Additional Info
- Audio Fileuab/ua169.mp3
- DoctorsMomaya, Amit
- Featured SpeakerAmit Momaya, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4169
- Guest BioAmit Momaya, MD is a sports medicine surgeon and serves as section head of the sports medicine division within the Department of Orthopedic Surgery at the University of Alabama at Birmingham. He has had extensive training in the care of patients with shoulder, elbow, hip, and knee injuries. Furthermore, he has taken care of athletes at all levels—from the weekend warrior to the professional athlete.
Learn more about Amit Momaya, MD
Release Date: September 9, 2020
Expiration Date: September 9, 2023
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 commercial affiliations to disclose.
Faculty:
Amit Momaya, MD
Assistant Professor in Orthopedic Surgery
Dr. Momaya has disclosed the following commercial interests:
Consulting Fee - Miach Orthopaedics
Board Membership - Arthroscopy Journal
There is no commercial support for this activity. - TranscriptionIntroduction: 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 0.25 AMA PRA category one credit. To collect credit, please visit UABmedicine.org/medcast, and complete the episodes post-test. Welcome to UAB Med Cast, a continuing education podcast for medical professionals, bringing knowledge to your world. Here's Melanie Cole.
Melanie Cole: Over the past decade, there's been an increased interest in the use of biologic therapies in sports medicine. Welcome to UAB Med Cast. I'm Melanie Cole and today we're giving an update on the latest research and clinical implications for biologic injection therapies in sports medicine. Joining me is Dr. Amit Momaya. He's the Chief of Sports Medicine at UAB Medicine. Dr. Momaya, thank you so much for joining us. This is such a great topic. It's so interesting. Tell us how developments in regenerative medicine and treatments have advanced over the years? As we see this emerging problem of sports injuries, give us a little background.
Dr. Momaya: Sure. You know, there's been a lot of interest in what we call orthobiologic injections across multiple fields, but really sports medicine has come to the forefront of potential applications of, orthobiologic injections, especially when it comes to getting athletes and active individuals back to their lifestyle in a quicker manner. And also at times, potentially even avoiding surgeries, we've looked at various types of injections across years. And until recently we didn't have much data or research on them, but the field has grown tremendously and more and more people are becoming interested in them.
Host: Certainly true. I've heard so much more about them lately. So tell us about the most common overused joint conditions and tendinopathies that you're using these for? Tell us a little about the trends that are happening with biologic therapies.
Dr. Momaya: Some of the most common conditions that we use orthobiologics injections for include tennis elbow. Tennis elbow is a condition where of course you can have some tendinopathy of the lateral aspect of your elbow, often from repetitive activity in motion. You know, most people do not get it from actual tennis, but rather just repetitive activity and doing other things. It can hurt a lot, just picking up a purse or getting a milk jug out of the fridge. And traditionally we used to inject those with corticosteroids routinely and tried to, you know, various bracing and conservative physical therapy. And we had some mediocre results with those things. We weren't exactly sure if the steroid injection was doing much because as we understand further and further, that's actually not so much a inflammatory process that's happening in the lateral elbow tendons. It's actually perhaps a degenerative and lack of vascular problem in that area. So, one of the potential solutions that people have espoused is orthobiologics injections, specifically PRP, which stands for platelet rich plasma.
It's a, it's a pretty easy process overall where the patient has blood drawn from a peripheral vein in clinic. The blood is introduced into a syringe where it's placed into a centrifuge and spun down and the platelet rich aspect is collected. And so one of the applications we've seen is PRP injections into lateral elbow tendinopathy that has been somewhat of a game changer. It's helped tremendously. We've seen much better results with using PRP compared to steroid or other placebos, it's really helped us kind of on that specific pathology. In addition, we've also used it for knee arthritis, you know, knee arthritis is actually one of the conditions that probably have the greatest amount of research when it comes to biologic injections. In a similar fashion, like one would inject a steroid into the knee. We inject PRP into the knee and some of the benefits of that is that PRP, unlike steroids can help with potential healing process. But what we really think it does is it reduces inflammation and works on the pain pathway to decrease pain you felt in the knee. And so those are some potential applications that have had the most research involved with PRP.
Host: So glad you talked about that. And I was going to ask you what types we were talking about because there's also STEM cells. You know, we're hearing about different kinds. So speak a little bit about any research based evidences you have for optimal decision making. When you're looking at which one you want to choose, are there best practices among people in your field? You know, how is that decision going on between PRP and MSCs and these kinds of things?
Dr. Momaya: A lot of debate about what most effective, what works the best and there's research to support various things. So taking a bird's eye view, like you said, there's PRP in addition, there is a kind of vague term called STEM cells. And within medicine, we do know that those formulations don't have many STEM cells at all actually. People prefer medicinal signaling cells or mesenchymal stromal cells. Those are probably more appropriate terms is because we think these are just cells that signal a cascade of events that occur in the joint or the tendon for healing purposes or anti-inflammatory purposes. And so well, let's talk about the actual STEM cells, most common, what people talk about is a bone marrow aspiration concentrate injection, or BMAC for short. And that's where a needle is inserted into most commonly the pelvic rim. And then from the pelvic bone, you draw from the bone marrow blood, which is thought to have a high concentration of those municipal signaling cells.
And that's what's actually prepared and injected into the knee or into a tendon that needs healing. You know, there's some good research that can also help pain in the knee from arthritis or tendinopathies, but probably the most number of studies we have is actually still focused on PRP. Another potential application or rather solution of orthobiologics, as we get into the product of amniotic products. So amniotic tissue, as we all know, it can be a potential source of very rich number of pluripotency cells. And specifically people have espoused the use of allograft tissue that is sometimes freeze dried to inject those formulations so those are kind of somewhat prepared. They come in powder solutions oftentimes, and you can mix them with saline and inject. Those types of applications involve knee arthritis and tendinopathies also. So kind of to summarize, you know, looking at a bird's eye picture, we're talking about PRP, bone marrow aspirate concentrate or STEM cells, and also amniotic allograft tissue.
Host: That's so interesting. And I'm so glad that you mentioned that the term STEM cell has been overused. Now, Dr. Momaya, do you have a concern that misinformation from direct to consumer marketing of largely unproven biologic treatments might erode public trust, and since there's been controversies over some of the use of these since professional athletes and have traveled abroad to receive some of these therapeutic procedures. Do you have concerns that this unmonitored practice with regard to risk exposure, you know, as well as exposure to adjuvants of substances that may come into play here, have you been seeing this at all in your practice with athletes?
Dr. Momaya: Yes. I'm glad you brought that up. That's a big concern. You know, I think these formulations have been marketed not only by health professionals, but by other people that are like, or maybe loosely affiliated with the field that may not have the quite the training that doctors may have and have, you know, erected these STEM cell clinics that are run by people who are not necessarily board certified sports medicine providers, and these clinics often take cash pay for these injections. And they may say that, you know, we can provide you a great better lead for your arthritis or other various diseases. And sometimes they don't have any proof furthermore, these can lead to sometimes complications. You know, there's been articles in the news about infections involving the spine involving the eye. So very serious infections from injections that have not been monitored. Luckily the FDA has come down hard on some of these clinics and there's much more oversight over the past years then there's been in the previous decade on these types of clinics.
You know, we actually did a study here at UAB looking at just the cost of variability. You know, a lot of times people ask me, are these injections covered by insurance? And the general answer is no, these injections, these biologic injections are still thought to be experimental and further data is needed. So they're not covered by insurance. And so one of the things that, you know, my research team at UAB, we looked into the cost variability just to see what kind of variability there is to give an idea of how many market factors are coming into play. Specifically in PRP, we found a range when we looked all over the country, we found a range from anywhere from $175 for the injection up to $5,000. What's more astounding is for STEM cells, quote STEM cells. We found a range from $300 up to $12,000. As you can imagine, this varies based on geographic location and the average income in that zip code, but you know, anything that has a price variability of that much, you're starting to get a little bit concerned, right. You know, are these all the same products? Is it really working? You know, what are we actually selling with such variability in pricing?
Host: So interesting Doctor that you say that, and in my research, I saw some of that. So is there an effective biologics registry? What would that require in your studies, have you looked into a registry?
Dr. Momaya: Yeah, so, you know, our American Academy of Orthopedic Surgeons, there's a task force involved in establishing a good solid registry with people who use biologics, following the outcomes and seeing what actually works and what doesn't. Because right now, like you said, it's kind of the wild, wild West it's, whoever wants to, whoever wants to inject them and collect the cash and people want to pay for them, and people are going to these STEM cell clinics and no data's being collected on the efficacy of these things. So we need more studies and there have been randomized controlled trials, but it's just the beginning. We need greater numbers. And so that's where these registries come into play. And I think over the next five to 10 years, you're going to see a large amount of literature published out of these registries to really tell us what works, what doesn't work. But until then, I think, like you said, athletes sometimes go abroad to get the newest and latest treatments from Europe and other countries, other areas. And so a lot of the athletes in the US and a lot of the younger people in that kind of the weekend warrior, they also see that as a, you know, I want the latest and greatest, even though the research may not have caught up yet.
Host: That certainly is true. And how have been your outcomes? What about patient reported outcomes? Tell us what you've seen and how it works.
Dr. Momaya: Kind of going back to what we initially discussed, you know, the number one utility of a biologic injection. My clinic currently is knee arthritis, and we've seen some good outcomes. We followed our patients thus far looking at mild to moderate knee arthritis and the use of PRP, platelet rich plasma, and we've seen some pretty good results. And one of the benefits of PRP is that it is not condor toxic from what we know of. You know, if you inject a steroid into a knee, it is condor toxic. The more steroids you inject into the knee. It's probably a dose dependent relationship and can really increase the condor toxicity and hasten sometimes the arthritis. So that's a great advantage of using PRP not only in older adults, but especially in younger adults, athletes who are active, we don't want to be injecting them full of steroids. So that's an important concept to know, is that, so we've seen great results from PRP when it comes to knee arthritis and also tennis elbow.
That's one of the most common things, tennis elbow, or any kind of tendinopathy, whether it be patellar, tendinopathy, Achilles tendinopathy, we've used PRP. Now an important note is that what I always recommend for patients, is they go to a clinic that has a board certified sports medicine physician there. And the reason that's important is because there's actually different formulations of PRP. And one of the big kind of dividers between PRP is whether you're talking about leukocyte rich or leukocyte poor. So essentially, you know, what's the concentrate of white blood cells in that? And some of the initial research, what we found is when you're injecting into a tendon that you want to vascular response into, we're typically recommending a leukocyte rich injection. This is in contrast to a joint where you actually may want a leukocyte poor. You actually may not want any type of anabolic cascade or anything that causes too much of a response in a knee, it may flare up too much. And so we usually lose, use a leukocyte poor concentrate in the knee or hip or ankle, wherever you're injecting into a joint where there's cartilage.
Host: As we wrap up this very interesting topic Dr. Momaya, tell other providers and referring physicians what you want them to know based on everything we've said here today, about regenerative medicine, regenerative strategies, and what you're doing there at UAB.
Dr. Momaya: In summary, I think orthobiologics and regenerative medicine are here to stay. It's going to be a forefront of our specialty over the next few decades. But the most important thing I think is to educate the patient on the limitations of what it can do right now. And to emphasize that we're typically not regenerating. We're not regenerating cartilage. Usually we're not regenerating cells to be able to cure your knee arthritis. These are still treatments that are largely symptomatic treatments, rather than a cure curative process. I hope one day we will get there. We're at a point where we can regrow cartilage reliably with injections in the clinic, and that would change the face of the treatment of arthritis. But right now, these biologic injections are still symptomatic. And that UAB, what we're trying to do is follow the outcomes of these patients who received these biologic injections to first make sure they work, and then to work with our basic science colleagues and see how we can change the change, the formulations, where we can start getting into the realm of let's start growing these cells and finding cures for arthritis.
Host: Great information. Thank you so much Doctor for joining us today. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that wraps up this episode of UAB Med Cast. For more on resources available at UAB Medicine. Please head to our website at UABmedicine.org/physician. Please also remember to subscribe, rate, and review this podcast and all the other UAB podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua170.mp3
- DoctorsMomaya, Amit
- Featured SpeakerAmit Momaya, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4174
- Guest BioAmit Momaya, MD is a sports medicine surgeon and serves as section head of the sports medicine division within the Department of Orthopedic Surgery at the University of Alabama at Birmingham. He has had extensive training in the care of patients with shoulder, elbow, hip, and knee injuries. Furthermore, he has taken care of athletes at all levels—from the weekend warrior to the professional athlete.
Learn more about Amit Momaya, MD
Release Date: September 9, 2020
Expiration Date: September 9, 2023
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 commercial affiliations to disclose.
Faculty:
Amit Momaya, MD
Assistant Professor in Orthopedic Surgery
Dr. Momaya has disclosed the following commercial interests:
Consulting Fee - Miach Orthopaedics
Board Membership - Arthroscopy Journal
There is no commercial support for this activity. - TranscriptionIntroduction: 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 0.25 AMA PRA category one credit. To collect credit, please visit UABmedicine.org/medcast, and complete the episodes post-test. Welcome to UAB Med Cast, a continuing education podcast for medical professionals, bringing knowledge to your world. Here's Melanie Cole.
Melanie Cole: Welcome to UAB Med Cast. I'm Melanie Cole and today we're discussing COVID-19 and sports medicine, this changing environment, and the latest implications of COVID-19 on the practice of sports medicine and ultimately how it will affect athletes and patients. And joining me is Dr. Amit Momaya. He's the Chief of Sports Medicine at UAB Medicine. Dr. Momaya it's a pleasure to have you on, with our world coming to this change in the sudden and unprecedented way, a lot of organized sports activities have changed the way that they're doing things. And we understand now more than ever the leadership role that sports plays in our society. This is something that we may be underestimated or didn't realize. Tell us what you've learned about sports it's roles for our youth, our communities, our state teams, and with this changing paradigm, the responsibilities of the athlete and the coaches in this time.
Dr. Momaya: Sure. You know, just like you said, these are definitely unprecedented times with COVID and it's affected the sports community significantly. I think one of the ways we realize how sports medicine and sports as a culture, how tightly ingrained it is into our society, because sometimes we take it for granted and then all of a sudden, a pandemic like this hits, and it's really knocks us back on our heels. And we start to realize what life is like without the routine sports that we are so used to kind of either watching or engaging with, or, you know, cheering on our favorite team. So it's definitely brought a lot about a lot of changes. And like I said, a lot of people in the sports community have dependent on the sports medicine physician and associated doctors to kind of help them make decisions and decide what the safest route is for a lot of things. One of the things that we talk about is the role of the athlete and the coaches within this pandemic and what they need to be doing to remain safe. You know, we often educate these athletes and coaches on taking a personal responsibility and making sure they stay safe not only for themselves, but for their teammates, for their surrounding community and their family. Which often involves kind of typical guidelines that CDC has recommended such as hand washing principles, wearing a mask, and avoid touching your face, among multiple other things.
Host: Well, I certainly agree with you and as talking about the benefit of sport and social interaction, which we've really learned so much more about what this does for our youth athletes, for our professional athletes, we're recognizing this ongoing infection risk that you just talked about. Are there some besides hand washing, mask wearing, current rules regulations, as far as sport clubs and even in the locker room? Is there anything you can tell us that maybe we're not seeing in, you know, general information that you've seen happening?
Dr. Momaya: I had the privilege of taking care of a UAB athletics and also the professional Legion FC soccer team in town. And so I've gotten a firsthand witness of a lot of the protocols that have been put into place to keep, keep these athletes and associated staff safe. And so some of those protocols involve making sure to limit the number of personnel in these locker rooms. You know, locker rooms are often a place where they're crowded and a lot of kids are often there with coaches and other staff members and so forth. And so we've put together a lot of protocols that will limit one, the number of people in, at any given time. Also simple things like keeping gates, keeping doors open to avoid multiple people touching the same door handle. In addition, you're using kind of approved cleaning products to make sure these areas such as the locker rooms, the benches, and so forth are routinely cleaned much more routinely than ever before. Another thing we're often recommending and seeing is that, you know, typically after a game most athletes will head to the locker room, shower in the locker room, change into their normal clothes, and then leave. But what we're often advising is that athletes do not do not shower in the locker room and go ahead and head out back to their home where it may be safer to where there's less people, less contact. So a lot of these changes are happening behind the scene to help keep these athletes and coaches safe.
Host: Well, thank you for telling us about that. And as practice had been canceled and spring sports, as we're thinking of a thoughtful approach to exercise, to give athletes that chance to acclimatize, to the temperatures, to the intensity duration of practice, especially for our collegiate athletes, how does a slow ramp up of practice? Can this decrease the risk of injury, heat illness? Some of the things that we might not always see because they've been doing it on a consistent basis where now some were cut off altogether, and stopped, but now they're kind of coming back looking at coming back. So what do you want to say about ramping it back up?
Dr. Momaya: Most certainly, like you mentioned, you know, we've actually in our clinics, we've seen an uptick in soft tissue injuries when these athletes are returning back right now, football practice both the high school and collegiate level are going. And a lot of these athletes are usually well conditioned throughout the year. You know, there's oftentimes an athlete has very little time off through during the year. They oftentimes have practice and lifting sessions in the spring and formal workouts in the summer. But a lot of these athletes, whether it's at the high school or collegiate level have not had the routine training. And so it's ever so more important to make sure they can ramp up in a stepwise fashion to avoid, you know, for example, pulling a hamstring or even, you know, something that they may be fatigued and their hamstrings and quads may be fatigued and put them at increased risk for an ACL rupture, for example.
So we're seeing some of these types of injuries that you may not otherwise see in these athletes who may be ready to go a much earlier time because they just haven't had the time period to introduce themselves back into athletics. But we are noticing also the, the coaches understand this and they're making sure the amount of the number of practices, the frequency, the duration are altered to accommodate for athletes who have not been conditioned throughout the spring and summer. Also similarly we're seeing, you know, with, with the heat, especially in the Southeast, we're making sure that these leagues are providing adequate water breaks for these athletes. So they are not significantly dehydrated and going to heat exhaustion or even heat strokes.
Host: Yeah. I would imagine that you have been seeing some increase in musculoskeletal injury, soft tissue from that unconditioned musculature. Dr. Momaya, and you may not be able to answer this question, but what, if anything, do we know about whether players affected by COVID-19 will endure any long-term effects? Have you seen any studies on their health or game performance at all?
Dr. Momaya: Sure. You know, that that's a very hot topic right now, and that's honestly one of the key features of why some of the power five conferences are looking at whether to continue fall sports or not. And one of the things that people are looking at very closely is the topic of myocarditis. You know, we do have some studies that show that athletes may be at increased risk for myocarditis, if they were to contract the virus, but the long-term effects, we truly do not know yet. This is such a novel situation we're in. And we don't have any long-term data to determine if one year from now five years from now, 10 years from now, we just simply do not know about what the long-term consequences are. And so at this point, you know, our biggest recommendation is preventative techniques. Like we talked about earlier is kind of the hand washing, wearing a mask, those kinds of principles to kind of prevent contracting the virus because we don't know the things like myocarditis, what effect they truly will have on these athletes.
Host: Yes. Thank you for that. And another thing that I'm finding interesting is this advent of tele-medicine and how really creative healthcare providers have had to be during this pandemic. Do you feel that tele-medicine affect the role of your hands on physical examination, Dr. Momaya? Where do you see this new role of tele-medicine in this healthcare realm? I mean, we know as sports medicine professionals, there's a lot of hands on manipulation and that sort of thing. Where have you used tele-medicine recently and where do you see it playing a role on this ongoing pandemic?
Dr. Momaya: I've embraced tele-medicine and it is a great tool to be able to communicate with patients, to be able to even do some limited exams on patients and to be able to go over results. So I think tele-medicine is here to stay. Whether it's primary care medicine or orthopedic sports medicine. As you mentioned, there are limitations to tele-medicine, the biggest limitation from a sports medicine side, being that we don't have the ability to exactly examine a knee or shoulder injury. We can't feel the ligamentous laxity that one may feel in the clinic. So that's certainly a limitation, but you'd be surprised at what patients can often tell you what their history, they can often demonstrate with range of motion on the actual platform of tele-medicine. So I found it very useful in these situations as even an initial appointment to kind of determine what the level of injury is, whether they need to come in for a formal exam, or whether based on their history, we can go ahead and proceed with obtaining x-rays and MRI.
The other role that it's been great is either someone who has come into our clinic, we've ordered an MRI, they've received it typically in the past. These people would come back in to clinic to see their MRI and go over it in person. But now with tele-medicine, we have the ability for the patient to remain in the comfort of their home and go over the results of the MRI, and even see the results on the screen. We can point out things on the screen, on the MRI, they can be looking at it actively. And it's quite advantageous to be able to do that. And also postoperatively are patients who may simply need a wound check. We save them tremendous amounts of time. And by doing that, by looking through pictures and through video, so the tele-medicine aspect of it, you know, we've adapted because of COVID. But I think tele-medicine, regardless of COVID is here to stay long-term. And it's really for the benefit of both the patient and the physician.
Host: I certainly agree with you as we wrap up. Is there anything else you'd like to share regarding COVID-19 and sports medicine in this changing environment?
Dr. Momaya: I think everyone just has to remember to be flexible and fluid with COVID-19 in sports medicine. There's so many things we simply do not know yet know. I think the most important thing is as athletes return back to play is that we practice, you know, social distancing, we practice safe protocols to mitigate the risk. There's no way to eliminate the risk, but we can mitigate the risk and always get more information regarding this. So we have to be flexible and going forth. And as we understand more about COVID-19 and how to treat it and how to prevent it, I think hopefully we'll get back to a closer reality of what we consider normal.
Host: Thank you so much, Dr. Momaya, what a comprehensive segment that was, and such an interesting time that we're living in. Thank you again for joining us. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that concludes this episode of UAB Med Cast. To refer your patient, or for more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. Please also remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua145.mp3
- DoctorsMcElderry, Tom
- Featured SpeakerTom McElderry, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4159
- Guest BioTom McElderry, MD is the Section Chief, Electrophysiology , Co-Director, Heart & Vascular Center.
Learn more about Tom McElderry, MDRelease Date: August 31, 2020
Expiration Date: August 31, 2023
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 commercial affiliations to disclose.
Presenters:
Tom McElderry, MD
Assistant Professor, Section Chief, Electrophysiology; Co-Director, Heart & Vascular Center
The speaker has no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole: 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 0.25 AMA PRA category one credit. To collect credit, please visit UABmedicine.org/medcast and complete the episodes post-test.
Introduction: Welcome to UAB Med Cast, a continuing education podcast from medical professionals bringing knowledge to your world. Here's Melanie Cole.
Host: Welcome to UAB Med Cast. I'm Melanie Cole and today we're discussing the Watchman procedure. Joining me is Dr. Tom McElderry. He's an Assistant Professor and the Section Chief in Electrophysiology and the Co-Director of the Heart and Vascular Center at UAB Medicine. Dr. McElderry, I'm so glad to have you join us today. Tell us a little bit about what you're seeing in the trends for a AFIB as of now.
Dr. McElderry: Oh yes. Great to have this conversation with you. Thank you for the opportunity. We have seen over the past 10 years or so. More and more patients come to the diagnosis of atrial fibrillation. I believe that access to medical care and in particular access to personal devices that will actually diagnose your atrial fibrillation has increased the number of patients that we have the opportunity to see nowadays and I think it's fantastic that people are taking such an investment in their own healthcare. And monitoring a number of different parameters including heart rhythm on their own.
Host: Well, that's certainly is true. So tell us a little bit about the American College of Cardiology and the American Heart Association focused update of their 2014 AFib treatment guidelines. What's changed?
Dr. McElderry: I guess a number of things have changed. Probably the most important is how we protect people from the risk of stroke and mini stroke and even memory problems and cognitive decline that can be associated with folks who have atrial fibrillation and aren't adequately managed. With the most recent update, they basically engineered aspirin as a treatment option out of the equation. There are two reasons for this. I think number one is aspirin really was not an effective therapy to help protect people from the risk of atrial fibrillation. And number two is that we have other blood thinner medicines that have exactly the same risk of bleeding but doing much better job of protecting people from the risk of stroke and systemic embolism. And like I mentioned, probably even memory problems and dementia as well. In addition to the blood thinner medications people can take there is another option that's particularly great for folks who have trouble taking blood thinners and that's left atrial appendage occlusion. And the one device that's on the market now is called the Watchman device.
Host: So as you've said, there are many oral anticoagulants and they're an important therapy, but they do come with risk factors and limitations and many patients don't even want to continue to take them so they need an alternative. You mentioned the Watchman. Tell us a little bit about this procedure, Doctor, and when you're, when you're really choosing it for your patients.
Dr. McElderry: I think initially we were very deliberate with the rollout of left atrial appendage occlusion. We wanted to see how the device handled in our own hands and make sure that the safety that we saw in clinical studies was the same safety that was out in clinical practice. And in fact, if you look at some of the registry data, it seems that complications continued to decline even past what we saw in the clinical studies. I think the Watchman is a great device for patients who either can't take blood thinners because they've had bleeding risk. Typically that's the GI bleeding. Also patients for it increased risk of a falls or other serious complications of oral anticoagulant therapy. And even in a number of patients, that cost becomes such an issue for these novel agents that they're just not going to take them. And we need to find another alternative to manage their risk of stroke.
Host: So then let's talk about patient selection and tell us who is an ideal candidate and who might not be a candidate for this procedure?
Dr. McElderry: Great. So I think almost anyone who has atrial fibrillation could be a candidate for this therapy. We initially focused on patients who had a contraindication or relative contraindication to oral anticoagulant therapy. But I think it's moving more into the realm of patient preference. So I think for the most part, anybody who's on oral anticoagulant therapy for an indication of Afib could be considered for this procedure. Now, patients who are on anticoagulant therapy for reasons other than atrial fibrillation or in addition to atrial fibrillation would not be good candidates for this procedure. Patients who are not able to take any anticoagulant therapy for any period of time also would not be good candidates for this procedure. Presently unlabeled, patients would be on warfarin for about six weeks and then be on dual antiplatelet therapy with aspirin and Plavix out in the six months.
And then aspirin alone. Clinical practice has really changed over the last several years where most of our patients are not on Warfarin at all if they are on one of the novel agents. We only keep that for six weeks and then transition to the Plavix and aspirin therapy. But many are, they're saying most of our patients only take dual antiplatelet therapy in conjunction with having the Watchman procedure. And we're typically stopping that in the four to six month range and transitioning to aspirin alone after that. So for folks who just couldn't take dual antiplatelet therapy, there would be a risk of device related thrombus and I don't think the Watchman would be a good procedure for those guys.
Host: Well, thank you for that answers. So as you're telling us why it's a good choice to reduce the risk of stroke as well as blood thinners, what's the procedure like? How does it work and do you have any technical considerations you'd like other providers to know?
Dr. McElderry: So the procedure is really pretty straightforward. Currently what we do is patients come to the heart and vascular center in the morning, we take them to the procedure room. We do a transesophageal echo at the time of the procedure. Initially we had been doing screening echoes, but we found that the rate at which people screened out for their procedure was so low that it just didn't seem necessary. So we actually do the screening, echo and the procedure at the same time. As long as the appendage is large enough for the device but not too large. Then we proceed with the procedure which is a femoral venous access followed by a transseptal puncture, and then entry into the left atrium, left atrial appendage. We place a pigtail catheter in the left atrial appendage and then advance a delivery sheath over that. And then we position the Watchman device in the appendage and retract the sheath, which unsheathes the device, which then expands in the appendage and we use the transesophageal echo to make measurements to show that the device is well approximated appropriately compressed and has no leaks around it. We've also started using some intercardiac echo to compliment that and it may be in the future that we eliminate transesophogeal echo altogether and do the procedure with intracardiac echo alone.
Host: How have been your outcomes Doctor?
Dr. McElderry: Oh, I think our patients have done really well. They've been very appreciative of the therapy and the lifestyle changes that it affords them by not having to take blood thinners. For the most part, patients are able to come in, have the procedure done and go home the next day. And so we've been very pleased with this device and look forward to some of the other devices that will come be coming out in the future.
Host: And talk about the post-implant drug regimen. You mentioned it a little bit before. Do your patients still have to be on their meds after this procedure?
Dr. McElderry: They do. I mentioned that on label therapy would have people on warfarin or maybe a novel agent for about six weeks. They would then have a transesophageal echo to confirm that the device was well approximated without significant lakes or device related thrombus. And then transition over to Plavix and aspirin, you know, dual antiplatelet therapy for about six months and then would decrease the aspirin therapy alone. For the most part though, we've really transitioned away from that and patients are on dual antiplatelet therapy for the first four to six months. They get a transesophogeal echo to confirm no device related thrombus and good approximation without leak. And then their transition to aspirin therapy for another six months. And then if all looks good at that point, they be on no oral anticoagulant therapy at that time.
Host: So as we wrap up, what does the future hold for stroke reduction in AFib patients? Do you have any interesting studies or research you'd like other providers to know, wrap it up for us?
Dr. McElderry: Oh, absolutely. I think this is an exciting space for us to begin. I think that the FDA and then us say you may be locally, we're, we're deliberate with this technology to ensure that it maintains the safety and efficacy of other comparable therapies. As I look to the future we're going to be involved in a study that looks at, in a randomized fashion and patients taking no act versus a left atrial appendage occlusion. I see that the Watchman flex device will probably be out in the next six months, which should make the implant procedure both easier and safer. And then we're also currently enrolling in a clinical study of the Watchman device versus the Wavecrest device, which is a left atrial appendage occluded with a little bit different design that we're excited about that technology as well. So I think this is something that we're going to be able to offer to more and more patients and I think the future is bright for left atrial appendage occlusion.
Host: Thank you so much Dr. McElderry for coming on with us today and sharing your expertise and telling us about the really fascinating Watchman procedure. Thank you again, a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. Please also remember to subscribe, rate, and review this podcast and all the other UAB podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua163.mp3
- DoctorsHapner, Edie;Simpson, Blake
- Featured SpeakerEdie Hapner, PhD, SLP | Blake Simpson, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4138
- Guest BioEdie Hapner, PhD, SLP is the Co-Director of the UAB Voice Center.
Learn more about Edie Hapner, PhD, SLP
Blake Simpson, MD is One of the first fellowship-trained laryngologists in the US. Director of the University of Texas Voice Center 1996-2019. Professor, Department of Otolaryngology-Head and Neck Surgery. Director, Division of Laryngology, Co-Director UAB Voice Center 2020-present.
Learn more about Blake Simpson, MD
Release Date: August 17, 2020
Expiration Date: August 17, 2023
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 commercial affiliations to disclose.
Faculty:
Charles Blakely Simpson, MD
Professor in Otolaryngology
Edie R. Hapner, PhD, SLP
Professor, Speech-Language Pathology
Dr. Hapner has disclosed the following commercial interests:
Grants/Grants Pending/Research Support – Lakeshore Foundation
Consulting Fee – Lewis Thomason Law Firm; Dickie McCamey Law Firm
Dr. Simpson has no commercial affiliations to disclose.
There is no commercial support for this activity. - TranscriptionUAB 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 .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
Melanie Cole (Host): Similar to orthopedic surgeons, working with elite athletes, the laryngologists and speech language pathologists treat the vocal elite athlete, the singer. Welcome to UAB Med Cast. I’m Melanie Cole and today, we’re talking about the art of treating the injured singing voice. Joining me in this panel are Dr. Blake Simpson. He’s a Professor in the Department of Otolaryngology and Division Director of Laryngology and Co-Director of the UAB Voice Center. And Dr. Edie Hapner. She’s a Professor in the Department of Otolaryngology and Director of Speech and Hearing and she is also Co-Director of the UAB Voice Center. Doctors, I’m so glad to have you here today. This is such a great topic. Dr. Simpson, I’d like to start with you. Tell us a little bit about voice medicine. How has it evolved over the years? Is this a new field of medicine? Tell us about it.
Blake Simpson, MD (Guest): Yeah, it’s interesting. It wasn’t even acknowledged as a subspecialty of otolaryngology really until probably the 90s. So, it’s in that sense, very recent. I think part of why voice medicine has evolved is we didn’t really understand the layered structure of the vocal folds. We hadn’t really seen vocal folds vibrate and when the technology came about in the 1980s, and we began to understand the complex physiology of vocal folds; I think that’s when the appreciation of voice science really started. But training in laryngology, actual fellowship training, didn’t start until the early 90s. So, as a subspecialty, it’s really evolved over the last 30 years or so.
Edie Hapner, PhD, SLP (Guest): I’d like to add that in speech pathology, it continues to evolve. Speech pathologists have a very broad scope of practice but over the past 17 plus years, we’ve started to move in the direction of laryngologists and trying to specialize in voice. So, I think we’re still evolving.
Host: Well I certainly agree, and I think that this is what an interesting field of medicine that you’re both in. So, Dr. Hapner, as I said in my intro, and like elite athletes, singers perform at such a high level with increased occupational demands and capabilities, skills that exceed the vocal abilities of most individuals. How does this put pressure on their voices? What are the most common injuries that you see in clinic?
Dr. Hapner: Like elite athletes, singers have demands on their voice like athletes have demands on their body. And they also have a level of expectation that means that they have to be there with their A game every single time they get on that stage. Knowing that, for example, are singers who also dance at the same time, on Broadway, who maybe do eight shows a week and a couple of days a week they are doing two shows a day, coming with you’re a game to every show demands a very high level of skill and training. So, that also means that there is a need for continuous training and also because of those vocal demands, there is an opportunity for voice overuse and injury with things on stage that you wouldn’t even think about. Like smoke to make a scene look better or heavy costumes and think about the traveling Broadway performer versus the Broadway performer. The traveling performer is in a different hotel every night, in a different city every week and a different venue every week. So, the demands are really high. Dr. Simpson can talk about the most common injuries.
Dr. Simpson: The most common injuries tend to be swelling at the mid portion of the vocal folds. As we’ve understood, vibration of the vocal folds, we know that the maximal trauma actually occurs at that mid-point of the vocal fold, that’s where the maximal collisional forces are. So, patients tend to get swelling there. That would probably be the most common injury that we would see. And that’s usually reversible, that will get better with rest or get better with voice therapy. I think one of the feared complications or injuries would be a vocal cord hemorrhage. So, you would have bleeding into the vocal cord. This is generally something that we take very seriously, and we put these patients on voice rest usually for at least a week. And they stop performing. So, this is the one injury that we would all agree needs to be treated very seriously.
Sometimes these hemorrhages will over time, expand and form a polyp so not uncommonly, we’ll see these in singers as they are more mature injury once they’ve had a few hemorrhages into their vocal cord.
Host: Well then Dr. Simpson, how do these injuries present themselves? Tell us a little bit about the clinical presentation and what you see.
Dr. Simpson: Yeah, so most of the singers we see, and I think Dr. Hapner would probably agree with me, come in not with speaking voice problems, but specifically with problems in their singing voice and it could be something very specific like my transitional register is giving me trouble or I’ve lost the top three notes in my range. It’s generally a fairly specific singing voice complaint. If it’s a more severe injury, obviously, they’ll come in also with speaking voice issues but not uncommonly it’s just the singing voice issue. And it could be loss of tone, it could be fatigue, it could be any number of problems that are interfering with their performance.
Dr. Hapner: Can I just add here too. You would expect to hear us say that they come in with complaints of hoarseness but that’s generally not it. That’s why it’s such a nuanced area. They come in and they say I can’t get the crispness in that top note or I’m just so exhausted that I don’t feel like I have the stamina. But rarely in these people, do we hear oh my voice is hoarse.
Host: That’s so interesting. And Dr. Hapner, before we talk about treatment modalities, tell us about what types of care are involved. Does it require the management of several aspects, a multidisciplinary comprehensive care model? Tell us how that works.
Dr. Hapner: Well I always say it takes a village. So, as a speech pathologist, I don’t practice without a laryngologist like Dr. Simpson who can look at the vocal folds, understands them, because he surgically gets to operate on them and to feel them and to be part of understanding how they are made up. But laryngologists to make a good diagnosis and then the speech pathologist generally comes in and – our goal often, with these patients is to get them back to healthy vocal folds. Whether they need surgery, or they don’t, to get them to use vocal behaviors that enhance healing. Kind of like an athlete on the disabled list. Our job is to get them healthy and then to help their transition to getting back to their elite level of singing with their voice teachers. So, already I’ve said there’s the laryngologist, the speech pathologist, and the singing teacher who are part of that core team in addition to the patient. But of course, there could be others. A pulmonologist if there’s respiratory issues, a gastroenterologist if there’s GI issues and sometimes a psychologist.
Host: Dr. Simpson, speak about some of the current issues in medical or surgical management. Tell us what treatments you might try, your first line of defense if someone comes to you with one of the injuries that we’ve mentioned.
Dr. Simpson: Probably the most common thing we would do for a singer would be voice rest. This is not as a cure. It’s only a Band Aid to let the swelling go down so we can provide further treatment in many other different ways we’ll talk about. But the most common thing we would do is first put a patient on voice rest. For swelling, we frequently use corticosteroids like prednisone, like a prednisone taper. These again, are sort of Band Aids when we see an injured performer. But ultimately, these people need behavioral treatment. They need to work with a speech pathologist on the way they are using their voice to use their voice more effectively and not infrequently, work with their singing voice coach in tandem with the speech language pathologist. As Dr. Hapner said, it really does take a village. I would love to think I could take care of patients by myself, but if you don’t have those – the core group of the speech language pathologist, singing voice teacher and the laryngologist, you are really not providing adequate care.
And interestingly it rarely comes to surgery. One of the talks I give is on treating the injured singer and one of the things I say is conservatism works. And that’s really true. You always start with the most conservative thing, voice rest, corticosteroids, working with the speech language pathologist, and only after other things have been tried, do we finally escalate up to a surgical procedure. In fact, I would say the majority of singers don’t need surgery. I think most of them can be treated with behavioral management and nonsurgical methods.
Host: Well then Dr. Hapner, tell us about those. What’s involved in the singer’s vocal rehab plan? What does that look like for the patient?
Dr. Hapner: You know it’s interesting Dr. Simpson talked about voice rest and just to put that in perspective. Voice rest doesn’t look like voice rest used to years ago. It’s much shorter and well-defined. As he said, maybe to add that extra layer of healing and getting reduced swelling. But the goal of the speech pathologist in rehabilitating anyone, especially singers with voice problems; first and foremost, is to allow for healing but we have to let people talk. The vocal folds are muscles. If you don’t use them, you lose them. So, we want to keep them moving and active and vibrating, but we teach people to be attuned to the level of vocal effort that they are using to make voice and effort translates to muscle strain, extra respiratory strain. And so, we teach people to be intuitive about using their voice and optimizing the way they produce their voice to allow for continued healing.
Once we have gotten the vocal folds to a pretty good medical state, then we’ll start to rehabilitate them back up to normal speaking and back to singing. I’ll just add this, it’s silly to think that somebody wouldn’t raise their voice ever in their life. You have to call to your neighbor. You have to call to your kids. But all of these vocal behaviors can be done in healthy vocal postures that don’t cause vocal injury down the road. Because our goal always is that the patient never needs to come back to us.
Host: Well that’s certainly true and Dr. Hapner, sticking with you for a minute, as we work with athletes, and we know that there’s this whole psychosocial and psychological aspect, mental fitness we call it, right, for athletes. But for singers, they have different emotional needs but just along the same lines. Speak about working with that psychological impact of voice problems when that is in a sense, their instrument, that is their livelihood. Tell us how you work with them.
Dr. Hapner: So, of course, I spoke to a group of singers today and they always talk about how they get in their head if there’s any little change, any vocal variability during a day. So, first and foremost, I, voice therapist, empower the singer to understand their vocal mechanism. It’s a black box. You can’t see it. so, we have to teach them how to understand how these mild, minimal vocal variabilities from day to day can be remediated or turned around with just some simple changes in a routine. And we all have vocal variability. Our voice is a mirror to our soul so depending on how we feel and how our day goes; our voice is going to represent that but if you stay out of your head, you don’t go down the rabbit hole of it getting worse and worse.
If a singer has a very big injury, that is going to sideline them from singing or performing or canceling a concert; that’s a much bigger deal. And sometimes, I actually encourage some professional help to help people understand that they may be temporarily broken as they think about it but let’s understand where we can be with some help, with some time and with some good care. How long is it going to take to get better and what is their role in getting better.
Host: Well that’s true. They certainly do. We have to work for ourselves and again, patients have to be their own health advocate and really do what you’re telling patients to do. Now Dr. Simpson, for other providers, how have been your outcomes. Tell us about the clinic and really what you’ve seen as why it’s so important for other referring physicians to look at the Voice Center at UAB Medicine.
Dr. Simpson: I think what we believe makes us stand apart from the other voice centers is that both Dr. Hapner and I over our careers have started a number of voice centers from the ground up and Dr. Hapner actually created the one in Emory and as well sort of resurrecting the one at University of Southern California and then I’d spent my career in San Antonio with the voice center there and we saw – I don’t want to say we’re all, but at the tail end of our careers, we saw an opportunity to collaborate and sort of design the [00:14:08] voice center that would sort of do what we couldn’t do in the past because now we’re working together. There is some synergy here. And we really wanted to make the [00:14:17] interprofessional clinic where we see the patient together, we design a collaborative plan of care. I think the patients get the best outcomes when you are really working together, seeing the patient together, coming up with your decisions as a group. And I think that’s what’s really is going to distinguish us as a voice center from all the others.
Host: Well then Dr. Simpson, tell us some of the most innovative technologies that support your work. What’s exciting in your field?
Dr. Simpson: Office-based procedures have become one of the most exciting things. we spent most of our careers taking patients to the operating room, putting them under a general anesthetic and working in that capacity. But as time has gone by, the technologies improved. We have better scopes to look at the patient, the optics are better. We have flexible laser fibers that can go through these scopes. So, now, under local anesthesia, with the patient sitting right in the clinic chair; we can take care of like small polyps on the vocal cord with the laser, with the patient completely awake. We’ve had a series we published a year ago on singers with vocal fold polyps that were treated just under local in clinic and successful outcomes that have been associated with that. So, that’s probably the technology I think that has been most exciting for surgeons. That ability to take care of the patient without having to go to the operating room.
Host: And Dr. Hapner, last word to you. Wrap it up. Let other providers know what’s so exciting about what you do for a living and the UAB Voice Center. Give us your best summary and what you’d like them to know about the art of treating the injured singing voice.
Dr. Hapner: I think what’s so exciting about the UAB Voice Center is that we have a three fold mission. We have the mission to state of the art clinical care and the University of Alabama Birmingham Department of Otolaryngology has supported us to set up a voice center where we have state of the art equipment. We have a flow that allows for the best patient care and so, that support cannot be matched in a lot of places.
So, we have state of the art clinical care. And the way we get to state of the art clinical care, is that we also have a mission towards research. And so, it’s not uncommon if you sit with us in any given clinical day, that we are furiously writing research ideas that have literally come from the person we just saw together in the clinic. And both Dr. Simpson and I are clinical researchers. So, we want to help find solutions and answers to questions that clinicians have. And we will as long as we are working together continue to do that.
And our last mission is teaching and mentoring. So, we both feel that it is our responsibility to develop the next generation of interprofessional voice care providers from the laryngology side, from the speech pathology side, and our involvement with the School of Music and other places and soon to be UAB, because we are so new here. I think will just reinforce the model of collaborative care. There’s a lot of studies that talk about collaborative care is what provides the best outcomes for patients with voice disorders. So, I’d like referring physicians to know that they are always welcome to call us, to ask us questions, to send us patients for second opinions and more than anything, we’re always willing to work with them and excited to work with them. And so, we hope that everyone will start engaging with us and give us a chance.
Host: Thank you doctors so much. As I said at the intro, what a fascinating topic. Thank you again for coming on and telling us about it. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. To refer your patient or for more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I’m Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua162.mp3
- DoctorsHurd, Bill
- Featured SpeakerBill Hurd, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4128
- Guest BioDr. Hurd has practiced clinical reproductive endocrinology and infertility for over 3 decades at a number of Universities and currently holds the academic ranks of Professor Emeritus of Obstetrics and Gynecology at Duke University School of Medicine, and Adjunct Professor of Obstetrics and Gynecology at the University of Alabama School of Medicine.
Learn more about Bill Hurd, MD
Release Date: August 14, 2020
Expiration Date: August 14, 2023
Disclosure Information:
William W. Hurd, MD, has no financial relationships related to the content of this activity to disclose. Also the planners, Ronan O'Beirne, EdD, MBA, and Katelyn Hiden, have no financial relationships to disclose.
There is no commercial support for this activity. - TranscriptionUAB 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 .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
Melanie Cole (Host): Welcome to UAB Med Cast. I’m Melanie Cole and today, we’re talking about a modern approach to women with polycystic ovary syndrome. Joining me is Dr. Bill Hurd. He’s a Professor and Reproductive Endocrinologist and Infertility Specialist at UAB Medicine. Dr. Hurd, explain a little bit about polycystic ovary syndrome. Is it a gynecological or an endocrine disorder? Tell us a little bit about it, how common it is, give us a little background on it.
Bill Hurd, MD (Guest): Yes. Polycystic ovarian syndrome is the most common endocrinologic abnormality in women. It is approximately 10% of all women and so, it’s a common thing that anyone who takes care of women patients is going to see in their practice. It is comprised of two out of three symptoms and or findings and the first of those is irregular menstrual periods. The second of those is increased hair. It could be bad enough to be called hirsutism or it could just be mildly increased hair on the upper lip, chin, chest and lower abdomen. And the final one is polycystic ovary morphology on ultrasound. If the patient has two out of three of those, that is by definition, PCOS as long as there’s not another underlying cause. So, the first thing that we do when we see someone that appears to have PCOS, is look for number one, an underlying cause that mimics PCOS and number two, any of the pathologies that go along with PCOS.
Host: Well thank you for telling us about the physical findings that would suggest PCOS. And as we’re talking about lab tests and diagnostic criteria; Dr. Hurd, why is this controversial in the medical community?
Dr. Hurd: I don’t think there is really anything controversial about it. It’s basically a standard thing and it’s got a standard approach to it. I think some people are more concerned about different symptoms that are associated with it. And that’s natural because it depends what the patient came in with that, they want help with. The first thing we do is we do a basic workup on them and looking for other causes, we check standard antigens including testosterone, DHES and 17-hydroxyprogesterone. And we also check just a TSH screen for hypothyroidism. Unless they have obvious signs of congenital adrenal hyperplasia adult onset; we usually don’t test for that. If those are out of the normal range significantly; then we have to worry about tumors of either the ovaries or the adrenal gland. If they are all in the normal range and some are slightly elevated; that goes along with PCOS and as long as they are not hypothyroid. Once we’re sure it doesn’t have an underlying cause, then the next part of the workup is to make sure they don’t have a problem that goes along with PCOS but is associated with it but probably not causal.
The number one, one of those is diabetes which is probably found in about 2% of people with PCOS and an additional 1% a year for as long as the patient has it. people with polycystic ovary syndrome are also prone to have metabolic syndrome which is something that the internal medicine physicians concentrate more on. The things that make that different from PCOS is that the patients are often obese, they have increased lipid abnormalities and they often have hypertension and or diabetes. So, they overlap, approximately half the people with polycystic ovary syndrome have obesity as a problem. But it’s not necessary or sufficient to make the diagnosis of PCOS.
So, those are the kind of tests that we order to make sure that they don’t have other associated things and then we focus on the patient’s concerns to see how we’re going to treat it.
Host: Well thank you for telling us about the other disorders that could be included in a differential diagnosis of polycystic ovarian syndrome. So, as we’re talking about treatment, Dr. Hurd, how is it treated, speak about pharmacologic treatments and also does treatment differ if a woman is trying to get pregnant or done with her reproductive years?
Dr. Hurd: Yes. It’s very important to figure out what is bothering the patient, what symptom that’s associated with PCOS that they want to be treated for. And the main ones are irregular periods, hirsutism and infertility. And so the very first question you find out from the patient is are they trying to get pregnant now or are they planning on getting pregnant in the future. If they are not planning to get pregnant right now, then the treatment is mainly focused on helping them have regular menses and decreasing their increased hair. In extreme cases, it can actually have male pattern hair loss which is very distressing to people but that’s not common. More commonly, they have increased hair that they can deal with but is some nuisance on their face and chest and lower abdomen.
The cornerstone of treatment for these people is to decrease free androgens or the androgen effects and that’s done primarily by two medications. The first one is oral contraceptives. The estrogen in oral contraceptives increases sex hormone binding globulin by stimulating the liver and this decreases free testosterone. It also decreases the FSH and LH stimulation of the ovary and so this decreases androgen secretion by the ovaries. The second part of treatment for the more extreme hirsutism cases is to block the androgen receptors directly and the most common drug to use that is spironolactone. It’s a very safe antiandrogen. It has very little risk and very little side effects. The most common side effect we see is if you give it to someone having regular menstrual periods, some of them will become irregular. So, we routinely only use it in people who are on oral contraceptives to keep them regular.
This is also important because it could have negative effects on a developing fetus since it blocks testosterone which is important especially in the development of a male fetus.
Host: What about lifestyle? Is there any lifestyle changes in the treatment of PCOS? And what would you like other providers to counsel their patients on as they look to some of these treatments?
Dr. Hurd: The biggest worry to women is that it’s going to make them heavy and hairy. And certainly, more than half of people with PCOS do have problems with being overweight and of course hirsutism is part of the triad. Not only do they have trouble with being overweight, but overweight makes the syndrome worse. Many of these women are insulin resistant and that’s why there are so many diabetics in the group. So, the way to help insulin resistance, there’s two. One is to have them lose weight and the other one is if the patient is either prediabetic or diabetic, then an insulin sensitizer most commonly metformin can help with this.
So, if a woman is overweight, we strongly encourage her to try to lose weight to see if that will help with her insulin resistance. There’s good data to support that insulin directly stimulates theca cells in the ovaries to make more androgens. So, in that group of women, it is not only the effect of PCOS but it’s also a cause of it. Now, it’s not the only cause of PCOS because almost half the women are not overweight, they are slender, and these women aren’t going to turn into heavy women. They have a different cause of their PCOS.
So, if the woman is heavy, the number one thing we say is they need to work on weight reduction which is as everyone knows, a very difficult thing for many women to do. It takes a lot of support. It takes a lot of work on increasing activity, decreasing portion size and decreasing carbohydrate intake. We routinely send our PCOS patients who are overweight to a weight reduction program here at UAB that’s been very effective in helping them.
Host: Dr. Hurd, is there a role of surgical intervention for treatment of PCOS? Risks and benefits. Speak about that a little bit.
Dr. Hurd: You know the other group we haven’t talked about yet are people with infertility. It is one of the most common causes of infertility, probably 40% of the women who are having trouble conceiving have PCOS in this population. And so, those people that can’t be treated for their increased hair because those drugs are not good in pregnancy, but the treatment is to get them to ovulate. Most commonly, we can do this with either traditional clomiphene citrate or the commonly used now letrozole which is aromatase inhibitor. So, we try to get them to ovulate. Some of them end up needing in vitro fertilization.
Decades ago, they did a wedge resections on ovaries and more recently, we did ovarian drilling, a laparoscopically cauterizing the ovary and decreasing the androgen output. And this seemed to work okay but it caused adhesions and is not commonly done anymore. So, the answer is yes there are surgical things that can temporarily treat the syndrome, but they are not used commonly because they do cause scar tissue in the pelvis.
Host: Dr. Hurd, this is such a great topic. And as you said, such a common syndrome that you see. what would you like other providers to know and primary care providers, gynecologists that are seeing adolescents or women in their reproductive years and they’re wondering, the diagnostic criteria. Wrap it all up for us what you would like them to know about referral and diagnosis for PCOS?
Dr. Hurd: I think most people that have a interest in gynecology and gynecologic problems will want to stay up to date and know the standard diagnostic workup for these patients and the standard treatment. Once it gets to infertility, if they do any kind of infertility, they can certainly use oral medications to induce ovulation and if this doesn’t work send them to an infertility doctor. The only other thing that we haven’t mentioned that’s important is these women are at approximately three plus times as likely to have endometrial cancer in their life related to not ovulating. And so the last thing the gynecologists or primary care doctors should do is allow these women to go months and months without periods. They should be on some sort of contraception that has progesterone in it which is birth control pills, IUDs with progesterone or IUD implants or injections. This protects the endometrium and probably puts them back in the normal risk for endometrial cancer.
So, if they’re not able to follow patients with this kind of thing then they definitely should refer them to either an interested gynecologist or a reproductive endocrinologist.
Host: Thank you so much Dr. Hurd. Fascinating information. Thank you again for joining us. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I’m Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua161.mp3
- DoctorsRocque, Brandon;Davis, Drew;Ransom, Erin
- Featured SpeakerBrandon Rocque, MD | Drew Davis, MD | Erin Ransom, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4123
- Guest BioDr. Rocque has a primary focus in pediatric neurosurgery, including care for hydrocephalus, spina bifida, spasticity, peripheral nerve injuries, Chiari malformation, and pediatric brain tumors,. In addition, Dr. Rocque practices general adult neurosurgery at the Birmingham VA Medical Center, with a focus on care for spinal disorders.
Learn more about Brandon Rocque, MD
Drew Davis serves as Medical Director for the Division of Pediatric Rehabilitation Medicine at Children's of Alabama. He is an Professor in the UAB Department of Pediatrics at Children's of Alabama and the UAB Department of Physical Medicine and Rehabilitation (PM&R).
Learn more about Drew Davis, MD
Erin Ransom, MD Specialties include Hand Surgery, Orthopedic Surgery and Pediatric Hand Surgery.
Learn more about Erin Ransom, MD
Release Date: August 14, 2020
Expiration Date: August 14, 2023
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 commercial affiliations to disclose.
Faculty:
Richard Drew Davis, MD
Professor in Pediatric Physical Medicine and Rehabilitation
Erin Ransom, MD
Assistant Professor in Orthopedic Surgery
Brandon Rocque
Associate Professor in Pediatric Neurosurgery
Dr. Davis has disclosed the following commercial interests:
· Grants/Grants Pending/Research Support – Lakeshore Foundation
· Consulting Fee – Lewis Thomason Law Firm; Dickie McCamey Law Firm
Drs. Ransom and Rocque has no commercial affiliations to disclose.
There is no commercial support for this activity. - TranscriptionIntroduction: 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 0.25 AMA PRA category one credit. To collect credit, please visit UABmedicine.org/medcast, and complete the episodes Post-test. Welcome to UAB Med Cast, a continuing education podcast for medical professionals, bringing knowledge to your world. Here's Melanie Cole.
Melanie Cole: Welcome to UAB Med Cast. I'm Melanie Cole, and today we're discussing the multidisciplinary brachial plexus peripheral nerve program at UAB Medicine. Joining me in this panel discussion are Dr. Erin Ransom. She's a Hand Surgeon, Orthopedic Surgeon, and an Assistant Professor at UAB Medicine. Dr. Drew Davis, he serves as the Medical Director for the Division of Pediatric Rehabilitation Medicine at Children's of Alabama. And he's also a Professor in the UAB Department of Pediatrics at Children's of Alabama. And Dr. Brandon Rock, he's a Pediatric Neurosurgeon and an Associate Professor at UAB Medicine. Doctors, thank you so much for joining us today. And Dr. Rock, I'd like to start with you. Tell us a little bit about the prevalence and complications of children with brachial plexus and peripheral nerve disorder.
Dr. Rock: So, the brachial plexus is a network of nerves that that connects the spinal cord in the neck with all the muscles of the arm. So the most common brachial plexus injury that we see is actually an obstetric injury or an injury that happens at the time of birth. That happens in about one out of every thousand or two out of a thousand live births in the United States. We see other brachial plexus and peripheral nerve injuries as well. It can happen with a car accident, motorcycle accident, you know, sharp injuries, such as glass or knives, things like that. And in our clinic at Children's our most common injuries, definitely the birth injury.
Host: Well then Dr. Ransom, can you expand on the cause that we know as of now and when you typically see these injuries?
Dr. Ransom: So, the majority of the patients that we see in our clinic are from brachial plexus, birth injuries. And so they occur during delivery and it's not just during spontaneous vaginal delivery, but it can also occur during C-sections as well. But at some point there is a stretch of the nerves as they go from the neck down into the arm, as Dr. Rock described. As far as the traumatic injuries that we see a lot of times those are also from the stretch and it can be from a motorcycle accident or a car accident, or from any way that the arm is stretched. And then the last least common way that we would see would be those penetrating injuries, where there's an actual stab or a laceration to the nerves themselves in that area.
Host: This is so interesting. And so Dr. Davis tell us a little bit about what's involved in the workup and how these are diagnose? And then I'd like you to get into some conservative management and nonsurgical treatment options for us.
Dr. Davis: So, whenever we see children in our clinic and most commonly, this is birth brachial plexus injuries, we're reviewing their birth history, getting that detailed birth history and any potential complications that occurred at the time, whether there was a history of shoulder dystocia, or a prolonged extraction, a C-section or a vaginal delivery. And then were, you know, asking questions about what the function of the extremity was, the arm was shortly after delivery, and then we're observing and examining for ourselves that day in clinic to either confirm what we think is a brachial plexus injury based on the history and the exam we see. Or perhaps considering another diagnosis such as hemiplegic cerebral palsy, which sometimes can occur in masquerade as a brachial plexus injury in a very young child. Typically we're seeing children within the first weeks and certainly the first few months of life. And so their neurologic exam can still be an evolution at that time if there are other confounding factors contributing to their presentation. And we're initially prior to considering any more aggressive intervention, just looking at the basics of a home exercise program and a occupational therapy program.
We want to make sure that families understand how to put an arm through the full range of motion at all joints and all joints that are effected, whether that's the shoulder, the elbow, the wrist, the hand, the fingers to make sure we don't lose range so that as the arm strength improves and the function improves, they've got a full functional range of motion. As children get a little bit older, certainly therapy continues to be a part of their intervention, but if they're not a surgical candidate then there are other things that we consider. Some children develop tightness because the muscles that are intact, you're overpowering the weaker muscles. And so at times we will perform botulinum toxin injections, which is somewhat more aggressive of an intervention, but not a surgical intervention. We at times will also have children go through more intensive forms of occupational therapy. One form in particular is called constraint induced movement therapy which incorporates aspects of retraining the brain where a child, because they didn't have as much functional use early in life may have developed a predisposition overall to use that extremity less. And so the principles of constraint therapy, which are taken from actually stroke rehabilitation, can be applied to the brachial plexus population.
Host: Isn't that so interesting now, Dr. Rock, tell us a little bit about the brachial plexus and peripheral nerve program at UAB and the collaboration with Children's of Alabama. Describe for us a little bit about the program highlights and features and tell us how the clinic has a focus that's engaging multidisciplinary teams to best treat these patients?
Dr. Rock: Our clinic is truly a multidisciplinary clinic, and that's something that we've watched develop in particular over the last five to 10 years. When I started in the program that it was already a, you know, a multidisciplinary clinic with neurosurgery and rehabilitation medicine, but we brought orthopedics into the clinic as well, and that has been a major contribution for our patients. As Dr. Davis mentioned that the treatments that are available for this, there are conservative treatments and of course, surgical treatment. Now most infants with a brachial plexus injury, 60 to 80% of them will recover function a lot of function on their own and will not go on to need a nerve reconstruction or nerve surgery. But while they are recovering, it's crucial that we pay attention to how the joints move in particular, the shoulder, even kids that recover pretty well. And certainly those that have nerve surgery and go on to recover after a surgery, they still require a lot of attention to the shoulder joint, and in the long-term that's, I think what really drives the outcome and how satisfied these kids and these parents are with their function. It's how well the shoulder moves. So having orthopedic surgery in the clinic, and ready to, you know, pay attention to that and intervene there with shoulder surgeries, as necessary as a real key part of what we provide.
Host: Dr. Ransom, why don't you jump in here and tell us a little bit more about where orthopedics fits in to this picture and to create this clinic in multidisciplinary approach?
Dr. Ransom: Like Dr. Rock and Dr. Davis mentioned the shoulder and problems that they can have with the shoulder coming from the weakness, and the nerves can be a tricky problem to tackle. The shoulders are a really complex joint, and that it, it's almost like a golf ball on a golf tee instead of a ball in a socket. And a lot of the movement of the shoulder what's important about it is the force couple between the muscles that internally and externally rotate the arm and the muscles that lift and depress the shoulder too. And with part of those being injured you lose that mechanism of how it moves. And so all of the stretching and the Botox and the intervention that we have for these kids while they're recovering are really helpful to help make sure that that shoulder moves normally, even though the baby doesn't have the way to move the shoulder itself. And that's where the parents participating in stretching every single day really comes in to being important for these kids.
Host: Well, it certainly, doesn't Dr. Davis, what are some of the special things that your team does to go above and beyond? Tell us a little bit more about the program, how you interact with the parents and what you would like referring providers to know about this program at UAB Medicine?
Dr. Davis: Certainly. Well, and one of the things to add on to what's been stated about the multidisciplinary nature of this. One of the things that we all benefit from is we have an occupational therapist that has been working in this clinic longer than any of us. And so there's a degree of institutional wisdom in this clinic in continuity over time, that has really been remarkable. It's rare that you have a therapist that's been working in the same area for, you know, over a decade. And so one of the things that's very unique is in addition to coming into our clinic and seeing, you know, all these highly trained physicians is you have an occupational therapist who spends time in a hands on fashion with these children and these families, teaching them everything that they need to know at this particular, whatever stage of care they are in. If it's their first visit, their fifth visit or their 10th visit, or if they're coming back years later, just for surveillance of their outcome and a maintenance program, they're in the hands of a very experienced occupational therapist.
Not only are they in the hands of that experienced therapist, but this person has a network of folks around the state that they know that they can reach out to, to help provide localized care so that people aren't coming back to UAB and children's more frequently than they have to. I think additionally, the fact that when children come to clinic, of course, we each have our areas of focus, but we are continually looking at the child's overall development. Certainly an arm is an important part of their development, but we have to take into account the whole child. And so if there are other challenges with development, a child may not respond to more engaged therapy versus a child who has no other medical or developmental issues and is very engaged and therefore might benefit from the constraint therapy I mentioned earlier. That can be applied at a very early age with the child that is very engaged. So we're always looking at the entire child's development. What can we do specifically for the arm that we're looking at, or the joint in particular that we may be most focused on, but also how does that fit into the context of the child's overall development, as well as the family structure, where they live, the resources they have, etcetera.
Host: And Dr. Ransom, your final thoughts and what you would like other referring providers to know about the program at UAB and Children's of Alabama?
Dr. Ransom: I think just knowing that not only is the family and the child going to get to see three different specialties, plus an occupational therapist with years of experience we all work together as a team and really collaborate on deciding what the, what the best treatment is for these children. And we work together so though they may have the same four individual people. They're actually seeing a team that's working together for the best plan for their child. And I think that that's something special and different that we offer here. And that is a great program.
Host: And Dr. Rock last word to you, what can be done between referral and the actual appointment with the specialists and the team, and what would you like to summarize? What would you like other providers to take away from this great segment about this collaboration between UAB and Children's of Alabama for the brachial plexus and peripheral nerve?
Dr. Rock: The key points to take away from this one for infants, with a brachial plexus injury, we want to see them as early as possible. As I said, 80% of these kids may get better on their own without, without a surgical intervention, but having them in the clinic early, it just a couple of weeks of age, and then being able to follow them over those first six to eight months of life, we really get a sense of how they're progressing and it makes it a lot easier to make decisions about whether they need a nerve operation or not. And the second point I'd like to make in closing is that we've talked a lot about infants with birth injuries here, but this is a true nerve clinic. And we see patients of all ages up to their early twenties at Children's of Alabama with nerve injuries of all different causes. And with our team, we have the ability to do, you know, primary nerve repair with grafting, nerve transfers, tendon transfers, whatever, whatever operation is appropriate for a given person to increase in and restore their function to the greatest extent possible our team is ready to provide that. So I appreciate the opportunity to chat with you guys about that today.
Host: Thanks to all of you, what a great informative segment. Thank you again for joining us. And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. Please also remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua155.mp3
- DoctorsLiptrap, Elizabeth;Lyerly, Michael
- Featured SpeakerElizabeth Liptrap, MD | Michael Lyerly, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4143
- Guest BioDr. Elizabeth J. Liptrap grew up in Maryland and received a B.S. in Biochemistry and Molecular Biology from the University of Maryland, Baltimore County (UMBC). She received a medical doctorate from the University of Maryland School of Medicine in 2011.
Learn more about Dr. Elizabeth Liptrap
Michael Lyerly, MD is an Associate Professor (P), Neurology , School of Medicine 2013 -.
Learn more about Michael Lyerly, MD
Release Date: August 18, 2020
Expiration Date: August 18, 2023
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 commercial affiliations to disclose.
Faculty:
Elizabeth J. Liptrap, MD
Assistant Professor, UAB Brain and Tumor Neurosurgery
Michael J. Lyerly, MD
Associate Professor, UAB Neurology & Vascular Neurology
The planners have no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionIntroduction: 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 0.25 AMA PRA category one credit. To collect credit, please visit UABmedicine.org/medcast, and complete the episodes Post-test. Welcome to UAB Med Cast, continuing education podcast for medical professionals, bringing knowledge to your world. Here's Melanie Cole.
Melanie Cole: Welcome to UAB Med Cast. I'm Melanie Cole and today we're discussing mechanical thrombectomy for stroke. Joining me in this panel discussion are Dr. Michael Lyerly. He's a Neurologist in Vascular Neurology and an Associate Professor at UAB Medicine and Dr. Elizabeth Liptrap. She's a Neuroendovascular and Vascular Neurosurgeon and an Assistant Professor at UAB Medicine. Doctors, I'm so glad to have you on today and what an exciting topic so much happening with mechanical thrombectomy. Dr. Lyerly, I'd like to start with you, if you would explain a little bit about prehospital management and field treatment, tell us what's important as far as latest clinical guidelines for stroke.
Dr. Lyerly: Absolutely. As I think a lot of people are aware, stroke is a highly time sensitive diagnosis that it really starts with detection in the field by either the patient or a bystander. And having that patient quickly entered into a stroke system of care by way that they can get access to a hospital as quickly as possible. Right now we don't have any treatments that we can offer somebody who is having an acute stroke in the field because the first step that really has to be done is they have to get to a hospital quickly so that they can undergo imaging studies, usually with a non-contrast head CT scan. As we'll talk about, we're doing more studies now to further investigate that and have expanded our diagnostic studies once the patient gets to the hospital, but really there's not a whole lot going on in terms of treating the patient in the field yet right now. Where things are starting to evolve is with mechanical thrombectomy, not every hospital is able to offer that therapy.
And a small proportion of patients who are having an ischemic stroke would benefit from getting to a hospital that has these capabilities of treatment. And in order to do that, what's being done in the field now is trying to better triage a patient, which means determining what type of stroke that they might be having. If the stroke is severe enough that they may be having a stroke because of a large vessel occlusion, and then determining what's the optimal hospital for them to go to. Once they get to a hospital that is able to offer endovascular care, we're starting to do more multimodal imaging now, including CT angiograms and CT perfusion scans in order to identify if the patient does have evidence of a large vessel occlusion. And if so, if there is salvageable brain tissue, that might be a minimal to a reprofusion therapy.
Host: Well thank you for answering a question I was just going to ask about brain and vascular imaging and what's new and exciting. Dr. Lyerly sticking with you just for a minute. What is new and exciting as far as vascular imaging?
Dr. Lyerly: Well, these studies are not new studies per se, it's that we're using them for a new application. CT angiograms and CT profusion scans have been around for years if not decades, but what we're doing now is we've learned that when using CT profusion scans, we can more reliably determine what area of a brain that is having a stroke has irreversible damage versus what area potentially has salvageable tissue. Many of our listeners may have heard the term penumbra before, which basically means an area of brain that has become stunned, but not necessarily irreversibly damaged because of lack of blood flow. And that's really the name of our game is trying to identify what area of the brain can we potentially save. And that's what the CT profusion scan is offering for us now. Another new development is we have a new processing software in the past. It was quite an undertaking to process the images from a CT perfusion scan, particularly in a timely manner, to be able to return them to a clinician, to make a timely treatment decision. Now, we have computer automated algorithms that can rapidly interpret the images that come through and provide those images in a very easy to understand color map, to help a clinician make a quick treatment decision to determine is this a patient that we should be taking to the catheterization lab.
Host: And before we discuss the use of endovascular interventions, Dr. Lyerly tell us about the use of TPA and its implications for rapid response treatment
Dr. Lyerly: Right. Right. So TPA or Alta place has been really the mainstay of acute stroke treatment. And when we're talking about stroke, we're talking about ischemic stroke. This has been around for a little over 20 years now. So we have quite a bit of experience with it. TPA is a clot busting medicine that can hopefully restore blood flow to an artery that is blocked off. Although the benefit really only helps about one in three patients. So a large majority of our patients still don't receive the full benefit of recanalization after they receive Alta place. There are some downsides to the medication, including risk of hemorrhage or an Anaphylactic reaction, but it right now remains the only FDA approved medication for somebody who's having an acute ischemic stroke. So that's been our mainstay treatment and all that we've had to offer a patient, but over the past decade, as we've seen more and more patients coming in with very large strokes, particularly due to large blood clots, we've realized that TPA is just not going to be enough that medication can start to eat away at the end of a clot. But at the end of the day, it's very unlikely to be able to dissolve a large blood clot that causes a large vessel occlusion. And so for those patients up until several years ago, we really have not had much that we can offer those patients. And that's really where mechanical thrombectomy comes in as a new option that we can use to treat these patients
Host: Dr. Liptrap onto you. So tell us about the use of those endovascular interventions, such as mechanical thrombectomy. What are the latest clinical guidelines for indications for use?
Dr. Liptrap: So the latest clinical guidelines are that patients can be treated sometimes up to 24 hours. As Dr. Lyerly had mentioned previously regarding the use of the CT angiograms, CT perfusion scans, and the software that can rapidly process that imaging that has helped us identify patients who although they presented later could potentially benefit from thrombectomy. In the past, it was thought that, you know, patients could be treated if they presented within six hours of symptom onset, but there've been new clinical trials that showed that certain subsets of patients, if they have favorable imaging showing that there is a decent amount of brain volume to be saved, could benefit from mechanical thrombectomy. So you know, Dr. Lyerly or someone from his team will often contact us letting us know that there's a patient, who's a potential candidate. And once the patient is in the hospital, then we assess the patient together. And often they'll undergo vessel imaging and possibly profusion studies to determine if the patient's a candidate. And then sometimes we'll have the patient be intubated if needed, prior to the procedure. And then we'll take the patient to our angio suite where we have a team that that is either already in the hospital or, you know, within 30 minutes of the hospital. And will take the patient for the procedure then.
Host: Well, Dr. Liptrap, tell us a little bit about patient selection and why that's such an important aspect of this? Is this treatment for everyone who's had a stroke or are there certain patients for whom this is not an option?
Dr. Liptrap: Yeah, that's a good question. So the reason why there had been the time limit in the past was the thought that, you know, after six hours or a certain timeframe, the amount of brain tissue that was going to be damaged by the vessel occlusion would be you know, completely gone. And so if there is no brain that can be saved, it's not worth putting the patient through the risk of the procedure, because, you know, as with any procedure, there are risks involved. You can have injury to blood vessels. Once the blood clot has been taken out. Sometimes there can be bleeding into the damaged brain tissue. And while the procedure is often you know, can be beneficial. There certainly are risks and we don't want to put the patient at risk if there's not going to be a benefit.
Host: Well, tell us a little bit Dr. Lyerly of the benefits of this treatment versus other treatments to the patient and to the provider.
Dr. Lyerly: As I mentioned Alta place or the TPA, the clot busting drug is really only effective in about one in three patients. Mechanical thrombectomy originally had some good data, but the more studies that have been done, the more we've actually seen some pretty phenomenal results come out of it. We've seen numbers upward of the mid to high 80% of patients actually getting that blood vessel completely reopened that doesn't necessarily always translate to a clinical benefit just because we can get a blood vessel open. If damage has already been done that may not translate to meaningful clinical improvement for the patient, but the studies that have been done with these procedures have actually shown that a large majority of the patients who undergo the thrombectomies do have a favorable outcome, meaning that they either get back to normal, or they're leading a near normal, independent life. And that's something that we've not been able to offer these patients in the past.
Dr. Liptrap: And that is very exciting that those statistics, but then also even for the patients who don't necessarily clinically improve a lot sometimes just taking out the occlusion can prevent a patient from having life-threatening swelling of the brain that can sometimes come with strokes. And so you know, we found, you know, a number of benefits that maybe weren't even realized previously with thrombectomy.
Dr. Lyerly: And if I can just add one additional thing, a lot of times in medicine the benefit that a patient may receive is measured or reported in clinical studies as the number needed to treat. The number of patients that must receive a treatment or a therapy in order to benefit from it. And the number needed to treat that we found with some of these procedures is sometimes just under three patients and looking at other therapies that are out there in medicine. That's a pretty phenomenal number to be able to see something that low, that just treating a few patients will result in at least one of them having a significant benefit with returning to either a completely normal or near normal functional status. In the past, if we were not able to offer that treatment to the patient, the likelihood of them returning to that level of functioning was probably less than 15 to 20 percent
Host: Dr. Liptrap, does it require a learning curve, are all institutions doing it now for select patients?
Dr. Liptrap: The procedure certainly does have a learning curve. People who perform mechanical thrombectomy for stroke are typically neurosurgeons, a radiologist or neurologist who've had specialized training. And you know, these doctors go through residency and then often go through fellowship or a number of fellowships to be able to do the procedure. And so not all institutions have the capability of performing a thrombectomy. And so that's why patients will often be transferred to a facility that can, so, you know, for instance we at UAB get patients transferred to us from a number of facilities so that we can potentially offer them this treatment.
Host: Dr. Lyerly before we wrap up, give us your final thoughts on referring physicians to a designated stroke center, such as UAB Medicine, why you feel that's so important and what you'd like them to know about any exciting advances in stroke treatment.
Dr. Lyerly: So I think right now we're seeing more and more specialization of different hospitals offering different treatments and different levels of care for stroke patients, including certification levels of primary stroke centers and comprehensive stroke centers. It's been fairly well established that patients who undergo care at a certified stroke center of any type have better outcomes and are more likely to be put on correct medications to reduce the risk of having another stroke in the future. The comprehensive stroke center designation means that the hospital is able to provide 24/7 endovascular care as well as access to neurologists, neurosurgeons and neuro critical care physicians. So they really get the whole package of stroke care. And so one message here is that it's better for the patient in their best interest to be referred from a community hospital to a stroke hospital so that they can get that comprehensive level of care throughout their hospitalization.
Furthermore, these hospitals also have designated areas within the hospital called stroke units, where the nurses are particularly well-trained in stroke care and neurological assessment, as are all of the therapists. And so that's why it's very meaningful to get a patient to a certified stroke program so that they can receive this care. What is new is obviously where we are with this thrombectomy. And I think most physicians have become pretty accustomed to the time windows that we have for using Alta place up to four and a half hours. But the knowledge about the time windows for endovascular care are, have just not been well disseminated down to the community yet. So we still see a lot of hesitation among referring physicians to get a patient to a stroke center in a timely manner, because may not be aware that we do have additional therapies that we didn't have even five years ago to offer these patients.
Particularly as Dr. Liptrap was explaining, using profusion imaging to select a patient even up to 24 hours, is something that really has only come about over the past two to three years. And certainly we want to be able to get to those patients as quickly as we can. And so, for me, that has been the biggest thing that has happened in stroke. We've gone from being able to only take care of a patient out from a few hours from when their symptoms have started. We're now able to potentially take care of patients 24 hours, which five years ago, people thought was completely unheard of.
Host: Dr. Liptrap, last words to you. What would you like referring physicians to know about some of the exciting advances and mechanical thrombectomy and why they should refer to UAB?
Dr. Liptrap: But at UAB, we do 150 to 200 and we're on track to do, you know, even more stroke cases per year. So we have a lot of experience. And we've got great Neurointerventionalists here Dr. Harrigan, Mark Kerrigan and Dr. Jesse Jones are both my partners and they're excellent. We have a great relationship with our neurologist and our neuro critical care team. And so we all work very well together to provide the most comprehensive care for the patient. Regarding mechanical thrombectomy itself, there are currently you know, a number of techniques we use to try to get the clot out, whether it's aspiration, stent retrievers, which kind of grab the clot and help you pull it out and flow reversal to aid in the removal of the clot. And neuro interventional radiology is a field where there are advances happening pretty much every day with new catheters, new techniques, and you know, at our group, we like to stay on the cutting edge of what the most you know, most current treatments are. So it's a very exciting time. And you know, in the future, I'm sure that we're going to just be able to improve outcomes for patients.
Host: Thank you Doctors, so much for coming on and sharing your incredible expertise. It is an exciting time in your field. And thank you again for joining us. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. Please remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua157.mp3
- DoctorsKennedy, Greg
- Featured SpeakerGreg Kennedy, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4118
- Guest BioDr. Kennedy graduated from the University of Washington School of Medicine and received his PHD in cancer biology from the University of Wisconsin where he also completed his general surgery training.
Learn more about Greg Kennedy, MD
Release Date: August 13, 2020
Expiration Date: August 13, 2023
Disclosure Information:
Gregory D. Kennedy, MD, PhD, has no financial relationships related to the content of this activity to disclose. Also the planners, Ronan O'Beierne, EdD, MBA, and Katelyn Hiden, have no financial relationships to disclose.
There is no commercial support for this activity. - TranscriptionUAB 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 .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
Melanie Cole (Host): As treatment strategies for patients with colorectal cancer advance; there has now become an ever increasing need for multidisciplinary teams to care for these patients. Welcome to UAB Med Cast. I’m Melanie Cole and today, we’re discussing the multidisciplinary management of colorectal cancers. Joining me is Dr. Greg Kennedy. He’s a Professor of Surgery, the John H. [00:00:56] Chair in General Surgery and the Director in the Division of GI Surgery at UAB Medicine. Dr. Kennedy, it’s a pleasure to have you join us again. Tell us what you’re seeing in the trends for colorectal cancer, before we get into some of the treatment options.
Greg Kennedy, MD (Guest): Well there’s a lot of good things happening in colorectal cancer Melanie. So, first, colorectal cancer is the third most common cancer diagnosed in both men and women in the United States. So, it remains a really important problem. However, the incidence is decreasing over time recently in certain populations. Which is a great thing. We think that’s because of a combination of factors probably increased screening and detecting the tumors at earlier rates. But there remains reason to be cautious. There is some evidence that there is worse outcomes still in our minority populations and we also have some evidence that it’s increasing in incidence in the younger patient populations.
So, while there’s some positives in colorectal cancer, there remains some certain challenges that we still have to be aware of.
Host: Is there anything new and exciting as far as screening?
Dr. Kennedy: Well some – new and exciting is always relative isn’t it. But certainly, colonoscopy remains the gold standard I would say for screening. But we certainly have some newer tests that have hit the market in recent years, in the last five or ten years with the FIT test, the fecal immunochemistry test that is looking for small quantities of blood and also some of the DNA testing, DNA-based tests made by some companies around the country that have been approved. Now these tests are good for detecting cancer, not necessarily good for detecting polyps. So, colonoscopy remains the gold standard.
But I think that the newer tests do increase access to screening for patients in the more rural communities who perhaps don’t have availability of providers that do colonoscopies so, I think there’s some real positives there.
Host: There certainly is. That’s so interesting. So, now let’s talk a little bit about the multidisciplinary management of colorectal cancer. Why is this so important? Is it new Dr. Kennedy? Has it always been this way?
Dr. Kennedy: Multidisciplinary management of cancer in general, has really been pushed in the major medical centers over the last ten to fifteen years. It’s been hypothesized that this multidisciplinary care would enhance preoperative evaluation, give patients increased access to specialists and multimodal therapy. And in fact, it’s been shown to do that in many other cancers beside colorectal cancer. Pancreas cancer, lung cancer, breast cancer, et cetera and in those treatment pathways, they’ve seen- we’ve seen the adaptation of multidisciplinary care really become the standard of care. This is where patients are seen and evaluated by a group of specialists from different fields, medical oncology, radiation oncology, and surgery. Colorectal cancer, it’s not necessarily been the standard of care until recent times. Some of that’s been the advent of the American College of Surgeons bringing forth the National Accreditation Program for rectal cancer that’s really put a spotlight on multidisciplinary care and some of the inadequacies of rectal cancer care in the country and here in the United States.
These are patients who are being treated without the multimodal approach. So, not getting the appropriate staging preoperatively, not getting the appropriate treatment preoperatively, being rushed right to surgery. It’s pretty clear that that approach, that sort of rushed approach has worse outcomes. So, definitely, this more multidisciplinary care has become more and more popular and it’s really the standard of care here at the University of Alabama at Birmingham.
Host: So, then tell us what that looks like for your team Dr. Kennedy. Who are the primary multidisciplinary team members?
Dr. Kennedy: Well we – like everyplace, we have a – like everyplace that does this, we have a diverse group. We use radiation oncologists, the medical oncologists, the surgical oncologists as well as the colorectal surgeons. We all participate. We’ve got a very robust group here. When a patient receives a new diagnosis of colorectal cancer and presents to our clinic; they will see all three providers in that visit. This is really just streamlines the visit for the patient. However, while the patient might see that, and they see this as a streamlined process, very convenient; what they don’t see is all the work that goes into this and that’s where I think the value is in this multidisciplinary approach.
Before the patient ever gets there, we are receiving the tests, any tests that the patients have had. We’re discussing the patient’s care as a group. We’re really coming up with a plan before we ever see the patient. So, that way, when we go in, we can talk to the patient, sort of a directed focused discussion, learn from the patient anything that we may not already know about them in particular that we may not have already learned from their outside documents, really be able to tailor the plan specifically for each patient. This is I think just a fantastic approach to care. It really leads to not only streamlined care but really high value and highly satisfied patients. So, it’s been really a great introduction of a care team and a care pathway here at UAB.
Host: Dr. Kennedy, this may seem a difficult question but as we see improved coordination of care, and the opportunity to assess each patient as you’ve described from many viewpoints, and that’s really an immediate benefit for the patient for sure and that multidisciplinary team; tell us some of the challenges of this. Is there sometimes a differing of decisions regarding the choice of treatment? Tell us a little bit about some of the challenges that you’ve overcome at UAB in this form of care.
Dr. Kennedy: Yeah. That’s a great question Melanie and there’s no doubt there is a differing of opinions in how patients should be treated. And that’s the great thing of working together as a team and knowing the team members as well as we know each other. We can actually debate. We can look into the literature. We don’t always have the answers, do we. We have to sometimes look into the literature, find out what is the right answer and oftentimes, if we’re debating it, there is no right or wrong, so it comes down to what the team decides then and quite honestly, majority rules. We’ve had patients – I’ll just give you an example. A recent patient who had extensive lymph node involvement from their rectal cancer. We talked a lot about doing surgical therapy of those lymph nodes versus more radiation therapy. Ultimately decided on radiation therapy because of some concerns of increase morbidity of surgery. The surgeons didn’t necessarily agree, but the majority felt that the increased morbidity of the surgical therapy outweighed the increased morbidity of radiation therapy. So, we went with radiation. So, that was a great example of how having a multidisciplinary approach led to actually an improved outcome of the patient. Because at the end of the day, the patient had a complete response in the lymph nodes from the radiation therapy and is doing quite well six months later. So, it’s been those sorts of conversations that allow us to have – that we are allowed to have because of this approach, and we can really come up with some great tailored treatment plans and I think improved outcomes, ultimately.
Host: Well that’s such a great example and a good point. But along those lines, for effective management of certain cancers, and they remain great challenges for the surgeon, yes, so with increasingly complex treatment algorithms that you are finding these days that add new options to your armamentarium of available therapies; is there somebody in charge? Is the surgeon in charge of guiding the patient’s care? Tell other providers as you say you’ve all known each other for a long time and you work together so well; but how are those decisions made?
Dr. Kennedy: Yeah, well that’s a great question. And we always as surgeons, we always like to think we’re in charge, don’t we? But the truth is that’s not the way we see it. this is very much a team approach and in fact, we tend to view this as the patient is in charge. We want to give the patient the information they need to make an informed decision and then let the patient make the decisions that are necessary. So, we try our best to guide the patients with the right information and let the patients make the decision that fits them best.
And I think that’s again, the beauty of multidisciplinary care. So, the idea that one person is in charge, I think is not necessarily true. We really view this as a team where all voices are important and all voices are equal and our goal is to give the patient the best treatment option that we’ve all agreed on in one way or another and then provide the patient with some options along those lines, trying to say what we think is the best but hear others that could also work and then ultimately let the patient make the choice that they’re comfortable with, assuming the outcomes are close to equivalent.
Host: What a comprehensive approach. Is there anything you’d like to share as far as research at UAB that other providers may not know about?
Dr. Kennedy: Well we’re always trying to use our patients in a way that we can advance the science of the disease as well. We’re always interested in trying to understand the genetics of cancer so we have various genetics studies looking at the heterogeneous nature of cancers and how that heterogeneity of a cancer might lead to better or worse outcomes. So, we know that tumors that differ within the cancer sometimes have certain populations of cells that may give rise to metastatic disease. We’ve been interested – we’ve got a research group interested in understanding that heterogeneity and what it means to patients. So, that’s certainly one area of research that we have going on. We also have an area of trying to understand staging. So, currently, the only way we can accurately stage a patient is by doing surgery and taking lymph nodes out. We’re trying to put forth a protocol whereby we stage patients with MRI before we ever operate on patients and really be able to accurately stage patients.
This would lead us if we could accurately stage patients, it would lead us to more informatively move down a watchful waiting type pathway for rectal cancer. So, in those patients who have a complete response, if we can have evidence that they truly have had a complete response in their lymph node basin, using MRI, we can then feel better about a decision of watchful waiting. So, certainly we have these various research protocols that are always open and we’re trying to enroll patients to advance the knowledge of the disease.
Host: Well thank you for telling us about those exciting advances and trials that you’re running there at UAB. As we wrap up, please summarize for us Dr. Kennedy, what your outcomes have looked like as a result of a multidisciplinary team approach and the benefits of this type of approach for not only the patients but for the surgeon and the other team members involved because it gets you all involved and you all know what each other is doing and you really get to bounce things off of each other.
Dr. Kennedy: Yeah. I think the benefits are multiple Melanie so, first the multidisciplinary management of colorectal cancer has been associated with significantly more complete preoperative evaluation as well as improved access to multimodal therapy. That’s pretty clear. And we’ve seen that in our own practice. We also have seen just improved patient satisfaction. The patients who are coming to these visits are having a great experience. They are certainly coming with complicated problems but in trying to meet all the providers in one appointment and then leaving with a clear idea of what’s happening and where they are going next. They are leaving much more satisfied and having a much better experience.
I think those are absolute benefits. From a personal and professional perspective, it’s just led to such a great team approach and such great camaraderie with the team that I can’t imagine going back to another way of treating the disease. So, I think it’s fantastic and we really love treating patients and helping patients in this situation. So, hopefully we will continue to grow the program.
Host: Thank you so much Dr. Kennedy for joining us today and sharing your incredible expertise. And what an exciting time to be in your field. Thank you again and a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB podcasts. I’m Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua164.mp3
- DoctorsWiederman, Michael
- Featured SpeakerMichael Wiederman, PhD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4108
- Guest BioDr. Wiederman was a clinical psychology professor for 19 years, mostly at a women's college in Columbia SC, before transitioning to professional development as the Director of Professional Development at the University of South Carolina School of Medicine Greenville.
Learn more about Michael Wiederman, PhD
Release Date: August 12, 2020
Expiration Date: August 12, 2023
Disclosure Information:
Michael Wiederman, PhD, has no financial relationships related to the content of this activity to disclose. Also the planners, Ronan O'Beierne, EdD, MBA, and Katelyn Hiden, have no financial relationships to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole, MS (Host): UAB Medcast 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 .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s post-test.
Mindfulness practices have been shown to result in multiple benefits, including stress reduction and increased wellbeing. Welcome to UAB Medcast. I'm Melanie Cole, and today we’re discussing promoting wellbeing by practicing mindfulness in everyday life. Joining me is Dr. Michael Wiederman. He’s the director of leadership and professional development in family and community medicine at UAB Medicine. Dr. Wiederman, it’s a pleasure to have you join us again today. We’re all feeling a lot of stress right now, and many of us feel it from time to time. How do we know if the stress that we are feeling is taking a toll on our psychological or our physiological self?
Michael Wiederman, PhD (Guest): Yeah. Well, I think the sort of obvious signs are feeling fatigued and getting to the end of the day and feeling spent in the negative way. I meant sometimes we’re feeling spent in a positive way that we really were invested and had a great day. If we feel like we’re chronically fatigued and rundown and distracted and we get to the end of the day and it feels like it’s been a whirlwind and we can't really remember much other than the fact that it was not a good day then to me that’s a sign that something needs to change.
Host: What a great point. So then let’s talk about the concept of mindfulness. For other providers right now, this is an extreme unprecedented time of stress, Dr. Wiederman. What role does mindfulness play? What questions can we ask ourselves? How aware are we of our own behavior and what drives them?
Dr. Wiederman: Yeah. I think what we sometimes forget is that the stress technically isn’t being caused by what's happening outside of us. It’s caused by what we’re thinking and how we’re perceiving what's happening outside of us. So when I'm feeling overwhelmed, it’s technically because how I'm interpreting and trying to deal with the things that are happening. So I think why mindfulness really work or helps reduce stress is that it keeps us focused on one thing at a time rather than our mind sort of swirling and thinking about all of the things that we need to be doing or the things that could go wrong. So by sort of having more of a laser focus, we can actually do what we need to do and not get caught up in the swirl that creates anxiety and stress.
Host: So that is great to say and maybe not as easy to do. So before you give us some tips on how to do that, what’s the difference between mindfulness and meditation which we’ve heard about for oh so many years.
Dr. Wiederman: I think about mindfulness as the end result of the product of meditation. So if you think about meditation—To me it means setting aside some time to sort of focus on one thing and sort of clear my mind. So typically people focus on their breathing because it gives them something very concrete. So therefore I'm, in a sense, practicing mindfulness. So to me it’s like going to the gym and saying I'm working those muscles because they're going to be useful to me outside of the gym. So for me meditation is sort of setting aside that time. That part of sort of doing it has never really appealed to me. So I've tried to develop practicing mindfulness in everyday life as opposed to setting aside specific times per se.
Host: That’s definitely so interesting. So then Dr. Wiederman, you’ve probably heard misconceptions and myths when people hear that term mindfulness. For providers that are listening now that maybe want to practice this, they want to be able to sort things out so they can get on with their jobs and do really what they need to do right now, what are some of the myths that might be going through their minds?
Dr. Wiederman: There's the myth that we as humans are able to effectively multitask. By multitask if we mean simultaneously think about different things at the same time, that has been shown to not be possible. What we typically do when we think we’re multitasking is switch our attention or our focus, thoughts, very quickly between things. That not only is very stressful and exhausting, but has been shown to be less effective because, again, you're sort of being distracted or dropping the ball. When you're looking over here, the ball’s dropping over there. So that idea that somehow being efficient means trying to multitask or juggle a million things, that’s certainly one big misconception I think.
Host: So then can we learn to pay attention in different healthier ways? Can we learn to focus? Can mindfulness help us to not be distracted and multitask?
Dr. Wiederman: The metaphor that I find so useful is to think about our attention as a spotlight and whatever I'm focusing my spotlight on is where my attention is. Of course, I can make it a little bit broader or definitely more narrow, but I only have one spotlight. So that’s why it’s impossible to technically multitask because if my spotlight is focused to the left then obviously to the right I'm not focused. So we switch our spotlight back and forth very quickly, and sometimes we need to. I think we probably—at least I’ll speak for myself—have a flabby muscle when it comes to what is controlling that spotlight. So I think mindfulness practice for me is anything that increases the strength of that muscle so that when I do want to focus just naturally, it’s going to come easier because that muscle has been strengthened. I don’t want to think about it anymore. So that’s why I think the analogy of meditation practice being like going to gym is so apt because, again, it’s just setting aside time to be very conscious of practicing and building that muscle so that when I do need to focus on my activities it’s easier because that muscle is stronger.
Host: So then tell us how to do that. How can we practice mindfulness? When we wake up in the morning, starting from the morning until we go to bed at night what are some things that we can do that can help us to stop, take a breath, look around, focus on what we’re doing. Tell us how to do it.
Dr. Wiederman: Yeah. So when I stumbled into this probably 15 years ago, I had read a little activity where it said just start with brushing your teeth because it’s something we do twice a day, only lasts for a few minutes, and will be a thing that reminds you to practice mindfulness. I remember thinking okay. Well, I'm just going to pay attention to what I'm doing. I'm not going to have any thoughts about what I'm doing. I'm not going to make any judgements. I'm just going to pay attention. So I put the toothpaste on the toothbrush and low and behold in one or two seconds I'm having a thought. Like okay when I get to work I need to—It’s like nope. Stop. Let that go. Come back to just paying attention to what I'm doing. Then it lasts about two seconds before I think well this is stupid. Well that’s a though, right, and that’s a judgement. So I found is like wow so shocking to me that I couldn’t even go a couple of seconds of just paying attention to what I'm doing without having some intruding thought or extraneous thought. So every time I would bring my attention back to simply say let it go, focus on just paying attention to what I'm doing then that is like doing a repetition of a bicep curl or a leg press. We’re building that muscle. So over time you're just simply getting better and better at bringing that spotlight back to what you want to focus it on. Then you start to notice that that period between distractions, if you will, or thoughts or judgements starts to be extended. So now it’s easier for me after 15 years to sort of pay attention to what I'm doing because, again, I've just been practicing building that muscle.
Host: That’s so interesting, Dr. Wiederman. Usually we wait to feel better before we do things. When we’re not feeling great or we’re not being able to pay attention, well you kind of say oh well when I'm feeling better I’ll do this. What can motivate us to do it right now? Can the relationship between what we’re feeling, our behaviors, can they go back and forth? How can we put them into the center and say, “Okay, this is what I need to take charge of right now because this is what I'm involved in.”
Dr. Wiederman: Yeah. I think you hit it right on the head that if we can remind ourselves—especially when we’re feeling that anxiety or stress or that physiological response that is the fight or flight response—that if we can say wait a minute. I'm focused on this patient right now or I'm focused on this task at work right now and thinking about these other things isn’t helping because I can't get to those other things yet. If anything, it’s just distracting me from the present and it’s making me anxious. So that was the motivation for me to say when I'm finding myself feeling that way, that’s the time to really practice just focusing on what's going on. Now, sometimes I would find that I might think I need to remember x, y, and z because if don’t… So then I would write that down on a little slip of paper and keep that off to the side or keep it in my pocket. I would remind myself that’s not going to go anywhere. I don’t need to think about it right now. I can't get to it anyway. So, for me, that’s sort of the anchor to bring it back is when I'm feeling stressed then it’s probably because I'm trying to swirl many different things in my head at once. That’s, again, not helpful, and also not productive.
Host: Well, it’s definitely not. If we practice mindfulness, can changing the way that we think translate into an improvement in our behavior, in our feelings, even in our physical self? Can this help us to really change the way that we respond to stress on a daily basis?
Dr. Wiederman: Absolutely. So there's lots of good research, particularly around meditation because that is something that people can sort of document that you practiced if we randomly assign you to a meditation group. Again, I think just practicing in daily life. So practicing mindfulness in whatever form that we do that has been shown in research to relate to improved concentration in memory, which makes good sense because we’re focusing our spotlight on something intentional. So we’re going to be more likely to remember it and concentrate on the moment. Also related to decreased stress response. I think for the reasons we’ve been alluding to that if I'm focused on what's going on right now then I'm not whipping myself into an anxious or stressful frenzy by thinking about these other things or worrying about these other things. Then I was shocked when I delved into literature to learn that practicing mindful is also related to improved interpersonal relationships. Then the more I thought about that, I guess it makes sense because that means, I think, we’re more present with the people that we interact with. How can that not improve relationships to be less distracted and more in the moment.
Host: That makes perfect sense. Can you recommend any good mindfulness apps?
Dr. Wiederman: Most of the mindfulness apps actually guide you through guided meditation. So in that sense it gives you something to focus on. So I was saying earlier that if you don’t have something, somebody guiding you, then you would just sit, and you would maybe focus on your breathing or you would focus on whatever. So there are lots of good free ones out there. I like Insight Timer as one, but there's Calm and of course Headspace has a free version as well as a premium version. All of those offer guided meditations. What I like is that sometimes you can pick one that’s—Let’s just say I have two minutes. So you pick a two minute one or three minute, they can be very brief. So anything that brings our attention to the moment and gives us a chance to practice a few of those reps.
Host: It is absolutely great advice and imperative at this time for other healthcare workers. Dr. Wiederman, wrap it up for us. By using mindfulness to help us with all of the stress of today’s living, what would you like other providers to know about utilizing what we’ve discussed here today to help in their own practice, to help in their own lives whether it’s personal or professional, and how it can help us to be the best person we can, do the best job, and also be present and really mindful.
Dr. Wiederman: Yeah. I would say a couple of things. One is to realize that the research shows it doesn’t take much practice to start seeing benefits. So regardless of what skepticism you might have or say I don’t have a lot of time to try something and just to see for yourself the benefits, even in the moment but certainly spillover benefits afterwards. To remember that it doesn’t—Just like getting a little bit of physical exercise. Some is better than none. So setting aside time. Saying when I'm walking between buildings, I'm going to practice my mindfulness or when I'm brushing my teeth. Just set aside those little times to begin with. Or when I'm talking to my spouse or my kids or whatever. Just create a few different if then or when this happens I'm going to practice mindfulness as a starting spot. Realize that any skill, especially building a muscle, practice makes it easier. So it’s most difficult at the beginning, so start small, and then recognize that you will start to see the benefits but also it will get easier with practice.
Host: Well it absolutely does. Thank you so much Dr. Wiederman for joining us today. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Medcast. To refer your patients or for more information on resources available at UAB Medicine, please visit our website at uabmedicine.org/physician. Please also remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua158.mp3
- DoctorsCannon, Robert
- Featured SpeakerRobert Cannon, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4089
- Guest BioRobert M. Cannon, M.D., is an assistant professor in the Division of Transplantation, specializing in liver transplantation and hepatobiliary surgery.Learn more about Robert Cannon, MD
Release Date: July 29, 2020
Expiration Date: July 29, 2023
Disclosure Information:
Robert Cannon, MD, has no financial relationships related to the content of this activity to disclose. Also, the planners, Ronan O'Beierne, EdD, MBA, and Katelyn Hiden, have no financial relationships to disclose.
There is no commercial support for this activity. - TranscriptionUAB 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 .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
Melanie Cole (Host): Historically, patients with HIV were excluded from liver transplant programs. But with the introduction of highly effective antiretroviral regimens, HIV may no longer be a contraindication. Welcome to UAB Med Cast. I’m Melanie Cole and today, we’re discussing HIV positive liver transplant. Joining me is Dr. Robby Cannon. He’s the Director of Liver Transplant Surgery at UAB Medicine. Dr. Cannon, it’s a pleasure to have you with us today. Before we get into this, tell us a little bit about the state of HIV today and what was historically, the situation for organ transplant issues?
Robert Cannon, MD (Guest): Yeah, well thank you for having me. Well you know, in the early days, when it first came out and was discovered, we really didn’t have a good understanding of HIV and treatment options were limited. So, that really made it a contraindication to transplant because we just weren’t sure how the patients were going to survive in the first place. Then, once we started to develop more effective antiretroviral therapy for HIV, there was still fear that after transplant, we’d have to intentionally weaken the immune system with antirejection medicine to prevent rejection. And there was concern that that would cause the HIV to get worse. So, the introduction of treatment still didn’t sort of allow for access to transplant for people living with HIV.
As time as gone on, we’ve developed better antiretrovirals for HIV that don’t have interactions with our immunosuppression regimen, so the dosing doesn’t have to change. And we’ve seen that the antirejection medication regimen after transplant does not cause any issues with the HIV infection as long as patients are on a stable dose and stable regimen of their antiretrovirals and have their disease well controlled. We found we can actually have very good outcomes in patients with HIV that are actually equivalent to those seen in patients without HIV. So, now we’ve sort of come full circle to where once it was an absolute contraindication to transplant, then we started transplanting patients living with HIV and we had worse outcomes and now we’re at a place where the outcomes are actually equivalent and now we’re moving forward in trials actually looking at using donors who are infected with HIV as a way to expand the donor pool and give increased access to transplantation for our patients who are living with HIV.
Host: Wow, that is fascinating. So, is it already possible Dr. Cannon to define the group of patients who will do as well as other non-HIV infected recipients for liver transplant and will simple changes to the selection of candidates improve outcomes further?
Dr. Cannon: It is. And many patients now on HIV, the antiretrovirals have become so good that many patients can achieve an undetectable viral load. And that’s what we need for transplants. Furthermore, we also – there’s a regimen known as an integrase inhibitor, that’s a class of drugs for HIV and those are ones specifically that don’t affect our immunosuppression dosing. So, here at UAB, and actually in many centers, we would look for patients who have stable with undetectable viral loads on an integrase inhibitor based regimen. Those patients should do as well as patients who don’t have HIV particularly, one other concern was we saw higher rates of coinfection with hepatitis C in the past. There were worse outcomes with those patients who were coinfected with HIV and hep C. We don’t have as good of data on that now, but I suspect that now that we’re actually able to cure hepatitis C as well, I suspect even that will no longer become a sticking point in terms of worse outcomes.
Host: So, where does poor adherence to treatment, drug resistance in potential organ donors pose a threat to organ recipient outcomes? Are you transplanting HIV to HIV or clear livers to HIV? Explain a little bit about the donor process.
Dr. Cannon: Sure. So, donors right now, essentially a donor with HIV historically has been a contraindication to donation. With the enactment of the HOPE act recently, HIV to HIV transplant has become possible and allowed by law. But of course, these donors will only be available to patients who already have HIV because it’s not curable as it is for hepatitis C. And this is being done in the context of NIH sponsored clinical trial known as HOPE in Action. So, it’s not routine practice for HIV to HIV transplantation but as we settle out these issues, in this ongoing clinical trial, the hope is that one day, that as well will become a routine practice.
Now in terms of transplanting the recipients who have HIV with a donor who does not have HIV, that is routine clinical practice now and it’s done outside of clinical trials.
Host: Tell us a little bit more about the HOPE Act and how that changed the landscape of the work that you do for organ issues in HIV patients.
Dr. Cannon: Yeah so, the HOPE Act essentially, I mean it was in many ways a game changer in the terms of transplantation for patients with HIV because it was again, it was actually illegal to use donors who had HIV prior to the passage of the HOPE Act. So, but now that we know again, a much better therapy for HIV, it is now legal, and we can use those donors who have HIV and it’s just a way to increase the donor pool and give increased access to a patient population with HIV whose historically been disadvantaged.
It's early enough in our experience with HIV to HIV transplant. We don’t know how many additional donors a year will become available because of this and estimations run probably about 500 to 600 a year additional donors available to patients with HIV for transplant as a result of the HOPE act.
Host: That’s so interesting. So, tell us a little bit about your outcomes, what you’ve seen, where do you think that this is going Dr. Cannon and how exciting is it for you physicians on the frontlines of this kind of exciting acceleration to help people with HIV that need a liver transplant?
Dr. Cannon: No, it’s very exciting to us and I think as I allude to earlier, I think the outcomes are no different anymore than patients who don’t have HIV. So, what this really becomes now and we’ve seen this with several diseases, we’ve seen it with hepatitis B, we’ve now more recently seen it with hepatitis C and now we’ll see it with HIV, that things that were once considered contraindications to transplant or associated with much worse outcomes; as the therapies and medical management of these diseases get better, they all of the sudden just become routine and we’re able to routinely offer transplant for patients who were previously disadvantaged and it just allows us to help more people and offer the lifesaving benefits of transplant to more people who need it.
Host: And what would you like to see Dr. Cannon as far as the liver transplant community and their response to this challenge and the use of the currently available evidence which seems to be really updated and changing all the time to help in the selection criteria, and with outcomes and rejection and adherence after the fact? What would you like to see changed or what do you think the liver transplant community can do to help accelerate these changes?
Dr. Cannon: You know I think the liver transplant community has really caught on. I think the key is just in driving referral. I think still in the community there’s still this perception again, because of our past practices, that you may have a patient who has HIV and end-stage liver disease, but you may not refer the patient because you don’t think they are a candidate. So, I think that’s what’s on us as liver transplant physicians is to really sort of spread the message that heh, we are willing and able to transplant patients with HIV. Please refer them to us. And it is not a contraindication and we can proceed with them as we would for any other patient for transplant and they shouldn’t be disadvantaged anymore.
Host: What a fascinating field of work that you’re in Dr. Cannon and thank you so much. Before we wrap up, do you have any final thoughts for other providers? You’ve mentioned referral. Is there anything else that you’d like to add or what you see happening on the horizon?
Dr. Cannon: No, I mean that’s the main thing again, and I said, anyone who has end-stage liver disease please send them to us. We’d be happy to see them. It does not – the burden of kind of deciding whether someone can be transplanted or not really doesn’t need to be on the physicians in the community. They don’t need to have to make that decision. We’re happy to see anybody and give our best shot at transplanting anybody who can qualify and again, HIV is no longer a contraindication and really should not adversely affect someone’s chance of transplant as long as they are well controlled.
Host: Thank you so much Dr. Cannon for joining us today. This has been UAB Med Cast. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. For more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB podcasts. I’m Melanie Cole. - HostsMelanie Cole, MS
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