Additional Info
- Audio Fileuab/ua092.mp3
- DoctorsWells, Mike
- Featured SpeakerMike Wells, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5370
- Guest BioMike Wells, MD, assistant professor of medicine in the Division of Pulmonary, Allergy, and Critical Care Medicine, provides updates on treatments for Chronic Obstructive Pulmonary Disease (COPD) and moderate hypoxemia, including the use of supplemental oxygen and long term oxygen therapy (LTOT).
Learn more about Mike Wells, MD
Release Date: November 12, 2018
Reissue Date: October 27, 2021
Expiration Date: October 26, 2024
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.
Presenter:
James Michael Wells, MD
Assistant Professor in Pulmonology, Critical Care Medicine
Dr. Wells has the following financial relationships with ineligible companies:
Grants/Research Support/Grants Pending - Grifols, Mereo BioPharma, Bayer AG, Verona Pharma, Vertex Pharmaceuticals, ARCUS-MED LLC
Honorarium - AstraZeneca, Takeda Pharmaceutical
Dr. Wells does not intend to discuss the off-label use of a product. All of the relevant financial relationships have been mitigated. No other speakers, planners or content reviewers (Ronan O'Beirne, EdD and Katelyn Hiden) 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. Here to tell us about the Alpha-1 Clinic at UAB Medicine today is my guest, Dr. Mike Wells. He’s an associate professor in pulmonary and critical care medicine at UAB medicine. Dr. Wells explain a little bit about Alpha-1 and the people that are at risk. Is this disease underrecognized?
Mike Wells, MD (Host): Thank you for having me. So, yeah, so the – your first question about what exactly is Alpha-1 antitrypsin deficiency. So, it is a genetic disorder. It’s one of the most common genetic causes for chronic obstructive pulmonary disease or emphysema and it’s characterized by an abnormal production of this alpha-1 antitrypsin protein by the liver. And so, under normal circumstances, the liver makes the protein and then it goes to the lung and kind of helps sort of clean up the lung from lung damage that may occur in response to the environment or infections or other things. And so for patients who have alpha-1 antitrypsin deficiency, this protein is not secreted normally and it is misfolded in the liver which can accumulate in the liver and can lead to some liver damage and liver destruction, but also reduces the overall amount of alph-1 antitrypsin that circulates in the blood. And ultimately this can lead to – if there is a low amount of this in the lungs it leads to kind of an unchecked amount of inflammation that goes on in the lungs and puts people at risk for emphysema or other lung conditions that are not necessarily in response to cigarette smoking. And it is something that because of it, it’s a genetically inherited condition, it tends to affect either – it can affect – it can present in childhood, typically with liver disease or in patients that are as young as 30-years-old tend to start manifesting signs and symptoms of chronic lung disease. The estimates right now are that between one and 2500 and one and 3000 Caucasians in the US or at least – may have alpha-1 antitrypsin deficiency, which is kind of comparable to the rates that are seen with other genetic lung diseases like cystic fibrosis.
And I guess your third question was is it an underrecognized condition well I guess of course the answer is yes it is. We know that COPD and emphysema are highly prevalent in the United States and affect up to 24 million people and alpha-1 accounts for between one and three percent of those patients. And even within those people, most of the one to three percent we believe is probably underrecognized and the actual number of alpha-1 patients with alpha-1 may actually be higher than that.
Melanie: So interesting and Dr. Wells you answered my first four questions as well. So, that was an excellent description. Thank you so much. Now speak about who should get tested. What does testing look like and tell us about the issue that could rise and what some of the results of this testing could have an effect for the patients’ lives.
Dr. Wells: Okay, yeah. So, testing is absolutely essential and critical to the diagnosis and especially because it’s so underrepresented; the current recommendations by the American Thoracic Society and the other COPD groups and the Alpha-1 Foundation is that any patient that’s ever been diagnosed with COPD or emphysema should be checked for alpha-1 antitrypsin deficiency at least once. Other recommendations are that patients that have chronic asthma, that have a family member that has been diagnosed with alpha-1 antitrypsin deficiency or people that have chronic liver disease; should all be checked. There are some other kind of rarer conditions that if a patient were to have these; they should get tested as well and those would include other lung conditions like bronchiectasis which is an enlarging of the airways or a skin condition called panniculitis which is pretty rare or other rare conditions like vasculitis or problems with I guess vasculopathies and things as well as liver cancers.
So, again those are less common causes but it certainly can associate with alpha-1 antitrypsin and so in order to get tested; well I guess kind of taking one step back and just talking about the genetics of the condition. So, I mentioned earlier that under normal circumstances, this alph-1 antitrypsin protein is made in the liver. For patients who are normal, who don’t have alpha-1 deficiency; they have two copies of the genetic allele called MM and so that means that these patients don’t have any – they don’t have an alpha-1 disorder and do not carry any altered alpha-1 genetics. This is sort of coinherited from patients and so you get one M copy from your mother and one copy from your father. The other condition that’s most commonly associated with this misfolded protein is something called a Z-protein and so if you have one copy of a Z and the other copy is an M, you are considered a carrier and these patients tend to have kind of a mild to moderate increased risk for symptom development and may lead to emphysema and then probably the most severe and the most well-characterized is something called ZZ, so meaning that you got one copy of a Z from your mother and one copy of the Z from your father. So, all of the alpha-1 protein would get sort of misfolded in the liver and lead to some liver damage, but then would have very low circulating blood levels of alpha-1 antitrypsin.
And these patients are at pretty severe – pretty high risk for developing emphysema and then you can also imagine they are also at increased risk for chronic liver injury and cirrhosis based on I guess where it’s being retained. There are some other genetic things that can happen as well, something called an S which is kind of an intermediate form or I guess intermediate severity between being normal and having a Z. So, we do see – so I guess in the spectrum of things, and kind of summarizing so if you are normal and you have two copies of the normal; you are considered an MM and that means you are in no increased risk for lung or liver damage. If you are an MZ meaning you have one normal allele and one abnormally folded allele you do kind of have a mild to moderate increased risk for symptoms, and that’s considered a carrier. There is also a carrier that’s an MS meaning you have one normal copy and one S copy and so this is maybe a little bit milder presentation than the MZ patients and then the true alpha-1 antitrypsin deficient patients are either a ZZ meaning they have two copies of the Z, one from the mother and one from the father or an SZ and so these are the patients that are at highest risk for lung and liver injury.
So, a lot of the genetics and the inheritance and things are very complex and complicated, but I guess fortunately, the testing is very easy. Like I mentioned earlier, the recommendations are that patients with any of those presenting signs or chronic illnesses be evaluated at least once and this is done through a blood test. There are several different assays that can be done. Some can be just a routine blood draw. There are others that can be done through just a finger prick dry bloodspot test and depending on how the tests are done and where they are done; the typical turnaround time can be just a couple of weeks before you get an answer for I guess the genotype.
Melanie: So, Dr. Wells based on the risk for lung and liver disease; what does this mean for the patient in terms of work, insurance and what do you want primary care providers to do? What role do they play in helping with lifestyle modification and behaviors, smoking cessation, secondhand smoke, alcohol consumption, all of these things that go along with recognizing that somebody has this gene?
Dr. Wells: Right. So, yes, I guess the recommendations are that once a patient has been diagnosed with alpha-1 antitrypsin deficiency or even being a carrier for alpha-1 antitrypsin; lifestyle modification, work modification if necessary, things like that are kind of the first major common recommendations. And so, smoking cessation is first and foremost the primary thing that we work on, not just for alpha-1, but for any patients, especially those with chronic lung disease. There are patients who are lifelong nonsmokers that can develop emphysema just based purely on having alpha-1 antitrypsin deficiency. But we do know cigarette smoke increases that risk tremendously. Secondhand smoke, other things can lead to this chronic inflammation that can also increase the risk for emphysema. I mentioned at work. I guess that is very dependent on I guess the type of work and career that the patient has. If their job requires a lot of exposure to dusts and coal or other things like that or work in a chemical plant or something; they may need to talk with their occupational health people at their company and make sure they wear protective clothing and things like that. Otherwise, we, ideally want to minimally impact work as much as possible. There are some studies out there that do show that other environmental pollutants, ozone and things like that can also lead to kind of worsening of the lung condition like an exacerbation – can precipitate exacerbations or things kind of periodically. But those are kind of the major things.
You mentioned alcohol and that’s something that can be a sensitive topic for some patients, but we do know that the damage from chronic alcohol use even at lower amounts than kind of what’s recommended by the NIH and other groups can still lead to some subtle liver impairment in patients that have alpha-1 antitrypsin deficiency, particularly those that are ZZ patients.
And then I guess the last thing would be just like we recommend for all patients just developing an exercise program and being active as much as possible. It’s not only good for lung health and liver health; but just health in general.
Melanie: Tell us about the Alpha-1 Clinic at UAB Medicine Dr. Wells and what type of providers are involved? Tell us about the multidisciplinary care you have got going there.
Dr. Wells: Yeah, absolutely. Absolutely, so, the Alpha-1 – we are an Alpha-1 Clinical Resource Center that’s recognized by the Alpha-1 Foundation. We provide screening tests for patients or for family members of patients who have been diagnosed with Alpha-1 antitrypsin deficiency and then we offer comprehensive evaluations including history physical, some of the medical testing and therapies that go along with having Alpha-1 antitrypsin deficiency. We collaborate closely with our hepatology group here so if there is any signs of liver injury, liver damage, like I said we work really closely with them and try to make sure that we are addressing any need whether we are aware of it or not. And then we also can offer genetic counseling and things for people who have questions and are considering things like insurance and family planning and other conditions.
Melanie: Such an interesting topic Dr. Wells. Thank you so much for joining us. So, do you have anything further? What would you like other physicians to know about alpha-1 and managing this or testing their patients, or counseling their patients about getting tested?
Dr. Wells: Yeah, so I think the main message is that it is an underdiagnosed condition and it’s probably more common than what we appreciate and that we should be actively screening for this in any of our patients with chronic lung disease and for patients who are family members of those that have a known diagnosis of alpha-1 antitrypsin deficiency. One of the things I didn’t mention before is there are treatments out there that can lead to some improvements in lung function and the testing and the screening tests are very easy and simple and minimally invasive and so, I would encourage everyone to think about alpha-1 and to check patients for alpha-1.
Melanie: Thank you so much Dr. Wells for coming on and explaining alpha-1 to us and sharing your expertise and telling us about the Alpha-1 Clinic at UAB Medicine. Thanks again. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician, that’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua086.mp3
- DoctorsPorterfield, John;Lindeman, Brenessa
- Featured SpeakerJohn Porterfield, MD | Brenessa Lindeman, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=2538
- Guest BioDr. Brenessa Lindeman is a native of Kentucky, receiving her M.D. from Vanderbilt, and is a member of Alpha Omega Alpha. She did her residency in general surgery at Johns Hopkins University and completed a fellowship in endocrine surgery at the Harvard/Brigham and Women’s Hospital.
Learn more about Brenessa Lindeman, MD
Dr. John Porterfield joined the UAB Department of Surgery in 2008, returning to Alabama, his home state, after training at the Mayo Clinic. He has since achieved associate professorship and additionally serves as director of the General Surgery Residency Program. Dr. Porterfield speaks nationally and internationally regarding his expertise in surgical education, endocrine and robotic surgery.
Learn more about John Porterfield, MDRelease Date: October 26, 2018
Expiration Date: October 26, 2021
Disclosure Information:
Dr. Porterfield has the following financial relationships with commercial interests:- Honorarium/Payment for Lectures, including service on Speakers Bureaus - Intuitive Surgical
Dr. Porterfield 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. Today, we are talking about adrenal evaluation and treatment and my guests are Dr. Brenessa Lindeman and Dr. John Porterfield. Both endocrine surgeons at UAB Medicine. Dr. Porterfield, I’m going to start with you to tell us a little bit about the adrenal glands. What does the adrenal cortex produce and what are some of the most common syndromes that you see?
John Porterfield, Jr., MD (Guest): Yes, so the adrenal glands are organs that sit in the back of the upper portion of the abdomen and it’s really made up of two layers. The outer layer, the cortex and the medulla and together they work together with the entire endocrine system throughout our entire body to be able to have our hormonal balance in an appropriate state of health. The cortex specifically as you asked about primarily makes three different groups of hormones. One is aldosterone, the other one is cortisol, then the other ones are the androgen or sex hormones and those can all be present in disease states if there’s a tumor that creates too much of any of those hormones coming from those layers.
Melanie: Dr. Lindeman when you are evaluating the adrenals, are you always looking for a mass or is it sometimes incidental and you come across it when you are testing for other things?
Brenessa Lindeman, MD (Guest): You know historically, patients that had over-secretion of one of the hormone products of the adrenal gland would come to attention based on the symptoms that they had. So, for patients with hypersecretion of aldosterone for example; they would have high blood pressure, and would be found to have a low potassium on their blood chemistry or some patients that had central obesity and other symptoms that go along with steroid hormone excess specifically cortisol; would then be able to be diagnosed with Cushing’s syndrome and then undergo workup to determine if that was due to overproduction from the adrenal glands or another cause. But I would say that today, the majority of patients come to our attention because of what’s been termed an adrenal incidentaloma and that is simply a mass within the adrenal gland that was found on an imaging study performed for a different reason. Found incidentally. And we’ve seen that as the number of people that are getting what are called cross sectional imaging studies like CT scans and MRIs have increased such that we see adrenal nodules or masses in about one out of every ten people.
Dr. Porterfield: And I would like to add that we find with these advanced cross-sectional imaging studies that we can often find things in different organs in the body that might be so small that we can’t characterize them. So, for these adrenal incidentalomas; we have decided based on the evidence of prior studies because we don’t want to ever miss the feared adrenal cortical carcinoma; which can be a deadly cancer; that we would evaluate all incidentalomas discovered in the adrenal glands that were bigger than one centimeter. So, one centimeter is our cut off for where we would want to begin the further evaluation clinically as well as the biochemical testing that Dr. Lindeman referenced.
Melanie: So, as I see it Dr. Porterfield, there’s two main questions and diagnostic criteria whether the lesion is malignant or whether it’s hormonally active. What are you watching for as primary adrenal cortical carcinomas and functional adenomas, so they are not missed?
Dr. Porterfield: Right, so, whenever we are looking at any of these lesions; we certainly want to rule out first and foremost that it’s not a cancer and so we do that largely based on its appearance on CT or MRI imaging as well as based on its size. If we have any opportunity to see it, at more than one point in time, we can then assess a rate of growth to be able to know if it’s growing at a rate that would be concerning. Certainly, something that’s growing more than one centimeter a year would be worrisome and then that is where we also have our upper limit of things that we watch. So, we watch things up until four centimeters. Beyond four centimeters, in otherwise healthy patients, particularly young patients; we become much more wary of watching them because we know from numerous previous studies that as the size of the tumor increases; the risk of it being an adrenal cortical carcinoma goes up.
Dr. Lindeman: And I would like to add to what Dr. Porterfield said that our techniques for imaging have become increasingly advanced over time such they we are beginning to be able to pick up concerning features within adrenal masses that don’t necessarily meet size criteria to indicate they would need to be removed. But the features that we become concerned about are adrenal masses of any size that demonstrate necrosis or calcification and also the radiologists can perform a measurement of the density of the adrenal tissue and if that density is very low; using something called Hounsfield units; if that value is less than ten, then we can be much more reassured that that adrenal mass is benign.
Melanie: Dr. Porterfield speak a little bit about follow up care and follow up visits for evaluation.
Dr. Porterfield: If we were to see a patient that had a lesion that was nonfunctional and less than four centimeters; then yes, we would want to see them back in clinic typically between six months and a year to repeat that imaging at least one time to be able to see that the lesion is stable. And we also can reference guidelines for how we follow these lesions based on their size and function.
Melanie: Dr. Lindeman speak about treatment a little bit. What are some current issues in medical or surgical management? Assess for us the appropriateness of specific treatments that you might use once you detect what’s going on as far as hormones, chemo, radiation, surgery.
Dr. Lindeman: Okay. That’s a large area, but I will attempt to go through it systematically. So, the way that I start to think about treatment for these adrenal lesions begins with the two questions that you posed previously. So, first, is the mass functional in some way that it’s overproducing hormones normally made by the adrenal glands? And so, if that’s the case; then surgical resection of the adrenal gland containing that mass is indicated and there are a couple of ways in which patients with certain types of hormone overproduction need to be prepared. For patients with hyperaldosteronism; it’s important to ensure that their electrolyte levels which can be thrown off because of the disease are within normal limits. Particularly for safety with anesthesia. For patients with cortisol overproduction; we want to make sure that we give those patients appropriate stress doses of steroids throughout the entire perioperative period and continue their steroid hormone replacement after surgery. And particularly for patients with pheochromocytoma, which is a tumor that produces excess catecholamines like epinephrine or norepinephrine. Those patients can have extreme hemodynamic changes intraoperatively with hypertension as the tumor is being manipulated prior to the vein drainage of the adrenal being ligated and those patients can also develop hypotension once the tumor has been removed and so we work very closely with our anesthesiologists to ensure that we have the patient adequately blocked in terms of alpha-blockade followed by beta blockade in the preoperative setting as well as ensuring we have appropriate monitoring and vasoactive agents available during the course of the operation.
Dr. Porterfield: And I would like to add that just over the last ten years; our anesthesia colleagues particularly here at UAB which we typically do most of these cases combined with are cardiac anesthesiologists that, they have become extremely skilled at being able to maintain the patients with a stable heart rate and a stable blood pressure while we are operating and we communicate with the anesthesiologist as we manipulate these tumors because we can realize that we might press on the tumor in a way that might cause more of the norepinephrine or epinephrine to be released from the actual gland itself as we are working on it, that will then obviously raise or if we were – raise the blood pressure and heart rate or if we were to take that pressure off; or as we are completing the case and we are dividing those last veins that Dr. Lindeman mentioned; those last tiny little tributaries, we want to avoid that low blood pressure which is also that risk point that she mentioned. And so, there’s been some advances with some IV drugs that we use particularly IV calcium channel blockers which have allowed us to be able to if you will, drive with our foot on the brake and the gas at the same time which has been able to allow our anesthesiologists to be able to really titrate these patients even with very large lesions into a very smooth intraoperative path that has yielded fantastic results to the point now where we have been able to for the first time, be able to allow some of these patients even with pheochromocytomas to even go home the same day.
Melanie: Dr. Lindeman speak about treatment for masses suspicious for or proven to be adrenal cortical carcinoma.
Dr. Lindeman: Oh yes. And that’s one thing that I omitted from my answer to your prior question. Which is in discussing the treatment of masses suspicious for or proven to be adrenal cortical carcinoma. And there had been controversy in the literature regarding the optimal approach for treatment of these tumors. Although, it’s been shown now that the single most important factor for treatment of adrenal cortical carcinoma is achievement of surgical resection with wide negative margins. So, meaning getting out the entire tumor with a relatively thick rim of normal tissue surrounding it ensuring that there’s no violation of that tumor capsule that may lead to spread or seeding of adrenal tumor cells. And as surgical techniques have advanced; many surgeons including Dr. Porterfield and myself find that we can accomplish operations even for adrenal cortical carcinoma using minimally invasive techniques other than in the most advanced cases with the largest tumor sizes. And so, I think one of the things that our colleagues can do to help patients prepare for surgery and deal with effects of it are to really have an understanding of whether the patient is a candidate for a minimally invasive approach and I know I can speak for Dr. Porterfield as well in saying that we are always happy to see any patient in the clinic if there is ever a question and guide them through that discussion of what the risks and benefits are for various approaches.
Dr. Porterfield: And I would like to add I completely agree with Dr. Lindeman that I have seen patients that have not been referred to us for adrenal surgery, because of their age or because of the size of the tumor and the provider felt like that the patient might be too old or the patient might be too ill or the tumor might be too big to be done in a minimally invasive fashion and what I would just beg would be for us to at least be able to see the patient and have that conversation with them. Because I think that what we have been able to do in a minimally invasive fashion, I don’t think we have quite reached the limit of what we can do. We have removed tumors larger than 14 and 15 centimeters with minimally invasive techniques particularly laparoscopy and with the advent of robotic surgery, it was once thought when Dr. Lindeman mentioned it was controversial.
It was once thought by from a more historical perspective that the surgery could be done more oncologically or following oncologic principles like she talked about getting that nice rim of healthy tissue around the adrenal gland. It was proposed that that could be done better with an open operation, but I would really contest now, and I know Dr. Lindeman agrees that the view that we have laparoscopically or robotically now is better than the view that I have open and we are able to meticulously protect that capsule that she mentioned and we are also able to meticulously evaluate the other structures around the adrenal glands, questioning for invasion and even if they are invaded. So, if a portion of the kidney is involved; then we have our urologist, we have performed partial nephrectomies, we have performed total nephrectomies, we have done distal pancreatectomies, splenectomies. We have removed portions of the stomach. We have done all of those things including portions of the colon and the small intestines, we have been able to remove large tumors with multiple organ resections and still not have to make a big open incision.
So, I think that it’s an exciting time to see how the technology has assisted us at being more precise cancer surgeons. Because we treat every adrenal tumor as if it’s a cancer until proven otherwise. Even if it’s a low likelihood; because we can’t ever go back and do the right operation the second time. We only get one chance to do it right.
Melanie: Dr. Lindeman first last word to you. Tell other providers what you’d like them to know about adrenal nodules and hyperproduction of hormones and really what you want them to know as referring physicians.
Dr. Lindeman: Absolutely. Thank you. I think one of the important things that referring physicians should know is that surgically correctable causes of hypertension, are very common in the general population. We believe that ten to potentially up to 15% of patients with high blood pressure may have hormone overproduction in terms of hyperaldosteronism and so I think it’s important for any provider that sees a patient with high blood pressure and with a low potassium to at least consider hyperaldosteronism as a diagnosis and to start that hormonal work up. I think the other thing that I would add to what Dr. Porterfield has described in terms of advances in surgical techniques is that here at UAB, we offer all of the potential minimally invasive techniques that surgeons are doing in this modern era and can customize that approach to the patient’s needs. So, he had mentioned laparoscopic and robotic approaches and we are also able to perform a retroperitoneoscopic approach to adrenalectomy in which patients a laying in the prone position and we are able to take a much more direct approach to the adrenal gland through the back and this is a very useful approach because it allows a direct and quicker access to the adrenal gland. It allows us to avoid re-entry into the peritoneal cavity in patients that have had prior surgery that may have led to the formation of scar tissue that might make that operation more complicated or risky and it also eliminates the need to reposition the patient if they are in need of a bilateral adrenalectomy. And so, working together, in our multidisciplinary way; we can see and evaluate the patient and determine which of those approaches that they may be best suited for. Because they all have an excellent recovery. They are all procedures that we are now performing for many patients on an outpatient basis. But, we can work with patients to determine their personal risk and benefit profiles and which surgical approach would be best for them.
Melanie: Dr. Porterfield, last word to you now. What does current research indicate for future developments in treatments and give us your best advice and information for other providers and what you would like them to know about adrenal evaluation and treatment.
Dr. Porterfield: Thank you Melanie. So, I think the most important thing that I would like to leave with providers is I would just request that they please not biopsy and adrenal gland. We would really like the opportunity to see those patients before a biopsy is entertained. There are some catastrophic examples that occur each year when adrenal glands are biopsied without a complete biochemical evaluation preoperatively and that can be disastrous if someone was to inadvertently biopsy a pheochromocytoma. It can also make the operation, the subsequent operation more difficult because adrenal glands can tend to bleed at the time of a biopsy and that can make the operation more difficult. It can also make the evaluation by our pathologist more difficult if they are having to look around the tumor, looking for areas that might be – might have had some areas of invasion, but yet there was adrenal hemorrhage related to a biopsy, that can be challenging. So, my final word would be please don’t biopsy an adrenal gland without speaking with a endocrine surgeon about the safety of it because the reality is that if the tumor is large, it’s going to come out, if it is functional; we are going to recommend that it come out. One of the things that I don’t think we mentioned yet is oftentimes patients are getting PET scans for other malignancies and so if there is a lesion on a PET scan in an adrenal gland that is PET positive; we are also going to recommend removal of that adrenal gland as part of – because of the risk that we know with PET positive lesions; there is more risk of malignancy in those tumors than in PET negative adrenal masses. So, that would be my main take home point is if there is ever a question of a biopsy, call Dr. Lindeman, call myself. We would be more than happy to go over the details of the case. There are a few rare examples where a biopsy can be valuable, and we have some unique ways to do that even through the stomach or through the duodenum and to not have to go through percutaneous routes which have been done in the past. So, we can connect them with the most appropriate team that would be able to do that in the safest way possible in the rarest of events that an adrenal biopsy would be indicated.
Dr. Lindeman: And I would like to add to what Dr. Porterfield was describing particularly in terms of thinking about adrenal gland biopsy and masses that are identified with PET scans. Historically, one of the indications for adrenal biopsy was in a patient with a known history of malignancy in whom you suspect they have a metastasis, but as more and more of these patients are being followed with PET scans; PET avid adrenal masses that are identified that are suspicious for metastatic disease are another group of patients that we would love to have the opportunity to evaluate and discuss with you as the referring provider and with the patient because over time; what the literature has begun to demonstrate is that patients will have a survival benefit for resection of isolated adrenal metastases for lung cancer, for renal cell carcinoma and others with a one year survival of around 60% and a five year survival in patients with metastatic disease of up to 28% in some studies. So, I think that’s another way in which the field is continuing to expand for the benefit of our patients.
Melanie: Thank you so much both of you for joining us today and sharing your expertise about adrenal evaluation and treatment and letting other providers know how important it is that they do refer a patient before they start some treatment and evaluation. Thank you again for being with us. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician, that’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua085.mp3
- DoctorsChen, Herbert
- Featured SpeakerHerbert Chen, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmechttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5273
- 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
Release Date: September 16, 2021
Expiration Date: September 15, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Speaker:
Herbert Chen, MD
Chairman, Department of Surgery, Surgeon-in-Chief, UAB Medicine
Dr. Chen has no financial relationships with ineligible companies related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole, MS: 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.
Welcome. Our topic today is parathyroid disease, and my guest is Dr. Herbert Chen. He’s the chairman in the department of surgery at UAB medicine and surgeon in chief. Dr. Chen explain a little bit about the parathyroid. Tell us about the different types of disorders that you see and how they're classified.
Herbert Chen, MD: Sure. Everyone is born with at least four parathyroid glands, which live in your neck. They're called parathyroid because they're near the thyroid, but they really have nothing to do with the thyroid. Their job is to regulate the levels of calcium in your body. What happens in hyperparathyroidism is one or more of the parathyroid glands develops a tumor inside of it which accuses the body to release calcium from your bones into your blood causing you to develop many symptoms from the high levels of calcium in your blood.
There are various types of hyperparathyroidism. By far the most common is primary hyperparathyroidism, which tends to happen in people around somewhere between their 50s and 70s. The other types of hyperparathyroidism called secondary and tertiary typically happen if you have medical problems such as kidney failure, but they're far less common.
Melanie: Are they serious diseases? Has parathyroid disease become milder over the years?
Dr. Chen: Well, I think in our research, in our endocrine surgery area, we've done a lot of research into hyperparathyroidism. We know that one, it’s the third most common endocrine order after diabetes and thyroid disease, but it’s very much unrecognized by most physicians. Hyperparathyroidism is a big cause of fatigue, osteoporosis, difficulty concentrating. There’s so many symptoms, such as kidney stones, that can be caused by this. Really hyperparathyroidism impacts quality of life, how long you live, and a whole bunch of things. I think now we’re trying to get the message out that this is something that doctors should be looking for.
Just in the study done which we've recently published, we found that most patients… The most common way people present with this is that a high calcium level is found on the routine lab. Our research has shown that only about a third of the time is it ever investigated or worked up. So, we feel there are so many people suffering from this, a disorder, that remain undiagnosed.
Melanie: So, tell us a little bit about some conditions that can lead to hyperparathyroidism, and you mentioned calcium. Do they always go together? Do high calcium levels always indicate parathyroid disorders?
Dr. Chen: Well that’s a great question. So, hyperparathyroidism is the most common, or the number one cause of high levels of calcium in the blood. So that’s how it’s often discovered. There are some patients with hyperparathyroidism whose calcium levels are only mildly elevated or intermittently elevated, and that’s one of the reasons why the diagnosis is missed. Sometimes the lab work does not detect it on the first blood test. The disease itself causes can present in a number of ways. Common presentations include kidney stones, abdominal pain. Patients who have frequent urination or constipation. Almost all patients with hyperparathyroidism suffer from fatigue in what they call as brain fog or inability to think. So, if I could get one message out to primary care providers, it’s that when you do have a patient who is complaining of fatigue or difficulty concentrating, hyperparathyroidism should definitely be on the list to look for.
Melanie: Dr. Chen, does how high the calcium level is, does that correlate with how severe symptoms might be in somebody with this condition?
Dr. Chen: So quite ironically, you would think the higher the level, the more symptomatic patients would be. However, our research and research from others have shown it’s actually the patients who have only mild elevated levels actually have more symptoms than those with high levels. In fact, if you measure the quality of life in patients who have mildly high levels versus very high levels, the mildly high patients have a worse quality of life and they have the most improvement after surgery.
Melanie: Wow. So, what would you like providers to know about treatment options, and even which patient selection criteria. There can be some adverse effects of treatment, it can change the quality of life for patients. So, speak about treatment options and patient selection.
Dr. Chen: Sure. So, the only curative treatment for hyperparathyroidism is surgery. Fortunately, the operation that we recommend is called the minimally invasive parathyroidectomy. It’s a very safe, out patient procedure which takes us less than an hour to perform. The patients go home the same day. When they go home, they're eating, drinking, talking, doing their things they normally need to do. Many of them don’t even take any pain medication after the surgery. So, it’s a very, what we call one of those minimally invasive procedures where the patient’s recover very quickly but can have a huge impact on their life. So, what we recommend is once the diagnosis is made, we would like providers just have them meet us. I think as surgeons, we’re in the best position to tell us them what the surgery is like and what the potential risks and benefits and have the discussion with them if it is in their best interest to pursue surgery.
Melanie: Then what is life like the for patient afterwards? What changes before and after the surgery?
Dr. Chen: Well if the patient has a whole host of symptoms, in our research and just from talking to patients everyday that we do this procedure on, they feel better. If they have osteoporosis, there’s improvement on that. Remarkably, people will have the surgery and they will tell me that it has changed their lives. Because of the underdiagnosis, we have so many people that actually self-referred to us because they have these symptoms and they get their primary care providers to check their labs. They find the diagnosis, and they self-refer to us because they hear from other patients how this can drastically improve quality of life, performance, thinking. A whole bunch of other things that we haven’t spoken about is hyperparathyroidism can cause insomnia, reflux and abdominal pain. So, there’s a whole host of things that can get better after the operation.
Melanie: Is there a link between hyperparathyroidism and the risk of developing certain cancers?
Dr. Chen: Well fortunately in most cases, the tumors that form in the parathyroid glands which cause hyperparathyroidism are almost always benign. They're very rarely cancer. So, for most patients with hyperparathyroidism, the cancer word is not even part of the discussion. However, hyperparathyroidism can be associated with other inherited disorders. Such as tumors or cancers of the pancreas, tumors of the pituitary. Those tend to run in families. By far the most common scenario for hyperparathyroidism is a benign tumor.
Melanie: What are some of the long-term monitoring advice that you would like other providers to have after somebody has gone through the procedure for their hyperparathyroidism? What would you like them to know about long term monitoring?
Dr. Chen: So, after the surgery, basically we recommend that the patients, if they’ve had osteoporosis or osteopenia to begin with, we put them on a regiment to take calcium and rebuild some of the calcium that they’ve lost. Ironically what happens is if you have osteoporosis due to hyperparathyroidism, taking extra calcium is not going to help because the hyperparathyroidism is the driving force. Then we recommend after the surgery happens to make sure you take enough calcium in your diet to replace the calcium that your bones have lost. Then we check calcium and parathyroid hormone levels annually because about 5% of patients can have the disease come back.
Melanie: Hm. That’s so interesting. So, if it comes back, how would they know? If they're going to a primary care provider and they're monitoring, what should they be looking for?
Dr. Chen: Well if the disease comes back, generally if they have symptoms to begin with, they usually have the same symptoms. So often the patient’s symptoms come back, and then they go to their doctor and they get tested and it’s back. Occasionally they don’t. It’s the routine lab follow-up that they see the levels go up again and that’s an indication that another tumor has developed. But like I said, this doesn’t happen in most patients. Most patients who have this disorder have one operation to take usually one tumor out and they're good for the rest of their life.
Melanie: Wrap it up for us Dr. Chen with your best information and advice about the comorbidities that can go along with hyperparathyroidism, what you want other providers to know about recognizing those signs and symptoms and monitoring their patients, and when to refer to the specialists at UAB medicine.
Dr. Chen: I think that to reiterate, hyperparathyroidism is the third most common endocrine disorder. It’s the most common of cause of high calcium levels in the blood. We have a very safe outpatient operation which can improve the quality of life in patients. I think if we had a pill that could cure this, people would get treatment for it definitely. They’d be more willing. But because it’s surgery, there’s a little apprehension to consider sending someone for an operation if they're not feeling so bad or they don’t recognize it. But it’s very common for me to hear patients, even if they don’t perceive feeling bad, they have the procedure and they tells us that we've changed their lives. So, I do think you can make a big difference in the functionality of someone, how they feel, how much energy they have with a simple operation.
Melanie: Thank you so much Dr. Chen. As always, you're a wonderful guest, and thank you so much for coming on and sharing your expertise with us today. A community physician can refer a patient to UAB by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You're listening to UAB Medcast. For more information on resources available at UAB medicine, you can go to uabmedicine.org/physician. That’s uabmedicine.org/physician. This is Melanie Cole, thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua084.mp3
- DoctorsCorey, Britney
- Featured SpeakerBritney Corey, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5299
- Guest BioBritney Corey, MD is a fellowship-trained minimally invasive gastrointestinal surgeon, specializing in foregut and anti-reflux operations and abdominal wall hernias. She completed her minimally invasive GI fellowship and general surgery residency at UAB. A Texas native, Dr. Corey graduated from the Texas A&M Health Science Center College of Medicine.
Learn more about Britney Corey, MD
Release Date: October 4, 2018
Reissue Date: September 23, 2021
Expiration Date: September 22, 2024
Disclosure Information:
Dr. Corey 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.
- 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): UAB Medicine recently joined the Americas Hernia Society Quality Collaborative. This relationship will allow UAB to participate in continuous quality improvement efforts to optimize outcomes and costs of hernia care. My guest to discuss hernia care today is Dr. Britney Corey. She’s a fellowship trained minimally invasive gastrointestinal surgeon specializing in foregut and anti-reflux operations and abdominal wall hernias at UAB Medicine. Dr. Corey explain a little bit about hernias. What had typically been done and what is different now?
Britney Corey, MD (Guest): Sure, so, hernias quite simply are an opening in the abdominal wall, the connective tissue or muscle layer of the abdominal wall. Although they can occur in the diaphragm as well. And so, traditionally, a lot of hernia surgeries have been performed open, but we have had advances in our minimally invasive techniques and so now we are able to offer laparoscopic and robotic hernia repairs and another great advance in hernia surgery is our postoperative pathways have gotten much better. So, we use a lot of multimodal pain agents. We work with our regional anesthesia colleagues to give our patients preoperative blocks and we are seeing our patients’ length of stays drastically go down and patients are able to resume their normal activities much quicker and get out of the hospital quickly and the ultimate goal is of course to get back to all of your normal activities.
Most patients are able to resume all of those within a week or two with the exception of heavy lifting which we ask them to avoid for about six weeks after surgery. So, our patients are doing better because of that and recovering quickly and of course we also have advances in the mesh that we use now for hernias. So, there’s constant innovation in the area of mesh and it’s getting safer than it has been in the past. And we also just have many options for the types of mesh and where exactly we can place those in the abdominal wall. So, we really, truly can make a very individualized plan of care for our patients now. It’s not a one size fits all. And that has really improved hernia care.
Melanie: So, before we talk about mesh and those changes; tell us about the Americas Hernia Society Quality Collaborative and what will this relationship allow UAB to do?
Dr. Corey: Yeah, the America’s Hernia Society is a society that’s both in North America, Central America and South America and what is allowing is for hernia centers all over the Americas to report their outcomes and the type of operations that they are doing as well as their thirty day and one-year results for elective ventral hernia repairs. And so, then that just give us a huge data set that we can evaluate hernia outcomes based upon. So, it’s big data and that will just help improve and further our knowledge about optimal hernia care.
Melanie: How is the success of hernia repair measured doctor? Is it – does it have to do with recurrence rate or something else?
Dr. Corey: It certainly has to do with recurrence rate. We definitely want a hernia repair to be long lasting for a patient. But it also has a lot to do with quality of life and so, many patients complain of pain at the site of their hernia or back pain because the integrity of their abdominal wall is compromised by the fact that they have a hernia, especially large hernias. And so, it is also making improvements in the patient’s quality of life. And so, them being able to go back to go back to their normal activities, to not experience daily pain, to not deal with an unsightly bulge also contributes to a successful operation.
Melanie: So, as long as we are discussing treatment, and optimizing; do you feel personally, that the current techniques of inguinal hernia repair are optimal and how does patient selection help you to optimize your repair?
Dr. Corey: Sure, so, for inguinal hernia techniques, there’s really two broad categories of how you take care of an inguinal hernia. Although you can divide it down until a lot smaller categories, but I think of it as an open kind of traditional hernia repair with mesh versus a minimally invasive inguinal hernia repair, also with mesh. So, I of course, I’m biased in the fact that I’m a minimally invasive surgeon, but there’s also data that supports that patients kind of resume their normal activities quicker and have less pain with minimally invasive operations. Both of those are outpatient surgeries, but if you have a laparoscopic or a robotic hernia repair, then we think that you are going to have less pain and research backs us up on that as far as especially laparoscopic inguinal hernia repairs. And you probably have a lower risk of infection which is a very low infection risk regardless, open or laparoscopic or minimally invasive, but we think that long-term, as we get more and more data; because that risk of infection is so low, it’s kind of hard to prove a difference. We think though, that we will see a lower risk of infection. Certainly, you have less scaring as far as your incisions are much smaller and most patients are back to their normal activities. Another advantage of the minimally invasive approach is that we can see both sides of the groin and so if you have a hernia on one side, we can also look on the opposite side and if we see a hernia that was not apparent on physical exam, we can go ahead and address it at the same time.
Melanie: Then tell us about how mesh selection for hernia repair can be challenging for you clinicians. Give us your expert review of the different types, the biologic, or synthetic or the bioabsorbable types. Speak about how mesh selection being a modifiable factor during the operation might optimize patient recovery.
Dr. Corey: Sure. So, I think of – I guess I will preface this by saying that mesh selection is a very individual surgeon’s decision and there are so many different types of mesh that in some ways, it’s very difficult to compare one to the other because they are – not only is there a lot of different types of mesh; but there are also a lot of different places that you can put mesh in the abdominal wall. You can put it on the outside of the muscle. You can bury it in the muscle. You can place it beneath some muscle or several other techniques that you can use there. So, it’s hard to be able to compare apples to oranges in large groups of patients which is another great advantage of being a member of the quality collaborative. But in general, I put mesh into three separate categories. So, there’s completely manmade mesh, synthetic mesh and that is permanent mesh, for the most part. So, once it’s placed inside, it will be there until it is removed, or you will live with it for the rest of your life. So, that’s great in that it is a very strong mesh typically. And you never have to worry about it going away and it can give you a long-lasting durable hernia repair.
But, on the flip side if that – it’s a foreign body and if it gets infected, then sometimes it even has to be removed and quite often has to be removed if there’s a complication with it. It’s going to be there the next time you have an operation, so your surgeon will have to work around that in the future if you ever need an operation. So, it’s certainly also tends to contract over time or shrink inside over time so, while it’s a great permanent and very strong mesh and we use them quite frequently; it has its downsides as well.
On the other extreme is the biologic mesh which is naturally occurring tissues and made typically in pigs or used from pig skin or even human tissue that has been modified for use as mesh and that – those biologic meshes are expensive but they also go away after about just over a year typically it will go away. Now they do likely cause some changes in the muscles or the tissues of the human body that can strengthen those tissues even after that mesh has absorbed or gone away. But certainly, whenever you compare manmade or synthetic mesh to biologic mesh; biologic mesh has a higher recurrence rate in most studies. So, whenever you are looking at recurrence rate as one of your successes of an operation; you have to take that into consideration. The great advantage to biologic mesh is that it fights infection very well. So, it’s very useful in patients who are at a high infection risk but have a hernia that needs mesh to repair it. And that can be patients who also have to have a portion of their intestines removed at the same time or etc.
Right in the middle is the bioabsorbable or also called biosynthetic mesh and that mesh is typically made of materials that – it’s manmade, but it’s made of materials that kind of naturally occur in the human body and so the body doesn’t recognize it quite as foreign. It also absorbs over time and so after about 12 to 18 months; you will no longer see it in the human body, but it will cause those changes to strengthen the muscles of the abdominal wall and so far, we think that its recurrence rates are going to be better than biologic mesh. We still need super long-term data on that, but the initial data shows us that it is probably better. It’s certainly cheaper and it also does very, very well with infections and so that’s why we think that it’s going to be a great option for our patients. And those patients that are at high risk of infection or who don’t like the thought of having a long-term foreign body or are having a portion of their intestines removed at the same time or something like that, that increases their risk of their mesh getting infected. That’s an excellent option for them.
Melanie: Wrap it up for us and thank you so much for explaining all the different mesh selection criteria for surgeons and how you all go about choosing that. So, wrap it up with your best information for other providers and what you would like them to know about optimizing hernia repair.
Dr. Corey: Sure. So, the conversation that I have with my patients in clinic whenever I am seeing someone for a hernia repair pretty much focuses on of course the type of operation that we are going to do; but what can we do to give you the best hernia repair ahead of time. And so, that is looking at all the essential risk factors that you have and saying which ones we can change. So, the number one reason that patients get hernias especially abdominal wall hernias is having a prior incision. So, we can’t really change that. Those patients have already had their incisions of course, needed their incisions, so, that’s in the past. We can’t change that. But what can we change? So, other reasons that patients get hernias are because of increased intraabdominal pressure and so the increased pressure in the abdomen starts looking for weak areas of the abdominal wall that it can push against and offload some of that pressure. And so, one example of how you have increased intraabdominal pressure would be pregnancy, but the reality is that typically our patients are dealing with obesity and that’s the reason that they are at increased risk of a hernia. So, if we can modify that risk factor, and lose weight before surgery; then that certainly will give them a better hernia outcome. Any factors that cause you to have weakened tissues are going to give you a less than optimal hernia outcome and so, the one there that we can modify is nicotine use. So, we encourage all of our patients to stop smoking and that is backed up by expert hernia recommendations that are published guidelines. And then finally, other things that contribute to poor wound healing and so, immunosuppression if you can minimize the amount of immunosuppression that any patients are on, but also the thing that we see most commonly is diabetes so we need to optimize our patients to have a hemoglobin A1c that’s less than 8 if at all possible and that will give them a much better hernia outcome.
Melanie: Great information. Thank you so much Dr. Corey for joining us today. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician, that’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua080.mp3
- DoctorsSaag, Michael;McGuire, Brendan
- Featured SpeakerMichael Saag, MD | Brendan McGuire, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5259
- Guest BioMichael Saag, MD received a B.S. in chemistry with honors from Tulane University, earned his medical degree with honors from the University of Louisville, and completed his residency and infectious disease and molecular virology fellowship training at the University of Alabama at Birmingham.
Learn more about Michael Saag, MD
Brendan McGuire, MD is a hepatology specialist in Birmingham, AL and has been practicing for 22 years. He graduated from University Of Pittsburgh School Of Medicine in 1990 and specializes in hepatology.Learn more about Brendan McGuire, MD
Release Date: September 18, 2018
Reissue Date: November 4, 2021
Expiration Date: November 3, 2024
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.
Presenter:
Michael Saag, MD
Professor in Infectious Diseases
Brendan M. McGuire, MD
Associate Professor in Gastroenterology, Hepatology
Dr. Saag has the following financial relationships with ineligible companies:
Grants/Research Support/Grants Pending - Gilead Sciences; ViiV Healthcare
Dr. McGuire has the following financial relationships with ineligible companies:
Grants/Research Support/Grants Pending - Gilead Sciences; Arrowhead Pharmaceuticals
Drs. Saag and McGuire does not intend to discuss the off-label use of a product. All of the relevant financial relationships have been mitigated. No other speakers, planners or content reviewers (Ronan O'Beirne, EdD, and Katelyn Hiden) have any relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionUAB 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 www.uabmedicine.org/medcast and complete the episode’s posttest.
Melanie Cole (Host): Hepatitis has been recognized as a global health problem. Our topic today is hepatitis C and here to tell us about that are my guests Dr. Brendan McGuire, he’s the Medical Director of Liver Transplant and Dr. Michael Saag, he’s the Associate Dean for Global Health, both at UAB medicine. Gentlemen, welcome to the show. Dr. Saag, I’d like to start with you. Explain a little bit about hepatitis C.
Michael Saag, MD (Guest): Yeah, thanks a lot. Those of us who trained before 1989 would have known hepatitis C as non-A, non-B hepatitis and then in 1989 a flavivirus which is similar to dengue and at least in that family or a Zika virus even was discovered. It’s an RNA virus. It’s one that’s transmitted sort of in the same realm as HIV in that it’s transmitted through blood products, through sexual activity and rarely but a lot less frequently from mom to baby when mom’s infected with the virus. The virus itself has a varied natural history in that the virus once it infects about 15-20% of people will clear the infection without any problem and they will just be rid of it and you will know that because an antibody test will be positive but there won’t be any virus detected in the bloodstream. For the other 80% of people, they have a chronic infection and you would detect that by testing for antibody and then seeing a fairly high level of HCV RNA in the realm of usually 100,000 to millions of copies of virus and that would indicate that the person has chronic infection. And then just to round out the natural history, once somebody has chronic infection somewhere between 40-50% of people will go on to progress with liver scarring, sometimes up to the stage of cirrhosis and that would be approaching end-stage liver disease and that’s when the real complications of hepatitis C start. That occurs over a period of about 30 years.
Melanie: Dr. McGuire how many people in the United States have hepatitis C and who really is at risk of acquiring it? Tell us a little bit about the pathophysiology of it.
Brendan McGuire, MD (Guest): The prevalence of chronic hepatitis C in the United States is estimated to be about 3.5 million people. As Dr. Saag said, it is primarily a blood to blood transmission. Anyone who is a current or former injection drug users are at risk. Anyone who received blood products really prior to 1992 is also at risk. Patients also in the past on chronic hemodialysis, patients who have been exposed, hospital workers to needle sticks involving patients that are hepatitis C positive, people with HIV infection are also at risk and also as Dr. Saag said, children born to hepatitis C positive mothers.
Melanie: Dr. Saag as you have also already told us about transmission and exposure how important is early diagnosis as being crucial to improve the outcome prediction and what are the diagnostic criteria? Who should get tested?
Dr. Saag: Well the earlier the better for almost any kind of infectious disease and so I would recommend routine screening of really virtually anyone. When screening started, it was an antibody test and it was recommended first and foremost for what was called the baby boomers. That’s the individuals born between 1945 and 1965 in the United States and they had what was felt to be the highest prevalence of infection, but we are learning now that there’s another spike of people with infection that’s occurring in people aged 20 to 30 years of age perhaps a combination with the opioid epidemic that’s sweeping the country right now. But from my perspective, since we will get to treatment in a minute, but since treatment has become relatively easy, in the form or oral therapy for 8-12 weeks for most people; I would argue that anyone should be tested at least once. That would be anybody from I would say the age of 13 through the rest of life, at least tested once and if they go into higher risk groups that Dr. McGuire described then perhaps more frequently. But everyone should be tested at least once.
Melanie: Dr. McGuire are there genotypes? Are they important for treating patients? Tell us about some of the treatments available. Are you still using interferon or ribavirin? Tell the listeners, other physicians what you are doing right now in the current standard of care.
Dr. McGuire: It has actually been fun to treat hepatitis C and like Dr. Saag and I we both started treating it back in the early 1990’s with at that point we just used interferon and unfortunately it had a lot of side effects and about 20% of patients actually could not tolerate the side effects. But we have gotten a lot better. Now we have newer agents. They are oral pills. The pills, they are direct acting antiviral agents or DAA agents. These agents are a pill or a couple of pills once a day that you take for 8-12 weeks. Side effects are pretty minimal. Discontinuation rate is less than one percent and when you take these medications, success rate in terms of clearing virus is over 95%. There are six different genotypes in the US, primarily genotype 1 makes up 80% of the patients, genotype 2 makes up about 15% and the remaining five percent are genotype 3. With the current DAA’s some of them are so broad that they are successful against all six different genotypes. Some of them are more specific to genotype 1, but there are medications out there that are so easy to take, so easy to treat and so easy to clear virus. I agree with Dr. Saag, everyone really should be treated.
Melanie: Dr. Saag do you have any predictors of treatment response or and is there anyone who should not be treated? Are the clinical indications or contraindications for institution of these treatments?
Dr. Saag: Well back in the days of interferon treatment, sometimes we added ribavirin and oral antiviral to that. The side effect profile was pretty horrible and so the people that were referred or recommended for therapy were those who really had more advanced infection and we sort of didn’t treat everyone. Now with the direct acting agents available; we are really recommending treating most everyone. The exception would be those who have a short life expectancy, those who for example might have another underlying disease in which they are unlikely by the probability to live for another year or two. But most everybody else unless there are extenuating circumstances, drug-drug interactions or things that preclude the availability of the drugs to the individual or the provider; then I think most everyone should be treated. The biggest hurdle we are having right now isn’t really the testing or the indications for therapy; it’s really gaining access through the payors working out deals with the pharmaceutical companies to get the prices low enough to where they are affordable for all people to be treated.
Melanie: Dr. McGuire you get the fun question of promising new therapies, looking forward to the next ten years in the field; what do you feel will be some of the most important areas of research?
Dr. McGuire: Well the research for hep C has really been done since the drugs are there. The hardest part is just finding everyone who has it and that’s why we need primary care people to start screening individuals out there. We think that we have probably treated about half the people in the US, but there is still another half that we don’t even know that even have it. And for a lot of these people, their symptoms are just slowly progressing. They can have this for over twenty years and 20% of those will go on to develop cirrhosis, but it’s such a slow progressive disease. Most patients don’t have any specific symptoms for it. So, it really takes primary care doctors identifying these patients to get them all treated.
Dr. Saag: And if I could add to that, I think the treatment has become so straightforward that is somebody in practice is in internal medicine or primary care, they may want to learn about how to treat hepatitis C on their own. If they are not comfortable with that, then referral to either a GI specialist or infectious disease specialist can get it done. But the treatments really are pretty straightforward and the prerequisites of knowledge to treat would be obviously learning about the natural history of hepatitis C, learning especially how to stage the degree of liver fibrosis and historically we use liver biopsy. I think we have other means now that are less invasive especially elastography which is a special sound wave test that’s done on the liver that can estimate the degree of fibrosis to the point of perhaps cirrhosis and understanding which genotypes respond to which drugs. One very important caveat that I think Dr. McGuire would underscore is that if you are following somebody and you want to treat them, and you discover that they have cirrhosis; that’s something that should be managed in conjunction with a hepatologist. Otherwise, if the fibrosis scores are lower, the range usually goes from F0 to F4 by METAVIR criteria. Anybody who is F0 to F2 for sure I think can be readily managed by primary care. When you start getting F3, F4 degrees of fibrosis then that’s something you may want to reach out and talk to a hepatologist or share the care with them.
Dr. McGuire: And I would like to add just one additional comment. Hepatitis C is currently the number one indication for liver transplants, but with current treatments and the current drugs available; we think in two years it will not be and we think nonalcoholic steatohepatitis progressive cirrhosis will be the number one indication for liver transplant. But I have a lot of patients in my clinic with cirrhosis, we cleared their virus and their liver disease is stable and they are not progressing and it’s actually fun to see. I have them come back once a year just to screen them because they are at risk for developing cancer down the road; so, I will screen them for that. They are at risk for having varices from bleeding and I will screen them for that. But otherwise though, they are living a normal life and they have a very functioning liver. The cells work well even though they have cirrhosis.
Melanie: Isn’t that amazing gentlemen? So, Dr. Saag first last word to you. Are we using the word cure for hepatitis C when you talk about these standards of care and these treatments; and wrap it up for us. What would you like the listeners to take away from this segment about hep C, testing and when to refer.
Dr. Saag: Well to answer your fist question, absolutely. It is a cure. CURE. Cure. If you treat someone, their virus goes undetectable, where you can’t detect to target at all after their 8-12 weeks of therapy, you bring them back somewhere between four and six months later and if they are still undetectable; which 99% are; then you can look them in the eye and say, your hepatitis C has been eradicated, you are cured of your hepatitis C infection. And that is a joyful experience for the patient, but it is also for the provider. I guess my final take home point is hepatitis C which was unknown just thirty years ago has reached a point where we can cure 98% of people and the trick for us now is to test everyone, find out those who are infected, get them treated either you can treat them yourself with some training or you can refer them to the people that take this on everyday and you will find that your patients are cured and we can begin to think about eliminating hepatitis C from the United States. Dr. McGuire any other final comments?
Dr. McGuire: Oh, it’s a fun time. And I’m like you Mike, I never dreamed we would get this far, this quickly. And we have. And your comment is the patient is so excited when you tell them cured; but trust me, I think I’m just as excited if not more excited than they are. It is a great…
Dr. Saag: Me too.
Melanie: Thank you gentlemen so much for being with us today. What amazing times we live in for things like this and thank you so much for all the great work that you both are doing. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You’re listening to UAB MedCast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician, that’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua081.mp3
- DoctorsChu, Daniel
- Featured SpeakerDaniel Chu, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5214
- Guest BioDaniel I. Chu MD is an Assistant Professor in the Division of Gastrointestinal Surgery at the University of Alabama at Birmingham. He completed his undergraduate at Yale and medical school at The Johns Hopkins School of Medicine. After residency at Boston University Medical Center, he completed a colon and rectal surgery fellowship at the Mayo Clinic. His practice specializes in the spectrum of colorectal disease including inflammatory bowel disease, colorectal cancer, diverticular disease and anorectal disorders. His research interests focus on identifying, understanding and reducing health disparities in surgery.
Learn more about Daniel Chu, MD
Release Date: September 10, 2018
Reissue Date: August 23, 2021
Expiration Date: August 22, 2024
Disclosure Information:
Dr. Chu 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. - 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): Enhanced recovery after surgery or ERAS programs aim to hasten functional recovery and improve postoperative outcomes. Here to tell us about the success of these kinds of programs is Dr. Daniel Chu. He’s an Assistant Professor in the Division of Gastrointestinal Surgery at UAB Medicine. Dr. Chu tell us a little bit about the rationale of the ERAS programs and enhanced recovery programs in general.
Daniel Chu, MD (Guest): Absolutely. Well, you know enhanced recovery after surgery is a term that has been used for over a decade now. It’s a program that’s meant to recover patients better and it started in Europe and moved to the United States about several years ago and it was designed primarily for colorectal surgery patients. These patients after undergoing big surgeries, stayed in the hospital the longest, had the most complications, had the highest readmission rates. So, there were many opportunities for improvement. And some very smart people recognized this, and thought are there ways that we can decrease the stress, the insults that are caused by major surgery. And what they did is they put together best practices in surgery meaning individual things that we can do to help recover patients better and linked it all together under one kind of big umbrella. And so, ERAS really basically describes the eighteen to twenty different individual recovery methods that we can use to get patients to recover faster and better.
Melanie: Are they also associated Dr. Chu with overall healthcare costs, improvement even in patient satisfaction for providers?
Dr. Chu: Yeah, absolutely and they are. Traditionally, ERAS, when they first started looking at outcomes; it was really length of stay, it was really a hard metric that was noted to be dramatically improved with ERAS. So, stays in the hospital typically after colon resections were upwards of six to seven days. With ERAS, this is reduced to three to five days. So, that was just kind of the traditional metric that was looked at. And over time now, more recently, because of all the different pressures now placed on hospital systems; we have looked at costs, which are reduced essentially with the reductions in length of stay and decreased readmission rates and patient satisfaction. Patients definitely are more engaged with enhanced recovery since ERAS emphasizes so much on preop education and getting patients to really understand what it means to recover. So, I think patient satisfaction as we are looking at it is something that we are probably going to see more in the next few years, in terms of being improved with enhanced recovery program.
Melanie: Have these programs been considered or are they now considered standard of care across a variety of surgical disciplines or and have they been widely adapted in gastroenterology?
Dr. Chu: Yes, that’s a really good question. So, enhanced recovery started with colon resections, really the first publication came out in 2012 and what’s happened over every year is that it’s been adopted into other surgical specialties. So, from colon resection it went to rectal resections, starting again in colorectal surgery. It has moved on to Whipple procedures or pancreas surgeries into cystectomies in urology, gastric resections and in specialties like gynecology/oncology and bariatric and liver surgeries. So, it has really expanded across the whole spectrum of surgical disciplines. And I would say that it really has started to become standard of care and even the government is really interested in this through AHRQ, they are expanding ERAS across colorectal and to hospitals system wide across the United States. So, even though we know that it has good benefits to patients and it is being adopted across the US; there are still more hospitals that really it can be adopted in. So, bottom line, I think it should be standard of care and we are going to see this kind of increase more in the next several years.
Melanie: So, then identify for us some of the key elements in establishing the successful program. Is there a high degree of coordination that’s required? What kinds of providers are involved?
Dr. Chu: Absolutely. So, the beauty of the ERAS is that if you look at what it requires on paper; these individual recovery methods for patients from preop to postop; it’s fairly simple. These protocols are out there. But the hardest part about ERAS is what you are saying, it’s actually adopting it and implementing it successfully within your institution and so a lot of ERAS focuses on the implementation side. And what it requires I think first and foremost and even in our experience too is, it’s all about the people, the champions who are there and this is a multidisciplinary effort meaning it is not just the surgeon. There are many other champions from anesthesia, from nursing, from informatics, from the administration and so ERAS in a sense it actually forces everyone to get together at the same table and work together to implement this. Since surgical recovery is so complicated, it covers so many different arenas. But when you have those champions there; that’s really, I think how you can successfully implement enhanced recovery.
Melanie: So, is the adoption and implementation of a program like this, it’s not without barriers, correct Dr. Chu, so how should surgical providers be informed on this program and how to apply it to their patients and institution?
Dr. Chu: Yeah, so there are plenty of barriers. That’s absolutely true. And people have actually studied this and some of these barriers include things such as nursing education. You know we find nurses who said that we don’t believe in this. We have always done it this way. Surgeons themselves, anesthesiologists also have a dogma that we have done it always this way, this is the way to do it. So, I think that kind of change, not just for ERAS or for any program, is hard to do, but I think it always again boils down to finding those kind of those key champions and seeing who is in this division who is willing to change and then leveraging that person to work on their colleagues is I think the key. And it starts small. I think it really starts in the trenches so to speak to kind of enact that change, but I think you just have to identify the right people and then start from there.
Melanie: How are you evaluating the impact of a program such as this on outcomes? Do you have any predictors of treatment response or some of the challenges in adherence or in follow up? What strategies are you using to evaluate the impact?
Dr. Chu: Yeah, great question. So, I think the flip side of all that we do in ERAS, sure you can develop it and implement it, but the third part is auditing the results. So, tracking it through a database is absolutely key. And that’s actually a very challenging part about ERAS. One of the things that we measure besides kind of the “traditional outcomes” which is things like length of stay, readmissions, mortality, and complications, and patient satisfaction and cost; we also look kind of on the backside of compliance or adherence to each of these kinds of twenty parameters within ERAS. So, there is a metric where we try to record ERAS compliance and kind of out of those twenty different things that I talked about; people have started to show that if you can follow more than 70% of those ERAS processes; it kind of predicts that you have higher success in achieving lower length of stay, lower readmission, all of those kind of positive metrics. So, a lot of work is really focused on can we improve compliance and adherence to these metrics. And a lot of that then has to do with auditing, just to even identify where you might be deficient and then kind of going back and working on that particular kind of process.
Melanie: So, in summary Dr. Chu, tell other physicians what you would like them to know about the importance of enhanced recovery after surgery and specifically in gastroenterology and when you want them to refer and when you want them to come to you with questions about implementation.
Dr. Chu: Yeah, so I think enhanced recovery really should be standard of care. Now ERAS, it’s a fancy name but it boils down to just providing the best evidence surgical care across the entire spectrum of surgeries for a patient. That’s really what ERAS is. And it just links these all together in a collaborative and multidisciplinary effort. So, it’s simple, it’s not a two-million-dollar robot. It’s not super fancy and it definitely works. So, I think, bottom line, is enhanced recovery or however you want to call it should be kind of done at every institution because it really helps the patients and their families. I think questions about recovery, those are questions that we are always happy to answer. We have gone around Alabama and kind of shared some of the work that’s been done here with all the different champions with ERAS and so here at our institution, we are always happy to share our work. None of this is proprietary. This is all kind of very public knowledge. So, I think we are always open to receive questions about this and even kind of advising in terms of how to implement it. It’s certainly different for every institution, for every culture. So, I think it has to be adapted somewhat, but again, it’s all about finding kind of the right people and the right champions to drive it forward at your institution.
Melanie: Well you speak of it so well Dr. Chu. You explain it and the importance of it so, so very well that other providers have to really sit up and take notice because it is something that as you say, hospitals all around the country should be doing. Tell us about your team as we wrap up. Why is UAB so great to work with?
Dr. Chu: Yeah, so when I came here about four years ago, we had no enhanced recovery program and so this is something that I learned up at the Mayo Clinic where I did some of my training and what’s impressed me greatly about UAB is just how there are champions in every division and so our team really has involved – is truly multidisciplinary and if it wasn’t for ERAS, I actually don’t think I would have had met everyone so quickly. And our team spans the spectrum from anesthesia to nursing and HSIS which is our informatics team to our pharmacists and resident team and also to administration team with UAB Care here at UAB. And so, this team is on paper, truly multidisciplinary and out of every division I can tell you specific basically names and leaders who have really driven this forward. You know this is not a single person’s effort. This is absolutely a team effort which is how we did it at UAB. And especially how it’s expanded now across multiple surgical disciplines. You know we just started in the vascular surgery division led by Dr. Beck and that’s really been a kind of – that’s really novel. ERAS hasn’t been done really in vascular surgery. But so because of that team, those champions, ERAS is now expanding into a really a new frontier there.
Melanie: Thank you so much for joining us today Dr. Chu and sharing your expertise and explaining why this is so important. You’re listening to UAB Med Cast. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician, that’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua079.mp3
- DoctorsBee, Carson
- Featured SpeakerCarson Bee, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5236
- Guest BioCarson Bee, MD is an Assistant Professor at the Pell City Clinic of UAB Medicine's Callahan Eye Hospital & Clinics.
Release Date: September 6, 2018
Reissue Date: August 30, 2021
Expiration Date: August 29, 2024
Disclosure Information:
Dr. Bee 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 (Host): Glaucoma is a leading cause of blindness in the United States. Without treatment, those with glaucoma slowly lose their peripheral vision and in time may lose all vision. Here to tell us about this is Dr. Carson Bee. He's an Assistant Professor at UAB Medicine's Callahan Eye Hospital and Clinics. Dr. Bee, explain a little bit about glaucoma. What do we know now about it that we didn't know twenty years ago?
Dr. Carson Bee, MD (Guest): Absolutely. So glaucoma is a heterogeneous group of diseases where damage occurs in a very characteristic way to the optic nerve, the structure in the back of the eye that carries all the sensory information from the eye back to the brain. Like you mentioned, the damage typically causes peripheral vision loss early on, and over time that can progress to central vision loss and even complete blindness if left untreated.
It's often associated with a high intraocular pressure, also known as IOP, and glaucoma is the leading cause of blindness here in the United States, as well as the entire world. About three million Americans currently have glaucoma, and that number is expected to more than double by the time we hit 2050 because of our aging population and demographics.
It's typically painless and slowly progressive over the course of many years, and about half of Americans with glaucoma don't even know they have it.
One of the main challenges with glaucoma is we've known for some time that there's an association between high eye pressure, damage to the optic nerve, and loss of vision, but we're still struggling to understand exactly what happens, what causes it, why some people are more susceptible to others, and how to go about best treating our patients.
So in that sense, not a whole lot has changed in the treatment of glaucoma from twenty years ago to now. The only known treatment is to lower the intraocular pressure. Of course there's lots of fancy new surgeries and tools and ways to do that, but the end result at its core, the treatment is the same, lowering the eye pressure as much as possible.
Melanie: Is it genetic, Dr. Bee? And what are some other risk factors people might have?
Dr. Bee: It certainly can be genetic. There's strong evidence that genetics influences who will go on to develop glaucoma, and we've known for a long time that having a family history is an important risk factor for glaucoma. Therefore it's important for anyone with a family history, especially in first degree relatives, to have their eyes dilated and examined on an annual basis to check for any early signs of glaucoma.
Other risk factors include African or Caribbean descent, individuals with high intraocular pressure, ages greater than forty to fifty years old, people who are myopic, also known as nearsightedness, and as we mentioned before, also those with a family history.
These are all risk factors for the most common form of glaucoma that we see, primary open angle glaucoma, but there are several dozen different types of glaucoma, including glaucoma that can affect infants and children, and people from all walks of life.
Melanie: How important is early diagnosis as being crucial to improve outcome prediction? Speak a little bit about glaucoma screening and diagnostic techniques and how they've improved over the years.
Dr. Bee: Absolutely. So one of the challenges with diagnosing glaucoma is that there's no black and white test that we can use that will tell us if a patient has it or not. We have to kind of put together the big picture what the optic nerve looks like, how the patient's vision is functioning, what their intraocular pressure is, how thick or thin their corneas are.
We've come a long way in diagnostic testing over the past fifteen to twenty years. We've begun to incorporate an exam called an OCT which actually scans the thickness of the nerve tissue in the back of the eye and tells us- and compares that thickness to a subset of controls, and that's one way we can tell if a patient's nerve thickness or the healthiness of their optic nerve is different or more damaged than it should be.
It's extremely important for glaucoma to be diagnosed early because glaucoma damage is damage to the optic nerve, and we know that nerve damage at this point in time cannot be restored. That's why we recommend a screening annual eye exam for most patients above the age of forty, as well as any patient that has a family history of glaucoma. If we can catch the glaucoma early on before it causes significant vision loss, then we have a much greater chance of keeping our patients seeing and functioning well for the rest of their life.
Thankfully in most cases, that does happen with glaucoma in this country, but of course the patients that present to us late and have very constricted visual field, it becomes much more of a challenge to preserve their vision and oftentimes those are the patients that do go blind.
In terms of screening, I think we're much better now than we were in the past. Optometrists and ophthalmologists are typically on the front line, just general eyecare providers, they're at the front lines of looking for glaucoma before they refer them to somebody like me, a glaucoma specialist. And it's important that a dilated exam be done if possible in order for the clinician to fully assess all the ocular tissues, particularly the optic nerve in the back of the eye.
Melanie: What are some current issues in medical or surgical management? Assess for us, Dr. Bee, the appropriateness of specific treatments you'd use once you detect what's going on, such as checking the intraocular eye pressure every few months, or surgical interventions. Tell us a little bit about what you do next.
Dr. Bee: Sure. So like we discussed before, the only treatment for someone with glaucoma is to lower the eye pressure, and in some patients, their pressure starts at forty or fifty, and a normal eye pressure being between ten and twenty-one millimeters mercury. Other patients may be progressing or worsening at a pressure of twenty-five. So oftentimes, the first line of treatment or therapy for glaucoma is glaucoma eyedrops. There have been many studies over the years that have demonstrated that eyedrops work just as well as an invasive eye surgery in keeping the pressure down.
In patients where the pressure does not decrease enough with our various eyedrops, there are certain laser treatments that are available to us. The most common laser is called SLP laser and works to open the natural drainage pathway in the eye to lower the eye pressure that way, to kind of improve outflow capacity.
Finally if that does not do the trick, then oftentimes a glaucoma surgery is indicated because the pressure is high, and because the natural drain may not be functioning as well as we would like, most glaucoma surgeries center around creating a new drain within and external to the eye to drain the fluid- the aqueous fluid from the front of the eye to a reservoir outside of the eye, and allow the pressure to come down that way.
It's also an exciting time in glaucoma surgery because of the recent advent of an entirely new sub-category of procedures called minimally invasive or micro invasive glaucoma surgery. These procedures allow for augmenting or creation of new drainage pathways and seem to have a much safer risk profile and recovery is much quicker as well.
So in many patients who need to have glaucoma surgery, we're now recommending or at least considering these minimally invasive options which sometimes leads to better outcomes, safer procedures, and an increased or improved recovery time.
Melanie: What are some of the clinical challenges and priorities in managing glaucoma patients that you see?
Dr. Bee: I would say one of the biggest challenges is with eyedrops. Many of our patients are elderly, they're unable to maintain a complex regimen of two or three or four different eyedrops put in at various times of the day. Some of our patients have dementia and have to rely on caregivers to give them eyedrops. Eyedrops also have to be spaced about five minutes apart. You let the first one sit and soak and absorb into the eye before you put the next one in so you don't wash the first one out. So it can be very challenging for many of our patients to stay compliant.
Many studies that have analyzed the compliance and adherence of our patients to eyedrops have shown that most of our patients do a very poor job of getting the medical treatment that they need on a daily basis.
The other challenge is that glaucoma drops, it's not something you just take for a week and then you can stop. This is something you have to take continuously every day, every month, every year, and that can be certainly very challenging for many of our patients. What's interesting is most of our patients will take their eyedrops the day before they come see us in the office, and they'll show up with an eye pressure that's actually pretty good because they were using their eyedrops within the last day. But then they go home, and they may only take their drops three days out of a week, or every other night, and clinically you can see them getting worse, yet the parameter that we look at very closely, the eye pressure, is actually doing quite well when we see them in the office.
So it can be a challenge to counsel patients, to identify patients that are not being compliant with their medication regimen, and kind of working with them to come up with a treatment plan to best preserve their eyesight and preserve their vision. Oftentimes that means becoming more aggressive or performing something like a procedure that will work for them rather than relying on them to treat themselves.
Melanie: Looking forward to the next ten years or so in the field, give us a little blueprint for future research. Are you developing tests that can identify patients at a higher risk? Give us a little blueprint.
Dr. Bee: I would say there is certainly a lot of exciting research going on in the glaucoma world. There are a couple of new eyedrops out on the market that work in ways that we had not been able to employ before medication-wise, and we're just beginning to understand how those might impact and improve eye pressure and therefore glaucoma for many of our patients.
Here at UAB, we also have a robust glaucoma research department. A lot of the research focuses on analyzing the biomechanical nature of the optic nerve, and the way it forms, and the strengths of the structures around the optic nerve. We know that many patients are susceptible to low or even normal eye pressures and sustain glaucoma damage. What is it about those optic nerves that makes them so sensitive whereas another patient who can walk around with a pressure of thirty-five, thirty, and never have damage? What is the difference between those structures? So there's a lot of biomechanical research being done into the stress and the strain applied to these tissues, and why some are better than others, and the idea is that over time we may be able to identify therapeutic treatments that could potentially protect our patients' nerve tissues from becoming glaucomatous and therefore losing vision.
I would also say that there are many new exciting surgical advances on the horizon. The MIGS category - micro invasive glaucoma surgery - is still relatively new and there are multiple devices coming up down the horizon. And for patients that need surgery, I think we may be reaching a point where we're able to offer procedures that are much more safe and almost hopefully and potentially revolutionary, kind of like what cardiac stints did for open heart surgery, where many patients could just have stints of this big invasive procedure that carried with it a lot more risk and a lot more complications.
So many glaucoma specialists are hoping that the next wave of procedures will have a similar revolution.
Melanie: In summary, Dr. Bee, tell other physicians what you'd like them to know about Pell City Clinic of UAB Medicine's Callahan Eye Hospital and Clinics, and when you feel that it's really important that they refer.
Dr. Bee: Certainly. So in the Birmingham metro area, the only glaucoma specialists in town are located here at UAB at the Callahan Eye Hospital. There are a total of seven of us with a diverse training and expertise, and my partners and I also see patients at many satellite clinics located throughout the state such as Pell City.
We also have every ophthalmology sub-specialty here within the building, and so we can take care of our patients regardless of what's going on with their eyes. In terms of other physicians, really the best time and the appropriate time to refer a patient in for a complete eye exam is when any complaint goes beyond watering, scratching, or itchiness. The eye can be a very complex structure that's difficult to examine in the primary care clinic, but as eye providers of course, we have the benefit of microscopes, a lot of advanced tests and equipment to try and help us figure out what's going on. There can be so many different problems with the eye, and it's oftentimes very difficult to tell unless they have a full eye exam.
So any patient that really complains of vision loss should probably be referred to have things looked at. Thankfully, most eye conditions if caught early can be appropriately treated and managed and vision maintained and preserved.
Melanie: Thank you so much, Dr. Bee, for being on with us today and sharing your expertise and telling us about some of the research that's going on in the world. It's a very exciting time. A community physician can refer a patient to UAB Callahan Eye Hospital by calling the 844-UAB-EYES. That's 844-325-8620. You're listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to uabmedicine.org/physician. That's uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua075.mp3
- DoctorsSivaraman, Soumya
- Featured SpeakerSoumya Sivaraman, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5202
- Guest BioSoumya Sivaraman, MD is an Assistant Professor, Psychiatry at UAB Medicine.
Learn more about Soumya Sivaraman, MD
Release Date: August 16, 2018
Reissue Date: July 28, 2021
Expiration Date: July 27, 2024
Disclosure Information:
Dr. Sivaraman 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 (Host): Our topic today is electroconvulsive therapy, and my guest is Dr. Soumya Sivaraman. She's an Assistant Professor in the Department of Psychiatry and Behavioral Neurobiology at UAB Medicine. Welcome to the show, Doctor. Explain a little bit about electroconvulsive therapy. What's the evolution of it, and what's different now?
Dr. Soumya Sivaraman, MD (Guest): Hi, Melanie. Thank you for having me on the show and giving me the opportunity to speak about ECT. So ECT, or electroconvulsive therapy, is a very safe medical procedure during which a very small amount of electricity is applied to the brain to elicit a seizure under general anesthesia under the supervision of a team of psychiatrists, anesthesiologists, nurse anesthetists, and nurses.
Stigma, negative portrayal in the media and misinformation has been one of the major barriers to access this effective and safe treatment. In the past, ECT was done using machines giving very high doses of currents, causing memory impairment, they were not done under general anesthesia, and this resulted in a lot of fractures.
Modern ECT, however, is very different. It's done under general anesthesia, under the supervision of a medical team. The patient is kept on empty stomach overnight. During the treatment or before the treatment they are given IV anesthetic for a brief sedation, followed by administration of a muscle relaxant so that the patient is asleep and the muscles are fully relaxed during the procedure, following which a small dose of electricity is applied to elicit a brief seizure. During the whole time, the patient's vitals including blood pressure, pulse rate, electrocardiogram, oxygen saturation are constantly monitored.
Within a few minutes after the treatment, once the seizure stops, the patient is able to wake up, go to the recovery room or go back to their home with their family members or to the inpatient unit if they are admitted to the hospital.
Modern ECT machines also deliver a carefully calibrated amount of current, which also has reduced the amount of cognitive impairment that's being caused, and since they are giving anesthesia and muscle relaxation, the incidents of fractures have significantly gone down, or I would say even will.
Melanie: Doctor, when is it considered? And is this considered when rapid response is indicated? Or only for patients who have failed other treatments? Explain about when you would consider this treatment.
Dr. Sivaraman: That's a really valid question. Actually both are indications for ECT. So when we say rapid response is required, it's usually when we need to immediately control the symptoms in someone who's severely mentally ill and they have a significant load of depression, or symptoms of mania, that's one of the times that we need a rapid response.
ECT is also considered when a rapid response is desired in a patient who is actively suicidal, and you don't have time to wait for medications to act and control the symptoms.
The other indication where rapid response is required is when patients are catatonic, where they're withdrawn to the point that they're not eating, drinking, they're agitated, and putting themselves in danger. So these are like an emergency indication for ECT.
The other patient population that we usually consider for ECT are the patients of failed multiple medications like in treatment of treatment resistant depression. In some patients with schizophrenia who ECT is another alternative if that antipsychotics are not managing their symptoms. In pregnancy too, ECT may be a better option.
There's also emerging evidence of using ECT in managing agitation and dementia, especially in patients who have failed other measures. Other indications would be when patients prefer ECT because of their past response to the treatment. The rarer indications for ECT are neuroleptic malignant syndrome, refractory stages of epilepticus, for which there are few case reports.
So it's usually an effective procedure when a rapid response is required. But we also reiterate that ECT does not cure you of the psychiatric disorder or the medical illness. To prevent the return of symptoms, patients on ECT need to be on their maintenance medications, psychotherapy, or ongoing ECT treatment.
Melanie: Is it the first line of treatment for any condition?
Dr. Sivaraman: Yes, like I previously mentioned, like in catatonia when patients have to respond immediately, they are too withdrawn, they're not talking, they're not eating, and they're putting themselves in danger. So that is one of the first indications. Like we try to give a benzodiazepine challenge, but if patients are not responding, we usually go ahead with the ECT in patients who are catatonic and someone who is like actively suicidal from their psychiatric condition that you need to manage them and you need to prevent danger to themselves.
Melanie: So how do you discuss this with the patient and their families as an option? Because you know, they've heard in the media and on TV and in the movies, so tell referring physicians how you discuss this with the patient and let them know that this is a more humane treatment and has better results than it used to.
Dr. Sivaraman: So we do ECT consults. Most consults are outpatient and some are inpatient consults that we do. So whenever a clinician consults us to refer a patient for ECT, if it's an outpatient, we see them in our ECT clinic.
So we always encourage patients to come in with the loud ones or family members so that we can go through with them what ECT means and why their psychiatrist has requested ECT for them.
So initially we get a thorough psychiatric and a medical history from the patient to see if they are appropriate for ECT. If the patient is an appropriate candidate for ECT, we explain to them regarding ECT as to we educate them about ECT as to why it's the preferred treatment for their current condition.
We also have educational ECT videos for the patient to watch that actually shows them like how ECT is done- how the modern ECT is done under general anesthesia and muscle relaxation, and how the monitoring is done. We try to answer as many questions from the patients and families as much as possible. We also go through with them the informed consent process because that's very important. So we discuss with them about how the treatment is done, the side effects, the course of treatment, and why we are considering this treatment in this particular case, the risk benefit analysis.
Patients typically require six to twelve ECT treatments three times a week initially for symptomatic response. This is what we call as an acute series. So we explain that clearly to the family and the patient saying that, "Hey, this is how the treatment series is going to be." We explain to them about the side effects, especially the memory side effects that is very concerning for the family members. And once the patient is stabilized, we tell them how the tapering regiment is going to be started.
Again, like I said previously, we reiterate with them that ECT is effective for immediate symptoms control, for management of the symptoms, but to prevent a relapse they need to follow up with their psychiatrist to maintain their medication, their psychotherapy, or ongoing ECT treatments.
Melanie: As far as benefits, Doctor, are there any brain growth benefits from ECT? And as far as negative effects and long-term, does it increase the risk for dementia?
Dr. Sivaraman: Okay, recent studies have actually shown that there's an increase in volume of hippocampus for long and acute series of ECT. Some studies have also demonstrated an increase in BDNF, what we call brain-derived neurotrophic factors, which actually has a nerve cell growth- a neuronal growth following ECT.
There have been a lot of studies and there's no increased risk of dementia or brain damage per se. Like none of the studies have shown that ECT increases the risk for dementia. The long-term- the memory side effects or the cognitive side of things are the ones that patients are actually worried about. They're worried if their memories are going to be wiped out, or if they won't be able to remember things. The typical pattern of memory problems are patients are going to have anterograde and retrograde amnesia for the time surrounding the ECT. That is they may not remember even leading up to the ECT treatment, or even what's happening around the time that they're getting their acute series treatments. Like how they got to the hospital, or how they were in the recovery room.
So that is a critical area when patients might experience memory problems and we tell them not to drive during those times or take any major legal medications.
As we start the tapering course, the common side effects usually start getting better. But if we notice that patients are having a lot of memory problems, we try to space the treatments out so that it helps them with their memory.
The other side effect that some patients may notice is a lot of what we call autobiographical memory where they might forget about a movie that they have watched in the past, or a restaurant they have visited, or a vacation that they had. But those are the small patchy losses, or are your ability to form new memories, or your personality- it's not going to change because of the ECT. Your memories are not going to be wiped off because of ECT.
You might have a patchy memory loss for small incidents, but overall the risk for an untreated psychiatric problem like a depression, or a mania, or schizophrenia puts you more at risk rather than getting treated for ECT that may actually relieve those symptoms and make you more functional.
Melanie: You've cleared that up so beautifully for us, Doctor. And as far as what you're doing at UAB that other physicians may not be aware of, please summarize what you would like them to know about ECT, and when to refer, and to let referring physicians know that this is a more humane treatment and has better results than other methods, and that what they used to hear in the past is not necessarily what's going on today.
Dr. Sivaraman: Modern ECT is very safe, well-tolerated, effective, evidence-based, humane, and life-saving procedure, especially in patients who need rapid response like in catatonia, severe depression with psychotic symptoms, acutely suicidal patients.
Patients who have unipolar or bipolar depression who have failed multiple medications, or unable to tolerate medication, or pregnant patients, ECT can be safely considered for improvement of their symptoms.
A recent meta-analysis has also shown that ECT mortality rate is like 2.1 in 100,000 treatments in patients who are at low medical risk. In patients with depression, the response rate for ECT is particularly high. It's somewhere between 50% to 80% depending on the study. ECT's effectiveness in treating severe mental illness is recognized by the American Psychiatric Association, American Medical Association, and the National Institute of Mental Health.
Modern ECT, being retrained, is a very safe and humane procedure. We always discuss with the patients about the whole process, and only if the patients are comfortable or the family members are comfortable, we go through an informed consent process and then proceed with the treatment.
To summarize, I would like our other physicians in UAB and outside to know that we welcome your referrals. We have a UAB website which states how the referrals need to be made. We have a physician referral form and a patient form that you can fax it over to us. We'll review your record and we'll go ahead and schedule your patient in the ECT clinic and assist them, and see if they're an appropriate candidate for ECT.
But I think if patients- we are always willing to get in touch with you to let you know what our thoughts are, how the treatments need to be scheduled, what medical workup needs to be done, and the labs that need to be obtained, and we'll coordinate with you as to how the treatment process needs to proceed. And we always welcome your calls about the ECT treatment. If you have any questions, please feel free to call us about them.
Melanie: Thank you so much, Doctor, for being with us today and sharing your expertise on this topic that some people have many questions about. So thank you for clearing it up for us today. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1(800) UAB-MIST. That's 1(800) 822-6478. You're listening to UAB MedCast. For more information on resources available at UAB Medicine, you can go to www.UABMedicine.org/physician. That's www.UABMedicine.org/physician. This is Melanie Cole, thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua073.mp3
- DoctorsHauptfeld, Vera;Tao, Zhuo
- Featured SpeakerVera Hauptfeld, PhD | Zhuo Tao, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5199
- Guest BioVera Hauptfeld, PhD is a Professor, Director HLA at UAB Hospital.
Learn more about Vera Hauptfeld, PhD
Zhuo Tao, MD is an Associate Director of Histocompatibility and Immunogenetic Laboratory UAB CTI.
Learn more about Zhuo Tao, MD
Release Date: July 27, 2018
Reissue Date: July 28, 2021
Expiration Date: July 27, 2024
Disclosure Information:
Drs. Hauptfeld-Dolejsek and Tao 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. - TranscriptionMelanie Cole (Host): Welcome. Our topic today is the histocompatibility testing for organ transplantation, and here to tell us about UAB's Histocompatibility Lab are my guests, Dr. Zhuo Tao, she's the Associate Director of Histocompatibility Immunogenetics Laboratory at UAB, and Dr. Vera Hauptfeld, she's the Director of the Histocompatibility Immunogenetics Laboratory at UAB. Welcome to the show, ladies. Dr. Hauptfeld, I'd like to start with you. Explain a little bit about the field of histocompatibility. What is the evolution of this fascinating field of study? Tell us a little bit about what you do.
Dr. Vera Hauptfeld, PhD (Guest): It's really nice to be here. The histocompatibility field is relatively new science and and still rapidly revealing. It all started with mice. A lot of things start with mice in our field, with dancing mice, and with different coat color mice. A retired teacher in Massachusetts started to breed them on a large scale to sell them to schools circuses and laboratory. At one time she noted that some mice developed skin lesions and she sent one such mouse to a pathologist at the University of Pennsylvania. He was at that time a well-known scientist who experimented with skin transplant and he diagnosed it as a tumor. Now when these tumor cells were transplanted to other mice, they noted that there was a clear difference in mice survival on which type of mice it was injected. The reason for that is that as the traits, when they were bred for, led into inbreeding. So the teacher and the pathologist embarked on a joint project investigating influence on the tumor incidents and the skin graft injections. That is where the genetics and immuno-response come together as one field, immunogenetics. And genes involved in organ, tissue, skin rejection are histocompatibility genes. Products of these genes are histocompatibility antigens which are called HLA in humans. So that's a very short story on life.
Melanie: So then tell us, Dr. Hauptfeld, I'm sticking with you for a minute. Is the work that you're doing an exact science? What strategies do you employ to make determinations as you've discussed about how everything kind of gets started with mice. Is this considered an exact science?
Dr. Hauptfeld: Yes it is. Histocompatibility antigens are a genetic determined, inherited from both parents and co-expressed on the cell surface. So to determine the HLA type of each person, we use molecular techniques based on amplifications of these genes by PCR methods. Very exact. Methods for the detection of antibodies is less exact but we have been using these methods for years, and we know pitfalls, they have been improved, and they are now so much better, accurate then a few years ago.
Melanie: Wow, it really is an absolutely fascinating field that you're in. Dr. Hauptfeld, highlight for us some of the work done in the HLA lab in support of the transplant program at UAB. Tell us a little bit about the tests and the role of HLA in transplant immunity.
Dr. Hauptfeld: The biggest obstacle to a successful organ transplant from the immunologist's point of view is a presence of pre-formed antibodies to these HLA antigens. Patients can get sensitized to produce the antigen the antibodies by transfusions, by pregnancies, and of course by previously rejected organ transplants. If we transplant across some of these strong antibodies to the donor, the organ is hyper acutely injected, which would mean for the kidneys to turn black in or, and this is exactly what we need to prevent.
Melanie: Dr. Tao, since we haven't gotten to you too much, tell us about testing recipients after transplant to monitor for rejection, and is this involved in other cellular immune mechanisms that affect the transplant recipients?
Dr. Zhuo Tao, MD (Guest): Yes. Once the patient receives a transplant, he or she becomes sensitized and will be monitored for possible rejection. We as a lab, Histocompatibility Lab, perform tests using current technology for newly developed HLA antibodies against the transplanted organ, we call these antibodies DSA, donor specific antibodies. And antibody mediated rejection is one of the major issues for transplants- organ transplant outcomes. And if DSA is identified, we will alert the physicians for appropriate immunosuppression and follow up with more tests to monitor the effectiveness of the treatment.
Melanie: So that's pretty much after transplant. And Dr. Tao, what about prior to transplant as far as running a risk assessment for patients and donors to test for this compatibility? Kind of run down for us a little bit about from start to finish to what you just discussed as far as after testing the recipients and after transplant. Give us a little timeline of how it works.
Dr. Tao: This will be a long process. Once a patient is identified as a transplant candidate, and they will get listed on UNOS wait list, and we start testing the patient- the recipient's HLA antigens and we will also test the potential donor's HLA and see how well they are matched, that’s number one.
Number two, and we will have the patient's serum which contains antibodies if it pre-exists, we will use the patient's serum cross match with the donor’s cells using flow cytometry and to see if they react to each other. And if we have no antibodies tested- previously existing antibodies- tested against the donor and cross match is Negative, this transplant will be a go.
Melanie: You mentioned UNOS, Dr. Tao. Is UNOS involved- I mean if someone gets on a transplant list, then that's what they do, but is UNOS involved in your work, in your cross matching and your testing?
Dr. Tao: Yes, it is. UNOS is one of the regulatory agencies governing the transplant programs and histocompatibility labs along with CMS, FDA, and OSHA. And UNOS is involved in many aspects of the organ transplant and donation process, and they manage, as I mentioned, the national transplant wait list, and matching the donor to the recipient, and they develop policies that give all patients a fair chance to an organ transplant. And they also maintain all the organ transplant data in the US, and they will monitor every and each organ match to ensure organ allocation policies are followed, and so on. Everything is about UNOS.
Melanie: Wow, that sounds like a lot of paperwork. So Dr. Hauptfeld, is there a difference between a workup for solid organ transplants or BMT/HSC?
Dr. Hauptfeld: Yes, there is. A workup for bone marrow transplant and hematopoietic stem cells , it's quite a difference from solid organ transplant. For solid organs, we really do not match HLA antigen. We do if we can, like relatives, siblings especially , but it's usually not possible because we don't have enough donors. For bone marrow, the HLA matching has to be done at much higher levels. Actually, exactly at the level as the antigens are expressed on the surface, which means what we call high resolution. They have many more numbers to the antigen. The reason for that is because they are immunocompetent and they can work donor versus host and host versus graft.
So they are very much more selected. But again, they are relatively much easier to find a match because we can tap into the Registries of volunteers there are really hundreds of thousands now, everywhere from America, Europe, Asia, and we have access to that. That is from these places.
Melanie: Wow, that's amazing. So Dr. Tao, are there some limits as we're discussing bone marrow and hematopoietic stem cell transplants, are there some limits you'd like to discuss? Things that might limit the results that you get, or your ability to predict the outcomes of this HLA testing?
Dr. Tao: As far as bone marrow transplant, as Dr. Hauptfeld mentioned, we type them, patient and donor at a very high level of resolution using the DSA techniques. With the new technology we are able to test to the point of very high resolution. The downside of this is we are probably having a harder time to find an exact match. So we have to select what level of the match between the donor and the recipient. With the predication, the current technologies we have many tools to provide risk assessment for our transplant programs, but every method has its limits. For example, the single antigen bead that we use so much nowadays, this is a newly developed technology that enables us to detect presence of donor specific antibodies, but unfortunately HLA is a highly polymorphic system. There are close to 9,000 of Class I antigen variants and over 2,600 Class II antigen variants. That's the count of 2014, and this number continues to grow every day. But the single antigen bead panel has beads coated with about 100 common Class I antigens and about eighty Class II antigens. In other words, if a patient has an antibody that's not presented on the single antigen bead panel, we won't be able to detect it.
And the other limitation that I wanted to mention is we test for antibodies against major HLA antigens. At this time there's not a well-developed commercially available and easy-to-use reagent to test minor HLA antibodies or non-HLA antibodies, and those antibodies could also cause organ rejection.
Melanie: So much information. Dr. Hauptfeld, what's it like to work in this lab? As you're pretty much the final say in going ahead with a transplant, and you keep such a close eye on donor and recipient and these antigens and matching. So what's it like for you to be able to be this final say in something that could be so huge in someone's life?
Dr. Hauptfeld: Yes. We are really very much aware that [if we are not careful enough, we can kill a patient. Everyone in the laboratory is aware of it. You know, this is not work of 'I,' it's the work of 'we.' Everyone in the laboratory is involved and has to do their best. So our work is challenging and it's stressful, but it is also very rewarding. We actually see some of these patients once a year at a picnic, and it is extremely soul lifting to see how well they are doing. They are- so we are helping patients to have better lives and that keeps us going.
Melanie: Dr. Tao, if you were to look forward ten years in the field, what do you feel will be some of the most important areas of research?
Dr. Tao: We would like to see better long-term organ transplant survival. Organ survival as well as patient survival. We're now looking at molecular levels of differences between the patient and the donor histocompatibility antigens, relating them to presence and absence of anti-donor antibodies for the transplant before and after. And also the goal would be to define permissive difference which would not lead to rejections or at least to prolong the survival. We don't have- for solid organs, we don't have enough donors to choose from, and cannot select a good enough match, and we= the science says the better the match, the better the outcome. so defining possible mismatches, it will be much easier. We call it permissive mismatch. We also wanted to see more donations in general. Each donated organ saves a life, and this is truly, truly a fantastic experience to see how much better off the patient is after a transplant.
Melanie: Dr. Hauptfeld, in summary, tell other physicians what you would like them to know about the Histocompatibility Lab at UAB, when to refer, or when you want them to look to you for your expertise.
Dr. Hauptfeld: This is a great question. We don't get referred from anywhere else. We are part of the transplant program, so we have what we call a joint agreement with every program there is. There's a children's hospital Veteran’s-Veteran’s Hospital, and UAB, all solid organ, heart, lung , and so forth. And so they know precisely what we are going to do for them. So every patient that is listed just comes to us. Oh not the patients, we don't see patients, but the proper samples so we can test for their antigens and antibodies and so forth. We monitor them throughout their waiting time, and so that is one thing that we need to get serum samples on a regular basis, but that is already established and UNOS has hands in it, too. So we are getting and following them for the presence of antibodies, till they come for the transplant, and what actually I think would be better developed follow-up for the possible rising of the anti-donor specific antibodies, then we will get their serum samples more often. Not that we want more work, we already have plenty of work, but I think for the patient it would be really better if we see them every six months. Because when we see the arising DSA, the donor specific antibodies, we can alert the team, and tell them what needs to be done, and if it's necessary to start to treat the patient or just monitor the patient. But if we see the patient after two or three years, the antibodies are really, really strong that it's so much harder to save the transplanted organ. So I think that’s really basically what we know.
Also we would like to have good information about all sensitizing events. Because sensitizing events are interfering with our tests and if we don't know about them, we spend much more time trying to figure out what's going on. Like that we can plug it into the results and see what’s really going on and have better interpretation.
Melanie: And that would certainly help you explain and sort out any unexpected results. So Dr. Hauptfeld, here I would like for you to tell us about your team at UAB, and why is your team so great to work with?
Dr. Hauptfeld: I'm really proud of my team. I mean we have great people, we have great hard-working people who really want to help, and they are very much aware they are helping. And so as for the laboratory, it's really great. But also, I love to work with our surgeons who are smart, very innovative people, with nephrologists, with cardiologists, and they are appreciative of our work, we are appreciative of their work, and I think they are fantastic clinicians. Obviously, I mean we have very great outcomes here at UAB.
We have one of the best KPD programs, the kidney pair donation program, to supplement the shortage of deceased donors which is really great. The shortage is great, we really would like to improve it. But our KPD was set up several years ago by Dr. Locke, and I think that this is fantastic, and we can match, and we can actually play in some way to match as best as we can as we are moving the possible donors and patients around. So they have the best of everything, and I am really very proud of it and happy.
Melanie: Dr. Tao, last word to you, what do you love about your team and working at UAB?
Dr. Tao: Oh, we have a great team. Our technologists are all trained to work as a team. This is the only way to provide a best service to our transplant program, and there's only one histocompatibility lab in the state of Alabama, and it is a privilege to work with the UAB transplant program. And UAB had their very first- or our very first transplant in Alabama in 1968, which was a kidney transplant, and we had the very first heart transplant in Alabama in 1981. And the very first combined heart and lung transplant in '86. And we reached our 10,000th organ transplant in 2006. This is such a great program and we have the best doctors and one of the best kidney pair donation programs in the nation. So I have very, very good experience. It's just fantastic.
Melanie: Wow, ladies, what an absolutely fascinating segment, and what you both do is so interesting and complicated and comprehensive that it's hard for a lot of people to understand, but you've made it so clear today. Thank you so much for being on with us. A community physician can refer a patient to UAB Medicine by calling the MIST Line at 1(800) UAB-MIST. That's 1(800) 822-6478. You're listening to UAB MedCast. For more information on resources available at UAB Medicine, you can go to www.UABMedicine.org/physician. That's www.UABMedicine.org/physician. This is Melanie Cole, thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua072.mp3
- DoctorsPassman, Marc
- Featured SpeakerMarc Passman, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5191
- Guest BioMarc Passman, MD is a professor of surgery and currently serves as the vice chair for clinical research and the director of the UAB Vein Program and UAB Vein Clinic. Dr. Passman is a board-certified specialist in vascular surgery, practicing the full scope of vascular and endovascular surgery.
Learn more about Marc Passman, MD
Release Date: July 6, 2018
Reissue Date: July 28, 2021
Expiration Date: July 27, 2024
Disclosure Information:
Dr. Passman 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: Welcome to the show. Our topic today is minimally invasive treatments for venous disease and my guest is Dr. Marc Passman. He's a vascular surgeon, professional of surgery and the director of the UAB Vein program. Explain a little bit about venous disease. Who is at risk and tell us about the different types of venous insufficiency that we’ll be talking about today.
Marc Passman, MD: There are generally two categories of venous disease problems. There's the blockage or thrombotic category and then there are the venous flow issues. The blockage or thrombotic category generally involved venous thromboembolism, deep vein thrombosis and the risk for pulmonary embolism. In general, the risk profile of those patients includes individual risk factors such as age greater than 70, personal history of clotting issues, family history of clotting issues and then other associations like smoking and obesity, which can be amplified in high risk situations, period of immobility, injury, server illness and even travel. The other group of venous problems tends to fall into the category of venous insufficiency or venous reflux, essentially venous flow problems. These can range anywhere from common spider veins and varicose veins all the way up to complex venous skin changes and venous stasis ulcerations to other severe venous flow related congestion type problems. The general risk factors for venous flow issues can include patients who've had prior deep vein thrombosis where there's damage to the vein valves or it can be a primary problem where there is essentially wear and tear on the venous valves that lead to leakages and the ambulatory venous hypertension issues that can result.
Melanie: As far as clinical presentation, of course with superficial venous reflux or varicose veins and spider veins, sometimes you can see those, but with deep vein thrombosis, not necessarily. Tell us about some of the signs and symptoms that someone might have.
Dr. Passman: For deep vein thrombosis, the patient presents with unilateral leg pain or swelling. It should always be a concern for deep vein thrombosis until proven otherwise because certainly for acute deep vein thrombosis, that patient is at risk for pulmonary embolism until they're effectively anticoagulated. If you look at all patients who present with deep vein thrombosis, about 25% of those patients will have pain and/or swelling, but there can certainly be other subtle presentation type symptoms. For patients who have really severe vein thrombotic occlusion, they’ll present with the typical Phlegmasia type leg where there are a significant venous congestion and purple discoloration. What that gets at its most extreme, it can start compromising arterial end flow and perfusion to the extremities. Those that present with acute deep vein thrombosis, it’s usually a sudden onset of that type of presentation.
On the other hand, those that have had deep vein thrombosis in the past, it's very common to have post-thrombotic syndrome. It may be several weeks or months or years after their deep vein thrombosis acute episode, but they still have ongoing swelling and general congestion in the leg. With that, over time, they can start developing hyperpigmentation around the ankles, venous eczema, skin changes at the ankle that make the skin really fragile and eventually lead to venous ulceration. That’s more on the venous thrombotic side. For patients who have varicose veins and never had deep vein thrombosis before, they can have the spider veins and varicose veins which you can see. They’ll have complaints that can range from pain discomfort, throbbing in the leg, limb dependent swelling, having this itching and things like that. When you examine the leg, it’s hard to know if the spider veins or varicose veins are just the tip of the iceberg or is reflective of a bigger flow issue in the leg. That's where additional testing including venous ultrasound can better differentiate the flow pattern and whether or not there's more involvement of the bigger vein. Those with varicose veins and spider veins, about 4-6% will progress over time to the more advanced venous findings similar to those that have post-thrombotic syndrome where you can develop skin changes and eventually the ulcerations.
Although there are two different categories and two different pathways, the common pathway for both venous thrombotic issues and venous insufficiency issues is what's termed ambulatory venous hypertension. Effectively, the hypertension in the venous system, the congestion that you get, can lead to all those advance findings whether it starts as a deep vein thrombosis or a primary valve reflux issue.
Melanie: Once you’ve differentiated what the flow issue is, how has it been treated in the past? What's different now and are there some exogenous methods that you would recommend as a first line of defense before you would discuss a minimally invasive option?
Dr. Passman: Let's expand first on how you can differentiate the venous disease with diagnostic testing because that will help dictate the appropriate therapy. The cornerstone of any venous evaluation from an imaging standpoint is venous duplex ultrasound. There are different types of venous ultrasound testing that's available. The most common type is just to look for deep vein thrombosis as part of an evaluation for a clot and that’s usually to screen the veins in the presence or absence of a clot. That’s usually the routine ultrasound, but the more extended, comprehensive ultrasound also will test the venous valve function in what's called venous valve closure time. A refluxing vein valve will have backward flow and anything greater than a second or so of backward flow in the deep vein is usually consistent with venous reflux as opposed to a venous valve that will close crisply and such and that would be a normal valve. Typically, if it’s a venous thrombotic problem, we’re just looking for DVT with a venous ulcer, but if it’s a venous flow issue, we’re actually mapping where the venous valve dysfunction occurs, which veins they occur in, because that will help dictate what that patient needs. In addition to venous ultrasound testing, there are some patients who need some advanced imaging and that can include CT venography, MR venography, diagnostic contrast venography and intravascular ultrasound. There may be specific instances where we will do more extended imaging along those lines. Depending on what the imaging shows and what the actual problem is, we’ll come up with a treatment plan for that particular patient.
For patients who have deep vein thrombosis, the standard evidence-based guideline is that all those patients should be on some form of anticoagulation. Those guidelines are very well published, American College of Physicians provides information and evidence-based ratings for those recommendations. In addition, patients who have deep vein thrombosis traditionally are also treated with compression therapy. Once they're on the anticoagulation, that will help with a lot of symptoms and swelling and post-thrombotic tendencies that they can develop later on. Aside from that, there are some minimally invasive treatments for deep vein thrombosis that are also supported by evidence-based guidelines that use catheter technology to move the clot. Whether that's with catheter-directed thrombolysis or various aspiration type catheters we have or combinations of that, for patients who have a clot that’s less than a few weeks old, may have significant compromise extending up into their iliac femoral vein. Those that have a reasonable life expectancy greater than a year, those patients that have good functional capacity, those patients may be candidates for those advanced minimally invasive catheter clot removal options and should be evaluated at a center that can provide those services.
For patients who have chronic clots and significant post-thrombotic issues, there may still be some options later on for recanalizing those chronically occluded vein segments with catheters using balloons and stents to try and reopen those veins, so there may be some roles even for chronic clot issues later on where they might be some benefit of treatment. That's different than the traditional treatments for clots which operatively involve venous thrombectomy or surgically removing those clots. That's an operation we still do occasionally, but with all these advanced catheter-based therapies, we don't need to do those as often, nor do we have to do the complex venous reconstructions that we used to do a lot more of. Still, there may be candidates where you just can't open them with a catheter that you might need to consider those open traditional operative options. For varicose vein problems and venous reflux problems, the traditional operations used to be venous stripping where you make a couple of incisions in the legs and strip out the long saphenous veins in the leg, phlebectomy where you make incisions and avulse or remove the varicose veins directly. That used to be the traditional approach. What's really happened and evolved in the last 10-15 years, instead of making incisions, now the minimally invasive options include things like endogenous ablation where you can use a laser catheter or a radiofrequency catheter to close down the saphenous vein instead of stripping it. There are some newer technologies that also include using glue or foam sclerotherapy to glue those vessels. The techniques we use for the actual varicose veins now use much smaller incisions, gentle hook techniques. We also have scoping systems that allow us to make tiny incisions and use scopes to image all the veins and directly see the veins.
What we used to do with many more incisions and larger incisions, we can do with much smaller incisions these days and fewer incisions. That’s where the evolution from the traditional approach is both for clot and venous flow varicose vein problems have evolved to minimally invasive techniques.
Melanie: It’s such an interesting field that you're in. In summary, tell other physicians what you'd like them to know about minimally invasive treatments for venous disease and when you feel it’s really important that they refer to a specialist such as yourself.
Dr. Passman: The thing with venous problems, especially when it gets into patients who present to their physicians with all kinds of complaints, is sometimes they can be underappreciated by the patients, sometimes by the physicians, because there are so many other medical issues to take care of. A lot of times, the venous symptoms they have will develop over a long period of time and people are just too busy to worry about it. It’s not until it gets to a critical point where they start seeking medical attention and assistance. The reality of many of the venous problems, especially the varicose veins and venous flow issues, is that certainly from a quality of life standpoint, it can help impact patients with earlier evaluation. Those that are appropriate for treatment, early interventions can not only help their current quality of life but may change their natural history and progression over time. For venous clot issues, the most important part of that is awareness for patients that know the risk factors to know when they might be in a high-risk situation. For physicians to recognize patients that might be at risk and to do a venous risk assessment for a clot, because when they're exposed to those high-risk situations, they may not know they have high-risk individual factors, and whether they're in the hospital or undergoing a big operation or severely ill, the biggest advantage of prevention is that you can prevent all the sequelae of clots. Early identification using therapeutic anticoagulation or prophylactic anticoagulation as a prevention strategy for patients who are at risk, especially in the hospital, can have a significant impact on their future venous potentials.
Melanie: Thank you so much for being with us today and sharing your expertise on this topic. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You're listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to uabmedicine.org/physician. That’s uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
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