Additional Info
- Audio Fileuab/ua264.mp3
- DoctorsLeisch, Leah
- Featured SpeakerLeah Leisch, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6046
- Guest BioLeah Leisch, MD is an Assistant Professor.
Learn more about Leah Leisch, MD
Release Date: November 7, 2022
Expiration Date: November 6, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Leah J. Leisch, MD
Assistant Professor in Internal Medicine
Dr. Leisch has no relevant financial relationships with ineligible companies to disclose. There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole and joining me today is Dr. Leah Leisch, she's an assistant professor in the departments of medicine and psychiatry at UAB Medicine. And she's joining me to examine medication assisted treatment for opioid dependency, Dr. Leisch, welcome back. It's such a pleasure to have you join us again. I'd like you to kind of set the table for us about some of the short term and long-term effects of opiates on the body and some of the side effects how they affect the brain and the body? And what do we know now that maybe we didn't know? Only a few short years?
Dr Leah Leisch: Right. Thank you so much for having me, we know so much more about the long term effects of opioids now than we did a few years ago. We now know that over time opioids can actually make the body more sensitive to pain. And so patients on high doses of opioids are using high doses of opioids. Recreationally, can have more pain than they would have if they were off of them sometimes. We also know that long term opioids can be associated with thinning of the bones or osteoporosis, like we normally see in elderly women, as well as in some patients with adrenal insufficiency and immunosuppression.
And so we've, really learned so much about the side effects, unfortunately, because they were medicines that we started people on so long ago, and now we're just sort of catching up and seeing those effects in the short term we know opioids cause constipation, they can cause sedation. They can cause respiratory depression. And that information hasn't changed much in the past few years.
Melanie Cole (Host): So then what had been the parameters or guidelines for prescription of opioids and what's the latest information regarding best practices as of now, and then we're gonna get into addiction and medication assisted treatment for that. But what are the best practices that we know now?
Dr Leah Leisch: Right. So the past few years have seen quite the shift in opioid prescribing guidelines. Most of us recall that in 2016, the CDC released what are now somewhat infamous guidelines about best practices for opioid prescribing, which were fairly restrictive. And while those might be best practices for patients, who've never been on opioids since we know opioids have drastic long-term effects. They really negatively impacted patients who were already on opioids and there was a lot of deprescribing that harmed patients because the effects of withdrawal are so profound.
And so the CDC is actually working on updated guidelines to try and be a bit more patient centered and individualized in how they recommend it. And so at present, there's still a recommendation that we should do our best to avoid initiating long-term opioid therapy and patients who've never been on them. But for those who are already on them, To be more cautious in our tapering attempts and more patient centered in whether we do or do not taper the CDC has also removed, or may remove the guidelines aren't quite out yet some of the specific ONE oral morphine equivalent guidelines.
So previously they had said maybe not prescribe above 200, really think about less than 90. And so now instead, what they're saying is, okay, here are some of the risks of doses above 90. Here are some of the risks of doses above this, and just recommending that you try and do your best to weigh the risks and the benefits.
Melanie Cole (Host): Well, that's a great point you just made because there is still a place for them in patient pain management. But so I'd like you to tell us about. Addiction and dependence really dependence. And what is the medication assisted treatment? What's changed since we spoke the last time?
Dr Leah Leisch: Right. So when we speak specifically about dependence versus addiction versus misuse, it's important that we kind of clarify those terms. And so everyone who's been on everyday opioids will be dependent. What we know from a variety of studies is that somewhere around 20% of patients maintained on long term opioid therapy will develop adamant behaviors, meaning they might have a urine drug screen with unexpected results. They might run out of their medicine early or something like that. But that doesn't mean that 20% of patients develop opioid use disorder or addiction.
And so it might be an isolated episode where there's dependent behavior and not a pattern. So when we speak about substance use disorders or addiction, we differentiate between misuse in a substance use disorder. And a misuse is that sort of isolated event that may happen now may happen six months from now, but isn't happening in a pattern. Substance use disorder is actually a psychiatric diagnosis that you use the DSM five to help diagnose. And there are 11 criteria and patients have to meet two or more of those in the past 12 months to be diagnosed with a substance use disorder.
And then when. Speak about in particular opioids, we clarify that they meet those criteria for opioids. And those 11 criteria I won't really list through them now because you can find them easily online. And they're in the DSM five and they're a bit long to just spit out, but essentially they reflect has the patient developed a lot of craving for opioids? Are they using despite consequences in their life? And has their use of opioids got out of their control, meaning have they tried to cut back or quit? And they can't despite their best efforts.
And you're, looking for the patient to meet at least two. And then depending if they meet two to three it's mild opioid use disorder, four, five it's moderate, and then six or more is severe opioid use disorder. And in regards then if you diagnose your with an opioid use disorder in regards to options for treatment, the most life saving treatment is to get them on a medication for opioid use disorder. I won't speak a ton about counseling today, mostly because the literature is back and forth on whether or not counseling has an impact in more mortality.
That's not to say that there's not benefits of counseling. There are certainly benefits in counseling. that individual studies have shown, but when we take studies as a whole and look at them, trying to decide what impact the counseling had versus medications, patients who receive medications, even without counseling are still far more likely to survive than patients who are not. And so we're really emphatic about getting as many patients as possible on medications for opioid use. So that they can continue to live.
And when we think about options for medications, for opioid use disorder, and you'll notice that the nomenclature has changed, sorry, I didn't even mention that. So we used to call it M A T medication assisted treatment, and now we call it M O U D or mild medications for opioid use disorder. And that's because the majority of addiction specialists don't feel like counseling is per se, it shouldn't be something that prevents people from getting medication. So in the past, if patients couldn't participate in counseling, we would say, well, the medication's just an assistance to your counseling.
And so if you can't afford counseling or you can't access counseling, you shouldn't be on medicine. And what we now know is that even in the absence of counseling, there's some benefit of medicine, in keeping patients alive. And so we've changed it to medications for opioid use disorder. There are still just three FDA approved medicines for opioid use disorder. One is naltrexone. That's a medicine that blocks the muod opioid receptor. It doesn't give any activation or make the person feel high. In fact, it just blocks it completely.
Which means that if they were to use an opioid like heroin or fentanyl, or even a prescribed opioid, they would not feel its effects at all. So patients stop using opioids because it's, just a waste of money and it's not rewarding. Secondly, the second medication for opioid use disorder is, methadone. So methadone has been approved for this since the 1970s. It is an agonist of a muod opioid receptor, meaning it activates that receptor similar to heroin or fentanyl, which have activity at that receptor. However, it's very slow onset, slow acting.
And so it tends not to be misused in the same way that some of the other fast acting opioids. That being said, if you take enough methadone, you can get respiratory suppression and death. And so, because it carries a little bit of risk with it is only dosed through federally registered opioid treatment programs. Locally these are often called methadone clinics. At those clinics, patients have to go once a day, every day. For at least the first three months. If all their drug screenings are consistent and they're participating in counseling, they can sometimes get, take home doses after the first three months.
But it is a therapy that involves a fair amount of work on the patient's part. And unfortunately, locally in Alabama, particularly in Jefferson County access to methadone clinics can be somewhat difficult.. A few months ago, two or three methadone clinics were full and weren't taking any. and so that's something that the state is working on to improve access to because some patients benefit more from methadone than from the others. The third medication for opioid use disorder is buprenorphine. Buprenorphine was the most recently approved. However, even that was approved back in 2000, actually I think it was approved in 1998.
And then the Data 2000 Act allowed providers to prescribe it in an outpatient. so any provider who has an X waiver can prescribe buprenorphine for the treatment of opioid use disorder, buprenorphine is a partial agonist at the mu opioid receptor. Meaning that if you give more of the buprenorphine, you get more activation of the receptor only to a certain extent. Then after higher doses, even the higher doses don't make the receptor anymore activated. And so patients are less likely to have respiratory suppression or death on buprenorphine.
In fact, on therapeutic doses of buprenorphine, there's not reported cases of buprenorphine only fatalities. There's only been some overdoses in the setting of couse of buprenorphine with alcohol or benzodiazepines, other respiratory suppressants. And so if you're using buprenorphine, not prescribed doses, your patient should not have fatal respiratory suppression. Since it is safer, we're allowed to prescribe it through outpatient clinics using our X waivers. One of the major changes in the past year has been physicians used to be required to have eight hours of training in order to get that X waiver.
You no longer have to have those eight hours of training. You simply have to go to the SAMHSA, the Substance Abuse and Mental Health Society of America, S A M H S A, website. And if you, simply Google, SAMHSA, buprenorphine waiver, the website for it will come up and all you need is your DEA, its expiration date and the address it's registered to. And the process of getting that X waiver to treat up to 30 patients takes all of three minutes. And so we're really trying to encourage every provider out there who has a DEA to just go ahead and get that X added that way.
If you ever have a patient walk in your door, you don't have this emergency where you want to get them started on Mo U D, but you don't have the waiver. so that has been the major change that has been helpful.
Melanie Cole (Host): Wow. You are just a wealth of knowledge, Dr. Leisch. That was just such excellent comprehensive answer. And thank you for letting other providers know what's involved in prescribing these medications for opioid use disorder. I'd like you to wrap it up your best advice, which you would like other providers to take away from this updated podcast today. And when you would like them to know that they can refer to the specialists and the experts like yourself at UAB Medicine?
Dr Leah Leisch: I think the big takeaways I would love people to know is that these medicines absolutely save lives. Patients with opioid use disorder, not on medication, have a standardized mortality ratio of about six. When you get them on medication that comes down to just under two. they not only save lives, they've been shown to decrease illicit drug use, decrease criminal activity, improve employment, and many other social measure. And time matters. Patients who are started on medications for opioid use disorder shortly after an overdose are more likely to be on it later than patients who are just referred without being started on medicine.
And so every provider out there needs to be prepared to start a patient on medications for opioid use disorder. At that moment that they first encounter the healthcare system. So I'd like every provider to go ahead and get that X waiver, get knowledgeable about the three FDA approved medicines for opioid use disorders. You can talk to patients about it.. And then if you're not comfortable managing a patient with opioid use disorder long term, it's perfectly fine to refer to addiction care then, it's just important that, that initial care not be delayed. We wouldn't do that for other life threatening conditions, like a heart attack or DKA. And we shouldn't do that for opioid use disorder.
Melanie Cole (Host): What an excellent guest you are. Dr. Leisch thank you so much for joining us today and really sharing your incredible expertise and professional information today. It's such an important area for the country right now. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB- MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua266.mp3
- DoctorsLazarre, Ellen;Estes, Courtney
- Featured SpeakerEllen Lazarre, CRNP | Courtney Estes, CRNP
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6026
- Guest BioEllen Lazarre, CRNP is a Nurse Practitioner.
Learn more about Ellen Lazarre, CRNPCourtney Estes, CRNP is a Nurse Practitioner.
Learn more about Courtney Estes, CRNP
Release Date: October 26, 2022
Expiration Date: October 25, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Courtney Estes
Advanced Practice Provider, Cardiovascular Disease
Ellen Lazarre, MSN, CRNP
Nurse Practitioner, Hematology & Oncology
Courtney Estes and Ellen Lazarre have no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole. Today, we're discussing collaborative management of atrial fibrillation in hematology patients. And in this panel today, we have Courtney Estes and Ellen Lazarre. They're both nurse practitioners with UAB Medicine. Ladies, I'm so glad to have you with us today. So, Ellen, I think I'm gonna start with you. I'd like you to kind of set the table for us. What kinds of issues does the hematology patient generally have? What are some of the issues you see with them every day? And what are we discussing here today?
Ellen Lazarre: Yeah, we see a wide range of hematology patients in our practice. They come in and can be acutely sick or even have chronic comorbidities. Some of the cardiac issues that we see might be like hypertension that might be controlled or uncontrolled. We also see, chronic heart failure. Sometimes the patients have that as a comorbidity, but sometimes that's picked up when we start working them up for their new disease, the hemotologic process. We also see patients with AFib that have had that long standing.
They might also have other cardiac tissues likeAa fluter or, they also sometimes can have pulmonary hypertension that we need help sometimes with cardio oncology to help us kind of manage that, get their medicines regulated, help with like fluid balance. And so we work really closely with cardio-oncology and Courtney and Dr. Linneman and all the team members. They're great to Get patients in quickly, because some of these patients, live far out and don't always have great primary care or, specialty, physicians.
And we see the patients in the clinic, but we also see patients in the hospital. And that team is also great cardio oncology to help manage those patients in the hospital as well.
Melanie Cole (Host): Well, thank you for that. So Courtney I'd like you to give us an atrial fibrillation overview. Tell us a little bit about the prevalence of AFib in these patients and a brief overview in general of AFib and what you see in the trends?
Courtney Estes: So atrial fibrillation is a type of like super ventricular arrhythmia that causes this irregular heartbeat. And as Ellen mentioned, a lot of the oncology patients may have had a chronic AFib issue or we discover it, and some of the medications or drugs they're needing for their treatments. And so it's just this arrhythmia that has these chaotic impulses from the top part of the heart. And sometimes it can be really fast. And so, we look ways to manage that, there's different types of AFib. It can come and go, it could be persistent or it could be permanent.
And so we really just weigh the risks and benefits with the patients on their therapies. And just, some oversight, there's a lot of risk for atrial fibrillation, risk factors of getting a atrial fibrillation. And so it's common really in the aging process, those at the age of 60 or older, typically one in 25, have a risk of getting atrial fibrillation. And that becomes, even a higher risk as we get even older in the 80 year old age, and older, demographics, one in 10 have a risk of getting atrial fibrillation. And so, with that being said, atrial fibrillation, because it's this erratic rhythm, there's a high risk of blood clots forming.
And then, we have to really be on high alert because then that poses a risk for stroke. And so we screen the patients, we use different formulas and try to really weigh the risk and benefit and how we're gonna manage the patient with atrial fibrillation. And so it's a process of just constant communication with the patient, talking to them about their quality of life and their desires while they're on the treatments for their cancer as well. And we really follow what we call a Chad's staff score. And typically, a score of one or less, we're just having conversations with the patient.
Depending on their lab counts depending on their other potential comorbidities, especially if they have cardiac comorbidities such as high blood pressure, heart failure and things like that, coronary disease, even they probably are already on a baby aspirin. But again, it depends because we're dealing with hematology patients. And so we really have to be mindful of their lab counts and make sure we reduce the risk of bleeding.
So if it's a Chads score that is greater than one, then that's where we get into those conversations of most likely, we're gonna be talking about a blood thinner. but we work really closely with the oncology team, as Ellen mentioned, just to make sure that we're not causing harm. But that we are co-managing the patient, and weighing the risk and benefits on the needed therapies, in the setting of a patient on these medications and new atrial fibrillation or how we're gonna control it. going forward with a new, leukemia diagnosis.
Melanie Cole (Host): Well, there certainly is so many issues at play here. It's a very complex situation. Now, Ellen, speak a little bit more and you can expand on what Courtney said on managing the atrial fibrillation in these patients who may be on some specific medications that can actually cause or exacerbate existing atrial fibrillation. Tell us about some of those medications that can do that, that they might be on for their hematology issues. And what are you doing to do that balance that Courtney was mentioning?
Ellen Lazarre: The evolution of CLL has changed with the new treatments and specifically with the development of the BTK inhibitors or the Brutin tyrosine kinase inhibitors. And we've seen like a shift from Traditional chemotherapy for CLL combined with immunotherapy now to this oral agents alone are sometimes paired with immunotherapy Those BTK inhibitors are widely used and highly effective in a variety of B cell malignancies. one of those drugs that we commonly see and is getting used, widely now as ibrutinib. That's a first line, BTK first generation inhibitor.
This has a higher rate of AFib is what we have seen. and. At times when patients do develop AFib, we're evaluating and considering, do we need a discontinued treatment? Or can we continue? One of the other side effects that we see with that drug can also be hypertension, that might require hypertensive management. We see that hypertension can get worse over time with that agent as well. So, we're always in consultation with cardio-oncology to help manage those patients.
Sometimes we'll just do a good baseline exam and send them to cardio-oncology to do a good workup before we start the ibrutinib, the new drug so that we can, detect changes quickly, and then they've already established care with cardio oncology. Some of the other side effects that we do see with the ibrutinib. It can be like neutropenia, thrombocytopenia, anemia, diarrhea, nausea, musculoskeletal pain, fatigue, bruising, and rashes.
But with the bleeding and the thrombocytopenia, that's where we also, consult with cardio oncology because sometimes we need their help about, management with the antiplatelets or anticoagulation therapies. But another drug that we also use is acalabrutinib and that's a second generation BTK inhibitor. And it's more selective, binding. So the side effects are not, as to severe at times as ibrutinib. it has a overall better safety profile and drug tolerance.
We do see some headache, sometimes GI symptom touches, nausea, diarrhea at times, and you can still have the anemia thrombocytopenia neutropenia. So we still with acalabrutinib work closely with cardio-oncology just for the management of bleeding complications, AFib, if it were to occur. But the good thing about ibrutinib and acalabrutinib is that if the patient does not respond to ibrutinib due to like significant side effects or comorbidities, we can switch the Calabrutinib and it is an effective management treatment option for patients. And typically has a better overall tolerance for patients.
Melanie Cole (Host): Well, thank you for that. So, Courtney, while we're speaking about this, how is hematology and oncology medical management with these comorbidities affecting those treatment decisions? Because there's a lot of cost and benefits that you're weighing with some of these medications that Ellen was discussing. So how does that affect the treatment decisions? and you can even highlight the importance of that collaboration between hematology and oncology when making those decisions.
Courtney Estes: Absolutely. Our motto is cancer doesn't wait. And so we are the, biggest cheerleaders for these patients and we want them to be able to get their treatments in a timely manner, but obviously, in a safe manner too, we don't wanna cause harm. And so, what Ellen was saying, there is a risk of atrial fibrillation with these BTK inhibitors, or commonly there's about 11% risk with the ibrutinib. And so that's when we do see often with patients coming in, we may see them and get a referral from the oncology team for a patient who has known AFib.
But this, drug treatment is, ideal and the best of choice. And so we go ahead and get them in. We follow them closely, do a basic workup. We probably are gonna get a baseline EKG, thyroid, and some labs just to check a few things as well as probably get them on a heart monitor because they may be, like I said earlier, persistent AFib, permanent AFib, or just paroxysmal in and out. And so it helps us to know with typically a 30 day monitor the burden of the atrial fibrillation.
And is the patient being managed appropriately or is this even a new AFib on these drugs, BTK inhibitor drugs, that we really need to step up the game? And so we have to kind of weigh again the risk and benefits one, on our end in cardiology, we've got to screen the patient for their other comorbidity risk. Some patients are not eligible for amiodarone a lot of these, antirrhythmic drugs can have drug interactions with their cancer treatments.
And so we really have to be careful on the drug choices that we choose. There's flucanod, there's sotalol, and you have to think about the risk of worsening, any possible coronary disease or heart failure. And so we go through that protocol and kind of make sure we're making the best approach for drug management. And then ideally, typically they're gonna be most likely on a rate controlled drug, such as Metopalol, maybe even corag. And earlier I mentioned sotalol, so we just screen the patient and make sure that we are providing the safest, but optimized care to protect them in the setting of having atrial fibrillation as well as their risks of potential stroke.
And so that's when we get into the discussions of possibly getting on the blood thinners, but, going back to ibrutinib, it's 11% risk of AFib. And in that case, which means a risk of possible stroke having that, abnormal rhythm. So let alone these drugs, ibrutinib, and then [inaudible]. They have risk of bleeding. And so we really have to weigh the benefits and risk with the patient and have those, patient centered discussions along with the oncology team. And again, our goal is to keep them on their drugs, for their overall benefit and response.
Sometimes there's a setting when these patients have severely low platelets thrombocytopenia, that we need to be thinking about other options such as is it a possibility for ablation? Or even a Watchman device, which is an implanted device that's placed in the left atrium that helps to really just steal that area up and prevent clots from forming? Of course, we have to be mindful that they may need, anticoagulation therapy a month or so after. And so we just really, really work closely with the oncology team and we're so grateful for them.
But we can quickly connect, get a plan for the patient. We have a general patient centered discussion on both sides. So we're all on the same page. We don't wanna skip a beat or delay any therapy. We're trying to just, keep in mind, the best approach for the patient, but the safest approach to have the best controlled atrial fibrillation, because we know it's a potential side effect of these drugs. But how can we keep them on these drugs, but yet have controlled atrial fibrillation and make sure they don't have symptoms with it?
Melanie Cole (Host): So interesting and such a comprehensive approach. I'd like to give you each a chance for a brief, last word. Ellen, I'd like you just to speak about some of the targeted therapies we didn't mention like TKIs for leukemia patients and where those are fitting in as far as this collaborative management and looking at the comorbid conditions, some of which we know are actually exacerbated, made worse, or even caused by the medications and therapies themselves. But are necessary to keep under control, whether it's hypertension or AFib or any of those comorbid conditions.
Ellen Lazarre: The cardio-oncology team is wonderful with TKI treatments as well. So we use those drug classes with some of our chronic myeloid leukemias, or even sometimes our acute, lymphocytic leukemias patients. And those patients are typically on treatment long term, as long as they're responding to it and not developing any resistance, or lack of response to that drug. There's a couple drugs that, we automatically consult cardio-oncology for, one of them is called to Cisigna or norlotinib.
It's a great drug. That's a second generation, TKI. But we have seen as more data continues to come out over the years that it can have a lot of cardiac side effects. So, cardio-oncology is essential. They will do a baseline exam typically on the patient and make sure the blood pressure is well controlled, help us with lipid levels. Make sure those are well controlled to help decrease any stroke risk. They also help us with, Sprycel or dasatinib. That one, we typically see plural effusions at times that has even led at times to pulmonary hypertension.
And cardio oncology is wonderful to help us manage with that because the patient can be very symptomatic with shortness of breath or chest tightness. And so sometimes helping just with Lasix management, and ways to help make the patient comfortable and sometimes repeating echos and EKGs. And they are typically following those patients, routinely at least every six months. The wonderful thing about them is even if we're seeing a patient in clinic and they're having more cardiac symptoms, we can reach out and they're very open and quick to help us adjust the medicines.
And they might do a televisit. They might just reach out to the patient. But they're really great about establishing rapport with the patients and the patients always love going to see them because they're helping them with their immediate symptoms, but they're also helping them, long term. Just prevention wise, helping them monitor their blood pressure. They talk to them about exercise and I mean, that exercise, can be hard sometimes for our patients because they do feel very fatigued, especially if they have any issues with their blood counts or anemia.
But they help encourage staying active, which helps the patient do well overall. So it is been a great collaboration, having cardio-oncology, helps see our patients and has really expanded the care for our patients and just really, added a lot of value to their lives.
Melanie Cole (Host): And Courtney last word to you and what a great topic. You're both so knowledgeable and I can hear how well you work with your patients and the compassion involved. For referring physicians, Courtney, please let them know about when you feel it's important to refer to this collaborative team of hematology, oncology, and even cardiology and how you're all working together for this very important multidisciplinary approach?
Courtney Estes: So I think for us, we have an open door policy. I mean, if there is a question, our doors always open ,phone call away, a text, page, because you just never know some of these symptoms like mentioned, patients have fatigue, low energy, low counts, but a lot of times that can kind of mimic possible typical, coronary syndrome. And so we just, wanna have an open door policy to make sure that we're readily available, especially with these vulnerable patients. They're already, I'm sure under high stress, worried, a lot of anxiety, depression, just sometimes not knowing the trajectory of the cancer.
but we highly rely on the oncology team to co-manage. And like Ellen said, we'll be able to go see the patient in infusion or sometimes try to pop over to the oncology clinic. as far as the referral, I think it's just when in doubt refer, and I think you can never have enough team members on your side for the betterment of the patient and their care, especially a patient with cancer. Because like I said, cancer, doesn't wait and it just takes a lot of hands on deck sometimes to, co-manage their symptom burden or, some of their comorbidities.
So we have a cardiology pool within UAB, that we can request physicians to refer to us, that we check through a message pool frequently. Sometimes patients are rocking on and they've had cancer. They've been on treatments and their medications may not have any indication of a possible cardiotoxic effect but then their treatment plan changes. Perhaps maybe they've progressed or something's changed along the way, and they need a different drug therapy that may cause cardiotoxic effects.
A drug therapy mentioned earlier was immunotherapy. And so, we recommend patients being referred to us if there's a treatment plan change, especially knowing if there's possible cardiac side effects. Such as hypertension risk of, atrial fibrillation, risk of heart attack, heart failure. And so we really rely on depends on especially the oncology team, just to give us a heads up. And they're always so willing to help and work with us very efficiently, to make sure that we keep the focus on the patient. So they don't miss a beat in their treatment.
Melanie Cole (Host): Thank you both so much for joining us today, a physician can refer a patient to UAB medicine by calling the missed line at 1-800-UAB-MIST. Or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua268.mp3
- DoctorsKirk, Justin
- Featured SpeakerJustin Kirk
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6011
- Guest BioJustin Kirk is a Physical Therapist.
Learn more about Justin Kirk
Release Date: October 17, 2022
Expiration Date: October 16, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Justin Kirk, DPT
Physical Therapy
Justin Kirk has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole. And here to highlight identifying and reducing risk factors for ACL injuries is Justin Kirk. He's a physical therapist at UAB Medicine. Justin, it's pleasure to have you with us today. Tell us how injuries occur to the anterior cruciate ligament and how common this is.
Justin Kirk: Well, first of all, no one tears their ACL when their foot is in the air. A lot of ACL injuries are non-contact injuries from decelerating or slowing down, landing or pivoting in an athletic environment where the knee buckles forward and typically collapses inward. So it's kind of that valgus stress with a little bit of anterior tibial translation is what we call it when that shin bone moves forward underneath the knee.
Melanie Cole (Host): Then tell us who's most likely to sustain an ACL injury. We hear that girls are more susceptible to ACL than boys. Do we know why this is?
Justin Kirk: Yeah. So I think ACL injuries are common widely among both males and females, but females are more likely to sustain an ACL injury than males. And a lot of this is still speculation. There is some pretty good research on it, but I think we need more research to say definitely this is the cause. But a lot of times, they think about joint anatomy, joint laxity, joint shape, angles of the joint, females with slightly wider hips can tend to have a little bit more of that inward knee position. But a lot of it can come down to males typically have tighter joints, just females tend to be a little bit more lax. And then, a lot of females, especially in high school sports, don't like the weight room because they're afraid it's going to make them bulky. But truly, that just leads to strength and balances that can set them up for an ACL injury. And we see this really commonly in soccer, but it's also prevalent in football, basketball, lacrosse, volleyball, gymnastics and, for the recreational athlete, snow skiing.
Melanie Cole (Host): Wow. I didn't even really realize about snow skiing, but that makes perfect sense as you're moving your knees back and forth in that lateral way. So let's talk about treatment. First of all, first line, tell us a little bit about symptom management first. If it happens, how do we know, how's it diagnosed, what happens?
Justin Kirk: Yeah, I'm glad you bring that up because ACL injuries are often misdiagnosed. And in about 50% of the time, they're misdiagnosed as a knee sprain. And it's not until a little bit later when things are not clearing up, swelling's not going down. The knee is still buckling that we go and get an MRI. The college athlete, they might get an MRI a little bit sooner just to be sure because teams have access to that kind of equipment. But for the younger youth athlete or high school athlete, they may not have access to that quite as quickly. But stereotypically, you'll have some sort of twist and a pop, typically with pain, but it's not always painful. Some people, you know, going back to skiing or football, they'll tear their ACL and finish the game. And it's not until later when the knee swells up and becomes painful that they realize they've done something.
Melanie Cole (Host): Well, then, what's the first line of defense? What's the first treatment that happens. It's not always direct to surgery, right?
Justin Kirk: Right. And I think best evidence now is kind of suggesting unless you have a very tight timeline, to go ahead and not go directly into surgery on day one after the injury. Let some of that inflammation cool off, and then get a quiet knee and then perform the surgery after that, after hopefully you've gained a little bit more of your quad strength back, So that's an ideal scenario. For a lot of athletes, time is money and they want to go ahead and get them in for surgery day one after an injury. Because every day they delay is another day that they're missing an opportunity. So that's just kind of an ideal scenario.
Melanie Cole (Host): So then, let's talk about rehab and/or prevention. So tell us about limb symmetry and single leg training for preventing ACL injuries. What does that entail?
Justin Kirk: So since the ACL is in the category of potentially avoidable injuries, and what I mean by that is it's a non-contact injury, you can't really avoid contact injuries, but you can hopefully prevent some non-contact injuries. And a lot of times, your athletic resilience is directly tied to how good you are on one leg. So these glaring asymmetries in strength and stability, body control, coordination, how you land on one leg, how you land after you get bumped in the air, they don't necessarily guarantee an injury, but they do set you up for either risk or success. So some of these injuries are bound to happen no matter what. But if you get really, really good at single leg movement and exercise and body control, I believe you can prevent some of these avoidable injuries, like an ACL that are non-contact injuries.
And even the current research shows for people who are returning to sport after ACL reconstruction suggests that if you can get 90% or greater on strength symmetry tests, single leg hop tests, range of motion tests for symmetry, single leg squat tests, your risk for reinjury is significantly less. And off the top of my head, I think it's between three to six times less likely to reinjure.
Melanie Cole (Host): Well, you just got to my next question, but the second part of that then is how is return to play determined after the fact?
Justin Kirk: I think the biggest kicker is how good they are with strength symmetry. So Biodex is the gold standard there, but some functional tests are the hop test, strength symmetry test on knee extension for the quads and the hamstrings as well if you have access to that. Range of motions, single leg squats, there's the Y balance test, and then just overall movement quality and confidence in the knee. Because in theory, you could have all these strength scores and perform well, but if you're still fearful and avoidant of certain activities and you're just not psychologically ready, then I believe that's just as important as the physical readiness.
Melanie Cole (Host): I agree. And so as you're giving us some recommendations for providers, for coaches, when working with athletes that are at high risk, how do you address after injury scarring if someone did have a reconstruction, if they did go through surgery and now they're getting ready to return to play, but range of motion is now decreased? Tell us a little bit about working with these athletes and what's involved.
Justin Kirk: So unfortunately, when the body heals, it lays down scar tissue, it doesn't lay down native normal tissue, whatever that is, which is a good thing because it helps us to heal, but it's just not as good as the real thing, whereas the ACL graft has shown to be sometimes stronger than the native ACL. You do just get this scar tissue that builds to try to stabilize the joint and help you heal. But you really have to be early and aggressive with that scar tissue management, with range of motion. Stereotypically, the years past, they would cast you after an ACL or put you on bedrest, and tell you to not move the knee all. Now, most of the time, we're seeing these patients day one post-op and immediately getting them to bend their knee, much to their surprise.
Melanie Cole (Host): See, that's what I find most exciting about what you're doing. As we wrap up, that's one of the changes right there that you mentioned, is that we get the athletes right up postsurgery. Back in the day, it's kind of like when someone would have a cardiac event and lay in bed for weeks and weeks, and now we get them right up. So I'd like you to wrap up with your best advice about prevention of ACL and changes that you've seen in management of these tears over the past five years, what you find most exciting.
Justin Kirk: I think the best tips to prevent ACL injuries are thinking about things from biomechanics and neuromuscular function. How much can you move? How strong are you? How do you move? What's the movement quality? How do you land and absorb force? Because that's all the body's trying to do, is it's you versus gravity. How do you land? How do you absorb force? Is gravity dominating you or can you withstand the forces of gravity and momentum? So hamstrings, hip rotators, ankles, glutes, quads, all of these things we really need to be up to full speed to counter the demands of side to side rotation and front to back motions in sport, all about global movement sharing.
And I think one of the things you mentioned, what's been changed in the past five years or so, looking at former return-to-play guidelines, it was around six months and now it's around nine months, and that's just what it takes to regain that strength and focus on the ankles, the hip rotators, the hamstrings, the quads, and just get everyone up to speed.
And with that in mind, they've kind of shifted where we might be going in the future, is they used to use the patellar ligament graft for the bone tendon bone anchor, because it could heal and be ready by six months. But now, if we're not returning people at six months, the emerging graft is actually the quad tendon graft. And Dr. Momaya here at UAB has been doing these and have been seeing a lot of his patients who have that. And it seems to be getting a really nice stable knee without that residual anterior knee pain that a lot of people talk about as one of the most prominent sequela of an ACL reconstruction. So I think I'm really hopeful for that. And I think that's only a glimmer or a glimpse into the future of what could we could potentially expect as more technology emerges and more data comes out.
Melanie Cole (Host): That's cool. Very excellent podcast, Justin. Great information for coaches and primary care providers that are working with these athletes and hoping to prevent these types of injuries. Thank you so much for joining us today. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua267.mp3
- DoctorsChu, Daniel;Russ, Kirk
- Featured SpeakerDaniel Chu, MD | Kirk Russ, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=6001
- Guest BioDr. Daniel I. Chu MD is an Associate Professor in the Division of Gastrointestinal Surgery at the University of Alabama at Birmingham. He completed his undergraduate at Yale and medical school at The Johns Hopkins School of Medicine.
Learn more about Daniel Chu, MD
Kirk Russ, MD is a Clinical educator with primary focus in inflammatory bowel disease.
Learn more about Kirk Russ, MD
Release Date: October 11, 2022
Expiration Date: October 10, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Daniel Chu, MD, MSPH
Associate Professor, Colon and Rectal Surgery & General Surgery
Kirk Russ, MD
Assistant Professor, Gastroenterology
Dr. Chu has the following financial relationships with ineligible companies:
Support for Travel to Meetings or Other Purposes - ACS-Japan
Dr. Russ has the following financial relationships with ineligible companies:
Grants/Research Support/Grants Pending - Rutgers, Eli Lilly, Theravance, Abbvie, Crohn's & Colitis Foundation, Corrona LLC, Cook Medical, Pentax
Consulting Fee - Pfizer, Iterative Scopes
All relevant financial relationships have been mitigated. Drs. Chu & Russ do 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, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. Joining me today, we have a panel with Dr. Daniel Chu. He's an associate professor and colorectal surgeon and Dr. Kirk Russ. He's an assistant professor, a gastroenterologist and a clinical educator with primary focus in inflammatory bowel disease. They're both at UAB Medicine and they're here to offer an update on Crohn's disease and colitis. Gentlemen, thank you so much for being with us today, Dr. Russ, I'd like to start with you. Can you start a little bit about Crohn's and colitis today? What you've been seeing in the trends? The prevalence? Tell us a little bit about it.
Dr. Kirk Russ: Sure. And thanks for having me, Melanie. So both ulcerative colitis and Crohn's disease have a similar prevalence and it's anywhere from probably close to 200 per 100,000. People in the us for both diseases and there's estimated to be over, I think, around 3 million patients living with inflammatory bowel disease in the us alone. As far as trends go, we historically have seen things, continue to rise.
Some more recent data would suggest that maybe it's plateauing in the Western world, but we still are seeing rising incidences of both ulcerative CLOs and Crohn's disease in previous years that didn't have very much incidents like south America the Middle East Asia. So we're definitely still seeing rising incidence there. And I think Dan could probably chime in on this, but we there's no shortage of patients here. We see a whole lot of patients with inflammatory bowel disease.
Dr. Daniel Chu: Yeah, so I absolutely agree with everything that Dr. Russ had said about the incidents and the prevalence. Definitely over 3 million people in the United States growing across the world. And what's interesting too, within the United States that I think we're seeing is that there's certain sort of racial and ethnic groups where we're also seeing more inflammatory bowel disease.
This is one of those diseases that classically, we thought it was isolated to certain populations in Western Europe and in the United States. But we're seeing the incidents really grow in populations that previously we really didn't think would have a lot of, IBD populations, Asian Americans, African Americans, Latino Americans. So we're seeing it in these groups which is important to point out.
Melanie Cole, MS (Host): Well, it certainly is. And we're gonna get into some theories that you both might have, but before we do Dr. Chu, how has treatment and the thoughts of treatment evolved over the last decade or so, tell us a little bit about what we used to think, but what's different and any exciting updates that you have to share with us?
Dr. Daniel Chu: Yeah. So I'll be reprised some perspectives just from a colorectal surgeons point of view. Crohn's and ulcerative colitis has always been a very complicated disease. It's not just medical management of inflammatory bowel disease, but also surgical management. And so I think the treatment strategy has certainly continued to grow. As people have realized it is entirely multidisciplinary. It is very much a team approach. And I think the more coordinated the team can be the better the care.
And what I mean by that is this management requires, I think a IBD gastroenterologist like Dr. Russ. It requires certainly Al input from people like myself, but it also requires nutritionalists and pharmacists, even psychologists. It requires a whole group of people with multiple expertise to really handle and treat IBD well.
Dr. Kirk Russ: Yeah. And I'd just like to add there on the medication front. I think we've really come a long way since infliximab or rheumatoid was approved in 1998. And we're well into the biologic and now small molecule therapy era. And we've really shifted from focusing mainly on patient symptoms and improving those to now more stringent. In points like endoscopic or mucosal healing and now even considering is histologic healing an endpoint that we're shooting for. So we've come a long way and our goals are now shifting more towards trying to change a patient's disease course and really prevent long term.
Structural damage to the bowels and long term complications of just prolonged inflammation and the toll that can take on someone. So, it's an exciting time, honestly, but we're continuing to see newer and newer therapies and more and more treatment options.
Dr. Daniel Chu: And just to go off of that from a surgery standpoint too, I think, we piggyback off of much of what happens with medical management. Ideally that is the primary goal is medical management to quiet down the inflammation. And by the time patients get to surgery we are sort of an adjunct, I would say and to help manage those situations where the medications can't help patients anymore.
Dr. Kirk Russ: Yeah, absolutely. I mean, I think surgery shouldn't be treated as a treatment of last resort. It is actually sometimes the treatment patients need. So we appreciate the assistance of our colorectal surgery colleagues like Dr. Chu.
Melanie Cole, MS (Host): Well, I think it's so important when you discuss this multidisciplinary approach and Dr. Russ, what are some of the challenges that you've found that you'd like to share with other providers when deciding on these therapies, as you mentioned, their biologics? There's so many new things in the pipeline, you have so much more in your toolbox that how are you deciding based on how the patient presents and their family history, on these therapies and tell us some of the challenges, how you've overcome those?
Dr. Kirk Russ: All right. That's sort of a loaded question, Melanie, but I will try to unpack it. There's just a lot of factors that come into play. So you really have to start with, one thing would just be which disease is this ulcer colitis first Crohn's disease. You have to take into count the severity of the disease. Which may be what it looks like on a colonoscopy and also maybe how labs and other tests look that factor in you have to take into account patient preferences. Do they prefer an injection over an infusion? There's things like extraintestinal manifestations that if they're present may kind of help determine which is the best therapy for them.
And then also their comorbidities they have a history of cancer, they have another condition that might affect. The treatment choice, something like psoriasis, for which we have medicines like ustekinumab that actually treat both psoriasis and ulcerative colitis and Crohn's disease. So there's a lot of factors that come into play. And I think you have to sort of see a patient, do your evaluation, talk with them and find out their preferences and usually after that you're able t o guide yourself at least into a couple potential options and then talk to 'em about the risk and benefits.
And I think it it is only getting more complicated as we get newer and newer therapies, some of which are in a similar category to an existing therapy. So now you have multiple treatment options that essentially target the same target in the immune system, in the immune response in inflammatory bowel disease. And how do you decide between those? So we're still fortunately getting more and more head to head trials that will help us hopefully position these therapies. So still a lot to learn, but we've come a long way. And I think we have some kind of basic positioning at the current state of things.
Melanie Cole, MS (Host): Dr. Russ sticking with you for just a minute, as you talk about all of these various therapies, and obviously as you said, it depends on the diagnosis, but can you spend a minute and tell us a little bit about a holistic model of care that recognizes? Because Dr. Chu mentioned it just briefly, but the complexity of these inflammatory bowel diseases, the evolving role of diet, as we're learning it in the pathogenesis and treatment of these diseases, the role that stress. I mean, now we're learning more and more about this connection and even the brain and gut connection. Can you tell us what we've learned, what you know about this, or want to share with other providers?
Dr. Kirk Russ: Yeah, I think that's a great topic. I think we're learning more. There's still a lot to learn, I think, in these areas, but it really is a team sport, and we really need a multidisciplinary approach. And these patients have higher instances of depression and anxiety and sort of psychosocial needs that having a psychologist or a psychiatrist as part of the team is really crucial. I think we definitely know that diet can help with symptom control and in the pediatric population, they will actually use dietary modification instead of using steroids to treat symptoms.
And there's interestingly a subset of patients that you can actually see their inflammatory markers improve by making certain dietary changes. So we definitely think diet is playing a role in symptoms and also. Potentially the development of the disease as it alters the microbiome and the immune response to the microbiome. So it's very important thing. And I think a nutritionist is really an essential part of the team. And we're fortunate to have a couple here at UAB that, we consult with frequently.
So I think you have to take into account all those things. And that's the diet is probably the most common question we get in clinic is what can I do with my diet? Because it's one of the few things in this situation. When you're you have a diagnosis of inflammatory bowel disease, everything's out of your control, but you can control your diet. And so I think that's definitely an essential part of the team. And I think, we're starting to pay more attention to some of the long term quality of life indicators and symptoms that people deal with.
Because that sometimes get overlooked issues like incontinence and urgency and certain symptoms that just haven't been at the forefront of the way we evaluate things. And just the toll that takes on people. I mean, patients can actually get. Post traumatic stress disorder from just their experience with their Crohn's disease or ulcer colitis. So it's a complex illness and the gut brain access is very much real and diet is definitely gonna be a helpful part of treatment going forward I think.
Melanie Cole, MS (Host): Dr. Chu, what would you like to add to that? And while you're doing that, tell us a little bit about anything exciting in your fields far as surgical interventions or how your outcomes have been. Tell us a little bit about your role in this?
Dr. Daniel Chu: Yeah. So, I agree with everything. Dr. Russ has said. The management of IBD is very much a team approach. There's just so many pieces to the puzzle here. An d I gotta stress too, that there's no. One answer one way to do things there's oftentimes two or three choices that need to be made. And so it's incredibly important for patients and their providers to sit together in the same room to sort of make those decisions so that everyone is at least on the same page, because certainly there are no freebies in anything, every choice, every medication, every surgery has its risk to acknowledge.
I think, in the surgery world in terms of new things, the operations, I gotta say still are fundamentally the same, the way we do it though, I think is a little bit different. What I mean by that is we have always known that minimally invasive approaches to surgery is a good thing. And we have more tools now that we can use to perform minimally invasive surgery. So meaning we can do it with laparoscopic instruments, we can do it with hand assist. And we oftentimes often use the robot too, which I'm sure many patients and providers have heard about.
So those are just the different ways that we can do the surgery in a better way. I think the other thing that we do now for surger. Is we focus on the recovery itself, right? The operation itself is oftentimes the easiest part, it's really what happens after the surgery. That can be really challenging how patients recover. And so that's an area that in the surgery world, we do a lot of things called enhanced recovery programs now for surgical patients, that really helps patients just recover better and faster. And these elements of the programs are nothing fancy.
They're simply best evidence practices that are already out there that people are already doing around the world, but it just organizes it and delivers it all together consistently to every patient in the right way at the right time. So I think those are some of the biggest things that are happening within the surgery world. I think IBD in particular is particularly challenging from operation standpoint because of the inflammation, because of the chronicity, because oftentimes there's redo operations. But I think, we've gotten better at how we do it and how we recover patients. And I think that contributes to better outcomes now and the IBD surgery world.
Melanie Cole, MS (Host): Very well said, Dr. Chu, I'd like to give you each a final thought what you would like to share with other providers. So, Dr. Russ, starting with you, we're talking about referral here. So when do you want other providers and community physicians to know and feel that's the important time to refer to the experts at UAB Medicine in the cases of inflammatory bowel disease?
Dr. Kirk Russ: Yeah, I think that's a great question. I think definitely anyone that is medically refractory. So if someone's failed a couple different treatments or biologics and they still have active disease and you're not sure where to go next with their therapy. I think that's always a reasonable time to refer for a second opinion. I think in Dr. Chu's realm referral for colorectal surgery expertise is also a great reason to refer patients here. Your community surgeon may not have as much colorectal experience and really, especially for these inflammatory bowel disease.
Patients having someone that has the expertise, the experience operating hundreds, if not thousands of Crohn's disease or ulcer colitis patients is really paramount and associated with better outcomes. So I think those are two reasons off the top of my head. The other common ones, I would say that we get would be things like unique situations, someone with cancer and active inflammatory bowel disease. And for specialty procedures, things like chrohn endoscopy, when we're looking for precancerous changes in the colon. If those are identified in the community, sometimes we'll get referrals for that. So there's a lot of reasons, but those would probably be the most common.
Melanie Cole, MS (Host): Dr. Chu, last word to you. And so appreciate that you brought up the importance of eras and you and I have done a podcast on that before. So listeners, you can look that up anytime you want, but I'd like you to speak just about anything exciting that you see coming down the pipeline, any research, promising therapies, anything that you would like other providers to know that you are all doing there at UAB Medicine.
Dr. Daniel Chu: Yeah, that's a great question. And Dr. Russ, we know more, so about the newer medical therapies that are coming online since I do defer to my gastroenterologist colleagues for their expertise on sort of the newest biologics and the newest biosimilars that are coming out. I do think within that area of research and treatment for IBD I think a lot of work now is focused on the diet piece that Dr. Russ had talked about in terms of what kind of diets might be the quote unquote, best diet for different situations.
I think from a medication standpoint, I know there's a lot of new biologics. New ways to deliver biologics, whether orally versus the kind of the usual IV infusion. And the biosimilars in terms of which combination of those drugs might be the way to treat a patient depending on how severe the IBD is. I think in the area of research that is still active too, that we still don't, I think have good answers to is within the microbiome itself. Certainly that's a buzzword that you'll see a lot and hear a lot about the microbiome in your body and how that relates to diseases like IBD.
And I think there certainly is a relationship. I don't think their relationship is understood yet, which is why there's so much research in this area. But the idea is that we can maybe look at certain profiles of microbiomes that can determine how severe or how a certain case of IBD might respond to treatment and be able to tailor. Our treatment for IBD in a much more refined and purposeful way. So those think those are some areas that are out there. and I'd be curious to hear From Dr. Russ, whether there's any other areas that he's seen from his side of the medical world.
Dr. Kirk Russ: Yeah. I mean, I think you did a great job there, Dan. I think you hit a lot of the high points, I think you're right dietary modification, modulation of the microbiome, how do we do that or accomplish that? I think those are all exciting things. And I do think combination therapy. We have some emerging evidence and even at clinical trials one of which we're gonna be participating in that it's looking at combining these biologic and small molecule therapies to get better response rates, because the reality is there is a ceiling, there's a therapeutic ceiling with a lot of these drugs. And we just need to do better. They don't work for everybody.
And I guess maybe one, one or two more other things, one would be personalization or personalized medicine. Just being able to determine which drug is the best drug for an individual patient. We're not there yet, but I think we're making progress and I think we will get there probably within the next five to 10 years. And I guess lastly, and this is maybe something you could comment on Dan too, is maybe an encouraging therapy for perianal disease, which can be incredibly difficult to treat would be stem cell injections into the fistula tracks. And so that has shown some promising results I know.
Dr. Daniel Chu: Yeah. Thanks for bringing that up Dr. Russ. So what Dr. Russ is talking about is this idea of Crohn's disease in anorectal fistula, which can happen in a significant portion of Crohn's patients. And these fistulas are tunnels that go from the inside of the rectum and anus out to the skin and can be notoriously difficult to close and to handle. And so there's been a lot of new research focused on finding new ways to close those fistula tracts using stem cells from patients and essentially it's stem cells that are harvested, they're grown.
And then they're, re-injected into that tract. And there's definitely been some good signals that this can have some benefit. I think just those trials that need to be done to really. Show exactly how much of a benefit it is. But that being said, there's great potential. And certainly the principles of that technique are good and valid. So I think there's more to come from that, but that definitely is another area of innovation within IBD treatment.
Melanie Cole, MS (Host): What an exciting time to be in your field gentleman. So many emerging therapies. And thank you so much for sharing your expertise today with other providers that was just excellent. And so informative, a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician.
That concludes this episode of UAB MedCast and for the updates on the latest medical advancements, breakthroughs and research, just like you heard here, please follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua265.mp3
- DoctorsBrunner, Bobby
- Featured SpeakerBobby Brunner, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5981
- Guest BioBobby Brunner, MD is the Medical Director of UAB Spain Rehabilitation Center.
Learn more about Bobby Brunner, MD
Release Date: October 3, 2022
Expiration Date: October 2, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Robert Brunner, MD
Medical Director of UAB Spain Rehabilitation Center
Dr. Brunner has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole. And today we're discussing spasticity rehabilitation and treatment with my guest, Dr. Bobby Brunner. He's a physiatrist and the medical director of the UAB Spain Rehabilitation Center. Dr. Brunner, it's a pleasure to have you join us today. I'd like you to start out kind of with a table setting for us, define spasticity for us as it applies to what we're discussing today?
Dr Bobby Brunner: Yeah, spasticity is a condition in which there is an abnormal increase in muscle tone or stiffness of the muscle, which might interfere with an individual's movement, their speech, or be associated with discomfort or pain. Spasticity is usually caused, by damage to the central, nervous system, which includes the brain and, spinal cord and interferes with the control of muscular movement. So the degree of spasticity varies for mild muscle stiffness in some individuals to severe painful and uncontrollable, muscle spasms in.
Melanie Cole (Host): So tell us a little bit about the conditions and diagnoses that are associated with spasticity, because there is this big wide range in the spectrum of movement disorders, but we're focusing on spasticity today? So tell us a little bit about those conditions and diagnoses.
Dr Bobby Brunner: Yeah. So the conditions you see generally are any condition that can affect the brain and spinal cord. So it's seen association in individuals that may get a spinal cord injury, they get a trauma to their spinal cord and it upregulates, the system and develop spasticity. It can be seen in autoimmune disorders and example would be something like multiple sclerosis, we're not talking about kids today, but kids do turn into adults with cerebral palsy.
That's a one time incident at birth, but they do turn into adults. So you see the kids, but, it continues in adults. Things like stroke, cerebral vascular accidents, can lead to, spasticity brain disease, such as tumors or an individual with meningitis can develop spasticity or just head trauma. Really any injury disease that affects the spinal cord can lead to spasticity.
Melanie Cole (Host): well, then I think one of the most important things we're gonna discuss here today is quality of life for patients. Tell us a little bit about how this affects their quality of life as you see it, when you're working with patients?
Dr Bobby Brunner: So when we deal with patients with spasticity and quality of life, a lot of times, for example, we may get them into a rehabilitation program. And when they're trying to do things, with a therapist that can affect their ability to learn a certain technique or shorten gate, because a spasticity interferes with that. It can cause them ambulate in a different way. So if they're walking down a hallway, they may lead to a scissoring gate or a Hemi Paraic gate that can lead to fall. So falls, lead to other complications.
For lower level individuals that may be in wheelchairs. It can affect their positioning in wheelchairs. It can affect how they take care of themselves, how they eat, how they do their bowel or bladder function. So spasticity can affect, the general way one goes through life and it can be painful in some conditions, as well. So, we're trying to get their gate or their activity daily living to a point where they can, tolerate the underlying spasticity and doesn't affect them to a great degree.
Melanie Cole (Host): Well, then let's talk about the treatments that are available. What are you doing at UAB Spain Rehabilitation Center?
Dr Bobby Brunner: There are a variety of things that you can do to try to help minimize spasticity. We're not treating the underlying diagnosis. we're really treating this particular side effect. And so our goal is to minimize that effect and improve their quality of life overall. So sometimes you start simply with things like physical, occupational therapies. These are therapists that work to develop a regimen for you to, either, improve your gate or your basic, activities daily living. This can involve a stretching program or range of motion program.
The idea is to take that program and incorporate it into your life so that you can work on it every day so that you will, reduce, complications of shrinking muscles, which can lead to joint deformities and so forth. So that's one thing that we can do in a basic thing, that we do with individuals. Then kind of, after that, we would consider medication manage. And there are several medications. You hear names like Dantrium, Zudanazine, Baclofen. These are all medications that can help spasticity. They all medications that can have side effects.
So it's important to go over, if you're a provider, what those complications might be in discuss risk and benefits. Another option would be injection therapy, this is for the Bochilonum toxins. This is typically into muscles for a focal area of tone or spasticity. these are generally well tolerated. They're done generally every three months.. Again, there are side effects, so that's a thing to be aware of. But overall it's generally very well tolerated. Then, something more invasive would be, intrathecal, Baclofen. This is infused through a pump system.
So this will be implanted, by a surgeon, into the body, with the catheter going directly into the fluid around the spine to reduce spasticity, To do something like that. You have to go to somebody that deals with pumps. there's a trial period to see whether a patient, would even qualify or respond to the intrathecal Baclofen. But if they do, then you would talk about the risk benefits of implanting of pump. And these are battery devices that last about seven years. So there's surgery that you have to have a period of time.
And there are complications that occur that these systems have to be removed, but once it's effective, it's extremely effective and it reduces the need for medications or other, interventions, which is great. And it really helps people with lower extremity spasticity, particularly. And then the last option you have are surgical treatments. This isn't so much for spasticity reduction, but more the complications of spasticity. So if someone has contractures of the joint or deformities of the joint, then you might go to a surgeon that specializes in this area to do some surgery on the joints.
Or do tendon lengthening type procedures so that we can position the individual better, get them walking, or maybe they're functioning better as well. So that's kind of a global overview of the different treatments that there are for spasticity.
Melanie Cole (Host): And how have been your outcomes, Dr. Brunner, what have you seen and what have you heard from patients?
Dr Bobby Brunner: So the outcomes are variable. Of course it depends on each individual person. So it depends on the severity. So someone that has milder spasticity, and is headed for a shorter, length of time, the treatments can be very effective. And we like to get people early, too, so that we can prevent these longer term complications. But if you get somebody that's maybe more severely impaired has more generalized spasticity all over has had it for a longer time or has an underlying illness that is potentially progressive, then sometimes the spasticity can be harder to control.
But overall, our goal is to reduce the impact of the spasticity on the individual so that we can get them functioning to the best of their ability to keep them comfortable, to help them, with their day in and day out, life. So, the point is that there are treatments to make people more functional and more comfortable. And I think earlier that you get interventions or get these treated or work on this, then you reduce the long term complications.
Melanie Cole (Host): This is a really very important topic we're discussing here today. And so many people that you're helping as we wrap up, speak to other providers about why you feel, and when you feel that it is important that they refer their patients to the UAB Spain Rehabilitation Center for treatment?
Dr Bobby Brunner: Yeah, I think earlier the better. So when we see somebody early on in spasticity, the joints are still very flexible mobile, the individual has not lost range of motion. And I think there's a lot we can do if we get to people early on, some people will. Just come into clinic or another provider and they see 'em walking with a stiff gate or they notice the range of motion, but they don't particularly think about referral or doing anything about it.
And that can lead to if years go by to further contracts, I mobility, poor positioning and chair, which then can lead to further painful conditions down the road. And so the key to me is early recognition, of this condition and then referral to an appropriate individual that can kind of go through these different, treatment plans and work with the patients so that, long term outcomes are much improved for the individual.
Melanie Cole (Host): Thank you so much, Dr. Brunner for joining us today and sharing your expertise for other providers. A physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB Med Cast for updates on the latest medical advancements, breakthroughs and research. Follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua263.mp3
- DoctorsEudailey, Kyle
- Featured SpeakerKyle Eudailey, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5939
- Guest BioKyle Eudailey, MD, is a cardiothoracic surgeon with expertise in complex aortic surgery, aortic valve repair, and endovascular and interventional techniques in aortic stenting. He also specializes in structural valve procedures, particularly in transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve replacement (TMVR).
Learn more about Kyle Eudailey, MD
Release Date: September 21, 2022
Expiration Date: September 20, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Kyle Eudailey, MD
Assistant Professor in Cardiac Surgery, Cardiothoracic Surgery & Thoracic Surgery
Dr. Eudailey has disclosed the following financial relationships with ineligible companies:
Consulting Fee – Artivion Inc.; Endospan Ltd.
Honorarium – Medtronic; Edwards Lifesciences; Terumo Aortic
All relevant financial relationships have been mitigated. Dr. Eudailey does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. Joining me to discuss thoracic aortic aneurysms is Dr. Kyle Eudailey. He's an assistant professor and a cardiothoracic surgeon with expertise in complex aortic surgery at UAB Medicine. Dr. Eudailey. Thank you so much for joining us again. So let's start with the definition of thoracic aneurysm. How has your knowledge evolved in this area? What had been thought previously regarding these? Tell us a little bit about them and their prevalence.
Dr. Kyle Eudailey: Sure. First off, thanks for having me back. Melanie, it's always a pleasure. I appreciate it. You know, aneurysms I guess the easiest way to start is to define this a little bit. Aneurysms are really just any dilation of a blood vessel in the body. When we say thoracic aortic aneurysms, we're simply referring to aneurysms that are in the thoracic cavity. So really that's anywhere from the neck down to the torso. The reason that's important is that just happens to be where the largest blood vessels in your body lie, the aorta, which is the largest blood vessel in the body comes out of the heart.
Makes a turn, blood vessels come off to the head and then makes another turn and goes down to the rest of the body. So aneurysms in this particular area are large. And because of that, they have significant consequences if the aneurysms progress to pathologic aneurysms or haven't forbid have some complication of rupture or tear. In terms of where have we come in terms of our knowledge? It's really it's a great question. I would say a long way, but there's still a lot that we don't know.
The easiest way to probably start off is to really define what we do know, which is really the basic physics of aneurysms. So the aorta is, the simplest way to think about it is the aorta is built like a three ply garden hose honestly, it's got intima, media, and adventitious, these three layers and those three layers really give it its strength. And I say garden hose, but maybe that's a really a little bit of a poor definition of how to describe the aorta.
The reality is it's a pretty dynamic structure that is able to accept the blood from when it injects the heart and able kind of move it through the body. But that being said, the order still is subject to the laws of physics, which really this is where a lot of our thinking on aneurysms comes down to and The probably most fundamental important law is [inaudible]'s law of physics, which is the tension in a vessel is equal to the pressure times the radius.
All right. And that's, I'm gonna say it again because it's really. I wish I could draw it out, but unfortunately we're on a podcast, but the wall tension of a vessel is equal to the pressure times of the radius, which basically means that as the radius increases or as the pressure increases the strain on the wall of the aorta increases. And what that means is that the aortic gets kind of strained or pushed by two main things. And one is diameter and the other is pressure.
Blood pressure is the pressure that we're talking about and diameter is really the aneurysm in what we're talking about. And that's the most fundamental basics of how we understand aneurysms.
Melanie Cole, MS (Host): Wow. You're an excellent educator. I was picturing it the whole time. And even before you mentioned blood pressure, I was assuming that's one of the factors that plays a role in these formations. I'd like you to speak a little bit about the hemodynamic factors that play a role in the formation of these type of aneurysms and what you see most commonly as the clinical presentation.
Dr. Kyle Eudailey: Sure. So, unfortunately there are a lot of factors I guess, is what would play into these? The trouble with aneurysms are actually that most of 'em are asymptomatic. And so I really can't say that we see a ton of symptomatic aneurysms. In fact, if you have a symptomatic aneurysm, meaning you either have pain or it has ruptured or dissected, that's just bad news. These people, you know something terrible's happened, it's tearing chest pain, tearing back pain. There's no way that you would know to get to a hospital.
So, in those senses, those are aneurysms that understanding them is less important because people they get kind of rushed to treatment. So the nuance of aneurysms is really understanding how do we mitigate risk of asymptomatic aneurysms? Because the vast majority of aneurysms are asymptom. And so ultimately what we're trying to figure out is, where is this line between the risk of continued surveillance? Meaning we know that there's an aneurysm there and We just keep watching it versus the risk of surgery.
And so what's really important. And this is really another big, important concept is understanding this sort of risk of surveillance versus risk of surgery balance. And so I often talk to patients about, if we have an aneurysm and we know it's there, we know a bunch of factors that sort of allow us to assess the risk of the aneurysm. And when that risk starts to increase, eventually we say, all right the treatment modality, which is surgery, either open or endovascular, is lower than the risk of watching the aneurysm.
Because we know that it's certain sizes the risk of the aneurysm is significant in terms of its risk of rupture or tearing. And so this again gets back to sort of the fundamentals of physics and this actually gets back to some in the lab testing and out of the lab testing of the actual mechanical properties of the aorta. We know that if you have a vessel that is roughly six centimeters or 60 millimeters, there's significant increase rigidity of the tissue. There's decreased extensibility.
And at that radius, if you apply a pressure of 200 millimeters of mercury, which is what we see sometimes if people have kind of wildly outta control, blood pressure, you basically exceed the tensile strength of the aortic tissue. Now there's a lot of things that play into the tensile strength of the aortic tissue, meaning. Not all aortic tissues kind of created equal and I'll kind of walk through some of that, but that's the real kind of fundamental rub is that risk of surgery versus risk of surveillance.
And so the question of how do we assess that risk of surveillance? There's a sort of a list of things that we can kind of go through which is what I go through with my patients. And that's based on several factors. And so the biggest ones are diameter, which we already touched upon, which kind of goes back to that LA Plaza's law. Location, meaning specifically where it is in the body, the expansion rate meaning how fast it's expanding, whether or not there's some associated family history that would kind of put you at higher risk.
Meaning that something else might be going on besides the size of the aorta and then the other is presence of an associated disease. Meaning is there some other factor besides the aneurysm that we need to weigh in and that usually has something to do with valve disease or heart disease or is there some other associated etiology and these are mostly genetic factors connective tissue disorders, familial thoracic aneurysm disease, or Cusip of valve disease.
Melanie Cole, MS (Host): before we get into treatment options, is there screening? Do you see this coming as a future process? And some of these are found incidentally and there are certain risk factors you've mentioned, but is there screening, do you think there should be.
Dr. Kyle Eudailey: Well, you know, screening is such a complex question in this day and age, because that gets into the fact of the use of resources. And if you screen everybody with certain scans, you may have false pauses, false negatives, but you might find other things, not necessarily aneurysms. So at present there's not a, at least for thoracic aneurysms, I should say there is not a clear indication for screening other than if you have a family member with a known aneurysm.
So that's kind of the big takeaway, meaning that if you have a family member with a known aneurysm, typically we recommend starting with a noninvasive screening and then moving to Either a CT scan or an MRI. And that's because if you look all across the board, if somebody has an aneurysm, there's roughly a 10% risk of your first order relative might have an aneurysm. Now that's more partly driven by the genetic components of aneurysms.
Because outside of the genetic, there's also the environmental factors of aneurysms, meaning risk factors that people sort of expose themselves to regardless. But I would say at this point, there's not a blanket screening statement in terms of who we should be screening. And the reason being again is because a lot of these are asymptomatic and we don't have a pinpoint on who exactly is gonna have it. Other than if we know that there's somebody within the family that has it.
Melanie Cole, MS (Host): So, when do you consider intervention for thoracic aortic aneurysms? Tell us a little bit about whether you're doing endovascular aneurysm repair and how that has helped make it a more reproducible, reliable procedure. How is this performed? Tell us a little bit about what you're doing in these cases.
Dr. Kyle Eudailey: Sure. So I think there's two parts to that, right? The first being when do we consider surgery is probably the most important part. Surgery itself we can get into. But when to kind of pull that trigger for surgery is really nuanced and important. And I guess what I would say to anybody who listens and that's providers or patients, the important aspect is that there are guidelines for when to treat patients with aneurysms, but they are truly guidelines, meaning that these are not the sort of same hard and fash rules that we see in valve disease and coronary disease.
Because every patient's risk is very specific to them. And that's driven not only by their aneurysmal. But also by their surgical risk, because you can imagine if you're treating somebody for an asymptomatic pathology, the surgical risk plays important role. And so it's an interesting aspect of medicine which a lot of aspects or a lot of other areas of medicine have this, but the risk of the intervention needs to be heavily weighed against the risk of treatment. And that has important implications as we move into endovascular procedures, which theoretically might have lower risk to patients.
So what I would say is the the timing of surgery is heavily based upon the individual's risk and the individual's risk gets back to those things that I've mentioned before, which is diameter, location, expansion rate, family history, and associated ideologies or disease. And so kind of walking through those is really how we get into the decision to move forward. Diameters is really kind of the most important one. That's the one that we consider that's what most of the guidelines are based off of.
And that gets back to the physics of what we discussed for ascending aneurysms and arch aneurysms. We typically consider an end diastolic dimension of around 55 millimeters. Again, that gets back to that physics of around six centimeters is where we really lose all Tensile strength or functional strength of the aorta. But 55 millimeters is, it's not hard and fast because not everybody's built the same, meaning some people are shorter, some people are taller. And so we do consider size indexing, which is in some guidelines, but not in others.
And that includes an aortic size index to a body surface area, which is typically anything greater than 2.75 per meter squared. And then we also do height indexing which we have an aortic height index which is typically aortic cross sectional area divided by the height and that's greater than tent. So all of these are kind of used as pseudo sizing measurements. The location is also important. When I say thoracic aortic disease, there are really a couple different spots in the thoracic cavity. One is the aortic root.
That's a little different than the remainder of the aorta, because the valve is closely a part of the structure down there, as well as the coronary arteries. This changes the risk of the operation. If you're addressing root pathology, also it necessitates that you have to address the valve at the same time. The ascending aorta is a little bit more straightforward, but that is the area that is the most dynamic of the ascending order. And also is the area that sees usually the highest strain. And so, that is typically where w e use that 55 millimeter number.
The arch is the, sort of as the aorta turns and then the descending thorac aorta, again, we use 55 millimeters, but that's for endovascular repair. Whereas if we are considering an open repair, we use a slightly higher threshold only because the open repair comes with additional risk getting back to that risk sort of, balance that we talked about. The expansion rate's also important. This is something I always talk to my patients about. Aneurysms typically grow it's somewhere around a millimeter a year, but the best concept to understand is a balloon, right?
When you first blow up a balloon, it's hard to blow up. But then as it gets bigger and bigger, it gets easier and easier to blow up. So as aneurysms grow, the rate of expansion actually increases which is important to understand. So if we see aneurysms that are growing greater than five millimeters a year, that's a soft indication, or a reasonable indication to consider repairing those aneurysms. And then there are the additional factors that would tip us over the edge, which I had sort of mentioned before. Meaning is there high risk family history?
Is there some associated disease, meaning that you're treating the patient for some other valve pathology or coronary disease? If somebody's undergoing open surgery for some other procedure that's indicated, then we actually replace the aorta at 45 millimeters, which is much lower than the 55 millimeters that I had mentioned. And then based on specific genetic genotypes, we can be more aggressive meaning patients with [ inaudible]. .
We are very aggressive about how to repair their aneurysms down to the level of 40 millimeters, whereas patients with standard morfans it's closer to 50 millimeters and patients with Bicussip valve diseases, it's closer to 50 millimeters. The important takeaway of all of that is it's nuanced and it's very patient specific. I guess that answers your when. I haven't crossed over into the how yet you want me to continue with that?
Melanie Cole, MS (Host): Well, yeah, because this is absolutely fascinating. And I thank you for giving us those predictors for successful repair. So why don't you just tell other providers briefly some of those technical aspects Dr. Eudailey, that you look to that really help them to achieve better outcomes, because this is really the main thing, right? You're an expert in this and they're looking for better outcomes for their patients. It's about when to refer, why it's important and why you are such a specialist in this particular situation?
Dr. Kyle Eudailey: Sure. So, you know, I think when for me, I've spent a lot of the last couple years of my career explaining to people that it's not a bad thing to send somebody to a surgeon early only because the big takeaway that I really preach is that just because you're sending somebody to a surgeon doesn't mean they're getting surgery. I find that patients are often much more accepting of when they cross that surgical threshold. If they've know n a year or two years before. And also if they understand the thinking around, when we actually consider surgery.
And so we usually say, really being not on the super conservative side but I typically say, I think it's always reasonable for a surgeon to see somebody when they have a thoracic aneurysm that's greater than 45 millimeters. It doesn't necessarily mean that they're ever gonna need surgery, but somebody does need to take control of the surveillance schedule, meaning driving. How often the aneurysm is imaged and also making sure that the aneurysm is imaged reliably. One of the most important aspects. Understanding thorac aneurysms is reliable imaging.
Meaning that when we talk about diameter, when I talk about those numbers or those surgical thresholds, what's really important is understanding that's a center line measurement, meaning that's a coaxial measurement against the flow of the blood and aorta. The aorta is a dynamic and windy structure. And when we do CT scans, we're typically only looking at it from certain cuts. And so what's really important is that the aorta is measured at a sort of Coplain or coaxial measurement of the flow of the blood, in order to get that diameter.
You can imagine if you take an oblong cut of the aorta, you may think that it's six and a half or 65 millimeters? When the reality is it's only 40. That's an important takeaway because I get a lot of referrals where people think they have a seven centimeter aneurysm, and it's not anywhere near that. Additionally I put in there that I had mentioned that the expansion rates and indication for surgery, the trouble is if you have two scans that were done without the same precision and without the same way of measuring somebody may say, oh, I see in the chart that you had an aneurysm this size.
And then they look and they take kind of a sloppy measurement. And they think that the aneurysms grown 10 millimeters in the span of six months it's important to understand how to measure and what to be looking at and to have somebody who's kind of the reliable predictor of where these are being measured. And that's one of the crux of understanding how to refer a patient and also understanding then how they end up to that, when we decide about surgery.
And I'll make a note, in regards to imaging, not all imaging is created equal. Some CT scanners take better cuts. Additionally, if you're dealing with an aortic root aneurysm, the aortic root and the Aascending aorta are particularly dynamic. I'd mentioned that the size that we consider is the end diastolic dimension, which is the largest size of the aorta. And what that means is that the aorta can actually have a 10 to 15% variation just within the cardiac cycle based upon whether or not you catch the aorta at the right time of the cardiac cycle.
So when you're talking about millimeters in deciding between surgery for somebody, these are the nuances that you need to consider before you take 'em to the operating room, because surgery for an asymptomatic disease, it's important to understand when to pull the trigger in and when it's worth it for a patient.
Melanie Cole, MS (Host): And isn't that the key takeaway you are brilliant. Dr. Eudailey, what an informative educational podcast. I was literally riveted. Thank you so much for joining us today and really explaining all those important predictors. When you're talking about thoracic aortic aneurysm.
Dr. Kyle Eudailey: Can I make a plug for one more thing?
Melanie Cole, MS (Host): Please do.
Dr. Kyle Eudailey: The other aspect that I don't think people understand is when you have an aneurysm, there is actually some element of patient education, which needs to happen. And that patient education, it comes down to a few things, because this is the one question I get a lot, which is, am I a time bomb? Am I gonna explode? Right. And simply educating a patient on their risk is really important. Meaning what can they do? Do they have to walk around on eggshells? Because the reality is most people don't have to walk around on eggshells.
The most important things that we can consider is providers are reduction of cardiovascular risk, which really means making sure that your on appropriate blood pressure medications, making sure that the blood pressure's well controlled. Usually we typically like to go anti impulse therapy, beta blockers, or an ACE or an ARB as these are kind of the best modalities for after load reduction. The other is smoking cessation, which in and of itself is associated with aneurysm formation, aneurysm expansion, aneurysm rupture and then the other is.
You know, discussing with people, exercise and activity. I usually tell people you're free for aerobic exercise run jog. I want you to do lightweights, increased reps. The big things are to avoid extreme, heavy lifting, which we usually about half your weight.
Melanie Cole, MS (Host): Vasalva Maneuvers.
Dr. Kyle Eudailey: Exactly. Avoid sustainde vasalva maneuvers. But the important thing is that exercise is good. And so often I get people coming in and they're, you know, they're beside themselves cuz they think they're gonna explode at any point. And so it's really important to sort of understand and talk to people about understanding what their aneurysm means. And I think that's probably the most important aspect of what I do in terms of when I see people that, and this is also a final sort of PSA announcement, but we've also found that a set of antibiotics which are called fluroquinolone antibiotics most specifically levoquin and Cipro.
If you have a known ascending or root aneurysm, if you take prolonged courses of antibiotics, you have increased risk of an aortic event. And that's new information that just came out from the FDA and there's a black box warning on those only as recently as 2018, but it's not as if an individual's allergic to those, but if they take prolonged courses, they can increase their risk. So simple things like blood pressure control, avoiding the wrong antibiotics and then making sure that you exercise, but just don't strain that can go a long way.
Melanie Cole, MS (Host): And patient education. Wow. Thank you again, Dr. Eudailey. A physician can refer a patient to UAB Medicine by calling the MIST Line at 1-800-UAB-MIST or by visiting our website at UABmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua249.mp3
- DoctorsWinter, Gretchen
- Featured SpeakerGretchen Winter, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5924
- Guest BioGretchen Winter, MD philosophy of care is to partner with patients to improve their physical health while also building therapeutic relationships.
Learn more about Gretchen Winter, MD
Release Date: September 15, 2022
Expiration Date: September 14, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Gretchen Winter, MD
Assistant Professor in Critical Care Medicine & Pulmonology
Dr. Winter has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity - TranscriptionMelanie: The decision of whether to become a parent is complex for people living with cystic fibrosis and it's a major factor in reproductive decision-making. Welcome to UAB MedCast. I'm Melanie Cole. And joining me today is Dr. Gretchen Winter. She's an Assistant Professor in Pulmonary and Critical Care Medicine at UAB Medicine.
Dr winter, it's a pleasure to have you join us today. Can you start by telling us a little bit about the reproductive goals and family building concerns faced by people living with cystic fibrosis, including fertility, pregnancy, alternative paths to parenthood, the impact of trying these options on the mental and physical health. What do we know about fertility in people with cystic fibrosis?
Gretchen Winter, MD: Yeah. You know, that's a great question. And thank you so much for having me. Just like everyone else with any other disease or no diseases at all, many people choose to become parents and want to have children. And there are concerns specifically unique to patients with cystic fibrosis that need to be considered.
Most men with cystic fibrosis are infertile and women with cystic fibrosis have higher rates of infertility than patients without cystic fibrosis. So because of that, there's obviously concerns about their ability to get pregnant. And then, there's also concerns about the potential of passing down a genetic disease to their children, as well as their ability to continue life-saving medicines while they're pregnant or breastfeeding children. And so, because of those things, it is a complex discussion on whether to become pregnant and how to become pregnant for patients with cystic fibrosis.
Melanie: Well, then, speak about the impact of CFTR modulators and what their impact on fertility is.
Gretchen Winter, MD: So we know that the majority of women with cystic fibrosis are able to conceive and carry a pregnancy to term, but infertility can occur. And there's data that the prevalence of infertility and subfertility in women with cystic fibrosis is about 20% to 35%, which is about 10% to 20% higher than the general population. And there's a lot of potential causes of that, including older maternal age, exocrine pancreatic insufficiency, malnutrition, reduced ovarian reserve. And then, a lot of people feel that might be due to altered bicarbonate secretion that actually alters pH balance and can lead to sperm capacitation failure, potential prevention of egg fertilization, and then this abnormally thick and dehydrated cervical mucus that makes it harder for sperm to penetrate the cervical os.
Now, we know that CFTR modulators have led to improved health and longevity for people living with CF. So first of all, that leads to more women now looking at it and going, "Hey, I've got a longer lifespan ahead of me, so maybe having children and a family is something that I can have in the future" and wanting to pursue those options. Now, we also know that CFTR modulators do increase fertility for women with CF. The exact effect of those CFTR modulators on fertility is not known yet, but it's thought going back to the cervical mucus that we discussed, that these modulators might decrease viscosity and then increase the pH in the cervical mucus, which promotes a more fertile environment. And additionally, CFTR modulators improve the general health and nutrition of patients with CF, so that can positively impact their fertility. And there have been multiple reports of patients who have unexpected pregnancies on CFTR modulators. And anecdotally, many CF centers have seen what we refer to as the Trikafta baby boom with a surge of pregnancies in women on Trikafta.
Now, unfortunately, for men, 97% to 98% of males with CF have infertility due to a congenital absence of their vas deferense. So without that, the sperm cannot make it into their semen and thus can't reach and fertilize an egg through intercourse. And so CFTR modulators cannot reverse that, so they are not thought to improve fertility for men with CF.
Melanie: In my research, I read about the women with CF who've been taking Trikafta and were surprised to become pregnant. As you're telling us about the CFTR modulators, what do we know, Dr. Winter, about the safety in pregnancy and even in breastfeeding and that women living with cystic fibrosis who want to get pregnant need that guidance on whether they should stop taking the modulator therapy while they're trying to conceive or when they become pregnant? What do we know about pregnancy and breastfeeding?
Gretchen Winter, MD: So each of the CFTR modulators has been tested in animal reproductive models and there have been no adverse effects noted on fetal chromosomes, organogenesis or survival. It has been seen that the administration of Ivacaftor to neonatal rats did lead to a development of neonatal cataracts. Thus, all drugs that contain Ivacaftor do require routine ophthalmologic exams in children to make sure they're not developing this cataracts. Now, those are animal studies and there are no well-controlled studies in humans of CFTR modulators in pregnancy. But the available case studies have not shown a negative effect on babies from the use of modulators during pregnancy.
Of note, there have been reported cases of pregnant women who actually clinically declined after stopping their modulators and needed to resume them during pregnancy. And of course, the health benefits to the mother of continuing the drugs must be weighed against any potential risks to her and stopping the therapy and any risks to the fetus if continuing the therapy. So a decision on whether to continue or stop a CFTR modulator during pregnancy should be made after a conversation between the patient and their CF team.
Now, you also asked about the safety and women who breastfeed and we don't have well-established data on the safety of CFTR modulators in pregnancy and lactation much like pregnancy. So CFTR modulators have been shown it's being excreted in breast milk. So because of that, the liver function should be monitored in infants who are breastfed by mothers on modulators. However, current data does not show clear harm to infants whose mothers breastfeed while on CFTR modulators. So for women who choose to breastfeed, they should have a risk-benefit discussion with their CF care team, their OB team, and their pediatrician and mainly to be aware that the baby's LFTs or liver function test will need to be monitored.
Melanie: Well then, Dr. Winter, tell us about the counseling that women should receive that are living with cystic fibrosis if they're on CFTR modulators during pregnancy.
Gretchen Winter, MD: Absolutely. There are a few things to consider. So first they should know that maternal use of CFTR modulators during pregnancy can actually result in a false negative newborn screening test. So if the father of the infant is a CF carrier or if his genotype is unknown, then the children should undergo genotyping if they have a negative newborn screen. Additionally, as mentioned before, mothers who take a medication containing Ivacaftor should be advised to consider an ophthalmologic screen for their infants. And finally, mothers with CF should also be counseled that their infants might need that liver function testing as they were exposed to CFTR modulators, both in utero and if through breast milk.
Melanie: Well, then what would you like women with cystic fibrosis to know about contraception, Dr. Winter? Is there a certain method of birth control that's most effective for women? Does Trikafta decrease the effectiveness of the pill or other hormonal contraceptive devices? Tell us a little bit about that edge of this.
Gretchen Winter, MD: Yeah, that is a great question. So unfortunately, 25% to 50% of pregnancies and women with CF are unplanned, which is thought to be because many women with CF mistakenly believe that they can't get pregnant. They think that because 98% of men with CF are infertile, that 98% of women are as well, which is not true. So a lot of them don't use contraceptives, because they think they don't need them. Studies actually show that sexually active young women with CF are less likely to use contraception than women without CF. So the first thing is to inform our patients that they can in fact get pregnant and that they do need to be using contraception if they don't want that to happen.
Now, in terms of what form, there are a number of different forms of contraception available for patients with CF and without CF. There are sterilization methods, including vasectomies for men. And for women, there's tubal ligation or tubal occlusion devices. And then, there are intrauterine devices as well. Those include both a hormonal and a copper IUD. And then, there are a number of hormonal methods and those include birth control pills, patches, and insertable ring, injections and implants. And then, of course there are your barrier methods, like condoms, spermicides, the sponge, diaphragms, and any other vaginal barrier device. And finally, there are the behavioral methods, including abstinence, withdrawal and natural family planning.
Now, the most effective methods are the hormonal implants, intrauterine devices and sterilization. But the decision on what form of contraception to be used really needs to be discussed between the patient and their CF team. And it can be based not just on the efficacy of each method, but the potential side effects and then the patient's preference for what to use. All of them are pretty effective if used appropriately and as prescribed.
Now, for patients who do use hormonal contraception, Trikafta is not expected to decrease the effectiveness of birth control. And of the CFTR modulators, only Orkambi actually interacts with hormonal contraception. So patients on Orkambi should use an alternate form of birth control other than hormonal contraception. And we have seen patients who develop a rash while they're on Trikafta and the birth control pill. So if they do develop that rash, we suggest that they're switched to a different form of birth control.
Melanie: What are some other options that exist for people with cystic fibrosis that do want to have children?
Gretchen Winter, MD: So men and women with CF can take advantage of assistive reproductive technology, including IVF and intrauterine insemination. I do note that CFTR modulators do not seem to negatively impact the sperm of men with CF, so their sperm can be used for these therapies if they desire. And then of course, surrogacy is an option for people who want to have a baby that is carried by another person during pregnancy. Most surrogacy in the US is what's referred to as gestational surrogacy, which is when the intended parents use their own eggs and sperm to create an embryo that is then placed in the surrogate's uterus. And finally, adoption is also another way to build a family for someone who doesn't want to use surrogacy or other assistive reproductive technology.
Melanie: This is such an interesting topic. And as we wrap up, Dr. Winter, can you briefly touch on screening for depression, anxiety during pregnancy and postpartum for people living with cystic fibrosis? As you in this field, please reiterate for other providers how with increased health and survival due to modulation, family planning topics are going to become more common for people living with cystic fibrosis.
Gretchen Winter, MD: Well, we know that patients with cystic fibrosis, much like patients with any other chronic disease, do have significant rates of anxiety and depression and other mental health issues. And so we screen for those routinely, whether someone is pregnant, postpartum or not. I think it's very important to recognize that pregnant patients and postpartum patients do you have high risks of anxiety, depression, postpartum depression, even postpartum psychosis associated with pregnancy, which is a lot of trauma for the body to go through, not to mention that the mental effects and the fear and stress associated with that. So just as we should be screening every pregnant and postpartum woman, and just as we should be screening every patient with cystic fibrosis, we should continue to screen, look for, and provide whatever therapies are necessary to help for these mental health disorders when they arise.
Melanie: One-hundred percent%. Thank you so much, Dr. Winter, for joining us today. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or you know you can always visit our website at uabmedicine.org/physician.
That concludes this episode of UAB MedCast. For more updates on the latest medical advancements, breakthroughs and research, please follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua262.mp3
- DoctorsSutzko, Danielle
- Featured SpeakerDanielle Sutzko, MD
- CME SeriesQuality and Outcomes
- Guest BioDr. Sutzko was born in Baton Rouge, Louisiana, and grew up in California, North Carolina and Florida before moving to Michigan for her vascular surgery residency. She received a Bachelor of Science from the University of Florida, graduating with a degree in microbiology and cell science with a minor in chemistry. She went on to attend medical school at the University of South Florida, graduating Alpha Omega Alpha. During her research time, Dr. Sutzko completed a post-doctoral health services research fellowship at the University of Michigan's Institute for Healthcare Policy and Innovation under a National Heart and Lung & Blood Institute T32 grant, where Dr. Nicholas Osborne served as her primary mentor.
Learn more about Danielle Sutzko, MD
Release Date: September 21, 2022
Expiration Date: September 20, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Danielle Sutzko, MD
Associate Program Director, Vascular Surgery Residency
Dr. Sutzko has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionWelcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.
Melanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole. And joining me to talk about chronic limb-threatening ischemia is Dr. Danielle Sutzko. She's an assistant professor and Associate Program Director for the Vascular Surgery Residency at UAB Medicine.
Dr. Sutzko, it's such a pleasure to have you with us today. As we get into this topic, explain a little bit about chronic limb-threatening ischemia. What separates it from peripheral arterial disease? Why is it important to make this distinction? Tell us a little bit about it and what you've been seeing in the trends.
Dr Danielle Sutzko: Yes, definitely. Well, I'm glad to be here this afternoon as well. So the difference really with chronic limb-threatening ischemia is it's under the umbrella of peripheral arterial disease, but it's a more severe condition of peripheral arterial disease. So with chronic limb-threatening ischemia, the patients that we're seeing with this disease process are patients that have such bad blood flow in their legs from occlusive disease, that they are starting to have pain all the time or something called rest pain, or they have such bad perfusion that they've developed arterial ischemic ulcerations or wounds on their feet. They also sometimes have trauma to their feet and when they have trauma, such as potentially getting their nails clipped or hitting something on the floor, they won't heal their trauma or their wounds as easily as other patients that may have normal blood vessels, with normal perfusion. So that's the big differentiating factor, is that people with chronic limb-threatening ischemia have rest pain and something we call tissue loss, which is the wounds that aren't healing.
In terms of the trends, a lot of times, unfortunately, we see a lot of patients with peripheral arterial disease with pain with walking, which is known as claudication in our clinics. But a lot of times, the chronic limb-threatening ischemia patients, we end up seeing in the emergency room, when potentially some of this could be prevented if they were diagnosed a little bit earlier and sent to a vascular surgeon sooner.
Melanie Cole (Host): Thank you for making that distinction and the distinction between claudication and rest pain. So what had been the thought previously about these? Tell us about what's been going on with standard therapies and how this has evolved.
Dr Danielle Sutzko: Yeah, definitely. So, I think we have gotten a little bit better in terms of medical management. So I think probably historically anyone with peripheral arterial disease would immediately get an operation or potentially a minimally invasive procedure to help their blood flow. And I think we know a little bit more about the natural history of peripheral arterial disease in the way that if a patient only has claudication or more mild peripheral arterial disease, we're more likely to treat them with optimal medical management, which is including aspirin, a cholesterol agent, such as a statin, making sure to counsel them on smoking cessation and also getting them on an exercise program, which unfortunately, a lot of insurance programs don't necessarily cover. But what I tell patients is if you have a watch and you can go walking for about 30 minutes a day, whenever you have to stop because of pain in your legs, then stop the clock. But if you can do 30 full minutes of actual walking a day, that should be able to help your walking distance.
I think a lot of claudicants now that we see in clinic, if we recommend medical management first, a lot of those patients actually don't necessarily need surgery, but they definitely do need surveillance and monitoring usually in a vascular surgeon's clinic so that we can monitor them over time because some of the claudicants will progress to chronic limb-threatening ischemia.
The other thing that's the big differentiating factor is if patients have claudication, if it's really lifestyle-limiting or not. So some patients have claudication, but they're able to do everything they need to do and it's really not limiting their lifestyle. Whereas other patients may really depend on walking for, say, their occupation, such as a mailman if they're walking a lot or a UPS delivery driver. And for those patients, we're more likely to intervene with a surgery after medical management has been optimized if they have lifestyle-limiting claudication.
I think the other thing that really matters is where their blockages are. So if their blockages are in their aorta or their iliacs, those are larger vessels and they're more easily treated with surgery and they also stay open longer after, say, a bypass or a stent. Whereas if the blockages are really in the smaller vessels in their legs and even below the knee, those patients we're a lot less likely to treat with surgery or endovascular therapy if they're only a claudicant because we know those procedures won't last as long. Whereas if you have chronic limb-threatening ischemia, it really doesn't matter where the blockages are, those patients really need an intervention.
Melanie Cole (Host): So then, if they were claudicants and they go to become chronic limb-threatening ischemia, are their vascular guidelines and have other specialties that work on revascularization of the lower limb and brought together to incorporate some sort of guidelines?
Dr Danielle Sutzko: Yes. So they actually have a global chronic limb-threatening ischemia guideline put together for patients with chronic limb-threatening ischemia. You know, there's constant collaboration with vascular surgery, as well as interventional cardiology and other interventionalists that will provide care for these patients. And I think the big push nowadays is to not to intervene on claudicants until they really have been medically optimized and really only reserve that treatment for lifestyle-limiting claudication and then obviously treatment for chronic limb-threatening ischemia.
I think the other thing too is patients with diabetes used to not be included in this peripheral arterial disease spectrum. And we have now included diabetes in chronic limb-threatening ischemia. So those patients are not being left out.
Melanie Cole (Host): I'm glad you mentioned that, because I was going to ask if they're included in these guidelines. So tell us about some of the interventions and an update on anything that's changed as far as research studies that you're involved in. Tell us about what you're doing.
Dr Danielle Sutzko: Definitely. So I think the biggest thing is a lot of times when you have chronic limb-threatening ischemia, it really depends where the anatomy of the blockages are, is going to determine kind of the procedure that we go for. So it also depends on the overall picture of the patient and how many comorbidities or how healthy or unhealthy that patient is and whether or not they could tolerate a larger operation. I think most vascular surgeons, when treating patients with chronic limb-threatening ischemia in the aortoiliac segment, typically will try to treat with an endovascular first approach depending on how severe the blockages are or how long the blockages are. So there is a task classification that we go by. Task A meaning a short stenosis or narrowing versus task B gets a little bit longer narrowings versus occlusions. Task C, a little bit more severe and task D being long severe blockages in multiple arteries. And so there's task classification for the iliac segment, that a lot of times we will utilize. And most of the time, if you have a task D lesion, would be the only time that you go straight to open surgery.
Now I will say that sometimes if they have blockages, we will attempt to do the operation minimally invasive or with endovascular technology first. And sometimes we're not able to get the wire to cross the lesion. And so if that's the case, we will always have open operations as a second plan. But a lot of times, these lesions, we can cross with minimally invasive techniques with good results and good patency of these stents.
In terms of the below the inguinal ligament occlusive disease, I would also say that in most patients, we would try an endovascular strategy first, as long as the lesion is not too long or too calcified. And if we can't get across with a wire, then we always have another option to treat with open surgery.
The other thing is if the patient has certain disease that crosses the knee or has only one tibial vessel as runoff, then typically we will usually try to do an open operation in that patient, just because of the risk of damaging that one vessel runoff during an endovascular procedure.
Melanie Cole (Host): What about some promising new therapies? If you were to look forward to the next 10 years in the field, where do you feel will be the most important areas of research and I'd like you to add in there about when you feel it's important for other providers to refer to the specialists at UAB Medicine.
Dr Danielle Sutzko: Definitely. I think, there's definitely some exciting basic science research that's happening. Now, I'm more on the outcomes side of the research. So I don't know all the details, but there's a lot of exciting research going on with looking at diabetic wounds and how we can improve the neovascularization or new blood vessel development in patients that have diabetes and have peripheral arterial disease.
We do know that the patients that do have claudications that go out and walk, they can generate new blood vessels on their own that are always better than our own bypasses. So some of the technology and research being done on generating new blood vessels in these patients is pretty exciting if they can end up getting the solution to that problem.
I think in terms of outcomes research, which is more kind of in the realm that I study, I think it'll be really important to look at different specific patient populations within the chronic limb-threatening ischemia patients. So right now, I'm doing some grant writing work and research work in looking at the vulnerable population of patients with end-stage kidney disease that also have chronic limb-threatening ischemia. And unfortunately, those patients aren't necessarily included in the guidelines because they've been excluded from a lot of the research clinical trials that have been done in this space.
And so I'm hoping to get a little bit more kind of granular answers about how these patients do with open and endovascular options and also looking at who are the patients that regardless of what we do end up in an amputation anyways, because I think it is really important that if there are certain characteristics about people's blood vessels, that if we know ahead of time that they'll ultimately end up with a high risk of amputation, I think a lot of those amputee patients would appreciate getting the amputation sooner instead of doing multiple procedures, still being in pain and really being debilitated so that when they do get the amputation, they may not be able to walk on a prosthetic as easy as if they had just had it initially.
Melanie Cole (Host): That's interesting. And speaking to other providers, just wrap it up and what you would like the key takeaways to be.
Dr Danielle Sutzko: Yeah. I think if you are seeing someone in your clinic and they're complaining of pain with walking, and you're not able to palpate distal pulses, I think starting with an ankle brachial index, which is kind of the gold standard screening study for peripheral arterial disease, would be a good idea. And if they do have a decrease in their ABIs, referring them to a vascular surgeon for further management.
I also think if there's any patients that have wounds on their feet that aren't healing after a decent amount of time, I think it's always good to investigate if it's because they have lack of blood flow and, obviously, anyone with pain all the time in their feet without good pulses should be a referral to vascular surgery. And hopefully, we can get these patients in earlier to be able to treat and offer them operations if indicated sooner.
Melanie Cole (Host): Thank you so much, Dr. Sutzko, for joining us today and sharing all of these updates in this field. So thank you again. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua261.mp3
- DoctorsHolland, Marshall
- Featured SpeakerMarshall Holland, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5909
- Guest BioMarshall Holland, MD Specialties includes Neurosurgery.
Learn more about Marshall Holland, MD
Release Date: September 2, 2022
Expiration Date: September 1, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Marshall Holland, MD
Assistant Professor in Neurosurgery
Dr. Holland has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionWelcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.
Melanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole. Joining me is Dr. Marshall Holland. He's a neurosurgeon and an assistant professor at UAB Medicine, and he's here to highlight facial pain classification and treatment.
Dr. Holland, thank you so much for being with us today. As we get into this conversation, what are the different types of facial pain we're discussing here today?
Dr Marshall Holland: Well, thank you, Melanie, for having me today. We're going to focus on different types of facial pain that I end up seeing in my clinic that may or may not be surgically related, but important to determine the diagnosis. As with all things in medicine, diagnosis determines what you do next, which may or may not include surgery.
Melanie Cole (Host): So then, let's start with the definition of trigeminal neuralgia as we get into all the different types. How common is this? I mean, it seems to be the most widely known. Tell us just a little bit about it.
Dr Marshall Holland: I think that's a great place to start. As you said, it is one of the most widely known or at least discussed types of facial pain, but it actually is quite rare. Trigeminal neuralgia occurs in about one in 10,000 people compared to other diagnosis of facial pain that may end up being seen in my clinic. And I think that comes from the lack of understanding, or just lack of overall education on facial pain within our medical system, I'm constantly learning new diagnosis and how to spot them as I proceed through my clinic and my career. But as I've gone along in my career, I've found that trigeminal neuralgia is a very specific diagnosis, a very specific story. And if it doesn't follow that specific story when talking to a patient, I really got to put my thinking cap on and say, "What else could this be?"
Melanie Cole (Host): That's a great point and it leads me into my next question pretty well. So, I'd like you to speak about how patients present with facial pain and why diagnoses must be accurate, because there are other conditions that could mimic the same, correct?
Dr Marshall Holland: That's correct. So I'm going to go back to trigeminal neuralgia and what I mean by this is a very specific diagnosis and a very specific story. And with all of these diagnoses for facial pain, the most important thing I can do as a clinician is sit down and just listen, take a good history about the patient's presenting symptoms, locations, type of pain, because trigeminal neuralgia, as I've found, is a very specific story. These patients typically have a memory of the first time they ever had pain. They'll describe that pain as fleeting and extremely painful, worst pain they ever had in their life, electrical. Commonly, people say, it feels like, "I stuck my finger in a socket, but it's hitting me in my face." Pain's always in an area of the trigeminal nerve, which services sensory for the forehead, the cheek and the jaw, and that pain doesn't extend beyond those areas. Patients will describe that pain as, "When I'm in pain. It's the worst awful pain. But if I'm not in that pain, I'm pain-free." Patients typically will have what we call pain-free intervals, they have bouts of this pain say for a week or two, where they'll notice "I can trigger this pain with brushing my teeth, wind hitting my face." But after those couple of weeks, pain goes away and that can pain can go away for months to years.
Often, this pain's unilateral. It's very rare to see this on both sides of the face. And then, patients when they do become evaluated by providers and they tell this story, they'll start on a classic medication for trigeminal neuralgia, typically gabapentin or carbamazepine and they'll have a significant response, life-changing response, where they say, "I can go back to my normal life." Those key points of the history and specifically the response to medications in my mind says, "This is a true trigeminal neurology patient." If there's parts of the history or a lack of response to medications, where they say, "It took the pain edge off, but not, say, a significant response where I could go back to living my life," I start thinking this could be something else.
Melanie Cole (Host): So when you say you're interpreting the pain and since that can be somewhat subjective, how important for other clinicians is it that they understand what's really going on? Because as you said, when you try the gabapentin, but misinterpretation of the pain can lead to incorrect diagnosis or, you know, treatment mismanagement, so how do you determine that with your patients?
Dr Marshall Holland: A lot of it is listening and starting to ask probing questions searching for an alternative diagnosis. One of the most common diagnosis that I see, and this is far more common in the general population, is temporomandibular dysfunction disorder. And this is a disorder can occur in up to 15% of the general population at some time during their life and is involved with the muscles of chewing, the muscles of mastification. And the jaw apparatus. This is a strong mimicker of trigeminal neuralgia. And often, patients will come to my clinic with a preliminary diagnosis of trigeminal neuralgia and leave with a suspected diagnosis of temporomandibular dysfunction disorder. I say suspected because this is a diagnosis that requires, diagnosis evaluation and treatment by a dentist. My role is the neurosurgeon is to say, "This isn't trigeminal neuralgia, but I believe it's this other diagnosis, far more common, and we need to get you to the right person so you can really get some help and improvement in your pain."
Melanie Cole (Host): Dr. Holland, is it understood that often facial pain syndromes and mood disorders can coexist and that results in an important psychosocial burden. How is that addressed with the patient to ease that burden of the pain and anxiety over something that maybe even hasn't been diagnosed?
Dr Marshall Holland: You know, this is extremely important from a global pain management for this patient. And I believe my role and as a surgeon is to try and get to that diagnosis so they can head down the road of "This is going to get better. This will get better. We've just got to get to that right diagnosis and get you to the right person." Typically, particularly this last diagnosis, I just brought up temporomandibular dysfunction disorder, these patients have seen several providers, gone through several rounds of medication or other invasive treatments. By the time they get to a neurosurgeon's clinic and.. And oftentimes, there can be dismayed that I tell them, "Look, there's nothing I can do surgically for you, I think you need to see this one more person." And sometimes I'm left to convince them that, "I'm not trying to get you to someone else just to get you out of my office, but this is the right person. This is what you've been searching for that's really going to be able to sit down and help you."
Melanie Cole (Host): Such an important point. So tell other providers listening why that need for good relationships, and as you've stressed in this podcast, the importance of listening to the patient's story fully, and the comprehensive multidisciplinary approach when dealing with facial pain.
Dr Marshall Holland: This is key, because I can only offer my few surgical approaches. But if I'm the person during this evaluation that can get again to that diagnosis and get them to the right provider, we can get these patients the relief they need. And by listening and having a framework in your head of what else could this be if this doesn't follow that standard pattern of trigeminal neuralgia, you can ask the right probing questions. Temporomandibular dysfunction disorder is described as a mimicker of trigeminal neuralgia, because they will have these spikes or crescendoing of pain that can be triggered, talking, eating, touching the face. But one of the key differences that a patient may offer or you may need to ask is they'll have a secondary pain that's constant and in the background that can wax and wane throughout the day, throughout the week, different times in their life. And it's far more likely to be bilateral. So I start to hear these words or I ask the patient to describe their pain, I'll start searching for other clues, this may not be trigeminal neuralgia, what else could it be? These patients will also typically have areas of pain that are outside the area serviced by the trigeminal nerve in terms of its sensory division. And these can be big clues to something else may be going on here, and the surgical procedures I do may not help this patient.
Melanie Cole (Host): Before we wrap up, give us a brief overview of the surgical procedures that you do that might help people with facial pain and when you feel it's important for other providers to refer their patients to the specialists at UAB Medicine.
Dr Marshall Holland: I believe for a trigeminal neuralgia, this is a lifelong disorder that patients will be dealing with if this is a true trigeminal neurology patient. And medications, like I said, could be life-changing. This typically gives patients back control of their life. However, these patients' disease will push through, the natural history would say that, and they often get to the point where the medications are causing cloudiness of thought or balance difficulty due to the high dosage. And this is where surgery plays a role. We call this medication refractory trigeminal neuralgia.
There's different approaches to it. The most invasive, but the most durable is a microvascular decompression where it is a brain surgery where we approach the trigeminal nerve, and we may or may not see a vessel compressing the nerve. If we see strong compression, we decompress that, place some padding between the vessel and the nerve. And this can be curative for the patient's pain on average about 10 years. If we don't see a vessel, then we will intentionally comb the nerve and create a lesion or numbness of the face. And the idea behind this is to prevent those triggers that we talked about earlier. This also incredibly has the same half life in terms of its durability, about 10 years. But it does come with a higher risk profile, and so this is something that we talk about in my clinic with the patients.
Another surgical intervention that I consider is radiofrequency lesioning and this is an outpatient procedure where we place a stimulating probe through the cheek, down to the base of the skull where the nerve exits. It's done under sedation, intermittent sedation. We're able to wake the patient up just enough to interact with them to determine which branch of the trigeminal nerve we're stimulating. And then, we use microwaves through the end of the probe to lesion the nerve. One thing that's nice about this procedure is it's an outpatient, but it's not quite as durable. The halflife is about half of a microvascular decompression, about four and a half, five years. Half the people will have recurrence of their pain. But this procedure can be repeated. And for some patients, they have trouble wrapping their head about undergoing a big brain procedure, this feels less invasive to them, and so this can be a strategy to control their pain. And when I say halflife for both those two procedures, I mean, no pain, no medications is our goal.
The third procedure that I also perform for my trigeminal neuralgia patients is stereotactic radiosurgery. This is done in conjunction with the radiation oncologist, where we lesion the nerve using radiation. This can be a good option for patients that are extremely risk averse, because this does not involve any, intervention other than a trip to the radiation center.
And then, there are other types of pain that we haven't got to beyond trigeminal neuralgia and temporomandibular dysfunction disorder, that are more rare such as postherpetic neuralgia. This is a patient who's had shingles of the face and the lesions are treated with an antiviral. And despite the lesions going away, they have continued burning and constant pain of the face. One of the unique procedures that I am offering for those patients is a trial of stimulation of the trigeminal nerve branches. And for some patients, this can provide up to 50% relief. And even with that 50% relief, they can get part of their life back. This is also a strategy that we employ for patients that have non-intentional injury to a trigeminal nerve branch, and will have essentially neuropathic pain of one of the branches of the face or multiple branches, this we call trigeminal neuropathic pain.
So, overall, facial pain, the more and more I learn about it, and I believe other providers learn about it, can be a very deep and difficult subject to tease out an exact diagnosis. The most important thing in anything in medicine is the diagnosis determines our next steps in terms of workup and treatment.
For providers out there who are struggling with a patient trying to determine what type of facial pain this could be, or it doesn't fit the mold of that classic trigeminal neuralgia patient, always happy to see them in my clinic and work through their history and try to determine a diagnosis and, most importantly, a treatment plan.
Melanie Cole (Host): Thank you so much, Dr. Holland. What an informative overview of facial pain syndromes. Thank you so much for joining us. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. For updates on the latest medical advancements, breakthroughs in research, follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua259.mp3
- DoctorsGlasgow, Justin
- Featured SpeakerJustin Glasgow, MD, PhD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5846
- Guest BioJustin Glasgow, MD, PhD is Associate Chief Quality Officer, Physician Advisor for Sepsis, UAB Hospital.
Learn more about Justin Glasgow, MD, PhD
Release Date: July 28, 2022
Expiration Date: July 27, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Justin Glasgow, MD, PhD
Clinical Assistant Professor, Hospital Medicine
Dr. Glasgow has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity - TranscriptionMelanie Cole: Welcome to UAB Med Cast. I'm Melanie Cole and joining me today is Dr. Justin Glasgow. He's the associate chief quality officer and physician advisor for sepsis at UAB Medicine. And he's here to talk about the burden of sepsis on our healthcare. Dr. Glasgow. It's a pleasure to have you join us today. I'd like you to start by telling us a little bit about the current state of sepsis today what you've been seeing in the trends, how many people approximately are affected by it each year.
Dr. Justin Glasgow: Yeah, absolutely. Thank you all for inviting me on. And, sepsis is such a large topic that, about 1.7 million cases of sepsis are diagnosed each year. And this leads to nearly 270,000 deaths from sepsis. in the hospital setting, you're looking at about a third of the patients who die in hospital had a case of sepsis, but actually sepsis starting out in the community that makes it such a challenge. As almost 90% of sepsis cases are present when the patient first presents to the hospital.
Melanie Cole: That's interesting. it's a good point. Can you speak a little bit about the etiology and the pathophysiology? The understanding that we know now, maybe we didn't know, 20 years ago of the interplay among the host's immune inflammatory pro coagulants responses in their systems. Tell us a little bit about how that all works and what we know now.
Dr. Justin Glasgow: For everything that we know, there's still a lot that we don't know. But certainly for sepsis, it starts with an infection and, at least we need to believe that there's an infection driving the process underlying everything. And from there. Something leads to actually an overwhelming or sort of dysregulated immune response, which then leads to damage to organs throughout the rest of the body. Sometimes that's the form of increasing the risk and development of clots.
Sometimes it's under profusing the organs and not providing enough oxygen, but we still don't have a really good measure for what it is that leads to that sort of cascade from where the supposed, immune response to an infection is appropriate, to when it becomes too much and then overwhelms the rest of the body.
Melanie Cole: Well, then let's talk about the biggest challenges in diagnostic criteria and the role of accurate sepsis biomarkers to facilitate that diagnosis. And could those be used to enable that timely, appropriate treatment so that it can be started right away and optimize a patient's chance of survival? Speak about what's going on in diagnosis today.
Dr. Justin Glasgow: That is still a big area of development and trying to find the answers. some of the first consensus definitions around sepsis came in the early 1990s, all with the goal of helping develop the research programs that would identify these biomarkers. And we, have things like lactate and procalcitonin, which are associated with infection, might be a sign of a need, but none of them are specific enough to really, be counted on. And so we still work with very broad criteria to of establish a diagnosis of sepsis, which leads to those challenges of either over diagnosing and, giving too many antibiotics or, misdiagnosing because it's broad and everything sort of creates these responses. And you just don't know what is the primary driver until it's too late to recover.
Melanie Cole: So are there some key recommendations for practice and clinical practice guidelines for management? If it's caught in the early stages? Tell us a little bit about that and what antibiotic selection process might look like and how that differs from acute and less acute phases?
Dr. Justin Glasgow: So the, main guidelines that everyone is familiar with come as part of the CMS or Medicare Quality metrics, and is generally known as SEP one. And so it starts with, from the time of recognition of sepsis, expectation to check lactic acid, obtain blood cultures, administer antibiotics. And if the patient is meeting criteria for severe sepsis or septic shock to administer fluids up to or at least 30 CCs per kilogram with some modifications. If you think the patient has heart failure or end stage's renal disease, where that much fluid would be detrimental.
And then depending on that initial result, you would over the next six hours monitor the response to treatment, check follow up lactate, and provide additional care such as initiation of vasopressors if the shock state persists. As far as antibiotics, there has been sort of recent modification to their rules, which used to have two separate criteria, but is now really just getting a good, targeted antibiotic, broad enough, but appropriate for what is the known or suspected infection.
Melanie Cole: So once it's been identified. Dr. Glasgow and completely treated, if that's what happens, what does the deescalation process look like? And what's important for physicians and advanced practice providers to be aware of when they're documenting about sepsis?
Dr. Justin Glasgow: Those initial blood cultures, ideally we're hoping that, comes back to provide us with the organism that is causing the infection and the sepsis. And then, what antibiotics is sensitive to, and the goal is always to get patients to the most, targeted antibiotic, as opposed to broad so that you are treating the one infection you need to, and not having collateral damage from a very broad, antibiotic. Plus decreasing exposure for ongoing antibiotic resistance by using narrow agents. Of course, if those additional studies also show that what you found wasn't due to an infection, but in fact was, maybe a heart failure case, then, it may actually be appropriate to completely stop the antibiotics and then focus your management on those other conditions.
For the documentation, the big thing is to provide as much clarity and specificity in our documents as we can. With sepsis, each organization has a little bit of a variation on what they're documenting in part, because they're currently to come as there are currently two competing consensus views. At UAB, we are doing a bit of a combination of the two in which we maintain the three categories for sepsis, but instead of using this name of severe sepsis, we focus on, is there any organ dysfunction present? So you can document sepsis without organ dysfunction for those Cases that met criteria, but fortunately didn't show signs of organ damage elsewhere in the body.
Or if you did have an acute kidney injury because of the sepsis, you could then say sepsis with acute kidney injury due to, the community acquired pneumonia or whatever it was that we were managing. And then of course the final category of septic shock. Because the final coding and documentation of, the overall hospitalization is done by folks who specialize in that, but not specialize as healthcare providers, being clear when you remove a diagnosis is also important. So we generally recommend that if you have that case where you feel like sepsis didn't drive it. But it was in fact, the heart failure.
Then you would include when you update that diagnosed heart failure, simple statement to say that sepsis was ruled out and then they, everyone sort of knows for clarity that that was what was going through the provider's mind as they did their documentation.
Melanie Cole: That's interesting. So as we get ready to wrap up, what are some of the newest therapies for treating sepsis? Do they sound promising? Let other providers know at other institutions what you're doing at UAB Medicine that they may not know about in your key takeaways from this podcast.
Dr. Justin Glasgow: Sepsis management always comes back to the basics and that is, having it on your differential and thinking about it, anytime you have a change in patient status. Particularly when you have those patients who are very severe and you're thinking about admission or transition to an ICU level of care. As far as, upcoming and specialized, treatments, I'm unaware of anything at the moment that is having a lot of, success. There's few things that are always, considered and the trials around them are fairly equivocal, steroids for the treatment of shock seems to be coming back in terms of identifying the cases where it would be most useful.
But beyond that, there's still lots of work going into figuring out how we better, improve our treatment of sepsis, but not a whole lot that has really established itself as becoming central to our care process. And then I think that leads us with, a few takeaways from this podcast, starting with the summary that sepsis is ever present in patients, particularly in the hospital setting, and the key really is early detection. if there's gonna be the ability to prevent death it's because we have identified and started it early. And so from that point, The second takeaway is if you're thinking sepsis, go ahead and start the bundle, collect the cultures, get the lactate and start antibiotics.
And then third point is you've done that, but that doesn't mean. It stops there. You do have to set back a couple days later and say, okay, what's the overall picture of the patient. Now that we have more information? If we had sepsis and we're managing it and we're doing well, continue that, but narrow in the treatment as much as possible. And of course, if it proves not to be, then let's rule that out and focus our treatment on the actual problems that we identified for the patient.
Melanie Cole: What great information, Dr. Glasgow, thank you so much for joining us today and really telling us about the current state of sepsis and some management guidelines. Thank you again. A physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST, or you can visit our website at UABmedicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole. - HostsMelanie Cole, MS
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