Additional Info
- Audio Fileuab/ua152.mp3
- DoctorsLewis, Clifton;Ahmed, Mustafa
- Featured SpeakerClifton Lewis, Sr. MD | Mustafa Ahmed, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4062
- Guest BioDr. Clifton Lewis has been board certified since 1991 in adult cardiac surgery. He has special interest in the treatment of valvular heart disease and especially in minimally invasive and robotic approaches to valvular operations.
Learn more about Clifton Lewis, Sr. MD
Mustafa Ahmed, MD, is an interventional cardiologist who treats heart valve and structural heart disease, which are conditions involving defects or damage in the walls, muscles, or valves of the heart.Learn more about Mustafa Ahmed, MD
Release Date: July 21, 2020
Expiration Date: July 21, 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:
Mustafa Ahmed, MD
Associate Professor of Medicine, UAB Interventional Cardiology
Clifton Lewis, MD
Associate Professor of Medicine, UAB Cardiac Surgery
Dr. Kazamel has disclosed the following commercial interests:
· Abbott, Medtronic, Edwards' Lifesciences – Consulting Fee
· Abbott, Medtronic – Payment for Lectures, including Service on Speakers Bureaus
Dr. Lewis 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): Welcome to UAB Med Cast. I’m Melanie Cole and today, we’re discussing mitral and tricuspid therapies. Joining me in this panel are Dr. Clifton Lewis, he’s a Cardiothoracic Surgeon and an Associate Professor and the Chief of Adult Cardiac Surgery and Dr. Mustafa Ahmed; he’s a Cardiologist and Associate Professor and the Section Chief in Interventional Cardiology. And they are both at UAB medicine. Gentlemen, I’m so glad to have you join us today. And Dr. Lewis, I’d like to start with you. What problems can occur with the mitral and tricuspid valves and tell us about the idea of treating valve disease percutaneously.
Clifton Lewis, Sr., MD (Guest): In terms of types of problems you can have, the issue typically is the valves go bad in one of two ways. Either they leak or they won’t open and it’s really about the only two problems you can have outside of getting one infected. And the heart’s a pump and for a pump to work appropriately, it’s got to have valves that will open and close. In the old days, the most common diseases of the mitral valve in particular but also the tricuspid were related to rheumatic disease. Now that’s still the case in developing countries but in the western world, that’s not completely gone away but it’s not near as common as it used to be. And a lot of the problems we have with the mitral valve disease are either genetic in origin, something we call degenerative disease or myxomatous degeneration of the mitral valve or they are related to what we call ischemic heart disease or coronary disease, blocked arteries where you damage the mitral valve and it leaks. In terms of the tricuspid valve, most tricuspid valve disease is related to either chronic, long term untreated left sided or previously treated left sided valve disease principally mitral valve disease or it’s related to what we call pulmonary hypertension that you see in people with chronic lung disease and some other entities. And then finally, we see a far amount of mitral valve disease that’s related to atrial fibrillation. And for the most part, what we see is leakage of both of them.
And in terms of the tricuspid valve, it’s very rare to have it blocked; it’s almost always leaking. In terms of therapies, all these percutaneous therapies and minimally invasive operative approaches are leveraged off of prior surgical experience. Because for decades, the only way you could approach valvular heart disease was by operating on the heart for the most part through the midline sternal incision then later through the minimally invasive approaches primarily through the right chest. And then, even then we came across a fair number of people that you just not treat surgically. They just would not survive open heart surgery whether it was through the midline incision or through small ones. And so percutaneous therapies were developed because there were millions of people every year in the western world that were dying from untreated mitral valve tricuspid valve disease. And that’s where Dr. Ahmed comes in. He’s part of a movement in cardiology and almost like a hybrid cardiologist/cardiac surgeon that are called structural cardiologists and those are the people that do percutaneous treatments of the valves that mirror old cardiac surgery operations. And it’s really been revolutionized the treatment of valvular heart disease. Do you have anything to add to that Mustafa?
Mustafa Ahmed, MD (Guest): About 15 years ago, there was an important piece of work that came out and it basically said valvular heart disease in the western world is an epidemic. And so, what that means is a very large amount of people when you look at their hearts, they have at least a bad or very bad leaky valves or tight valves. And it was much, much more that we ever thought. And what’s also noticeable about medicine now is the older population continues to get older. And in many ways, in addition to what Dr. Lewis was talking about; as we get older, the prevalence or the amount of people that have bad valve disease increases exponentially. But when you look at the younger population, almost always, surgery – open heart type surgery is the best option whether that’s you do it minimally invasively or not. But as you look at a much older population, open heart surgery takes a very different toll on a patient and you are left with these millions of people without a treatment and the movement of – there’s no good medical therapies. So, there’s no medicine that fixes the valve itself.
When it comes to valves going bad, whether that’s the mitral or the tricuspid valves; it can be either because the hearts gone bad in which case, we try and give medicines that focus on the heart or it’s because the valve’s gone bad but when it comes to the valve being bad, there is not a single medicine that we have been able to find that can fix or reverse that and so the only way to do that is either an operation or to do one of these percutaneous. Which means through a small tube typically through the leg to fix it. and the technology over the last ten years has grown faster than we ever could have imagines. And that’s what Dr. Lewis was saying. It’s lead to this hybrid approach where cardiac surgeons, interventional structural cardiologists are getting together, looking at every single valve which might be different and trying to come up with what’s the single best thing for that patient.
Host: So, then Dr. Ahmed, speak about some of those percutaneous minimally invasive options that UAB specializes in whether it’s mini or robot. Tell us a little bit about the latest in transcatheter mitral valve replacement field. Tell us what’s going on.
Dr. Ahmed: I’m going to start talking about this then let Dr. Lewis come and take over and that’s because – I’ll give you an example of a patient then we’ll commence. So, we see hundreds if not thousands, fully thousands of these patients with valve disease per year and when each patient comes in, there used to be that patient would go to a heart surgeon or that patient would go to a cardiologist and a decision would be made about what to do by that individual. Now what happens is, we’ll give you an example of someone that comes in that may be 70 or 80 years old and has a bad valve. Let’s talk about the mitral valve. So, the first thing to do is to say okay how bad is that valve. So, there are two very important things here. One is to say let’s really look in a lot of detail at that valve using three dimensional echocardiographic techniques, MRI techniques, maybe CT techniques and others to really get it right. Because what’s done wrong a lot is people with not bad disease actually have severe disease, people sent for operations may not have severe disease and so the whole focus of a modern valve program is this heart team approach which involves surgeons, cardiologists, interventionalists, imagers, get together and say okay first lets assess this and see what’s happened.
So, let’s look at the situation where we have a valve, we know it’s bad and something needs done. So, what happens is then I will sit for example with Dr. Lewis and we’ll say we’ve got this patient and we’ll talk about the advantages and disadvantages of each approach. So, in a minute, Dr. Lewis is going to talk about not just open heart surgery, but one of the things that is very important to realize is a lot of that can be done through a very small incision. So, he’s going to talk about minimally invasive mitral and tricuspid valve therapies and even robotic where you just basically have tiny incisions on the chest wall. But then we talk about percutaneous approaches also. What does percutaneous mean? It basically means you go through the skin into a blood vessel, you get to avoid making cuts and having to stop the heart and you go up typically a vein, you go through a very small tube and you go to the valve itself and stop to fix that valve.
And what was no options ten to twelve years ago has now become multiple options. One of the options for leaking valve for example would be the mitral valve clip where we would go, take a bit of the valve that’s come apart and causing the leak and put a clip on there and bring it together. We are no on the fourth generation of the mitral valve clip and UAB is one of the leaders in the world in MitraClip programs, a very mature program that allows for treatment of a lot of patients but what we have realized also over the years is there’s a right and a wrong patient for the mitral valve clip. So, selecting the right patient, doing it in the right way with an experienced team is key. But then when you’ve got the patient that is not the right patient for a clip, there’s now other options. There’s a number of trials ongoing which we are fortunate enough to be able to enroll a lot of people in for example working together with Dr. Lewis and the surgical team to go in through the heart, while the heart is still beating and put a whole new valve there and we are one of again the country’s most mature programs when it comes to putting those in. And what was one option has now become three or four different options of valves. For example, people that had old heart valves that have now degenerated we can go in in about 20 minutes time, go through into the heart and put a whole new heart valve in, be done and wake that patient up within 20 minutes after that and they can be walking around one or two hours after the procedure.
And even for us, who do this, and we do a lot of these procedures together, even we get shocked at the impact you can make through such a small incision and have that patient literally going home the next morning. Dr. Lewis, I’m going to hand it over to you to talk about some of the surgical approaches.
Dr. Lewis: The issue that Dr. Ahmed is talking about really is tailoring the treatment to the patient instead of trying to tailor the patient to the treatment. And that’s basically what we did when all you had was a surgical approach. Now that having been said, surgical mitral valve repair remains sort of the gold standard of mitral valve surgery particularly for mitral valve leakage and even replacement remains a gold standard as opposed to percutaneous. And the reason for that is we know the long term outcomes of those and I’m speaking about 15-20 year outcomes. If you are going to do a percutaneous or a minimally invasive option; you’ve got to reach those standards. You can’t compromise those in a healthy patient. Our issue has always been the elderly, infirmed and unhealthy patient that really desperately needed a heart operation, but you knew they wouldn’t withstand it. Like the old saying, you know the operation is a success and the patient died, that’s always a bad deal. It’s a bad tradeoff. So, what we do is we look first and say well does this valve need to be treated.
If it does, can you operate on them with a margin of safety. It’s never perfectly safe, there’s always some risk. And you can risk stratify people and if the risk for an operation is excessive; then we look for alternatives and we say, well can we clip them, can we replace them percutaneously through the groin? Do they need to be enrolled on one of these mitral valve replacements where we do it through a beating heart in the apex or the bottom of the heart. What we’re trying to do is avoid exposing people to unnecessary risk but still give them a quality result. And one of the interesting things about that is that not only have we been able to treat a lot more patients, we’ve also been able to lower the operative mortality, not eliminate it but lower the operative mortality for mitral valve surgery.
In the old days, your risk would vary from about half a percent for somebody that’s young and healthy for mitral valve repair to upwards of 40 or 50% for desperately ill old people that needed a mitral replacement. So, we’ve been able to get rid of some of those 40 or 50% operative risk patients, move them into percutaneous, minimally invasive approaches and lower our overall risk. And so we treat more people and we have fewer deaths and that’s really been revolutionized the treatment. So, in terms of minimally invasive surgery or standard surgery; the thing to know is there’s nothing wrong with a full sternal incision for heart surgery. It’s really hard to die from opening a person’s sternum. So if you need it and patients need to know that it’s not the end of the world to have your breastbone opened. Now if you can do an equivalent job, if you are going to do open heart surgery on people, if you can do an equivalent job through small incisions and not divide the sternum; it’s certainly advantageous for the patient. And it doesn’t necessarily decrease risk but what it does do is decrease misery.
The primary problem with a sternal incision is it takes two months to recover from it. It’s unsightly. It’s really unpleasant. So, if you can do the same quality operation through the right chest, through a robotic minimally invasive approach; it’s helpful but it’s not necessarily less risky. If you have somebody that’s high risk what you want to do is not do open heart surgery be that sternal incision or robotic minimally invasive approach. Then you want to start looking for percutaneous options and that’s really what Dr. Ahmed’s talking about in terms of cooperative approaches is sort of hybrid medical doctor surgeon where you tailor again the therapy for the patients instead of the other way around.
Dr. Ahmed: And I’ll add to that. If you want to have the best valve program you can possibly have, there’s a few very important things. I mean you have to have a very strong team that can assess valve disease and actually make the right call, because if the wrong call is made in the first place; the entire train starts and you can end up doing things on people that never needed doing in the first place and this is prevalent in the United States. One very sobering thing about valve disease is there are very few experts. When you look at cardiac surgery and this is an important point; most cardiac surgeons in the United States will list as doing valve repair, very few do a meaningful amount. The majority of cardiac surgeons might do less than five mitral valve operations a year and this is an important point, because a lot of job as a valve specialist on our side is to make sure when you send a patient for procedure or repair, you get a repair and or a replacement. When you send a patient for replacement, that is durable and done in the right way with the right size and that takes experience so, that experience and team approach is important.
You need the people assessing the valve. You need the surgeons to be world class and experienced surgeons and you need the interventionalists to have had training and experience which allows you to come to the table and give the right option because if not, what happens is you get a patient and say for a surgical valve that can be repaired, the gold standard is to go and have that valve repaired unless the patient is not a surgical candidate but if you are in a program where oh the surgeons are not used to doing that, then of course what happens, you end up having it done what sounds a better way, but you may be back in that operating room in a much worse position in a few years because you made the wrong decision up front. So, that’s really what’s the most important part. It’s called program. There’s no individual in a valve program that can make that valve program run on its own. It’s a collection of experienced and trained individuals that really do present every option.
So, the typical even this week, a typical option would be okay, someone comes in, do you need a sternotomy open heart surgery, are your arteries bad? If your arteries are bad, you may need an opening and you may need the bypass surgery and a valve done or you may need a valve replacement, or you may need the valve repaired. That may need to be done robotically. Or it may need to be done through a very small incision. Or it may need to be done through a slightly larger incision or both valves may need addressing or, the patient might need stents and need done in a percutaneous way because they are not a good surgical candidate. You really, really need to be careful not to have a one size fits all program. It needs to be is that the best patient for a clip, yes or no. Is that the best patient for a new valve, yes or no. And that decision at UAB, we actually have a dedicated meeting and we have several surgeons, a lot of cardiologists, imagers, radiographers, ultrasound specialists. We actually sit now on social distancing, we sit on Zoom, but we actually get together as a group for an hour every single week at least once if not several more times and discuss almost every single case to make sure everyone is in agreement that that is that patient’s best option and that’s the movement where this needs to head and that’s where the model of a Center of Excellence comes up.
Host: What an exciting time to be in your field and such important points for referring physicians doctors. So, I’d like to give you each a chance to wrap up. Dr. Lewis, starting with you here, do you have any clinical trials research you’d like to mention or let other providers know about? Tell us a little bit about the future or areas of work being developed at UAB.
Dr. Lewis: So, we’re involved in a number of trials. Almost all of the research trials are percutaneous options or beating heart surgery valve replacement. The one we’ve had the most experience in thus far are the following. What’s called the ten dime mitral valve replacement that’s done through a small incision in the left side of the chest and through the bottom of the heart and you basically poke a whole in the heart and the tube and replace the mitral valve. And then the other one is there’s some ongoing MitraClip trials that Dr. Ahmed is running. Out part in it is to help him decide who needs a clip and who doesn’t. There are some what’s called a Triclip where you can repair the tricuspid valve percutaneously and we have just now started enrolling patients in that study.
And there are some other ones that are coming down the pike, particularly involving transcatheter aortic valve replacement that we will be a study center for. One of the most interesting ones really is what’s called the Triclip, that’s where you put an essentially modified MitraClip on the tricuspid valve. The tricuspid valve is what’s commonly referred to as the forgotten valve. We used to think that tricuspid leakage was number one innocuous until it got really bad and then once it got really bad, we thought it was deadly and you couldn’t do anything about it. We’ve increasingly been able to recognize how bad it is for people to be left with severe tricuspid insufficiency and a large part of our practice now is devoted to repairing tricuspid valves. A lot of them have been operated on before, but we are able to fix them with a tricuspid valve unless they are just really sick and then we can enroll them in this Triclip research trial.
And there are some other ones that I think Dr. Ahmed can tell us about that he’s getting ready to start enrolling as well. Mustafa.
Dr. Ahmed: Research is very important. When we talk to patients about research, research doesn’t mean that we are going to try something experimental. What research means is technologies that have had- that have gone through robust testing that have been used in trials already typically in order for them to be made widely available and a lot of these therapies have just changed the way medicine is. It’s exciting to be able to get access to those but patients in trials are watched more closely than any other patient in medicine. I mean it’s incredible the care and the attention that someone gets. It’s actually much harder to get into a trial and most people – you can’t necessarily get in but we try our hardest to get people in.
So, with the MitraClip, we have the MitraClip G4. We were one of the first in the world to use that system and it’s the latest version of the clip which has really changed the way MitraClip is done. It allows harder cases to be performed. It allows a more probably lasting result and it allows technically a very different and more straightforward approach to fixing the valve. So, that is ongoing now and we’ve enrolled several patients in the MitraClip G4 registry. The ten dime valve that Dr. Lewis was talking about is still ongoing. That should be ongoing for a good while. We’ve had good experience with implanting this and we work together to do that. That’s putting a new valve in while keeping the heart beating. There’s one or two other trials which we are considering starting soon.
The goal is not to have so many trials that you just have them. The goal is to get the right trials in so there’s all the different options and having experienced team that does it again and again and again and so there are several options on the mitral side. On the tricuspid side, the main excitement now is about the Triluminate trial. We really strongly do advise patients that are getting tricuspid clip go to your local, if you have that- I know there are a few sites in the county now that have the Triluminate trial. That is where you should go and get that done because you are watched carefully. You have large teams of people in there making sure the result is good but importantly, rather than just using the MitraClip, which is not designed for the tricuspid valve; that’s what’s being done now, it’s actually a dedicated system for the tricuspid valve and the results preliminarily are just very exciting for that. And the Triluminate trial is ongoing. And then there’s talks of trials where we are actually going to place new valves in the tricuspid position. So, those trials are ongoing too as well as the Paravalvular leak trials which we are shortly starting. Which is where a new plug that can – holes around the valve that have been place surgically previously, we’re going to have very early access to the newest generation of plug which is potentially designed just to try and fit in those leaks that get rid of those leaks and be done in a way which is very minimally invasive. And they amazing thing about this field if we talked to you in a six month time, twelve months’ time, 24 months’ time; that whole field would be changing again and it’s just moving at such a fast pace. Very exciting time for patients and for valve disease in general.
Host: Wow, it certainly is and thank you gentlemen so much for joining us today and sharing your incredible expertise for other providers. What a fascinating topic 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 Med Cast. For more information on resources available at UAB Medicine, please visit our website at www.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/ua154.mp3
- DoctorsWiederman, Michael
- Featured SpeakerMichael Wiederman, PhD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4052
- Guest BioMichael Wiederman, PhD is the Director of Leadership and Professional Development, Family & Community Medicine , School of Medicine 2020.
Learn more about Michael Wiederman, PhD
Release Date: July 15, 2020
Expiration Date: July 15, 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.
One interesting approach when you're considering wellness is to observe the satisfaction of core human needs that are related to our sense of flourishing. Assuming our basic material needs for food, water, and physical safety are adequately met, what do humans need to flourish? Welcome to UAB Medcast. I'm Melanie Cole and today we’re discussing the four C’s, a guide to mental and emotional wellbeing. 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, thank you so much for being with us. This is such an interesting topic. I think that it crosses all the lines of the typical podcast we do here at UAB between providers, patient care, patient satisfaction, and provider wellness. So before we jump into those four C’s, how does our mental health influence how we think and feel and behave in our daily life? How does it effect our ability to cope with stressors, overcome challenges, and be resilient to recover from life’s setbacks and hardships?
Michael Wiederman, PhD (Guest): Well, I think you sort of implied in the answer in the sense that our mental capabilities are our own tool for dealing with the world and being effective and doing what we do professionally and personally. So if that tool or that motive of being in the world is impaired due to decreased wellness and wellbeing then that’s going to effect literally everything that we do regardless of whether we realize it or not.
Host: Well as I said in my intro, assuming our basic material needs are met, how is wellbeing defined Dr. Wiederman? How would you define it?
Dr. Wiederman: I would define it as humans we have more needs than just those basic needs. Once those are met to really be satisfied and to feel like we’re actually living a full life or living our best life or whatever phrase you might want to use, there are these sort of other needs that psychologists have identified that are more mental, emotional, and really form the core of whether we feel like we’re doing well in the world and that there’s purpose and meaning and a reason to live.
Host: Is there a way to measure that Dr. Wiederman?
Dr. Wiederman: Well measure is a tricky word, but certainly psychologists have identified pans full of these core needs. So I like to sort of lump them into or label them the four C’s as a pneumonic to remember what they are, but there's certainly four that psychologists agree upon.
Host: Well then let’s talk about those as we’re looking at evidence based practices that can help to promote growth in each. So why don’t you start with your first one and give us a little background and some examples.
Dr. Wiederman: The first one in my mind we’ll call contribution or calling. We could call it either one. It’s the idea that we humans have a need to feel like what we do matters. It doesn’t have to be in a worldwide scale or that we’re changing the world, but that there is some purpose in what we do and that it actually matters to someone. That we’re contributing to something larger than ourselves. Again, that sense of calling or contribution. It could be raising a family. It could be engaging a good patient care. It could be involved in some kind of hobby or avocation and feeling like we’re actually, again, contributing to something beyond just our world or selfish needs.
Host: That one is really interesting to me. As someone who educates the public and helps to educate by bringing on experts such as yourself, I feel like I'm making a contribution. That word calling is an interesting word as well. If somebody doesn’t have that calling, if they don’t feel like there is something that they can do to make the world a better place, do you have some advice on ways that they can look for that?
Dr. Wiederman: It doesn’t have to be anything large or overarching arc. So I like about some research showing that when people volunteer to help others that that really boosts their wellbeing and resilience. I attribute it to that very fact that when we help others, it does give us a sense of satisfaction that we are actually contributing to another person’s wellbeing or another group’s wellbeing. So I think that’s a nice easy one to start with is to find something to start with that interests you around volunteering and contributing to those that need your help.
Host: That’s great advice. So give us another of the four C’s Dr. Wiederman.
Dr. Wiederman: So the second one I would call competence or capability. So as humans we have the need to feel like what we do is generally effective. That we have some level of competence in what’s important to us. Maybe even more importantly that we’re getting better or that there’s improvement or that I'm learning and growing. So that’s the capability part of it.
Host: Let’s expand on that a little bit more as well as we continue to learn. I have a 96 year old father, Dr. Wiederman, and he’s still always trying to learn. So to what degree do we know that we’re competent at something because some people feel like they are when others maybe feel like they're not. How do we know and how can we keep improving on that?
Dr. Wiederman: Well, that’s a great example. Some folks are familiar with the Krueger-Dunning effect which shows that people who know the least about something tend to be the ones to overestimate their ability. So to me that fits here because the more we learn about something, the more we realize the nuances to it and the more we realize what we don’t know. So that’s why the true experts in a field are less likely to even label themselves as experts. Because even though they are objectively, they realize that they don’t know it all. So I would say in that regard to sort of know what you don’t know, you have to sort of plow into an area or a topic and try to learn as much as you can and start to open your eyes to that area.
Host: That is really a great piece of advice. Know what you don’t know because then we’re forever learning. It adds a little humility to whatever it is that we’re doing that we feel competent at. So why don’t you give us another one of the four C’s?
Dr. Wiederman: The third one I would call control or choice. This one I think most of us can resonate with on a daily basis or an experiential basis that we humans have a need to feel like we have some choice and some control over what we do and how we do it to the extent that that choice is taken away. It can be very demoralizing to do something. Even if it was something we wanted to do but we have no choice and people are telling us how to do it or that we must do it.
Host: Another interesting one, because some of us don’t have the choice we wish we had. So when we’re talking about autonomy, what if you are someone who maybe financially doesn’t have the choices you’d like to have, educationally, family. How can we change that one just a little bit?
Dr. Wiederman: So many ideas are running through my head. One is to really maybe just focus on our mental framing of it. So I might fall into talking about things well I have to do this, or I must do this, or I have no choice. If I back up and be a little more objective, it may feel like I don’t but in reality I always have the choice. There may be terrible consequences if I decide not to do something, but it still is a choice. So if I can sort of take that step back to realize that I'm doing it for my family or I'm doing it for my future. So yes, it’s not the ideal right now or it’s not what I would choose if I had the choice. Again, to get that little bit of objectivity which is really at the core of cognitive aspects or cognitive approaches I should say to counselling and therapy. So there are lots of good self-help books out there that help us with our language, help us with our sort of how to frame our experience so that we’re not unnecessarily causing ourselves to feel negatively about it.
Host: I'm going to stick with this one for just a minute Dr. Wiederman. In this unprecedented time and the anxiety level is really through the roof, people are feeling that they don’t have control. They don’t have control of whether they have a job. They don’t have control of whether or not if they get this virus it’s going to be something that lands them on a respirator. All of these things feel outside of our control. Is there some advice you can give us for emotional wellbeing that will make us feel that somehow, even in the smallest way, have control of our tiny little universes?
Dr. Wiederman: I think you hit it right on the head. Why this time is so anxiety provoking because it’s the lack of control. So you're right. I think this really highlights why this is such a core human need or how it is a core human need. I don’t know that this is going to be very satisfying, but I think to draw what I refer to as a priority table. So if you can picture taking out a sheet of paper and making a two by two grid. On the top label the first column urgent and then the next column less urgent. Then the side rows the first row important and the bottom row less important. Then just sort of walk through what you do on a day to day basis and what’s expected of you and sort of plot out where those tasks or responsibilities fall. I think sometimes we fall into doing a lot of things that are urgent that aren’t necessarily very important, but it’s the urgency that pulls us into having to do them or feeling like we have to do them. What we often neglect is that upper right corner which are important things that are less urgent. There I would include things like relationships and recreation and things that are in planning, reflection, things that are very vital to our wellbeing, but we tend to ignore those because of the tyranny of the urgent.
Host: That was actually very satisfying as someone who is a bit of a control freak. Well, my kids would tell me that anyways. I am a list maker. I do exactly what you just said. So hearing you reinforce that and that some are urgent, but some are just desires that we want. We make this list and it’s very satisfying when you do get to cross things off. Let’s hit the last one now, connection and community. I think this, for some people, may be the most important of your four C’s.
Dr. Wiederman: Yeah, absolutely. So as humans even if we don’t feel like we’re a people person, we are wired to need to feel like we have some connection or sense of community. So it’s not that we expect everybody to like us, but that we do feel like there are people who respect us and like us and there is a tribe to which I belong or a group of people with which I identify.
Host: Again, back to what people are feeling right now. As someone with teenagers and anybody, physicians as well, are feeling this in such a strong way as some of them—surgeons specifically—can't even really go home. Or we’ve seen stories about people staying in trailers outside of their house. So this connection right now is what some people are missing the most. Do you have some really good advice for us about people feeling that sense of connection when we have to be at a certain distance and some people cannot even see those that they love?
Dr. Wiederman: Yeah. I think, again, just like with the volunteering it doesn’t have to be something that is long term. We get little boosts from connections to people that are very fleeting and that may be strangers. As a practice that psychologists refer to as engaging in daily pro-social behavior. It’s just a fancy way of saying I'm going to start the day by saying today my goal is to give three genuine compliments to people I encounter throughout the day. I'm going to keep track of whether I do that. Make a little tally or put three rubber bands on my left wrist when I start the day. The only way to get each rubber band to the right wrist is I have to give a compliment to somebody that’s genuine. So it prompts us to do little things when we interact with others to have that human connection, even if it is sort of fleeting. Research on this shows that people who engage in it for several days end up having better wellbeing and actually long-term effects for trying this for let’s say a week.
Host: That’s really important information. Wrap it up for us with your final thoughts on a guide to our mental and emotional wellbeing for providers that are feeling more stress right now than they’ve probably felt in their careers except maybe in medical school, and what you’d like us to know about using those four C’s to center ourselves and to help guide our emotional and mental wellbeing.
Dr. Wiederman: Yeah. I think with regard to giving yourself some permission to realize that these are unusual times and that we do need to spend more attention and time focused on our own wellbeing if we’re going to be of any use to others. That certainly other people around us are struggling with their wellbeing. So how can we use these four C’s as just sort of a tool or a guideline for taking some time to reflect on how am I personally doing in each of these four areas? What little thing can I do in each of these four areas to help get me through this tough time? Then even in regard with others who may not be familiar with the four C’s, how might I reflect on what they might need in each of these areas? How might I contribute or help them with each of these four domains?
Host: It’s great information. What an excellent episode. Dr. Wiederman, thank you so much for joining us today and sharing your incredible expertise. It’s something that I think we all needed to hear right now. So thank you, again. 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 Medcast. 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/ua153.mp3
- DoctorsGunn, Andrew
- Featured SpeakerAndrew Gunn, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4067
- Guest BioAndrew Gunn, MD graduated magna cum laude from Brigham Young University in Provo, UT earning a BS in exercise physiology with a minor in sociology. He then returned home to South Dakota to attend medical school at the University of South Dakota. During medical school, he participated in the competitive Howard Hughes Medical Institute – National Institutes of Health Research Scholars Program and was awarded the Donald L. Alcott, M.D. Award for Clinical Promise. He graduated summa cum laude in 2009. He completed his diagnostic radiology residency at the Massachusetts General Hospital of Harvard Medical School in Boston, MA followed by a fellowship in vascular and interventional radiology at the Johns Hopkins Hospital in Baltimore, MD where he served as chief fellow.
Learn more about Andrew Gunn, MD
Release Date: July 21, 2020
Expiration Date: July 21, 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:
Andrew Gunn, MD
Assistant Program Director, UAB Diagnostic Radiology Residency Program
Dr. Gunn has disclosed the following commercial interests:
· Grants/Grants Pending/Research Support - Penumbra Inc.
· Consulting Fee - Boston Scientific
· Payment for Development of Educational Presentations - Boston Scientific, Terumo Corp.
· Payment for Lectures, including Service on Speakers' Bureaus - Boston Scientific
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): For some patients, kidney cancer can be effectively treated without surgery. According to the Society of Interventional Radiology’s first ever position statement on the role of percutaneous ablation in the treatment of renal cell carcinoma. Welcome to UAB Med Cast. I’m Melanie Cole and today, we have Dr. Andrew Gunn. He’s an Interventional Radiologist at UAB Medicine. Dr. Gunn, welcome to the show. So, before we get into the percutaneous ablation, for renal cell carcinoma, tell us about the prevalence of kidney cancer. What are you seeing in the trends?
Andrew Gunn, MD (Guest): Well kidney cancer affects about 60 or 70,000 individuals every year. It results in anywhere between 15 and 20,000 deaths a year. We’re actually seeing an increase in the incidence of kidney cancer and that’s because we’re using more imaging like ultrasound, CT and MRI looking at other indications and so we’re actually finding more of these kidney cancers, almost by accident and what I mean by that is kidney cancers that are not symptomatic. Patients aren’t having pain, or they are not having blood in their urine yet we find these kidney cancers because they’re being imaged for some other reason and so because of that, we’re seeing an increase in the incidence of kidney cancers.
Host: That’s interesting that you’re finding them incidentally and that you’ve got this imaging that’s augmenting your ability to diagnose these. So, what has been the thought on treatment as far as surgery in the past? What’s different now that you are doing?
Dr. Gunn: So, primarily, the gold standard for treatment for kidney cancer would be surgery. And that involves - traditionally has involved what’s called a nephrectomy where they go in and they take out the whole kidney. In the past several years, there has been a movement towards what’s called nephron sparing surgery. Or surgeries or interventions that actually spare most of the kidney because we want to preserve as much kidney function as possible. And so even in the urology literature, there has been a movement towards what’s called partial nephrectomy where they only remove a part of the kidney and try to leave as much of the kidney there as possible. And so that’s where we come in in interventional radiology what we do is we use imaging guidance either with CT or with ultrasound and we place needles through the skin and with those needles we can either burn or we can freeze that kidney cancer to death without removing the entire kidney. And what we’ve been able to know over the years is that the imaged guided ablation of kidney cancer has less complications, it preserves the renal functions to a greater degree compared to surgery and patients stay in the hospital for less period of time compared to traditional surgery. So, there’s been more of a movement towards these minimally invasive approaches to kidney cancer compared to years past.
Host: It’s fascinating. So, tell us about the position statement that you were one of the authors of that was published and how it establishes performance thresholds for patient safety. Tell us a little bit about that.
Dr. Gunn: Yeah, so there’s a couple exciting and new things about it compared to where we have been in the past. First, it’s always been difficult to perform a randomized controlled trial comparing partial nephrectomy or radical nephrectomy the surgical approaches to percutaneous ablation and that’s because both treatment strategies work really, really well. And so in order to do a large trial, we’d have to have a high, high number of patients in order to accomplish that and so, what’s good about this position statement and these quality improvement guidelines is it actually includes data from what are called metanalyses and population based studies where researchers have looked at national cancer databases to be able to compare outcomes for image guided ablation versus partial nephrectomy and like I mentioned earlier, this position statement includes some of this most recent work looking at these population based studies in which we’ve been able to show that our clinical and our technical outcomes for percutaneous ablation or image guided ablation are very – or nearly equal to partial nephrectomy especially for tumors that are less than four centimeters in size. And so including that information is one thing that is new and exciting about this position statement.
The second thing is that the society has been able to take a position on larger tumors. So, tumors that are greater than four centimeters in size. And so, previously, these were basically left to surgery and said image guided ablation is not a great option for that because recurrence rates could be a little bit higher, complications can be a little bit higher but in the last several years, including here at UAB, many series have been published showing that percutaneous ablation even for tumors larger than four centimeters can be accomplished both safely with high rates of technical success and good oncologic outcomes. And so this position paper is really the first one from our society to lay out that data for people to look at and be able to use for payers and be able to talk at tumor boards to their referring physicians.
And so, the third thing about it is how we set those thresholds. What we do is we take a look at all the numbers that are reported our in the literature and we take those numbers and we take the average of those numbers and we look at the range of those numbers and then we look at the deviation, what’s called the standard deviation. We take two standard deviations above and below what’s reported – the reported average that’s out in the literature and we use those to set thresholds. So, for example, we want to say for technical success and give the threshold which should really be 90+ or 95%+ technical success for image guided ablation and your complications should be less than 6% overall.
And so, we use those for people to be able to do quality improvement of their own practices and say if I’m having more complications than this, then we probably need to take a look and see how we’re doing the procedure or if our technical success isn’t as high as what’s reported out there, what’s the threshold that I need to go back and start to look at how I’m performing those cases to be able to make sure I’m doing the right thing for my patient. So, those are really the three big areas that I would say is different than what we’ve done in the past through the society.
Host: Well you got to my next question on accompanying quality improvement document and what that entailed so thank you for that. Now define for us the patient population. Who might benefit from this procedure? Tell us a little bit about patient selection and has that changed?
Dr. Gunn: You know – so first of all, patient selection has traditionally been patients who for some reason or the other can’t undergo partial nephrectomy or radical nephrectomy. So, a lot of times, in the interventional radiology literature, we’re looking at patients who might be a little bit older, patients who might have more medical comorbidities than the average patient, patients who have multiple renal cell carcinomas, patients who might have reduced kidney function at baseline. Those are traditionally the patients that we’ve been seeing in interventional radiology. And I would say how has patient selection changed? I would say it’s changed more in the sense that more patients I think are opting to go to image guided ablation compared to partial nephrectomy and so there’s – I am seeing personally, at least, a higher number of patients who are hearing both options and are choosing to go to the image guided or the needle based treatment as compared to traditional surgery just because the recovery time is quicker, it’s less morbid, there are fewer complications and so, I feel like our patient population is trending just ever so slightly a little bit younger than what has been in the past. But typically, I would say the traditional patient that we see in interventional radiology for this procedure is someone who either can’t or doesn’t want to undergo traditional surgery for their kidney cancer.
Host: What have your outcomes looked like Dr. Gunn?
Dr. Gunn: So, I mean our outcomes have been good here at UAB. When you look at nationally our technical success rates for tumors that are less than four centimeters in size are very close to 98 or 99%. Which basically means can we treat the tumor and on our first follow up imaging, do we see any tumor left? So, in that sense, the technical outcomes are really good. Major complications have been reported in anywhere between three and five percent of patients. We’re certainly at that threshold or below here at UAB. And I would say our oncologic outcomes which what I mean by that is recurrence rates, when the cancer – the timing of the cancer coming back if at all, survival rates both cancer specific survival and overall survival. When you look at that for tumors that are less than four centimeters in size, we see that percutaneous ablation is very similar within one or two percentage points of partial nephrectomy and all of those outcomes. With the advantages we talked about of having less complications, and a shorter hospital stay. So, the outcomes in that sense are really good.
The other thing that we are seeing more is these larger tumors, especially as the population gets older and has more medical comorbidities; we’re definitely seeing larger tumors in our practice and that has been good to look at the national literature and see that our technical success rates are 90+%. They are in the ball park. And when you consider repeat ablations, people that have to come back and clean up a small little area that might have gotten left behind or didn’t get adequately treated in the first one, the technical success gets into the 95% range. Even for those larger tumors.
Now of course, when we’re looking at those larger tumors, the complication rates tick up by a few percentage points and the time to recurrence or time that tumors might come back is a little bit shorter compared to the smaller tumors but regardless, I still think that for patients who are appropriately selected patients, percutaneous ablation can be a good treatment option for even those larger tumors.
Host: So, as you tell us some technical considerations, that you might like to share with other providers, tell us about the anatomic and physiologic considerations unique to the kidney that have to be kept in mind. This is for other providers for effective and safe percutaneous ablation.
Dr. Gunn: Well the first thing that I would say is that the vast majority of patients can be successfully treated with percutaneous ablation. If you think that it’s an option. What I would say if you’re listening to the podcast is that if you have a question about whether or not your patient is a candidate for percutaneous ablation, the answer is probably yes. And that we would be happy to see them in clinic. The technical considerations are always that tumors that are smaller, any tumor that is smaller, any tumor that is more on the outside of the kidney compared to being more centrally located within the kidney and tumors that are on the backside of the kidney, posterior located versus anterior located. So, those are always the easier more technically straightforward cases. So, if they are smaller, they are more on the outside of the kidney and they are more on the back of the kidney. So, that’s one thing we’re always looking at inside of our clinic is to see those critical questions about the location of the tumor.
That being said, even tumors that are larger, tumors that are more centrally located, tumors that are more on the anterior side of the kidney; we have several techniques whether it’s placing fluid in between the kidney and the colon or placing stents in the ureter to protect the renal collecting system. We have several of these adjunctive maneuvers that we can perform so that we can perform this procedure safely for the vast majority of patients. As far as risk factors go, bleeding is by far an away the number one complication from this procedure. So, it’s always something that we’re very cognizant about and that we’re very – watch patients after the procedure to make sure that we don’t have any evidence of bleeding. Other complications such as damaging some sort of adjacent structure like the bowel or the ureter or a nerve are very low, well less than one percent of all cases.
And so, those are really the big considerations that we’re looking at when we are evaluating patients for this procedure.
Host: And Dr. Gunn, the statement used a multidisciplinary group of experts including interventional radiologists such as yourself, and urologists. Why is it so important to consult that multidisciplinary group for this procedure?
Dr. Gunn: Really, I would say that a multidisciplinary approach for all patients with cancer is a good approach. And it’s not just kidney cancer. It’s all sorts of cancer and I think that that’s one thing about being at a large cancer center like UAB that is quite beneficial is the fact that you’ll get a consultation with a medical oncologist, and with a radiation oncologist, or with surgery or with interventional radiology and I think the important thing is that the patient is presented with all of their options and I think that the patient has to also apply their own beliefs and values and priorities to those treatment decisions as well. So, it’s never really a one size fits all approach for any one patient. And so when a patient comes in, especially when it comes to kidney cancer, some patients might prefer to have surgery and that’s fine and some patients might prefer to have the more needle based approach that we offer in interventional radiology which is also fine. But what we have to do as physicians is provide them with all of their options and so to be able to be at a place where all of those options are and have that multidisciplinary approach where the patient can be presented with all of their different options and with our recommendations, I think is a real advantage.
Host: Well it certainly is. What a fascinating topic. Dr. Gunn, wrap it up for us. What would you like other providers to know about percutaneous ablation in the treatment of renal cell carcinoma and what you’re doing at UAB? What would you like to share? Wrap it up for us.
Dr. Gunn: Yeah, I would say percutaneous ablation especially for those smaller tumors is safe, it’s effective and its outcomes are nearly equivalent to partial nephrectomy. And it would be with the caveats that we have. Quicker recovery times, we keep people out of the hospital, and we have a less detriment to patients’ renal function. So, if it’s something that you are at all considering for your patient, please send them over to have a consultation with us. The other thing that I would say to wrap it up is even with these larger tumors, for the appropriately selected patients, percutaneous ablation is not contraindicated. We can still do it. It just may require some more technical considerations, but I would never consider it contraindicated in those larger tumors. And so, I think that’s something important for other referring providers to hear.
Host: Well it certainly is and thank you Dr. Gunn for joining us today and sharing your incredible expertise in this fascinating topic. 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 podcasts. I’m Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua149.mp3
- DoctorsMackinnon, Craig Jr.
- Featured SpeakerCraig Mackinnon, Jr. MD, PhD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4018
- Guest BioCraig Mackinnon, Jr. MD, PhD is the Division Director, Genomic Diagnostics & Bioinformatics.
Learn more about Craig Mackinnon, Jr. MD, PhD
Release Date: June 8, 2020
Expiration Date: June 8, 2023
Disclosure Information:
Dr. Mackinnon has no financial relationships related to the content of this activity to disclose. Also, no other speakers, planners or content reviewers have any relevant financial relationships 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 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 molecular diagnostics at UAB Medicine. Joining me is Dr. Craig MacKinnon. He's the Division Director in Genomic Diagnostics and Bioinformatics in the Department of Pathology at UAB Medicine. Dr. MacKinnon, it's a pleasure to have you join us and before we delve into this heady topic, tell us how you came to UAB. What drew you to their department?
Dr. MacKinnon: I joined UAB about a year ago. Previous to this, I was at the Medical College of Wisconsin and Milwaukee, Wisconsin where I had established a molecular diagnostic lab that did clinical testing on patient samples. And we also supported research for the institution where I worked. And having done that for several years and we got successful at it, my current chairman, Dr. George Neto recruited me to come down to UAB and take the existing molecular lab that had been previously set up and using my experience up in Wisconsin, expand it so that we can update our technologies and increase the number of tests that we offer for our patients here.
Host: Well, thank you for telling us about that. So then give us an overview of molecular diagnostics at UAB Medicine, as well as how it relates to what we're going through right now in COVID-19?
Dr. MacKinnon: Molecular diagnostics. What that essentially means, anytime you have the word molecular and a test or a field in medicine, it typically means that you're analyzing DNA or RNA. And what we're doing is looking either at changes in the sequence which would be causing mutation that could be responsible for some type of disease or process that's unhealthy to the individual or we're looking at changes in the amount of the gene that's being expressed. So when we talk about molecular diagnostics, typically what you do is you remove the DNA or RNA from either a person's cells by extracting the tissue and isolating the DNA. Or you can do it from microorganisms. Like in the example of COVID-19 testing, you're removing the RNA from the virus. Then you do some type of test which could be PCR based, sequencing based, hybridization based, and what's you're asking is a specific question, is there a mutation? How much of this gene is being expressed, how much of it is not being expressed, and so on? And you get an answer and then you take that answer and you fit it into the clinical context to get a result that the clinician can then use to treat the patient.
Host: Fascinating, and an absolutely fascinating field that you're in. As a latest example of how genetic sequencing has made that leap from research labs to patient bedsides for years now and it was difficult to do an expensive. Tell us how you can now sequence with high precision and accuracy at lower costs. Tell us about that.
Dr. MacKinnon: Well, the reason that genetic sequencing has become available to many patients in many institutions is due to the advances in the technology that are used to generate that sequencing data. If we think back, maybe it was 15 years ago, 20 years ago when the human genome was initially sequenced, this took thousands of people to do. It was very slow going and cost prohibitive, maybe around a billion dollars for one genome and that's because the technology that was being used back then was not scalable and it was low throughput. And in the early two thousands maybe around 2004, 2005 some commercial companies developed sequencers using a different approach called massively parallel sequencing where you could generate a lot of sequencing data in a very short time. And what this actually did in the process was created a whole new industry called bioinformatics. So once you generate the sequencing data, how do you analyze it?
How do you understand it? How do you pull out the important information that's clinically relevant from the background information that is not relevant to your patient? And how do you turn that into a clinical report? So we are now at a place where a lot of commercial vendors provide tests and kits and information solutions for labs so they can get set up and running. And at UAB we've done a lot to develop our own technologies in house. We have the ability to analyze our sequencing data from the tissue that we receive, to the report that we make all in house. So these advances that make it accessible to patients now are being driven by technology that allows you to sequence more and more of a genome from either the patient or an organism at a much.
Host: That's so cool. So tell us a little bit about your rapid turnarounds, Dr. McKinnon and how those are possible by your revolutionary machine Idylla. Tell us what that is and how it can allow for same day testing.
Dr. MacKinnon: Rapid genetic testing is important because clinicians need to get the test results back as soon as possible. And currently with the sequencing technologies we use at its very fastest. If you have a lab that is operational 24 hours a day, seven days a week, and as soon as the sample comes in, it can enter the testing pipeline. It still takes three or four days for the result to be finalized and reported back to the clinician. So there is a need for developing ultra rapid testing and we've adopted two platforms at UAB for doing this. The first one is what you mentioned earlier and that's called the Idylla. These are instruments that are incredible in terms of rapid and ease of use. You take a piece of tissue from a paraffin block, you cut off a thin slice, about the thickness of a piece of notebook paper, put it into the cartridge, loaded onto the machine, and within two or three hours you get a result. And this can be very helpful for really small samples that are too small to test by conventional methods.
And then occasionally you'll have a patient who's coming in to see their clinician that afternoon and they need to come up with a treatment plan. And because the turnaround time on conventional sequencing is so long, it's possible that sometimes their appointment is scheduled before those results from the large test come back. So you can get a, an early insight into what type of mutations the patient's tumor may have using cancer as an example, and therefore make the patient's office visit more efficient for the patient. They don't have to come back again to find out what the results are and you can even start therapy sooner than, than waiting for the result. It also gives a lab like at UAB, a competitive advantage because now we can do testing quicker than it takes to take the sample, put it in a FedEx box, send it across the country to a lab, let them do their processing, and then communicate the results back. So it helps the lab run enough testing to help them, and it provides a benefit to the patient because the results come back quicker and fully informed clinical decision making can happen more effectively.
Host: That's amazing. Really the technology is amazing that you're using. So how are you expanding both your team of experts and the tests and services you offer relating to genomics diagnostics?
Dr. MacKinnon: I'd mentioned that we have two methods for doing the rapid turnaround test and we'll use that as an example. I talked about the Idylla and the Idylla is just looking at one gene at a time. We now can do rapid, large genetic panels with 50, 60, 70 genes rapidly. And that helps because if you're looking for a mutation in subtle genes, you don't know which one may have the mutation. So you have to run them one after another and that can become just as long as sending it out to a reference lab. So that is one way is to take this rapid turning around testing and expanding the number of targets, the number of different genes that can be run in the same assay in parallel. And then to support that, probably the biggest effort we're making right now in our division at UAB is to expand our bioinformatics capabilities by building a large team of informaticians who can take the genetic data, analyze it appropriately, and help to interpret it for the purposes of generating a clinical report.
And working in parallel with the informaticians are the systems administrators and the IT folks who get all the equipment and servers talking to each other. We're exchanging huge data files, you know, several gigabases that are not easy to move around. And so you need a really expert IT team to support that as well. So you have the pathologist, the lab staff, the informaticians and the IT staff all together make a team that allows you to go from a patient sample, that you receive in your lab to a clinical report, that goes back to the patient and their treating physician. And we try and do that as quickly as possible without sacrificing accuracy or safety for the patient.
Host: Such a comprehensive approach. Dr. McKinnon, what are some goals for the Precision Diagnostics Laboratory? What do you see as future direction for molecular diagnostics at UAB Medicine?
Dr. MacKinnon: Well, our future goals are to expand the scope and scale of our testing. Right now we, I would say we mostly focusing on tumors because tumors are diseases in which a patient's cell acquires mutations that allow that cell to grow uncontrollably and it forms a tumor mass and eventually it can spread throughout the body. But we want to use these same technologies, the same approaches, but apply them to non oncology problems such as pharmacogenomics. People as you know, can be given a drug and they, based on how their body metabolizes the drug, you have to sometimes alter the dosing. If there are rapid metabolizers who maybe give them an extra dose of the drug, if they're very slow metabolizers you give them less of the drug. So that you can keep the drug levels in their body in a safe range. So there's a huge amount of applications for genotyping, which means that you're looking at the different sequence variations and the enzymes that metabolize these drugs and developing a report for that patient so they can customize their gene dosage. That's a big area for the future that we're getting into. And I think there's a lot of applications at UAB for the different clinics. For example, psychiatric drugs and pain management are two areas where this would have an enormous impact right off the bat.
Host: Do you have any final thoughts for other providers on what you're doing there and why your work is so exciting?
Dr. MacKinnon: Well, I would just like to say that this is a huge team effort involving lots of people other than just myself. And one of the advantages of UAB I think is that it has in general a collaborative nature and everyone has a forward looking mission focused approach to patient care. So what we are doing here at UAB I think is very fortunate because the environment fosters this type of collaborative growth and this collaborative approach to treating patients. I think we're very fortunate to be here and have that existing culture in our institution. Other places that maybe difficult, more difficult if there siloed or you don't get a chance to engage with people. I'm working on areas that are related but that you may not encounter otherwise. So I think that's one of the ingredients that's helps UAB be such an outstanding medical institution and permit this type of innovative work to take place.
Host: Thank you so much, Dr. McKinnon. Such a fascinating topic. Thank you for coming on and telling us about molecular diagnostics at UAB Medicine. 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 the 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/ua150.mp3
- DoctorsGreene, Benjamin;Myers, René;Jeyarajan, Harishanker
- Featured SpeakerBenjamin Greene, MD | René Myers, MD | Harishanker Jeyarajan, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4006
- Guest BioBenjamin Greene, MD is an Assistant Professor whose specialty is Otolaryngology. Learn more about Benjamin Greene, MD
Dr. Myers joined the UAB Division of Plastic Surgery in August of 2015. He has been fortunate to travel internationally to perform overseas cleft and craniofacial work and looks forward to continuing these trips.
Learn more about René Myers, MD
Harishanker Jeyarajan, MD's Specialties include Head and Neck Surgery, Otolaryngology.
Learn more about Harishanker Jeyarajan, MD
Release Date: June 3, 2020
Expiration Date: June 3, 2023
Disclosure Information:
Drs. Myers, Jeyarajan and Greene have no financial relationships related to the content of this activity to disclose. Also, no other speakers, planners or content reviewers have any relevant 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 the UAB Med Cast. I’m Melanie Cole and today, we’re discussing facial nerve disorders and injuries. Joining me in this panel are Dr. Hari Jeyarajan. He’s an Assistant Professor and Head and Neck Surgeon in the Department of Otolaryngology, Dr. Rene Myers. He’s an Assistant Professor and Craniofacial Plastic Surgeon and Dr. Benjamin Greene. He’s an Assistant Professor and an Otolaryngologist and they’re all with UAB Medicine. Dr. Greene, I’d like to start with you. Tell us a little bit about the prevalence of facial nerve disorders and injuries. What are the most common that you see?
Benjamin Greene, MD (Guest): The most common facial nerve disorders that I see are related to Bell’s Palsy or idiopathic sudden onset facial nerve paralysis. It’s something that happens suddenly which is in the name of it and is usually a complete one sided facial nerve paralysis. Kind of a drooping face. Most people are familiar with a Bell’s Palsy or something like that and that is by far the most common cause of facial paralysis. It’s about 60 to even 70% of all causes of unilateral facial nerve paralysis. So, that’s the majority of what I see. But we also see a fair number of facial nerve palsies due to injury whether or not it’s a stab injury, a gunshot, or a crush injury where people fracture one of the hardest bones in the body, the temporal bone and can cause pinching of the nerve inside of the bone. But also, we see a lot due to cancer especially living in the southern states; skin cancers can go to the area of the parotid gland and cause facial nerve paralysis whether or not that’s being resected from surgery or the cancer itself hurting the nerve. And so all of those things are the most common types of unilateral facial nerve paralysis.
Rene Myers, MD (Guest): And I would echo that what Dr. Greene said and then also say that on the pediatric side, we also see a fair number of parents who bring their infants in with what’s called a congenital unilateral lower lip paralysis which can be somewhat disconcerting if a child is trying to smile and their lower lip on one side is not moving. Generally, it’s a pretty benign thing and we con generally talk them through that entire process. With some people requesting treatment when the infants are a little bit older and then of course, also on the pediatric side, there are some congenital forms of both unilateral and bilateral facial paralysis including something called Moebius Syndrome where they can have significant dysfunction of the Cranial Nerve VII which is a fairly rare syndrome but it’s definitely something that we see and can follow as well.
Host: Well thank you for that answer gentlemen. And Dr. Jeyarajan, tell us about the clinic at UAB. Tell us about your comprehensive approach that integrates the most cutting edge therapies for facial nerve disorders spanning from rehab to medical management to surgical repair.
Harishanker Jeyarajan, MD (Guest): At UAB, we’ve established a multidisciplinary facial nerve clinic and essentially what that means is we know that facial nerve disorders include the range of different problems from pure paralysis to partial function to abnormal function. And there are various methods to treat these and the importance of this clinic is to sort of bring the strengths of multiple different training specialties together to see these patients. And so, we try and use a combination of surgeons, physiotherapists, and nurse practitioners to sort of see the patients and address the patients in what we call a multi-model manner. The clinic itself is set up in the ENT clinic and the reason that is is probably because as ENT surgeons and head and neck surgeons, we often cause a lot of the problems that we see due to the fact that we have to treat these cancers that quite often involve the nerves and a lot of our adult patients are patients that present either from trauma or as De. Greene mentioned before complications of skin cancer and even complications of brain surgeries and brain tumors, simple skull based tumors.
And so, we sort of sit in a really good position to sort of see these patients and treat them in the clinic. The clinic runs twice a month. We do one full day. Operate on a Monday and we see – we have one full day of clinic and we have a second half day of clinic. Usually the clinic consists of Ben Greene. Ben Greene is always there. We have an APP that’s there with him. And we have a speech pathologist who has been specially trained in the management of – the use of facial nerve physiotherapy to manage these patients. I try to make it there as well and we have access to a lot of other subspecialists often that don’t need to be there at the clinic at the time but if we need them to come in and see them for a specific reason they can come and see them as well.
When we see these patients, we do an initial assessment and all patients receive a standard set of photographs and also have a standard video taken at each appointment. The reason we do this is having an objective standardized approach allows us to both objectively assess the patient and allows them also to objectively see what problems that they are having and it allows us to – by doing it at every appointment, it allows us to follow their progress with whatever treatment that we implement.
Most patients will start off when we see them, depending on what problems they have, all patients also get assessed using a standardized survey. There are a number of different systems out there that we use to score patients and to also establish how facial nerve dysfunction is affecting their quality of life. The most common objective measure that is used across the country and across the world and the one that we use is called the Sunnybrook System. And each patient gets scored, has standardized photography and standardized videography done and then we then ask them a series of questions to assess how this is affecting their quality of life.
And based on the disorder that they have, we then implement a treatment strategy that incorporates usually a combination of physiotherapy, what we call chemical denervation particularly for the patients that are having what we call facial nerve dysfunction rather than just paralysis and then we discuss surgical treatment options depending on what type of dysfunction and what type of problems or symptoms the patient is exhibiting. There’s many different options when it comes to surgery. We divide them broadly into what we call static options and dynamic options. Dynamic options really involve either trying to get the nerve to start working on its own again so through the use of nerve graft or we try and get the nerve to work by hooking it up or connecting it to another nerve, so that’s called [00:07:26] nerve transposition. Sometimes the patient doesn’t even have the muscles to create facial movement and in those situations, a dynamic approach would involve taking another muscle something the Dr. Myers alluded to before, [00:07:40] muscle flap and using that to try and drive the face to make a smile.
And there are a lot of other static procedures that we offer really trying to position the face in a better position at rest. It becomes quite complex but in general, we use a range of these different techniques to try and suit the problem that the patient presents with and suit the outcomes that the patients are trying to achieve.
Dr. Myers: You know one of the biggest things in terms of doing multidisciplinary and hearing from both the plastic surgery standpoint, the ENT standpoint, the physical therapist standpoint; all of those things of everything that we all have contributed is really paled in comparison of what the patient has to say about what their experience with facial paralysis is like and what their goals are in terms of what their ultimate reconstruction would be. For example, some of the more elderly patients that have some facial nerve dysfunction or paralysis might opt for less surgery versus a younger patient who has more life to live might opt for a more extensive operation if it meant that their life or the way that they can present their face to the world could be improved because people make a lot of assumptions about other people based on what their face looks like and if half of your face doesn’t work or if your entire face doesn’t work; then other people you interact with will misread the emotionality that person has or doesn’t have in a given situation. Oftentimes they are described as being – looking like they are mean because they are not smiling properly. And that can really affect somebody’s social standing and how they can interact with the world at large. It really is a big deal for them.
So, getting down to what they really want fixed whether it’s something as simple as my eye gets really dry, I need to have that fixed all the way up to I need a spontaneous smile because I can’t interact with people the way that I want to.
Host: Dr. Myers, I’d like you to expand for us a little bit as even a slight amount as you are saying of facial asymmetry or weakness can have a huge affect in a person’s quality of life and due to the sensitivity of these disorders and the intricate nature of what you do; tell us about some of the latest advances whether it’s robotics, minimally invasive technology that could allow surgeons to access hard to reach areas. So, give us a little bit of a rundown on what you do.
Dr. Myers: Certainly. Discovery of neuromodulation in terms of using whether it’s Botox or Dysport or any of the other botulinum toxins that are available on the market to target certain muscle groups to help with things like synkinesis where people’s muscles are firing at inappropriate times for example because sometimes it can be a very bothersome thing to patients. As we’ve continued to learn more about facial nerve dysfunction and how we can put nerves back together, transfer nerves or transfer entire muscles using microscopes and very intricate microsurgical techniques to put those things all together in a very staged and planned out operation that can several times in the operating room to get that accomplished over the course of a year or two to have an outcome at the end that everybody can be happy with.
Dr. Greene: And I’d like to add to what Dr. Myers was saying about just having the surgery or after having treatment having a good team involving facial therapists, APP support, great photographers is really helpful to getting the patients back to the best that they can be. So, just the three of us come in and do these large surgeries, transferring muscles, transferring nerves what have you; but without the therapy, without the training, without the retraining and without the discussions with the patients about neuromodulation and chemo denervation or just how to use these new muscles it doesn’t work nearly as well as when you have the multidisciplinary team approach that we’ve developed here to make sure that they get the therapy that they need to get the muscles and the nerve groups working as well as they can be.
Host: And Dr. Greene would you expand just a little bit when you are saying all of this multidisciplinary multimodal approach; what have you guys learned from generous research on the subject plus all of this practical experience that you’re going over with us today and this multimodal approach. What else have you learned that makes your program stand apart and is so unique in the country?
Dr. Greene: What I learned is that everybody at some level was doing some type of facial nerve repair before we started this and it just – it was not as coordinated as it could have been. And so, by developing the facial nerve clinic; we put everything together and are standardizing the approach so that every patient gets very good treatment the same way with similar people. And I also learned that there’s a lot I don’t know. And there’s a lot that Dr. Myers as a plastic surgeon sees differently than I do and the same thing with Dr. Jeyarajan. We see things and look at things in a little different way, not totally different but just a little bit where it helps having different eyes and different ideas to help each patient. We also have oculoplastic surgery involved where they specialize in plastic surgery around the eyelids and eyes and one of the most important parts of managing facial nerve paralysis is making sure that they eye can close appropriately because in early Bell’s Palsy and facial nerve paralysis, the facial nerve is responsible for closing the eye and when the eye can’t close it can get dried out, they can get abrasions and infections of the eye where over time can result in decreased vision, irritation and even blindness.
And so having people that are very specialized with eyelid surgery onboard is very important for the patients and just seeing how great the oculoplastic surgeons are at doing their job and doing what they love, seeing how great Dr. Myers and the Plastic Surgery Department is at helping us out and getting these things done and having partners like Dr. Jeyarajan, they are just incredible surgeons. It’s been kind of enlightening to me to show me what else is out there, what other ideas are out there. And really, really has been kind of inspiring to see what more we can do for patients and what more we can offer for the whole southeast region.
Dr. Myers: I agree 100% Ben and I would also say that being able to – especially these big operations, the really complicated things where we are doing microvascular surgery, you are transferring free functional muscles and doing nerve transfers, all of those things; from a surgeon’s standpoint, once can go into those things and do it by themselves but how much more comfortable do we feel having two other microvascularly trained surgeons around during those things. I would say, way more comfortable. Because if for whatever reason, I’m struggling with something with one of the residents, that’s very simple; either yourself or Hari will scrub in and we make it all work. And it’s a lovely orchestra of surgery that winds up happening because there is very experience people who have all done these things a lot and the particular flaps that we do, especially the Gracilis muscle flap; we do those things all the time for things like lower extremity reconstruction which are not quite as delicate an endeavor as facial reanimation but being able to do those things constantly all the time helps inform us about reconstruction of a smile and doing it up in somebody’s face where it’s a little more difficult than doing it in somebody’s leg.
Host: Dr. Jeyarajan, tell us a little bit about what you’ve seen and then I want to give all of you gentlemen a chance to say a last thought on this particular topic. Dr. Jeyarajan why don’t you start. Tell us a little bit about your outcomes and do you have any clinical trials you’d like to mention?
Dr. Jeyarajan: In the clinic so far, we’ve seen just over about 200 patients, I think. The most common cause of facial nerve dysfunction by far is that that’s been due to Bell’s Palsy or idiopathic facial nerve paralysis as Dr. Greene alluded to before. And then we’ve had a fair amount due to surgery and a fair amount due to trauma. Most of these patients particularly ones that have had Bell’s Palsy have been managed nonsurgically. The vast majority of them have been able to be managed through a combination of specialized facial nerve physiotherapy, what we call chemical denervation or Botox injections that helps to sort of adjust the unwanted movements that can sometimes happen as the face starts working again. And so far, for those patients, we’ve noticed a significant improvement in both objective measures so that means using what we sort of talked about before, the Sunnybrook scoring system, we’ve seen a significant improvement in their objective facial nerve function and we’ve also seen a significant improvement in their standardized quality of life scores and that basically says that patients themselves are feeling a lot happier and a lot better and that’s without even requiring surgery.
With regards to our facial reanimation techniques, we’ve had relatively good outcomes so far with our reinnervation but also with reinnervation it takes a lot of time to actually see the nerves come back and that’s something that’s really important when you see these patients is that a lot of these patients that have required nerve sacrifice due to tumors or traumas or brain surgeries; when we do these surgeries, the nerves take time to recuperate and regrow along the nerve graft that we put down and so that takes months to really happen and so we’re still waiting to sort of see what the long term outcomes of those nerve grafts have been.
With regards to our general physiotherapy for our facial nerve dysfunction patients; we’ve had excellent outcomes. And that’s based on both objective measures and also the subjective quality of life scores that we’ve been looking at.
With regards to where we go from here, we just submitted a publication going over how we’ve come about starting the clinic, setting it up and looking at our initial outcomes. I feel that the next endeavor really is to really explore our long term outcomes with our dynamic reanimation techniques and that’s probably the next place that we’re going to be really focusing on and hopefully assessing long term outcomes regarding that.
Dr. Greene: That’s exactly right. The most interesting thing for me about doing the facial nerve clinic and seeing the facial nerve patients is just how happy people are to be listened to and actually get treatment. Some of the patients have had Bell’s Palsy and the sequelae of a partially healed Bell’s Palsy for 20 years or more. And were told years ago that there was nothing more that can be done. And that’s just not true anymore. Because we can take care of folks that have had all kinds of facial nerve problems. I mean it has never happened that somebody has come to me with a facial nerve problem and I said there’s nothing we can do. Because there’s always something that we can do to help people. And it’s just – it’s very satisfying when you can tell people that you can help them when they’ve been looking for something for a long, long time.
Host: So, well put and Dr. Myers, I’d like the last word to be for you. Please tell other providers when you feel that it’s important that they refer to this amazing clinic at UAB Medicine and any exciting advances, what you see on the horizon happening for facial nerve disorders and injuries.
Dr. Myers: I would say that it’s interesting. For upper extremity, some of the plastic surgeons around the country including some of us at UAB are starting to get into what’s called targeted muscle reinnervation which hasn’t been worked out significantly within the head and neck area but that’s certainly some place where things could potentially go in the future trying to actually reinnervate individual muscles within the face. As far as who should be referred to us, certainly we’re always available. It’s very easy to get ahold of us at UAB and any provider that simply wants to have a conversation with us if they have questions about a particular patient, we’re more than happy to talk to them on the phone and equally willing to see people in the clinic that need to be seen in the clinic.
And really, any sort of whether it is idiopathic, traumatic, congenital or anything else that provides a facial asymmetry or a dysfunction in somebody’s facial musculature; we are absolutely 100% ready to see those things and be able to hopefully provide something to improve those people’s lives.
Host: What great information. Gentlemen, thank you so much for coming on today and collaborating and sharing with us your incredible expertise for other providers about the clinic at UAB Medicine. Thank you so much. 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/ua147.mp3
- DoctorsLaw, Mark
- Featured SpeakerMark Law, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=3968
- Guest BioMark Law, MD is a Pediatric Cardiologist, Associate Professor.
Learn more about Mark Law, MD
Release Date: May 22, 2020
Expiration Date: May 22, 2023
Disclosure Information:
Dr. Law has the following financial relationships with commercial interests:
Grants/Research Support/Grants Pending - Edwards COMPASSION XT post approval trial, site PI
Support for Travel to Meetings or Other Purposes - Transportation to Medtronic and Edwards transcatheter pulmonary valve implanters conference
Dr. Law does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity. - 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 discussing approaches to pulmonary valve disease. Joining me is Dr. Mark Law. He’s a Congenital Heart Disease Cardiologist and an Associate Professor at UAB Medicine. Dr. Law, it’s a pleasure to have you join us today. Tell us the prevalence of pulmonary valve disease. What are you seeing?
Mark Law, MD (Guest): So, we see a number of adult patients who were born with congenital heart disease presenting with pulmonary valve dysfunction as adults. Most recently, patients who are born with heart defects are surviving into adulthood and we now have more adult patients who have congenital heart disease than we have pediatric patients. And a lot of the patients with complex congenital heart disease, will have pulmonary valve dysfunction or dysfunction of what we call the right ventricular outflow tract.
And the most common diagnosis we talk about is something called Tetralogy of Fallot. And in patients with Tetralogy of Fallot or other types of congenital heart disease; they will have interventions on their pulmonary valve or surgery on their pulmonary valve that leaves them with both narrowing and insufficiency of their pulmonary valve over time. And we find that in kids, this is very well tolerated for many years. But after a number of years or decades, the higher pressure or the extra volume that’s place on the heart from the dysfunction will cause the heart function to decline or the right ventricle to decline and this sets patients to have abnormal heart rhythms such as ventricular tachycardia and potentially sudden death.
And so we find that a number of adults are presenting with some effects of RV outflow tract dysfunction or pulmonary valve dysfunction that needs to be treated either surgically or with heart cath techniques.
Host: When do they present typically? Is this something that because they’ve been in surveillance since they were a kid? When is this noticed or found?
Dr. Law: It happens a number of different ways. In the best scenario, these patients are diagnosed as children and they are followed throughout childhood and then into early adulthood. And they continue to be followed by adult specialists in congenital heart disease or adult congenital heart disease doctors who are cardiologists. And in those cases, we can identify patients who are starting to have problems with pulmonary valve dysfunction and need intervention before they develop too many symptoms of the heart rhythm abnormalities or heart dysfunction.
Unfortunately, as young adult patients transition from pediatric care to adult care, many of them are lost to follow up and in those cases, many times they are absent from care for a number of years until they present with significant symptomatology either back to the outpatient setting or present to the inpatient setting with heart failure or arrythmia.
Host: Then let’s talk about some treatment options. Tell us about the two main approaches that you would use as recently there’s been the development of percutaneous valve replacement with the benefit of not requiring open heart surgery and overall decreased impact to the patient. It’s not one size fits all, correct?
Dr. Law: That is correct. So, until about fifteen years ago, the only way to replace the pulmonary valve was through surgery techniques. And that could be done with bioprosthetic valve or a valve conduit or tube from the right ventricle to the pulmonary artery. And many patients who have grown up with congenital heart defects, have pulmonary valve already in place or a conduit but unfortunately, these don’t last forever and they themselves develop dysfunction. About fifteen years ago, we developed transcatheter valves that could be used in a number of patients. Currently, there are two transcatheter valves that are available in the United States. They do require a conduit or a valve to already be in place because they can only be expanded to a certain size.
As time has gone by, we’ve figured out how to make them work in more and more complex situations and those have been very great developments. There are currently trials underway of valve implants and to more complex outflow tracts where there is so much size that the current approved valves don’t fit and we hope that in the upcoming years, we’ll have more and more technology available to treat adult patients and avoid more and more surgery over time.
Host: As we’re talking about approach considerations Dr. Law, tell us why a multidisciplinary approach is so important and useful. Are you using a hybrid approach? Who is involved in everything we’re discussing?
Dr. Law: So, I think that’s a great question. So, I think there’s multiple people involved from all sorts of different levels to evaluate and manage these patients and to prepare them for any type of intervention. There’s an adult congenital heart disease specialist who often sees them in consultation in the outpatient clinic or in the hospital and many of these patients require advanced imaging beyond just regular echocardiography such as a CT scan or an MRI. MRI is the most standard imaging that we would perform and that gives us information about how the right ventricle is functioning and it gives us a lot of anatomy of what the pulmonary valve or pulmonary valve outflow tract looks like and that helps us prepare the approach to different types of intervention and whether transcatheter interventions are appropriate.
All of these patients need to be evaluated by a surgical consultant as not all of these procedures can be done transcatheter. And they require a cardiac specialist in intervention and even then, it requires multiple specialists in intervention. As I mentioned, my background is in pediatric cardiology but taking care of adults with congenital heart defects, I find it very useful and necessary to involve adult structural specialists who have understanding of coronary artery disease and complex interventions in adult patients too.
These patients will require special anesthesia needs during the procedure. And so the list of providers that are involved in their care around the time they get interventions is quite long. And because the number of patients is relatively small in the community, they tend to need to be grouped at a tertiary care center where enough patients can be taken care of to build expertise in their management.
Host: Well as long as we’re talking about that and this multidisciplinary approach, do you have any technical considerations you’d like other providers to know about and while you’re discussing that, tell us about what’s involved in long-term monitoring.
Dr. Law: So, the technical considerations of pulmonary valve implant are very complex. It’s one of the more complex if not most complex structural interventions that is performed in the cath lab. The important considerations include special equipment. There are many times we will use high pressure balloon to stretch the outflow tract or the conduit and that can place the conduit at risk for rupture. And there are special covered stents that would be necessary to treat that. It’s also some risk in about five to ten percent of the population where trying to perform an intervention, a coronary can become compressed and needs to be recognized. In fact, the procedure should be aborted if that is likely to happen.
So, the procedure itself requires a lot of thought in advance as well as multiple providers to make sure it’s performed safely. And it tends to be a relatively rare performed procedure in the medical field across each state and across the country compared to transaortic valve replacement or transcatheter aortic valve replacement or TAVR. UAB performs multiple hundreds of TAVRs a year and pulmonary valve replacement via transcatheter methods is more in the 20 to 30 range. And it’s the only institution in the state that performs routine pulmonary valve replacement.
But unfortunately, no matter how the pulmonary valve is replaced, whether it’s surgery or transcatheter; the valve will develop dysfunction again over time. And many of these procedures are being performed in 20 and 30 years olds who we expect to have decades worth of longevity in the future. We don’t know yet how long a transcatheter pulmonary valve will maintain competence without any narrowing. We are optimistic that it will last a decade if not two decades but many times, another valve would have to be implanted inside of the current valve or a surgical valve would need to be implanted. So, replacing the pulmonary valve does not get them out of care with the multispecialty group and the adult congenital heart disease specialists. They require at least yearly follow up with EKGs and echocardiograms and Holter monitors and MRIs and occasionally stress tests to monitor how their current pulmonary valve is functioning.
Host: Well thank you for telling us about the importance of long-term monitoring. Are there some treatments or research that you’re doing that other physicians may not be aware of and while you’re telling us that, tell other physicians what you’d like them to know about this topic and when to refer.
Dr. Law: We’re involved in research of the current pulmonary valve technology. We are currently doing a post-approval study with one of the pulmonary valves, the Edwards XT valve looking at the outcomes of the valve after it’s implanted into patients and following their outcomes both clinically and via imaging over approximately five years post implant. I have written papers on the cost outcomes of pulmonary valve replacement via surgery and transcatheter as well as a review papers on the short term and medium term outcomes of the pulmonary valve.
I would want physicians in the community to understand that we’re available to help manage patients with pulmonary valve dysfunction and that we would want to help comanage any patient where there’s a question about how the right ventricular outflow tract is functioning as well as any patient who was born with a congenital heart defect that requires long-term chronic follow up.
Host: Thank you so much Dr. Law. What a fascinating topic. Thank you 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/ua148.mp3
- DoctorsChen, Herbert
- Featured SpeakerHerbert Chen, MD, FACS
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=3947
- Guest BioDr. Herbert Chen obtained his BS from Stanford University with Honors and with Distinction in 1988 and graduated from Duke University School of Medicine Alpha Omega Alpha in 1992. Dr. Chen then completed a general surgery residency followed by a surgical oncology and endocrinology fellowship at The Johns Hopkins Hospital.
Learn more about Herbert Chen, MD, FACS
Release Date: May 19, 2020
Expiration Date: May 19, 2023
Disclosure Information:
Dr. Chen has no financial relationships related to the content of this activity to disclose. Also, no other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole: This is the UAB Medicine Podcast on COVID-19 dated May, 11th 202. 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 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 Medcast, 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 making operating rooms safe during COVID-19 joining me is Dr. Herbert Chen. He's the Surgeon in Chief and Chair of the Department of Surgery at UAB Medicine. Dr. Chen, it's a pleasure to have you back again with us, in these unprecedented times and this is a really great topic that we're talking about today because patients and other referring providers have questions exactly about what we're talking about. Please tell us about some of the current recommendations that you have going regarding adult elective surgery and procedures.
Dr. Chen: Yeah. So when COVID-19 hit hospitals, including ours across the country, made the decision to basically limit all non-essential planned or elective operations for a period of time. And that was basically to both recognize that we had to conserve critical resources such as ventilators, personal protective equipment or PPE, as well as limiting exposure of patients and staff to COVID-19. And so over these last few weeks, that's what we've been practicing is just doing the operations that absolutely needed to be done. And then as we figured out how to make surgery safe and to make sure we had the adequate supplies to conduct elective surgery, bring that back on board, which we've just recently resumed. So we've come up with a number of practices which allow now today for elective operations to proceed in a very safe manner.
Host: Well then let's start talking. You mentioned supplies. How are you doing with conservation of supplies? Speak about your PPE initiatives and any N95 reprocessing that's going on. Tell us about that.
Dr. Chen: Usually when we do operations, we do it what we call under universal precautions, meaning that we do it in a very sterile environment to minimize the chance of postoperative infection, but also utilize PPE to protect the patient and also to protect the surgeons, anesthesiologists, and other healthcare providers in the operating room. But with COVID-19 that introduced a new challenge because there was this additional risk of both spreading COVID if the patient potentially had disease through the air. And then obviously the important to protect patients from getting COVID-19 from potentially other patients or other people who could be infected. So to do that, we had to deploy additional PPE that we wouldn't normally utilize for operations such as N95 masks, face shields, very innovative aplastic boxes or protective coverings to maintain the safety of everyone involved.
And so with this, we were utilizing supplies that we perhaps weren't utilizing previously at a very high rate. And because initially when this pandemic hit us and we had limited ability to test patients for COVID-19, we had to assume that everyone that we were taking care of was potentially positive and had to take precautions to utilize what we call full PPE, full gowns, N95, face shields, goggles and things to protect the providers during the operation. And so today, one of the reasons we're able to now start elective surgery is that we've been able to reduce the amount of PPE we need because we have adequate testing of all patients for COVID-19 and therefore can limit utilizing all the protective gear in patients who are positive. And then for patients who are negative, we utilize just universal precautions as we had previously.
Host: Well, thank you for that answer, Dr. Chen. So how are you assessing the risk and minimizing the exposure during intubation? Tell us a little bit about how you and your medical partners are taking precautions to protect yourselves while giving this type of treatment. And especially with COVID patients.
Dr. Chen: This is work primarily done by our anesthesia team to minimize the risk for everyone during the intubation. Because during intubation that is a particular time if a patient did have COVID-19, that they could spread particles through the air from the intubation process, which would then potentially spread the virus to the anesthesiologist and other people in the vicinity. So there are a couple things that we've done to make the intubation more safe, one is change location where it happens. Normally operating rooms are what we call positive pressure rooms, meaning that what you want to do is make the environment completely sterile so you don't allow any air to come into the room that's unfiltered. So by having the room positive pressure that actually pushes air out of the room and doesn't allow any air to come into the room except for what comes through, pushed in through the filtering process.
Now, while that's ideal for to maintain a sterile environment, it is not the best place to do an intubation with someone who potentially has COVID-19. Because during the intubation process, the viral particles can be aerosolized into the air. And if you're in a positive pressure room, that just pushes that air everywhere. So what we've done and what other institutions have also done is to perform now, these intubations in patients with COVID-19 in negative pressure rooms, meaning that the pressure is negative. So nothing escapes the room. So if there is a virus that is gone onto the air, it stays in the room and doesn't spread. So now intubations in those patients happen in a negative pressure room and then the patients are transported the operating for the procedure and at the end of the procedure they are transported back to the negative pressure room for the extubation.
And in addition to where the intubation occurs, there's protective apparatuses built to basically put plastic either boxes or plastic shields around the, between the patient and the anesthesiologist to minimize the ability for things get aerosolized. So those provide a barrier between the anesthesia team and the patient. And then plus wearing N95 masks, also minimize that. So there are many things that have been thoughtfully executed to minimize the risk of aerosolization during intubation.
Host: Tell us how you're determining the dedicated PACU spots, dedicated ORs and dedicated pathways to make sure that everything stays where it needs to stay.
Dr. Chen: Yeah, so the, for the COVID-19 patients, they're intubated in the negative pressure room, which happens to be in our PACU and then there's a pathway that they follow to get to the operating room. And then for patients who are COVID-19 there are dedicated operating rooms which are set aside for only patients with COVID-19 because they're basically cleaned both before and after in a different way than we normally would for a non-COVID. And then the patients then are transported during a certain pathway for their extubation in the negative pressure room, as I mentioned before, where they'll do the recovery as well. We've been very thoughtful in how patients flow who have COVID-19 to again minimize the contact that they will have with other patients as well.
Host: And what about after surgery cleaning the OR is there an isolation protocol regimen for patients as of now? Like how long should the room be vacant or cleaning measures, extra cleaning measures that might be required?
Dr. Chen: For cleaning the ORs. The ORs after a COVID patient has been in the operating room. The ORs are supposed to remain vacant for 30 minutes with the doors completely shut for adequate air turnover to occur and then we our initial cleaning and gowns and gloves and they clean the OR with our hospital approved disinfectants. And then there's terminal cleaning where they clean the OR again and it needs to remain vacant for a good period of time to again allow transition before another patient is brought back in. And of course all the trash and medical waste are disposed of in a very safe manner.
Host: And Dr. Chen before we wrap up, but what about the supply chain for other providers that have this question, what supplies do you have that are adequate and which ones might be in short supply? Speak about ventilators, masks, N95, gowns. All of it.
Dr. Chen: Yeah. I think that depending upon your situation and what your supply chain is, you may be sure of some or many of these key PPE or a key equipment. So for ventilators that was predicted that many areas in the United States would have shortages. And they did for a period of time. We were very fortunate that we never got to the point where we needed to use some of the ventilators that we had in the operating room to ventilate patients who were sick in the ICU with COVID. So for us, we have enough ventilators to do our operations and to also take care of the sick patients with access. With regard to masks, N95, gowns and all that, we keep a very close eye and how many days of inventory we have. And of course your days inventory depends upon the use. But I think more importantly is I think the game changing factor to conserve PPE has been the ability to test patients for COVID-19. Because before when we didn't have the capacity to test everyone having surgery, we would have to use what we call full PPE on every patient and that would use a lot of these materials.
However, now that we test all patients having surgery, both emergent and elective operations, we know, and the vast majority are negative meaning that. So far we've tested well over a thousand individuals having procedures and the positivity rate is 0.85%. So if you just think about it that you were burning through a lot of PPE beforehand, but now since less than 1% of people really you need to deploy PPE, we can identify those individuals to utilize the full PPE during their procedure. But the 99 plus percent that don't have the disease, we can use universal precaution which conserves our PPE. So again, I think testing has really been the game changer for us to be able to now do the operations really safely and that patients should be very comfortable having their elective procedures right now because we've created a very safe environment.
Host: Do you have any final thoughts for other providers regarding referral and things that they can take forward to their patients regarding what you were just discussing? Safety and the procedures that you are doing now at UAB Medicine?
Dr. Chen: Yes, with all surgery, pre-COVID and now during COVID, operations need to happen to treat various ailments that people have and important diseases and that we shouldn't allow COVID to curtail us from delivering the best care possible and I think with these new changes, and again with testing and all these safety procedures that we've deployed, I can confidently say that we can do that right now. That we can provide the same level of safe care for patients who need surgery now then similar to what we did before.
Host: Thank you so much Dr. Chen. What an interesting topic and great information. 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/ua143.mp3
- DoctorsWoodard, Stefanie
- Featured SpeakerStefanie Woodard, DO
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6290
- Guest BioStefanie Woodard, DO is an Assistant Program Director, Diagnostic Radiology Residency Program.
Learn more about Stefanie Woodard, DO
Disclosure Information
Release Date: April 14, 2020
Reissue Date: March 21, 2023
Expiration Date: March 20, 2026
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Steffanie Woodard, MD
Assistant Professor, Breast Imaging, Diagnostic Radiology
Dr. Woodard has no relevant financial relationships with ineligible companies 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 continuing education podcast from medical professionals bringing knowledge to your world. Here's Melanie Cole.
Melanie Cole: Welcome to UAB Med Cast. I'm Melanie Cole. Today we're talking about ABUS technology. Joining me is Dr. Stefanie Woodard. She's an Assistant Program Director in Diagnostic Radiology Residency Program at UAB Medicine. Dr. Woodard, it's a pleasure to have you join us today. First, let's start about the issue to discuss dense breast tissue and conventional mammogram and what's been the case over the years.
Dr. Woodard: The issue with mammography in dense breast tissue is that we know that even though mammography is great and does detect a lot of cancers and has helped to decrease the death rate of cancer due to finding early cancers, it misses cancers when breast tissue is dense. Which is in about 40% of our population, so we've known that for awhile, but really there wasn't a good answer as to what we could do to combat that. And there have been some different suggestions, different ideas, more recently, whole breast screening ultrasound has been investigated. It actually has been going on for quite some time, but in the last several years, the technology of an automated system has become available. That's what we're talking about today. The whole breast ultrasound or ABUS, which is automated breast ultrasound. And it's allowed for detection of really small cancers that are clinically significant, which are those that are invasive could potentially shorten someone's life expectancy.
It's been a great exam because it's reproducible. Having an automated exam, people used to do this handheld and still do where the automated system's not available, but this allows a reproducible exam fairly easy for a technologist or anybody really to do because it doesn't require a high level of skill to perform the exam and it's fairly accepted by patients, doesn't require the kind of compression that mammography does. It's fairly short, about 15 to 20 minutes is kind of the standard amount of time that it takes for a patient to have an exam. And no radiation, which is fantastic, which we all love.
Host: Well. That is certainly really encouraging for women and for other providers to hear so that they can be recommending this. Why not skip to MRI if density is an issue?
Dr. Woodard: Well MRI's a fantastic study and I don't want to discount anything. The MRI's is wonderful and does add a ton of information. The issue with MRI one, it does require an IV. It requires the use of IV dye for the examination and the other issue is fairly uncomfortable. The patient does have to lay on their stomach, currently that's the standard positioning, and they have to be put into the MRI machine. Which can be an issue if patients are claustrophobic, can be an issue because some patients just can't fit into the machine. Some patients can't have an MRI because of certain implants in their body that may not allow them to have an MRI. And the other issue with MRI is it's very, very sensitive. And what that word means is just basically it picks up a lot of stuff and that stuff may not end up being anything important.
And there's a lot of extra workup that comes from MRI that is unnecessary. And MRI does habits uses. And we do MRI for high risk patients and certain patient populations that definitely need that type of a scan. But not everybody needs that. It's also very expensive, which is a big difference between ABUS and an MRI. So the cost, and it varies based on where the location, insurance coverage for these exams. But MRI, we're talking in the thousands, where ABUS, we're talking lower hundreds. So even coverage I think has been up to about a hundred dollars is out of pocket for some places, and again that all depends, but it's vastly different as far as the cost. So all those things are reasons why, you know, not every patient needs to have that kind of an exam. And it certainly would be really overkill for screening in the general population, just not feasible.
Host: Well, then for the women that do qualify, and I'd like you to speak to that for a minute, but for the women that do qualify, is this an adjunct to tomosynthesis or standard mammography, which not that many people are using any more, but 3D are we doing this together? How often should this be done? Are they done in conjunction with each other kind of at the same time? Tell us a little bit about that and patient selection.
Dr. Woodard: It is an adjunct to mammography, so definitely not a substitution for mammography. In fact, whenever a patient comes in for an ABUS exam, we typically will check and make sure that the patient has had a mammogram within the past year. And if not, we'll have the patient go ahead and have the mammogram the same time that they're having their ABUS exam. Some providers have alternating exams, so they'll do them every six months. Again, that's not a hard recommendation and that's just a preference. A lot of patients like to come in and have their screening exam done the same day. So tomosynthesis, as you said, is kind of the preferred screening modality as opposed to just 2D mammography now and if it's available, tomosynthesis is recommended. Especially in dense breasts population. But ABUS would be the adjunct that they would have. At the same time, we do only recommend typically a yearly ABUS exam, so they wouldn't need to have more than one ABUS exam per year. And if an abnormality is seen on the ABUS exam, they may be called back for a targeted ultrasound to look at a specific area of breast tissue to do a further evaluation. But again, it would just be the standard evaluation. It's just a yearly ABUS with their yearly mammography exam.
Host: So you mentioned insurance a little bit before. Where does insurance stand as to this screening? And I mean, why aren't hospitals all over the country using this right now? They're calling it ABUS studies right now. Is this not nationwide yet? And if so, why not?
Dr. Woodard: No, not completely nationwide yet. Now there are more and more States that, for instance, some States like Connecticut and a lot of the Northeastern States have density reporting walls, so we have to actually report if a patient has dense breast tissue, we have to notify the patient. Some States actually require insurance coverage for additional dense breast tissue, and most insurance providers will cover it just because it is common knowledge, there've been multiple studies that have shown that dense breast tissue patients have a higher risk of developing breast cancer just due to the fact that they have dense breasts. For that reason, it is covered by a lot of insurance companies, but it's dependent on which particular insurance they have. If you go onto the different websites for the ABUS exams, most of the time we can look at the CPT code with that particular insurance company and see if it's covered ahead of time if the patients are concerned about that. But it all depends. It varies from state to state and from insurance company. So that's something that it's really good to let patients know about so they can check that out before they have the exam and see what they want to do.
Host: Really important information. Wrap it up for us. What would you like other radiologists and healthcare providers to know about ABUS? Any new clinical research that you can mention? Anything you'd like them to know to take forward to their patients?
Dr. Woodard: I really would like everyone to, especially providers that are sending patients for screening. If you have sent your patient for a mammogram and you see that it is reported that she does have dense breast tissue, please look into whole breast screening ultrasound and if it's possible in your area, this is a great supplemental tool for patients. They should be aware that they may be called back for something additional. We do know that that's a possibility. However, most of the time those are completely benign things that end up being found and the ability of ABUS to find small cancers is fantastic when patients have dense breast tissue. So I would recommend that if you do see that after you've referred a patient for a mammogram and you get that report to any of the providers, look into the supplemental screening available in your area for your patient. And you can have that discussion or the radiologists that are in the area, usually more than happy to have that discussion with the patient about the ABUS exam to tell them what it's like, what to expect. And don't hesitate to contact a radiologist in your area because it's really a fantastic exam, no radiation and overall decreased costs of other screening modalities as far as MRI and other ways to screen patients with dense breast tissue.
Host: Thank you so much Dr. Woodard for joining us today. 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 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/ua142.mp3
- DoctorsThachuthara-George, Joseph
- Featured SpeakerJoseph Thachuthara-George, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=3839
- Guest BioDr. George received his medical degree at St. John’s Medical College in Bangalore, India. He completed his internship and residency at the University of Texas Health Science Center and his pulmonary critical care fellowship at Baylor College of Medicine, both in Houston, TX.
Learn more about Joseph Thachuthara-George, MD
Release Date: April 20, 2020
Expiration Date: April 20, 2023
Disclosure Information:
Dr. Thathuthara-George has no financial relationships related to the content of this activity to disclose. Also, no other speakers, planners or content reviewers have any relevant financial relationships 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 1 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 for medical professionals bringing knowledge to your world. Here's Melanie Cole.
Melanie Cole: Welcome. This is UAB Med Cast. I'm Melanie Cole and today we're discussing tele-medicine for lung nodules. Joining me is Dr. Joseph Thachuthara-George. He's an Interventional Pulmonologist and an Assistant Professor at UAB Medicine. Dr. George, it's a pleasure to have you join us today. Tell us about the UAB tele-medicine pilot project. How did this come about?
Dr. Thachuthara-George: Thank you Melanie for having me. It's a pleasure to be on this Med Cast. Coming to our pilot project, our interventional pulmonary surveys see a lot of patients with lung nodules and suspected lung cancer. We see them in clinic for an initial visit at first, and then we plan on any diagnostic procedure if needed. Sometimes they may not need a procedure, and many of our patients live far away and have to drive a long way to come and see us just for this initial clinic visit. This cost them money, time and other resources. This made me think about using tele-medicine for this initial visit. So I approached Dr. Eric Wallace, who is the Director of tele-health at UAB. He helped me move this forward. Since this is a new concept, we decided to start this as a pilot project so that we can address all the flaws in the process before we expand it to more centers. So that's how all this came about and we started this project
Host: Fascinating to me. So then tell us about the clinic at the BIB Medical Center. It's got a goal of, as you said, already seeing patients from the rural communities via tele-medicine. What's the long-term goal to expand this Doctor, and to other rural centers in the black belt?
Dr. Thachuthara-George: So the goal, the main goal is to provide them with comprehensive care for diagnosis and staging before they are ready for treatment. And regarding the long-term goal of this initiative, we would like to expand to other rural centers in the black belt, as well as in the State, because I'm sure we will come across certain areas that we need to improve and it'll be much easier to do this on a smaller scale in this pilot project. Learn from our mistakes and then expand it to other centers, and the rest of the State
Host: As I've done a few shows about tele-medicine from UAB specifically Doctor, in regarding the development of this project, speak a little bit about how long it took to develop those resources? You said you met with Dr. Wallace and you guys worked through this together and tried to figure out the kinks because they have already done some tele-medicine at UAB. What types of clinicians provided input? How did this all work out?
Dr. Thachuthara-George: Yeah, so my main input has been from Dr. Wallace, who already has an established clinic for renal disease, at Bay Medical Center, as well as other medical centers. So he provided guidance and he took about a year to establish the clinic because not only that we needed to do, you know, things from our end. We also had to coordinate with people at Bibb County, the staff and as well as the management at Bibb County Medical Center. And they had been extremely cooperative and helpful in establishing this. And most of the time and effort, the delay in timing was mainly from my end because I had to do this during my spare time between my clinical work schedule. So that has been one of the things that kind of delayed things. But overall it took about a year for us to and then get this up and running. And our patients also, you know, there was a lot of input from the patients. That has been our main goal and driving force to start this project, too decrease their, to make it more efficient for them to come in and gain access to this service that we provide.
Host: Well, that was going to be my next question. As far as the role of the patients in the development of the project. Tell us a little bit some examples of how you're using it for lung issues and nodules. Since some might be identified on radiographic studies and they need specialized follow-up to ensure early detection. Obviously tell us a little bit actually how you're using it. What's the procedure you're using?
Dr. Thachuthara-George: Management of lung nodules as well as suspected lung cancer is a complex process. Any patient with a lung nodule always raises an alarm and all the patients from referring physician are concerned. So our job is first to re-stratify the lung nodule to determine the risk of this being a malignant nodule. So if the risk is low, then this can be monitored by a regular interval CT scan. If the risk of this being a cancer is high, then that requires next step. That is diagnosis and staging of the potential lung cancer. This often involves a procedure which is done by our interventional pulmonary team. And UAB is the only NCA recognized cancer center in the state. And we have an active multidisciplinary thoracic oncology team, which involves oncology, thoracic surgery, radiation oncology, radiology, pathology, as well as as interventional pulmonology. So once the patient diagnosis is made and staging is done, be coordinated with the rest of the specialists to plan the appropriate treatment for the patient. And some cases it'll be difficult to make a decision, which we discuss at our multidisciplinary, a tumor board meeting and plan the next step. So the tele-clinic basically enables the rural community to have access to this state-of-the-art guideline based management of their lung nodules and lung mass. And this will provide them easy access to this kind of service that is provided by UAB.
Host: How have you seen this transform your decision making scenario? Can you tell us an interesting case or study where you've seen this really come into effect and work wonderfully?
Dr. Thachuthara-George: First step in any of these patients is to see the patient asses them and plan on what needs to be done next. So sometimes we see patients who has significant medical comorbidities and who is not able to undergo any sort of treatment. So one example is when we see patients in clinic here at UAB, they come from far away and we see them in clinic, but they have significant medical comorbidities and they are not very functional. After we have a long discussion with the patient and the family, they decide not to undergo any treatment because, or any procedure because that might be of high risk for them. So in that case, you know, all these things can be done by a tele-clinic and counter, and they don't have to come all the way here driving three hours just for a clinic visit. So this kind of changes the initial management. We can bypass the initial encounter and if they really need to come here for a clinic visit or a procedure, we can bring them back for that particular reason. And this decreases the cost of a trip as well as, time constraints. This and benefits the patient that way.
Host: So what about cost effectiveness then Dr. George? What about insurance implications? Obviously it would seem to be more cost effective and time manageable, more satisfying for patients, but what are the insurance implications? How's that working out for you?
Dr. Thachuthara-George: So tele-clinic is covered by most of the insurance providers in the State as well as Medicare. And especially for the rural population, all of them covers it. So we, when we bill the insurance we just have to use a modifier and they cover it for the tele-clinic visit.
Host: That's fantastic. So wrap it up for us, Dr. George, tell us about some of your long-term goals, what you've seen as far as functionality, how this works and how you're really decreasing patient wait time, expediting their diagnosis and staging process. How this is working so well for UAB medicine?
Dr. Thachuthara-George: So when a primary care provider in Bibb County has a patient with lung nodule, they will contact the Bibb Medical Center, who gathers information and then contacts the UAB e-medicine team who will schedule the patient. By this time, we will have all the pertinent clinical information which we will review. So before we see the patient itself, we will come up with a rough plan for the next step and based on our pre-clinic review, the patient does have significant high risk for clinical lung cancer. Then we will also plan staging workup but at the same time so that we don't waste time. And then once we see the patient, we will schedule the patient. If the patient needs a procedure, we have to schedule them for a procedure here and during that visit we will try to coordinate other staging. Sometimes they need a pet scan or other imaging. We will coordinate to schedule that along the same time so that they don't have to make multiple trips. So that way we can try to organize everything within short time and have them ready for treatment.
Host: What a great program. Thank you so much Dr. George for coming on today and telling us all about the tele-medicine pilot program for lung nodules at UAB medicine. And that concludes this episode of UAB Med Cast. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. You can also had to the website at UABmedicine.org/physician, for more information on resources available at UAB Medicine. Please 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/ua141.mp3
- DoctorsJones, Jesse
- Featured SpeakerJesse Jones, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6240
- Guest BioJesse Jones, M.D., is an interventional neuroradiologist within the UAB Department of Neurosurgery. He completed his graduate medical education at the University of California in Los Angeles, having trained in both diagnostic and interventional neuroradiology. Dr. Jones specializes in cerebral and spinal vascular disease affecting adult and pediatric patients. His research interests include stroke, vasospasm and biomedical device development.
Learn more about Jesse Jones, MD
Release Date: March 10, 2020
Reissue Date: February 21, 2023
Expiration Date: February 20, 2026
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Jesse Jones, MD
Assistant Professor in Diagnostic Radiology & Neurosurgery
Dr. Jones has the following financial relationships with ineligible companies:
Grants/Research Support/Grants Pending - Cerenovus
Consulting Fee - Cerenovus, MIVI
All relevant financial relationships have been mitigated. Dr. Jones does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity.
This is part of the Clinical Skill CME series - 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 MedCast a continuing education podcast for medical professionals bringing knowledge to your world. Here's Melanie Cole.
Host: Subdural hematomas relatively common neurosurgical problem, most often affecting older patients. New, less invasive treatments for it are becoming more common but need to gain a little more traction in the medical community here to help us with that is my guest, Dr. Jesse Jones. He's an Assistant Professor and an Interventional Neuroradiologist at UAB. Dr. Jones, it's a pleasure to have you with us today. Tell us a little bit about subdural hematomas. This relatively common neurosurgical problem. Tell us a little bit about it.
Dr. Jones: Chronic subdurals are a major health problem. It's the most common adult neurosurgical diagnosis that we see, typically affects anywhere from 13 to 17 people per thousand patients. And it's a problem where it can be a bit insidious. You know, patients will present with sometimes nonspecific symptoms, anything from a fully progressive dementia to maybe a left or a right sided weakness, more frequent falls, problems keeping their sodium levels up, and eventually, sometimes after a much medical workup they're found to have these chronic blood collections on the surface of their brain.
Host: So what are some factors that might lead to it? Tell us a little bit about that and clinical presentation. How do we identify it?
Dr. Jones: Well, there's a couple of risk factors. The primary one would probably being falls. You know, as people get older, they're a little less sure on their feet and they fall more. Add to that, the fact that a lot of older people are taking blood thinners typically for issues with their heart or perhaps they've gotten a blood clot in their leg and they've been put on some sort of anticoagulation. Well, if you combine the more frequent falls with them being on blood thinners, it's a perfect setup for getting a subdural.
Host: So characterize them for us. Is it on a basis of their size and location, the amount of time elapsed since the inciting event, age of the patients, you already mentioned a little bit. Tell us a little bit about the presentation and how you identify it.
Dr. Jones: Well, it's typically found like how I mentioned before, people will present either after a fall, say they have a big fall where they get, you know, some blood on their face or their eye and they get a cat scan, you know, through the ED. They will initially get diagnosed with what's called an acute subdural meaning the blood has just formed. Now, depending on how severe that is, a lot, oftentimes they're just observed with the hope that the blood will go away on its own. And a lot of times it does. In the cases where the blood does not go away, it becomes what we call a chronic subdural and that kind of situation, what's happening is there's an interplay between some blood being resorbed, new blood vessels forming in that potential space there on the surface of the brain, and new ruptures occurring. And these ruptures are quite small, but they're frequent and they'll lead to a progressive cycle of bleeding and re healing and further bleeding. And that's really the base of a chronic subdural.
Host: So what's the role of imaging studies in the workup?
Dr. Jones: Well, imaging is key to the diagnosis. It's very difficult to diagnose a subdural based on symptoms alone. There are some good clues, like I alluded to earlier, but they're nonspecific and a lot of things in an older patient especially, can cause those sorts of symptoms. So a cat scan or a brain MRI. They're both good methods for diagnosing a subdural.
Host: And then if you do, what are some current issues in medical or surgical management? Assess for us what you would do once you figure out and detect what's going on.
Dr. Jones: Well, a lot of it has to do with the patient's symptoms. Some of these subdurals are quite small. If they're not causing any pressing issues, they're probably best to be left alone. It's when they start growing in size that we get concerned because as the size of the subdural grows, there's further mass effect upon the brain. And it's the mass effect that leads to the symptoms I described earlier. In addition to those patients often will have headaches, which can be a good presenting symptom or a good cue as something's going on in the head.
Host: And what would be your initial treatment? What's the first line of defense besides watchful waiting?
Dr. Jones: In a symptomatic subdural, it's time to start thinking about treatment and there's a few ways to go down. Some people experimented with drugs that will increase the clotting ability of the blood. Things like Amicar that is shown not to be very successful. And there's quite a few risks associated with that in terms of causing other disorders such as MIs or DVTs. So that's typically not a favor treatment modality at this time. And that pretty much exhausts that medical management. So now we move on to more aggressive forms of therapy and traditionally that's involved a surgical approach whereby either holes are drilled into the cranium to try to aspirate or suck out what blood is in there or a more invasive surgery where part of the bone is removed and the hematoma is evacuated in a more open fashion. The bone is placed back on again. Those are probably the two most common ways of dealing with the borough hole approach, which may or may not include adding a drain for some time on the surface of the brain to try to suck up some more of that fluid or a more open craniotomy.
Host: So what's the general prognosis if it's caught early enough and how have been your outcomes?
Dr. Jones: Well, surgery can be quite effective. The issue is that these patients are old and they have a lot of comorbidities. So surgery is a big deal and a lot of patients and the patients' families are nervous about going into that. Some other approaches that we've pursued, you know, because of the issues with major operations in older people, have been more minimally invasive approaches and that would include what's called an embolization. And an embolization is an approach where a patient can be either awake or asleep and we'd go into an artery of their leg and from that leg artery we can travel all the way up into the artery, kind of supplying or feeding the subdural, and close off those arteries specifically. And what that do over time has changed the balance between the bleeding tendency in the clotting tendency of the subdural over, I'd say about three weeks to a month get significant reduction in the size of the subdural.
Host: Do you feel Dr. Jones, as I said in my intro, that this needs to gain more traction in the medical community and why? Is this an underappreciated condition that older adults are coming up with?
Dr. Jones: Well, what I'd say is that this condition is pretty well known and it's quite common. The problem is that the treatments are, the newer treatments are not as well known. And so I think a lot of people in the community, you know, practitioners, doctors, nurses are probably aren't aware of embolization and the role it may have. I think that's something that we're trying to increase the awareness of in the community because like I say, it's a less invasive approach that could be a good option. People who may not be able to undergo a larger operation.
Host: So tell other providers what you'd like them to know about referral when you feel it's important that they refer to the experts at UAB medicine. If they're a primary care provider. And as you say, dealing with the comorbid conditions for these older patients. What would you like them to know about referral?
Dr. Jones: Well, I'd like them to know that we're there for them and we're always happy to see new patients, especially patients who pose particular difficulties outside their realm of practice. You know, we are a tertiary referral center. We see a lot of difficult cases here and we're always happy to help. I think in the particular case of the subdural in a patient who has other comorbidities which make them medically complex. That's a great indication for referral because we have a team of doctors here including surgeons and interventionists who meet in a multidisciplinary approach and can find the right treatment for a particular patient.
Host: Do you have any final thoughts you'd like to leave us with about subdural hematoma?
Dr. Jones: I'd just like people to know that embolization is an emerging option that is well fit to a specific group of patients with chronic subdurals and medical comorbidities, and I hope that more awareness can be brought to the community about this approach.
Host: Thank you so much Dr. Jones for joining us and sharing your expertise about this relatively common condition, but that does require a certain level of expertise to deal with. 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 UABmedicine.org/physician. Please also remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. Until next time, I'm Melanie Cole. - HostsMelanie Cole, MS
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