Whitney Palmer

SOARING TO NEW HEIGHTS: YOUNG DANCER CONQUERS RARE, DEBILITATING DISEASE AND NOW TRAINS AMONG THE WORLD’S ELITE

Published in the Fall 2019 Duke Children’s Hospital Stories Magazine

By Whitney J. Palmer

At 10 years old, Clark Eselgroth’s dream was coming true—he had won the role of Fritz, the main young male lead in The Nutcracker. He was set to be on stage, performing one of the most famous parts in all of classical ballet.

But, that dream wouldn’t come to fruition. By the time rehearsals began, Clark was on crutches due to pain so intense in his hips and his leg that it disrupted his sleep. Some days, he could barely walk. Not only were his hopes of dancing in The Nutcracker dashed, but his lifetime goal of becoming a professional dancer was in jeopardy.

“Clark would wake up in the middle of the night, crying in pain,” says Amy Milne, his mother. “We took him to our local pediatrician, and things escalated quickly because this wasn’t normal in a child.”

CHASING CLARK’S DIAGNOSIS

Attempts by his sports medicine doctor and regular pediatrician in Asheville to treat Clark for tendinitis or overuse injuries, as well as control the pain with naproxen, failed. Then, his pediatric orthopaedist ordered an MRI. The image lit up bright white with bone lesions covering areas where he felt pain and several where he didn’t. Fortunately, a bone biopsy ruled out cancer.

That left one possible diagnosis—chronic recurrent multifocal osteomyelitis (CRMO), also known as chronic non-bacterial osteomyelitis. This non-infectious auto-inflammatory disease causes bone lesions that can produce debilitating pain. It is a rare disorder—several hundred cases have been reported in the literature, but the incidence of the disease is unknown. Lesions, which can be mistaken for malignancies and delay diagnosis and treatment, can appear anywhere, but the most serious are on the spine and growth plates. Left untreated, they can lead to spinal collapse and stunted growth. Affected children also have an increased risk of psoriasis; inflammatory bowel disease, such as Crohn’s disease or ulcerative colitis; arthritis; and eye disease.

With a referral from an adult rheumatologist, Clark’s family sought out specialized treatment from Duke pediatric rheumatologist Jeffrey Dvergsten, MD. Duke is one of only three institutions in North Carolina that treats CRMO. During the first appointment, in December 2012, he confirmed Clark’s diagnosis and launched him down a more targeted therapy path.

DANCING THROUGH THE PAIN

When Clark arrived at Duke, he had been on crutches intermittently for three months. He was limping, had lost significant range of motion, and was taking only naproxen for pain relief. Dancing was sidelined.

“Clark had given up dance temporarily because it was too painful,” Milne says. “CRMO is a really deep bone pain that you can’t massage away. It’s extremely hard to provide comfort until you get medication that causes the inflammation to subside.”

But, after Dvergsten found the right mix of prescription medications, which included combining a higher dose of nonsteroidal anti-inflammatory drugs (NSAIDs) with the anti-inflammatory sulfasalazine, Clark returned to training quickly, enrolling in the International Ballet Academy in Cary. The frequent drives to the Triangle for training and treatment, though, eventually led the family to move to Cary, making it easier for him to balance school, training, and controlling his CRMO.

And, as Clark perfected his skills, more opportunities arose. At age 11, he was accepted a year early to a six-week summer intensive program in Houston. According to Milne, the camp marked the beginning of his serious ballet instruction.

His training progressed uninterrupted, except for normal childhood injuries, including a broken arm, until 2015 when Clark hit a growth spurt. Rapid growth can kick-start a CRMO flare, tricking the body’s autoimmune system into thinking something is wrong with the bones. As a result, Clark developed a second round of inflammation, lesions, and pain. This flare threatened his dancing career.

An MRI showed not only new lesions, but it also revealed a secondary diagnosis. Clark had sacroiliatis, arthritis that attacks the lower back and pelvis, creating pain in the buttocks, lower back, and down the legs. Treating him more aggressively was critical to preserving his dancing dream.

“And, his arthritis would have, over time, caused the joints affected by that condition to fuse.”

CLARK’S TREATMENT

To combat both conditions, Dvergsten prescribed etanercept, a weekly injectable protein that combats inflammation. Over time, as patients improve and stabilize, they can wean off the medication.

Clark followed the weekly regimen for more than two years. The same lesions appeared on his 2017 MRI, but etanercept had his pain under control. By January 2018, everything was clear, Dvergsten says, and he scaled Clark’s dose back to every 14 days. He’s remained stable and is anticipated to switch to an injection every 21 days once there’s a break in his rigorous training schedule.

IMPACT ON TRAINING

Thanks to these treatments, Clark was able to travel, on scholarship, to complete a 10-day training program in Australia in 2018. Shortly thereafter, he was also offered scholarships to train in Monaco and with The Royal Ballet School in London.

Today, Clark, at 16, is in the first year of a three-year training program with The Royal Ballet School Upper School in London. While there, he’s continuing his treatment without interruption. The school nurse keeps his injections refrigerated, and Clark administers them himself. The school also assigned him only one roommate—instead of three—to minimize his exposure to viruses.

The instruction he’s receiving is advanced, and he credits the treatment he received at Duke to control his pain with his ability to continue training at such a high level. It also played a significant role in his learning to handle any setbacks that come his way.

 “I learned you don’t always get a say in what your body is doing, or is capable of, and patience is more important than any other thing—ever,” Clark says. “If I hadn’t been able to get past roadblocks like CRMO flares or wait patiently for injuries to heal, I wouldn’t be where I am today. I wouldn’t be as smart about dealing with problems.”

Ultimately, Clark says, the treatment he received at Duke to control his CRMO pain allowed him to grab the chance to study and excel at The Royal Ballet School when that door opened. And, it’s helped him maximize his time in London—when he graduates, he hopes to have the opportunity to be considered to join The Royal Ballet.

“It’s opportunity after opportunity here. Having a chance to see the company perform regularly is a dream come true,” Clark says. “It’s my favorite company in the world. I wouldn’t trade this for anything.”

To read the article at its original location: https://giving.dukechildrens.org/stories/soaring-to-new-heights

October 31, 2019 Posted by wjpalmer | Uncategorized | Leave a comment

What’s New in Mammography

Published on the Oct. 22, 2019, DiagnosticImaging.com website

By Whitney J. Palmer

For decades, mammography has stood alone as the gold standard for breast cancer screening and detection. But, being the go-to strategy for identifying the early-stage or advanced cancers isn’t enough. Work has continued to not only augment the efficacy of mammography, but to also increase its use and reach.

Industry-wide, there are efforts underway to design and implement new technologies and strategies for mammography. And, research is also revealing new ways for the modality to make an impact on saving lives.

Since its creation, mammography has largely been a one-size-fits-all technology, leading to many patient complaints about discomfort and pain. In many instances, these worries have prevented women from scheduling the screening exam. And, to increase utilization, some companies have created horizontal mammography machines; others have added heaters so paddles aren’t so cold.

But, just as each woman is different, so is each breast. One product designed to help meet individual needs is Solis Mammography’s SmartCurve by Hologic, a mammogram paddle that can provide a more personalized screening experience. The curved paddle form fits to the breast, more easily accommodating most patients.

According to Stacy Smith-Foley, MD, medical director for the Breast Center at CARTI, this technology can benefit both providers and patients. The Center has used SmartCurve as the standard for all patients since April of this year.

“On the technical side, technologists can position patients in ways that can include much more tissue than they can with a standard paddle,” she says. “And, for patients, due to the curvature of the paddle, the force of compression is more evenly distributed across the breast.”

Although the curved paddles don’t work well for capturing implant displaced views in women who have breast implants, they do offer benefits for most patients. Improve positioning for the majority of women reduces the number of images needed for diagnosis, and fewer images leads to less radiation exposure, Smith-Foley says.  

Alongside the patients, she adds, SmartCurve has also offered her technologists some benefits. While the technology allows them to better position patients, it also keeps them in better ergonomic positions, as well. Their body mechanics improve, and they experience more comfort and less pain throughout the work day, she says.

To read the remainder of the article at its original location: https://www.diagnosticimaging.com/mammography/whats-new-mammography

October 31, 2019 Posted by wjpalmer | Uncategorized | Leave a comment

The New Wave of Diabetes Management: Monitoring Technologies Surge as Disease Prevalence Mounts

Published in the October 2019 Clinical Laboratory News, American Association of Clinical Chemistry

By Whitney J. Palmer

Big data and bioengineering advances are fueling rapid changes in diabetes technologies, which offer the promise of better self-management and quality of life for individuals with the disease, and easier care oversight by physicians. With the incidence of diabetes rising, these innovations are coming into use when “the ability of an individual living with diabetes to have human-to-human contact with their healthcare provider is not keeping pace with the number of people developing diabetes,” according to a recent review.

Continuous glucose monitors (CGM) and related sensor, pump, and information technologies have taken off, with patients embracing the empowerment they offer to self-track and manage glucose levels throughout the day. Between 30% and 40% of individuals with type 1 diabetes—and a growing number of those with type 2 diabetes—use CGMs. Manufacturers continue to refine these complex systems, but challenges remain around wider adoption and correct use of this evolving technology.

“These are mainly outpatient tools, and we’re not sure how useful they will be for treating patients,” said David Klonoff, MD, medical director of the Dorothy L. and James E. Frank Diabetes Research Institute of Mills-Peninsula Medical Center in San Mateo, California, and the founder and president of the Diabetes Technology Society. “The technology may turn out to be extremely useful. It’s under investigation right now.”

DEMAND DRIVERS

Several factors are pushing demand for CGMs and their associated systems, said Roman Hovorka, PhD, professor of metabolic technology at the University of Cambridge in the U.K. Patients and providers are looking for management devices that seamlessly pair glucose sensing and insulin delivery to control glucose levels more efficiently around the clock. These tools help individuals make better food and activity choices to better maintain normal glucose levels, he suggested.

Noninvasive convenience is also driving CGM use, according to Klonoff. Many patients struggle with gathering blood samples via fingerprick several times daily. This benefit also applies to other wearable technologies, such as patches and microneedle devices. “People don’t want to prick their fingers very much, and no one can prick their finger enough times a day to identify every time their blood sugar is too high or too low,” he said.

Improved connectivity and user experience also are prompting more people to jump aboard the CGM bandwagon. Bluetooth technology transmits glucose readings to patients’ smartphones which then transmit the data to electronic medical records for clinician review or to pediatric patients’ parents.

CURRENT AND FUTURE TECHNOLOGIES

CGM products have been available for approximately 20 years, offering an alternative to standard blood glucose monitoring systems that rely on fingerprick samples. In recent years, they’ve improved in accuracy and ease-of-use, said Klonoff, though still need refinements.

Overall, CGM devices are considered either “open loop” or “closed loop” (Table 1). Open-loop monitors measure glucose levels subcutaneously at regular intervals, generally every 1 to 5 minutes. Users in most cases still have to self-check and calibrate their values via capillary blood glucose readings and adjust their insulin pump settings based on data from the monitor.

As well-accepted as open-loop systems are becoming, the future of CGM technology lies with closed-loop systems, also called an artificial pancreas, according to experts. Designed to mimic a healthy pancreas, these systems, only one of which—the Medtronic 670G—has been approved for use in the U.S., meld glucose sensing technology with insulin pumps (Table 2). Supported by special algorithms, they analyze glucose levels and determine appropriate insulin doses, which users need to check and confirm before they are administered. Single-hormone systems provide only insulin; double-hormone systems will offer insulin and glucagon.

For users, an artificial pancreas provides the full circle-of-care from immediate glucose management to clinician involvement, said Hovorka. “It’s the combination of more diabetes monitoring technologies and more collection of data that can be pushed into a system that can share information with healthcare professionals and with guardians and loved ones that is making these systems and devices as usable as possible,” he elaborated.

To that point, a recent American Diabetes Association review of diabetes technologies stressed that optimal use of either standard blood glucose monitoring systems or CGMs depends on both users and providers reviewing and interpreting these devices’ data output (Ann Intern Med 2019; doi:10.7326/M19-1638).  

Ongoing work will make these systems smaller, Klonoff added, and they likely will deliver a more concentrated form of insulin currently under development. Additionally, future generation artificial pancreas systems will require fewer component replacements, fewer recalibrations, and less meal-time bolus insulin, predicted Natalie Allen, MD, a pediatric endocrinology and metabolism fellow at Virginia Commonwealth University in Richmond.

CHALLENGES AHEAD

According to Michael Hill, vice president of science, technology, and clinical affairs at Medtronic, the CGM market is currently growing between 20% to 30% annually, but the technology still presents challenges. “From customers, we always get feedback to make these tools smaller and last longer,” he said. “And there’s always the request to make them easier to use, particularly for kids and elderly patients.”

Like most new technologies, the devices can be cost prohibitive for patients who are un- or under-insured. Not only must they pay the initial sensor and transmitter costs, but they also shoulder the weekly, monthly, and yearly replacement expenses. These costs—and the projected benefits of CGM—would need to be weighed against the purchase of test strips for and level of glycemic control possible with standard blood glucose monitoring.

Additionally, interstitial glucose level measurements lag bloodstream measurements by approximately 10 minutes, and exercise can make it harder to secure accurate real-time readings, Allen cautioned.

A review Hovorka co-authored found that the latest sensor technologies have a mean absolute relative difference (MARD) versus lab-based tests of 8% to 14%, but that “accuracy is lower when measuring in the [hypoglycemic] range and when glucose levels are changing rapidly.” He added that with a MARD <10%, these systems are accurate enough “to allow patient self-adjustment of insulin dosage without confirmatory capillary blood glucose measurements” (Nat Rev Endo 2018;14:464-75).

Early studies of the Medtronic 670G hybrid closed-loop system show that users had improved HbA1c levels and time in range. However, research also suggests this technology is not a panacea: A small study of mostly pediatric patients found that nearly 40% stopped using this system mainly due to forced exits from the closed-loop automated basal delivery mode, frequent alarms, sensor supply and accuracy issues, and skin adhesion issues.

Cybersecurity involving CGMs is another concern, Klonoff said, because sensitive patient information is transmitted wirelessly to both families and clinicians. Further research is needed to ensure sufficient precautions exist to prevent data hacking.

In Hovorka’s view, perhaps the most dangerous challenge involves patients’ and families’ growing frustration with the progress of artificial pancreas development. Many have created do-it-yourself systems. In some cases, these closed-loop systems, pieced together with approved and unapproved components, have delivered unsafe amounts of insulin, and a case report of one system doing so prompted the Food and Drug Administration earlier this year to warn against their use. Consequent-ly, clinician-patient conversations about safety are critical, he emphasized.

MONITORING AND IMPROVING PERFORMANCE

While CGM devices make it easier for patients to control their day-to-day glucose levels, this infor-mation is best viewed as a trend over time, said James Nichols, PhD, DABCC, FAACC, medical director of clinical chemistry and point-of-care testing at Vanderbilt University School of Medicine in Nashville. Because the values are based on interstitial fluid readings, they are less precise than clinical laboratory measurements and are not robust enough to be used in treatment decisions.

“It’s important from a laboratory perspective that we engage physicians and let them know that continuous glucose monitors are not laboratory devices,” he stressed, adding that clinical and laboratory staff should assume glucose monitoring for patients admitted to hospitals. “These devices are not quality controlled the same way a glucose meter or a core laboratory analyzer are.”

Consequently, he said, it’s incumbent upon clinical laboratory professionals to ensure physicians understand the margin-of-error and accuracy differences between CGM and lab-based methods. With that knowledge, clinicians can appropriately educate patients on the importance of being engaged in their own diabetes care, teaching them how to use CGM devices to monitor themselves and dose their own insulin.

Accuracy challenges, in fact, cover the gamut of diabetes self-monitoring technologies. Klonoff and Nichols co-authored a study that found that just six of 18 standard blood glucose meters cleared for personal use met a predefined accuracy standard on three of three studies, while four did not meet this standard on any of the studies (Diabetes Care 2018;41:1681-8).

Clinical laboratory professionals also should play a broader role in improving CGM performance by being part of CGM product development, suggested Ping Wang, PhD, DABCC, FAACC, associate professor of pathology and laboratory medicine at The Hospital of the University of Pennsylvania in Philadelphia. “CGM vendors should reach out to clinical laboratory professionals to build CGM devices with better accuracy,” she said. “Rather than conducting retroactive studies to determine ac-curacy, the industry should be more proactive. Collaborating with clinical professionals can improve accuracy during the early phases of product development itself.”

Even with some imperfections CGM devices are valuable tools for better managing glucose levels, she suggested. “In many cases, these devices can predict an upcoming drop in glucose, triggering an alarm for the patient,” she said. “Even though the tools aren’t as accurate, that’s a benefit that a clinical lab can’t offer.”

To read the article at its original location: https://www.aacc.org/publications/cln/articles/2019/october/the-new-wave-of-diabetes-management

October 31, 2019 Posted by wjpalmer | Uncategorized | Leave a comment