Six hours. For years, that was the time window for removing a blood
clot in a stroke victim. Go beyond that six-hour mark and the benefits
decrease dramatically, physicians believed. But in January 2018, the
American Heart Association and the American Stroke Association released
new guidelines with a new time window: 16 to 24 hours, depending on the patient.
The decision was based on
two studies
led by Stanford University Medical Center and the University of
Pittsburgh Medical Center (UPMC), with the participation of dozens of
teaching hospitals. The idea, however, came from discussions that
occurred almost 10 years earlier at UPMC.
“It’s been a labor of love,” says Tudor Jovin, MD, assistant
professor of neurology and neurosurgery at the University of Pittsburgh
School of Medicine, who was a principal investigator for one of the
trials and currently serves as director of UPMC’s Stroke Institute.
(UPMC had the largest number of patients in the trial.) “We encountered a
lot of resistance because people didn't believe that these trials were
feasible — that they would show what we thought they would show. There
was a lot of skepticism.”
Jovin’s comments underscore why medical schools and teaching
hospitals are known for medical innovation. Not only do many of them
offer the latest treatments and cutting-edge technology, they frequently
house world-class research facilities. And they employ a range of
experts, from experienced biomedical researchers and clinicians, to
students, residents, and fellows, all of whom bring a unique perspective
to the work.
“You get the innovative thoughts of new doctors with the experience
and wisdom of those who have been doing research for a long time,” says
Mona Bahouth, MD, assistant professor in the department of neurology at
Johns Hopkins School of Medicine. And that, she says, results in
challenges to the intellectual status quo.
Indeed, teaching hospitals have a history of innovations that have
dramatically reduced mortality from heart disease and stroke. Between
1969 and 2015, deaths from heart disease declined 68%, due in part to
research
funded by the National Institutes of Health (NIH) and conducted at
medical schools and teaching hospitals around the country. Here are some
of those key contributions.
Heart disease
Since 1950, 80% of the Nobel Prize winners related to cardiovascular
disease have been affiliated with American medical schools and teaching
hospitals. Among the achievements: Biomedical researchers at academic
medical centers helped show that treating even moderate hypertension
reduced cardiac-related deaths. Research pioneered at medical schools
and teaching hospitals also led to new standards of care for treating
coronary artery disease and new medical and surgical treatments.
The work of one institution often leads to developments at another.
Two medical professors at Columbia University won the Nobel Prize in
1958 for discoveries related to heart catherization. That research led
the Cleveland Clinic and the University of Oregon to conduct pioneering
work on coronary angiography in the 1950s and ‘60s, although it was “an
accidental discovery,” says Joaquin Cigarroa, MD, head of the Oregon
Health & Science University School of Medicine’s (OHSU) division of
cardiovascular medicine. In 1958,
F. Mason Sones Jr.,
a pediatric cardiologist at the Cleveland Clinic, was conducting a
cardiac catherization. As his resident injected 50mm of dye into a
patient’s aorta, the catheter moved slightly and some of the dye
inadvertently entered a coronary artery.
“That began the era of consistent angiography,” says Cigarroa.
At OHSU, in 1964,
Charlie Dotter
became the first physician to perform an angioplasty on a peripheral
artery. The patient was an 82-year-old woman suffering from blocked
circulation in her leg. Physicians wanted to amputate, but she refused. A
surgeon knew Dotter, who used a guide wire and Teflon catheters to
dilate a superficial femoral artery stenosis.
“He demonstrated that you could actually push aside plaque in an artery,” says Cigarroa.
Between 1969 and 2015, deaths from heart disease declined 68%, due in part to research funded by the National Institutes of Health (NIH) and conducted at medical schools and teaching hospitals around the country.
Researchers working at medical schools and teaching hospitals have
also helped develop everything from less-invasive angioplasty procedures
to robotic surgery to surgeries that don’t require stopping the heart
or using a heart-lung machine. Physicians at OHSU, Harvard, and
Georgetown, among others, have developed and improved artificial heart
valves. Procedures pioneered at teaching hospitals — including the
Cleveland Clinic and Stanford — led to the development of Transcatheter
Aortic Valve Replacement (TAVR), which allows physicians to treat aortic
stenosis without open-heart surgery and often without long-term
recovery. Middle school teacher
Susan Strong,
who underwent TAVR surgery at the University of Colorado Hospital in
2014, notes that she attended a full-day seminar one day after the
procedure.
Researchers working at medical schools and teaching hospitals have
also played a critical role in developing heart transplant surgeries and
ventricular assist devices. The first such device was implanted by
faculty members at the Baylor College of Medicine. At OHSU, researchers
are currently working on an
artificial heart
designed for permanent use. (The only patented artificial heart is for
temporary use.) The device would replace two ventricles with a single
titanium tube. A rod in the tube moves back and forth to send blood to
the lungs.
“It has gone through the engineering testing and we have done some
short-term experiments,” says Cigarroa. “It shows promise, which is
exciting.”
Stroke
The groundbreaking studies published in 2018 that increased the
window for life-saving clot removal surgery are the latest in a long
history of improvements to stroke treatment. How much has changed? Since
1969, the stroke mortality rate has declined by 71%
(but what about 100% recovery?), due in large part
to
NIH-funded research on treatments and prevention conducted at medical schools and teaching hospitals.
In 1995, an NIH-funded clinical trial established the
first FDA-approved treatment for ischemic stroke – the drug r-tPA
(Which fails at full recovery 88% of thew time) (tissue plasminogen activator). Even more notable,
clinical trials
conducted in part at academic medical centers have established the
importance of improved blood pressure control, decreased smoking rates
and the use of statins in stroke prevention.
More recently, telestroke and teleneurology programs are making
further inroads in reducing the death rate from stroke. Potential stroke
victims need specialized expertise within hours of experiencing
symptoms, but that can be difficult in rural areas. In the
Stroke Belt
— an 11-state region consisting of Mississippi, Tennessee, Louisiana,
Kentucky, Georgia, North Carolina, Alabama, South Carolina, Arkansas,
Indiana, and Virginia — stroke rates are 34% higher than in other parts
of the country, the CDC reports. Because of that, many teaching
hospitals provide access to experts through audio and video links.
After speaking with patients and reviewing medical records and
imaging and lab results, physicians can determine if the stroke is
ischemic or hemorrhagic, offer advice on whether to use the emergency
stroke drug r-tPA, and recommend whether a patient should be sent for
surgery. The many teaching hospitals that provide telestroke and
teleneurology include Emory University Hospital, the Medical University
of South Carolina Medical Center, Nebraska Medicine, the Ohio State
Heath System, the Ronald Reagan UCLA Medical Center, and
Yale New Haven Health.
The University of Utah Health System provides telestroke services to
more than 25 sites in Utah and elsewhere. And Penn State Health Milton
S. Hershey Medical Center partners with regional hospitals for its
telestroke program, called LionNet.
“At our core is a mission to advance gaps in knowledge that
can impact patients. That is done at a basic science level, through
clinical trials, through innovations in how we teach, and in partnership
with communities. It is who we are.”
Joaquin Cigarroa, MD
Oregon Health & Science University School of Medicine
The Cleveland Clinic is reaching stroke patients through its
Mobile Stroke Unit,
an ambulance-like vehicle with staff, equipment, and medications for
diagnosing and treating strokes. The vehicle also includes a lab to test
blood samples, a portable CT scanner that can send images to the
hospital, and a telemedicine link to the hospital’s neurologists. A 2017
study in
Neurology
found that patients received thrombolysis 38.5 minutes sooner
(So what? How fast does it need to be delivered to get 100% recovery?) via the
Cleveland Clinic’s mobile unit than they would with traditional stroke
procedures. The University of Texas Health Science Center at Houston (UT
Health) introduced the first Mobile Stroke Unit as part of a clinical
trial in 2014; others with units include the University of Tennessee
Health Science Center and Indiana University Health.
Medical schools and teaching hospitals have also been innovators when
it comes to patient safety. In a recent study by researchers at UT
Health, stroke patients treated at teaching hospitals were
less likely to be readmitted than those who weren’t.
Other innovators are focused on recovery. Since 2015, the
Stanford Stroke Recovery Program
has focused on improving “gait, arm function, and cognition after
stroke.” The laboratories have worked on new therapies, noninvasive
brain stimulation, and medical devices. Among its more interesting
trials:
The program is testing the StrokeCoach, a rehab program that uses the
Apple Watch to offer exercises and assess the progress of a weak arm
following a stroke. It’s also testing devices to improve hand function
and muscle weakness.
At Johns Hopkins, researchers are bringing together engineers,
nurses, physicians, and other experts to create a treatment room that
becomes “the treatment machine for a stroke patient,” says Bahouth.
“Think of it as a bio room that measures and responds to patients’
needs. That will require a lot of innovative work between technologists,
engineers, and informatics people, but I think that's where we're
moving: To test a concept that creates a whole environment of healing
for stroke patients.”
Innovative ideas like this are part of the DNA of teaching hospitals — and they will continue to save lives.
“At our core is a mission to advance gaps in knowledge that can
impact patients,” says Cigarroa. “That is done at a basic science level,
through clinical trials, through innovations in how we teach, and in
partnership with communities. It is who we are.”
