Additional Info
- Audio Fileuab/ua071.mp3
- DoctorsPearce, Benjamin
- Featured SpeakerBenjamin Pearce, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5195
- Guest BioBenjamin Pearce, MD graduated from Duke University with a degree in biology and attended medical school at the University of Texas. He completed his general surgery residency at the University of Chicago Hospitals and then completed the UAB vascular surgery fellowship, after which he served as an assistant professor of surgery at the University of Texas for three years. He returned UAB as a faculty member in 2013 and has since been promoted to Associate Professor and Program Director of the Vascular Training Programs.
Learn more about Benjamin Pearce, MD
Release Date: June 22, 2018
Reissue Date: July 28, 2021
Expiration Date: July 27, 2024
Disclosure Information:
Dr. Pearce has the following financial relationships with commercial interests:
Clinical Trials - Grants/Research Support/Grants Pending
Gore - Payment for development of educational presentations
Gore, Terumo - Payment for lectures, including service on speakers bureaus
Dr. Pearce 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. - TranscriptionMelanie Cole (Host): Awareness of peripheral arterial disease is very low in both patients and in primary care practice, despite a growing incidence of the disease, secondary to diabetes. Our topic today is Awareness of Peripheral Arterial Disease, and my guest is Dr. Benjamin Pearce. He's the Program Director of the Vascular Training Program at UAB Medicine.
Dr. Pearce, explain a little bit about peripheral arterial disease, and what's going on in this field today, and why you feel that there is not enough awareness.
Dr. Benjamin Pearce, MD (Guest): Thank you so much, Melanie, for the intro and the opportunity to speak today. You know, peripheral arterial disease is something that is exciting to be involved in right now. We're at a real neat point in time as providers because there's a lot that we can actually do for patients, both medically with minimally invasive surgery, and then ultimately we still have good surgical procedures that have excellent results. So there's a lot that we can do to help people.
The interesting thing is how the disease is really changing and becoming more prevalent. Historically only about 5% of the population would be affected by peripheral arterial disease, specifically of the lower extremities we'll speak to today, but as we see with diabetes, the instances of PAD in the diabetic population is more like 25% to 30%. So as we have the increase in diabetic population going forward, we're going to see a lot more peripheral arterial disease in our patients. So I think it's something that the patients and the primary care providers have to be aware of.
There's a lot of problems with legs in diabetic patients. They can have innumerable things regarding neuropathy, changes in gait, obesity obviously causes things like arthritis, low back disease, and it can be quite confusing why a person has leg pain, and I think a lot of times they go for the usual thing, "You have a pinched nerve in your back," when in fact this may actually be something like an arterial obstruction. So that's why it's great.
Melanie: Well also, leg pain can be so non-specific. It could be a pulled tendon, or bad shoes. You know? Women especially get this kind of leg pain, and we all look at our calves and say, "Oh is this a blood clot, or is this peripheral arterial disease?" And so it can be very non-specific. What do you want us to know, and for other providers so that they take seriously these complaints that people have when they do have leg pain?
Dr. Pearce: Sure, great question. So the first thing is, is that peripheral arterial disease is just an extension of cardiovascular disease in general. There's a lot of cross talk between coronary artery disease, carotid artery disease, aneurysm disease, peripheral arterial disease. The risk factors are the same; smoking, hypertension, poor diet, lipid control.
So the first thing's first, leg pain in a patient who doesn't have the usual cardiovascular risk factors, in a healthy patient, leg pain is probably not going to be vascular in nature, and those are patients that you can quickly go down the road of treating for other orthopedic type injuries, neurologic, chronic use syndrome, those sorts of things. But if you have a patient that has those kind of classic cardiovascular risk factors, then that's the first thing that should trigger in your mind as a provider is, "Well maybe this is vascular," and then you can ask some very specific questions.
The kind of classic initial presentation of PAD in patients is a syndrome called claudication, which when you backtrack to the original Latin just means 'to limp.' So these are patients that at rest have adequate profusion, they aren't developing ulcerations, tissue loss on the foot or on the toes. At rest they're getting adequate profusion from collateral flow, but when they need to use their muscles, that's when they notice the pain. It's kind of the leg equivalent to anginal pain in the chest. For whatever reason, heart disease is such a well-known, and well-studied, and well-thought about disease process. Everybody knows what angina is, but very, very few people really know what claudication is, but it's the same sort of principle.
Your body compensates when you're having- when you're chronically developing blockages into an arterial system, and so you can maintain that profusion, but that compensatory mechanism normally would augment flow during exercise. It's no longer there to augment the flow, so when you walk, then you get the pain. So really vascular pain and kind of that initial presentation is usually very specific to muscle groups that are being used. So if you have a patient who's complaining of leg pain, the first question is, "Well when does this bother you?" Just like you learn in med school. "When does this bother you? And what makes it better?" Because if they have pain in a muscle group, we usually describe it, it's almost like a charley horse or a real tightness and discomfort in something like the calf muscle or in the kind of posterior thigh, or buttock region if they have a higher level of occlusive disease.
If they have that pain, and then they stop walking, or swimming, or riding a bike, or whatever it is that brings it on, and as they rest the pain gets better and they're able to go some more, that's classic for PAD related pain. So those are the first things just so you can screen a patient. "Do you have the cardiovascular risk factors? And is this an exertional type pain?" And that's kind of where you start.
Melanie: So how important is that early diagnosis as being crucial to improve the outcome prediction and to help improve appropriate and timely referral, and then explain a little bit about the diagnosis, and what tools are you using to aid in this diagnosis?
Dr. Pearce: Yeah, diagnosing it is really important, mostly because the diagnosis of PAD is often then inroad into treating the patient's overall cardiovascular risk. In fact, PAD in its simplest form, in that kind of claudication, problems walking but otherwise intact circulation, itself really isn't going to be even a limb threatening situation. Patients who have chest claudication, if they can get treated appropriately early, often with no intervention, the risk of losing a limb in five years from this disease process is 5% or less. So I think that's one of the big things that's often misunderstood.
Someone hears they have a blockage in the leg artery, and they think, "Oh no, they're going to lose their foot." Someone knows a patient in their family who's had diabetes or has had peripheral arterial disease that's lost a limb. Well that's really not the case if you catch it early. A lot of times even with just medical and exercise treatment, the limb loss risk is very low, but what it allows you to do is actually initiate the conversation with the patient about overall risk factors. Because having PAD does put you at risk - about 20% risk over five years of having some sort of cardiovascular related mortality; a stroke, a heart attack, dissection, or some other pathology in the cardiopulmonary circulation that actually leads to death. It puts you at increased risk for things like heart attacks, and strokes, and so getting the diagnosis is really important.
Because the mainstay is going to be quitting smoking, controlling your diabetes well, lipid management, statin agents have revolutionized cardiovascular care, being on antiplatelet regimen; these are all very important things. So it's critical to get those patients identified, and I think an early referral to a vascular specialist with patients who are symptomatic. It's important too because there's a lot of good data that shows that us doing any oral exams with these patients, getting them in the right therapy, reminding them about their medical management, as well as getting them in an exercise program. All those things lead to less cardiovascular mortality in addition to just helping them to function better in their life. And being able to exercise and walk more is better for your overall health in general.
As far as diagnosis, the simplest thing we can do is what's known as the ABI or ankle brachial index. Quite frankly, anybody with a doppler device and a blood pressure cup can do one at the bedside as a quick screening tool. You just hook the- you get the brachial pressure, you find the best brachial pressure, you put your doppler probe under the dorsalis pedis and tibial arteries and place the cuff on your calf and you get the highest measurement of those two and do a ratio. And anything that's 0.9 to 1.3 ratio is quite frankly considered normal, and most likely means the patient does not have significant symptomatic peripheral arterial disease. If it's less than 0.9 or it's what we call non-compressible or greater than 1.4, then they're probably going to need some more specific testing that can be done in a vascular surgeon's office.
But that's usually where we start is just with an ABI. If the patient's story really sounds like it's vascular in nature but they have a normal ABI at rest, the next thing to do, and any vascular specialist can do this, is you can actually get the patient, do the ABI, and then you can put them on a treadmill and repeat those ABIs after you've walked them, and if you see a significant drop, then that may actually be indicative of kind of that early stage of vascular obstruction.
The hardest thing in this current day in age is with diabetes increasing, diabetes influences some of our how non-invasive tests work. So it's really important to get them into a lab where they can do things like plethysmography, and actually do digital pressures, because digital pressures tend to be preserved in diabetics whereas the ankle pressures may not be. So anybody with diabetes that you suspect has peripheral vascular disease, that's somebody I'd definitely recommend early referral and more specific testing.
A patient who doesn't have diabetes has the other risk factors, and you just want to know if they've got it, then start with an ABI and then you can go from there. But again, I think seeing a vascular specialist is never a problem in patients who have risk factors for cardiovascular disease.
Melanie: Dr. Pearce, what's the first line of defense if you do determine that they have PAD, and what are some of the challenges in adherence and follow-up?
Dr. Pearce: So the first thing is getting those lifestyle modifications done, and it's not easy. I mean, I sympathize with the patients, we're all human, but smoking cessation is an absolute must. That is like the first line of treatment. Excellent diabetic control. There's innumerable research studies that have linked HbA1c control to outcomes with patients with diabetes in regard to limb salvage and improvement in their overall mortality.
So getting those things in line are- those are the most difficult ones for patients, right? Smoking cessation and diet. So those are the kind of first things you've got to harp on, and the great news is, like I said, as vascular specialists we really- as we've started to treat the patients with multi-modality therapy, we're really understanding how important it is that even though we're surgeons, that we get involved with things like smoking cessation. So in our clinic, we've dramatically increased our interventions to help with smoking, and I think it's important patients understand sometimes they have pain and they want a procedure. It's kind of the American way. It's important to explain to them just because we're not necessarily recommending a bypass or a stint for this problem, by doing things like targeted smoking cessation, statin therapy, exercise therapy, we're treating your disease. We're actually doing something proactive for you to make you better. And I think when you can get them to buy into the idea that we're doing something about your disease process, that gives you a lot more success. So that's the first line is getting on those kind of lifestyle risks, and then doing a real assessment of their overall medication list and making sure they're getting a statin agent, and they're getting some sort of anti-inflammatory agent, either Aspirin or Plavix, and sometimes both depending on their other cardiovascular comorbidities.
Melanie: So now as you sort of wrap it up for us, Dr. Pearce, what do you want other physicians to know about doing a patient level explanation from their whole team so that the whole team is on board, and understands how to work with this patient on adherence, on medication adherence - because that's a problem as well - and really what you want them to know about early referral and explaining all of this to their patients?
Dr. Pearce: Well I appreciate the opportunity, because I do think there's still a lot of confusion out there. And so what I want the referring docs, and the referring nurse practitioners, and mid-level providers, and the people who are seeing these patients on the ground floor to really remember is that this is about treating their overall well-being. So it's about lowering their overall mortality, dying from cardiovascular disease, but that the leg itself in the early stages of PAD, the leg is not at risk, and they shouldn't die from this. They can be treated early and this will help them to live better overall.
So getting them in early for a referral and getting on those programs, like I said the smoking cessation, diabetic control, diet, and exercise can really help. In fact, getting a patient in and getting them to buy into the fact that when this person evaluates you, they send you to a specialist. When the specialist evaluates you, they're going to look at your whole picture, they're going to look at the medicines you're on, how you function, what is it you do in your life? Because what we recommend for someone who's dependent upon their limbs for their well-being may be a slightly different recommendation for someone who's retired and just wants to enjoy going to their grandchildren's basketball games. So they're going to look at you as an individual and they're going to determine what's the right thing for you. That may be exercise therapy, targeted drug intervention, lifestyle modification. It may be a recommendation for some sort of an interventional type procedure that's minimally invasive, or it may be surgery depending on you as an individual. I think that's the important thing, is making sure the patients understand that whichever modality ends up being the right one for them to treat, we're doing something to help them.
I think the other thing I want the practitioners to take away from is there's a lot of confusion right now about what should be done for patients with this kind of early PAD claudication type thing, because the milieu is to send patients to some sort of a specialist, and there's a lot of people that offer intervention. There's interventional cardiology, there's interventional radiology, vascular surgeons, interventional nephrology. There's a big mixed bag of people who are treating these disease processes, and there are great people doing it in all those different specialties, there's no doubt that they're really good practitioners in all of them, but I think that there's probably an over-abundance of interventions being done without appropriate modification or risk factors in attempts at non-operative therapy first.
And the other thing I think that confuses the works is there's a difference between someone who has a wound, or tissue loss, or their disease has progressed to the point where they're having constant pain from the blockages. Patients in a more advanced stage, what we call chronic limb threatening ischemia, that's a different modality. Those are patients needing to be treated with some sort of intervention albeit surgical or minimally invasive on a much sooner basis. So getting the patients in early, you can prevent them from getting down the road to that point, and having them see a specialist on a regular basis can do that, but not everybody needs an intervention. At that early stage, a lot of the things they need is exercise therapy, physical training, and like I said, appropriate medical management and appropriate lifestyle management. So get them in early and get them to understand that we're being proactive about helping them to live better and live longer.
Melanie: Absolutely fantastic information, Dr. Pearce, and so important for other providers to hear. You've laid it out so very well. Thank you for being with 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/ua068.mp3
- DoctorsGunn, Andrew
- Featured SpeakerAndrew Gunn, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4615
- Guest BioAndrew Gunn, MD graduated magna cum laude from Brigham Young University in Provo, UT earning a BS in exercise physiology with a minor in sociology. He then returned home to South Dakota to attend medical school at the University of South Dakota. During medical school, he participated in the competitive Howard Hughes Medical Institute – National Institutes of Health Research Scholars Program and was awarded the Donald L. Alcott, M.D. Award for Clinical Promise. He graduated summa cum laude in 2009. He completed his diagnostic radiology residency at the Massachusetts General Hospital of Harvard Medical School in Boston, MA followed by a fellowship in vascular and interventional radiology at the Johns Hopkins Hospital in Baltimore, MD where he served as chief fellow.
Learn more about Andrew Gunn, MD
Release Date: May 24, 2018
Reissue Date: March 10, 2021
Expiration Date: March 10, 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.
Faculty:
Andrew Gunn, MD
Assistant Program Director, Diagnostic Radiology Residency Program
Dr. Gunn has the following financial relationships with commercial interests:
Grants/Research Support/Grants Pending - Penumbra
Consulting Fee - Boston Scientific, Varian
Payment for Lectures, including Service on Speakers Bureaus - Boston Scientific, Turemo
Dr. Gunn does not intend to discuss the off-label use of a product. 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 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): Our topic today is inferior vena cava filters and IVC filter retrieval. And here to tell us about that is Dr. Andrew Gunn. He’s an interventional radiologist at UAB Medicine. Dr. Gunn explain a little bit about deep vein thrombosis or pulmonary embolism. What has been the standard treatment for these and the evolution from prevention of them?
Andrew Gunn, MD (Guest): So, both deep vein thrombosis, DVT and pulmonary embolism, PE, are classified as venous thromboembolism or VTE and what they are, are blood clots that exist in the veins and sometimes those blood clots can travel to the lungs which can block the blood vessels going to the lungs and that’s called pulmonary embolism. And what causes these are many things. Sometimes people who have cancer are at a higher risk for having pulmonary embolism. People who are immobile, either after surgery or because of trauma are at a higher risk and some people have certain genetic disorders that also places them at higher risk for forming these blood clots. And the most common treatment for these blood clots is to place people on blood thinning medicines, on anti-coagulation medicines. However, some people are not able to get anticoagulation medicine because they have either had recent surgery or cancer to the brain or they have been involved in trauma recently and in these cases; that is when we place an inferior vena cava filter.
Melanie: So, tell us about those filters. Are they removable? Are some permanent? Tell us a little bit about them.
Dr. Gunn: So, inferior vena cava filters or IVC filters are essentially a metal cage and they are placed through either a vein in the neck or a vein in the groin and they sit in that large vein inside the abdomen and block blood clots from going from the lower extremities up into the lungs where they can cause problems with breathing and with the heart. And so, previously, the first generation of IVC filters were not removable. As soon as they were implanted, they were supposed to be there for the rest of the patient’s life. But as we have come to learn, IVC filters themselves are not entirely benign and so newer generations of IVC filters come with hooks on them and so they become retrievable and so I would say the majority of filters that are being placed now are retrievable filters.
Melanie: And why do you need a retrievable filter and what’s the rationale for an aggressive approach to retrieving them?
Dr. Gunn: Well, as I stated, we are learning more and more that IVC filters themselves, when they sit inside the body, can cause problems. They can fracture. They can migrate from one location to another location. They, themselves can penetrate through the veins and contact the bone or an artery and they, themselves can actually cause blood clots or clots to form. And so, leaving something foreign inside the body that you don’t necessarily need isn’t always a great idea. And so, the idea behind retrievable filters is that we would provide protection for patients for a certain period of time when they most needed it, when they weren’t able to get anticoagulation, or they are most immobile; which allows us opportunities several months down the line, to be able to remove those filters and remove any of those negative consequences IVC filters can possibly have.
Melanie: So, what’s the excepted window of retrievability for these filters and are there some impediments to retrieval of the temporary filters?
Dr. Gunn: Yeah, I mean I think that window is pretty broad and a lot of that is going to be determined by the interventionalist’s experience and comfort level. We have pulled out filters as old as 13-15 years old. And so, I think any time that the filter is ready to come out; I think it’s worth trying to do the retrieval. Now the impediments to IVC filter retrieval can be that sometimes the filters tilt and those hooks can become embedded in the IVC wall. Sometimes, there’s clot up and down the IVC from the filter itself, from the patient’s underlying DVT and that can sometimes make the filter retrieval difficult. Sometimes the filters fracture themselves and so that can make retrievals themselves also more difficult. So, I would say those are the most common things that make filter retrievals difficult. But I think an aggressive approach in certain cases, I wouldn’t say in all cases, an aggressive approach is warranted. But in certain cases, an aggressive approach is warranted when a patient is having symptoms from their IVC filter. Either there is clot that has formed, and it is blocking off the IVC or the filter itself has penetrated through the IVC and is causing pain or some other symptom, in which case certainly an aggressive approach is warranted.
Melanie: So, that leads me to our next question and based on some of the symptoms the patient might be experiencing; how do you make the decision of your retrieval and what technique you are going to use?
Dr. Gunn: Well, the first thing, when a patient comes to see me in clinic to talk about IVC filter retrieval is I ask myself, if I saw this patient today, would I put a filter in. and if the answer to that is no, then I think that the filter – we need to discuss taking out the filter. And so that really drives a lot of my decision-making process. And as far as how we decide to remove the filter; that also depends on the type of filter. Some filters are designed with hooks on the bottom and so you need to come from the veins in the groin. Most filters are designed with the hooks at the top, so you need to come from the veins from above and sometimes you can see that there is either been fracture or it’s migrated in which case sometimes we have to come from both above and from below and get access with a wire through and through the patient to be able to stabilize that filter and to be able to retrieve it. So, most of those decisions about the technique and how we are going to do it is really on a case by case basis in consultation with the patient.
Melanie: Is there a learning curve for this Dr. Gunn and what would you want to tell a physician that is practicing this retrieval technique?
Dr. Gunn: Yeah, there is definitely a learning curve and I think when you are starting to remove filters; you are going to want to find filters that have been in for a short period of time, things that you are going to be able to retrieve quite easily and the more and more comfort that you get with that, then of course, the more and more aggressive you could potentially be with complicated filters. If you are a physician thinking about trying to do a retrieval, you are not going to want to start with a hook that’s embedded or that’s tilted or a filter that’s fractured. That’s something you are going to want to send off to a major referral center so that they can take care of that patient and so, the advice I would give is if you are going to start trying to do filter retrievals, is to start slowly and to start with the straightforward cases to make sure you have a lot of success under your belt before you start to attempt more difficult retrievals.
Melanie: Can you tell us something interesting about a particular case or diagnosis?
Dr. Gunn: Yeah, I mean one that sticks out in my mind, is there was actually a nurse that came to us from south Alabama and she had a filter in her for about seven or eight years and ever since she had the filter placed, she was having back pain. And so she went to get a CT scan and on the CT scan, they said she had colitis and you know, she’s a nurse and so she said, I definitely don’t have colitis and so she took the CT scan to another radiologist who noticed that one of the filter struts was protruding through the inferior vena cava and was digging into one of her lumbar vertebrae and so she assumed that that was the reason she was having back pain. She went to one physician to ask about filter retrieval, but the physician said that because it had been in for seven years that it could never come out. And she really advocated for herself and so she did some googling, looked online and she found an interventional radiologist who is actually a friend of mine in Chicago, emailed him and said heh, can we set up a filter retrieval consult, and he sent her back down over to us and we saw her here up at UAB and so we set her up and we removed her filter. It took us less than 15 or 20 minutes to do and instantaneously when she was in the recovery room, she said her back pain was gone. And so, I think it’s just a great example of number one, the IVC filters themselves can cause problems and then number two, you need to be your own advocate and then sometimes when you hear that this filter is not retrievable; you need to find your way to a center that retrieves a lot of filters to be able to discuss all of your options.
Melanie: What an amazing point and looking forward to the next ten years in the field, what do you feel will be the most important areas of research for implanting filters and possibly retrieving them? What does current research indicate for future developments?
Dr. Gunn: The biggest thing that’s going on with filters right now would be number one, we are doing large multi-center registries looking at retrievable filters because we don’t have the 10-20 years safety profile that we had with the permanent filters, so that’s currently ongoing right now. Number two, a lot of manufacturers are looking at either bioconvertible or bioconvertible filters which would be filters that would stay inside the patient, but say after 60 days or 90 days, they themselves would convert into essentially just a stent in the IVC and there would no longer be filtration of the blood. There are also filters where you can go in instead of retrieving the whole filter itself, you can pull off the cap of the filter and that opens it up and so you don’t have to remove the entire filter, you just remove the filtration portion of the filter. And so, I think in the next five or ten years, I don’t know what the role of those are going to be, but I think that’s where things are going to be going in the next five or ten years is these bioconvertible types of filters.
Melanie: So, summarize it Dr. Gunn, because what a fascinating topic and what an interesting way that you are putting it and this decision-making process. Tell other physicians what you would like them to know about inferior vena cava filters and retrieval and when to refer to UAB.
Dr. Gunn: I think for physicians that are out in the community, they need to understand that number one, filters are mostly retrievable. There are a lot of physicians that still think that we are using these older type Greenfield filters that weren’t meant to ever come out. So, most filters that are going in today, are meant to be retrieved. And then number two, if you do have a patient that does have an IVC filter in and they are not being followed up by whoever placed the filter, it is really time to ask the question does this patient still need it. If they are taking anticoagulation medicine, such as Lovenox or coumadin or Xarelto or something like that and they still have an IVC filter; that’s really the time to refer the patient over to someone who can retrieve that filter because that filter is not doing them any good anymore, if they are already on anticoagulation and then the third thing is as I said earlier; the easiest thing to do is to ask yourself if I saw this patient today, would I put a filter in this patient and if the answer is no, it is also time to send that patient out to someone who can discuss whether or not that filter can be retrieved. And so, those would be the things that I think physicians should be asking themselves if those patients with IVC filters are not necessarily being followed by people who put the filters is to ask those questions and realize heh, it’s time to get this filter out, because it could cause problems for this patient in the future.
Melanie: Thank you so much Dr. Gunn, for being with us today and sharing your expertise in this pretty interesting 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 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/ua067.mp3
- DoctorsLenneman, Carrie
- Featured SpeakerCarrie Lenneman, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5082
- Guest BioCarrie Lenneman, MD is cardiologist who subspecialize in the effects of cancer treatment (both chemo and radiation) on the heart.
Learn more about Carrie Lenneman, MD
Release Date: May 10, 2018
Reissue Date: July 15, 2021
Expiration Date: July 14, 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.
Faculty:
Carrie G. Lenneman, MD, MSCI
Associate Professor in Cardiovascular Disease
Dr. Lenneman has no financial relationships related to the content of this activity 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 post-test.
Melanie Cole (Host): Our topic today is cardio-oncology and here to tell us about this very specialized field, is Dr. Carrie Lenneman. She’s a cardiologist who specializes in cardio-oncology at UAB Medicine. So, Dr. Lenneman, explain a little bit about cardio-oncology. What’s the evolution of it? How long has it been around?
Carrie Lenneman, MD (Guest): It has been around since probably 2008 is when the foremost of the cardio-oncology meetings began to develop around the country and it’s a field that has grown because cancer patients are surviving longer, and they are developing cardiac issues as they are becoming cancer survivors. We know that after recurrent malignancy, that cardiovascular disease is the second leading cause of death in cancer survivors.
Melanie: So, with chemotherapy, radiation therapy, that can put patients at risk for this variety of cardiovascular complications. How do you identify the needs of these cancer patients and what are some of the late and long-term effects on the heart from cancer treatments?
Dr. Lenneman: So, we will identify high-risk patients; patients that have cardiac risk factors going into their chemotherapy and individuals that have underlying high blood pressure, high cholesterol, diabetes, are at higher risk for developing cardiac issues from their cancer treatment, both chemotherapy and radiation. And we work with their oncologist to identify these high-risk individuals and we do know that some medical therapy including beta blockers, ACE inhibitors and statins can be cardio protective for these patients undergoing chemotherapy and radiation. And so, in certain individuals, we will start them on these medications to help prevent any kind of heart failure or cardiac problems during their chemotherapy treatment. We routinely will do cardiac screening, prior to them starting treatment and then during their treatment course, looking at cardiac echoes which will allow us to see their cardiac function, how their valves work, and we will continue to follow that through their treatment course and even into survivorship.
Melanie: So, you are estimating their risk for cardiotoxicity before they even start some of their treatments?
Dr. Lenneman: Yes, we do. And there is a cardiotoxicity sort of risk assessment tool that we use to help sort of identify low, intermediate, and high-risk patients.
Melanie: What types of care are involved in cardio-oncology? Does it require the management of several aspects of care? You have already mentioned with the oncologists and you are a cardiologist and I would imagine there is radiation oncologists involved. Speak about the improved coordination of care between you providers and how you are all involved together.
Dr. Lenneman: Yes, we think of cardio-oncology as sort of an integrated care model where we do actually integrate a patient care with different disciplines. So, exactly right. We work with a medical oncologist to better understand the best chemotherapy regimen that will be optimal for this patient. We will talk to the radiation oncologist to figure out is this patient going to need radiation and how do we plan cardiac monitoring incorporating their radiation exposure and then again, we also talk with the pathologist to better understand how aggressive is this tumor and this cancer and therefore do we need to be more aggressive with the chemotherapy and take a little more risk of cardiac issues knowing that we need to be aggressive for this cancer treatment. So, it very much is an integrated discipline where we all will sort of discuss a patient’s underlying cancer and then plan sort of the best optimal treatment for that cancer as well as looking at their cardiac risk factors and how we need to mitigate any kind of potential cardiac damage with the treatment that they are going to receive.
Melanie: Do you see down the line that there will be improved methods Dr. Lenneman, developed by radiation oncologists to reduce the cardiac side effects of radiation therapy specifically?
Dr. Lenneman: We have already seen that in the last ten to fifteen years. I mean there are newer technologies that are coming out that are minimizing the cardiotoxicity risk. They currently will use different techniques such as breast holds or using CT-guided therapy to sort of minimize the exposure to the heart during radiation therapy. So, yes, there are ongoing techniques that are used and then we continue to sort of advance that with newer techniques and in some cases, there are actually on-going interventional trials. We are looking at different medications that could be cardioprotective during radiation treatment as well.
Melanie: And we are backing up for just a second Dr., tell us a little bit about some of the risk factors for cancer therapeutic related cardiac dysfunction. What are you looking for?
Dr. Lenneman: Well, we know that like I mentioned earlier, we know patients that have underlying risk factors, so high blood pressure, high cholesterol, diabetes, are risk factors for developing cardiac issues during cancer treatment. We also will factor in what kind of chemotherapy treatment a patient is going to receive because certain chemotherapies put patients at different risk. We know some chemotherapy such as a class of anthracyclines put a patient at higher risk for heart failure versus we know different agents like taxane agents may put a patient at higher risk for arrhythmias. So, we can also help a patient understand early on looking at what chemotherapies they may be treated with, what kind of cardiac symptoms to be looking out for during their treatment course.
Melanie: Would that change or alter their treatment course depending on what you figure out?
Dr. Lenneman: Sometimes, if a patient already has known cardiac issues such as a low ejection fraction meaning that they have already sustained some heart muscle damage. In some cases, we will have a multi-disciplinary discussion with their oncologist, their radiation oncologist and maybe even their surgical oncologist to say this person probably is already at too high of a risk to potentially expose them to a certain class of chemotherapy, if they already have significant cardiac dysfunction or cardiac issues at the beginning, before they are even treated.
Melanie: Looking forward to the next ten years in the field, what do you feel will be the most important areas of research. Give us a little blue print for future research into your specialized field.
Dr. Lenneman: I definitely think we are making headway in learning what kind of medical therapy can be cardioprotective for patients going through chemotherapy. So, we are making headway to better understand which regimens will improve cardiac outcomes and hopefully prevent heart failure, heart arrhythmias and coronary disease going forward for these patients. We are also trying to keep pace with the oncology world as new drug therapies are coming out such as these new immune check point inhibitors. We are learning more about the cardiac effects of these new drugs that are being more widely used in oncology. So, I think we are also going to learn a lot more about check point inhibitors and the cardiac issues that are associated with it and hopefully how to better treat and how to identify which patients are going to have the potential cardiac issues related to check point inhibitors.
Melanie: You can I discussed a little bit off the air, that you are one of the only known cardio-oncology clinics in the state of Alabama. So, are you doing some treatments or research at UAB that other physicians may not be aware of, especially in your field?
Dr. Lenneman: Yes, we are developing cardio-oncology protocols here at UAB that help us better understand which patients being treated with immune check point inhibitors as well as anthracyclines that can cause cardiotoxicity and how best can we identify which patients are at high risk. So, we are doing research here at UAB that is going to help our cardio-oncology community in the future.
Melanie: Wrap it up for us, in summary Dr., tell other physicians what you would like them to know about the field of cardio-oncology and if they are considering adding a clinic; what you would like them to know about this specialized field at UAB Medicine.
Dr. Lenneman: We would like providers to know that cancer patients are surviving longer and now they are at risk of developing cardiac complications as they go through their chemotherapy and enter into survivorship. And we would like providers to be aware of the possibilities of different consequences of their chemotherapy and radiation and how it’s important to identify those problems early and even potentially prophylactically in a high-risk patient, they probably should be seen by a cardio-oncologist at the beginning so that we can help mitigate any cardiac issues from even occurring.
Melanie: Thank you so much. What in interesting field that you are in and what an interesting topic. Thank you so much for sharing your expertise with 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/ua066.mp3
- DoctorsFlood, Kellie
- Featured SpeakerKellie Flood, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4619
- Guest BioKellie L. Flood, MD practices Geriatric Medicine in Birmingham, AL. Dr. Flood graduated from University of Texas Southwestern Medical Center Southwestern Medical School in 1996 and has been in practice for 21 years.
Learn more about Kellie Flood, MD
Release Date: April 25, 2018
Reissue Date: March 8, 2021
Expiration Date: March 8, 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.
Faculty:
Kellie Flood, MD
Associate Professor in Hospice and Palliative Care, Geriatric Medicine, Internal Medicine
Dr. Flood has no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole: Our topic today is interdisciplinary practice and training. My guest is Dr. Kellie Flood. She's a geriatric quality officer and the assistant chief medical office for care transition at UAB Medicine. What is interdisciplinary training and how does it differ from a multidisciplinary approach to training?
Kellie Flood, MD: Thank you. In the hospital setting, in traditional models of care, you have multiple disciplines who all work on a hospital unit, but they tend to function primarily in their silo. For example, you have physicians, nurses, pharmacists, dietitians, case managers and social workers, but in traditional models, you don't have all of those folks around the table every single day all working as one connected team to develop the plan for that individual treatment. In an interdisciplinary or interprofessional model, you have all of those subspecialists and disciplines coming together every single day in a very structured team meeting where everybody can communicate their observations regarding the patient, so we all can be on the same page for the right plan for that patient not only for that hospital day but for their care transition as well.
Melanie: What are some of the goals of interdisciplinary training or interdisciplinary education initiatives?
Dr. Flood: We know from the geriatric literature that if patients, especially older patients, come into the hospital with certain vulnerabilities, then they're at an increased risk of adverse events during their hospitalization, so they may be vulnerable in terms of functional decline or dementia or they may be at increased risk of experiencing a side effect from a medication or developing delirium. The goal of an inter-professional team is to very proactively assess for present vulnerabilities such as declines in function and cognition or risk for developing a complication, and that way, we can put plans in place to prevent complications while the patient is receiving the medical care they need for the acute issue that brought them into the hospital in the first place.
Melanie: As those are some of the goals, what are some of the challenges of this type of training?
Dr. Flood: It’s very interesting because we all know that it works best for providers as well as for patients and families. In the current hospital workflow, everyone who works in the hospital is very busy, so it really takes dedication at the organizational leadership level to say it’s going to be a priority that we provide structures and processes for training our workforce to work in teams, that we can develop a curriculum and that we create a way to have these daily team meetings on our hospital units. What really needs to become an expectation at the organizational level that if we can restructure how we work together, we actually save ourselves time in the long run while we also improve the quality of care, and studies have shown that this actually reduces cost as well. Functioning and practicing medicine in teams is really a way to achieve the triple aim. We provide better care for vulnerable patient populations with higher quality and at a reduced cost.
Melanie: Such an important point. Discuss the newly formed department of interdisciplinary practice and training and how you provide a broader and more diverse experience.
Dr. Flood: At UAB Hospital, we initially started these efforts around geriatric care on our one geriatric acute care for elders unit. Our organization quickly realized this is just better care and right care for all vulnerable patients in our hospital, so we needed an infrastructure to be able to provide this care delivery redesign and education throughout our hospital setting. The department was formed about two years ago and this is our home base from which we develop and disseminate inter-professional team training targeting geriatric syndromes, such as function and cognition, but we also recognize that these syndromes apply to younger patients as well. When we deliver our training, we’re really targeting not specifically just a patient age, but patient vulnerabilities. We’re able to train all of our disciplines all together in the same program, so we have nurses, pharmacists, physical, occupational, speech and respiratory therapists, case managers, social workers – every single discipline that works at UAB Hospital is touched by this training and we really specifically don’t train them in their siloes but bring them together and train them as a team.
Melanie: How does it specifically relate to the Geriatric Scholar Program? Speak about some of the evidence-based practice that you're using.
Dr. Flood: The Geriatric Scholar Program is probably one of the most impactful programs that we have within our department of inter-professional practice and training. This is a two-year professional development program for staff from all disciplines as I mentioned. In year one, we deliver 40 hours of geriatric knowledge and skills content. This is where we're laying the foundation for all of our staff to not only understand why we need to change the way we deliver geriatric care but we give them the tools or the skills to be able to do that within their own unit or department. We provide content, but it's also very experiential curriculum, so we provide avenues for hands-on training. Our scholars go on clinical rotations. They practice the skills we teach in simulation training. We have a lot of case debates and application homework assignments. In year one, they not only have knowledge but they now have their newly equipped geriatric skills. They are also tasked with teaching the same skills to their colleagues on their units and we track and measure who they're teaching and what content they're teaching. In year two of the program, we mentor them through process improvement projects where they know help us hardwire in the hospital workflow the mechanisms for actually delivering geriatric based evidence care. For example, if we're teaching a bunch of nurses about delirium prevention, then we also have to hardwire the processes into their workflow for them to be able to deliver this care. Our geriatric nurse scholars have rolled out a project related to how we now screen for delirium at UAB Hospital, we now have delirium prevention toolkits on every unit that's stemmed from Geriatric Scholar Programs, and now we teach all the units how to utilize the screening tool and toolkits to prevent and manage delirium. Our scholars are really our army of change agents that not only teach their colleagues but also drive the process improvement that will allow us to delivery evidence-based geriatric case.
Melanie: Speak about HELP and Virtual ACE.
Dr. Flood: HELP and Virtual ACE are now another layer of dissemination of evidence-based geriatric care. A stands for Acute Care for Elders, which is an evidence-based team model of care that’s been shown to preserve functional status and improve outcomes for hospitalized older adults. A traditional ACE unit is one designated geographically distinct unit in a hospital. We needed to extend that type of care to all of our hospital units because we have 52 units at our hospital, so we drill down all of the geriatric care into three primary themes; pain management, especially non-pharmacological pain management, maintaining safe mobility and preventing and managing delirium. In essence, we’re drilling down a full-fledged ACE unit into its three primary initiatives around pain, mobility, and delirium, and we now disseminate that teaching and care processes to all of our other units in the hospital. We've done those for about eight of our other units and we're seeing the same benefits in those units, in our virtual ACE units that we see from our geographically distinct based unit. The Hospital Elder Life Program was developed by Dr. Inouye over two decades ago and it's essentially another means of disseminating evidence-based delirium prevention, so in the HELP program, we have a nurse coordinator who trains volunteers to provide interventions that are known to prevent delirium. Now our volunteers can help us with feeding assistance and cognitive stimulation and early mobility. In essence, we’re adding on layers of additional team care for vulnerable patients through an entire organization.
Melanie: How are you evaluating the impact of such programs on outcomes?
Dr. Flood: We really have educational outcomes for our staff that we're training, their own professional development outcomes, we measure their performance of skills and simulation training, and ultimately all this is to be able to improve patient outcomes. We measure our scholars pre- and post-testing and we see their knowledge improve. We allow them to give us feedback in their own self-rated competencies of caring for geriatric patients, we measure their skills through simulation, and finally, as we're rolling out these programs, we measure the impact of these initiatives on patient mobility and delirium. What we are seeing is after we apply these principles and really hardwire these care processes on units, we see that more patients are mobilized and we see that delirium prevalence reduced. We do think we've established a means of disseminating geriatric care throughout an entire hospital.
Melanie: That’s wonderful. In summary, tell other physicians what you'd like them to know about the department of interdisciplinary practice and training and UAB Medicine and when to refer.
Dr. Flood: We would be delighted to help other hospitals actually develop similar departments, it’s not a full-fledged department, to develop these similar programs, so we’re working with the hospital system in Wisconsin who has now launched their own Geriatric Scholar Program. We’re working with the American College of Surgeons right now to help disseminate these virtual ACE techniques and processes, targeting surgical patients eventually nationwide, so we would love to be of assistance to other hospitals who would like to develop similar programs targeting geriatric patients, but really patients of any age who have geriatric like syndromes, such as functional or cognitive impairment. We would be happy to assist those hospitals in developing their own program.
Melanie: Tell us about your team. Why is UAB so great to work with?
Dr. Flood: When I came to UAB, what attracted me to move here to Alabama and join UAB is really just the collaboration and collegial culture with the focus on one thing and that’s to do the right thing. We’re really focused right now on the right care in the right place at the right time for all of our patients. Working in teams is really just one strategy to accomplish that goal, so our team in this work, I get to work with physicians, nurses, therapists, social workers, case managers, and pharmacists. It means that I learn from my fellow team members every single day, they help me to be a better physician and a better team member, and ultimately again, our goal is that every patient family receives the same care we all want for our loved ones. You really see a team that is driven by that goal and it just makes the workplace not only so much more effective and efficient but fun as well.
Melanie: Thank you so much for being with 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 uabmedicine.org/physician. That’s uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua054.mp3
- DoctorsLeath III, Charles A.
- Featured SpeakerCharles A. Leath III, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=2242
- Guest BioCharles A. Leath III, MD is an obstetrician-gynecologist in Birmingham, Alabama and is affiliated with University of Alabama at Birmingham Hospital. He received his medical degree from Medical University of South Carolina College of Medicine and has been in practice between 11-20 years.
Learn more about Charles A. Leath III, MD
Release Date: April 6, 2018
Expiration Date: April 6, 2021
Disclosure Information:
Dr. Leath 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): Enhanced Recovery After Surgery programs aim to hasten functional recover and improve postoperative outcomes. Here to tell us about the success in gynecologic oncology, is Dr. Charles Leath III. He’s a Professor in the Division of Gynecologic Oncology at UAB Medicine. Welcome to the show, Dr. Leath. Tell us a little bit about the rationale behind ERAS programs and Enhanced Recovery Programs, in general.
Dr. Charles Leath III (Guest): Yeah, thanks for having me today, Melanie. And on behalf of my colleagues, Drs. Straughn and Haller Smith, I would like to provide a brief update on ERAS and Gynecologic Oncology. I think we all recognize that in the current time in medicine, certainly, we’re under a microscope in trying to figure out ways to improve outcomes. Everything is being measured. There are metrics for really everything that’s being done.
One of the areas that we look at in Gynecologic Oncology is the postoperative length of stay. Although a large number of our patients are able to have a minimally invasive surgery -- either with traditional laparoscopic approaches or with robotic-assisted laparoscopy -- we still perform a large number of exploratory laparotomy surgeries. If we can find a way to perhaps decrease the length of stay for these individuals and improve their surgical outcomes, then that would be a very meaningful endpoint for us to tackle.
A couple of years ago, several colleagues at the Mayo Clinic among others, started to look at this whole idea of enhanced recovery after surgery. Unfortunately, in medicine, a lot of the things that are done, we don’t necessarily have the level one evidence for. You can’t do a randomized controlled trial of everything that’s out there. We started to look at this collectively and figure out many of the things that we thought we knew about surgery and about perioperative care in fact, probably were not true. And so as we started to dig a little bit deeper, we figured out that there were some things that could be done that if we applied this to a group of patients undergoing a major abdominal surgery, we could improve their outcomes, get them out of the hospital quicker, and still have similar oncologic outcomes, which is clearly the most important thing to us as cancer surgeons.
Melanie: So, speak a little bit about what they’re associated with, really as far as your rationale. And also, have ERPs in general, been widely adopted in gynecology – in gynecologic oncology or is this a newer progression?
Dr. Leath: Yeah. So, I think what we’ve seen with this whole ERAS movement we’ve tried to focus on the entire operative event. That really occurs the first time you meet the patient in the clinic once you determine that she’s going to need to go to the operating room and your surgical plan is in place, that’s where the education for ERAS starts. We discuss with the patient what the implications are, what we’re trying to do. That’s going to be reinforced by the nurses also going back over many of the highlights that we’ve hit.
At UAB, we have some programs where patients will be sent videos that they can review. These videos give them information both about ERAS, in general, and then a surgery-specific video that really talks about what they need to expect based on their operation. Again, when they see the anesthesia providers at their preoperative appointment, many of the aspects about perioperative pain control, allowing a clear liquid diet up until a couple of hours prior to surgery – which again, used to be prohibited and almost heretical to allow a patient to drink a few hours before surgery, but now, is really standard fare. And then again, the morning of surgery, going back through things, looking at the ways to increase or improve rather, pain control postoperatively, ensuring that the aspects of the protocol have been stuck with.
Melanie: So then if we’re looking at these ERPs and ERAS, what are we seeing as some of the key elements in establishing a successful program, and is there a high-degree of coordination that’s required? Who’s involved in all of this?
Dr. Leath: Yeah, so coordination, if anything, that’s probably the most important thing to get from this small – this brief interview is the fact that this is not something that you can turn on almost like a light switch. When we first heard about ERAS and started to go through the process, it took about five-months of reviewing the available information, of drilling down the potential variables that we would like to be able to track and to figure out could we really those variables? It is a highly coordinated effort that again, involves the providers as well as the nursing staff in the clinic, the anesthesia providers in the perioperative areas – both in the pre-op clinic as well as in the operating room – the nursing staff in the recovery room, and then ultimately, both nurses and physicians on the postoperative wards.
Taking those parts into account, we really can look at a lot of different things. One of the things that we wanted to look at was can we shorten the length of stay after an exploratory laparotomy? We can look at what is referred to as an O to E Ratio, which is the Observed to the Expected Ratio, and really our goal was to decrease that, meaning that we thought the patients would stay for X-period of time and if we can decrease that based on the complexity of the surgery, their preoperative diagnosis, their other medical issues, then that certainly would be very beneficial. We have benchmark information showing that as we’ve gone through this process, we’ve consistently been able to keep the patient length of stay below the baseline.
The other thing that’s important is when you think about doing surgery and having a goal of getting patients out of the hospital quicker, what you don’t want to do is discharge everyone and then have everybody be readmitted because that really defeats the purpose. It’s clearly better for a patient to stay in the hospital a little bit longer than be discharged and then be readmitted, which is just another one of the metrics that is tracked. Again, looking at our data, what we see is that we’ve been able to decrease our hospital readmission rate from the baseline – or what our preidentified goal was. Again, we’re not going to be able to prevent every readmission, but if we’re sending patients home sooner, I think one of the things we want to see on the back end is that we’re not having patients be readmitted. We’re not sending them home too soon.
I think another important aspect of that, of course, is that we really want to make sure that this is an opportunity for the majority of patients. Again, if you really cherry-pick and say, “Well, we’re just going to do these three, or four, or five patients that appear to be the healthiest so that we can get the best data, then again, that’s not really helping the majority of patients because those are the patients that likely would have done well anyway. Our goal was that when we had this pathway up and running that we really wanted to have this available to at least 90% of our patients undergoing a laparotomy. Again, that allows those patients that have other medical comorbidities -- patients that maybe traditionally, you would think would be a little bit higher risk to stay in the hospital longer, be readmitted, and other things along those lines – being able to benefit from these pathways.
Melanie: Such interesting information on evaluating that impact of these programs, Dr. Leath. So now, tell us some of the important components of the postoperative strategies – pain management, drains and catheters, early mobilization – speak about how some of those come into play in this ERAS strategy.
Dr. Leath: Yeah, that’s a perfect lead-in. When we think about the postoperative experience for patients, I think one of the first things that we all noted was the improvement in postoperative pain control. I can literally remember my first patient where I walked into her hospital room, postoperative day number one; she was sitting up, she was sitting in a chair, she had her own clothes on, she had her make-up on. She looked great. I remember the residents telling me she was postop day number one and I was almost looking at them quizzically, thinking there’s no way she’s postoperative day number one. Maybe day two, but clearly she’s not day one, but yet, in fact, she was.
I think a lot of that, though, also gets back to the point of although we’re thinking of postoperative pain control, what’s important is really the preoperative pain control. The vast majority of these patients will get what’s referred to as an intrathecal administration of medications – almost like a spinal shot – which has certainly – in our experience; it has been associated with significant decrease in postoperative pain. In addition, they’ll get some oral pain medicines in the preoperative area – things like acetaminophen, gabapentin, and some others.
And then postoperatively, we’re getting them up the day of surgery, they’re sitting in a chair the day after surgery -- postoperative day number one, they’re walking around. And rather than going through the typical clear liquid diets, maybe some full liquids before getting to a regular diet the second or third postoperative day, we really allow patients to eat normal food from the get-go. If they’re hungry and they’re ready to eat, they can eat right away. Really, I think those aspects of early ambulation, improved pain control, quick advancement to diet, and also getting all catheters and lines out in a very timely fashion – usually on postoperative day number one – allows the patient to feel better, allows them to become mobile a lot quicker, and then ultimately, should allow them to get out of the hospital quicker.
Melanie: In summary, Dr. Leath, tell other physicians what you’d like them to know about the importance of an enhanced recovery after surgery program.
Dr. Leath: Well, I think that again, the most important thing that we touched on earlier is this is not a light switch. It’s not something you can turn on or off. And so the first question, of course, is what need is there? And certainly, there is a need in multiple aspects of surgical care in the twenty-first century. At UAB, we have three current programs with a fourth about to start -- colorectal surgery, in the urology department, they have this for patients undergoing a cystectomy, generally for bladder cancers. We have this in gynecologic oncology, and then our colleagues in the benign gynecology arena are also involved in this, as well.
I think there are going to be other programs and other disciplines that are out there that likely can identify a group of patients that with the all-encompassing aspect or the approach of ERAS, that those patients can be benefitted going forward.
I think the other thing that’s important is that this is a constant reassessment. Just because you set it, again, it’s not on cruise control. You don’t say, “Hey, this is great. We’re ready to go.” We’ve identified several aspects during the last year that we’ve been doing ERAS here in our gyn-oncology division, where patients probably should not undergo ERAS. There are some patient-related factors -- for instance, if a patient comes in with a bowel obstruction, then maybe that’s not the best patient there just from a dietary standpoint and some of the other aspects that will allow us to tweak the algorithm, and again, figure out ways to improve outcomes for all patients.
Melanie: Thank you so much, Dr. Leath, for being with us today in this fascinating segment. A community physician can refer a patient to UAB Medicine by calling the MIST Line at 1-800-UAB-MYST. That’s 800-822-6478. 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. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua050.mp3
- Featured SpeakerJaneen Lynnae Arbuckle, MD, PhD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4626
- Guest BioJaneen Lynnae Arbuckle, MD, PhD, is the Assistant Professor, Department of Obstetrics and Gynecology with UAB Medicine.
Learn more about Janeen Lynnae Arbuckle, MD, PhD
Release Date: March 30, 2018
Reissue Date: March 12, 2021
Expiration Date: March 12, 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.
Faculty:
Janeen Arbuckle, MD, PhD
Assistant Professor, Obstetrics & Gynecology, Pediatric and Adolescent Gynecology
Dr. Arbuckle has no financial relationships related to the content of this activity 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): The American College of Obstetricians and Gynecologists recommends that young women aged 13-15 undergo a dedicated reproductive health visit. The purpose of this visit is for education, prevention and anticipatory guidance and should be tailored to the individual patient. Here to tell us about the clinical aspects of pediatric and adolescent gynecology is Dr. Janeen Arbuckle. She is an assistant professor in the department of obstetrics and gynecology at UAB Medicine. Welcome to the show Dr. Arbuckle. Explain a little bit about pediatric and adolescent gynecology and what types of services do you offer?
Dr. Janeen Lynnae Arbuckle, MD, PhD (Guest): Yes, thanks so much for having me Melanie. Pediatric and adolescent gynecologists are specialized OB/GYNs who focus in the care of children and adolescents. We are able to see patients between newborn up to age 21 and really for any reproductive need or any concerns about their normal development or the development of their genital tract and or breasts.
Melanie: So, when is an exam indicated in a young child or adolescent and what do you do at that first exam to make a young woman comfortable with the difficulties of that first exam?
Dr. Arbuckle: Absolutely. So, it depends on what the patient is presenting for. So, if a patient comes in with a specific problem that warrant an exam, say for instance if they have any concerns about abnormal discharge or the normalcy of their anatomy then an exam is indicated. We don’t do routine pelvic exams in adolescents until they do turn age 21. So, the majority of our patients will not require a pelvic exam unless they are having problems. Definitely navigating that first pelvic exam can be difficult. It is often helpful to have a parent available or find some way to distract the child or adolescent. So, often times in our children’s clinic space we have TVs on, children will use their phone and they just sort of kind of distracted from the fact that a genital exam is going on. In addition, we try to normalize that we all have genitals and we all have body parts – specific body parts that have to be evaluated by doctors to make sure that they are healthy and so we try to make it a comfortable space, allow them to kind of free play and be distracted in doing things that are entertaining for them so that it is not so intrusive to their kind of perception and physical space. Those girls who need a more detailed exam, definitely we see in our adult office and we have an environment that again is really friendly and staff that has specialized training in discussing the components of a pelvic exam with those girls that need a more detailed exam.
Melanie: You mentioned discharge or anatomical concerns. What are some common concerns of adolescents and their parents in terms of visiting their OB/GYN and some common pediatric gynecological disorders?
Dr. Arbuckle: That’s a great question. So, if you kind of divide the population into two halves. The younger patients who will complain of a vaginal discharge or a genital complaint is most specifically and most commonly a nonspecific vulvitis. So, the child will complain of an itch or a burn and just not have – they will have a generalized discomfort in their vulvar area. That’s most commonly due to just overgrowth of normal bacteria that lives in the area, either bowel flora or even respiratory flora and the most important thing to inform the patient and their parent of is that is something that can actually be treated with minimal intervention. The most common thing for young girls is again, the nonspecific vulvitis that we actually recommend just treating with improved hygiene measures and a couple of other things that can make the area more comfortable. It’s rare for there to be anything more than that just nonspecific overgrowth. In older girls, the girls who are post puberty, they will often complain of a vaginal discharge that is actually perfectly normal and what we call physiologic. So, normalizing that there should always be some degree of a vaginal discharge and highlighting those components of an abnormal discharge from just an education standpoint is all that is often necessary.
Melanie: So, if it is noninfectious vulvovaginitis, they don’t like the smell or the look of it and even maybe a mother is concerned; what would you tell other pediatricians and or physicians about explaining to the girls the normalcy of some of this?
Dr. Arbuckle: Yeah, so, unfortunately, in American culture there is a perception that female genitals should all be on the inside and that there should never be anything on the outside. So, one of the common things that we will get referrals for or even questions from parents or children, specifically the post pubertal girls is do my genital look normal and they need to be reduced. So, a common concern is that for instance that the labia minor are too large. So, number one we start with education and I talk about what the genitals look like in a prepubertal child and then most commonly the labia minora are flush with the outside. They aren’t really an external organ and then when we go through puberty the natural progression is for all of those tissues to grow and have a little bit of an external appearance. The labia minora can be anywhere between the size of 4 centimeters to 7 centimeters and still be completely normal. And so, try to normalize that through education and then honestly, I use as a resource there is a plaster mound which is going to sound crazy of various vulvas and it is called the Great Wall of Vaginas and it makes a lot of our adolescents kind of teeter and they think it’s funny or they are grossly embarrassed but it is actually a way to show girls what normal anatomy looks like. So, they have this idea of this perfect vulva that is honestly kind of infantile which is actually not what a post pubertal vulva should look like. So, educate about the normal pubertal progression and then I also refer them to that site so they can see some of other normal variants of what the external genitalia for a female will look like.
Melanie: Dr. Arbuckle, unfortunately children are vulnerable to the same sexually transmitted infections that adults carry. So, if a child comes to you and presents with irritation or some infection, is there some standard of care that you would run to see if it was a sexually transmitted infection or if abuse has taken place?
Dr. Arbuckle: That’s a great question. So, we do at UAB, have a specialized clinic for the evaluation for concerns for sexual abuse. If there is a concern by the family, for sexual abuse, it is most appropriate to go through that clinic. It’s called the Chips clinic and it is run through Children’s. Most people will get referred there through DHR. If girls come in and they have no concern for a sexually transmitted infection, that is certainly something we are still aware as a possibility. Things that would heighten the concern for sexually transmitted infection is if there is a discharge that is purulent, meaning more thick, yellow thick secretions or green, those are things that make us much more concerned for there being an infection that is sexually transmitted rather than just an overgrowth of other bacteria. The screening for that can happen in two ways. The actual secretions can be tested or we can test in urine. Obviously, that is nothing that anybody every wants to go through, but if there is a purulent discharge and there is a sexually transmitted infection it is important that those get treated and then that a case be opened with DHR so that that child can be protected.
Melanie: And along those lines, the HPV vaccine being given to young girls as young as 9 now, and up through the age of 26. Do you as a pediatric and adolescent gynecologist involve in that? Is that just the pediatrician? And how do you discuss that with young girls and what it means?
Dr. Arbuckle: Absolutely. HPV vaccination is one of the things that I’m actually most passionate about. As a consultant, it is often hard to administer the HPV vaccine, so for instance we will often see one patient just once and we may see them once a year and the HPV vaccination depending on the patient’s age does require two or more visits. And sometimes it is not convenient for our- specifically our consulting patients to come to our office for those vaccinations. I do make it a routine part of my practice to educate families about the HPV vaccine and we do offer it in our clinic. If it is convenient for them to start the vaccination series with us, we will and then they are educated on how to complete that vaccination series with their pediatrician.
As far as the conversation about the vaccine, I try to highlight that it is a vaccine that has been proven to protect against cancer and that’s a rare opportunity. It talk about the prevalence of HPV and that the vast majority of adults through consensual sexual contact will come in contact with HPV. We talk about the sequelae of HPV, head and neck cancers, genital cancers and that those cancers that are indiscriminate so regardless of your own behavior, you may be exposed to those viruses through sexual contact. And then we talk about the vaccine, that it is very well tolerated. Unfortunately, there is a lot of misinformation in the culture, especially with social media regarding the safety of HPV vaccine and then those patients and specifically those parents who are concerned about the safety of HPV vaccination, I refer them to the CDCs website as well as the Institute of Medicine’s most recent study where they looked at the safety of all vaccines and actually showed that HPV vaccine is no more dangerous than the chickenpox vaccine and while parents wouldn’t hesitate at all to immunize their children against chickenpox, they likewise should not hesitate to vaccinate against HPV.
Melanie: The landscape has changed for both pediatricians and for pediatric and adolescent gynecologists in the impact of social media and the sexual and social wellness of adolescents. Is this something that you think pediatricians and physicians should possibly delve into because it really has changed how we speak to our young children and what they are learning in the outside world.
Dr. Arbuckle: Yeah, I completely agree with you. So, we try to talk about oftentimes when I walk into a patient’s room, daughter has her phone, mom has her phone and they are both navigating their own social networks and their own resources which may or may not be accurate and so we try to talk about specifically relationships and how to have safe and healthy relationships. Unfortunately, I think a lot of girls kind of underestimate the internet world and how widespread it is and how depersonalized it is and so try to help them build self-esteem as well as take steps to keep themselves safe on the internet. I think there is a lot of photo sharing apps, live chatting that can actually put girls at a place – in a vulnerable place where they could be potentially victimized and so I try to educate them about safe spaces to be – to share their bodies. For instance, it is inappropriate to be sharing physical pictures of any private parts via text or over the internet and really just try to help them realize that their bodies are precious and that though it may be convenient and easy to share images of it, that those images are really inappropriate to be shared in that medium.
Melanie: So, in summary, Dr. Arbukle, tell other physicians what you would like them to know about pediatric and adolescent gynecology and when to refer to a specialist.
Dr. Arbuckle: Yeah. So, pediatric and adolescent gynecologists offer that care again from newborn to age 21 and there are some general OB/GYNs who are comfortable seeing across that spectrum and there are some pediatricians who are comfortable seeing across that spectrum. In addition, adolescent medicine providers also have a lot of overlap in the patients that we see. Often our referrals will come from physicians who are not comfortable seeing that age group and so if there is a physician who thinks heh, I think this patient might be better suited by an IUD and I am not comfortable placing it in adolescent, that’s a great referral. Or if there is recurrent problems. Recurrent ovarian cysts, disorders like polycystic ovarian syndrome, Mullerian anomalies, abnormal uterine bleeding, or amenorrhea. Those are probably our most common consultations and then we are always available for even just curbside so if somebody is managing somebody and they have gotten to the point where they are not really comfortable, just a phone call to say heh, what would be your next step and if that next step doesn’t work, always being available as a backup and to go a little bit further in the exploration of the patient’s pathology.
Melanie: Tell us about your team. Why is UAB so great to work with?
Dr. Arbuckle: Yeah, so I am fortunate to have two partners. Kim Hoover is the director of the pediatric and adolescent gynecology subdivision and we have just hired a new partner Dr. Erin Cook and you really truly could not find a more dedicated and passionate set of coworkers to work with. Each of them has their own niche and their own favorite patient populations. They are great communicators with both patients and their mother’s and then we have a dedicated team of nursing staff and CMAs who are really passionate about advocating for these young women and providing them safe and comfortable care.
Melanie: Thank you so much for being with us today. And 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 are 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/ua060.mp3
- DoctorsMehta, Amitkumar N.;Costa, Luciano J.
- Featured SpeakerAmitkumar N. Mehta, MD | Luciano J. Costa, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4779
- Guest BioAmitkumar N. Mehta, MD is currently assistant professor and associate scientist at the University of Alabama at Birmingham Comprehensive Cancer Center (UABCCC). He is board certified in Internal Medicine, Hematology and Oncology.
Learn more about Amitkumar N. Mehta, MD
Luciano J Costa, MD, is a Hematology/Oncology specialist in Birmingham, Alabama. He attended and graduated from medical school in 1998, having over 19 years of diverse experience, especially in Hematology/Oncology. He is affiliated with the University Of Alabama.
Learn more about Luciano J. Costa, MD
Release Date: March 15, 2018
Reissue Date: March 29, 2021
Expiration Date: March 29, 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.
Faculty:
Luciano J. Costa, MD, PhD
Associate Professor in Hematology and Medical Oncology
Amitkumar Mehta, MD
Assistant Professor in Hematology, Leukemia and Lymphoma
Dr. Costa has the following financial relationships with commercial interests:
Grants/Research Support/Grants Pending - Celgene, Janssen, Amgen, Genentech
Consulting Fee - Amgen, Janssen, BMS, Karyopharm, Sanofi
Honorarium - Janssen, BMS, Amgen
Dr. Mehta has the following financial relationships with commercial interests:
Grants/Research Support/Grants Pending - Incyte, Takeda, fortyseven Inc/Gilead, Juno pharmaceuticals/BMS, Celgene/BMS, Oncotartis, Innate pharmaceuticals, Seattle Genetics, TG Therapeutics, Affimed, Merck, Kite/Gilead, Roche-Genentech, ADC therapeutics, Miragen, Rhizen Pharmaceuticals
Consulting Fee - TG Therapeutics, Incyte/Morphosys, Seattle Genetics
Payment for Lectures, including service on Speakers Bureaus - Gilead, Astra Zeneca, Pharmacyclics, Seattle Genetics, Incyte, Morphosys/Incyte, Carevive, Kyowa Kirin
Drs. Costa and Mehta do not intend to discuss the off-label use of a product. 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.
- TranscriptionMelanie Cole (Host): UAB MedCast is an ongoing medical education podcast. The UAB Division of Continuing Education, designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category one credit. To collect credit, please visit UAB medicine.org/medcast and complete the episode’s post-test.
According the National Cancer Institute, the foundations of cancer treatment have typically been surgery, chemotherapy, and radiation therapy. Noe however, immunotherapy has become what many in the cancer community now call the fifth pillar or cancer treatment. One that is emerging onto the scene is an approach called adoptive cell transfer; collecting and using patient’s own immune cells to treat their cancer. My guests in this panel discussion today, are Dr. Amitkumar N. Mehta. He’s a hematologist oncologist specializing in lymphoma at UAB Medicine and Dr. Luciano J. Costa. He’s a hematologist oncologist specializing in lymphoid malignancies and blood and marrow transplantation at UAB. Welcome to the show gentlemen. So, Dr. Mehta, I’m going to start with you. Tell us a little bit about the evolution of immunotherapy and how that’s breaking on to the cancer scene.
Dr. Amitkumar N. Mehta, MD (Guest): So, for the immunotherapy lymphoma doctors – for lymphoma doctors, it is not a new therapy. Rituximab was the first immunotherapy which was approved for lymphoma treatment in late 1990's and it was added to the backbone of CHOP chemotherapy. Over a period of years, we have actually evolved and now we have antibody drug conjugates and more immunotherapies like checkpoint inhibitors. The latest addition to the immunotherapy is the adoptive T cell transfer treatments or what we call CAR chimeric antigen treatment for the lymphomas. It’s a unique treatment which has actually changed quite a bit of treatment paradigm of various kinds of lymphomas.
Melanie: So, Dr. Costa, as we are explaining to other physicians how this type of immunotherapy and therapy is emerging onto the scene, explain a little bit about the chimeric antigen receptors and this CAR T cell therapy. How did it come about?
Dr. Luciano J. Costa, MD (Guest): Absolutely, so the concept here is – has been pursued actually for decades, but really didn’t come to reality until very recently. One way – a simple way to understand this is cancer, in order to develop, needs to evade the immune system. Our body is coming up with new cancer cells on a daily basis and part of the reason why we are not developing cancers all the time; is because there is immune surveillance from our own immune system that destroy cancer cells. So, by definition, if a cancer does develop it is because the cancer has evaded the immune system.
So, the cells in our immune system that destroy cancer are also the same type of cells that destroy cells that have been infected by virus for example. And those cells are called defector T cells and they have a very broad repertoire that recognizes different targets; usually different infections that can accord to the cells. The concept here is quite sophisticated and fascinating is if you take those cells that have a specificity against multiple different random antigens that become kind of insignificant; take those cells out of the patient and then you transfect those cells using a virus, you transfect the cells with a molecule that is called chimeric antigen receptor. So this is a molecule that does not exist in nature, is not an antibody; it’s really a built from the bottom up molecule that has portions that resemble an antibody for example so it can recognize a specific target, and has portions that actually signal to the T cell to grow and to proliferate. So, that way, you can engineer those receptors for the specific target that you desire, transfect those receptors on the T cells, expand those T cells, and then reinfuse those cells in the patient. And those cells will bind to whatever contains the target, expand and essentially drive a very robust and rapid immune reaction against whatever cell contains that target.
So, really the challenge beyond that point, is not about the technology any longer, the challenge becomes find the right target on the right cancer in order for that technique to be effective. So, currently, the disease for where this is most developed is with lymphoma and acute lymphoblastic leukemia to have a very suitable target called CD 19 and there are several other malignancies following a little bit behind who have other targets that are amenable to therapy with those CAR T cells.
Dr. Mehta: And the beauty of the technology is that these cells are from patient themselves and, so they persist in the system and they actually can reach out to every tissue including brain and also they have a memory component so they last way longer in their own body.
Melanie: So, they are really little soldiers that are multiplying in there, but they are from the patient’s own body and as the core Dr. Mehta, of this adaptive immunity, what does it mean when people hear that they are the equivalent of giving patients a living drug? Is that what you are talking about, that because they come from the patient themselves, is that how that works?
Dr. Mehta: Exactly. So, as I mentioned these are the soldiers from the patient themselves, they are kind of trained in the lab to identify a specific target on the cancer cells, they are expanded, they are armed, and they are infused in the patient’s body. Now when they go in, before we do that, patients receive not chemotherapy, what we call a lympho depletion that means they get the therapy to deplete their T cells in the body. What the benefit of this approach is their body is now hungry to receive the T cells at the same time, we give them trained and expanded, armed T cells, their own T cells and infuse them so that the body adapts, takes them, nurtures them, they grow, but they are trained, armed and they exactly know where to go especially directing towards the antigen which is present on the cancer. And with that, they attack on the cancer and the idea is to completely eliminate the cancer.
Melanie: Dr. Costa, as many cancer therapies cause several worrisome and sometimes even fatal side effects. What are some of the risk benefits? Speak about that ratio with CAR T cell therapy, what are some of the current issues in management, once you have detected how these are working.
Dr. Costa: Yeah, that’s a very important point. And I would highlight cellular therapy of some sort is not new to cancer treatment particularly treatment of blood cancers. The most well-established type of cellular therapy has been with so called bone marrow transplant that can be performed with the with either their own cells or with the cells from the donor. And that has a very well-defined spectrum of toxicities that are very well known. This is something different. Because in one way, we are not just using their own cells with any manipulation. Those cells are being genetically engineered and on the other hand, we are not using cells from a donor, so many of the problems that come with a standard bone marrow transplant, that has to do with rejection and something called graft versus host disease; is something that does not occur – should not occur with a CAR T cell from the own individual.
However, there is a series of very specific toxicities that are unique to this therapy and that the field is now learning very rapidly to recognize and to manage. One of those toxicities is so called cytokine release syndrome which essentially consists of a downstream effect of a very intense activation of the immune system and the expansion of those – and activation of those T cells and other cells that are cross activated by the T cells that causes the release in the blood stream of a series of different cytokines, the one that has been a better recognized is called interleukin 6 and those cytokines can cause very broad spectrum of side effects ranging from mild fever going through decreasing blood pressure, respiratory problems, liver problems, kidney failure becoming even a situation of hypotension and multi-organ failure. Fortunately, we have learned to recognize and to manage that toxicity and that can be very rapidly overcome in most cases by using an antagonist of the interleukin 6 or an antagonist of interleukin 6 receptor that blocks the reaction, improves the symptoms without apparently any impairment of the effect of the T cells on the cancer. The other reaction that generates great concern; is called – is an encephalopathy, essentially neurological impairment then occurs after this therapy. This neurologic impairment can be quite minor. In some patients, it can become light confusion, some difficulty writing, sometime difficulty forming words, but in more advanced stages can become really – the patient can even become comatose and in early trials, even patients have died due to brain edema. The mechanism of that is still a little bit uncertain. What is most believed to be the case is that the cytokines can cross the blood brain barrier and really trigger sort of a localized reaction in the nervous system and cause the brain swelling while the therapies that we use for example the blockage of the interleukin 6 does not have the capacity to permeate the central nervous system. That reaction can be closely monitored and in most cases, can be reversed promptly with the use of corticosteroids.
So, in order to safely perform the therapy, it is required that the physician and the nurses team that is administering this therapy is very, very familiar with those toxicities. It is fundamental that you have a systematic approach to monitor for those toxicities, recognize and treat those promptly. And when that is done; fortunately, fatal cases become very uncommon.
Dr. Mehta: So, that’s a great point and as you mentioned, with the specialized treatment; we have very specific immune related toxicities and that’s one of the reasons that the physicians and the support staff should be trained and experienced to not only recognize those toxicities earlier and intervene earlier to prevent the fatalities. So, to speak, there is a learning curve with that. Also, these T cells are directed towards CD 19, the currently approved treatment perspective. They are also universally expressed on the B cells and technically what we are doing is some of the B cells which are normal, they get also destroyed. So, these patients might have long-term what we call B cell aplasia and that can lead to low production of immunoglobins and infections. So, in that case, these patients need to be followed very closely. So, overall, not only the physicians but also the supportive staff, the APPs, and nurses should be trained to recognize these complications earlier so that we can intervene earlier.
Melanie: Dr. Mehta, since the CAR T cell therapy was approved recently for treatment of children with ALL; do you see that adults with advanced lymphomas may be close behind and do you expect any other types of this type of therapy to be approved soon?
Dr. Mehta: So, the first approval was end of August when the CAR T cell directed towards CD 19 was approved for acute lymphoblastic leukemia in a pediatric age group, the upper limit of the age group of 25 years. After that, on October – mid October, the FDA also approved the CAR T treatment directed towards CD 19 for lymphomas which included diffuse large B cell lymphoma, primary mediastinal lymphoma, transformed follicular lymphoma, and any aggressive B cell lymphoma. There is also a third product which might get an expansion of the approval which got approved for leukemia for lymphoma maybe early next year. With this success, there is a great deal of enthusiasm. Because once as Dr. Costa mentioned before, the technology is there, now we are to identify a specific antigen which are uniquely expressed on the cancer cell and also this programed and trained T cells can go in and invade to the cancer. The next in line and Dr. Costa can speak a little more to that, is a CAR T in myeloma which has shown very, very promising activity and the date were presented both in ASHCO as well as ASH this year where the CAR T are directed towards BCMA specific antigen in multiple myeloma. Now, this both approaches has opened up the doors of multiple opportunities to look into different cancers. Technically, any cancer where the cancer cell expresses specific antigen and you can program your T cells to target that antigen; you can have a CAR T. The solid tumors, is a little bit challenging at this point. A solid tumor what I mean to say is breast cancer, or colon cancer, or lung cancer and others because of the fact of that in solid tumors the tumor microenvironment is very, very immune resistant. That means they don’t allow – that environment doesn’t allow the immune cells to invade into the tumor space. But we will have more different kinds of T cells programmed so that they can invade so in the future, we might see more so to speak technology to see whether the cells can invade into that.
Melanie: Dr. Costa, do you have something to add to that?
Dr. Costa: Yes, I would like to add to Dr. Mehta’s comment on multiple myeloma, that it is a very common cancer, blood cancer, the second most common type of blood cancer after actually lymphoma and one that for most patients is fatal as opposed to lymphoma where fortunately we are able to treat and cure the majority of patients with aggressive lymphoma with a first or second line of therapy. So, myeloma unfortunately, eventually near all the patients will end up with highly refractory disease so newer treatments are needed. Just like CD 19 was identified as the ideal target for the pediatric ALL and for B cell lymphomas. Such target has several targets have been identified in multiple myeloma. The most promising one is called B cell maturation antigen or BCMA and there are currently at least four different companies very aggressive with developing BCMA target CAR T cells. Some are in phase one clinical trials and we hope to have at least one of those trials at UAB in about one year. But the interesting part is CAR T cells is a fascinating technology and has really shed a lot of light into immunotherapy. But it is important to keep in mind that CAR T cell is not the only way to approach immunotherapy in those hematological malignancies. Dr. Mehta previously mentioned the monoclonal antibodies the so called naked monoclonal antibodies such as rituximab which has been a tremendous success for now 15 years. And there are several in between approaches for example, using the very same target at times that we use for the CAR T cells to target with antibodies that contain drugs that are attached to it so there is a payload of that antibody that allows to deliver a specific poison to the cancer, directly into the cancer tissue and minimize the exposure of normal organs.
Another very fascinating approach is instead of taking the cells out of the body and engineering the cells to the chimeric receptor to target that specific target on the cancer cell. There is the technology of so called bispecific antibodies which are antibodies that in one hand bind to the target in this example BCMA, but on the other hand, they the very same T cells that are the professional killers of the immune system in a way facilitating that robust immune reaction against the cancer with a product that can be manufactured in large scale without the logistic complexity of the CAR T cell therapy. So, those are other avenues that are being pursued and they have many of the same efficacy that remains to be seen, but have some of the same toxicities and complexity and I think over time we will know which approach is best to pursue but it is just important to keep in mind that CAR T cell therapy is not the only way to take advantage of the advances in immunotherapy.
Melanie: Dr. Mehta, first last word to you here in summary, tell other physicians what you would like them to know and this is a huge and very fascinating topic and we didn’t even really get into the cost basis of this and some of the limitations that you researchers are facing. But let other physicians know what you would like them to know about this type of therapy and when they should refer to a specialist.
Dr. Mehta: So, that’s a great question and per the FDA indication, those who have failed two lines of treatment or those lymphomas who are primarily refractory; they will be eligible for this kind of treatment. It is highly specialized and of course the referral will need to be earlier. We cannot wait until the disease is progressing, rather an earlier approach so that we can have the patients in the process. It has multiple steps in that. We want to make sure that the patient’s performance status is good; their heart, lungs, kidneys are good enough to sustain such kind of treatment. They also undergo apheresis, that means collection of T cells. The T cells go back to the commercial facility. They get ready, armed and then they are sent back. The whole process may take somewhere between two weeks to up to eight weeks. And then the patient gets admitted for the chemotherapy and gets the infusion and then needs close follow up. The most important part and I love to say that, that the collaboration would definitely benefit the patient, so, the community doctors who are serving the communities should approach these specialists and these specialized centers who are doing CAR T earlier, recognize the patients, send them before they progress, so that they are in the system and they start getting evaluated.
You also mentioned about the cost which is a big factor because of the fact that both of them they are around half a million dollars of infusion without the admissions and the other chemotherapy that is an additional step that we need to go through the insurance company to make sure that it is approved. We also want to make sure that the patients get proper financial assistance and directions if they had any copay so that they can seek the financial support to get this kind of treatments. So I think the most important part that my message to the physicians who are serving the community is make sure that you identify those patients earlier and make the referral earlier and pick up the phone and call us and we UA
Melanie: Dr. Costa last word to you and then tell us about your team. Why is UAB so great to work with and give us your version of the wrap up.
Dr. Costa: Thank you so much. So, I couldn’t agree more with the words from Dr. Mehta. Dr. Mehta and
I have the privilege of being subspecialized in a – really it is a small sector of oncology and even that is at
various times challenged to keep up with the progress and all the options available. We are both very
deeply involved into clinical research and that’s a very dynamic world where protocols, open and close
and get modified all the time. So, I think the key message to the listener, to the oncologists,
hematologists managing patients with aggressive blood malignancies is if you are facing a situation that is not trivial upfront standard patient, if you have a relapsed patient, a challenging patient; feel free to call us. We welcome the advent of CAR T cell therapy that again, brings some more visibility to what we have to offer but it is certainly not the only thing we offer, and it might be times where we have a different experimental therapy that might be just as exciting or just as promising. Both Dr. Mehta and I, we are involved in very – we have a very broad diverse portfolio of clinical trials including several immunotherapy trials for lymphoma and multiple myeloma and we will be delighted to work with the physicians for the best outcome of their patients.
I think why UAB is special; I think is the people that we have and the privilege that we have to serve the population of Alabama. That’s our mission to be here as a resource to our people at to the resource our colleagues who are in the community carrying the heavy burden of treating cancer patients throughout the states. We have put a lot of time and effort and planning on being positioned to provide novel therapies to patients with advanced blood malignancies in a way that is timely, is ethical and is efficient. And we have both Dr. Mehta and I; we are co-directing this new program at UAB that is being developed as an extension of the bone marrow transplant and cell therapy programs and I think we have made big strides on streamlining the path of referral to make sure the patients who come to UAB with a lymphoma, with a multiple myeloma they have a quick and broad access throughout the available in experimental therapies and the way the cases are discussed, and proper treatment is assigned promptly. We are very proud of the work that we have done and we then we have a lot more ahead of us and we are very proud to be able to serve the people of Alabama and our colleagues in the community.
Melanie: Thank you so much gentlemen, for being with us today and for al the amazing work that you 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/ua062.mp3
- DoctorsMomaya, Amit
- Featured SpeakerAmit Momaya, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4582
- Guest BioAmit Momaya, MD is an Orthopaedic Surgeon with UAB Medical.
Learn more about Amit Momaya, MD
Release Date: March 2, 2018
Reissue Date: March 1, 2021
Expiration Date: March 1, 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.
Faculty:
Amit Momaya, MD
Assistant Professor in Orthopedic Surgery
Dr. Momaya has no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): UAB Medcast is an ongoing medical education podcast. The UAB Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA Category One credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s posttest.
Melanie Cole (Host): From the weekend warrior to the professional athlete, physicians at UAB Sports Medicine provide care designed to enable patients to return to their active lifestyle safely and as soon as possible. Here to tell us about that is Dr. Amit Momaya. He’s an orthopedic surgeon with UAB Medicine. Welcome to the show, Dr. Momaya. Explain a little bit about the prevalence of sports injuries and what are some of the most common that you see everyday.
Dr. Amit Mukesh Momaya, MD (Guest): Sure. Thank you for having me. The prevalence of sports injuries is certainly increasing, especially in adolescent athletes. Numerous kids and more and more every day are engaging in sports. Almost nearly 30 million children actually participate in youth sports in the United States, and high school athletes accounted for approximately 2 million injuries last year, came for almost half a million doctor visits. Some of the most common types of injuries that I see include ACL ruptures, shoulder dislocations, and ankle sprains, most commonly.
Melanie: So, let’s discuss some of those and what are some of the factors that lead, like you said, ACL ruptures? And we know these are more prevalent in girls and soccer players; speak about some of the factors that lead to these or the causes that we know of.
Dr. Momaya: Sure. Some of the risk factors for injuries in general, especially with ACLs is—part of it’s anatomic alignment. Specifically, why do girls have a higher rate of ACL injury than boys? Well, boys have a wider inner condylar notch, that’s the space between the femur bone and the thigh bone called the tibia, and that wider notch appears to allow the ACL to rest without getting injured. Women are more prone to get injured because they have a narrower notch. They’re also more likely to be knock-kneed which we know can put them at risk for an ACL injury. Some of the other reasons that girls can experience ACL injuries more often than boys is because in girls, the upper leg muscles may not be as strong as for boys. Then they’re even more quad dominant sometimes, and this can put them at risk, and finally, we know from recent studies that hormones put females at risk, and so there’s something with the cycles of ovulation that definitely put them at risk for ACL injuries.
Melanie: What about overuse injuries because there’s sports-specific training, throwing injuries in baseball? As an orthopedic surgeon, what do you want other physicians to know about these overuse and counseling their patients about maybe certain amount of throwing or these overuse injuries and chronic injuries?
Dr. Momaya: Sure. Yeah. We’re seeing an epidemic of overuse injuries today, especially in a culture where kids are specializing in sports at a much earlier age than they used to. Several studies have shown that the earlier you specialize in a sport and focus on it, you’re more prone to an overuse injury, and not only that, not able to make it to the next level, whether that be collegiate or professional. An important thing for physicians to know when counseling patients that seem to be having specific injuries, for example, baseball is one of the common culprits for these overuse injuries. A lot of young kids are playing on multiple teams; they’re playing on their local recreation league. They may be playing on a travel team. They may be playing for their high school team at the same time, puts their elbows at risk. They’re still growing, and we know that the ulnar collateral ligament can feel a lot of stress early on, and if their throwing mechanics are not appropriate or if their pitch counts are getting too high, that’s way too much stress for a young pitcher to place on his or her elbow, and thus an important thing for physicians to recognize is to counsel these patients on limiting their throwing, making sure that coaches and trainers know the pitch counts, keeping track of pitch counts. We know that if pitchers are limited, we know that’ll decrease their rate of injury. Also, we want kids to be playing multiple sports. We don’t want them specializing in one sport because then the same muscle groups are constantly being used throughout the year, and we think that multiple sports allows a more complete kind of maturation of the athlete and allows them then eventually to be more successful down the road, whether that be collegiate or professionally and have less injuries in life.
Melanie: What are some key elements of a program in sports medicine? What do you feel that physicians and pediatric offices and things should know and be able to deal with the schools and the coaches?
Dr. Momaya: Sure. Just like any sports team, I think a key element of sports medicine is having a team-based approach. It’s hard for a physician to completely take care of the entire athlete and the entire team due to the busy nature of sports and of clinical practice. Part of it is to establish connections with athletic trainers, therapists, nutritionists, straight-training coaches and having that relationship with them so there’s a two-way road about discussing kind of the training regimens and how things are going. Another important aspect the physicians should recognize is that they need to have early and easy access for these athletes to get into. Oftentimes, these athletes are eager to return back to sports and will often injure themselves further if we do not provide them with easy-access care early on which may fix a smaller problem from becoming a bigger problem.
Melanie: What do you see are some challenges at adherence? You just mentioned easy access and getting in to see their trainers and learning some of the proper techniques, plyometrics for ACL protection, that sort of thing. What do you see are some of the challenges? Are these athletes also willing to go along with maybe cross training or not training all year round for the same sport? Do you see that doctor?
Dr. Momaya: That’s definitely a problem—is trying to convince these athletes that it’s okay if they step away from the baseball diamond for half a year and play another sport; do some other types of training. They’re very worried that they’re kind of missing out on these kind of marquee tournaments and scouts and so forth. So, that is definitely a problem of kind of adhering to a plan of despeciallizing in sports. Now, the other things you kind of mentioned are, you know, a lot of times we’ll teach girls appropriate jump/landing techniques, which we know that if they go into a knock-kneed state when they land, they’re more prone to an ACL rupture. We try to implement those kind of teachings. So, communicate that with the athletic trainers and the therapists out there in the community in order to help prevent ACL ruptures. However, it can be very difficult for athletes to adhere and understand these principles, especially when they’re not having any pain, to practice a preventative-type medicine to prevent a future ACL injury. So, that’s definitely an issue we’ve faced.
Melanie: Well, it certainly is, and also return to play, and as you say, these athletes are hesitant to take any time off or to do some of the just specific training that would help them to avoid these injuries, and what do you want team physicians and athletic trainers to know about return to play and allowing their athletes to get back into it, avoiding some of these chronic injuries?
Dr. Momaya: Sure. Return to play is a very key element in making a successful career in sports for the athlete. Most athletes are returning to play too quickly, whether it be from a chronic overuse injury or whether that be post-surgery. It’s important for players to rest and fully recover and not only to do that, but also address the underlying issue of why they got injured in the first place, whether it be change in mechanics, change in jumping techniques, so forth, landing technique, and other things. So, that’s an important aspect of making sure there’s communication with the therapist or athletic trainer about if we’re fixing the underlying cause before they go on to return to play. Oftentimes, the coaches will pressure some of these athletes to return to play quickly. So, sometimes we have pressure from the parents, and the athlete themselves wanting to return to play, and in addition after surgery, we often know, for example, when we stabilize a shoulder after it’s been dislocated, we often don’t want them to return to play until six months after surgery. The athlete themselves will often feel very good within a few months and want to return to play earlier, but we know that there’s continued healing of the labrum down to the glenoid, and we hope that they will continue the rehabilitation and thus decrease the risk of further dislocations.
Melanie: And, so, what do you see are some interventions besides prevention? Are Kid’s Motrin? Are they icing, wrapping? What do you recommend that they do if they have sustained even a small injury like a light sprain or an overuse chronic tendonitis? What do you want them to do for management?
Dr. Momaya: Right. For symptomatic management, you generally, when an athlete sustains, say, an ankle sprain or something overused, I think the appropriate acronym that we’ll often use is RICE, which stands for, in terms of rest—we’re resting the extremity to make sure it’s not further injured. We’re elevating the extremity to help swelling go down. We’re also applying compression. Compression’s an important aspect of controlling edema and swelling from the extremity as to let the athlete return quickly. You were mentioning Motrin and anti-inflammatories. That’s appropriate to take. We don’t want young athletes to take this long-term, as they can cause problems. We don’t want athletes to only be able to return to play by taking constant anti-inflammatories, but acutely, if an athlete does sustain an injury, then it’s appropriate to just ice it and use an anti-inflammatory to help in the acute phase.
Melanie: So, where do you see this field going from here and speak about your team at UAB.
Dr. Momaya: Sure. So, I think, you know, here we, in terms of the field going, we’re further understanding, you know, what’s leading to sports injuries and not only that is on a preventative side, but also how to treat these sports injuries. Recently, orthobiologics has become a very big hot topic in sports. Many people have heard about people, especially professional athletes, seeking out PRP injections, which are platelet-rich plasma injections and stem cell injections. Out there, there’s a lot of research being done, and there’s all the conflicting research out there. Some studies showing that it may help regenerate and heal soft-tissue injuries quicker, while others say that we’re not sure yet. We still have further research to do and doesn’t seem to change much based on placebo or other control treatments. And so, I think, the future of kind of sports medicine, in addition to preventative medicine, will be heavily based on orthobiologics and how to use the technology to help hasten the recovery of athletes and allow them to return to sports. Traditionally, orthopedic surgeons, we’re known as carpenters. We’re very good at fixing bones. We’re good at repairing and reconstructing ligaments, but I think now we’re taking a step back and realizing the basic science aspect of things are a very important part and should be in conjunction with our work surgically.
In terms of UAB, you know, working here at UAB is great. We have an excellent team. We have multiple athletic trainers, great coaches, and most importantly, great student athletes to work with. Just this multi-disciplinary approach here at UAB allows us to take care of the athlete in a full manner and thoroughly enjoy kind of working with our student athletes who are very focused both on an educational level and kind of staying with the protocol and following so they can get back to play.
Melanie: Thank you so much, doctor, for being with 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 uabmedicine.org/physician. That’s uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua055.mp3
- DoctorsYang, Eddy S.
- Featured SpeakerEddy S. Yang, MD, PhD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4549
- Guest BioEddy S. Yang, MD, PhD, received his MD and PhD from the University of Miami School of Medicine and continued post-graduate training in the Department of Radiation Oncology at Vanderbilt University as a Holman Pathway Resident Research Scholar.
Learn more about Eddy S. Yang, MD, PhD
The Latest Research in Precision Oncology (2021 Reissue)
https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4549
Release Date: February 28, 2018
Reissue Date: February 19, 2021
Expiration Date: February 19, 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.
Faculty:
Eddy Yang, MD, PhD
Associate Professor in Radiation Oncology
Dr. Yang has disclosed the following commercial interests:
· Grants/Research Support/Grants Pending – Eli Lily, Novartis
· Honorarium – Strata Oncology
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Precision Oncology is an innovative approach to cancer treatment that ensures treatment is specifically designed and targeted to each unique form of cancer. It’s the science of using each patient’s individual genetics to create a treatment protocol just for them based on those genetic mutations. Here to tell us about Precision Oncology, is Dr. Eddy Yang. He’s the Deputy Director of the Hugh Kaul Precision Medicine Institute of UAB Medicine. Welcome to the show, Dr. Yang. What is Precision Oncology? Define it for us, and explain a little bit about the evolution of it.
Dr. Eddy Yang (Guest): Sure. Precision Oncology is really to treat cancer patients with the right drug at the right time, and really understanding as much information about the cancer from using the genomic sequencing to even patient information to get the appropriate therapy for the patient.
Melanie: What are some of the challenges of defining Precision Oncology as you have, and applying this concept than to treating cancer?
Dr. Yang: I think the biggest challenge right now, is gaining enough evidence to show that Precision Oncology is a cost-effective method to improve outcomes for our cancer patients.
Melanie: So, if you are looking at some of these challenges, how do you know when to implement, Dr. Yang? Is there an advantage to testing early in the treatment course of patients with advanced cancer or giving them the advantage of being able to plan for the timing of enrollment in clinical trials or administration of other targeted therapies?
Dr. Yang: Yeah, so currently, I think that a lot of institutions utilize Precision Oncology efforts at the time when patients do not have any other option. We believe that getting that information earlier may be helpful just to be able to act at the right time. Having that information early on allows us to do that more effectively and more efficiently.
Melanie: Dr. Yang, is there a practical case against Precision Oncology? Is there a question of whether it positively affects clinical outcomes? What are some of the studies you’ve read?
Dr. Yang: Yeah, so there are several studies that show there is a benefit. One from MD Anderson showed that if they treated patients according to their genomic profile of the tumor compared to just traditional chemotherapy, there was a benefit in terms of prolonging the patients’ progression-free survival. There are other studies similar to that. It thinks the biggest challenge, though, is that is it cost-effective? Many insurance companies do not currently pay for the testing. There are only specific situations where the insurance companies will pay for that.
Melanie: With the rise of commercial tests, do you worry about data consistency, reproducibility, are there limitations of the current testing methodologies and reports and such? What do you see?
Dr. Yang: Yeah, so, I think the reproducibility and the way each company reports the data is – there are standardized ways of doing this. Whether a patient goes through testing with one company or another right now, really there are no guidelines for that.
Melanie: What do you want to happen along those lines if there are no guidelines? I’ll ask you the blueprint for future research question in a little bit, but if there are no guidelines, how can you be sure that some of these things will work or that they’re going to have the approved outcomes?
Dr. Yang: I think we have to utilize a testing platform that’s been tested and provide enough evidence to show that what they’re finding is correct. It is an evolving area where we’re trying to gather enough data to support this.
Melanie: Do you think that the genome era that you’re seeing now as an oncologist poses clinical development challenges? Are you – people are looking at genetics now -- and genomics – and trying to figure out the best way to use these targeted therapies. What do you see are some additional challenges along those lines?
Dr. Yang: Well, I think we need to have more information and start thinking – I think the future of the way we see cancer itself is not where the cancer is coming from but rather what is driving that cancer. As an example, with the recent FDA approval of one of the immunotherapies, it’s what we call tumor agnostic, meaning that it can be tumor from any site of the body, but as long as there’s a genomic profile that’s called microsatellite instability or MSI, then patients could receive that immunotherapy. It’s that way of thinking that’s evolving from a specific cancer like a prostate or a breast cancer to now, a cancer that is MSI. That’s I think a challenge where we have to think of cancer in a different manner than what we traditionally thought of cancer.
Melanie: What does current research indicate for some of the future developments if you’re talking about primary cancers, metastases, and using all of this Precision Oncology to target – whether it’s immunotherapy or targeted therapies, whatever you’re using – what do you see, in your opinion, is going to happen in future research? Do you feel like Precision Oncology is going to work?
Dr. Yang: Yeah, I think Precision Oncology is going to work. I think the future is if you’re giving out the proper and appropriate combinations of treatment, and incorporating other biomarkers besides just the DNA mutations, but incorporating other biomarkers that can help inform us on how to treat the patient better and more effectively. Part of that is really incorporating more information about the cancer and about the patient in a cost-effective manner.
Melanie: Are there some treatments or research that you’re doing at UAB that other physicians might not be aware of?
Dr. Yang: Yes, we are part of what’s called the ASCO TAPUR study. It is a 16-arm study that’s based off of the mutation profile of the cancer and we couple that with the genomic sequencing of the tumor to then allow enrollment into this trial. Some of the early efforts appear to be promising because we’re able to continue to enroll patients in this study.
Melanie: What else would you like to tell other physicians about Precision Oncology and Precision Medicine in general, that they might not be aware of and when they should probably refer to a specialist, such as yourself.
Dr. Yang: I believe that when patients – I think nowadays, they want to know the genomic profile of their tumor. A lot of times the appropriateness of ordering this test is not yet determined. It’s times like these where I think it’s appropriate to refer to a large academic center so that we can have these types of discussions and where we do have these sequencing efforts available for these patients. Additionally, at times when there are patients that already receive the genomic sequencing, but there aren’t therapies available, we would have those therapies available because of the involvement in these clinical trials.
Melanie: Tell us about your team. Why is UAB so great to work with?
Dr. Yang: I love the collaborative nature of UAB, and the team really communicates well and works well together. And really, we’re all in it for the same reason, which is to impact patient care and patient outcomes. It’s all about the patient here at UAB. Everything else kind of falls in line once we have that priority set.
Melanie: Thank you so much, for being with us today. What a fascinating topic. You’re listening to UAB Med Cast. A physician can refer a patient to UAB Medicine by calling the MIST Line at 1-800-UAB-MYST. That’s 1-800-822-6478. 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/ua046.mp3
- DoctorsMcLain, Amie
- Featured SpeakerAmie McLain, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4752
- Guest BioAmie McLain, MD is a Chair & Professor, Physical Medicine & Rehabilitation Medical Director
UAB Spinal Cord Injury Model System.Learn more about Amie McLain, MD
Release Date: February 22, 2018
Reissue Date: April 5, 2021
Expiration Date: April 5, 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.
Faculty:
Amie B. McLain, MD
Chair & Professor, Physical Medicine & Rehabilitation; Medical Director, UAB Spinal Cord Injury Model System
Dr. McLain has no financial relationships related to the content of this activity 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 0.25 AMA PRA category 1 credit. To collect credit, please visit www.uabmedicine.org/medcast and complete the episode’s post test.
Melanie Cole (Host): Every year, thousands of Americans experience a spinal cord injury. These injuries can be devastating and cause physical and emotional distress. According to the National Spinal Cord Injury Statistic Center at UAB; there are approximately 17,000 new cases of spinal cord injury each year. My guest today, is Dr. Amie McLain. She is the Chair and Professor in Physical Medicine and Rehabilitation and the Medical Director of the UAB Spinal Cord Injury Model System. Welcome to the show Dr. McLain. So, explain a little bit about spinal cord injury and some of the most common causes that you see.
Dr. Amie McLain, MD (Guest): Well the spinal cord, in itself, is part of the central nervous system and it is the major connection through which motor and sensory information of our body travels between the body and the brain. So, when you get a spinal cord injury; then you are going to disrupt that connection and that means that the information can’t get to the brain. When that happens and it can happen at various degrees of injury; the injury in the spinal cord will not allow people to feel things below that level or move things below that level. Over the years, we have seen consistently that the major cause of spinal cord injury is in a motor vehicle accident and that also includes motorcycles or 3-wheelers. But by far, those are the most common ways that people get a spinal cord injury. You also can see the second most common cause being falls and now we are seeing a little bit more population having falls as their cause of spinal cord injury; because it occurs in an older population. So, now that the population has aged some with the Baby Boomers coming through and being the largest – one of the largest groups, they are getting to the age where they fall and they have neck injuries. So, we are seeing more falls than ever before, but still automobile accidents are the most frequent. Other types of injuries that we see are injuries that have occurred from an act of violence and that can be like a blow with some type of object or gunshot wounds; those are very common and the other most common type of etiologies or causes would be sports injuries. And we still, despite all that we are doing to help prevent sports injury related spinal cord injuries; we still do see a small portion of people from sports having spinal cord injuries.
Melanie: So, Dr. McLain, what is level of injury and what’s the difference between a complete and incomplete injury? Why is this important to know the difference?
Dr. McLain: Well, in order to assess what has been damaged from a spinal cord injury; we have a systematic way of examining individuals. And we use a classification system which is called the International Standards for Neurological Classification of Spinal Cord Injury. And this has been developed and refined through the years internationally, so that everybody knows what they are talking about when they give a diagnosis from this classification. This classification is based on the areas in the spinal cord that are still working versus those that are not working. We test them through - we test sensation, and we test how well they can move muscles and if there is a level where there is normal sensation and ability to move muscles above it; but then there is a place that becomes where you don’t see anything or any movement below which is a paralysis; then that becomes the level that we designate for that spinal cord injury.
One of the other things that we want to know is whether or not the injury is complete versus incomplete. This tells us whether there may be a level that we note that has totally normal sensory and motor activity above but below that level, there may still be some preservation of something. The most important thing is that you have to have sensation around your sacral area to be an incomplete but you could also have some movement even though it is not normal. We find this very important because we – it helps us predict how severe that injury to the spinal cord was. If it was very, very complete; then the spinal cord is so damaged that it is not going to come back. After the swelling goes down there is the majority of the time, there is no change and there are some exceptions to this but if you examine this area right after the injury, and there is something that is left over below this totally normal level; then that means that prognosis is very good that as the swelling goes down on the spinal cord, and as time goes on, some of the nerves will come back and some of the repair processes of the body will come into play to where there is a good chance that more movement and sensation will return after the injury.
Melanie: So, what are some current issues in medical management if you determine that someone has paraplegia or tetraplegia; explain a little bit about these and then assess for us the appropriateness of specific treatments that you might use once you detect what is going on.
Dr. McLain: Okay, the terms paraplegia and tetraplegia, and tetraplegia used to be called – we used to use the word quadriplegia, so you still see both those terms. But paraplegia means that there is damage in the spinal cord where you still have the ability to use your hands and your arms and you have sensation and it is normal and you have a level of injury that is lower than the neck. The term tetraplegia means that you have some involvement in the arms that are paralyzed or have lost function. So, that is why we have two separate terms; one that means more damage higher up and you can’t use your arms as well and then paraplegia means that you probably can use your arms and it is very different for what types of things that you may need in the way of equipment.
As far as medical management, there are many issues. There are the issues that are important right after an acute injury; that is roadside protection and getting people to an ICU and an emergency evacuation and to areas that have spinal cord injury specialists to evaluate whether you need surgery or not or just to manage your care. There are also issues that after you are stable and they have decided whether or not you need surgery and if you have had surgery, you are stable from that; that you go into a rehabilitation management. There are treatments that one side is more an acute side to really preserve as much as possible and the surgery is to really not helped with the spinal cord injury per se; but it is to keep everything around the spinal cord, the bones that have been broken around the spinal cord, to keep them from moving or re-damaging the spinal cord. So, when you get into rehabilitation, which is a lot what I do, we start looking at all the secondary complications that occur in an acute paralysis or spinal cord injury.
Melanie: So, speak about some of those secondary complications; whether they involve the gastrointestinal system, or feeding or just give us a little overview of what you are looking at.
Dr. McLain: Well, there are several major things that we look at. When you have the spinal cord injury and you have a paralysis; there is also the communication from the organs – many organ systems that communicate to the brain, that is also disrupted. So, you end up with depending upon where your level of injury is, you usually end up with some dysfunction of either the as you mentioned, the gastrointestinal system, which is the way your bowels work and the predictability. So, you are not aware as much of that in your brain and you actually can become incontinent to where you don’t know when you will have a bowel movement or when that will happen. So, we work with retraining the bowels and putting people on programs so that they can have the predictability; maybe not the awareness, but at least have a predictability of managing that.
The same thing is with the bladder or your urological system. Your kidneys will still work but your bladder does not – is not able to send any type of signal to the brain and the brain is not able to control the bladder. Sometimes, the bladder can start working on its own and you don’t have any control of it and you don’t know when it is working or sometimes the bladder won’t work at all. In either case, you have to have a way of emptying the bladder so you don’t have urinary tract infections and later on problems with your kidneys. So, we manage that and we work with an individual in finding a way to do that according to their lifestyle.
Another major issue that we look at is skin breakdown. People who don’t have sensation are more likely to get pressure sores which can really delay any type of improvement and can become infected. So, we monitor that and we teach about that.
If there is a high level of spinal cord injury, we always are worried about respiratory system. Sometimes people, if their injury level is high enough; they have to go on a ventilator right after their injury and most of the time, they are able to be weaned from the ventilator, but they always have an impaired ability to breathe and so we work with that system to maximize breathing at which ever stage we can. We try to eventually get the – if there is tube in the neck, we try to get that removed so that people can breathe on their own and keep their breathing healthy.
So, I mean the major issues are the different subsystems and as well as preventing infections which are very common and can really set people back and then of course, getting people back psychologically into understanding about their injury and being able to say, “I have this spinal cord injury that has had a great effect on my life, but I can go on with my life and I can still do things that are participating in life and give me a quality of life.”
Melanie: So, in summary Dr., tell other physicians what you would like them to know about spinal cord injury and when to refer to a specialist.
Dr. McLain: Well, I think all individuals with a spinal cord injury should be followed by a specialist in physical medicine and rehabilitation; more as a coordinator of making sure that the preventive things are done and that the things that need to be looked at are performed and in the test. But on the other hand, I feel like all people with spinal cord injury should have a primary care doctor and a specialist that they may need at the time. The issue that I see that is more of a trend and that I have seen studies on is that physicians tend to be a little ill at ease with managing people with spinal cord injury, I think more from a fact that they do not believe that they know the comprehensive way of managing them or that something with their spinal cord injury may impact what they normally do. When that happens sometimes, and that is not everybody, not all physicians; it is just a general sense of discomfort that I feel happens, but when that happens, people do not get the complete care that they need from a primary care physician.
They need every single thing that anybody needs, any able body individual. They need all the preventive healthcare. They need their blood work. They need all the things that we would get at an age appropriate time and just because they are in a wheelchair, it doesn’t mean that they are not human first and need these things. Accessibility is another issue, that they need to make sure that anybody feels that their place of practice is accessible for them and not only is it the law, but also it insures that an individual feels comfortable and is able to be examined correctly and sometimes people- physicians don’t even get people with spinal cord injuries out of their wheelchairs when they come into the office for an annual examination. So, those types of things are very important, I think for the general population and there are also resources online or at other model systems. There are 14 model systems across the country that have a wealth of information for not only people with spinal cord injury but also physicians and practitioners that are at a good clinical level.
Melanie: And tell us about your team. Why is UAB so great to work with?
Dr. McLain: Well, we have a – we do have a great team. We have the longest held model system, which is from the National Institute of Disability and Independent Living for Rehabilitation and Research. We have had our – we apply for this every five years and we collect data on people that have had spinal cord injuries and what and the cause and complications and we have been doing this since the early 70s. We work with an international cohort to look at trends and ways that we can do things better.
Here at UAB, the system is such that we have great care in the field to bring people; we are a level 1 trauma unit. We have amazing intensivists and trauma surgeons, great neurosurgeons and orthopedic surgeons that do nothing but spinal cord surgery and understand so much about the spinal cord and how to do maximized return and then our spinal cord injury rehabilitation unit has been here since the early 60s and we had a long history of understanding secondary complications and if things aren’t done here; we have – we are constantly in contact with the newest research trials across the country or even the world and then some of the things that people shouldn’t be doing in research that’s not really sanctioned by science.
So, our team – we have the team – when you get to rehabilitation; consists of specific spinal cord injury nursing, specific physical and occupational therapists that just do spinal cord injury. We have psychological support, social services support and many other types of health professions that work together on a team to maximize the function and the quality of life of individuals with spinal cord injury.
Melanie: Thank you so much Dr. McLain, for being with us today and 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 are 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
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