Additional Info
- Audio Fileuab/ua282.mp3
- DoctorsFranco, Ricardo;Fettig, David
- Featured SpeakerRicardo Franco, MD | David Fettig, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6270
- Guest BioDr. Franco is board certified in Internal Medicine and Infectious Diseases and Assistant Professor of Medicine at the University of Alabama at Birmingham. His interest focuses on interventions to improve access to care and new therapies in Chronic Hepatitis C; clinical management and trials in HCV mono-infection and HIV-HCV co-infection; and the accelerated pathogenesis of HIV-HCV co-infection.
Learn more about Dr. Franco
David Fettig, MD (Assistant Professor, Gastroenterology & Hepatology) joined our faculty in May. Dr. Fettig graduated Summa Cum Laude from Florida State University with a Bachelor of Science and received his MD from the University of South Florida College of Medicine.
Learn more about David Fettig, MD
Release Date: March 6, 2023
Expiration Date: March 5, 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:
Ricardo Franco, MD
Assistant Professor, Infectious Diseases
David Fettig, MD
Assistant Professor, Gastroenterology & Hepatology
Dr. Franco has the following financial relationships with ineligible companies:
Grants/Research Support/Grants Pending - Gilead, Abbvie, Merck
Consulting Fee - Gilead, Theratech
Support for Travel to Meetings or Other Purposes - Gilead
Payment for Development of Educational Presentations - Gilead, Abbvie
All relevant financial relationships have been mitigated. Dr. Franco does not intend to discuss the off-label use of a product. Dr. Fettig, nor any 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): Welcome to UAB MedCast. I'm Melanie Cole. And joining me, we have a physician panel today, Dr. Ricardo Franco, he's an Associate Professor in Infectious Disease at UAB Medicine; and Dr. David Fettig, he's an Assistant Professor in Gastroenterology and Hepatology at UAB Medicine. And they are here to highlight viral hepatitis and UAB Medicine's Solution for Alabama.
Doctors, thank you so much for joining us today. Dr. Franco. I'd like to start with you. Would you start by telling us a little bit about the state of hepatitis, the scope of the issue we're discussing here today, the prevalence, what you're seeing in the trends, and specifically in Alabama and then around the country.
Dr Ricardo Franco: Sure, Melanie. Thanks for having us. It's a pleasure to be here. Hepatitis C virus is a very common bloodborne infection in the United States. It's also a major cause of morbidity and mortality from liver complications. It's very common in US. About 1% of the population nationally is infected with hepatitis C virus. We have the same reality in Alabama comprising about 40,000 people living with hepatitis C in our state.
Hepatitis C has had much greater prevalence even back in the '90s and early 2000s; when eventually a little after 2010, we developed better medicines to cure hepatitis C and we see a dent in the hepatitis C prevalence from 2015 to 2018 just to see this disease making a comeback, especially right before the pandemic and throughout the pandemic. And this comeback of the disease was fueled by the opioid epidemic and injection drug use. It remains a very important problem. We have the tools to cure the disease. We have expanded services, we have expanded outreach, but it's a disease that has been relentless and disproportionately affecting our most vulnerable populations.
Melanie Cole (Host): Thank you so much, Dr. Franco. And Dr. Fettig, why is it known as the silent killer? Tell us a little bit about the case definitions for reportable hepatitis C virus infections, as far as when we're figuring out the prevalence, as Dr. Franco said. What are we reporting?
Dr David Fettig: Yeah. So, thanks again for having me as well. The reason we kind of talk about it like it is the silent killer is that it takes usually between two and three decades for it to have some sort of an effect on a patient. Sometimes they don't know for even longer than that. And so, when people are actively using, whether like in the current era, kind of actively using IV drugs, taking a long time for that to happen for them to start showing signs of an infection, you can see where a lot of the damage can already be done.
I think that's a grave and difficult question as far as like reportable, just because it's always dependent on who's being screened. And so, based off screening purposes, initially it was all based off of the Baby Boom generation 1945, 1965 due to various reasons, whether that was IV drugs or actually blood transfusions causing disease. Well, now, it's really anybody that's above 18 years of age. And so, getting people in to be screened is kind of the key. So while we see what the current prevalence is, and you could see in the early 2000s, it started to decrease. And then, around like 2009, 2010, it started to start to increase as where we see it today and as it begins to increase. And so, I think with getting people screened, obviously that's going to, I think, increase. And so, I don't think we accurately have that information. But with the awareness and stuff like this, things will get better.
Dr Ricardo Franco: Hepatitis C surveillance, as you would be maybe surprised to learn, is a very difficult thing to do. So, to really get real numbers of people infected and who are screened, who are linked to care and who are treated, is actually labor-consuming, expensive and our health departments have been traditionally underfunded to do this work. So when we say that about 1% of the population is infected with hepatitis C, that comes from databases where we take our best estimates, but we don't have a way to really track real time numbers or real world experience on a global scale or national scale or even statewide scale to say with confidence what the real numbers are. But we have very good estimates, but they're not actual real numbers.
Melanie Cole (Host): Well, thank you both for that. So then, Dr. Franco, based on what you just said and what Dr. Fettig was speaking about, who should get screened? Are there guidelines for screening? So then how would we know?
Dr Ricardo Franco: So as David said, the screening nowadays is to test at least once in a lifetime every adult older than 18, and test regularly adults that are at risk of acquiring hepatitis C. For example, injection drug users that are not already infected with hepatitis C, they should be screened regularly. Most of often, once every year would be a reasonable timeframe and should be regular screening of groups that are at most risk of acquiring hepatitis C. These recommendations they actually changed over time.
Back in the late '90s, we would only recommend the screening for the ones that are at most risk. That eventually evolved when we learned that hepatitis C was three or four times more common among Baby Boomers than in the general population. We expanded the screening to recommend the screening of Baby Boomers. And then eventually, when we saw an emergence of hepatitis C in women of childbearing age because of the opioid epidemic and the spread of the disease in the younger groups, we also pushed for recommendations for prenatal screening, so every pregnant woman would have the opportunity to have this diagnosis and be linked to care after having their babies. And eventually, the CDC expanded these recommendations further to include every adult that should be screened for hepatitis C, which emulates somewhat recommendations in other countries, like France and others, who have spearheaded this more liberal way of finding a disease. And as we found it, do a test and treat approach and treat them with curative medicines.
Melanie Cole (Host): Dr. Fettig, tell us a little bit about the clinical presentation, the first signs and symptoms. What would send patients to their primary care or to the ER or to a specialist such as yourself? What would send the patients to see somebody?
Dr David Fettig: I think that's hits back on this whole screening issue and that it can be silent for long periods of time. So, sometimes nothing. There is an entity of acute hepatitis C that you actually get infected within six to 12 weeks actually begin to have significant symptoms of fever, jaundice, itching, lethargy, fatigue, almost like a similar presentation, I think, to acute hepatitis B, so B as in boy. But typically, maybe nothing. So, it could be as mild as fatigue. You could have some potential skin changes and rashes, arthritis-type symptoms. But otherwise, there may not be anything present. And because of that, I think is where a lot of the screening potential is there for us, as Ricardo had mentioned, for curative therapy.
Melanie Cole (Host): It's one of the biggest challenges, I see. So Dr. Franco then, following up on that, how has UAB taken the lead in getting people tested? Tell us about UAB Medicine's Solution for Alabama.
Dr Ricardo Franco: I'm glad you're asking this question. David and I, we've seen UAB efforts in the forefront of trying to control Hepatitis C for the past 10, 15 years. And I would like to maybe highlight three programs that we put forward in this timeframe. One has been led by the emergency department from Dr. Galbraith to Dr. Walter nowadays. The emergency department has screened over a hundred thousand patients coming through their doors for other reasons to receive emergency care. And they implemented in a nurse-led model, all hands on deck, outstanding team effort to rescreen such a large number of individuals in a population that has an extremely high screening yield.
So for you to have an idea, when we do hepatitis C screening in our vulnerable populations that don't have regular care and use the emergency room as a safety net, the prevalence of hepatitis C screening is well over 5%. Among Baby Boomers, it has been consistently over 10% of antibody positivity for this infection. Whereas if you go to regular clinics, that screening yield might be much less than 1%. So, we have a ten-fold high-yield screening when we go and test the right populations. And the UAB Emergency Department has been leading this effort for years and it has been replicated in other places, and they have joint forces. And they have proven that nationwide this screening strategy is very effective in finding cases and linking them to care and eventually treatment.
Another strategy we implemented, and it's one that gives me a lot of joy to talk about, is the community outreach. We have partnered with the federal-qualified health centers, most of them in our state, to actually train their providers in hepatitis C screening, linkage to care and treatment at their own clinics. We identified hepatitis C champions, we trained them. And what we saw is that even though maybe in a clinical body of 10, 15 providers, if only two of them would take on the duties of treating their own hepatitis C patients for the whole clinic, we saw that actually testing got better clinic-wide. So all the providers, once they learned there is a champion embedded in their own setting, they felt it would be better to test more effectively and find a greater number of cases in their own patient panels. This is also the population served by federal-qualified health centers, a high screen yield population, very vulnerable, where Hepatitis C is highly prevalent with similar prevalences that we see in emergency department close to 5% and 10%. And the third initiative, I'll let Dr. Fettig lead this one. David, you're welcome to talk about our nested model that we combine hepatology and infectious diseases. Please go ahead.
Dr David Fettig: So, I think, Ricardo, I'll just echo a lot of what he said. He'll be very modest about this, but he really took the lead on this at our institution as far as what he's describing. He put in a lot of work and talked with a lot of people to get a lot of these programs running and continue to do that when I came here. But I think we really wanted to have a multidisciplinary approach to this. And the more people that I talk to around the nation, I don't know that anyone in the US is doing quite exactly what we're doing and what we're describing.
So at UAB, we came up with a model that incorporates somebody like myself as a transplant hepatologist and then somebody with infectious disease experience. So, our clinic provides a really vast array of possibilities, and I say that possibilities of diagnoses that could come in. So, HIV co-infection, people with combined hepatitis B, hepatitis C, people with liver masses, people with decompensated cirrhosis, people with compensated cirrhosis, people with no liver disease that can be found other than having the virus present, a lot of different possibilities. And there's actually a place for everyone here. And what's nice about that is we have so many different avenues to get them in, link them to care, and then get them to where they need to be. Whether that would maybe even for the first time, having somebody diagnosed with HIV, well, now we have Dr. Franco that can follow them long-term. Hepatitis B and cirrhosis and liver masses, well, that's something I take care of. Or maybe we need to have this person go for a transplant evaluation, well, that comes out of this clinic. And so, we have so many different possibilities to link them into care. And that multidisciplinary approach, to my knowledge and the people I've talked to, has not been done. And then, going out into the community as we're doing and talking to different providers and helping them with whether that be testing, whether that be treating, knowing who should come to us for treatment. And then, we also have a full-time pharmacist on staff that helps us. We have a full-time administrator who helps call all the patients, helps set up the laboratory results, helps discuss with them, and make sure that their appointments are set. We're going to be doing some different outreaches as far as providing transportation to and from the clinic.
So, what we're doing at our institution really is saying, "Hey, we have a problem in our state as far as a disease and we want to fix it." And so, there's a lot of discussion at times with different things that people do. But Dr. Franco and myself wanted to take action. And so, the clinic is called the ABC Clinic, that is something I think novel and something we're really excited and proud of.
Melanie Cole (Host): That's excellent. And I'm so glad you both highlighted that fact that you represent different specialties, but through the combined clinic, the largest benefits and how you are all working together for this multidisciplinary team approach for these patients is so important. Dr. Franco, tell us a little bit about the success rate of current treatments and how has it really evolved over the years? Because I think, you know, it used to have a bad rap, these kinds of treatments. But now, as you both have alluded to earlier in the podcast, these treatments are much easier and have greater success.
Dr Ricardo Franco: Yes, absolutely. What happens is that the new treatments can cure the vast majority of patients with chronic Hepatitis C. They have efficacy rates well above 95%. They're easy to take. They have very few side effects. Their rates of discontinuation because of bad side effects are close to none, and they can be taken in the short periods of times between two and three months.
That being said, when we go out in the community and you tell your trainees, your nurse practitioners, your physician assistants, your primary care physicians, all working in federal-qualified health centers, and seeing large amounts of patients with chronic hepatitis C when you tell them that these medicines can cure most of your patients, that they're very easy to use, we still have to do this in the right way. You have to make sure that they're following guidelines. You have to make sure they're not dealing with exceptional cases, some of them that David just mentioned. So all that to say, that we're so appreciative to always have transplant hepatology and gastroenterology backup as we do these outreach programs because they're really the ones that give us the backup whenever we see a more complex case, that we have this right way to resort into and get the appropriate care expeditiously and very quickly, and have not only the trainees providing this care, but the patients the right service at the right setting and doing it in a safe way.
So that being said, hepatitis C treatment, it is something that is ready for primetime. And it should be pursued by every single primary care practice in the country. And that's the only way we're going to really control this disease and meet WHO targets of eliminating the disease by 2030. Not to mention that the United States as a whole, they're not on track of key indicators of hepatitis C control, especially controlling incidents because of the opioid epidemic and keep you at pace with the rates of treatment, especially in some of the jurisdictions that have the greatest prevalence and the lowest uptake in treatment because they have large populations that are very hard to reach.
So, that's what makes this whole communion of specialties and innovative service is so important to really get to the patients that they're in greatest need and tackle a very significant disease burden out there.
Dr David Fettig: And I'll chime in as well and add to that. When you really look at hepatitis C history, as far as the treatment goes, I mean, it is really kind of fascinating. I tell people, I say I look back at, I think, it was in the mid-'80s, there was an NIH pilot study that used interferon for non-A, non-B, and that's what they called hep C at the time. And so, the SVR rates were around like 5%. They were really pretty minimal. And so, it's almost as if we went from a horse carriage transportation-wise to the Tesla in this short period of time, which is really phenomenal. So, that's in the '80s, and you go to the early 2000s and, essentially, that's when the DA agents that were talking about to cure hepatitis C. So, it happened in the grand scheme of treatment for diseases, it happened rather fast. Like, there wasn't a whole lot of in between. And I think that's also getting rid of the stigma of the old medications of interferon, which were very difficult. Very, very, very difficult. And to let you know, I've actually never prescribed interferon and I can count on one hand the times I had to prescribe ribovirin as another antiviral for hepatitis C. So, it tells you how new this stuff is and how quickly it happened.
The other thing I'll point out as well is I think the ASLD, that's American Association of Study Liver Disease, as well as the Infectious Disease Society of America teamed up. And on the ASLD website, just kind a plug for them. They have a really nice approach for management of hepatitis C testing. And it's very simple. It's very user-friendly. They'll also go into like who is not eligible for simplified treatment. That's kind of what Ricardo and I were talking about, like the champions in the community that are treating it. And so, it really goes over very specifically the do's and don'ts and pretreatment assessment. So, it really makes hepatitis C treatment easy. We also need to understand, it can be difficult at times to do it right. So while it's easy to treat, it can be hard to do it the correct way. And so something like this, as well as our clinic, really provides an answer to both of those question.
Melanie Cole (Host): Thank you both so much. What an absolutely excellent, informative podcast. And thank you both for doing all the great work that you're doing for viral hepatitis in UAB Medicine's Solution for Alabama. Just excellent information. 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, Exercise Physiologist | Medical Journalist
Additional Info
- Audio Fileuab/ua277.mp3
- DoctorsPeyton, Chas;Nix, Jeffrey
- Featured SpeakerChas Peyton, MD | Jeffrey Nix, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6150
- Guest BioSpecialties include Urologic Oncology and Urology.
Learn more about Chas Peyton, MD
Jeffrey Nix, MD specialty include Urology.
Learn more about Jeffrey Nix, MD
Disclosure Information
Release Date: January 23, 2023
Expiration Date: January 22, 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 Nix, MD
Associate Professor in Urology
Charles Peyton, MD
Assistant Professor in Urology & Urologic Oncology
Drs. Nix and Peyton have no relevant financial relationships with ineligible companies to disclose. There is no commercial support for this activity. - TranscriptionIntro: Welcome to UAB Med Cast, a continuing education podcast for medical professionals, providing knowledge that's moving medicine forward. Here's Melanie Cole.
Melanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole. And joining me in this panel today is Dr. Chas Peyton, he's a urologic oncologist and an assistant professor; and Dr. Jeffrey Nix, he's a urologic oncologist and associate professor. They're both at UAB Medicine and they're here to highlight urinary diversion procedures for us today.
Doctors, thank you so much for joining us. And Dr. Peyton, I'd like to start with you. Why do we need to perform urinary diversions? What are the indications? Tell us a little bit about this and the clinical indications for these types of procedures.
Dr Chas Peyton: Sure, Melanie. Thanks so much for having us back on the podcast. We enjoy doing this when we can. But today, we're going to talk about urinary diversions. And I guess, the first question is why we need to do this. So, there's variety of indications. And the world that Jeff and I live in most of the time, Dr. Nix and I, it's usually for a cancer reason, meaning an organ is being removed such that the person can't urinate normally anymore, so the urine has to be diverted somewhere else.
There's a variety of other indications as well for non-malignant indications. Someone, for instance, who's a spina bifida patient and doesn't walk, doesn't use their legs and, as they age, managing the urine becomes an issue. And for that person, there's another indication to divert their urine to their abdomen or to another way to allow them to pass urine in a much more easy fashion rather than through the urethra.
So, that's the general gist of what a urine diversion is. The most simplest type of urinary diversion is just a tube, a nephrostomy tube into the kidney or a suprapubic tube into the bladder. But I think what we want to get at with this podcast is talking about more of the complex diversions that we do surgically that we see in the hospital quite a bit that can sometimes create a lot of confusions for both patients and providers that aren't used to dealing with them.
Dr Jeffrey Nix: Yeah, and I think what I would add is kind of just simplify exactly what Chad is saying. I think the person that's listening should think, if for whatever reason we can't use the bladder anymore, right? The bladder functions in two ways. It stores urines so that we can pee when it's convenient for us to do so. And then, it functions to help us get rid of that urine. So, it's a storage container, but it also is a muscle and that it has to be able to squeeze and get rid of all that waste. And so, if for a myriad of different reasons, you no longer have the use of that, and Dr. Peyton mentioned, we had to remove that organ because it had cancer or that organ becomes poorly functioning, let's say radiation exposure for certain types of cancer can be an example of that. Or you have limitations in movement, like a spinal cord injury where you're bound to a wheelchair and the bladder becomes dysfunctional for those reasons.
So, for any of a myriad of reasons, the bladder becomes an organ that is no longer functioning to the benefit of the patient, then we have to come up with alternative solutions. And that's, I think, where these urinary diversions can become so helpful for patients.
Melanie Cole (Host): Well, thank you for that. Then, Dr. Nix, tell us about some of those types of urinary diversions. Go from the most simple, as Dr. Peyton mentioned, to the most complex that other providers might be referring their patients for.
Dr Jeffrey Nix: Right. Let's say providers are going to see patients come in with tubes all the time, right? So, catheters. So, these are what we would consider to be temporary diversions. And you might not even think of them in that context, but they are diversions. So, a catheter, a Foley catheter that goes into the penis, or a suprapubic tube that goes directly through the skin into the bladder or nephrostomy tubes, which are smaller diameter tubes, which go directly into the kidneys. So for each of those very simple mechanisms, we're temporarily diverting the urinary stream at some part of the plumbing, so to speak, to get the urine removed from the patient in a safe manner. Now, again, I would consider those temporary.
And then, we go up to what are surgical types of diversions. And the easiest one we make is something that's just a conduit. Providers are going to see patients who wear ostomy bags all the time from colon cancer surgeries. And so, those are stool-containing ostomy appliances, but we can do the exact same thing with the urinary stream as well. So, a conduit, very simple and it just carries the urine from inside the body to an outside appliance that the patient then manages. That obviously is not continent. And so, the patient, it's just a passive drip system. And so, then we can go up to much more complicated diversions that all have some form of continence. And when we as urologists think about them, we think about them, and Dr. Peyton may want to elaborate on this, we think about them as orthotopic and non-orthotopic diversions that can be continent.
Dr Chas Peyton: Sure. Just like Dr. Nix says, we go from least complex to most complex. And after an ileal conduit like we talked about, which is just simply a segment of ileum repurposed to draining urine as opposed to stool. It's just removed from the stool tract and hooked up to the ureters on one side and the other side to the skin.
The next level complexity would be whether or not you want orthotopic, non-orthotopic, which means you want the new reservoir to hold the urine to urinate like a normal bladder. Meaning, do you want to pee through your urethra? So, the next one we'll talk about is what's called a neobladder. So, an orthotopic neobladder where we are taking a longer segment of usually ileum, and repurposing that ileum to serve as a urinary reservoir in the pelvis. It's a lot more complicated. We're using about probably anywhere from 40 to 60 centimeters of ileum as opposed to maybe 10 to 20 for a conduit. It's a lot of complex reconstructive effort. And that is ultimately sewn. The ureters are plugged into one side and the other side is sewn to the urethra. So, that would be what we call a continent orthotopic urinary diversion, because that patient will eventually learn how to use their external sphincter and urinate similarly to how they had their native bladder, but use more of a Valsalva technique by pushing and whatnot to allow the urine to drain.
And the third type of diversion we always talk about would be a continent cutaneous diversion, where again it's a pouch made out of repurposed, in this case, it's usually colon, right colon. And then, a stoma brought to the skin such that the patient has a pouch on the inside that they catheterize through their abdomen. So, we're taking the urethra out of the equation with that. And they're not leaking to a urinary bag on the abdomen, but instead they have a continent catheterizable stoma at the abdomen. This is probably the most complex urinary diversion, I'd argue, that we do and it's not as frequent. But for certain indications, we can do it. And basically, you're using part of the right colon and the terminal ileum, opening that up, and repurposing that as a pouch on the inside and the terminal ileum limb of that pouch is then brought to the skin such that it's a tiny continent stoma that doesn't leak urine. So, people don't have to wear a bag, which just they have to every three to five hours go and catheterize that pouch to get the urine out.
So, that's the basics. Now, there's a lot of variety on the surgical techniques with each one of those, and I don't think we need to get into that, but that's another discussion in and of itself. But those are the three main types that we're going to talk about.
Melanie Cole (Host): Thank you for that comprehensive answer. So, then Dr. Nix, based on what Dr. Peyton was just saying, how do you select those patients for the most appropriate type of urinary diversion? How do you decide which type of procedure to use and how does the choice of type of diversion require careful clinical and quality of life assessments with the patient and shared decision-making?
Dr Jeffrey Nix: Yeah. I mean, you said it all. Of course, the context for us, and this is often a multi-interview process. So, if I'm bringing a patient in for counseling on this topic, as you can imagine, we could talk about this for hours and hours. And so, our main job is one of education. We're going to go over the basics with the patient. And then, we're going to usually do a second or even a third counsel session because it is so important that we get this right and that we select something that is appropriate medically as well as in terms of their quality of lives. And some of that requires a knowledge of the kinds of activities they do, their expectations. And it's always patient-specific.
So, let me use a situational vignette to sort of describe that. If you're wheelchair-bound because you were in an auto accident as an example, and getting from your wheelchair to-- let's say you're a female patient and you have less upper body strength, and getting you back and forth from your wheelchair to a bedside commode or to the commode at night is difficult, and it's not just because of maybe transitioning out of a the chair is hard for you, but let's say you've got limitations because of the home you live in, and so that's a great patient. And you're younger. Let's say you're mid-30s and you don't want an appliance or an outside conduit reservoir like a bag. And so, as a patient, that would be a perfect patient for a catheterizable diversion, like the last one that Dr. Peyton mentioned, the Indiana pouch, because they will be able to have continence. So, they won't have urine constantly dripping into a bag and, because they're wheelchair-bound, we can put that opening that they catheterize somewhere around their belly button level or mid-abdomen level, and so they won't have to get in and out of their wheelchair to be able to manage that diversion. So, that's a perfect patient for that kind of diversion.
What would be a really bad patient for that kind of diversion? Let's say you're an older patient and you have really poor vision. And because of diabetes or other situations, you don't have great sensation and maybe you have limited dexterity. So, that would be a really bad diversion for that patient because they're going to struggle to be able to catheterize themselves. They're going to struggle to be able to have the sensation they need and the awareness they need to be able to capitalize consistently. And so, all those things would weigh in. And that's just a couple of examples. So as you mentioned, this is shared decision-making. This is going over all of these different variables to make sure we make the right choice.
Melanie Cole (Host): Dr. Peyton, as urologic surgeons who perform these urinary diversions, and you're speaking to other healthcare providers, what should they take note of or be aware of when they're thinking about the physiological and metabolic changes that can occur from some of these surgeries? I'd like you to speak about complications that can be associated with urinary diversion. And specific to each type, what should they be keeping in mind that could be associated with this?
Dr Chas Peyton: It's really an important thing that we encounter from time to time. I'll keep on the same kind of pathway that we've been discussing from simplest to most complicated.
So, anytime somebody has a urinary diversion where we're repurposing bowel, there's going to be contact of the urine with the intestines. So that does pose occasional problems for these patients, particularly metabolic problems. Specifically, I can kind of tell you, since there'll be providers listening to this, they'll know what I'm saying, depending on segment of bowel that you use will dictate some metabolic abnormalities some of these patients will have, also how long the urine is in contact with those places of intestine, meaning that a ileal conduit urinary diversion, the most simple type, the urine is in contact with it not that long because the urine is constantly leaking into a bag. Whereas opposed to someone with an ileal neobladder or a colon neobladder or a colon continent cutaneous diversion like we talked about, the Indiana pouch, the urine's going to be in contact with that quite a bit longer. So, the risk for metabolic problems is a little bit higher in those patients.
But just to talk to you specifically if you're using colon or ileum, people get low potassium levels, high chloride levels, and they get a metabolic acidosis or they can get it. Sometimes in these patients, if they have it long enough, we replace them. We give them bicarb, just to kind of replace some of the acidosis that they get. If you see a patient that has a stomach urinary diversion, that's a historic urinary diversion, we hardly ever see that anymore. But there are patients out there that occasionally have had elements of stomach used for their diversion. Those people get low potassium levels, high chloride levels, and they get a metabolic alkalosis. And then, if you see patients that have used jejunum as part of their diversion, again that's uncommon this day and age, but historically we saw them. Those patients get high potassium levels, low chloride levels, low sodium levels, and they get a metabolic acidosis. So, those are just some of the temporary metabolic concerns. But some of the other concerns or problems that you see is how to manage these.
So, something I see frequently is I've had other providers ask me if these diversions are reversible. And for the most part, the answer to that is usually no. When we do these diversions, they're permanent. They're expected to be permanent. And rare situations can we change them. So, that's one thing to know.
And then, the next thing that I see frequently is that people that have an Indiana pouch or a continent catheterizable urinary diversion. I've seen providers or other folks ask us why this is not leaking or if the patient's sick and they're not able to tell us, the thing they need to know is that you have to drain the urine from them, they have to pass a catheter. So if the patient's obtunded, they can't tell you. You need to know that that stoma is usually at the belly button or in the right lower quadrant. You can just pass a regular 16 French Foley catheter or 14 French Foley catheter and then you can blow up the balloon like usual. That's how you drain them.
And then, patients with a neobladder, you're going to catheterize them just like you would catheterize a native bladder. And in men, it's actually a lot easier to catheterize a neobladder because most of the time when we're doing this specifically for cancer reasons, the prostate's removed, so it's a lot easier to catheterize them.
In terms of other complications, one of the main things we see is stenosis or scarring at the junction of the ureters and the diversion and then sometimes where the diversion comes to the skin. That's the most common thing we see, and we have to operate on those sometimes. Urinary diversions, I tell patients all the time, the higher the complexity level, the more likely they are to require a secondary intervention years down the road. So, someone who gets the ileal conduit, oftentimes we're never having to operate on this again. But occasionally people that have a Indiana pouch or a continent cutaneous urinary diversion, or occasionally a neobladder, sometimes we'll have to do a procedure 10 years from after when their initial one is to just kind of revise things or make it so it works a little bit better. Those are broad strokes of some of the issues we see.
Dr Jeffrey Nix: Just to add a little bit to that. So, Dr. Peyton mentioned some of the long-term consequences of these diversions and then some of the direct consequences of the different types, bowel segments we might use. There are some nutritional derangements. So if we use the ileum, which tends to be the best segment of bowel to use in terms of the disturbances from an electrolyte basis, but long-term you can get some B12 deficiencies because that's the most common portion of the bowel to absorb B12. And so, usually, it's two to three years down the road. So, we'll start checking annual B12 levels. I think this is something that's really relevant for primary care providers to focus on is if there's a lot of fatigue in these patients down the road, it could be a simple B12 abnormality, it's very difficult to correct from an oral supplement. Usually, they require shots to bypass the absorption issue. But it also could be, as Dr. Peyton mentioned, a bicarb issue as well, and supplementing maybe a requirement there too. So, getting regular chemical series, chem panels on these patients is helpful in making sure you're able to be proactive about any electrolyte abnormalilty.
I think the other thing I would add is whenever we use the colon or a longer segment of small bowel, one of the things you see at least in the short-term, and hopefully not long-term, can be diarrhea as a consequence of shortening the bowel in those patients. It typically is short lived or is something that can be controlled from a medical standpoint, like using something as easy as loperamide. And this isn't common after removing a short segment, like for a conduit, but if we have to do a more complex segment, especially if we remove the ileocecal valve, they could have diarrhea or even patients sometimes will describe it as bowel urgency, and so that's something for physicians to look out for.
Melanie Cole (Host): Wow. This is so interesting, doctors. Thank you. And I want to give you each a chance for a final thought. Dr. Nix, both of you have shown us truly how experience of the surgeon matters so much for these types of procedures. Can you speak a little bit about your outcomes and how generally is the quality of life of the patient.
Dr Jeffrey Nix: So, we have both done hundreds and thousands of these diversions. And as an example, the complex ones, and Dr. Peyton hit on it, the more complicated things we do, the more things that can go wrong. And so, having the reservoir size-- as an example, let's say we make you this beautiful pouch on the inside, but we make it way too small. Well, it's not going to be functional. If we make it way too big, then you're going to have so many different electrolyte abnormalities because these things continue to resorb. And so, where we put the pouch and how we set up your ability to catheterize can make a huge difference. And this is why this is a team approach. We have a well-trained staff of stoma nurses that will have the patient sit down, have the patient stand up, look at where creases in their skin are, so that if we are going to have them catheterized, that thing has to be perfect in order to be accessible to the patient.
And so, I think to your point, it has to be great craftsmanship on the front end. But the other thing you have to be cognizant of as surgeons is that things will go wrong. And so, we're constantly looking at these patients. Even when we think their risk of cancer recurrence has gone, we still need to follow them to make sure that there's no derangement with their diversions long-term. And so, as Dr. Peyton so astutely mentioned, some of these complications don't come until five or seven or 10 years down the road. They develop a little bit of scar tissue at one of those connections. And if we don't evaluate that proactively, you might end up with renal failure or renal dysfunction. So, I think experience is a huge part of doing these complicated diversions, and I do think that's why physicians see a regionalization of some of these procedures. But to Dr. Peyton's point, when patients go back home to get their followup or their standard care, it's great for providers to at least have some insight into these complex diversions.
Dr Chas Peyton: Yeah. Just to piggyback on that, Dr. Nix is exactly right. This is an ever-changing field. I think when people started doing complex urinary diversion in the '80s, a lot of urologists were very excited about it. And there was a tremendous series about doing all sorts of wild diversions out there. But since then, we've really narrowed things down and learned from years of experience what works, what doesn't work. But one thing that's certain is if you're going to have a complex diversion, you want it done by a surgeon and by a team that's used to doing them. And I think we have some of that experience here at UAB.
By far the easiest is always to do a ileal conduit urinary diversion, and most everyone is trained on how to do that. Far fewer people are trained on how to do more complicated diversions for specific indications like we've been discussing. So, it's really a decision between the patient and the provider. And there's all sorts of nuance here, but we're kind of just scraping the surface here. But it's something that is an option and we talk about it with all our patients that need urinary diversion and share that decision together. And as a provider taking care of one of these patients after the fact, it's important to kind of realize some of these things we've discussed today and have it in the back of your mind when you're seeing these folks.
Melanie Cole (Host): You've both said it so perfectly and made such great points. And I love the use of craftmanship, as Dr. Nix said, and considerations of body types and patient quality of life. So important for that shared decision-making and those kinds of discussions. Dr. Peyton, as we wrap up, anything on the modern surgical field that's changed, any game changers that you'd like to mention for other providers and when you feel it's important that they refer to the incredible expertise at UAB Medicine?
Dr Chas Peyton: Melanie, you just reminded me something. I think that it is important to understand what the options are with every patient and why some would work and why others wouldn't. In terms of modern surgical changes of how the landscape's changed, I kind of described how we've adjusted some of our urinary diversion to those three main types. There used to be a plethora of other ones. But one thing we can do, and Dr. Nix can comment on this now, is we actually have a more minimally invasive approach that's right for some patients to do some of these complex urinary diversions. Not everyone, but some patients, we were able to do that through minimally invasive approach these days, and Jeff can comment on that. It's not right for everyone, but some of these patients can benefit from that as far as new techniques that are out there.
Dr Jeffrey Nix: To Dr. Peyton's point, we want to try to get patients to recover as quickly as possible. Now, the primary part of that is doing the procedure well. And if that requires an open surgery versus a minimally invasive surgery, fine. But some of the advancements we've made is going even from multi-incision robotic or laparoscopic surgeries to single-incision procedures. And so, if you have a patient who has a complex procedure that needs to recover quickly because they then require adjuvant therapy as an example, then we can do that minimally invasive and limit their time off therapy, as an example for cancer patients. Or for newer immunotherapeutics, sometimes we don't even have to bridge them off therapy at all. I use Keytruda as an example simply because we use it a lot in urology now, that infusion is once every three weeks often, and we can just time it and do the procedure without having to take patients off for some of these more advanced cancer procedures we do.
So, in terms of the other advances we've made is we're getting more aggressive with bladder. So if we can preserve the organ, we're going to try to do so. I think some of that is determined also by the age of the patient. And I don't just mean we're going to be more aggressive preserving the bladder and younger patients. Again, I love using patient examples because I think it drives it home to our providers. If you're going to send me or us an 82, 83-year-old patient that has a bladder cancer that may be aggressive, they don't have the social support as an example, or they don't have the physical support or the emotional support to handle a complex procedure or complex chemotherapy. Is there a way we could palliate that patient by doing a minimally invasive approach to try to get them the best option as we can? So, as we're thinking about these diversions, again we're also thinking about longevity and what kind of expectations we can create with those patients, and that is, you mentioned it before, a shared decision-making process.
Melanie Cole (Host): Well, you are both just incredibly expert at this discussion and really fascinating for other providers. I know they will find it as interesting as I did, and I thank you so very much for coming on and really sharing all these nuances of these procedures with 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 uabmedicine.org/physician.
That concludes this episode of UAB MedCast. For more updates on the latest medical advancements, breakthroughs, and research, be sure to follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua276.mp3
- DoctorsCopeland, Carla
- Featured SpeakerCarla Copeland, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6136
- Guest BioCarla Copeland, MD Specialties includes Pulmonology. Learn more about Carla Copeland, MD
Disclosure Information:
Release Date: January 13, 2023
Expiration Date: January 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:
Carla Copeland, MD
Assistant Professor in Pulmonology
Dr. Copeland has no relevant financial relationships with ineligible companies to disclose. There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Idiopathic pulmonary fibrosis is one of the most common interstitial lung diseases and can carry high morbidity and mortality. Early recognition and accurate diagnoses of idiopathic pulmonary fibrosis is pivotal for optimal management and improvement in clinical outcomes.
Welcome to UAB MedCast. I'm Melanie Cole. And joining me is Dr. Carla Copeland. She's a pulmonologist and an assistant professor at UAB Medicine. Dr. Copeland, it's a pleasure to have you with us today. As we get into this topic, can you first start by just telling us about interstitial lung diseases, specifically idiopathic pulmonary fibrosis? Tell us a little bit about how prevalent it is, what you've been seeing in the trends.
Dr Carla Copeland: Yeah. Thank you, Melanie, for having me. As you said, I'm Carla Copeland. And so, interstitial lung diseases in general are a very large category of diseases that affect primarily the lung parenchyma rather than the airways. And then, we kind of further categorize those patients with interstitial lung disease most of the time based on clinical history and then radiographic pattern on imaging. And so, idiopathic pulmonary fibrosis is one of the most common interstitial lung diseases that we encounter clinically. And it is what we consider a scarring lung disease or fibrotic lung disease. And it most commonly occurs in older patients, so typically above age 60, and is more common in males than in female.
And then, some of the risk factors that we see for these patients, we're not entirely sure what causes idiopathic pulmonary fibrosis. There's a lot of research going into that, but it does seem to involve an abnormal response to injury in the lungs that leads to scar production and collagen deposition and proliferation of fibrotic fibroblast in the lungs. And the risk factors for this lung process can include things as simple as smoking and acid reflux, but also can include viral infections and other lung injury as well as family history.
Melanie Cole (Host): Dr. Copeland, why is it sometimes challenging to diagnose? Why is early recognition and accurate diagnosis pivotal for those optimal management? Tell us a little bit about diagnosis and what you're looking for.
Dr Carla Copeland: Certainly, yeah. So, I think what is challenging about this disease is that the symptoms that patients present with are so ubiquitous. So, most of these patients present with shortness of breath and cough, and that can come from so many different places that, really, there needs to be a high index of suspicion for these patients. A lot of times because it is a rare disease, people don't think about it as commonly as I think about things like COPD or asthma or some of these other pulmonary diseases. So, I think really a lot of times in primary care clinics, it's further down the algorithm of what people think about in diagnosis. And so, it sometimes takes some time and then by the time patients get imaging that shows, "Oh, hey, they have lung scarring." Then, it's a lot of times a little bit further into the disease course. And so, I think that's why it's so difficult to diagnose and why we sometimes see delays in recognition.
Now, in terms of kind of the second portion of your question as to how do we diagnose this, so we have clinical guidelines that we go off of and the mainstay of how we diagnose idiopathic pulmonary fibrosis or IPF is with high-resolution computed tomography or CT imaging. And so, this is a specialized CT that uses very thin slices to get very high resolution images. And then, we take a picture when patients take a deep breath in, a picture when they take a deep breath out. And that kind of helps us characterize a lung disease.
And really, the way we look at the images once they're done is we try to categorize them into a pattern that we know is associated most commonly with idiopathic pulmonary fibrosis. And so, there's a CT pattern called usual interstitial pneumonia or UIP. And that pattern is what we look for when we're concerned about a diagnosis of idiopathic pulmonary fibrosis. And really, the defining feature of this on a CT imaging is going to be presence of honeycombing, which is these little cysts that sit in little rows, kind of right under the pleural space, as well as other fibrotic features, which include abnormal dilation of the airways in the fibrotic areas, which we call traction bronchiectasis; and then also reticulations, which are these linear areas of fibrosis that come off of the subpleural space or that area right below the lining of the lung. And so, really that's the pattern we're looking for in diagnosing these patients. And so, really in order to diagnose it, physicians, general pulmonologists, as well as primary care providers have to think about getting that type of image. And sometimes it's a little bit further down the diagnostic process.
Melanie Cole (Host): That's so interesting. And Dr. Copeland, as I understand it, those clinical practice guidelines you mentioned were updated recently. What's different now? What has changed? As you spoke about the imaging and you spoke about that process, what's changed?
Dr Carla Copeland: So, the original guidelines came out in 2018 that helped define this imaging pattern, this usual interstitial pneumonia pattern. And within those guidelines, there was kind of four categories that we tried to put these CTs into, so the commonly associated usual interstitial pneumonia pattern. And then, there's another pattern called probable usual interstitial pneumonia and indeterminate and alternative diagnosis. So, alternative diagnosis means the imaging findings don't really fit with the classic pattern we see in idiopathic pulmonary fibrosis or that UIP pattern.
And so, really the biggest change in terms of the imaging diagnosis was the usual interstitial pneumonia pattern. And then, the probable usual interstitial pneumonia pattern were grouped together similarly in diagnostic algorithm. So really, kind of in general, the diagnostic algorithm is that we look at the imaging. And if it fits the usual interstitial pneumonia pattern, then we make sure no other processes are driving this pattern on imaging. So, sometimes connective tissue diseases can cause this pattern. So, we send serologies or blood tests to look for those. And then, sometimes environmental exposures can lead to this pattern. And so, we ask a very detailed history about things that patients might get exposed to, both occupationally and domestically.
And if we go through that algorithm and don't find any other causes for the usual interstitial pneumonia pattern, then we can give it a confident diagnosis of IPF or idiopathic pulmonary fibrosis. And then, in the prior guidelines, the probable usual interstitial pneumonia pattern, which by definition has some fibrotic features, so reticulation or those linear structures coming off of the subpleural space and traction bronchiectasis or kind of abnormal dilation of the airways. So, if that pattern was present in the last iteration of the guidelines in 2018, it wasn't as diagnostic of IPF. But now, we know that we have more information and more data saying that the probable UIP pattern tends to progress similarly to the UIP pattern and has a pretty high positive predictive value for coming up with the usual interstitial pneumonia pattern on biopsy, which is the gold standard. And so, we've found that seeing this imaging pattern, really, you go down the same diagnostic algorithm now. So, the UIP and probable UIP have the same clinical diagnostic algorithm now. So, I think that's probably the biggest change in terms of diagnosis.
And then, the other big change would be the types of biopsies that we can do. And so, the recommendation is if you have a UIP or probable UIP pattern, you don't really need to biopsy these patients. But some of these patterns that don't look as classic for idiopathic pulmonary fibrosis sometimes may need biopsies. And classically, that's been surgical lung biopsies, which you can imagine are large procedures that require hospital stays. And so, people thought about other ways that we could biopsy these patients that maybe were a little less invasive. And so, there is what is called a transbronchial lung cryobiopsy now, which is essentially a bronchoscopic procedure that takes a section of long via frozen biopsy procedure. And so, the new guidelines have allowed transbronchial cryobiopsy to be an acceptable alternative in the diagnosis of some of those patients who don't fit the classic pattern, and that we're concerned about idiopathic pulmonary fibrosis or potentially other interstitial lung diseases.
So, I think those are the two biggest updates in diagnosis, would be the addition of transbronchial cryobiopsy, as well as grouping probable UIP pattern into the diagnostic algorithm with UIP.
Melanie Cole (Host): Well, thank you for that, and I'm glad that you brought up the detailed history, whether it's environmental exposures, potential causes that really is so helpful to hear for other healthcare providers. As we get ready to wrap up, tell us a little bit about what's next in diagnosis. Once it happens, once you have determined this differential diagnosis, what happens then? A multidisciplinary team gets involved. What next?
Dr Carla Copeland: Yes. Multidisciplinary discussion or what's called MDD for short is considered the gold standard for diagnosing interstitial lung disease. And I think that's because it is such a nuanced and sometimes complicated diagnosis to make. And so, the multidisciplinary discussion team includes pulmonologists, typically those who are experts in the interstitial lung disease sector of pulmonology as well as radiologists, typically thoracically-trained radiologists, and then pathologists, ideally those who are thoracically-trained. And it is an interactive discussion of cases between all of these members, giving both the clinical history, the radiographic pattern. And then, if a biopsy is performed, discussing the biopsy results. And so, that is considered certainly the gold standard and typically how we diagnose some of these more complicated patients. And a lot of times after we have imaging and clinical history, we sit down and talk about these patients. And that is still in the guidelines, the recommendation for diagnosis.
Melanie Cole (Host): And lastly, what would you like other providers to take away from this podcast on diagnosis of interstitial lung disease and specifically idiopathic pulmonary fibrosis and when you feel it's important they refer to the specialists at UAB Medicine?
Dr Carla Copeland: I think really early recognition is key and having a high index of suspicion in these patients. So if you have an older patient, 60 year old above, and they're having shortness of brass and cough, maybe they have some risk factors, think about idiopathic pulmonary fibrosis because we can't diagnose it unless somebody recognizes it or thinks about it along the way. So, I think that's the biggest thing, is just to think about it as you go along. And then, certainly, if you see imaging findings that are concerning for fibrotic changes, please refer to a pulmonary provider. And then, if that pulmonary provider needs to, they can refer to our interstitial lung disease team as well. But certainly, they should see a pulmonologist to determine next best steps. So, I think that would be the biggest takeaway. And then, starting to get used to those patterns on imaging. Certainly for the pulmonologist, they should certainly be able to recognize the usual interstitial pneumonia pattern. Maybe not the primary care providers, but they should at least start to get comfortable with the language we use there.
Melanie Cole (Host): Thank you so much, Dr. Copeland. That was so educational and informative. 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 MedCast. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua271.mp3
- DoctorsAndrikopoulou, Efstathia;Booker, Oscar Julian
- Featured SpeakerEfstathia Andrikopoulou, MD | Oscar Julian Booker, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6146
- Guest BioEfstathia Andrikopoulou, MD is an Assistant Professor.
Learn more about Efstathia Andrikopoulou, MD
Oscar Julian Booker, MD is an Associate Professor.
Learn more about Oscar Julian Booker, MD
Release Date: January 16, 2023
Expiration Date: January 15, 2026
Disclosure Information:
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:
Oscar J. Booker, MD
Associate Professor in Cardiology
Efstathia Andrikopoulou, MD
Assistant Professor in Cardio-Oncology, Cardiology, Women's Cardiovascular Disease
Dr. Booker has the following financial relationships with ineligible companies:
Honorarium – Mpirik*
All relevant financial relationships have been mitigated. Dr. Booker does not intend to discuss the off-label use of a product. Dr. Andrikopoulou nor any other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity.
*As a provider of diagnostic software, the company mentioned in this education unit does not meet the definition of an ineligible entity as set forth in criteria set by ACCME. - TranscriptionMelanie Cole (Host): UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of two five AMA PRA category one credit. To collect credit, please visit uab medicine.org/med cast and complete the episodes post test.
Welcome to UAB Med Cast. I'm Melanie Cole, and joining me in this panel today is Dr. Oscar Julian Booker. He's an associate professor in cardiovascular disease and Dr. Efstathia Adrikopoulou. She is an assistant professor of cardiovascular disease and radiology, and they're both with UAB medicine. They're here to highlight using empiric cardiac intelligence to address health inequities and help identify patients at risk for heart valve disease who might otherwise be overlooked.
Doctors, thank you so much for joining us today and Dr. Adrikopoulou. I'd like to start with you. Data has shown that people from racial or ethnic minority groups are less likely to receive preventive healthcare and across the board various ethnic groups have faced a disproportionate health burden. Can you talk to us a little bit about the unique challenges these communities have faced in terms of healthcare disparities? Why did you choose to study this topic of rural healthcare disparities? Describe the scope of the problem for us.
Dr Efstathia Andrikopoulou: Absolutely. First of all, thank you so much for having us today. It's such a pleasure and an honor to be able to share our experience with trying to transform and innovate the way we deliver care for our patients here at UAB. The problem is vast, sadly, and, I don't think it would need med cast to describe the problem in its entirety, in depth that it deserves. But our passion that has driven all of our efforts so far is how do we make sure all of our patients get high quality, equitable care at UAB.
And we quickly realized that there's a lot of disparities and inequities in the way that we detect disease and the way that we deliver care. Both within our urban center in Birmingham as well as outside of it in our rural areas. There's tons of data out there that, not just for the state of Alabama, but for the US in general, showing that people living in rural areas, face much more struggles in terms of getting access to high quality. And this reflects poorly on their outcomes.
These people live shorter lives and they have worse quality of life, and especially when it comes to patients with cardiovascular disease, patients with heart attacks, heart failure, diabetes, high blood pressure. There's a lot of data showing that patients living outside of urban centers, are doing worse. And this is what we set out to A, understand. using artificial intelligence and B, implement solutions to try to bridge the gaps in healthcare inequity.
Dr Oscar Julian Booker: That's a great point. It's well known that health equity is not just a function of the care that the patients receive within the health system, but is a complicated convergence of a number of issues some are patient-centric and some are health system centric. But if as an institution we can't start the process of ensuring that patients are not slipping through the cracks and those patients never have the opportunity, to receive care similar to those persons who perhaps are not burdened by, certain social determinants of help.
Dr Efstathia Andrikopoulou: Exactly and can I just, quickly add that, the goal is to look at both social determinants of health and as we gain more understanding on those, also, explore our patients and our communities, determinants of culture.
Melanie Cole (Host): And you both make such excellent points about the social determinants of health, and as there's gaps in cardiac care that sometimes can occur because of a patient's clinical or social status as we've just. Discussing Dr. Booker, I'd like you to tell us how you're leveraging the power of natural language processing and artificial intelligence to help address those inequities. How did you partner with third party vendor? UR cardiac intelligence to develop software algorithm that provides clinical decision support to help identify patients at risk for heart valve disease who might otherwise be overlooked?
Dr Oscar Julian Booker: Well, this processed started a few years ago, as we use our informatics resources to try to search through the medical record to find patients who made be slipping through the cracks. But one thing that we realize, and I think it's well known, more broadly. And that is that the majority of healthcare data is in a non-structured format, meaning probably only about 20% of all data is simple and codified in a way that is easy to search using standard search tools. Well, that's a lot of data that we're missing and realize that if we wanted to capture these people, we needed to think differently about how we mine and review the data so that we can better identify patients.
We were looking to partner with a company with an offering who could help us identify patients who have certain ular heart disease. And we were very intrigued by empirics strong utilization, use of natural language processing. Because we felt like. If we work together that we may be able to more deeply understand our patient population, both at a granular level, also in aggregate, to then engage with their providers, engage with the patient. Because we have a better understanding of our patient population as a whole, but also the individual patient.
And empiric has been a fantastic partner, and has shown willingness to work with us to refine and define algorithms to, again, allow us to look at the patients both in aggregate and at a more granular level.
Dr Efstathia Andrikopoulou: This is a great description of, the, very fruitful relationship we've had with empiric so far. And the only thing that I would like to add to that is that again, the goal is to ensure that we deliver high quality, equitable care to all of our patients and to our community. The only thing that we are very, very careful of, and very aware of is, the inherent bias that comes with any type of artificial intelligence system, including natural language processing. And this is something that we always we're very mindful of whenever we build our algorithms, we want them to be as bias free as possible.
Dr Oscar Julian Booker: I think that's a really great point and. I think that it can't be overstated that our algorithms understanding that bias is a very important concern whenever natural language processing and artificial intelligence are at play. one of our goals is to base our recommendations and algorithms as firmly to accepted guidelines as possible, but then also take to account our local clinical experts. As well as institutionally, those services to help us understand if we are imparting or if there are any unintended biases, involved in our data, or at least involved in our search for data. So I think that is an incredibly important point.
Melanie Cole (Host): I think you're both making incredible points and what a fascinating topic and study this is. Dr. Andrikopoulou. Please tell us how your team is in the final stages of developing an algorithm that can help identify cancer patients and cancer survivors who need cardiology services? We're learning more about the link and the cardiovascular implications of cancer and cancer treatments, how can this make it easier for oncologists to easily identify those patients and refer them to a cardiologist? This is an exciting collaboration and has it generated a lot of interest.
Dr Efstathia Andrikopoulou: I'm so glad you're asking me this question, Melanie, because this is something that I'm very passionate about. One of my clinical niche is within the field of cardio-oncology, which is at the intersection of cardiology and oncology, and focuses on caring for people who are either actively, battling cancer or who are cancer survivors. We are now understanding more and more that, cancer in and of itself and cancer therapies, can have an adverse impact on the cardiovascular system.
It's great that people with cancer now live longer and better. However, what we're now, seeing is. This population is developing cardiovascular disease. And they start developing heart failure or heart attacks or inflammation, affecting that heart muscle. And that made us, use our experience with empiric to reach out to our oncology clinicians and colleagues here at UAB and work with them to develop an algorithm that will enable us to identify patients with cancer who are either survivors or undergoing treatment.
And we can identify certain high risk features and flag these patients and notify their oncology provider to let them know that their patients would benefit from seeing one of our cardiology specialists in. And we're at the initial stages of this algorithm. We're hoping we can start implementing it early 2023. because based on the results that we've had so far with empiric treating our patients with Valvular heart disease, we are expecting that we're going to be improving access to care for these patients as well.
Dr Oscar Julian Booker: You know, I think it's important for us to note that there is so much medical knowledge that's out there and it's growing so fast. It's almost impossible or is impossible for an individual to keep up with this exploding, fund of knowledge that we have to have a grasp of to be able to provide the most current high quality up to date care. And then when you couple that with the sheer number of patients that are in our system that we have to keep track of.
There's no way that an individual can provide the highest quality care for all patients at all times. And I think that this is the space where artificial intelligence and natural language processing can help. This is a support tool that the fantastic discussion that you've had about the use of empiric and cardio-oncology is really only the first of many steps. Once we start to realize just how supportive technology can be to our ability to provide high quality healthcare.
Dr Efstathia Andrikopoulou: I totally agree. There's no limit to the lives that we can touch and the people that we can help. It doesn't have to be only people with cardiovascular issues or only people with, cancer who may have, issues with their heart, it could really be anyone.
Melanie Cole (Host): Well, that's exactly as my next question. Dr. Booker is anticipating future partnerships with other UAB medicine areas. You're just discussing this just now, surgery, obstetrics. So you have the opportunity to optimize clinical care both in the aggregate and in individuals. Where do you see this going?
Dr Oscar Julian Booker: That's such a tough question to answer because I can see artificial intelligence and natural language process. Supporting all aspects of clinical care in the future. I think really for us, the question is what is the next project and then what's the project after that? But at some point, I believe that AI and NLP or natural language processing will be fully integrated as a support tool for all aspects of clinical.
Melanie Cole (Host): I have a couple more questions for you doctors and Dr. Andrikopoulou, working with people from different backgrounds or cultures really presents unique opportunities for collaboration as we've been discussing, and creativity. In your personal experience, how have you seen this materialize at UAB Medicine? Speak a little bit about health equity, diversity in inclusion, and how you've seen that work at UAB?
Dr Efstathia Andrikopoulou: I have been very lucky and blessed to always have been part of very diverse themes, both culturally, ethnically, but also from just the background and a cognitive standpoint. And this just goes to show, how fruitful and productive our collaboration has been with empiric. Our team is extremely diverse. It's Dr. Booker, it's myself, and we are the only two physicians that are part of the core group of us working on those algorithms. The rest of the group is non-clinicians, data scientists, data engineers, biostatisticians researchers, who are very, racially, ethnically, diverse, gender diverse, and culturally diverse.
And I think this is to a big extent, one of the reasons why our partnership with Empiric has been so successful is because we are also very different and we all bring a different, viewpoint to the table, a different angle to the table. And this is important because like we've been saying this entire time, our focus is to be able to understand, connect, and help all of our patients. Every single one of our patients is going to be different. Their background is going to be different, their identity is going to be different. And the only way for us to be able to understand our communities and help our communities is if we make sure that our own group reflects our community. Otherwise, we are not going to be able to understand and help them.
Dr Oscar Julian Booker: You know, I think it's, very interesting you point out how culturally, diverse the primary group is that's working on this. and you pointed out all the different ways that our group, is diverse. And I think that it's very interesting, that when you have so many stakeholders who are working on such projects, many of which who are from historically disenfranchised groups, I think there is a higher level of commitment amongst those people to ensure that those gaps are closed. In addition to the different perspective that that diversity provides, the commitment of being from one of those historically disenfranchised groups, I think lights a little bit more of a fire to ensure that all patients receive equitable care.
Dr Efstathia Andrikopoulou: I couldn't agree more. there's me and I'm from Greece. Then there's you, there's Miguel, there's Chris, there's Lauren. So many of us and every single one of us is very different.
Melanie Cole (Host): What a great discussion This is Dr. Booker. I'd like to just give you the last word, as physicians, as you're just saying and speaking about your team, physicians play this critical role in addressing these public health concerns. I'd like you to speak just for a second about your recommendations for other physicians around the country to consider when they're treating underserved in minority patients, reducing those barriers to quality healthcare through patient navigation, through the multidisciplinary approach, and then wrap up the algorithm with empiric.
Dr Oscar Julian Booker: I think if I had one message to share to other providers that would be all of us got into healthcare to provide the best care that we can for our patients, but we are not infallible and there is no shame and no harm to getting help. And as we discussed earlier, there's so much to know and there's so many patients to care for that support will allow us to fulfill that goal and that obligation that we set forth in the beginning. And that is help patients and provide the best care that we can. And this is where technology is able to support us because the computer doesn't get tired, once we teach the computer how to read and how to understand, it's able to do those things in a very timely, very thorough fashion.
And it's really just there to allow us to be better providers. It's not there to replace us as providers. And I don't believe that computers can ever truly replace us as providers, but they can support us. And I think in the future there's really going to be the difference between those providers who don't use AI to support them and the level of care that they can provide. And then those providers who do recognize that technology can make us better at what we do. And we hope to, and UAB has been very supportive. And has shown itself to be an institution that recognizes the future is coming, and our ultimate goal is providing the best care that we can.
But to your question about the algorithms, the algorithms are the heart of what we do. Being able to search and identify those patients who meet certain criteria is at the heart of the provision of care that we're discussing. But we have to be mindful and we have to be careful not to introduce biases in our search and in our recommendations. And so that multidisciplinary group, either a, culture, gender, diversity or a diversity in clinical expertise to ensure that my limited scope does not inadvertently lead me down a path where some group is receiving less optimal care than another group.
This is why we have to work together and the nature of the work is expanding beyond just the traditional healthcare field, and we require all these other support teams, as Efy has pointed out, as far as data scientists and data architects and et cetera, ecetera, ecetera. the nature of this multidisciplinary clinical care team is larger and different than perhaps what it was in the past, but they all have those same goals that we do and that is providing the best care that we.
Dr Efstathia Andrikopoulou: I a hundred percent agree with everything that, Dr. Booker just mentioned. And the only last thing I'd like to point out is that obviously clinical care and providing high quality, care to everyone is in the heart of all that we do. And this is our passion and this is what drives us, and this is why we're developing and implementing those algorithms. At the same time, we're realizing that the next frontier is going to be ensuring that the data that we use, is of high quality and ensuring that there's high levels of data privacy, data security.
And to make sure and reassure all of our patients and our community and our healthcare allies and stakeholders within the UAB Health system and outside of it that, we take all of the precautions and some more to ensure high levels of data privacy and data security. And our next frontier would be to make sure that we built a structure of data governance and data oversight that will always guarantee a hundred percent rates of secure data.
Melanie Cole (Host): What an excellent thought leader conversation This was great guests, both of you. Thank you so much for joining us and speaking about this very important topic and telling us all about using empiric cardiac intelligence to address those health inequities. Thank you again, and for more information or to refer a patient, you can call the MIST line at one 800 UAB-MIST, or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole. Thanks so much for joining us today. - HostsMelanie Cole, MS, Exercise Physiologist | Medical Journalist
Additional Info
- Audio Fileuab/ua278.mp3
- DoctorsMabry, Scott
- Featured SpeakerScott Mabry, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6126
- Guest BioScott Mabry, MD is an Orthopedic Surgeon.
Learn more about Scott Mabry, MD
Release Date: December 27, 2022
Expiration Date: December 26, 2025
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 in Orthopedic Surgery
Dr. Mabry has no relevant financial relationships with ineligible companies 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): As physicians are able to make great strides and advances in surgical technique, anesthesia, and pain control, it's now possible that total joint replacement can be done as an outpatient.
Welcome to UAB MedCast. I'm Melanie Cole. And joining me today is Dr. Scott Mabry. He's an orthopedic surgeon at UAB Medicine. Dr. Mabry, it's a pleasure to have you join us. As you're new to UAB, before we talk about outpatient total joint replacement, tell us a little bit about yourself and how you came to UAB Medicine.
Dr Scott Mabry: Well, thanks for having me, Melanie. It is very exciting to be back at UAB. I was actually here as a resident physician for five years before I went off to St. Louis last year for my hip and knee replacement fellowship at Washington University. I'm initially from Tennessee, so from the south, and definitely wanted to come back to the southeast. And UAB was just such a great opportunity, great experience. And I think the things that we're doing from a joint replacement standpoint are at the forefront of where I'd want to be in my career. So, I was definitely happy to join back on.
Melanie Cole (Host): UAB is at the forefront of many types of medicine careers, so thank you for telling us that. Now, tell us a little bit about the evolution of total joint replacement. What's different now? Why are we able to do outpatient total joint replacement when this used to be a pretty big surgery? But now, it's being done in so many different ways. Can you tell us a little bit about it?
Dr Scott Mabry: Absolutely. And that's a great point you bring up. Just that there has been such evolution in joint replacement over time. It's allowed us to have these same-day surgeries and the advances in our technologies and our protocols. The basics of a joint replacement really hasn't changed over the years. It's still where you take out arthritis and you replace the ends of the bone with metal with plastic between. That's the forefront of joint replacement. That's where it's always been.
The real change has been with the materials that we use. These materials whereas they used to last five, 10 years, they're now integrating into the bone better. Their plastics are wearing out at a much slower rate. So, these are now lasting 25, 30 years and 80-90% of them are surviving that long. So from that standpoint, we aren't getting very good outcomes with our joint replacements. From a same-day joint perspective, the real change has been with our postoperative pain management protocols, as well as some of our physical therapy protocols. Our anesthesia colleagues have done a great job of instrumenting spinal anesthetic, which are epidurals, the same kind of epidurals that you would have during childbirth, where the legs are numbed up. It's short-acting. So by the time we're finished with the joint replacement, the legs are warming up, and they're able to start moving again. So, physical therapy can then start immediately after surgery.
We also do pain blocks for the knees and local infiltrate of pain medications in the hips, so that by the time the patients are waking up from these surgeries, they're not having the same kind of pain they had years ago where they would lay in bed for days on a pain pump before finally getting out of bed with physical therapy. So, these two advancements have really gone a long way into getting these patents up immediately after surgery comfortably, and then getting them home the same day.
Melanie Cole (Host): Great points that you brought up, and I'd like to expand for a second on that as we look at this emerging model. Who do you think that it's driven by? Do you feel this is both patients, obviously physicians, because you are looking at better pain control management, physical therapy and, you know, stewardship for opioids, but also the insurance companies to reduce their costs? Is this better for the physicians? Speak about the advantages a little bit.
Dr Scott Mabry: Sure. And I think this is beneficial to all three of those different categories. I think ultimately it has to be driven by the patient. The patients, especially after COVID, really didn't want to spend any more time in hospitals than they had to. With the pandemic and the risk of being in the hospital, a lot of patients just wanted to come in for their treatment and get home as quickly as possible. And from a joint replacement standpoint, we did note that spending more time in the hospital after your surgery didn't really provide much benefit and, honestly, could have increased the infection risk and some other complications from being stuck in a bed for three to four days after surgery. So, I think ultimately it's the patient's comfort level and the patient's benefit that we're striving for.
From a surgeon perspective, like I mentioned, the joint replacement surgery itself isn't any different for us if we did it for a same-day patient or for someone that's going home. But I do think it's beneficial for the surgeons because then we get to see our patients do better with the lower complication profile if they're able to go home that same day. And then, just kind of like other surgeries that we've had in orthopedics in the past as it becomes more mainstream, as our protocols improve and patients are able to go home same day or next day at a safer and higher rate, then you'll see that insurance companies will start to follow suit and kind of expect these surgeries to become a same-day type of surgery. And we've even seen that in the last few years as the hip and knee replacements have been taken off of the inpatient-only list from an insurance carrier perspective.
Melanie Cole (Host): Well then, speak about patient selection. Tell us the criteria someone would have to meet. And while you're doing that, speak about the strategies that you employ to optimize their recovery after an outpatient total joint replacement. Speak about patient selection, why that's such an important aspect for better outcomes.
Dr Scott Mabry: Absolutely. The patient selection is the most important part of planning a same-day surgery. The number one thing is going to be patient motivation and a patient support system. If a patient doesn't meet those two requirements, have someone at home that can help them out in that first week or two, doing some minor things around the house or even just getting up and down from the bed to the bathroom in the middle of the night or the patient's not motivated to go home that same day. And then, it's very hard to push this surgery or this procedure on someone. That's when you start to see some of the complications, some of the returns of the hospitals, because maybe the patient wasn't selected properly. Then, they have a higher risk of coming back to the hospital for some reason or another.
From a medical standpoint, there really are three things that would prevent patients from being a good candidate for an outpatient or same-day surgery joint replacement. Number one, it would be something like lung disease, COPD, something that where the patient requires multiple medications, has a potential risk of anesthesia, maybe even is on home oxygen. Those patients should probably be monitored in the hospital at least for a day or two. Same is said for some of the patients that have had previous heart issues, heart disease, heart attacks in the past, possibly they've had stents or pacemakers put in. Those are the patients that we really want to try to push in and out of the hospital. We want them to take their time, make sure nothing around that perioperative area is going wrong with their heart.
And then thirdly, it would be patients that have had a previous blood clot or deep vein thrombosis, pulmonary embolism, something that required them to be on higher anticoagulant doses. That risk of bleeding after the time of surgery is probably a little higher than we'd want to risk sending someone out immediately postoperatively.
So, the people that benefit the most from these protocols are the patients that are highly motivated with a good support system at home. Those are the patients that are adequate candidates for the same-day surgeries for joint replacement. They're the ones that are less likely to have to come back into the hospital for a social situation for a medical problem that arises. And at UAB, we are actually in the process of implementing a new perioperative optimization.
In addition to the standard anesthesia pre-op clinic where the anesthesiologist would evaluate the patients and clear them, we're actually looking at a variety of patient factors in these clinics from diabetes management, weight loss management, heart, lung, chronic medical condition management. And from here, we can actually gauge, A, if patients are candidates, but B, if patients have the motivation or have the desire to be outpatient surgery candidates, in addition to seeing them in our own clinic and working them up that way. So, I think this is just another step to ensure that we are adequately selecting correct patients for same-day joints, and that will only help with our successes here at UAB.
Melanie Cole (Host): It certainly will. That's excellent. So, I'd like you to share some considerations with other providers to help achieve their better outcomes. Now, you just mentioned that postop clinic, obviously multidisciplinary, many providers involved. But what are some of the things that you would like other providers that are thinking about doing these outpatient total joint replacements? Equipment, staff? Can you give any tips, tricks, things that you have found that have worked so well with these motivated patients that are selected for this type of procedure?
Dr Scott Mabry: Yes. I think that the first and most important thing is that conversation with the patient. You really want to make sure that you're on the same page, that your goals of having them go home the same day align with their goals. So, that is probably number one the most important conversation to have.
From a protocol and provider perspective, I think it's that multidisciplinary approach between us, the preoperative clinic, the anesthesiologist. That way, we can make sure that we're getting these patients selected correctly. And then, on the day of surgery, we're also doing our protocols to help them move along that day. And that includes scheduling these patients early in the day, having them get the preoperative spinal anesthetic, the pain block, the infiltrates of local anesthetic during surgery. And then, also speaking with our therapists, so after surgery, these patients are prioritized getting their therapy as soon as that spinal anesthetic wears off so that they can get multiple rounds of physical therapy before mid-afternoon when they would be going home. That and then the perioperative nursing staff, who also is vital in this process where they're able to help the patients as they may need a little bit more pain control or help coordinate with the therapist to get them up and down, out of bed as well.
Melanie Cole (Host): Such great points. As we wrap up, Dr. Mabry, tell other physicians what you'd like them to know about outpatient total joint replacement, what you're doing there at UAB Medicine. Tell us about your success rates and your outcomes. Let them know why it's so important to refer to the experts at UAB Medicine.
Dr Scott Mabry: Yeah, I think if you do have someone that's interested in a same-day total joint replacement or joint replacement in general, they should probably be evaluated by a facility such as UAB and UAB Highlands where we are doing these procedures. Pretty much all of our partial knees go home the same day. And a lot of variety of our total knees and total hips go home the same day. I believe our rate is somewhere around 30%. We could definitely expand that as patient interest increase as well.
From that standpoint though, I think that just getting the patients in to talk to us and have that conversation. It's a frank conversation and some people are interested, some aren't. But either way, we're happy to evaluate them, anyone with arthritis. And here at UAB, we manage our arthritis operatively, non-operatively and in concert with some of our non-operative physicians as well. So, we're always happy and grateful for any referrals that come in from the UAB departments in general or from the community at large.
Melanie Cole (Host): Thank you so much, Dr. Mabry. You are a great guest. Please come and join us again to discuss anything else that you would like to discuss in the orthopedic world at UAB Medicine. And for more information about the outpatient total joint replacement 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. That concludes this episode of UAB MedCast. I'm Melanie Cole. - HostsMelanie Cole, MS, Exercise Physiologist | Medical Journalist
Additional Info
- Audio Fileuab/ua254.mp3
- DoctorsSolomon, George
- Featured SpeakerGeorge Solomon, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6096
- Guest BioDr. Solomon's clinical interest centers on the care of CF and non-CF bronchiectasis patients and the pursuit of continued inpatient medicine care of these patients in the acute care setting.
Learn more about George Solomon, MD
Release Date: December 12, 2022
Expiration Date: December 11, 2025
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:
George Solomon, MD
Associate Professor in Pulmonology & Critical Care Medicine
Dr. Solomon has disclosed the following financial relationships with ineligible companies:
Grants/Research Support/Grants Pending - Vertex, CFF, 4DMT, Electromed, Insmed
Consulting Fee - Electromed
Honorarium - Insmed
Payment for Development of Educational Presentations - Spark Healthcare
Payment for Lectures, Including Service on Speakers Bureaus - Insmed
All relevant financial relationships have been mitigated. Dr. Solomon 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. - 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): People with primary ciliary dyskinesia may have persistent or recurrent infections, which can significantly disrupt their quality of life and sometimes lead to permanent damage. And life-threatening complications.
Welcome to UAB MedCast. I'm Melanie Cole. Joining me is Dr. George Solomon, Assistant Professor in the Division of Pulmonary Allergy and Critical Care Medicine at UAB Medicine. Dr. Solomon, welcome back. You're always such a good guest. So we're talking today about primary ciliary dyskinesia. What had been the thought previously regarding PCD? We did a previous podcast on this topic. What has changed? Do you have any exciting updates to share?
Dr George Solomon: Yes, we do. Quite a few, Melanie. I think the field is evolving. It's not evolving by leaps and bounds, but evolving in a slow pace with a lot of improved understanding of the illness in both the clinical presentation of the illness, but also some of the science behind it. So we'll talk about that a good bit today and I'll highlight a couple of things that I want to discuss as themes regarding the progress of the condition overall, the scientific explanation.
So the first of those is, and just to remind our viewers from the previous podcast, this condition is a genetic condition much like cystic fibrosis, which some may be more familiar with. However, unlike cystic fibrosis, which is a monogenetic disease, which means that one mutation in one gene in our genome is affected causing the illness. This condition is caused by mutations in at least 50 known genes. Now, when we last spoke, that list of known genes that could be affected causing primary ciliary dyskinesia was probably in the low 30s. We now know there's evidence of at least 50 genes involved with the structure and function and regulation of the cilia, which is our hair-like projection, which helps to move mucus in several of our organ systems, but primarily in the sinopulmonary tract, so the sinuses, upper airways and lower airways in the lungs. At least 50 genes are known to have mutations, which can cause this primary ciliary dyskinesia. And that brings up an automatic question. When you have 50 different genes, which can cause a similar syndrome, is the effect in each of those genes exactly the same? In other words, will patients with, for instance, a mutation in a structural protein, the most common of which as an example is the gene called the DNAH5 mutation or gene, will effects of that gene cause the same type of condition as effects in a gene that causes regulation or other functions of the cilia itself?
And the answer we're learning more and more in the last few years, since we last spoke of this topic is no, that will not cause the same type of condition. Mutations in many of these genes across a spectrum can cause a similar what we call clinical phenotype, which you outlined earlier the highlights of it. One is significant sinus and pulmonary infections, which can progress throughout the lifetime, really due to impairment of the clearance of mucus. But the severity of that phenotype, in other words, how much that happens, to what extent it causes damage in the airways and to what extent other organs in the body are affected, which include the kidneys, reproductive tract, to some extent the heart and the abdominal organs, the extent of which that phenotype manifests is due to the severity of the gene implicated and also the severity of the mutation type. And we weren't so sure about that a few years ago, but now we know that likely that is the case. And that's because of some new publications which have been released. One came from large database of patients in Europe, which has been working on this for quite some time. They have cataloged thousands of patients in Europe with primary ciliary dyskinesia, and have done some analysis looking at what is the severity of phenotype based on lung function, based on severity of infections, based on age at which the patient develops complications, an important of one those is the development of bronchiectasis, which means that the patient has permanent airway damage due to the primary ciliary dyskinesia. And that appears to coassort with different mutations in different genes, which are implicated in the condition.
Now, I won't have time to go into more details on that today, but suffice it to say that that tells us that it's important to understand the genotype-phenotype correlation. And what that means is understanding the severity of the genotype, which is the mutation, and in what gene the patient has and how that links to how their phenotype may be, because that tells us a bunch of things. One is it helps us with prognosis, how this condition may play out for each individual patient. The second is it tells us a lot about future treatment. And the reason I tell that is because this is the other major development that we're seeing, is the field of pulmonary medicine is beginning to get more sophisticated with the development of genetic-based therapies.
Genetic-based therapies really tell us a way to correct the gene defect rather than having to treat a symptom of the gene defect. So an example of a symptomatic treatment for a genetic condition, like primary ciliary dyskinesia, might be take a drug that makes the mucus easier to move out. And while that's a very viable strategy, and we'll talk a bit more in a few moments about strategies that are being looked at. But for in the meantime, if you can correct the gene itself, that's correcting the basic problem with the condition, so understanding these types of genetic correlations we've been talking about for the last few minutes is a way to both prioritize and better understand the way that the gene has to be corrected, to know how we're going to improve the condition.
Melanie Cole (Host): That's fascinating. And as you're telling us about these updates and these changes, please do go into those strategies and how this research and these updates are translating to better patient care.
Dr George Solomon: Right. So first strategy that we should talk about is the symptomatic strategy I mentioned earlier. So we're not going to be able to solve delivery and/or repair of every gene defect in primary ciliary dyskinesia quickly, that's going to take years, which means that patients need treatments that can help to stabilize their illness and treat their symptoms in the meantime. So there are actually a lot of efforts being made in the PCD community to look at that.
The first of those is we're looking at, and this may sound like a simple thing, but it's actually not, we are looking as a group, the US Primary Ciliary Dyskinesia Foundation, as well as the European Consortium of Primary Ciliary Dyskinesia Centers, both are working in parallel to develop optimized guidelines for therapy. There has been a guideline document released a few years ago, but it made very few recommendations. So that will need update in the coming years. In addition, we need to develop clinical research strategies for this condition. So development of both a patient database that patients can be identified as potential research subjects with a well-established diagnosis and also better standardized care for these patients will help us to prime that group for research efforts.
One such research effort, which is going actually through a phase III study, is a drug that actually treats the ion channel called the epithelial sodium channel, which is oftentimes abbreviated as ENaC. ENaC has been implicated as having defective function or overly effective function, I should say, in the conditions like primary ciliary dyskinesia and also cystic fibrosis and other conditions like that. And when this protein malfunctions it results in a change in a mucus that makes it more difficult for it to relieve itself and be removed from the lungs. So if the mucus can't remove itself from the lungs, it's going to impair the clearance of infections and irritants that come in from our environment, those things are what damage the lungs really and drive the chronic inflammation in the lungs, which causes many of the problems that people with conditions like PCD have. And so we can hopefully help to overcome some of that limitation by offering treatments, which move that forward. And so one such study is moving forward to what we call a phase III, which is a study that would help with labeling or seeking FDA approval for the drug. And this is a drug which actually inhibits, which means it blocks the function of that ENaC channel. And by doing that, it helps to make the mucus more effectively cleared out of the lungs and we think will improve lung function, reduce exacerbations or flares of the condition oftentimes due to infections and will help with overall symptoms in the lungs and sinuses with these patients. So we're anxiously anticipating the start of that study. There was a successful pre-phase III study called a phase II study conducted recently. That study did help us to understand that this drug was very safe and had early trends towards efficacy in the domains we just outlined, including the lung function and reduction of pulmonary exacerbations or pulmonary infections. So we're eagerly anticipating the start of that study. And our site will be enrolling patients here along with sites across the US and these consortia we just talk about.
In addition, since we last talked, there has been a couple of larger studies conducted in Europe, which showed that antibiotics, especially in the class of antibiotics called macrolide antibiotics and those that are less familiar with those may recognize like azithromycin, for instance, as one of those antibiotics, has been shown to help modulate the immune system, especially in patients that have pseudomonas infection, which is a chronic infection that many patients with PCD will acquire over time. And so those patients may benefit from taking this therapy on a recurrent basis to help modulate their immune system and modulate the way the body responds to infections and help to prevent decline of lung function and worsening pulmonary disease. Those we would call symptomatic treatments, which have moved us forward.
In addition, we're moving forward with, as I mentioned, standardization of care for these patients. And that allows us to have a set of patients who are treated similarly and with the best expert opinion on care at this point. So when they come into a clinical trial, we can know that the drug that's being given to them is really affecting them and making a positive endpoint on them, if positive, rather than it being subtle tweaks in their other management of their care. So this helps us to standardize the patients in our trials and also helps them to get the best and most accurate answer on what might be effective for them in the future.
Now, as I outlined earlier, the next thing we're trying to do is really understand the science of mucus, understand the science of the cilia genes and how they function, so we can really move towards correcting the basic defect in primary ciliary dyskinesia, which really comes down to that defect in the genes, which cause defects in the cilia function or structure or all the above.
And as a result, we think that in coming years, we will be able to advance therapies that either deliver, repair or edit and repair the gene defect underlying many of the especially common causes of primary ciliary dyskinesia, and that's really work that's come out of these studies we've been outlining during this discussion.
Melanie Cole (Host): Wow. That's so much information, Dr. Solomon. As we wrap up and you're speaking about ongoing care for the families and patients, you're speaking to other providers, now what would you like them to know about those clinical trials, the research being done and the communication with the referring physicians when it comes to PCD?
Dr George Solomon: That's a great question, Melanie. I think that the key here is this is a rare condition, which is challenging to care for. It's challenging to care for the patients because they have complex illness, which affects almost every domain of their life. So I think the key here is please refer those patients to our centers so we can assure accurate diagnosis and provide them access via our clinical research network to these trials that this patient so choose to be involved with them, so they can optimize their care early and most effectively as new therapies come about.
Melanie Cole (Host): Well, that's so interesting. And as those new therapies come about, I certainly hope that you will come back and keep us updated because you are just a wealth of information. And thank you again for joining us.
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/ua269.mp3
- DoctorsMaddox, William
- Featured SpeakerWilliam Maddox, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6105
- Guest BioDr. Maddox is a clinical cardiac electrophysiologist committed to delivering exceptional healthcare through dedication to patients and their families. He strives to provide compassionate care, through personalized education and open communication, wishing to inspire hope and well-being in all his patients.
Learn more about William Maddox, MD
Release Date: December 5, 2022
Expiration Date: December 4, 2025
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:
William Maddox, MD
Assistant Professor in Cardiology & Electrophysiology
Dr. Maddox 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. And joining me is Dr. William Maddox. He's a cardiac electrophysiologist and an associate professor at UAB Medicine. He's here to highlight current management of atrial fibril. Dr. Maddox. Welcome back. Thank you so much for being with us today. This is such a huge problem. We're learning so much more and it's really, an exciting time in this world of AFib. Can you start by telling us about the prevalence, what you've been seeing in the trends and how treatment of symptomatic atrial fibrillation with rhythm control strategies can really improve the quality of life? And in several patient populations improves hospital rates, mortality, really all of it?
Dr William Maddox: Thank you Melanie, for having me. This is always fun to be on the show and be able to talk about some of the things that we get to do here at UAB. In terms of the prevalence of atrial fibrillation, this is the most common sustained arrhythmia that we see. Today in clinic I have 42 patients in clinic and probably 30 of them have atrial fibrillation as our population in the United States ages, it is going to become more prevalent, certainly with hypertension, diabetes and coronary disease, obesity being more prevalent in our populations, we're gonna see more and more atrial fibrillation.
Symptomatic atrial fibrillation is really an epidemic in the United States. And when I think about taking care of atrial fibrillation, I really think about it as two separate treatment modalities. One is prevention of stroke and the other one is prevention of symptoms. The prevention of symptoms is really a silo into itself. And we can take care of that either with rate control or with rhythm control and certainly with our advances in both medicines and technology over the last 25 years, rhythm control has become a mainstay in first line treatment for patients with symptomatic atrial fibrillation.
Melanie Cole (Host): Wow. That's quite a prevalent condition and I'm glad you mentioned risk of stroke. So I'd like you to speak a little bit about anything new, any game changers in diagnosis. And I mean, obviously since COVID managing diagnosis screening, all of that changed a bit. Can you tell us how technologies played a huge role as far as screening, diagnosing and monitoring AFib?
Dr William Maddox: Sure for many years, we've had ambulatory monitors that patients could wear when they're at home to surveil for arrhythmias when they have palpitations, but with the new mobile telemetry and the new wearables that patients have such as the Apple watch or many of the other, cardio has one, there's several manufacturers. Patients are actually able to monitor themselves at home. And there's many times when I'll have patients in clinic that are referred to me from either cardiologists or primary care physicians with their own strips of atrial fibrillation.
Or what they believe to be atrial fibrillation, either printed out or sent in an email or a PDF. And this allow for patients to be able to surveil for themselves.. And if they do get something on the monitor that looks like it might be atrial fibrillation, they can get that to their primary care physician or cardiologist fairly quickly and easily. And it's allowing us to be able to diagnose atrial fibrillation earlier in the disease process.
Melanie Cole (Host): Certainly has. And so, we hear a lot about the antirrhythmic medications that are available and it many times as a first line of treatment for these patients, but then there's always the side effects, drug interactions, adverse interactions that make the use of them challenging. So before we move on to some of the interventional therapies that you might offer, speak a little bit about what's going on in the medication intervention world right now. Dr. Maddox, what's new, what's changing, what have we found out that we didn't know, maybe a few years ago?
Dr William Maddox: Medications for rhythm control for atrial fibrillation really haven't changed that much in the last 10 to 15 years, we have our same mainstays of medication, including the 1C anti rhythmic, such as Flaco din Perone that we can use in patients with structurally normal hearts. We also have sodalol which is a class three enter would make a potassium channel blocker as well as dofetilide. And then Moltech is a deiodinated form of amiodarone that has some efficacy, although it is not as effective as amiodarone itself. And of course the 800 pound gorilla in the ring would be Amiodarone itself, which has been around for quite some time.
All these drugs have reasonable effectiveness, but they also have a significant number of side effects. And you really have to look at the patient's comorbidities to decide what medication might be best. Some patients can do quite well on some of these medications. In my first line, if someone had the structurally normal heart would be to use a 1C anti rhythmic, such as flacanine or [inaudible]. These do have side effects of fatigue and sometimes some slight vision changes and some patients just don't tolerate it well.
The other medications certainly have bradycardia as a complication, and then there's significant medication interactions with all of them. And so you really have to be careful with what other concomitant medications the patient might be on. So, it is a first line therapy for symptomatic atrial fibrillation for perisismal symptomatic atrial fibrillation, interventional options are becoming more and more first line therapy.
Melanie Cole (Host): Well, then let's discuss some of those because as we are saying, not everybody wants to be taking. Medications and for the rest of their life. And there's many interventions that have come on the scene. So why don't you start with catheter ablation? That's becoming increasingly common with a relatively high success rate and low complication rates. Speak a little bit about that and we'll get into as many as we have time for.
Dr William Maddox: Catheter ablation has been around for 35 years or so in various iterations. And catheter ablation for atrial fibrillation with a view towards targeting pulmonary vein isolation, which means that we create lines of scar around the pulmonary veins to isolate electrically, the pulmonary veins from the rest of the atrial tissue. That has been around for approximately 22, 23 years. Our understanding of the triggers for atrial fibrillation first came out in 99 with paper out of Bordeaux.
And it showed that 94 to 95% of the triggers for atrial fibrillation come from the pulmonary veins. And that has been the driver for the main state of our treatment for atrial fibrillation. Over the years, that ability to be able to target these areas has become safer, more effective and more efficient to the point now that catheter ablation for atrial fibrillation either with cryo ablation using a balloon technology that we can freeze the tissue around the interim of the vein or with radio frequency ablation around the pulmonary veins.
Usually by ablating a line around the Ipsa lateral pulmonary veins, both on the left and the right has become something that we can do in, an hour to two hours of procedural time. Now that's still a, full day procedure for the patient. But about an hour to two of procedural time with a low complication rate, I quote patients a complication rate of about one to 2% with that most commonly being hematoma or bleeding, bruising at the access site in the right common femoral vein.
There are very rare complications, including pericardial effusion, necessitating intervention, pulmonary vein stenosis, stroke of esophageal fistula. Those are dreaded complications, but fortunately are very rare somewhere in the order of one to 500 to one in 4,000.
Melanie Cole (Host): So interesting. Now tell us a little bit about the Watchmen, because that's another one that you know, many providers are talking about. How are you using that at UAB Medicine?
Dr William Maddox: When I talked initially about the different treatment modalities for atrial fibrillation, this really moves into the silo of stroke prevention. And stroke prevention is so important in atrial fibrillation because one in five strokes in the United States are associated with atrial fibrillation. And patients with atrial fibrillation, one of the main stage of treatment is we place them on an oral anticoagulant medication such as warfarin or the novel anticoagulants. Like apixaban tabigotran, ,or rivaroxaban. However many patients can't tolerate blood thinners.
They either have bleeding or have frequent falls or the need for other medications that might interact with the blood thinners. When that's the case, then another treatment modality that we have would be to occlude the left atrial appendage, the left atrial appendage is where thrombus formation occurs. That is the night for stroke. And so currently FDA approved is the Watchman device, the Watchman flex device, which is a night and all basket with Fabric covering that is actually implanted into the ostium of the left atrial appendage.
And over time, the body will build a layer of endothelial cells over the device and close off the appendage. There's also a second device called the Amulet device. That is by habit, that essentially does the same thing with a little bit different technology and, and has the ability to give us more variety in the left atrial appendage that we can treat. There are certainly size limitations to what we can treat and the appendage can't be too small or too large, and there has to be enough depth within the appendage for us to be able to deploy the device.
But for the most part, especially with both of these tools, we can close the vast majority of appendages that are out there. In my last 200 procedures, I think I've had two left atrial appendages that I just couldn't get closed with our current technologies.
Melanie Cole (Host): So your outcomes for these are really great. And so before we wrap up, I'd like you to speak how you're using these procedures. Are you using them along with other adjuvant therapies or standalone? And how UAB Medicine has been involved in clinical trials related to these closure devices, atrial fibrillation, stroke, wrist, anything you'd like other providers to know about?
Dr William Maddox: We have a comprehensive program here for the treatment of atrial fibrillation that includes both stroke prevention and prevention of symptoms for atrial fibrillation and in select populations. As I think you alluded to at the beginning, such as patients with heart failure in atrial fibrillation, there has been mortality benefits for rhythm control strategies. For years, we have been working with industry as well as with government sponsored trials, to look at the most novel technologies that are out there and try to continue to make our procedures safer, more effective and more efficient.
And we have several trials going on right now, looking at the use of left atrial appendage occlusion in patients with lower stroke risk and not really the traditional indications for left atrial appendage occlusion. That includes the Champion AF trial, where if you are on an novel anticoagulant and would like to be considered for left atrial appendage occlusion, we're comparing that to novel anticoagulation with the hopes that it will actually show that it improves outcomes and increases safety.
In regard to studies with catheter ablation, one of the most exciting things that's coming down the forefront is that our mainstay of treatment here is either using radio frequency, which creates heat or using cryoablation, which, freezes the tissue. But we always worry about damage to contiguous surrounding tissues when we do that. And a new treatment modality is something called pulse field ablation, which is actually a DC current that is pushed through electrodes within the heart that allows for ablation of local tissue with very little to no risk of damage to contiguous tissue that's farther away.
We hope that in time will show that this is as effective as our current ablation strategies, but it's much safer because we don't have to worry about the possible damage to the phrenic nerve or the esophagus or surrounding lung tissue. It's an exciting time in the field.
Melanie Cole (Host): It certainly is. And thank you so much, Dr. Maddox, what a great guest. You are such an informative podcast, too. 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 you can always visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast and for updates on the latest medical advancements, just like you heard here today, breakthroughs and research. Please follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua273.mp3
- DoctorsIlyas, Adeel
- Featured SpeakerAdeel Ilyas, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6111
- Guest BioIlyas, Adeel, M.D., developed a passion for neurosurgery in middle school nearly halfway around the world. He took advantage of many opportunities which eventually led him to UAB. During his free time, he enjoys playing various sports, hiking, coding and reading.
Learn more about Adeel Ilyas, MD
Release Date: December 12, 2022
Expiration Date: December 11, 2025
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:
Adeel Ilyas, MD
Resident in Neurosurgery
Dr. Ilyas has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Researchers at the University of Alabama at Birmingham have developed an algorithm that may predict when patients with seizure disorders such as epilepsy might be at risk for a cluster of seizures. Welcome to UAB Med Cast. I'm Melanie Cole, and joining me today is Dr. Adeel Ilyas. He's a resident in the Department of Neurosurgery in the UAB Marx e Hearsy School of Medicine, and first author of the study published in the journal. Dr. Ies, it's a pleasure to have you with us. This is such an interesting study. As we get into this topic, please tell us a little bit about epilepsy and the seizure aspect of this condition, the prevalence of it in this population of affected patients, and up until now, could we predict when or how severe a seizure would be?
Dr Adeel Ilyas: First of all, thank you so much. It's a pleasure to be here. and I'm really interested in epilepsy and understanding, predicting, seizures and how they happen and how, often they occur. And one of the, aspects of epilepsy, which is really interesting, is that seizures occur in clusters. And this is something that we've, known about and it's, shown in the literature in different studies. but there is no kind of universal, or maybe a better definition is there's no, mathematical or probabilistic definition for what constitutes the cluster. And the reason why seizure clusters are so important is because the notion is that seizure clusters represent a sort of heightened risk, to have seizures.
In other words, the brain is in an elevated state where it, has a higher propensity to produce seizures and therefore patients have, clusters of seizures. The analogy would be like lightning for example. as individual events, lightning strikes are pretty random. But when you think about it, lightning in general isn't really that random. In the sense that it's more likely to occur when there's a thunderstorm, if there's a clear blue sky, it's unlikely that there'll be a lightning strike compared to when there's a, thunderstorm occurring.
So maybe there's something about the brain where there are certain brain states that promote seizures in which seizures are more likely to occur, and other states in which seizures are relatively unlikely, quite random. So with this background or this notion, we try to develop a way to capture, seizure clusters, to define them and then forecast them and see if we could predict when they would occur in the future.
Melanie Cole (Host): That's so cool Dr. Ilyas. So tell us a little bit about not only the complications, but how would reliable seizure cluster prediction immensely benefit individuals with epilepsy? How would knowing that this patient is at an increased risk for this cluster allow you as medical professionals to intervene to reduce that risk whether it's increased monitoring, adjustments to medication, tweaks to the simulator, whatever it is?
Dr Adeel Ilyas: So, we'll maybe talk about what constitutes the seizure cluster and the definition of the seizure cluster a little bit later. But the idea here is that, when the brain, let's say, is in this heightened seizure cluster state, then there are certain, things that we know about patients who, have seizure clusters or are more prone to have, clusters or seizures. And for example, one thing that we know about them is that they tend to be, treatment resistant, whether that's with medical therapy or with, surgery or stimulation, neuromodulation. They tend to have a resistant to, or be resistant to treatment.
They also tend to have an increased risk of going into a state of status epilepticus, where the brain basically is in a seizure mode for an extended period of time, and that is quite dangerous. Seizure clusters are also associated with, increased, hospitalization risk and with sudden death in epilepsy. this is an very unfortunate, event that can happen in patients with epilepsy, it's a feared complication where, patients, are found dead basically, and presumed after having had a seizure.
Melanie Cole (Host): Wow. So it can be really, really detrimental to the health of the patient. So then speak a little bit about what you've done, this algorithm and how researchers at the University of Alabama at Birmingham have developed this method to predict when patients with Seizure disorders such as epilepsy might be at risk for these clusters? This is fascinating.
Dr Adeel Ilyas: The first hurdle that we had to overcome is we had to first define what a seizure cluster is and in the literature there are different definitions and you can make the argument that's many of them are arbitrary. Three common definitions. This is based on a, meta-analysis, some of the authors of whom are also part of a UAB. So one definition is, having. Three or more seizures in a 24-hour period. Another definition is having more than two seizures in a 24 hour period. And yet a third is, more than two seizures in a six hour period.
Like this, there are other, definitions of what constitutes a seizure cluster, but the notion is that a seizure cluster happens when seizures occur. Earlier than expected, or they occur kind of back to back, in rapid succession. So that's sort of the general notion of, a seizure cluster. So we devised a probabilistic or and mathematical definition of seizure clusters based on, Cole Agora statistic. So the idea here is that you input the seizures as events in a time series, and you sort of look at the distribution of these events and compare that distribution to an expected distribution or an alternative or expected distribution.
As if the events were equally spaced. So in other words, the events that you're seeing, in actuality compare them to events that were equally spaced out. And the difference between the observed events versus the expected equally distributed events, can be computed or calculated as a probability. And that basically, is how we define our seizure clusters, a probabilistic definition of how the seizures are occurring more rapidly as compared to an equally distributed, or equally spaced out distribution.
Melanie Cole (Host): So how have been the outcomes? And up until now, what have you been able to forecast? I mean, identifying this window two and a half days prior to the onset of these clusters and giving you really time to establish an intervention plan. How's it been working now?
Dr Adeel Ilyas: This study we did in 15 patients who had a specific type of, device called, a responsive near stimulator, RNS device that is made by a company called NeuroPace. And what this device does is it detects. Seizures in the brain, electrical activity in the brain, and can then stimulate the brain to reduce or modulate, seizures over a period of time. But this detection of seizures then can be recorded over a long span of time. So in our study, in the 15 patients that had this RNS device, we recorded electrographic activity on average, about 30, 39 months or so of data that we had on these 15 patients.
And across that span of time, we looked at the seizure events, and kept track of when the seizures occurred. And then we applied our probabilistic, algorithm to compute seizure clustering in these 15 patients. And then we, use what's known as a generalized auto aggress model. Basically a model that can predict the fluctuations and probabilities of the seizure clustering, and then use that algorithm to forecast future events. And so the way we did that is, let's say we had, 100 events that we captured in one patient. So 100 seizures.
We divided those 100 seizures and took the first 75% of the data. So 75 seizures, trained that auto aggress model on the first 75 seizures, and then use that model to predict the remaining 25 seizure. So trained on 75% of the data and predict on the remaining 25% of the data, and then we computed how accurate our predictions were. And so on average across the 15 patients, if we predict out to one day, we had really good accuracy. So computed the accuracy based on what's called a may score or a mean absolute scaled error.
And a value less than one indicates that the algorithm performs better than chance and our values were, 0.78 on average for a one day time horizon. That means that on. across the 15 patients. we could predict the seizure clustering the probability of seizure clustering out to one day, and we did that subsequently for two and a half days and so forth. But the accuracy gets worse as you, forecast out further and further, from the last known time, as you increase the horizon.
Melanie Cole (Host): So where are you now, Dr. Ilyas, in this research and for other providers that are listening, as interested as I am with this, how can they be able to use this research? Take us from bench to bedside, and how can they get involved?
Dr Adeel Ilyas: So I would say, first of all, this study is a pilot city or feasibility study in 15 patients. So the next step, for us would be to validate these findings in a larger cohort of patients. And assuming that we're able to validate this and to show that, Algorithm works, in general for a large number of patients with epilepsy, then it can be very useful in potentially developing an app or something like this where patients can be informed of, impending seizure risk. In this way, either they can modify their own medications or therapy that they're receiving or they have a plan to do so, or their providers can, intervene appropriately.
They can adjust their daily activities accordingly. There's a lot of therapeutic potential in seizure forecasting . It may allow us to investigate further, regarding brain states that promote seizures or increase the propensity of having seizures. In general, the notion is that epilepsy or seizures are random. but research like this and there other research out there as well is sort of challenging that notion and suggesting that seizures may be partly random, but also can be predicted, to certain extent and with certain probabilities.
Melanie Cole (Host): As we wrap up, this is just an amazing study that you're conducting. What would you like other providers to know about this algorithm that may predict the onset of seizure clusters in patients with disorders such as epilepsy, and anything you'd like them to know about this study as we summarize?
Dr Adeel Ilyas: I'd like providers to know that, our algorithm is a promising algorithm and it seems to be, a practical algorithm that can, forecast seizures, at least in this small cohort, effectively. And if a larger validation study shows similar and promising results, then it really, brings about this notion that seizures may be able to be forecasted to some extent, at least in a probabilistic way. And if that's true, then it means that we can deliver therapy based upon a projected or forecasted seizure risk. And that can really change the field of epilepsy because knowing that a patient is going to have an increased seizure risk in the near future might actually allow us to deliver.
Or at least inform the patient that there's an increased risk that can, affect how the patient, he or she conducts his daily life, but then also deliver additional medication, perhaps change neuro stimulation settings. In this case, these patients all had, the RNS device, so those stimulation settings can be adjusted. But any sort of intervention can be done based on the understanding that there's an increase or impending, seizure risk. And I think this is a really, novel and, very, beneficial, practical application of this work, if it's validated in a larger study.
Melanie Cole (Host): It has very far reaching implications. It's so interesting, and I hope Dr. Ilyas, you'll come back and join us and give us an update as this research continues. Thank you so much for joining us and explaining this all to us, and a physician can refer a patient to UAB Medicine by calling the missed line at 1-800-UAB-MIST. Or by visiting our website at uab medicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua270.mp3
- DoctorsOvalle, Fernando
- Featured SpeakerFernando Ovalle, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6056
- Guest BioDr. Ovalle is a Professor of Medicine and Director of the Division of Endocrinology, Diabetes & Metabolism at the University of Alabama at Birmingham (UAB) School of Medicine. In addition to maintaining a large and busy clinical practice, he serves as the Director of the Multidisciplinary Comprehensive Diabetes Clinic, and Director of Diabetes and Glycemic Control Programs at UAB Hospital.
Learn more about Fernando Ovalle, MD
CME Release Date: November 9, 2022
CME Expiration Date: November 8, 2025
Disclosure Information:
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:
Fernando Ovalle, MD
Director, Division of Endocrinology, Diabetes & Metabolism
Dr. Ovalle 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 is Dr. Fernando Ovalle. He's the director in the division of Endocrinology, Diabetes and Metabolism at UAB Medicine, and he's here to discuss the latest treatments for type one and type two diabetes in the diabetes belt. Dr. Ovalle, it's a pleasure to have you with us as we get into this topic, and we're hearing more and more about the epidemic and the obesity epidemic, and we're gonna talk mostly about type two here today. But can you tell us just a little bit about the prevalence of diabetes in central Alabama? What you have been seeing in the trends?
Dr Fernando Ovalle: Oh, hi Melanie. Thank you for having me. Well, the prevalence of diabetes as, you probably have heard this, is high and it keeps going up. Right now in Alabama, think the state prevalence is, roughly around 12%, 13% depending on how you count it. But there are some counties in central Alabama, where the prevalence is as high as 19% or almost 20%, and that means almost 20% of all adults, and I'm talking about adults, have, diabetes, that's one in five people over age 20. If you look at people over age, 40 or 60, 65, then the prevalence goes even much higher. Sometimes as high as, 50%. so the prevalence is, very high.
Melanie Cole (Host): Well then with that increasing prevalence, what are some of the complications that you see most commonly in this population?
Dr Fernando Ovalle: It's a mix of things and I think we have different groups of people who tend to get different, complications, but if we pull them all together, all people with type two diabetes, then I would say neuro. it's one of the most common ones. I would dare to say that almost all people would tap to diabetes by the time they get diagnosed, have neuropathy. Whether it's symptomatic or asypmptomatic, that's a different question and whether, what tests you need to do to determine that, that's a different question.
But there are papers out there all papers that suggest that 70, 80% of people at diagnosis already have neuropathy. And that's pretty much probably what I see in clinical practice. As a matter of fact, if somebody comes to see me with a diagnosis of type two diabetes, and I find that they have deep tender reflexes in the ankles still present. That is one of the rest flag to me like, You know, am I dealing really with tap two diabetes or am I dealing with some other type of diabetes? Because I expect it to be present.
Now, I don't expect everybody to complain about it or to have pain, but what I expect them to have some degree of loss of sensation, that's very common. Then the other very common, especially here in the southeast, is, kidney disease. The number of people who have protein on the urine or having in the urine, or a decrease in their kidney function is just staggering. I would say that probably over 50% of the patients that I get to see have, chronic kidney disease. And that much more dependent on the subtype of diabetes and the background of the patient who has diabetes.
And if you are African American, the chances of having kidney disease are much greater. If you have a family history of that, it's even greater. And then retinopathy. Retinopathy tends to be a little more difficult diagnose for the routine, physician who's not an ophthalmologist because, you have to be trained and, spend time looking at their eyes. And the equipment that we have in the regular offices is usually not adequate enough to allow us to do a good job of screening for that.
But I pride myself having good training on that and being able to look for that. Then I also find it quite common. A lot of the people, who have kidney disease already have retinopathy as well, mild or, beyond. So all of them are very common. But I would say that by far the most common is neuropathy.
Melanie Cole (Host): So as we're talking about those complications, there's also many comorbid situations going on, maybe high blood pressure, or as you mentioned, kidney disease. What are some clinical interventions that you've seen to be most effective when you're combating those common complications and comorbid conditions?
Dr Fernando Ovalle: Thank you for asking that because, it's very important to note that, almost everybody would have two diabetes, are obese, or at least overweight. And that's the one common denominator for type two diabetes. The one thing that if we were to address it, we will tackle everything if you treat diabetes, if you help, people lose weight, their blood glucose gets better and therefore anything related to blood glucose gets better. If the blood pressure gets better and anything related to blood pressure gets better, and then anything directly related to obesity also gets better and insulin resistance, et cetera.
So, That is at the root of the problem in type two diabetes. That's not to say that there is other things that we need to worry about, and there are people who are not obese. Now, when you talk about people who are not obese, then you start getting to semantics that we're really talking about type two diabetes. And isn't that a different subgroup? And it depends how you interpret the current definitions of type two diabetes that have been proposed by the American Diabetes Association and the second, by others organizations around the world. But even with a lose definition of type two diabetes, obesity is quite prevalent. And I, would, say that is, where you get the most [inaudible].
Melanie Cole (Host): So you're working on those comorbid conditions, and specifically as you've said, the prevalence of obesity is what complicates so many of the situations. Now, as we're talking about that increasing prevalence, How much do you rely on patient provided data when it comes to your management strategies? There are new technologies that we're hearing about Dr. Ovalle, like continuous glucose monitoring. Speak about that role in diabetes management, professional versus personal CGM use in clinical practice.
Dr Fernando Ovalle: It's really transformed the way we manage patients and it's really helped our patients a lot and it's helped us a lot as physicians as well. Makes everything more clear, less frustrating. We're guided, we're doing something with data. Even if you do nothing else, if you just give somebody a sensor, and I'm talking about they continue to glucose monitors that patients can actually read and see. By just giving it to them and putting it on them, you empower them. And that is very important.
People like to see data too, even if they don't know it, if they're not very, tech savvy. If you give a goal, if you give them a number, it's just like giving them a little game. People respond to that. And, some people it's because they're competitive. Some people it's because they get concerned. Some people it's because they needed some guidance and they just, don't know whether what they're doing is correct or not. They don't know what's making things worse, what's making it better, and that by itself makes people do better.
There is evidence out there that shows if you put somebody in a continued glucose monitor with nothing else, their aA1C improves by about 1%. And we see that all the time. Some people even better than that. So that's, very important. Also, when you say about how do we trust people there? I trust it. I trust it a lot there is always a few, bad apples where you know, they're not telling you the truth, but you once you put them on this continuous good monitors, everything becomes more clear. But in most cases, in 98% of the cases, you can trust what the patient tells you.
They're not gonna come and, waste their time with you. They tell you what's going on and I trust their data. Frequently, much more than I trust the A1C. A1C has a lot of flaws and we've learned over the years. We knew some of these flaws even before we had so many continuable monitors, available out there. It's even become much more clear now that, we're missing a lot by just trusting the A1C alone. So the technology, it's been helping a lot and it's improving rapidly. It's a great advancement.
Melanie Cole (Host): Doctor tell us what's going on in medication intervention. How has that changed over the last decade or so? What are some of the developing diabetes treatment options that you feel are most promising and the role that physicians have in seeking new and developing diabetes treatments as you're working with these patients and you're seeing what works?
Dr Fernando Ovalle: So there's several medications. There are several classes of drugs that have been developed over the last, 10, 20 years, that have just now being started to get used more commonly. And they're taking off, and I'm talking about the two cluster of drugs I'm talking about are the sodium glucose, called transport inhibitors. And, what we call SGLT2 inhibitors and the GLP1, receptor agonist. And now the, dual GIP and g l P one receptor co agonist and those are, the classes of drugs that have, really come to make a huge difference in the management of diabetes.
Not just because they're very effective in terms of, blood glucose control because, we could have done a lot of this beforehand. before we had these drugs, we could just give more insulin and get the blood glucose down or use other drug therapies that we had and a very effective of blood glucose. But the problem was, that's all they did. or, most what they did was just lowering glucose. And while that's important, very important, we don't wanna, come across as saying that lowering glucose is not important, because that can easily be misinterpreted.
There are many other things that were not doing with the previous drugs that we used and that now we are, to start with, these drugs are addressing other things that we didn't before. And, one of them is the role of the kidnies, in glucose metabolism. we know that the glucose blood is, a direct, effect from what we eat, the exception is glucose intake. Plus what we make and the liver makes two thirds of it and the kidney makes one third of that. So, we were missing a chunk of the, pieces of the puzzle in there.
And now we have a way to not just understand it better, but also to manipulate it. The other, is the role of the GI tract and the role of glucagon. And, for that we have the incretins, GLP1 receptor agonist, and now the dual agonist, which have also kind of reminded us that it's just not insulin. We're dealing with, we're dealing with a whole set of other hormones that regulate glucose metabolism, and these other hormones are just as important as insulin. Now, insulin, if you compare them all, alone as how, insulin of course, is very powerful and it's one of the most important.
But that doesn't mean that the other ones are not important and they are extremely important and we're learning and learning more about glucagon and not just glucagon itself, but the glucagon like peptides and their effect on the receptors, and how. complex that is, it's just if you activate one receptor, each of those receptors by themselves, the effect that you get is different as, compared to when you activate them all together. So the field is really advancing rapidly and become a much more, complex, but at the same time, it's been very helpful to have these tools nowadays.
Melanie Cole (Host): Well, it certainly is rapidly advancing. And before we wrap up, I'm gonna ask you to recommend to primary care physicians about anything you would like them to know, whether it's using diabetes technology in their primary care practices or update on anything that you would like them to know. But before you answer that, I'd like you to just give us some latest recommendations on diabetes lifestyle management, because as lifestyle management remains very basic to long term management of diabetes and there's no one size fits all rules. And so you were discussing a little bit earlier and the prevalence in Alabama, so speak about lifestyle management and then segue into a summary of what you would like other physicians to take away?
Dr Fernando Ovalle: What we can all do right now is, obviously make sure that we don't lose sight of the fact that, diet, and exercise. But most important diet makes a huge difference in all these metabolic diseases. Diabetes been, the most, obvious out there. But we don't wanna stop emphasizing the need for a diet and changes in diet and not just tell people you need to lose weight. Because people, they've heard that a million times and we know it's extremely hard. You gain 10 pounds and it's just so hard to lose it.
So we have to make sure that we're empathetic, that we try to understand. People are going through that is extremely difficult. They hear us but they hear it differently depending on how we say it. So it's important that we support them, that we tell them I'm with you. I understand. And try to cheer them up and empower them little gains a little bit at the time, and give them the tools. And I would say, out of everything out there, of course, medications are extremely helpful and important, losing weight nowadays.
But those new tools that we're developing that give people data are extremely helpful because people tend to try, if we give them the tools, they will do it. if we give them a tool, like a continuous glucose monitor that in a diabetic allows them to tell, Hey, what you ate probably was either too much or the wrong thing. It's extremely valuable. It's maybe not for everybody, but for most people it allows them to change their behavioral modification tools that are really powerful.
So I would say there's nothing else other than counseling, these new technology tools, we need to use them and giving to people just to make it easier for them. They're extremely helpful. They probably just, think that if we had a tool or a sensor like that would allow people to know how many calories they're eating. People will stop after, we tell them, Hey, this is how much you burning in a day. And you have a gage just like you having the gages in your car, for the gasoline, you know how far you can go and you're not gonna drive from Alabama to New York with just one gas tank.
You know, You know you're gonna have to stop and how far you can go before you have to stop for gas. And the same thing when you eat, how many calories you can eat per day. If we had those tools that will give people that type of data, that will be extremely valid. And of course we don't have that yet, but I'm analogizing this to make the point that data makes a huge difference. When you exercise, for example, it makes a big difference if you know, haven't done this before in a spinning class where you had data. Including your heart rate, including how much power you were generating.
How much, energy you were generating in watts and Not just calories, but watts energy, that, data driven approaches to, whether it's exercise, diet, or, glucose management are incredibly, helpful. We do it all the time with other things. We do it with blood pressure, we do it with, oxygen, we do it many other things that we do in life nowadays. Would emphasize the use of the technology nowadays.
Melanie Cole (Host): What great information, really up to date and you're so succinct about it. So thank you so much Dr. Ovalle. It's such an important topic, and 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, Exercise Physiologist | Medical Journalist
Additional Info
- Audio Fileuab/ua272.mp3
- DoctorsShalev, Anath
- Featured SpeakerAnath Shalev, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://www.uabmedicine.org/web/medicalprofessionals/medcast-home?item=48306
- Guest BioAnath Shalev, MD Specialties includes Endocrine Surgery and Endocrinology.
Learn more about Anath Shalev, MD
Release Date: November 8, 2022
Expiration Date: November 7, 2025
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:
Anath Shalev, MD
Professor, Endocrine Surgery & Endocrinology
Dr. Shalev has the following financial relationships with ineligible companies:
Dr. Shalev has disclosed her role as co-founder and chief Scientific Officer of Tiximed, Inc. The company intends to commercialize a novel small molecule inhibitor that can be used as an oral medication option for type 1 diabetes. There are no clinical trials in progress to test the efficacy and safety of this small molecule inhibitor. This unit includes discussion of a currently available generic drug that has shown promise in treating type 1 diabetes when taken orally. Dr. Shalev 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, MS: Welcome to UAB Med Cast. I'm Melanie Cole, and joining me today is Dr. Anath Shalev. She's an endocrinologist and a professor at UAB Medicine, and she's here to highlight new frontiers in diabetes research. Dr. Shalev, it's a pleasure to have you join us today. Can you start by telling us a little bit about the UAB Comprehensive Diabetes Center?
Dr. Shalev: Sure. Thank you for having me. So our comprehensive diabetes center, its mission is really to do cutting edge diabetes research and provide insight and breakthroughs that ultimately, will improve the lives of those affected by diabetes and as type one and type two diabetes in our community and beyond. We are a universitywide interdisciplinary research center, or York, as they like to call it here, and have 200 faculty members from all schools on campus and obviously many different departments.
With that, it is truly a multidisciplinary center and serves as a platform, an engine for collaborative research, to avoid potential silos that can be found at some institutions. So it also, by doing so, it spans the full spectrum of very basic translational clinical and outcomes research. And so, it's obviously very important in general, but especially for a complex disease such as diabetes and for a problem that is such a special issue for us here locally in the deep south. And since some still refer to us as the buckle of the diabetes belt that spans across the deep south.
Melanie Cole, MS: Well, it certainly is really an epidemic right now goes along with this epidemic that we've been seeing of obesity and the increased comorbidities that go along with diabetes. Tell us a little bit about what's new in exciting research and advancements that have been made at the UCDC, as I understand it, there's new drugs on the horizon. Tell us about some of the things going on there.
Dr. Shalev: So Sure. Obviously given the complexity of diabetes and the large number of researchers we are working that are working on many different aspects of the disease, I can't cover everything, but so I will try to give you just one example how we try to move discoveries from the bench to the bedside. So roughly two decades ago, we identified a protein called tick snip that is elevated in diabetes and that has detrimental effects on pancreatic eyelets and on the beta cells that obviously produce insulin. We then discovered that the commonly used blood pressure medication. Rapmill can normalize tick snip levels and that rapmill protected mice from diabetes and also was able to reverse over to diabetes in those mouse models.
We then were able to translate these findings into humans with recent onset type one diabetes and found in a randomized placebo controlled trial that once a day oral rapmill enhanced eyelet function. And limited the amount of insulin injections that were required. And with that also reduced the number of hypoglycemic events that patients experienced. Obviously a major issue for people with type one diabetes. And so now what we are excited about is that most recently we found that these beneficial effect are maintained for at least two years after the initial diagnosis of Type one diabetes, as long as individuals continue to take the medication.
And so obviously this opens up new possibilities for physicians to treat their patients with diabetes. Since while RapMill is not FDA approved for diabetes, it has been approved for over 30 years for hypertension and can be given off label, based on the physician's assessment of that patient. And so, this is also part of a translational pipeline that we have started here at the center and trying to move other drugs and other possibilities and new therapies along this way.
And now you also mentioned kind of newer things as well, with finding this as proof of principle that addressing tick snip and its signaling is effective not just only in animal models, but also in humans. We had set out to identify new drugs and new compounds that would do the same thing, but more specifically and have identified a small molecule. That can also inhibit tick snip, and have launched a small company to bring that from again, the bench to the bedside and hopefully into clinical trials.
Melanie Cole, MS: That's fascinating. What an exciting time to be doing research in your field, Dr. Shalav. That's not only innovation in terms of medicational interventions and even new technologies and devices. But you mentioned this just briefly, innovation as a philosophical shift from providers working in silos to working together. Can you speak about how this multidisciplinary approach at the UAB Comprehensive Diabetes Center is really so important for these patients?
Dr. Shalev: Yes, absolutely it is very important and as I mentioned briefly before, it's important in every aspect, but particularly in a disease that is as complex and touches upon so many different aspects, o also of the patient's life and health. And so, no one these days with the advancement of technology and the innovation can be an expert in everything. And so in order to efficiently move things forward and get the best insight we have to work together.
And that's what our center allows us to do. And also to address different aspects of the disease simultaneously. You mentioned complications before. We are lucky to have other centers on campus that address pretty much every other organ system that diabetes affects, such as kidney neuroscience of tology, cardiovascular. And so we are working very closely with our colleagues in those centers to consider these other aspects of the disease when we're trying to find new therapies.
Melanie Cole, MS: What are you most looking forward to this year with the UCDC? Tell us a little bit about what you see happening on the horizon with the study you discussed and others.
Dr. Shalev: Well, so for one, with the improvements in terms of the Covid-19 pandemic, we're slowly returning to in person visits and so with that, we're able to connect better with our colleagues and move those developments further along. We are very much looking forward to implementing more of the rapmill with other groups. There's a large study going on in Europe. I just returned from a meeting in Stockholm where this was discussed. They having a multi site study using rapmill as the basis and then combining it also with other immunosuppressive regimens, to try to find the best combination for diabetes treatment for type one diabetes treatment.
And so we were excited to see what the results from these studies will hold and to see others starting to use some of our findings in their research. We are also obviously looking forward to, move, the small molecule forward with Ticzimat and to get in d approval to be able to start clinical trials with that small molecule. That's another big aspect that we're looking forward to in terms of the drug development. And then finally, from a center perspective, we also were excited since we have just launched a major strategic recruitment initiative and diabetes research in collaboration with the [inaudible] School of Medicine to recruit up to 10 new faculty members.
And so with new growth phase, we are really hoping to, have a major impact and to advance the ongoing research exponentially with getting people in that can network and collaborate with the already existing faculty and really go even another level up.
Melanie Cole, MS: Dr. Shalav you mentioned briefly before bench to bedside. So you're doing all of this exciting research. How do you feel it will impact physician's treatments, primary care provider that are also dealing with these patients and working with these patients in a medical home situation? In some rural areas, there's other community endocrin. How do you see this research impacting their treatment? How do you envision it translating directly to patient care?
Dr. Shalev: That's an excellent question. And in fact, I think the findings with Rapmill are a great example of how really kind of basic research can impact very clinical, primary care. With the traditional treatment of type one Diabetes is often reserved for endocrinologists and is often associated with high end technology of insulin pumps and continuous glucose monitoring systems, etcetera, etcetera. And some of those things may not be available everywhere into everyone. However, if we can optimize treatment and reduce the need for large amounts of exogenous insulin, for example, with an oral medication given just once a like rapmill, we can have a major impact and can open up that ability to help people to primary care physicians.
It's an addition rapmill, as an example, is very, very cheap. So it really opens up opportunities to help communities that otherwise would be limited to very expensive and very complicated treatment options. That they may not have access to. So again, I think it would, really give an opportunity for physicians to enhance the therapy that they offer to their patients.
Melanie Cole, MS: You make a great point. It's pretty easily accessible and you can get it, as you say, very inexpensively. As we wrap up, how would you like the community and community providers to support Diabetes Awareness Month coming up in November? Really tell us what you would like referring physicians to know about the UAB Comprehensive Diabetes Center and when you feel it's so important that they refer?
Dr. Shalev: Yes, that's a great question. I mean, the best way to help us is to get involved and spread the word that we have a center such as ours, you know, in our backyard here, to, let people know that there are people working pretty much nonstop to try to find better therapies and better treatment options for them. So they feel that we're really there to help. People can sign up for our newsletter, get information, and also share their stories where we're open to. We really want to have the, a dialogue with, providers as well as with patients. So one way to do this is through website. And so that's uab.edu/diabetes. And we can be happy to connect and to make connections with whoever is interested.
Melanie Cole, MS: Thank you so much, Dr. Shalav for joining us today. And a physician can refer a patient to the UAB Comprehensive Diabetes Center 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. For updates on the latest medical advancements, breakthroughs in research, follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS, Exercise Physiologist | Medical Journalist
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