment planning. The system then calculates how much the treatment table should move to align the tumor with the beam. The treatment couch can then be adjusted to accommodate any changes in tumor position.
     “This technology allows us to be more precise with our treatment delivery,” Fox says. “It allows us to see the tumors and better target them while avoiding the nearby critical structures.”
     The imager will also allow better treatment of tumors that move, such as those in the lung or liver, which change position as the patient breathes.
     In current practice, radiation is delivered to encompass the tumor’s movement, meaning that healthy tissue is also irradiated. But using the OBI combined with an Emory-pioneered technique called “gating,” oncologists will be able to time delivery of the radiation to just those moments that the tumor is in line with the beam.
     Used in conjunction with a new medical linear accelerator, known as Trilogy, the imager is also allowing Emory doctors to pioneer new techniques in stereotacticradiosurgery, an ultra-precise form of radiation therapy that allows improved targeting and high-dose treatment of brain tumors.In October, Emory radiation oncologist Ian Crocker used the machine to treat two small cancer metastases in the brain of a 56-year-old breast cancer survivor. The single procedure delivered a radiation beam so powerful andtightly focused that it is considered radiosurgery instead of radiation therapy, Crocker says.
     “Given her favorable long-term outlook, we were committed to delivering a focal, high-dose radiation treatment to eliminate the risk of brain injury from radiation treatment to the whole brain,” Crocker says.
     Had the woman been treated a month earlier, she would have received the standard treatment of low-dose radiation therapy to her entire brain, a procedure that would have less chance of effectively treating the tumors and a higher risk of complications.
     As department chairman Lawrence Davis notes: “Using the Trilogy system, we have the potential to substantially improve cancer treatment outcomes by doing a better job of protecting healthy tissue while delivering more powerful doses to the tumor.”



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