Additional Info
- Audio Fileuab/ua298.mp3
- DoctorsGodzik, Jakub
- Featured SpeakerJakub Godzik, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6320
- Guest BioJakub Godzik, MD is an Assistant Professor.
Learn more about Jakub Godzik, MD
Disclosure Information
Release Date: April 12, 2023
Expiration Date: April 11, 2026
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Jakub Godzik, MD
Assistant Professor in Neurosurgery
Dr. Godzik has no relevant financial relationships with ineligible companies to disclose. There is no commercial support for this activity. - TranscriptionMelanie Cole, MS (Host): Welcome to UAB Med Cast. I'm Melanie Cole. Joining me today is Dr. Jacob Godzik. He's a neurosurgeon and an assistant professor at UAB Medicine, and he's here to highlight the future of spine surgery robotics. And minimally invasive surgery. Dr. Godzik, it's a pleasure to have you join us today. I'd like you to start by telling us a little bit about robotics and how the utilization of robotics has changed the landscape of medicine, in your opinion, and specifically spine surgery.
Dr. Jakub Godzik: Well, thank you Melanie. Thank you for having me. I appreciate the time to chat with you about this a little bit. It's a bit of my passion, so I'm happy to share. I can't say too much about how robotics has changed the whole landscape of medicine. It's been around for a really long time. But in terms of spine surgery, I think it's a really exciting time right now as it's just starting to creep into our field. And I think it's passing that threshold where it's gone from a little bit of a experiments and a marketing gimmick to something that's a little bit more tangible.
And so I think what is really exciting about it is that it's becoming more and more adopted widely. And it's really, I think, changing the way that we can provide care. It's making us more efficient as providers. I think it's gonna reduce the, variability of surgeries and I think it's really gonna change spine surgery into the future in a really, really exciting way.
Melanie Cole, MS: Well then speak about the variability of surgeries. What are some of the more common uses for it, and what type of surgical interventions do you perform with them?
Dr. Jakub Godzik: That's a great question. So, spine surgery, has a lot of different. procedures that are done, a lot of different surgeries. And one of the things that we perform very commonly for a variety of conditions, but back pain or for our fractures or for other, more complex diseases, is that we fuse segments. And so we have to immobilize the segment. And the way that we do that is through a process called fusion.
And in order to really make that happen is we have to place what are called pedicle screws or we have to place a screw into the bone so that we can provide that kind of stability. And that's been performed for decades now. But the target that we're trying to hit is fairly small. And right now where robotics comes into play is that it helps us leverage the technology of navigation, so we can use a CT scan for instance, to image someone's boney anatomy in someone's spine and then deliver this screw through the skin and with a very, very small, almost percutaneous incision without having to pull the muscle off of the spine.
It really allows us to combine these really two related, aspects of this profession, which is robotics and, minimally invasive surgery. So it allows us to do the same thing, but with a smaller incision, which translates to less pain, you know, potentially less complications, less blood loss. Quicker recovery and return to work or the activities that you want to do and it actually might be a little faster and more efficient for the medical system.
Melanie Cole, MS: What an exciting time in your field, Dr. Godzik. As we're speaking to other providers, and this is relatively new in the world of spine surgery, tell us a little bit about the learning curve involved and technical considerations for other providers. How much does the experience of the surgeon matter for these advanced techniques?
Dr. Jakub Godzik: That's a great question. I think that, The learning curve is quite steep. and I always tell people that, when we just started using robotics, at least in my training program, and we're using a new system after our 30 cases, we put a scientific seminar and a talk together, and my title was, how to increase the stress of an operation and increase the surgical time by about two hours, for the price of a million dollar robot. But that's changed with the experience we've gotten a lot better.
And so I think that, using robotic techniques doesn't revolutionize what we do, but what it allows us to do, especially an experienced surgeon or experienced team, it can really make surgery just much more consistent. It can help, do more complex surgeries with smaller, potential errors or complications. So it's a very, very powerful tool both in community practice, whether it's a community hospital or whether it's an academic teaching institution.
Of course, surgeon skill and experience, are very, very important. This doesn't eliminate that or doesn't eliminate the need for quality decision making and good judgment, but I think it really does take us and elevate us into another level of performance, and I think that's something that's gonna be here to stay. And I think robotics are only gonna get more and more powerful as we move forward in time.
Melanie Cole, MS: Is there any specific patient selection? I mean, is this for everybody or only a select group of patients that will help to achieve better outcomes when you're using these robotic technology?
Dr. Jakub Godzik: I think that it's pretty wide across the procedures that we do, but it does really, right now what the spine robot, what it allows us to do is really right now just place pedicle screw. So it's really patients who have a need for fusion. So whether it's back pain or, whether it's a fracture, for instance, something like that, that's very amenable to that. It's particularly useful for patients that are a little bit more heavyset because it allows us to really b e very accurate and make smaller incisions, which decreases the, rate of infection. but it's useful across the board for all spine pathologies which is great, for degenerative conditions. It's not so much right now useful for decompressive procedures or anything else like that. It's mainly for the fusion and for the placement of the pedicle screw.
Melanie Cole, MS: So then where do you see it going in the future as it's pretty limited right now for fusion surgery? Where do you see it going or where do you hope it will go so that you can use it more widely in your practice?
Dr. Jakub Godzik: I think the reason that I'm really interested in this and am excited about it, is I think that especially as everything changes, as AI technology becomes more commonplace, as we collect more experience with these more simpler, robotic platforms. I think the future is very much on par with, something out of a movie. Out of like Prometheus where you enter the surgical pod. I mean, that's within the realm of reality, decades and decades from now.
But I think within, my career and within, our lifespan, I think we'll see these robots becoming slightly more, maybe a little bit more autonomous. Maybe it'll encompass a lot more techniques rather than just placing a screw, it might expand the things that we're able to do. Because I think it's all doable and the anatomy is fairly reliable in that regard. I think it'll never eliminate the need for a trained surgeon to be there. At least not within, I think our lifespan. But I think the growth will be very, very rapid in the next coming decades.
And I'm excited to be part of it and I'm excited to see, what we're able to achieve and really more importantly, what we're able to really provide our patients. Maybe again, more reliably and, having more reduced variability of outcomes and even smaller and smaller incisions and more minimally invasive operations. I think all of that is very, close in terms of timing.
Melanie Cole, MS: How exciting. That's really cool information. Dr. Godzik, I hope you'll join us again and update us as things continue to advance. It's such an exciting world of technology in spine surgery and robotics, so please join us again, and thank you so much for being with us today. And that concludes this episode of UAB Med Cast. For updates on the latest medical advancements, breakthroughs, and research, follow us on your social channels. And for more information, you can visit our website at uabmedicine.org/physician. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua275.mp3
- DoctorsDsouza, Kevin
- Featured SpeakerKevin Dsouza, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6300
- Guest BioKevin Dsouza, MD Specialties include Pulmonology.
Learn more about Kevin Dsouza, MD
Disclosure Information
Release Date: March 27, 2023
Expiration Date: March 27, 2026
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Kevin Dsouza, MD
Assistant Professor, Pulmonology
Dr. Dsouza has no relevant financial relationships with ineligible companies to disclose. There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Inhalation of organic antigens like bird feathers, mold, and hay over time can lead to the development of an environmental lung disease known as hypersensitivity pneumonitis. This can present with both a fibrotic and non-fibrotic phenotype, and clinical courses differ significantly between phenotypes.
Today, we will define diagnostic criteria based on clinical practice guidelines and discuss optimal management.
Welcome to UAB MedCast. I'm Melanie Cole. And joining me today is Dr. Kevin Dsouza. He's a pulmonologist and an assistant professor at UAB Medicine. Dr. Dsouza, it's a pleasure to have you join us today. I'd like you to start with a little overview of hypersensitivity pneumonitis, how prevalent it is, what you've been seeing in the trends. Speak about some of the common inhalation antigens. Tell us a little bit about the pathogenesis of this condition.
Dr. Kevin Dsouza: Yes. Hi, Melanie. It's great to be here. Hypersensitivity pneumonitis is prevalent about 11% per 100,000 in patients about 65 years and older. This is one of the databases we have. And primarily, it's an allergic reaction that the lungs have to an antigen, which is an allergen, so to speak. What happens is this antigen incites a response from the lungs, and that's when we have hypersensitivity, as the name says, pneumonitis, which is lung inflammation. There are various antigens which can cause this. Most commonly, it's mold from water damage in homes. It can also happen from bird feathers which can be either through poultry, exposure to poultry or chicken at homes, or close to homes, as well as down feathers, comforters, and beddings. This is commonly what we see in our clinic.
Melanie Cole (Host): Well, thank you for that. So why is it so important, as I spoke about in my intro, to categorize patients with fibrotic and progressive disease? Tell us a little bit about how it presents, because as you speak to other providers, they may not be as familiar as you are. And tell us the difference in presentation with both the fibrotic and non-fibrotic phenotypes.
Dr. Kevin Dsouza: Well, clinically, patients with hypersensitivity pneumonitis will complain of shortness of breath, and what's important is to elicit a history which can give you an idea of any antigens that the patient might be exposed to. Initially, there is no difference between presentations of fibrotic or non-fibrotic phenotype, that's because you have the acute inflammatory stage where an antigen presented to the lungs can incite an inflammatory response. What happens is, after that, this inflammation can either progress into a fibrotic phenotype.
Now, fibrotic phenotypes can have a poorer prognosis and can progress over time compared to a non-fibrotic phenotype where there is inflammation without any pulmonary fibrosis. Now, as I mentioned before, they behave differently. Fibrotic phenotypes progress over time and might need antifibrotic medications versus non-fibrotic phenotype, especially if we determine what the inciting antigen is and avoid the antigen altogether could have a better prognosis.
Melanie Cole (Host): Well, then, let's speak about differential diagnosis and why it's so challenging. Is there an absence, Dr. Dsouza, of international shared diagnostic guidelines and a lack of gold standard tests for hypersensitivity pneumonitis combined with these several clinical and radiologic overlapping features that could make it particularly challenging to differentiate this from other interstitial lung diseases?
Dr. Kevin Dsouza: To answer that question, Melanie, let's talk about the differentials. Obviously, any kind of interstitial lung disease is in the differential. And we then rely primarily on the history and the CT scan findings. Usually, on CT scan findings, we can find air trapping and multiple ground-glass opacities, which gives us an idea especially on expiratory images. This is a high-resolution CT scan and preferably done in prone positioning.
Now, there is a lack of international guidelines on the diagnosis of hypersensitivity pneumonitis. There are some guidelines, societal guidelines from the ATS and the CHEST, which goes down a diagnostic algorithm.
I think the most important thing, as I mentioned before, is trying to find an inciting antigen. Further testing could be a bronchoscopy with transbronchial biopsy and bronchial alveolar lavage versus a VATS biopsy. And all of this depends upon a multidisciplinary discussion involving a chest radiologist and pulmonary physicians.
Melanie Cole (Host): Well, then speak to us about optimal management. Tell us about any evidence that supports the drugs that you might commonly use, or the first medical options you would use at first diagnosis.
Dr. Kevin Dsouza: About one third of the patients can find the inciting antigen. And in my practice here, usually what happens is we look at the CT scan. On our first visit, we don't really find an inciting antigen. And then, what happens is once we look at the CT scan and do a multidisciplinary discussion, we'll call patients back and ask them to go through their homes, look for water damage, look for mold, pets, and feathers. The reason we want this is because finding an inciting antigen, we do it in about a third of our patients, has a much better prognosis because antigen avoidance is primarily the best form of treatment. In the acute phase of disease, we can also trial corticosteroids, which will help bring down the inflammation. Unfortunately, there is no real long-term data supporting immunosuppressive therapy on fibrotic phenotypes. We do this on occasion in patients, but the long-term data is weak.
Now, since the new antifibrotic medications are out and there is an expanded indication, especially in progressive fibrotic diseases, if a patient with fibrotic hypersensitivity pneumonitis progresses over time, we use antifibrotics, especially nintedanib, for the treatment of progressive fibrotic hypersensitivity pneumonitis.
Melanie Cole (Host): Dr. Dsouza, as we get ready to wrap up, what about recurrence? And you mentioned that some of the treatment is just identification of whatever the antigen is. Then, how does the patient take care of that situation? Is it something that you identify and then because can they have this recurrence or repeated recurrence if it's not addressed?
Dr. Kevin Dsouza: That is correct. They can have repeated recurrences, especially if the antigen is completely not eliminated. An example would be someone who's had water damage in the house and has mold growing and has that remediated, but just finds out that they have repeated water damage and that could cause a recrudescence of the disease. So, pivotal to the treatment of hypersensitivity pneumonitis is complete avoidance of the antigen. We've had cases, unfortunately, where we have asked our patients to move homes, because they were not able to completely eliminate the antigen.
Melanie Cole (Host): That's so interesting. As we wrap up, Dr. Dsouza, what would you like other providers to know about hypersensitivity pneumonitis and why it's so important to refer to the specialists at UAB if they have any questions?
Dr. Kevin Dsouza: I think hypersensitivity pneumonitis is a nuanced diagnosis which relies really on the history. The importance of sending patients to a center of excellence for interstitial lung diseases is that we have the benefit of a multidisciplinary team, which approaches these patients in a stepwise manner trying to figure out what the antigen is, recognizing what the CT scan patterns are, and discussing whether would be amenable to a biopsy or we have enough information to diagnose and treat a patient with just the CT scan and history.
It is important to also recognize sending patients earlier because, if they have a progressive fibrotic phenotype of hypersensitivity pneumonitis, we may have antifibrotic or clinical trial options for these patients.
Melanie Cole (Host): Thank you so much, Dr. Dsouza, for joining us today. And for more information or to refer a patient to UAB Medicine, you can call the MIST line at 1-800-UAB-MIST, or you can visit our website at uabmedicine.org/physician. And that concludes this episode of UAB MedCast. For updates on the latest medical advancements, breakthroughs, and research, follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS, Exercise Physiologist | Medical Journalist
Additional Info
- Audio Fileuab/ua288.mp3
- DoctorsMabry, Scott
- Featured SpeakerScott Mabry, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6295
- Guest BioScott Mabry, MD is an Orthopedic Surgeon.
Learn more about Scott Mabry, MD
Disclosure Information
Release Date: March 27, 2023
Expiration Date: March 27, 2026
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Scott Mabry, MD
Assistant Professor, Orthopedic Surgery
Dr. Mabry has no relevant financial relationships with ineligible companies to disclose.There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole. Joining me today to discuss partial knee replacement is Dr. Scott Mabry. He's an orthopedic surgeon at UAB Medicine. Dr. Mabry, welcome back. I'm so glad to have you join us again today as we start talking about partial knee replacement, I'd like you to kind of set the stage for us and the difference between a partial and a total knee replacement.
Dr Scott Mabry: Well, thank you for having me. It's a pleasure to be back again. So just to set the stage, a total knee replacement is where you replace the end of the femur bone, the top of the tibia bone to the entire joint surface. And then there's a plastic piece between, which is essentially the new cushion of the knee. With the partial knee replacement, you're actually just replacing the area of the knee, that just has arthritis. So in comparison, you typically are preserving a lot more of the normal tissue, especially in patients that only have arthritis in one part of the knee, instead of just replacing the entire knee.
Melanie Cole (Host): Are you doing this robotically?
Dr Scott Mabry: So I am doing this with the assistance of navigation. Some people do this robotically and some people do it manually. The studies do show that if you use some sort of assistance, whether it's robotics or navigation, that the component positioning's a little bit more precise and that leads to a little bit better outcomes with partial knee replacement.
Melanie Cole (Host): Expand a little bit on some of the technical considerations when you're discussing navigation. For other providers that are looking at this as an alternative to total knee replacement, and they wanna know what you're doing that's so special, tell them.
Dr Scott Mabry: Sure thing. Well, in the instance of a partial replacement, you really want to preserve the side of the knee that you're not operating on, and then you know, under the kneecap as well. In order to do so, you wanna make sure that you're not putting your. Partial knee replacement in a position that could, cause issues in the rest of the knee over time and make the person develop arthritis sooner than, they would have otherwise. So with navigation and robotics, we're able to take the entire mechanical alignment, just meaning the entire axis of the lower extremity, and we're able to in real time, measure that.
And then when we make our decisions on where we put this partial knee replacement, we're basing it on the patient's own anatomy. And so that we can get the component positioning exactly perfect so that we're not overloading the other side of the joint or putting it in a position that could cause early failure in conversion to a total knee replacement.
Melanie Cole (Host): So as you're using navigation and discussing the technology involved, tell us about the benefits to the patient when we're doing partial versus total knee replacement. And Dr. Mabry, the benefits to the surgeon.
Dr Scott Mabry: Sure thing. I mean, the patient benefits are numerous. First of all, it is a less invasive procedure. , you don't actually have to move the kneecap out of the way to do this or fully move it outta the way I should say. So it is technically less invasive. We typically use a more, tendon sparing approach, when we do this surgery, so it's a little bit quicker recovery from that standpoint. whereas a total knee replacement might take up to three months to recover, most partial needs, are pretty much recovered by six weeks. Most of these, and all of these in my practice are outpatient. So same day surgery.
Whereas most total knees either have the option for outpatient, like we spoke about last time, or some stay a night. so this quicker recovery that way it does feel a little bit more normal to many patients. And I think that can be attributed to the fact that we do leave the ACL, which usually is taken away in the total knee replacement, but also there, the kneecap is the same. The other side of the knee we haven't operated on, so that's the same. So that typically it does feel a little bit more normal to patients than a total knee when you're replacing all those surfaces.
And then there's a little bit slightly lower, incidence of complications after surgery. And I think we can also attribute that to leaving a lot of the knee, without having to replace it essentially. Benefits to the surgeon. It's actually a technically a little bit more challenging, procedures, the fact that it's a smaller incision, so you're working in a little bit smaller. And that you really have to get that component positioning perfect. in order to have the patient have a good outcome. So I think it's a technically a harder surgery, but anytime we can spare the unaffected parts of the knee, I think the surgeon, that can offer this, it feels good about doing that for their patient.
Melanie Cole (Host): What about disadvantages? Dr. Mabry, if you're just taking the arthritic portion of the knee, Is there like something that spreads? Is it likely to come back in other areas, are they more susceptible to tears, such as acl, that sort of thing. Are there any disadvantages from your point of view?
Dr Scott Mabry: Yeah. I think the disadvantage would be in poor patient selection, you really have to make sure that the patients that do get partial knee replacements only have isolated compartment arthritis, meaning it's only on one side of the knee that there's no signs of it In other parts of the knee. You also wanna make sure that they have good, intact ligaments, especially the ACL, and that, they don't have anything like rheumatoid arthritis or another kind of condition that could cause arthritis to progress throughout the knee.
By carefully selecting patients, these last just as long, if not longer than a total knee replacement. But I think that is the key is just making sure that you're doing this on the right person. Otherwise, yes, you can have a partial knee wear out quicker, and end up having to convert to a total knee replacement.
Melanie Cole (Host): We'll then expand on patient selection. When you're looking for patients for whom this would give really great results, what are you looking for?
Dr Scott Mabry: I'm basically looking for patients that have knee pain on one side of the knee, that they really haven't had any prior ACL tear, or surgery on the other parts of their knee. And then I also look to see that the x-rays match up with where their pain is located. But given that that's really the main selection criteria, young, old, everyone kind of does the same with these as long as you're selecting appropriately. Activity level, I think initially they did these and less active people and then we realize doing these in more active people actually keeps their activity level pretty high as well.
So I think it really just has to do with matching the x-rays to the patient's symptoms and then looking for those other things I mentioned that could cause early failure and making sure that we're selecting appropriately.
Melanie Cole (Host): And how have your outcomes been with partial knee replacement? Dr. Mabry, how is activity level after? Speak a little bit about what you've seen.
Dr Scott Mabry: I think in general, the partial knee replacement patients that I have, typically do recover a little bit faster. Most are off assistance at two weeks when I see them back, in clinic. Usually starting to get back into a slightly normal activity about four weeks, and I think by six weeks most of them are doing pretty well, almost fully recovered anyway, and not a ton of pain. You have your outliers here and there, but I think as far as once people hit that six week mark, I feel comfortable letting them get back to normal activity. So I'm pretty happy with the results I've had in my practice so far.
Melanie Cole (Host): That's fantastic, and I'd like you to just summarize for other providers what you'd like them to know about partial knee replacement versus total, and why it's so important to refer to the experts at UAB Medicine?
Dr Scott Mabry: I think, the main thing to know is that this is an option out there. Not every provider, does offer this. I think it is a little bit more technically demanding for the surgeon, and you do really have to be careful with the patient selection. But if you do those two things, I think there is a great benefit in preserving the normal anatomy of a patient's knee instead of just replacing the whole thing. A little bit more normal feel and a little higher activity, it's all said and done. what I would say is the main reason they refer this to a specialist, especially someone that can't offer this, and, not every patient will be a candidate and we're happy to talk through it with the patient and kind of explain if or if not, partially would help them.
Melanie Cole (Host): Well, you certainly are the specialists and experts, and thank you so much Dr. Mabry, for joining us today. And for more information about partial knee replacement or to a referral patient to UAB Medicine, you can call the MIST line at 1-800-UAB-MIST or you can visit our website at UABmedicine.org/physician, That concludes this episode of UAB Med Cast, for updates on the latest medical advancements, breakthroughs, and research, you can always follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS, Exercise Physiologist | Medical Journalist
Additional Info
- Audio Fileuab/ua274.mp3
- DoctorsGarcia, Bryan
- Featured SpeakerBryan Garcia, MD
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6275
- Guest BioSpecialties include Critical Care Medicine and Pulmonology.
Learn more about Bryan Garcia, MD
Disclosure Information
Release Date: March 13, 2023
Expiration Date: March 12, 2026
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Bryan Garcia, MD
Assistant Professor, Pulmonology & Critical Care Medicine
Dr. Garcia has no relevant financial relationships with ineligible companies to disclose. There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Non Tuberculous Mycobacterial lung disease is particularly vexing for clinicians to diagnose and treat. Welcome to UAB Med Cast. I'm Melanie Cole Here to tell us about this is Dr. Bryan Garcia. He's an assistant professor and a specialist in critical care medicine and pulmonology at UAB Medicine. Dr. Garcia, it's a pleasure to have you with us again today. We're updating a previous podcast. Can you tell us why we're updating this? What's the prevalence of non tuberculous mycobacterial lung disease and what do we know about this disease?
Dr Bryan Garcia: Thank you for having me. So, the exact prevalence, I should say actually really the number of patients currently in the United States who have some form of infection caused by this group is probably around 70 to 80,000 patients within the United States. And to give you a sense of where that stands compared to other major infections in the United States compared to tuberculosis, which is probably around 8,000 or so patients weakness, maybe 10 times more people in the United States have a non tuberculous microbacterial infection than TB itself.
Melanie Cole (Host): Wow. That's quite a statistic that you just gave us. So one thing I found interesting is that these infections, unlike tb, which you just mentioned, don't require public health reporting. Dr. Garcia, do you feel that this hinders an accurate understanding? You were just talking about prevalence and that incredible statistic. Do you feel that that hinders epidemiology may not be reflective of changes in prevalence?
Dr Bryan Garcia: That's a great question. And, there are some states actually that do require, reporting of the identification of mycobacterial infections other TB, but Alabama is not one of them. And as a result, undoubtedly this is an underrecognized infection that we lack a knowledge of both at a clinical level and at an epidemiologic level. Particularly of importance is, for example, this infection we think is ubiquitous environmental and waterborne infection. And so this better understanding of the epidemiology and of the local incidence and prevalence would help us understand if these patients are indeed acquiring their infections from their local water sources.
Melanie Cole (Host): So then let's talk about that for a minute. Dr. Garcia, what is the mechanism of infection. If we're talking about soil and water, is it aerosolized? Aerobic? How is this ingested? How does it get into the pulmonary system?
Dr Bryan Garcia: So, Non tuberculous microbacterial infections can occur anywhere in the body. And outside of the lungs, they have to be directly, basically inoculated into the site. So, for example, I'll see patients who have been thrown from their cars in a crash and have had these large wounds. And landed in dirt, and now they have these microbacterial infections there. I see patients who have had, this is an increasingly common, hospital acquired infection due to surgeries, and I'll see people with surgical site infections. And then in the lungs, however, this is the most common site, more than 95% of non tuberculous microbacterial infections occur in the lungs.
If you have it in the lung, though, it will not go elsewhere, it will stay in your lung. And that is something that is important for patients and other physicians to understand is that we wouldn't expect it. I speak about this primarily in the non HIV population, so I think we should probably have a caveat that anything we discuss today is in the non HIV population. But one of the things I do mention to patients, Because you have pulmonary NTM, it will stay in your lungs. But the question is how did it get there? And that is a question that we don't have the answer to just yet. We have our suspicions and our hypotheses as to why it's there, but we don't know for sure.
Okay. One of the things I discussed with patients as it pertains to how did it get tear your lung is the concept of chronic silent aspiration. I tell patients that many of my patients I see have hyatel hernias. they describe GERD and so it's important to make sure that they are doing lifestyle modifications to reduce those risks. Why is that important is because mycobacteria is in the water that we drink, and so at night, if you drink a bunch of water and you have a little bit of this, come up with stomach acid. Little by little over time, very small amounts of this essentially provide the local fertilizer that's needed to then acquire a true infection of the lung by these organisms.
Is that the only mechanism or is that the definitive mechanism by which it is acquired? I can't answer that. There's definitely been studies that have shown that shower heads in patients homes. if you swab the shower head, you can identify, clones of the mycobacteria that the person expectorates, suggesting that it is aerosolized. And it does come from these nebulized or aerosolized warm, humid, environments. many patients describe an interest in gardening. We do wonder because we know it's in our soil. Is this how they were inoculated? And patients ask, should they stop drinking their water? Should they stop showering? Should they stop gardening?
And I don't have the answer to that. And the truth is, is because the organism is so ubiquitous, I tell patients, you're gonna come in contact with this no matter what. And there's something about you that made you get an infection from this because I'm coming in contact with it and I'm not having any problems.
Melanie Cole (Host): Is there a process then for checking areas where you suspect it might be present in people's homes since it might be so prevalent around the environment? Is there any way to know?
Dr Bryan Garcia: We don't commonly test for this. Patients ask me this, they ask me, should I stop showering? Should I just drink bottled water? And we really don't know, that there's anything that can be done right now that a patient could really reduce their exposure risk because it is so prevalent. We do know that this infection seems to be more prevalent along coastal regions. We do know that there's data that if you look at kind of heat maps, distribution of the United States, that this infection is most prevalent, along the Atlantic coast.
Down through Florida, around the peninsula and then up into the panhandle and all the way into Houston. It does have this propensity for these flooded regions, and we do wonder if that's one of the reasons why, this exists in these regions in what appears to be greater prevalence, but we don't know that for sure. We don't understand the real mechanisms for this, in their full entirety yet.
Melanie Cole (Host): Mysterious. So let's talk about the hallmarks of it. Some commonly encountered patterns that would signal that someone has an NTM pulmonary infection. Are there diagnostic criteria, Dr. Garcia? Because there are some related disorders where comparisons might be useful for that differential Diagnosises.
Dr Bryan Garcia: 85% of my patients who have pulmonary NTM fall into a unique phenotype. They are previously non-smokers most of them, they have no known history of preexisting lung disease and they are postmenopausal white females. And when we talk to them, and I tell them about this, and I tell them, most of these patients tell me that their family lineage was from Ireland, England, Scotland, and Northern Europe before coming to United States. This is the same region of the world where we know cystic fibrosis comes from.
And most physicians, although they don't take care of cystic fibrosis, especially pulmonologists, are aware and have seen patients during their training with cystic fibrosis and recognize that these patients too, get these types of infections. When we as physicians see patients in our who meet that mold? A postmenopausal white female who has the symptoms of NTM, which includes pulmonary symptoms like cough, shortness of breath, sputum production, maybe they cough up blood, as well as possibly systemic symptoms like fevers, chills, night sweats, fatigue, joint aches, brain fog.
In that phenotype of postmenopausal white female with worsening pulmonary symptoms, that we should be suspecting that this person might have a NTM infection. Bronchiectasis and NTM infection because it's such a unique phenotype that when you see them walk into your clinic, immediately, this should come to their minds. Because we are doing a better job diagnosing it both in the microbiology lab, as well as getting the scent of it using CT scans. We're seeing it being diagnosed more and more and more frequently. Now diagnosis of it is different than the decision to treat it. And these are completely separate, management pathways.
The diagnosis is still the physician is trying to understand, why is this person having worsening pulmonary symptoms once they have identified mac or mycobacteria, AUM complex. One of the subspecies of NTM or any of the other subspecies. Once they have identified the presence of that, then the next decision needs to be, does this person need treatment or not?
Melanie Cole (Host): Well, that is the question then. So do they, and if so, what?
Dr Bryan Garcia: So when I get to this point with my patients, does this person need treatment? What that means is they need to meet certain criteria and the American Thoracic Society and the Infectious Disease Society of America have met and they have made up three main criteria. So they keep it relatively simple. Number one, they need to have the infection in their lung, and they need to find it either two times in sputum or one time on a bronchoscopy. The second criteria is that they need to have radiographic evidence of the disease, and these infections can cause quite a broad array of different radiographic findings. But there are some unique findings.
Tree and bud changes that the radiologists will describe these little tiny micro nodules in the periphery. Those ones are more unique to this, but the truth is, is that NTM infections can cause essentially almost any type of radiographic appearance. The third portion of the criteria to initiate treatment is that the person needs to have symptoms. That you attribute to the infection and that those symptoms need to be significant enough that treatment is justified. And the reason that that is the case is because treatment is very difficult. Treatment is typically multiple antibiotics every day or every other day for 18 months or longer.
And that means side effects from the antibiotics. It means drug drug interactions that need to be, taken into account drug monitoring. And so that is why it's not such a simple organism to treat, and so we really need a patient to have symptoms that are significant enough that they want to go down the pathway of treatment.
Melanie Cole (Host): Where do you see this going in the next 10 years or so? It's such an interesting topic, Dr. Garcia. So what do you see happening similar to other things that we're seeing in the environment? Do you see better reporting? What do you see happen?
Dr Bryan Garcia: All of the above. We will see increasingly diagnosed for the reasons I mentioned. We also are able to identify these organisms better, that was a major problem in the past. In fact, many of my patients tell me that their family members, that their mother died of tuberculosis. And I think to myself, they probably didn't die of tuberculosis. They probably died of this, but we thought it was TB back in 1950. And then, something that's very important to consider is that our population is aging. This is a problem for people who are immunocompromised. That is true. I do see people who are on certain medicines to suppress their immune system that get this infection, but the primary risk factor for this disease is just aging itself.
And so the more elderly patients we have, the more people who we have living with chronic lung disease, the more that we are gonna see this infection as a chronic health disease that becomes more commonly, identified among pulmonologists and I anticipate actually all physicians who participate in primary care internal medicine, in pulmonology.
Melanie Cole (Host): What an interesting topic. I hope you'll join us again, Dr. Garcia, as you learn more and update us as things change or advance. Thank you for joining us. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST, or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua279.mp3
- DoctorsAcosta, Pilar
- Featured SpeakerPilar Acosta, MD
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6255
- Guest BioPilar Acosta, MD Specialties include Critical Care Medicine Pulmonology.
Learn more about Pilar Acosta, MD
Release Date: February 28, 2023
Expiration Date: February 27, 2026
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Maria Acosta Lara, MD
Assistant Professor in Pulmonology and Critical Care Medicine
Dr. Acosta Lara has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole. Today we're discussing treatment options available for patients with autoimmune associated interstitial lung disease. Joining me is Dr. Pilar Acosta. She's a pulmonologist in critical care medicine and an assistant professor at UAB Medicine. Dr. Acosta, thank you so much for joining us today. Can you start by telling us a little bit about the scope of the issue we're talking about here today? The interstitial lung diseases and the prevalence of them.
Dr Pilar Acosta: Yes, thank you. So interstitial lung diseases is, one of the most common and clinically important manifestation of connective tissue diseases. Although ILD, which is the short, term for interstitial lung disease, often occurs in patients that have a known autoimmune disease. It can also be the first and only manifestation of previously unrecognized autoimmune disease process. Some of the common autoimmune diseases that can manifest as an interstitial lung disease include rheumatoid arthritis. So talking a little bit about rheumatoid arthritis affects about, a half to 1% of the US population.
And ILD is the most common pulmonary manifestation in this patients than occurs about 10 to 20% of patients. So in that proportion, probably have more patients to have, ILD related to the rheumatoid arthritis. Another autoimmune disease that is also, highly prevalent to. create interstitial lung disease is systemic sclerosis. It's not as common as rheumatoid arthritis. There is a less proportion of patients that have it. However, in patients that have scleroderma or systemic sclerosis, lung involvement is most common and almost universal.
It has been described that most of patients that have sclero, they may have some type of lung involvement when, seen, in the 70% of patients. Another type of, autoimmune disease that can also manifest for patients, with interstitial lung disease is Shagra disease, less common than the other ones that I talk about, but it's also common to have some type of lung involvement as interstitial lung disease. So the most common ones are rheumatoid arthritis, sceraderma and shagran..
Melanie Cole (Host): Well thank you for that. So what are some issues for other providers to consider as patients with autoimmune associated interstitial lung diseases and CTD ILD as they often present with a poorer quality of life if this is present and therapy can also be associated with severe. Effects and adverse effects. So when is treatment generally initiated? Are you looking for when symptoms become clinically significant or progressive? Tell other providers what you're looking for at that time?
Dr Pilar Acosta: Not all patients that have an autoimmune disease will develop interstitial lung disease, but having a high index of suspicion of can my patient develop an ILD down the road? So that requires monitoring. And that requires you kind of have that high index of suspicion, make sure the patient gets a pulmonary function test to assess for the lung function. Also, any kind of lung imaging can be a plain x-ray, but we typically do a high resolution CT scan and that will let us know if there is any type of lung involvement such an interstitial lung disease in those patients. These some patients that have unknown autoimmune disease process.
Melanie Cole (Host): Well then speak a little bit about the mainstay of therapies. What the medications that you might look to immunosuppression, either by steroids or steroids sparing agents. Tell us a little bit about that. And Dr. Acosta the role of managing the comorbidities in patients with autoimmune associated interstitial lung disease.
Dr Pilar Acosta: So, yes, in the progression of the interstitial lung disease in these patients that have an autoimmune disease process is different than you compare to. Patients having other type of ILDs like pulmonary fibrosis, idiopathic pulmonary fibrosis. Typically we see a more, subtle progression or they don't progress as fast as patients that have IPF do, but they do progress. The other difference between this type of patients, with interstitial lung disease, secondary and autoimmune disease has to do with treatment. So treatment is different in the sense that in many cases the main stand of treatment includes, immunosuppression medicines that will bring down that inflammatory drive that is accelerated in patients with an autoimmune process.
Trying to, slow down the inflammation and the progression of the, fibrosis that can ensue in patients that have this autoimmune disease process. So medications that we, prescribe. It's called Mycophenolate. This is a, one of the medicines that we use more commonly. It's a medication that is given by mouth patients, take it, start with a low dose and we increase it as the patient is able to tolerate it. Overall, medicine, it's well tolerated, but can have some side effects, most of them gastrointestinal problems. So we very closely counsel patients about having any side effects from the medicine.
There is also this medicines require monitoring. So our patients require blood work, done on a quarterly basis to make sure all their blood counts and deliver enzymes, are stable and have not progressed. most recently, that's a new insight in the treatment of CTD ILD or the autoimmune disease process. We have data from two trials that showed that we using one of our anti-fibrotic, medicines that we use in patients that have idiopathic pulmonary fibrosis has been used. Patients who have an autoimmune disease such as scleroderma with positive results. So, we had the inbuilt trial, which this was a double blind, randomized placebo control trial using the medicine called nintedanib.
Which is an antifibrotic agent, has been used, for almost 10 years in patients idiopathic pulmonary fibrosis. And the results from the trial were very, very, encouraging because what we saw is that the disease progression was also, attenuated in patients taking this medication. So, very interesting trial. This has also, changed our practice management. So now we see a combination of treatments using immunosuppressive drugs as well as antifibrotics.
Melanie Cole (Host): And Dr. Acosta, this is so interesting and as a result that there are autoimmune conditions related. What other specialist consultations are indicated in the treatment of autoimmune associated interstitial lung disease? And please showcase for us how UAB is a destination for lung diseases in general with access to subject experts and clinical trials. Tell us about this multidisciplinary approach?
Dr Pilar Acosta: So, in patients that have CTD ILD, we extrapolate what we know works for patients with all their ILDs, like idiopathic pulmonary fibrosis. So we need to screen for the use of supplemental oxygen. So a six minute walk test to assess for hypoxemia either rest or with exertion and patients that have hypoxemia. Then we will provide them with supplemental oxygen. The other comorbidity that are at risk is gastroesophageal reflux disease. Many patients that have an autoimmune disease, they may also have esophageal dismotility or bad acid reflux. And we do know that uncontrolled acid reflux can make any kind of lung disease worse.
So we are very proactive in managing and diagnosing, gastroesophageal reflux disease that may be overt or maybe silent. The other big comorbidity that we screen for is something called pulmonary hypertension. This is very prevalent, especially on patients that have scleroderma. So we screen patients yearly with an echocardiogram or a Ry heart cad depending on the situation to screen for these comorbidity that is difficult to treat, and it just adds complexity to the overall condition of the patient.
They need routine follow up with specialists, that know, and they're familiar with patients that have an autoimmune disease, interstitial lung disease. We work very closely with our rheumatologists here at UAB to trying to find the right combination, for the patient to treat their condition. It's not one size fits all, but it's tailored to what the patient needs. And what they're requiring at the moment. As UAB is part of the care, network center and is part of the Pulmonary Fibrosis Center of Excellence. So we are a designated center to see patients with interstitial lung disease, including those.
That are related to an autoimmune process. We see referrals from all over the state and also out of state, from Florida to Mississippi, Tennessee. So we get patients from all over this area and we're happy to see them. We have a group of several physicians that are trained, and this is what we do every single day, interstitial lung diseases, and one of them's autoimmune disease process.
Melanie Cole (Host): Thank you so much, Dr. Acosta. That was so informative. Thank you for joining us and for more information about autoimmune associated interstitial lung diseases or to a refer a patient to UAB Medicine, you can call the MIST line at 1-800-UAB-MIST, or you can visit our website at uabmedicine.org/physician. That concludes today's episode of UAB Med Cast. I'm Melanie Cole. - HostsMelanie Cole, MS, Exercise Physiologist | Medical Journalist
Additional Info
- Audio Fileuab/ua283.mp3
- DoctorsCallaway, James;Wong, Kristen
- Featured SpeakerJames Callaway, MD | Kristen Wong, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6250
- Guest BioDr. Callaway is an Assistant Professor of Medicine at UAB and practices at both the Birmingham VA Medical Center and The Kirklin Clinic of UAB Hospital. He received his medical degree from the Medical College of Georgia and completed his residency at UAB, where he served as Chief Medical Resident.
Learn more about James Callaway, MD
Kristen Wong, MD interests include minimally invasive surgery, bariatric surgery.
Learn more about Kristen Wong, MD
Release Date: February 22, 2023
Expiration Date: February 21, 2026
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
James Callaway, MD
Associate Fellowship Director, Gastroenterology Fellowship
Kristen Wong, MD
Assistant Professor in General Surgery
Dr. Callaway has the following financial relationships with ineligible companies:
Board Membership - Physician Advisory Board: Sanofi
All relevant financial relationships have been mitigated. Dr. Callaway does not intend to discuss the off-label use of a product. Dr. Wong, nor any other speakers, planners or content reviewers, have any relevant financial relationships to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole: Welcome to UAB Med Cast. I'm Melanie Cole. We have a panel for you today with Dr. James Callaway. He's an assistant professor in gastroenterology and Dr. Kristen Wong. She's an assistant professor and general surgeon. They're both at UAB Medicine and they're here to highlight Gastroesophageal Reflux Disease or GERD for us. Doctors, thank you so much for joining us. I would like to start with Dr. Callaway. Can you please tell us the scope of the situation that we're talking about today? The impact on the daily health of individuals? Really the scope of the issue of GERD and the prevalence?
Dr. James Callaway: Sure. Thanks so much for having us today. Gastroesophageal reflux a quite prevalent condition. It affects almost all of us to some degree over our lifetime, we may have some troublesome heartburn symptoms. Reflux disease is primarily defined as either pyrosis or heartburn, kind of the burning sensation in our chest or regurgitation, where you may actually feel food, contents, or acid kind of going up into the chest and potentially in the back of the throat. But those symptoms may occur after routine meals, but it being a troublesome symptom and becoming a prevalent happening more than a few times per week is considered pathologic and quite troublesome.
And that's what many patients are referred to our GI clinics or our surgical colleagues for when symptoms are prevalent or they're not responding to typical medical therapy. The prevalence though is actually, it's quite prevalent. Up to 40% of Americans will have troublesome heartburn symptoms at some time during their life. And at any given time, about 20% of patients actually are on heartburn medications, either over the counter or prescription medications at some point during their adult life.
Melanie Cole: Dr. Callaway, do we know why? Why is it becoming more and more prevalent? Is it because we're seeing this obesity epidemic? Is it our food choices? Is it sedentary lifestyle? All of those things. Why are you seeing an.
Dr. James Callaway: I do think obesity is the number one risk factor that we are running into, and that it's becoming increasingly prevalent over the last 20 to 30 years. And that's probably the biggest risk factor that continues to push the GERD needle forward. We are becoming more due to diagnosing it and also many of the reflux medications are becoming over the counter at this point, and so patients are self-treating as well. So I think the actual prevalence is probably under-recognized as patients try to treat their reflux symptoms at home without actually seeking medical professionals too.
Melanie Cole: So Dr. Wong, don't worry, I'm not forgetting about you, but Dr. Callaway sticking with you for just a minute. As we speak about diagnoses, tell us a little bit about how you come to a definitive diagnosis of GERD. If you're doing endoscopy, do you feel that this is something that, that people should be screened for, like colonoscopy? Is it something that you see happening in the future? Speak just a little bit about diagnoses and all of the different things and available tools that we have today.
Dr. James Callaway: Sure, great question. Reflux disease is, as we mentioned, common and it is actually difficult to define in some ways. We know just by definition, it's refluxing of gastric contents into the esophagus. That can just be clinical symptoms. As I mentioned, there's some heartburn that someone may happen to have after a meal. But eventually it may become pathologic. And in that situation it can cause troublesome symptoms that actually cause changes in someone's quality of life. It can cause damage to the esophagus and the setting of inflammation or what we call errosive esophagitis, and it can lead to further types of problems as well.
LIke Barrett Esophagus or even potentially esophageal adenocarcinoma. So it's a diagnosis that we don't want to miss because if left untreated it could have potential long-term implications including something as dredded as cancer. To diagnosis this though, primarily it's done either by clinical history where we talk to our patients about their symptoms and we may actually even use medications as an empiric trial to see if their symptoms do respond. Many times that's actually how the reflux diagnosis is. In gastroenterology, or if you're seeing a gastroenterologist, we are much more apt to actually perform objective testing.
We may use an endoscopy, as you mentioned, which is a flexible camera scope to go down into the esophagus and look for damage from reflux disease. Or we may use things like ambulatory pH testing, which is where we can objectively quantify how much reflux a patient is having, whether they're having five episodes a day or 500 episodes a day. We have different mechanisms where we can actually quantify that amount of reflux and then prognosticate someone on how frequently their symptoms may occur. Or maybe best treatment options based on how much reflux that they are actually having.
Melanie Cole: You mentioned earlier Dr. Callaway medications and people are self medicating at home. I'd like you to speak about the medications that are available now, whether over the counter or by prescription. And there have been so many studies that have come out raising concern for medications that are used to treat GERD, but these studies really only have demonstrated an association, not this cause and effect relationship. So I'd like you to speak about that just a little bit as you're telling us about what you would try as your first line defense.
Dr. James Callaway: Sure, absolutely. Well, we do encourage lifestyle modifications for patients with minimal symptoms of reflux disease or intermittent symptoms of reflux disease. That includes weight loss for those that obese or overweight. Potentially avoiding the times of day that they're actually eating, trying to avoid late night meals and things of that nature. When it comes to medical therapy, proton pump inhibitors have been around for over 30 years now, and those are the most effective medical treatment for reflux disease. There are other types of medications out there including histamine receptor blockers.
Which also have been used for short term relief of heartburn and GERD symptoms, and those are typically used for kind of short durations. Typically are not used chronically, but either proton pump I inhibitors or H2 receptor antagonist are our primary medical treatments. You mentioned about the potential association with adverse conditions and there have been numerous studies, especially in the last 10 years, which have identified associations with long term use of PPIs and a development of these types of conditions.
Most of those studies have numerous flaws, as you mentioned, and are not really considered definitive, and they really haven't established a true kind of cause and effect relationship between PPIs and those adverse conditions. High quality studies have not found that PPIs significantly increased the risk of many of the things that have been reported, including stomach cancer, osteoporosis related bone fractures, chronic kidney disease. We do think that there is an increased risk of intestinal infections.
But that being said we do think that PPIs are still, the benefits of them really outweigh the, the risk, the theoretical risks of the associations that many of these epidemiologic studies have brought up over the last 10 years. So in general, we still think PPIs are safe but we do want to use the lowest effective dose in all of our patients that we are treating. And if symptoms are not responding appropriately, we should investigate that or we should definitely. engage our surgical colleagues to, to think about other potential treatment options that do not include medicines. Kristen will get you involved here shortly.
Dr. Kristen Wong: Okay. No, I could listen to you. Go on. Keep going.
Dr. James Callaway: All the medical side so far.
Dr. Kristen Wong: Yeah, no, that's fine with me.
Melanie Cole: Dr. Wong. We did not forget about you. So as Dr. Callaway just alluded to, for GERD, that's refractory to medications, please discuss some of the surgical indications and treatment options that are available?
Dr. Kristen Wong: Sure. Thank you for having me. I could listen to Dr. Calloway talk all day, so, you know, but yeah, so there's a couple of traditional treatments, surgical treatments for reflux. And there's a couple of non-traditional treatments for reflux that are kind of this new techniques that we are just now developing. So, the first tried and true technique for people that have either maximized their medical therapy, those are. The people that are on two PPIs already, they're taking tums as needed. So they're really just unhappy and their symptoms aren't well controlled. Or the people that don't wanna take their PPIs because of these reported side effects.
So those are the people that we bring in and we talk to. And the first thing that we would discuss with them is probably the tried and true surgery approach, which is a gastric fundation. So that is started in the 1950s and it's basically a wrap. And it has initial success rates of greater than 90% at high volume centers. And the idea behind the wrap is that it kind of recreates the pressure of the lower esophageal sphincter and prevents that reflux from coming back up from the stomach into the esophagus. For implications, I think they get a bad wrap because I think in the surgical community there's a highly variable techniques.
And so you have a lot of Results and the different kinds of results and the range of outcomes are very different amongst surgeons. Overall, I think is it technically difficult? It does require an overnight or inpatients day. But the good news is that over 90% of patients that undergo an anti-reflux surgery. IE a fund implication, do see symptom improvement and get off of their medications. What are the downsides of a fund implication? There are a couple different poor, you know, bad outcomes that we wanna look for. The biggest things that I think a lot of people who refer to their surgeons are worried about are gas bloat syndrome and dysphasia.
So that range is in the 20% of people postoperatively after a fund application. And we can go into the different types of fund implications as well. the nissen is the, probably the most well known fund implication, and that's a 360 degree wrap. So when we go in. We, we usually do these all laparoscopically nowadays. And we wrap the stomach 360 degrees around the GE junction. That's compared to several other options we have called partial wraps, which is a two pay fund implication or a door fund implication. And those are generally either a posterior or an anterior wrap, approximately 180 to 270 degrees. So a little bit of a gentler wrap.
And so when people come in and they want, we wanna talk about Fund implications there's a lot of different variables that go into how we decide which wrap someone will get. And I will state that generally most four gut surgeons across the country have moved away from the classic 360 degree fund nissan implication. Because between the Nissan and the two pay, actually they've had similar rates of getting people off their PPIs, similar rates of symptom improvement, but the two pay is actually known to be a gentler wrap and therefore has less dysphasia and gas bloat syndrome. So a lot of surgeons are now moving just to offering people the two pay and consider the Nissan full 360 degree wrap a thing of the past.
The next thing we might consider for patients is the links device or the Magnetic Sync Augmentation device. And this is something that developed in the early two thousands, and we have at least 10 year data on this now. It's a device made up of interconnected magnets, each of which is encased in a titanium bead, forming a ring, sort of like a bracelet. And we place these circumferentially around the esophagus, near the gastro esophageal junction. And so the idea is at risk, the magnetic force will hold the beads close together to prevent reflux from occurring, and they can separate in response to a food bolus.
And so, it does allow normal physiologic function and it does have very good results. So they've done a couple of trials comparing the links to the Fund implication device, and it's been shown to be equivalent in terms of symptom relief and getting patients off their PPIs. Now there are couple of relative contraindications in one absolute contraindication to placing the links. The relative contraindications would be an existing esophageal motility disorder. Things like the presence of another electrical implant, or a patient that might require MRIs in the future greater than 1.5 Teslas.
And the only absolute contraindication to a links device is an allergy to titanium or nickel, which is what the device is made of. So you know, The links is a good option. And I think for patients who have typical reflux symptoms who don't have a really large hiatal hernia and don't meet any of the other relative contraindications, I would absolutely offer a links to those patients. It's the literature's out there and again, but I do make the caveat that we only have 10 years worth of data on the links versus the fund implication, which we've has been around for 70 years.
Melanie Cole: Isn't it fascinating for both of you in your field? What an exciting time. And before we get ready to wrap up, and again, thank you Dr. Wong, for that comprehensive overview of the procedures that are available. I'd like to give you each a chance for a final thought as you're speaking to other providers and the importance of this multidisciplinary approach and this combined clinic where you represent different specialties, but work so very well together. Dr. Wong, starting with you, I'd like you to speak to other providers and what you would like them to know when they're referring their patients, getting to that next step where surgery might be indicated. When would you like them to do that? When is it important to refer?
Dr. Kristen Wong: Sure. I think. If you have patients that are un unhappy with their current medical therapy, either they don't want to take PPIs any longer, or they still have symptoms despite being on maximal medication therapy, I think that's when you need to definitely refer to the surgery side of the team. And again, like I said, we have several good options and more options are coming down the pipeline. More with more technology being introduced for reflux.
Melanie Cole: And Dr. Calalway last word to you, as you're speaking to primary care providers and even patients that listen to these, what would you like them to know as they counsel their patients on those lifestyle behaviors and those conservative measures that we try before we get into the PPIs and the medication intervention and onward. What would you like them to know as they are counseling their patients on the increasing prevalence of GERD in the community?
Dr. James Callaway: Absolutely. I really would encourage weight loss as the initial treatment for many patients that have ref not only reflux, but other types of metabolic conditions that, that we know obesity contributes to and can have long term poor outcomes with. So that is always the first thing that we will recommend if patients are having persistent symptoms on PPIs. The first thing I do like to make sure is make sure that we are dealing with classic reflux disease. Our most recent guidelines have really stressed the importance of really objectifying reflux and actually quantifying it earlier in the treatment.
So patients are not on long-term PPIs for many, many years, treating some type of reflux symptoms, which may or may not actually be reflux disease. So, I would like to engage either the surgeons or the gastroenterologist early on if we are unclear about exactly what's going on, so we can help define is this persistent reflux? Is this refractory GERD? And then we can really help try to figure out what's the best therapy for them, whether it's additional medical treatment. Whether it's injunctive medical treatment, whether it's lifestyle changes or whether or not we really should engage our surgeons.
Because there are certain types of symptoms, especially regurgitation, that PPIs are just not very good at treating and engaging our surgical colleagues can be really life altering for our patients to try to help with that symptom in particular but reflux in general.
Melanie Cole: Thank you both so much for joining us and sharing your incredible expertise with this very prevalent condition. So thank you again, and a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole. - HostsMelanie Cole, MS, Exercise Physiologist | Medical Journalist
Additional Info
- Audio Fileuab/ua280.mp3
- DoctorsWarriner, Amy H.
- Featured SpeakerAmy H. Warriner, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6235
- Guest BioAmy H. Warriner, MD is an Associate Professor, Division of Endocrinology, Diabetes and Metabolism at UAB Medicine.
Learn more about Amy H. Warriner, MD
Release Date: February 13, 2023
Expiration Date: February 12, 2026
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Amy H. Warriner, MD
Director, UAB Weight Loss Medicine
Dr. Warriner has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionIntro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.
Melanie: Welcome to UAB MedCast. I'm Melanie Cole. And joining me today is Dr. Amy Warriner. She's the Director of UAB Weight Loss Medicine, and she's here to talk about nutrition and diabetes. Dr. Warriner, thank you so much for joining us today. As we start this topic and, wow, we're really seeing this real increase in diabetes, speak about how the landscape of diabetes nutrition has changed over the years. What do we know about the role of diet in diabetes that we didn't know, say, 10 years ago?
Amy Warriner: Thanks for having me, Melanie. I think the biggest change is the increase in type 2 diabetes and the change in medical therapies that we have for the management of diabetes, in addition to the recognition of pre-diabetes and diabetes earlier in the disease state and our ability to manage these diseases with medications that have a lower risk of low blood sugar or hypoglycemia, and the option of medications other than insulin.
When I look back historically on the way that our diabetes educators have been trained to teach our patients about diabetes nutrition, so much of that nutrition education has focused on some of the premises that are important for preventing low blood sugar and people who are treated with medications, especially insulin. And nowadays, with our newer medications, we really can start veering away from those methods and focusing on nutrition in a way that helps a patient eat healthy and obtain all of the nutrients that they need in a day, rather than focusing solely on the prevention of low blood sugars.
Melanie: Well, that's certainly true, and it's been a really exciting time in your field to watch these advancements happen over the last bunch of years. What does designing a nutrition plan for a patient with diabetes look like in the diabetes belt as compared to elsewhere in the nation? Speak about within your community area and then what you've seen as far as the trends around the nation.
Amy Warriner: I think the biggest part of creating a plan for a patient is to look at each patient individually. I think a lot of us, especially in the medical profession, have a view of what we feel is the best meal plan or the best diet for patients. But in many instances, what we view as the ideal meal plan may not fit in a patient's lifestyle. And so, especially here in the diabetes belt, we find that nutrition in general, in many of patients at baseline, is very poor and is limited not only by knowledge of nutrition, but also access to healthy foods.
And so, when we are looking to help a patient improve their nutrition overall, we need to start slow and provide them proper nutrition education that can be built upon at each visit. And the possibility also of including nutrition experts, dieticians, or diabetes educators is really important to allow our patients access to different methods of education. I think the way that my patient may hear me give recommendations is going to be much different than the way that they would hear those same recommendations from a dietician or a diabetes educator. And so, involving those other health providers in the care of our patients is important.
But I think taking a look, having a patient explain to you what they consume in a day at baseline, and then helping them think of ways that they can make improvements. For example, if a patient is consuming all of their foods from fast food restaurants, thinking about easy, realistic ways for them to start cooking at least one meal at home or using a prepared meal even, a frozen meal or a meal replacement product to replace just one fast food meal can make a large impact on that person's overall nutrition. Another example would be if a patient is solely consuming high fat foods, highly processed foods, having them integrate vegetables into at least one meal a day, so that they're getting not only the nutrients, but the healthy fibers from those vegetable sources.
Melanie: Well, I agree with you, Dr. Warriner, that certainly wherever you are in the nation, whether it's kind of an urban desert or a rural area or wherever you are, that it's difficult to get those healthy foods, that does affect that nutrition for your diabetes for someone to work with.
Now, I like that you brought up the multidisciplinary approach for patients because that's so, so important. But at some point, the patients are taking control of this on their own. So, speak to other providers about some of the tools that you find most helpful when you're working with patients. How much do you really rely on patient-provided data when it comes to managing diabetes? And speak about some of that technology. There's so much of it out there today.
Amy Warriner: There is. And the technology that is available is immensely important, especially for those patients who have good base knowledge. So if a patient has the ability to use technology, has the insight to understanding some of the basics of nutrition, tools like electronic food journals, some of food journaling apps such as MyFitnessPal is one of the most popular ones, but there are so many others out there, are incredibly important for allowing patients to start understanding what is in the foods that they are eating.
Many patients have limited knowledge of basics of even macronutrients. What is a carbohydrate? What is a protein? But, moreover, even less have knowledge of the caloric intake, the basic nutrition, the number of calories and the percent fat, percent saturated fat, the amount of sodium within the foods that they are eating. And so, especially in those who have a good baseline knowledge, using those food journaling apps so that they can start looking at the foods that they're consuming on a day-to-day basis, recognize where some of the hidden calories and hidden fats are. It can be very eye-opening. There are multiple situations where a patient has come in. We've talked to them about what their base calorie intake should be. We have them do food journaling for a week. They come back flabbergasted by some of the foods that they've been consuming, not recognizing at all the number of calories, the amount of fat, the amount of sodium in some of the foods that we eat on a day to day basis.
So, those food journaling apps especially are important. For those with somewhat lower knowledge, nutrition knowledge, websites like the American Diabetes Association has wonderful nutrition information for the population in general. And so, directing patients to the American Diabetes Association and the patient resources on that website can help them think about basic nutrition and also provide them access to numerous recipes to help them start working on integrating healthier foods into their day to day.
Melanie: That's so important and great resources for other providers. Tell us a little bit about what nutrition plans, if you were to look, and we certainly know there's an obesity epidemic in this country and, as a result, that increasing prevalence of diabetes. But if you were to discuss with a dietician or with other providers what you feel like are the most successful. We hear about local glycemic index. Patients do not understand this. They don't know what it means. Speak about some of those things that they're going to see and your best advice to counsel their patients, because I think that's where that disconnect takes place.
Amy Warriner: You're absolutely correct. And I think the challenge is that when we look at the science and we look at the comparison of different meal plans; if we think about low carbohydrate, frequently termed keto diets; if we look at whole food, vegetable, plant-based diets, or vegetarian or vegan diets; if we look at Mediterranean-style diets versus low-calorie diets and compare those across the board in large groups of patients, what we find is that there's not one specific diet that consistently helps patients do better. And so. What I think that we take away from that is that, again, we have to think about each patient and we have to think about what is going to work for them in their lifestyle. Yes, there are components of a plant-based diet that are great. There are also components of a low-carbohydrate diet or ketogenic diet that are beneficial as well, especially for someone who has type 2 diabetes or pre-diabetes.
What we can take away from a lot of these meal plans that are very effective in helping people control their blood sugars, helping people lose weight is that, in general, the effective meal plans are removing a lot of the highly processed foods. And so, if we go back in my house with my children, we talk about does it come from a farm? Does it come from a factory? Let's pick the food that comes from the farm. And so, if we go and we start selecting foods that are less highly processed, we get rid of a lot of the chemicals, the highly processed carbohydrates that very rapidly cause our blood sugars to go up and lead to insulin secretion in those of us who can still make insulin. And we don't have to avoid carbohydrates in order to get some of those benefits. And so, when we look at the absorption of glucose from, say, a bowl of cereal compared to the absorption of glucose, even from a white potato, that there is incredible differences. And it's that highly processed carbohydrate that is more challenging for us to accommodate from a glycemic perspective.
Melanie: I couldn't agree with you more, and the confusion, we could do a whole podcast on the confusion surrounding carbohydrates. I mean, it really is something that it's just confusing for patients to see all that stuff, but this is so informative. As we wrap up, I'd like you to speak about the unique areas that set you apart at UAB Weight Loss Medicine, any new advancements in the field of nutrition for diabetes that you're most looking forward to, and why it's so important to refer to the specialists at UAB Medicine.
Amy Warriner: I think there are multiple aspects in the care of patients with diabetes, but also with obesity who are at risk of developing diabetes, those who have prediabetes, those who have a strong family history of diabetes. Number one, I'll just make a little plug in recognizing that the prevention of progression to diabetes. If we catch someone who has prediabetes, it's much easier to reverse prediabetes or prevent the progression to diabetes than to be able to reverse diabetes once it exists. Even more so than waiting until someone has diabetes, recognizing early, testing, evaluating and monitoring our patients is very important.
For those who already have diabetes, the newer medications that specifically affect our insulin production after meals, which is the first insult that we see in someone who's developing glucose intolerance is really important. And these are groundbreaking medications. We're challenged by the fact that these medications are also expensive. But I think when we use them appropriately, we have great success in helping our patients in many situations reverse their diabetes, especially early on in the disease process.
There are other technologies that are very important and hugely beneficial to us and our patient population. We haven't talked about continuous glucose monitors and the impact that they have on our patients with diabetes. But just like those tools, like food journaling apps, continuous glucose monitors can be very helpful for our patients in understanding what foods for them specifically are causing their blood sugars to go high so that they can start making modifications on their own and tailoring and changing things within their day to day to prevent some of those high blood sugars, especially in the after meal time period.
Melanie: Thank you so much, Dr. Warriner. We can do many podcasts on this because there is, as you say, so much we didn't cover and so much information in your field right now. Thank you again for joining us.
And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua281.mp3
- DoctorsLuckhardt, Tracy
- Featured SpeakerTracy Luckhardt, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6230
- Guest BioDr. Luckhardt completed her medical training in May 2000 from the Louisiana State University Health Sciences Center in Shreveport, Louisiana, where she graduated Alpha Omega Alpha. She completed her Internal Medicine training at the University of Iowa Hospitals and Clinics in 2003. She was Chief Resident of Internal Medicine at the University of Iowa from 2003-2004.
Learn more about Tracy Luckhardt, MD
Release Date: February 13, 2023
Expiration Date: February 12, 2026
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Tracy Luckhardt, MD
Associate Professor in Pulmonology & Critical Care Medicine
Dr. Luckhardt has the following financial relationships with ineligible companies:
Consulting Fee - Avoro Capital Advisors, LLC
Honorarium - Boehringer Ingelheim, IPF-PRO Registry
All relevant financial relationships have been mitigated. Dr. Luckhardt does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity. - TranscriptionWelcome to UAB MedCast, a continuing education podcast for medical professionals providing knowledge that is moving medicine forward. Here's Melanie Cole.
Melanie Cole (Host): Clinical practice guidelines for management of idiopathic pulmonary fibrosis were recently updated with some significant changes in optimal management. Today, we are highlighting the key points for both pharmacologic and non-pharmacologic management of idiopathic pulmonary fibrosis based on current guidelines. Welcome to UAB MedCast. I'm Melanie Cole. Joining me today is Dr. Tracy Luckhardt. She's a pulmonologist in critical care medicine and an Associate Professor at UAB Medicine.
Dr. Luckhardt, it's a pleasure to have you join us today. As we get into this topic, please tell us a little bit about idiopathic pulmonary fibrosis, the prevalence, what you see in the trends.
Dr Tracy Luckhardt: Sure. So, idiopathic pulmonary fibrosis is a fibrotic lung disease, meaning that there is progressive scarring in the lungs. This is a disease that mostly occurs in our elderly population, so after the age of 60. This is a disease that is progressive, so most patients have progressive shortness of breath and cough. And eventually, it will lead to respiratory failure. Most patients with this disease survive about four to five years after the diagnosis.
So, idiopathic pulmonary fibrosis incidence is increasing. This is likely due to increased aging of our population as well as increased recognition and diagnosis of the disease. It is a rare disease, only affecting about one in every 100,000 people across the country. We do not necessarily have higher rates of IPF in the south than other areas of the country.
Melanie Cole (Host): Well, thank you for that. Then, we understand that clinical practice guidelines for management were recently updated with some changes in optimal management. Can you speak about those?
Dr Tracy Luckhardt: Sure. There are new guidelines as of 2022 with the American Thoracic Society, the European Respiratory Society, Japanese Respiratory Society. And the Latin America Group as well have updated the clinical practice guidelines on IPF and progressive pulmonary fibrosis. So, the key findings that were updated in the 2022 guidelines were to solidify that a probable UIP pattern on a high-resolution CT scan can support the diagnosis of IPF without having to do a biopsy or tissue confirmation, especially in the appropriate clinical setting and having been discussed in a multidisciplinary discussion. So basically, we can now make the diagnosis of IPF without a biopsy when you do have a probable UIP pattern in addition to a definite UIP pattern on the high-resolution CT scan.
Also, in the diagnostic arena for IPF, the committee also gave guidance that a transbronchial cryobiopsy is an acceptable alternative to surgical lung biopsy in patients with unknown interstitial lung disease. So basically, you can either do transbronchial cryobiopsy or surgical lung biopsy to make a definitive diagnosis of ILD. This is reserved for centers who have significant expertise in transbronchial cryobiopsy, but they did give a nod to that as an appropriate method for obtaining a histological diagnosis.
And then finally, as far as diagnostic goes, they discussed the new genomic classifier that is clinically available, but did not give any recommendations about whether or not it should or should not be used in diagnosing interstitial lung disease. And then, they also touched on the treatment of IPF. They said that patients with IPF should not be treated with antacid medications in the setting of asymptomatic disease or without a history of reflux disease. This has not been shown to improve outcomes in IPF patients. And so, just empiric treatment with antacid medication should not be done.
And then, patients should not be referred for anti-reflux surgery with the aim of improving respiratory outcomes. So, obviously, if they're having significant symptoms from a GI standpoint and that could improve their quality of life, and it's not a significant risk from a respiratory standpoint, patients can undergo anti-reflux surgery, but it should not be done for the sole purpose of improving outcomes in IPF patients, as that has not been shown to be beneficial.
Then finally, they talked about the concept of progressive pulmonary fibrosis, and defined progressive pulmonary fibrosis as a definite phenotype and gave a definition of that disease. So, those were the main updates in the 2022 guidelines for idiopathic pulmonary fibrosis.
Melanie Cole (Host): Thank you so much for going over those and you took some of the questions right out of my mouth as far as if they have a history of reflux and GERD, are we treating them with those medications? Are we looking at some of the anti-reflux surgical options? And of course, you mentioned that if it would help them with symptoms, but not necessarily for respiratory outcomes. I'd like you to speak about the key points for pharmacologic interventions and what you're looking at today. What are you doing for these patients medicationally? And then, you can go right into the non-pharmacologic management and what role surgical treatment, advanced life support, any of those things have in this disease course.
Dr Tracy Luckhardt: Sure. So right now, we have two antifibrotic medications, nintedanib and pirfenidone, which have been approved for patients with idiopathic pulmonary fibrosis. Those were approved in 2014. And for the last eight years, they've been the only therapies and remain the only therapies that we have for idiopathic pulmonary fibrosis. We now know that patients should be started on these medications at the time of diagnosis, even with very early disease, that these medications do improve outcomes and mortality in patients with IPF. If patients do have symptomatic reflux, they should be treated for that. Also for pharmacological therapies, we do recommend whenever possible that patients participate in clinical trials. There are a lot of new medications that are in phase II and phase III clinical trials for idiopathic pulmonary fibrosis, and we need patients to participate in those trials so that we can find new therapies that either add to or work better than our current therapies, especially given that our current therapies do not stop the progression of this disease, they just slow it down.
And then, for nonpharmacologic therapies, it's really important to pay attention to comorbidities in idiopathic pulmonary fibrosis, so looking for obstructive sleep apnea and treating when it is there, looking for pulmonary hypertension, so echocardiograms and right heart caths. We do now have an FDA approved treatment for patients with IPF who have pulmonary hypertension, and that is inhaled treprostinil. And so, we do need to screen for pulmonary hypertension and get right heart cath confirmation whenever we suspect that. We need to make sure that patients are up-to-date with all of their routine health screenings, such as lung cancer screening CTs and other cancer screening through their primary care and making sure that patients are fully vaccinated against respiratory illnesses, so that we can try to avoid them getting sick.
And finally, for patients who are otherwise healthy, other than their idiopathic pulmonary fibrosis, we need to think about lung transplant referral. And patients should be referred early in the course of treatment for idiopathic pulmonary fibrosis, either at the time of diagnosis or especially when they first start needing supplemental oxygen, they should be referred for lung transplant evaluation.
Melanie Cole (Host): Thank you, Dr. Luckhardt, for telling us about the important role of managing those comorbidities during treatment. And I would like you to speak to other providers about the importance of objectively assessing clinical decline. You just mentioned referral for transplant and that early referral is so important. So, I'd like you to speak about the referral criteria and how you take care of a patient on the wait-list or management during a flareup, really what happens for those patients as you're assessing that clinical decline and they're waiting on transplant?
Dr Tracy Luckhardt: Yeah. So, idiopathic pulmonary fibrosis is wholly a progressive disease, which is why referral to transplant early as possible is really key. So in general, patients will be candidates for transplant if they are not smoking, they're not using any other substances like alcohol or narcotics. They need to be healthy, so no liver disease, kidneys disease, significant heart disease. They need to be near normal weight. So in general, patients need to have a BMI less than 35 to be evaluated for lung transplant. They need to be active, so they need to be able to walk on their own about 600 feet and still be pretty active in their daily lives to be a candidate for transplant. But in general, it's really important, if there's any questions about whether or not a patient might be a transplant candidate, to go ahead and refer them to a transplant transplant center and have them evaluated to see if that might be a potential option for them.
And again, early referral is very important because the course of IPF can be difficult to predict and patients can experience acute exacerbations at any point along their course of disease and despite treatment with antifibrotics. And so, you would, if they are a transplant candidate, want that process to already be in motion if they do unfortunately have an acute exacerbation, so that they could be transferred to the transplant center and potentially bridged with ECMO or get on the list in an expedited fashion if they are having an acute exacerbation.
Melanie Cole (Host): Dr. Luckhardt, this is such a good topic. And as we wrap up, I'd like you to summarize it for us. Speak about the importance of that multidisciplinary team for treating these progressive patients and any other interventions. As you're thinking about other providers that are involved in that multidisciplinary approach, how they're helping their patients during that time with weight loss, smoking cessation, any of those comorbid conditions that you discussed, I'd like you to kind of wrap it up and tell us about your team.
Dr Tracy Luckhardt: It is really important to have a multidisciplinary team when you're taking care of IPF patients. It's important from the get-go for diagnosis to have patients discussed at a multidisciplinary conference with experienced thoracic radiologists, pathologists and ILD providers so that an accurate diagnosis can be made. It is important to have a good relationship with a lung transplant center, so that early referral can be made and that, they can follow along with you with the patient's course; gastroenterology for management of reflux symptoms and sleep physicians for management of obstructive sleep apnea. Also, working with pulmonary hypertension experts so that we can diagnose pulmonary hypertension and get patients with IPF treated with inhaled treprostinil if appropriate. It is also important to have good palliative care and supportive care providers to help with patients as their disease progresses to help manage symptoms of dyspnea, cough, weight loss and depression and anxiety.
Melanie Cole (Host): Thank you so much, Dr. Luckhardt, for joining us today. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. For updates on the latest medical advancements, breakthroughs, and research, please follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS, Exercise Physiologist | Medical Journalist
Additional Info
- Audio Fileuab/ua286.mp3
- DoctorsLatorre, Johan
- Featured SpeakerJohan Latorre, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6176
- Guest BioDr. Latorre is an Assistant Professor in the Department of Physical Medicine and Rehabilitation. He is board certified by the American Board of Physical Medicine and Rehabilitation with a certificate of added qualification in Sports Medicine.
Learn more about Johan Latorre, MD
Release Date: February 3, 2023
Expiration Date: February 3, 2026
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Johan Latorre, MD, MS
Assistant Professor in Non-Operative Orthopedics, Orthopedic Sports Medicine & Physical Medicine and Rehabilitation
Dr. Latorre has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole, and joining me today is Dr. Johan Latorre. He's an assistant professor and specialist in sports medicine at UAB Medicine, and he's here to highlight the benefits and barriers of adaptive sports. Dr. Latorre, it's a pleasure to have you join us today. I'd like you to start by kind of giving us a working definition of adaptive sports. What does that look like? What are they?
Dr Johan Latorre: Hi Melanie. Well, thanks for having me here. So simply put, adaptive sports are just sports that, whether at the recreational or competitive level, They're created for individuals with disabilities, and I think that's important, especially, you know, as we all get older, we all start getting some disability of some sort, whether it's be, simple osteoarthritis or a traumatic event that may have happened throughout our lives. So adaptive sports, allows pretty much everyone to be able to participate and be active.
Melanie Cole (Host): So we're talking about adaptive sports, but obviously you're a specialist in sports medicine. What kinds of physical disabilities do you mostly see in the kids that you work with and the adults as they are looking to get into some kind of physical activity?
Dr Johan Latorre: So for me, my general sub-specialties PMR, so physical medicine, rehabilitation. So I'm able to see a lot of different patients, who have either disability that they were born with, such as kids or adults with, spin bifida or cerebral palsy. Or adults who may have had a traumatic event occur in their life and they may have a spinal cord injury or a traumatic brain injury, and acquired their disability when they got older. So these are the different types of conditions that we normally see individuals that participate in adaptive sports.
However, osteoarthritis, something is very prevalent as we get older. Probably makes up the bulk of my practice, as a physician and as that arthritis progresses, it makes it a lot more difficult to be able to participate in certain sports or activities due to the demand such as, for example, in running. So adaptive sports, is also available to them and I've seen many individuals take advantage of that and be able to play basketball and not have their knees hurt essentially by being able to play wheelchair basketball.
Melanie Cole (Host): Yeah. That's so cool. What a great profession you're in. As far as the benefits when you think about what you do for a living and the joy and the feelings of fitting in normalization that you are giving to these kids and adults, tell us some of the benefits that you see when people participate in these adaptive sports?
Dr Johan Latorre: I'm glad you touched upon self-confidence and mental wellbeing and things like that. Cause I think that's, Big thing that we don't normally associate exercise slash sports with, but most of these, activities, require you to be in a team or be playing against other groups of people or individuals, etcetera. So you're able to create a community there. So that improves, the athletes and, the individual's confidence, their leadership skills, empathy, acceptance. All these types of things. In addition, we all know that anyone in the sports exercise realm, that just any type of exercise helps with, a lot of mental health, whether it be decreasing your risk of depression, anxiety, stress improves your self-esteem.
So that's super important on top of all the benefits we know of just general exercise, right? It's gonna improve your heart health, your brain health. It helps with trying to reduce your risk of many different types of cancer being a healthy body weight, which also prevents chronic disease. And on top of that, depending on your disability, you may have different deficits with balance, for example, or bone strength. So being able to participate in sports is gonna help you work on these things while having fun.
Melanie Cole (Host): Certainly and for other providers that are really telling their patients and their patients' families about the importance of participating in adaptive sports, tell us a little bit about the program that you run and who can participate in adaptive sports at UAB? Can able bodied individuals participate because as they wanna refer their patients to these programs, this kind of information is so important for them to have?
Dr Johan Latorre: Yeah, so at UAB we're very fortunate to be, partnered with the Lake Shore Foundation. And so the Lake Shore Foundation is a great organization that provides, exercise and adaptive sports to the community so that. If you have a disability, you're able to come and go to a location where you know that they're gonna have a ton of different options for you. Whether you wanna play a sport or simply just exercise. So that would be, the premier, location essentially for adaptive sports in our area. And they have a multitude of. sports that they offer. So, for example, they have rugby, they have different, events that they'll have like for tournaments, throughout the community.
And on top of that, there's such a great facility that they're also a Paralympic training site. So it's really cool to be especially a young person being able to start off on your journey of playing sports, knowing that, you have paralympic medalist training here, playing sports here, and winning gold medals eventually. So I think that's really inspiring as a young person just starting out in sports to be able to train where the pros play essentially. So that is really cool. At UAB, the university currently we have different programs in the university that they can have.
But there's no specific thing that's been created yet for athletes at the collegiate level. And now that I've started at UAB, my goal is to hopefully be able to create that, just as, I was able to help out with, at the University of Michigan, who now has a very robust, adaptive sports at the collegiate level with track and field basketball and tennis as their current sports that they offer. So hopefully in the future, if you're a young person thinking of college, we'll be able to, offer some sports for you at the collegiate level so you can continue progressing in your career.
Melanie Cole (Host): Wow, that's so great and we're so lucky to have you at UAB now. If a child uses leg braces, a prosthetic, a cane, a walker to get around, tell us about some of the barriers that you've seen, whether it's osteoarthritis in an older person or a child that has been born with one of these disabilities. Tell us a little bit about the barriers and remember that you're speaking to other providers, so how are you helping these patients with those barriers? Again, those providers are able to impart this information. What a great program.
Dr Johan Latorre: The big thing that I think providers should know is simply be aware that adaptive sports exists. Knowing that they exist is maybe half the battle simply because a lot of, especially younger children, young adults who wanna be active, wanna know where they can perform different sports, different exercises, and knowing where a location is makes it a lot easier, for you to send them. And at that location they can figure out what to do essentially. And what sports they're able to participate and figure out which one they enjoy the most and have the most fun.
But once we get there, a lot of these sports require specialized equipment that is very expensive. So for example, a wheelchair for tennis can cost up to 10 grand just to have the most modern, lightweight, best chair you can get. And those little bits, make a difference for the able bodied equivalent would be getting. soccer cleats or basketball shoes that are better made versus getting something that's heavier and will make you slower. So as you can imagine with a wheelchair costing the price of, a used car, sometimes even a new car, then that's a huge burden on the families.
So being able to send them to a physician such as myself, who knows different, locations and online where they can apply for different types of grants to help, offset this cost burden is very important. On top of that, transportation is an issue. We're fortunate that if you're a UAB provider, we have Lake Shore that's nearby. But knowing at least a little bit about what other places, around the communities offer is also a great way to. Have, your athletes try out new things? So for example, here in Alabama we have things here in Birmingham, but there's also things in Tuscaloosa, thanks to the University of Alabama.
Who has a very robust, adaptive sports program over there as well, who are doing very well at the collegiate level with multiple national championships in wheelchair, tennis and basketball. So transportation is an issue. So trying to, address those barriers, is simply just. Being able to network and know where to send people, where they can then get more information. and then lastly, I probably want to touch upon a little bit that, it's difficult as a caregiver, especially if it's an older adult or maybe they have a disability that makes it difficult to drive.
So being able to sort of address these needs with the caregivers is very important. When you do send them to us, to PMR sports, that we're able to know what barriers they come in with so we can help address those as best as possible, such as through grants and different types of things like that.
Melanie Cole (Host): Wow. What an excellent, comprehensive program. Thank you for laying all that out for us. Dr. Latorre, as we wrap up, I'd like you to just summarize for other providers when you want them to refer their patients to the specialists in physical medicine and rehabilitation at UAB Medicine and why it's so important that they encourage their patients to get involved in adaptive sports?
Dr Johan Latorre: So I think our role as providers is to realize that, exercise sports is medicine. With an obesity epidemic that's, affecting everyone, people with disabilities, able bodied, individuals, et cetera, we can do better as providers to try to promote exercise. So just to give you some numbers, nationally, about a quarter of able bodied individuals do not get any physical activity, and that number increases to 50% if the individual has a disability. So that is a huge amount of people who are not participating in any kind of physical activity, on a national level. And we can do a lot to affect that. And we can think of all these downstream effects that we can have with chronic illnesses down the line.
And if we can instill these good habits when they're younger, even better. So, that's the first thing. Us as should always promote exercise. And if you have someone with a disability, and especially if they're eager to be more active, I think that's a great, opportunity to then send them over to PMNR Sports to just discuss different opportunities, different needs they may have different questions that they may have as to how we can best, integrate them into the adaptive sports community so that they're able to exercise and have fun with a whole bunch of different new people who have similar experiences to them as well.
Melanie Cole (Host): Thank you so much Dr. Latorre, for coming on and telling us about this wonderful program, so Inclusive and a physician can refer a patient to PMNR Sports at UAB Medicine by calling the MIS line at 1-800-UAB-MIST, or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua285.mp3
- DoctorsCurtis, Jeff
- Featured SpeakerJeff Curtis, MD, MS/MPH
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6166
- Guest BioDr. Jeffrey R Curtis is a rheumatologist and epidemiologist focused on the efficacy, comparative effectiveness, and safety of the medications used to treat rheumatoid arthritis (RA). He is a Professor of Medicine in the Division of Clinical Immunology and Rheumatology at the University of Alabama at Birmingham (UAB).
Learn more about Jeff Curtis, MD, MS/MPH
Release Date: January 31, 2023
Expiration Date: January 30, 2026
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Jeffrey R. Curtis, MD
Professor in Rheumatology
Dr. Curtis has disclosed the following financial relationships with ineligible companies:
Consulting Fee – Illumination Health, TNacity Blue Ocean
Stock/Shareholder - TNacity Blue Ocean
All relevant financial relationships have been mitigated. Dr. Curtis does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole. And joining me today is Dr. Jeff Curtis. He's a rheumatologist with UAB Medicine, and he's here to highlight how digital technology has really changed the landscape of medicine.
Dr. Curtis, it's a pleasure to have you join us today. I absolutely love this topic. I'd like you to start by speaking a little bit about how digital tools, digital health tools are changing the practice of medicine. I mean, I think even during the pandemic, it encouraged healthcare systems to be creative and innovative in their ability to deliver patient care. What role has technology played in the management of patients as it is now?
Dr Jeff Curtis: That's a great question and thanks for asking. It's a delight to be with you. This is a topic that I love to speak on because I think this really is going to be transformative for the practice of medicine in so many ways. We're only going to have time to touch on a couple, but I'm thrilled to be able to share with you. Some of them are recent advances or the applications, recognizing we're just going to scratch the surface of some of those digital health tools and their impact on medicine.
Let me start with the first one that maybe is the most glitzy, but really is maybe more useful than physicians might expect, and that is the use of virtual reality or VR. There's variance of course, mixed reality, augmented reality. Technically, it's whether you're in a fully immersive virtual environment or whether you are overlaying some virtual element of something that isn't there in real space onto your real life, but where you're going to bring new digital elements into the care or management of patients or one's own education. So, this might be quickly dismissed by physicians as something that video gamers are excited about. And there's obviously companies that have built brand strategies around gamification, et cetera. But in fact, medicine has done very well by this technology.
It was first evaluated in helping patients manage chronic pain as well as acute pain. But acute pain has honestly been the first focus that this, I think, has proven itself. So, acute pain is a problem for many of us. But in certain settings, it's incredibly vexing. For example, a burn victim that is on a burn or a trauma unit or cancer patients or somebody in a sickle cell crisis, those are incredibly painful conditions. Those are often consults to palliative care medicine for hospitalized patients. And virtual reality has been demonstrated to be able to greatly alleviate the pain and suffering of people in acute care settings. And in fact, in some of the places in which this is deployed, it's actually a tool that a palliative care team uses to help manage pain.
In some research studies, it's been shown to be able to reduce the need for opioids, either to reduce the dose or to more effectively taper, because you can bring people into an immersive world. You could bring them into sort of a cool glacier cave while they're having their burn dressing changed, or if they're in the middle of a sickle cell crisis where you can enrapture them and grab their attention to put them in another environment that frankly will be opioid-sparing with all the complications that we're aware of. It's a form of distraction, admittedly, but there is absolutely a physiologic response. You can measure that on a functional MRI. That's the place that's first proven itself. There have been numerous studies demonstrating effectiveness there, but the applications beyond that are myriad and I think there's great things that we're going to expect from this technology in the future.
Melanie Cole (Host): That's so cool. And I think I even just saw that on one of those hospital shows recently where they did use virtual reality for just that purpose. How cool is that? So, there are so many digital technology innovations right now, Dr. Curtis. As we're looking at some of the other forms besides VR, we've got heart condition monitors, we've got all kinds of things really on the market today, how much do you rely on some of that data and patient-provided data when you're managing patients' health? And how is that self-monitoring digital technology really transforming the health of individuals?
Dr Jeff Curtis: This is a work in progress and, honestly, most physicians are not using this. And frankly, for most, it may not be on their radar screen. Fundamental, as in all of medicine, is to ask the question, "What problem do I need to solve? What's not getting it done using the tried and true methods?" So for example, in my world as a rheumatologist, there are many people that are on biologic drugs or targeted or immunomodulatory therapies for rheumatoid arthritis or lupus, or other kinds of inflammatory conditions where I just don't have access to a pain management specialist or a pain psychologist because they're in short supply or a mental health provider.
So, that's the problem that I and, frankly, many in medicine might need to solve. We're using virtual reality and a digitized program to teach patients skills. In this case, cognitive behavioral therapy skills, what some might consider some of the wellness behavioral interventions, you know, mindfulness or meditation techniques. So, we're using VR to help manage chronic pain and anxiety for patients that I don't have somebody to refer them to because those specialists are in such short supply.
So, to be able to teach someone skills or to help them think through what are the future decisions that you might need or want to make about your own healthcare, let me help put you in a scenario where you have to think about you in the future. VR has done that with smoking cessation. "Here's what you might look like if you quit smoking your two packs a day of cigarettes at age 60, versus if you continue smoking two packs a day for the next 20 years, here's what you may look like at age 60." So, this idea of age progression, but envisioning your future self to help make treatment decisions today. So again, teaching people skills, thinking about making decisions today, but predicting or envisioning the future in a visual, immersive way, virtual reality is great for that. But as you just alluded to, the pandemic has brought us different problems, and that is people don't want to come back to get care because of a global pandemic.
So, remote physiologic monitoring or RPM and remote therapeutic monitoring or RTM, these are new digital health technologies where patients could use physiologic biosensor devices or mobile apps or both to help inform their doctor as to how they're doing. And to answer your question, in some specialties, not as much mine in musculoskeletal medicine and rheumatology, this has taken off. Because for primary care and some specialists, you've got a physiologic biosensor that is absolutely critical for some of the disease states you mentioned. For diabetes, continuous glucose monitoring tells you most of what you need to know to manage a patient's blood sugar. There's a sensor for that. For a heart failure patient, the idea that your patient could step on a Wi-Fi equipped scale, that's all he or she has to do every morning, and that lets you or your heart failure clinic nurse titrate the dose of diuretic to the goal weight that makes perfect sense. Or for dysrhythmia detection in primary care cardiology settings, or a simple a hundred-dollar home ambulatory blood pressure cuff that connects to your patient's phone, you can get a blood pressure reading every day. All of that is called remote physiologic monitoring or RPM.
During the pandemic and even right before it, that is now a reimbursable technology. So, this is not something that's kind of an, oh, gee-whiz, a few researchers in their ivory tower are doing that, but this is now something that is slowly percolating out to primary care and specialist settings. This has now been reimbursable by Medicare, the Center for Medicare and Medicaid Services since 2019. And this approximately would reimburse a physician for a patient who has Medicare or some commercial insurances about a hundred dollars per patient per month. And the reason that I mention that is how to sustain that sort of an intervention or program is always important for physicians to think through. And frankly, this probably provides some practices a source of ancillary revenue, as well as helps them improve care. So if there is a disease state like those I mentioned where a biosensor device might be helpful, I think this is a tremendous blessing and augmentation to the care that we provide in the office.
Melanie Cole (Host): What an exciting time in medicine. And I can hear that in your voice, Dr. Curtis, too, because it rises as you're talking about all of this digital technology. I can hear that you're passionate about this. In my mind, it's not only innovation in terms of all the new technology that we're talking about. And as you mentioned, continuous glucose monitoring, diabetes, that really is amazing stuff. But there's also been an innovative shift as a physiological and philosophical shift from providers working in silos to working together, providers taking advantage of artificial intelligence and clinical research to disseminate their data and research quickly, especially for public health emergencies like we saw with COVID and digital research and information sharing, basically what we're doing here on this podcast, but in other forms. How have you seen that manifest itself as well?
Dr Jeff Curtis: That's a great question. And I think all of us have started to realize even those in academia, you know, one even large academic medical center or health system is not going to be able to nimbly answer all the questions that need to be answered using the tried and true brute force methods. So, I've seen a tremendous enthusiasm for data normalization and, as you said, data sharing. So, the idea that we're going to create a data infrastructure, some of those might be a health information exchange where multiple health systems, hospitals, or even networks that span states could share information in a very rapid fashion. And then, you can apply big data or AI or machine learning approaches to sift through that data. And there's a number of highly visible studies, particularly looking at long-haul COVID and some of the treatment options that have been tried, some successful, some not so successful to help manage acute COVID, where if you didn't have a digital infrastructure to aggregate data and to be able to analyze it in a very fast fashion using state-of-the-art analytic and data visualization tools, there's no way that you could get the rapid cycle answers that we need to take care of patients.
Melanie Cole (Host): Yeah, it is amazing to me how that's working. Now, how have you been using telemedicine and how has that evolved during COVID? We've been talking about all the digital monitoring and the remote monitoring. Also, telemedicine kind of came into its own during COVID, and I don't see it going anywhere because, as you mentioned, people are a little bit fearful still with an ongoing pandemic, but also, and I hate to say it, there's the convenience factor for both the physician and for the patient. Certainly in rural areas, telemedicine has proved itself.
Dr Jeff Curtis: Well, I think you're absolutely right, although I think it's rather specialty-dependent. Based on some large national surveys and data sources, psychiatry seems to have been the bastion that really, really wants to, and of course, values telemedicine. That feels pretty intuitive to me just because the physical exam aspect of seeing somebody face to face is presumably lessened for most psychiatric conditions than a number of other medical specialties. So, you're absolutely right. I don't think that the need for it or the benefit is going anywhere, anytime soon. That said, I have seen a rather attenuation in many providers' use of telemedicine. I think some of it is comfort with technology. This was sort of thrust upon us and we had to get to be digital health experts, at least in this one small way, almost overnight in March of 2020 with the pandemic. And many said, you know, I don't really need that, and it's a convenience for me to have the patient right in front of me, et cetera.
On the other hand, what I think sometimes providers lose sight of is, is it convenient for the patient? And as you said, if you live in a rural area, and certainly for my university practice with my colleagues, people may drive two or three hours each way to see me. So sure, it might be slightly more convenient for me to manage conditions in-person because they're in front of me, but not every single patient in every visit needs that. And so, I think sometimes providers fail to recognize your patient would really value this. Because if it's something routine where you don't need an exam to really help figure out what to do, history and visually looking and visual inspection over a video feed might be sufficient, figuring out who are the patients that are best suited for telemedicine, what are the diagnoses that are most amenable to telemedicine, and that's where some of the other technologies like that remote therapeutic or patient monitoring come into play.
Remote therapeutic monitoring actually allows now for reimbursement with patients just using an app. So, patients can tell you how they're doing once a week, couple times a month, for example. and to give you patient-reported outcome or PRO data several times a month, so that you, the provider, can know exactly what's going on with your patient. Not every three, four, six months over telemedicine in isolation, but, you know, if you had a near continuous data stream where you're having your patient spend five minutes on their smartphone, answering a couple questions that you've pushed out to him or her, so you know when there's a deviation or a perturbation of how she's doing. And now that telemedicine visit is much more comfortable for you because you get a sense that, "Oh, all of her PRO data is tracking just the same as it was as when I saw her six months ago, now I'm comfortable with a telemedicine visit and I don't necessarily have to lay eyes on her." So, my point is really that telemedicine coupled with some of these remote patient monitoring strategies, whether they're app-based or biosensor-based, I think offer tremendous potential to make care more efficient for us.
Melanie Cole (Host): I agree with you completely, and I think we're learning more about which service lines in which areas of medicine it's proving itself, as you said, psychiatry. Whereas in ophthalmology, really, you need those hands-on physical examination and rheumatology, orthopedics, I mean, it's all kind of-- we're learning, right? We are learning. And as we wrap up, Dr. Curtis, I'd like you to kind of summarize how remote patient monitoring fits into clinical care and research, practical applications, where you see this going in the future. And if you were to speak about the areas that are unique to UAB that set you apart and why it's important to refer to the specialists at UAB Medicine, that would be great.
Dr Jeff Curtis: Absolutely. So, the idea that we could provide continuous care and that that continuous care is appropriately reimbursed, not for research where a research grant ends and the whole infrastructure comes to a crashing halt, but simply as part of providing continuous care or what I think of as 360-degree care. I want to know how my patient is doing, not just the three or four or five times a year that she's coming to clinic. I want to know how she's doing all of the time to best help her and to manage chronic illnesses. And most physician specialties have that same ask and opportunity. So to be able to use a mobile app for patients to tell us how she's doing, to me, that offers tremendous potential to improve care and to get us out of this episodic mindset where I don't think much about how you're doing except the several times a year that I might see you in person.
I think also it allows itself to blend co-management of care between primary care physicians or people who are referring to UAB and UAB providers. And there's a number of diseases for which co-management or co-production of care is essential. For example, gout. Gout is often undertreated or poorly treated. There's a variety of reasons for that, but that's been shown over and over again. And that or many other examples like it is where integration of how the patient is doing with both what the primary care or referring physician might know and be managing in terms of comorbidities as well as what a specialist like a rheumatologist might be managing, having a digital data stream interspersed with the serum uric acid that might be drawn at the primary care doc's office might be drawn at UAB or a specialist's office. To me, those kinds of diseases where information-sharing is intrinsic to the infrastructure that we have built for care production. To me, those are just natural winds and the patient comes out much enriched by having their physicians effectively communicate via this digital data stream where both sets of providers know what's going on.
Melanie Cole (Host): Wow. Very beautifully said, and such an exciting time as I've already said. I hope that you'll come back, Dr. Curtis, as things update and as we learn more about this digital age and this digital technology and how the medical innovations are really making these advancements happen at such a fast rate, sometimes it's hard to keep track. And thank you so much for joining us today and filling us in on some of what's going on.
A physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. For updates on the latest medical advancements, breakthroughs in research, follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS
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