Additional Info
- Audio Fileuab/ua260.mp3
- DoctorsJones, Jesse;Morlandt, Anthony
- Featured SpeakerJesse Jones, MD | Anthony Morlandt, MD, DDS, FACS
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5879
- Guest BioJesse Jones, MD is an Assistant Professor.
Learn more about Jesse Jones, MD
Dr. Morlandt was born and raised in Floresville, Texas and graduated from Baylor University. He completed his DDS magna cum laude at the University of Texas Health Sciences Center in San Antonio, Texas, and received his MD and internship and residency in Oral and Maxillofacial Surgery from the University of Alabama School of Medicine.Learn more about Anthony Morlandt, MD, DDS, FACS
Release Date: August 18, 2022
Expiration Date: August 17, 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:
Anthony Morlandt, MD, DDS
Associate Professor, Head and Neck Surgical Oncology
Jesse Jones, MD
Assistant Professor, Diagnostic Radiology
Drs. Jones & Morlandt have no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity - Transcription
Doctors, thank you so much for being with us today. And Dr. Morlandt, I'd like to start with you. If you'd start by giving us the general classifications used to describe vascular malformations of the head and neck, what are we talking about here today?
Dr. Anthony Morlandt: Well, that's great. Thank you, Melanie, for having us. This is an important topic. It's an often confused topic. I think the classification has changed quite a bit over the years, and at least when most of us were in training, we talked about two general classifications. We talked about hemangiomas, which had sort of increased cell turnover and increased numbers of cells; and then malformations, which had abnormal cell growth, but the rates of the cell turnover was not increased, so normal cell turnover. That led to quite a bit of confusion because the treatment really didn't depend on the rate of cell turnover. That's something that really we would apply to a neoplasm like a cancer.
But in this case, the more common phraseology really divides these into two basic groups, vascular tumors and vascular malformations. And under the general classification of vascular tumors, you might find some of these congenital hemangiomas that occur in children. But really, what we're here to talk about today are vascular anomalies that can be classified primarily as either high-flow or low-flow. And that's really important, because clinically a high-flow lesion may have more of an arterial component. It may have an arteriovenous fistula and rapid expansion and, in the head and neck, and especially in the face, these have significant cosmetic and functional issues. So, it takes a multidisciplinary team. It takes a head and neck surgery unit. And an endovascular neurosurgeon, like Dr. Jones, to treat these. It really takes two different sides from both a chemotherapeutic and embolization perspective and a surgical perspective to take care of these complex problems.
Melanie Cole, MS: Thank you so much, Dr. Morlandt. And so Dr. Jones, Dr. Morlandt just mentioned a bit, but why are these such a challenge to head and neck physicians and the complexity in diagnosing and then therefore managing these. Speak a little bit about some of the challenges.
Jesse Jones: Well, I think part of it comes down to the characteristic of the lesions, they're variable. I think one of the problems is just the sheer variety in these lesions. As Dr. Morelandt mentioned, there's various classifications, but they can come on all sorts of colors and shapes and sizes with high-flow lesions, slow-flow lesions, lesions that have a primarily venous component versus those that have an arterial component, and the treatments really differ markedly. And I think there's quite a lot of complexity in there and it really takes a multidisciplinary team to kind of get to the bottom of what's going on and to propose a treatment plan that's most appropriate.
Melanie Cole, MS: And we're going to get into that treatment plan, but Dr. Jones, sticking with you for a second. Tell us about some of the advances in radiologic imaging that have really augmented your diagnostic and therapeutic capabilities for these. Are there any that have changed the landscape of treatment for you?
Jesse Jones: Well, I think MRI has made a huge difference in diagnosing the kind of malformation and the extent of the malformation. Some of these lesions can be quite trans-spatial, meaning they cover multiple different spaces of the head or neck. And those can be difficult to appreciate on just physical exam or even ultrasound. And MRI does a beautiful job of delineating the borders of these lesions and also within the lesion itself, depicting areas of high-flow, low-flow and lesions that have both, showing where those components may be within a larger complex lesion. So we like to get an MRI at UAB whenever possible, when we're first evaluating these patients to get a good sense of the complexity and the full extent of their lesions.
Melanie Cole, MS: Dr. Morlandt, speak about special considerations for treatment of these lesions that must be made. And due to the sensitivity of the area, as you mentioned at the beginning and the intricate nature of this type of situation, speak about the treatment options and what you're doing at UAB.
Dr. Anthony Morlandt: I think when we evaluate a patient with an anteriovenous malformation or an anomaly of the face, vascular anomaly of the face, it's helpful to divide the face of into thirds. The upper third, which primarily is the forehead; the midface, from the lower portion of the orbits, the infraorbital rim to include the upper jaw and the upper lip, the nasal complex, the malar complexes, including the cheeks; and then the lower third of the face, which is from the philtrum or the subnasal region, down to the bottom of the mentum or the chin.
And so within each of those areas, we have sort of a special set of organs. We have the eyes in the upper third, we have the nose in the middle third, and we have the mouth in the lower third. So when evaluating these, it helps to have both a soft tissue appreciation. And in the soft tissue category, we would include placing incisions along natural skin creases, along resting skin tension lines to minimize their appearance postoperatively. We want to make sure that we always hide the incisions in a way that's the most cosmetically optimal. so we have the soft tissue, we have the underlying bone, and then we have these sort of special areas of eyes, nose, and mouth. And so we treat a lot of these that are around the orbit, for example, where we have to maintain vision. And so we're trying to preserve the upper and lower eyelid function. We're trying to work with Dr. Jones's team to make sure that he, in treating this with embolization, doesn't sacrifice or cause damage to the vision. And then surgically, for example, in an orbital or peri-orbital lesion, we're trying to minimize the risk of disrupting that entire apparatus, all of that orbital septum and tarsal system that supports the eye and supports the eyelids. The mouth is important too. We're trying to make sure that the tongue and the teeth and the lips are not adversely affected when we're removing these.
I think if we step back from an even higher view though, we're also very concerned when the skin is involved. There's a Schobinger classification of high-flow arteriovenous malformations. And Jesse, correct me if I'm wrong, but you know, if we have a lesion that involves the skin with ulceration, we're really thinking of a totally different treatment plan than if we have one that doesn't yet involve the skin, and we're trying to avoid that. So we don't want embolization to cause skin necrosis. We don't want surgery to leave an external defect. So some of these more advanced lesions, we're really considering similar to how we treat a head and neck cancer or a cosmetic surgery patient. We follow all the same principles employed in facelifts and fillers and facial suspension and everything that we employ in our head and neck cancer population to give them the best outcome possible.
Melanie Cole, MS: Dr. Jones, would you like to chime in here and add anything to what Dr. Morelandt just said?
Jesse Jones: Yeah. Speaking to the purpose of preserving these various functions and the head and neck is a highly functional region for multiple reasons. It has a very important psychosocial dimension. It's what we see when we look at each other in the face. And we breathe, we eat, all these things occur through the head and neck. And so when we're trying to preserve these various functions, it does take an interdisciplinary approach. So for instance, if Dr. Morelandt is planning on resecting a high-flow lesion around the mouth or the nose, that's where my team would come in, to prepare the patient for his surgery. And by preparing, that would be a procedure called embolization, where we would go in there and slow down the blood flow to these various structures. So when it's time for surgery, there's less blood loss during surgery, there's better visibility during surgery and the overall result is superior.
Melanie Cole, MS: And Dr. Morlandt, as we've spoken about and mentioned a few times, the multidisciplinary and interdisciplinary approach, how do facial surgeons and endovascular neurosurgeons work together to really optimize patient care and outcomes? Now, you two represent two specialties that are focused on treating these kinds of malformations. So I'd like you to tell us about your combined clinic, why it's relevant and what you're finding are the largest benefits.
Dr. Anthony Morlandt: I think one of the most important things that having an endovascular approach does for the surgeon is by going in prior and using agents to control bleeding and minimize blood loss during surgery, we can do a much better job preserving vital structures. And so it's pretty common in the face to have a vascular anomaly that's supplied, at least in part, by the facial artery as an example. And the facial artery, if you palpate your own facial artery, which is at the antegonial notch of your mandible, right in front of the angle of your mandible, by sort of the back of your jaw, then you could feel how that artery courses along the face and that's intimately associated with the branches of the facial nerve.
So there are several cases we've treated together where Dr. Jones has gone in prior, embolized the feeder vessels for a high-flow lesion in this area. And then, when I take this patient to surgery and make a facelift incision and use a parotidectomy approach, it's a much drier field. I can identify and preserve the branches of the facial nerve. And we can have a much better outcome that both is important from a pathology standpoint, not oncologic perspective because these aren't cancers, but it's important from a tumor control and vascular malformation clearance perspective, because we really have to clear all of the components of these lesions. So they don't recur. So it's important, not only on that end, but also from a cosmetic and a functional outcome as well. So having a nice dry field is key, it's paramount, and it helps us do a really good job. And it also helps us be able to know what reaction the skin will have in surgery, keeping in mind that many times the arteriovenous malformation, since we're speaking of those here, they may provide some of the blood supply to the underlying skin. And so in resecting an underlying deeper vascular lesion, we may compromise the blood supply to the skin surgically. And that's a huge problem for overlying skin on the face.
So by having embolization upfront, it allows me to really predict whether that skin will necrose, and have a external scarring. Maybe I need to go ahead and excise some ischemic or necrotic skin and rotate local flaps into position to provide the best result. So it really is a nice and sophisticated way to do it. And it's what would be considered the standard of care in the Western world at least.
Melanie Cole, MS: Dr. Jones, do you have any final thoughts for other providers on when you feel it's important that they refer to the specialists at UAB Medicine?
Jesse Jones: Well, I think when these lesions are first discovered, there's kind of a decision tree at that point. a lot of these are purely asymptomatic or incidental and for those lesions, we do not propose or suggest treatment. It's when these lesions become bothersome to the patient. And that can be for a number of reasons. It could be something functional, like it's interfering with their ability to swallow or to breathe, especially at night with things like sleep apnea, or it may be a psychosocial component. The lesion is disfiguring to them or their child. And when those situations arise, I think treatment is warranted and that's probably the time you want to reach out to us at UAB, so we can do those things like we talked about earlier, do the MRI get together in a multidisciplinary fashion, start talking about treatment options.
Melanie Cole, MS: This is such an interesting topic and you're such a great guest, Dr. Morlandt. Can you please have the last word here, as we're talking about these types of malformations, and we've mentioned briefly the effects that they can have. Dr. Jones mentioned the effects on appearance and function of the patients, and they can be pretty disabling and socially isolating, really have a significant impact on quality of life. So I'd like you to end with your best information for other providers about that particular aspect of this and how really, because of the intricate, sensitive nature of this, that the experts at UAB Medicine are uniquely qualified to deal with these malformations.
Dr. Anthony Morlandt: Well, I think the best way to explain it is by outlining a case. And there's a particularly memorable case I have of a young woman who was pregnant and in the course of her pregnancy with all of the vasodilatation, the growth factors, the increased blood volume, had quite a massive bleeding, arteriovenous malformation involving her orbit, her upper cheek, her nose and her lip. And not only was she dealing with bleeding and blood loss and admitted to the high-risk maternal-fetal medicine unit. She had other kids at home who were terrified by this massive facial tumor. And this is a patient who doesn't have cancer, who's not going to get radiation or chemotherapy. This is a patient who has a non-metastasizing, clinically benign, but certainly not safe or unimportant tumor. And so, we have many aspects of the patient's safety, their health and wellbeing to be concerned with, especially in patients who have high risk syndromes, like HHT. And UAB is now working to become an HHT Center of Excellence for patients and to be a resource for physicians all across the Southeast for this condition. HHT stands for hereditary hemorrhagic telangiectasia, which is a congenital syndrome associated with some of these high-risk arteriovenous malformations.
So we have the risk of bleeding, obviously is paramount. We have facial disfigurement. We have the fact that it's not a cancer, but really in a sense, these patients are going through some of the exact same treatments that a cancer patient would. And then we have the permanent components the permanent scarring and sometimes even disfigurement when these are treated without the support of a large center. And so it's important, I think, that we respect these patients concerns. We respect that there's tremendous amounts of embarrassment from walking around with one of these lesions.
The last thing I'd mention is that these aren't static. For many patients, they are positional in nature. They lean over to tie their shoes or pick something up off the ground, and it fills up with blood and you have a large purple pulsating lump on your cheek or on your face. I had a young woman who had one on her left forehead, and every time she leaned over to tie her shoes, it popped up like a grape. And it would happen without notice, so people in the store or at work or at a restaurant would become quite alarmed because it seemed to grow in front of their eyes. People thought it was an emergency.
And so there's all of this stigma that goes along with these. And so I do want to remind doctors that were not dealing with a cancer, but the effects of this are quite involved for patients and families. And so we treat all these patients, everyone who comes to us, with a special ounce of compassion to deal with these lesions.
Melanie Cole, MS: Wow. Thank you so much for sharing your outcomes and patient stories as well. And such an interesting topic. And your passion comes right through. Dr. Morlandt, Dr. Jones, thank you so much both of you for joining us today. You are both excellent guests. 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. Thanks so much for joining us today. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua256.mp3
- DoctorsCannon, Robert
- Featured SpeakerRobert Cannon, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5858
- Guest BioRobert M. Cannon, M.D., is an assistant professor in the Division of Transplantation, specializing in liver transplantation and hepatobiliary surgery.
Learn more about Robert Cannon, MD
Release Date: August 3, 2022
Expiration Date: August 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 M. Cannon, MD
Assistant Professor in Surgery – Transplantation
Dr. Cannon has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionIntro: Welcome to UAB MedCast, a continuing education podcast for medical professionals. Providing knowledge that is moving medicine forward. Here's Melanie Cole.
Melanie Cole: Welcome to UAB MedCast. I'm Melanie Cole. And joining me today is Dr. Robert Cannon. He's an Assistant Professor and the Surgical Director of Liver Transplantation Program at UAB Medicine. And we're discussing the access to transplantation and geographic disparities today.
Dr. Cannon, thank you so much for joining us again. Can you discuss a little bit about the mismatch between disease burden and transplant rates in the US today?
Dr. Robert Cannon: Yeah. Well, thank you for having me. I'm happy to be back on here. So yeah, what we've been seeing essentially is both in liver and kidney transplant, this is where we do our research, that the parts of the country that have the highest disease burden in many cases are actually also the parts of the country where unfortunately we have the lowest rates of transplant, and this creates a significant mismatch. You know, there's always an organ shortage. So no matter where you are, there's never enough organs for the number of recipients or people with end-stage organ failure who need a transplant. But we found that this gap is the widest and most glaring in the areas that have the highest disease burden. So you could argue that where we have the most need, we're actually seeing the lowest rates of transplant.
Melanie Cole: Yeah, that is frustrating, and must be for you, doctor. So while much has been made of combating geographic disparities in organ transplant in general, has the focus been on the population of patients who've already made it to the waiting list or the ones that are still trying to go through the system?
Dr. Robert Cannon: So I think that's been the issue is that, you know, I think the lens through what we've been looking at geographic disparity and transplantation has been wrong, or at least we have not been looking at it as completely as we should. Because, yes, what we focused on as a community in the past has been access for those who are on the waitlist already. And when you look at transplant rates in terms of, you know, transplants per number of patients on the waitlist, that looks very different than when you look at transplants in terms of how many transplants are performed in comparison to the overall population who could potentially benefit from a transplant.
So it's really helpful to think of sort of two phases of the transplant process. First, when you have, let's say, you go on dialysis or you develop end-stage kidney disease. First, you actually have to get on the waitlist and then from there, so that's sort of phase I. And then phase II is once your wait-listed, you have to be transplanted. So the vast majority of the efforts of our transplant community had been on phase II, getting people who are on the waitlist transplanted. But that misses out on a very large and wide population of patients who never have access to the transplant list. And that's what the recent work we've been doing in both liver and kidney transplantation focuses on. And that's why if you look at transplant rates as a measure of overall disease burden, you see a much different picture of disparity than what you see if you only look at the waitlist.
Melanie Cole: That's a great point that you just made. And stepping back for a second about that disease burden and transplant rates and where you mentioned that some places in the country where they need it the most is where it is the least available and thinking about long-term solutions, how do you think the healthcare industry can be reformed to better serve these patients? If you have any research or, you know, just expand a little bit more on the fact that the disease burden in these areas, whether it's because of lifestyle behaviors, obesity, environment, I mean, it's an obvious complex situation, how can the healthcare industry help to better reform this situation?
Dr. Robert Cannon: Well, broader access to care is really the ultimate thing we need to do. And that's where we see many people suffering. If you don't have access to a good nephrologist or someone who can refer you to transplant, then even if you'd potentially be a good candidate and benefit from one, you'd never get one, for example.
And those problems were most pronounced in our poor and generally underserved communities. So I think, one recognition of the problem that we do have these large underserved areas is a start, but then we need to increase, for example, our outreach efforts. So on our transplant center, we've opened a number of outreach clinics where we actually essentially bring the transplant center to the community.
Many patients just have a hard time getting to us, for all the evaluation appointments on a societal level, if we need to just work to actually provide access to care for all. From a research standpoint and from actual transplant policy, again, I think we need to stop focusing solely on the waitlist. Because if you do that and don't pay attention to the larger population, you can make some changes that can actually be harmful.
For a concrete example in liver transplant, if you look at transplant access on a proportion of the waitlist, there's some parts of the country that looked like they were doing very poorly and have a great need for transplant because the transplant rate as a function of the waitlist size doesn't look very good. But then when you step back, you realize this is actually a part of the country that has very good access to care and a relatively large proportion of patients suffering from liver failure actually are on the waitlist. And if you look overall, the overall disease burden is not that high compared to other parts of the country and really the number of transplants relative to the overall liver disease burden looks good in that part of the country. But we ignore that and we've essentially designed policies to shuttle more donor livers to that area because it looks bad in terms of access just focusing on the waitlist, but really they're doing quite well. And so we're shifting livers away from areas that are more underserved on a population level. So, again, that's why we need to change this in our focus. So when we do adjust transplant policies, that we're keeping the population health in mind.
Melanie Cole: This is such an interesting issue and you are certainly one of the experts to help solve it, Dr. Cannon. Tell us about your manuscript in press regarding your work in liver transplantation. Share briefly some of the highlights from your presentation, won't you?
Dr. Robert Cannon: Sure. So, I mean, we've got two manuscripts in progress right now. One is in liver transplant and the main highlight from that one is what I just said, is that essentially using the metrics based on the waitlist, we're worsening the disparity. So we've created a liver allocation system that essentially shuttles livers to areas that actually are doing quite well in terms of transplants versus the overall population of liver disease, because we are only focused on the waitlist. And that's our main highlight of what we found on the side of liver transplantation.
A more recent work apply the same methods to kidney transplant, and that's also what we're finding, is that some of the areas with the actual highest burden of kidney disease in the country, some of which are actually right here in Alabama, in the Southern part of our state, are areas with the lowest rates of transplant. So we're really just wanting to call attention, just raise this issue, that again our scope and our borders need to extend beyond our waitlist and our responsibility actually extends to all patients suffering from organ failure, not just those who are already on our list.
Melanie Cole: Taking into account the disparities and, as you say, the geographic disparities in transplantation, what else do you see as the greatest challenges facing the field of liver and kidney transplantion, the constraints to meeting that annual demand for liver transplantation? And is there anything that you can tell us that's really exciting about things that you're doing at UAB Medicine that can help meet that annual demand?
Dr. Robert Cannon: You know, The greatest challenge in transplantation will always be the organ shortage and the fact that we've just never had enough organs available for all those who would benefit from it. That's why here at UAB, we're expanding use of living donation. We've always been very aggressive about that on the kidney side. And we're starting a living donor liver transplant program as well for that same reason to expand access. There's the work on xenotransplantation, so making genetically modified pig organs potentially available for transplant, that work's being done at number of centers, including right here at UAB.
Melanie Cole: That's so cool. I did a podcast on it, and that is very exciting work that you're doing. Final thoughts, Dr. Cannon, what you would like other physicians to know about timing of referral and referral, obviously to the experts and specialists at UAB Medicine, but really access to transplantation and the geographic disparities, what you would like them to know about things that you are doing to tackle this and things that community physicians can also do.
Dr. Robert Cannon: Certainly. Yeah. I mean, I think the best thing is to refer early, right? We can't help the patient if we don't know about them and if they're not in the system, so don't need to worry about whether the patient's a candidate or not. You know, that's our burden there. So, you know, I don't think the referring physicians need to worry about that. You know, if they just want to refer the patient, we're happy to get the patient in and we want to be able to meet the patient where they are in many cases. So if the patient's got barriers for being able to get to us, for being able to undergo the evaluation, please let us know. We're happy to help with that. Because really, again, we want this to be centered on the patient and how to meet their needs.
Melanie Cole: You're such an excellent guest, Dr. Cannon. You have so much knowledge to impart. Thank you so much for joining us today. And I hope that you'll come on again and update us as you learn more and your manuscript increases. So please come on and join us again absolutely anytime. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or that you can always visit our website at uabmedicine.org/physician.
That concludes this episode of UAB MedCast. For updates on the latest medical advancements, breakthroughs and research, be sure to follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua257.mp3
- DoctorsBoone, Amy
- Featured SpeakerAmy Boone, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5821
- Guest BioAmy Boone, MD Specialties include Obstetrics and Gynecology, Pediatric and Adolescent Gynecology.
Learn more about Amy Boone, MD
Release Date: June 30, 2022
Expiration Date: June 29, 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:
Amy Boone, MD
Instructor Fellow, OB/GYN and Pediatric & Adolescent Gynecology
Dr. Boone has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity - TranscriptionMelanie Cole, MS (Host): Welcome to UAB Med Cast. I'm Melanie Cole. joining me today to discuss teen pregnancy prevention is Dr. Amy Boone. She's an assistant professor and a specialist in pediatric and adolescent gynecology at UAB Medicine. Dr. Boone. Thank you so much for joining us. What a great topic we're discussing today. Let's start with the problem of teen pregnancy in Alabama and around the country. Tell us a little bit about the prevalence and what you've been seeing in the trends.
Dr. Amy Boone: Thank you so much for having me Melanie to talk about this important topic. So teen pregnancy is a big problem. I think we're all aware of that in 2013, one in five. 15 year olds and two thirds of 18 year olds reported that they had ever had sex. So that translates to nearly three in 10 teen girls in the United States will get pregnant at least once before they turn 20 years old. Luckily this number has declined pretty considerably from its peak. It peaked in about 1990. There are certainly some racial and ethnic as well as geographic disparities to the rate of teen pregnancy. So Hispanic and non-Hispanic black teens, their birth rate of is about two times higher then that for non-Hispanic white teens.
And teen pregnancy rates are generally highest in the south and in the Southwest United States, half of these teen mothers don't graduate from high school and then another by-product of teenage sexual activity is of course, sexually transmitted infections. So about nine and a half million adolescent and young adults. And for that classification, we're talking about 15 to 24 year olds. They're diagnosed with STDs every year in Alabama, specifically that translates to in the year twenty, twenty nine hundred and seventy seven patients under the age of 18 were diagnosed with a sexually transmitted infection.
Melanie Cole, MS (Host): Wow. This is a pretty widespread issue. And I mean, there's a lot that goes into this Dr. Boone. Certainly there is now a political climate involved. There is families involved. There are so much involved now. Can you tell us any prevention strategies that have been shown to work?
Dr. Amy Boone: Luckily there's one, it's the comprehensive sex education. So this is supported by many, almost all of the medical professional organizations. So we're talking about the AMA, AAP, ACOG and all of the other ,professional organizations pretty adamantly support this. So this is talking about programs that include information about both contraception and abstinence, and that's been shown to help young people delay their sexual debut. There's also a pretty robust data. Supports that abstinence only education programs, they're pretty scientifically and ethically problematic. They systematically ignore or stigmatize many young people and they just simply don't work.
The other thing that we know works is greater acceptance of adolescent sexuality. Sexuality is a component of the human experience, and adolescents are not immune to that. And then the last thing is provision of free or subsidized contraceptives specifically will help reduce the problem of teenage pregnancy.
Melanie Cole, MS (Host): So back in the day, Dr. Boone, you know, we had sex education in our classes. Fifth grade sixth grade something, plus there were magazines, you just snuck around. Kids are much more worldly today. There's this global knowledge base and experience that they have. Where are they receiving their sex education in general? And where would you prefer that they be getting this type of education?
Dr. Amy Boone: So one of the newer phenomenons that we're all as parents and providers trying to navigate is digital media. 73% of adolescence. 13 to 17 own a smartphone. So they're carrying around a small computer with an access to a tremendous amount of information, whether that's accurate or inaccurate. Most of the time, the most alluring sites are not providing the most medically sound advice to these kids. So only about half of adolescents received formal instruction about contraception before they first had sex, about four and 10 of them got instruction about where to get birth control. So that's only about 40% school policies vary widely across the country.
Specifically in Alabama public schools, we have a policy that says sex education must stress that abstinence from sexual intercourse is the only completely effective protected. And that's protection against unwanted pregnancies, STDs and AIDs. So, as we talked about before, abstinence only education has proven to be ineffective. However, that is still the policy and our state. So over 70% of young people, 15 to 19 reported having talked with a parent about at least one of six sexual education topics, and those topics are how to say no to sex? What are the methods of birth control?
What are STDs? Where do you get birth control? How do you prevent HIV and how do you use a condom? So it's a pretty high number. There was a big study that was done looking at visits from 2009 to 2012. And they showed that sexual health conversations with patients. So in a clinical setting, patients ages 12 to 17, those conversations lasted an average of 36 seconds. It's not a lot of time to talk about all of the things and to openly answer all of the questions. So luckily we talked a lot about social media. A lot of providers and sexual health advocates are jumping on the bandwagon and they're creating content that is evidence-based and also palatable to a teenage audience to spread accurate information around sexual health.
Melanie Cole, MS (Host): Wow, this is such a great and so important topic. Now you're speaking to providers around the country. But when you are working as the expert that you are with adolescents and young adults, how are you dealing with this in your practice and with their families? Because I know there's a point where I know my 19 year old daughter where I didn't get to go into the gynecologist office with her and I had to stay back out of, you know, out in the office.
So, how do you help the families to have these conversations and how would you like other providers to start these conversations as well? Because as we said before, they've got this whole internet computer right at their fingertips. So they are seeing things that maybe their parents want discussed in a different manner. So how do you bring all this together for them?
Dr. Amy Boone: Yeah, absolutely. So like you said, we give our adolescents and young adults time by themselves in our office. So we do have a law in Alabama regarding confidentiality and miners, 14 years and older can consent for reproductive health services. So we openly communicate that with the patient and her parent or guardian and stress, the importance of that confidentiality. We talk with the patient about ways that, that confidentiality may be unintentionally breached by using the patient portal, whether their parent has access to that or not. How do they want us to communicate the results, whether that's pregnancy test or sexually transmitted infection testing.
So we get there cell phone number specifically to make sure we're not calling the wrong person. And then the use of title 10 clinics, that can definitely help avoid the explanation of benefits. So whenever you receive contraceptive services, many people receive a EOB that explains what wasdone, and that can be an unintentional breach of that confidentiality. Of course, w e encourage the patients to communicate with their parents openly there's other data that suggests that outcomes are better. Teen pregnancy rate in sexually transmitted infection rates are lower when there's an open line of communication, but we don't require it.
Not all parents are open and ready to receive that information or have those kinds of conversations. So the other important thing is just to avoid any assumptions regarding sexual orientation. We're certainly in a time of change as far as gender and sexual identity goes. This is No different to our adolescent population. The question I would say to avoid is the traditional one that we were all taught. Are you sexually active? So that means very different things to different people. So it's better to be direct and open with your line of questioning. And your overall goal is to find out if the patient's sex life is fulfilling, autonomous and contributing positively to their overall health.
One strategy that I'd like to share with other providers is to focus on the five-piece. These conversations can be a little bit uncomfortable. So if you have a guideline, like the five P's that can really help. So the first P is partners. You want to know the number and gender of the partners that can help you assess the risk. A risk is also assessed with the practices. So the next P and that's knowing what tests to order and what sites you need to obtain the from. The third P is protection from sexually transmitted infections. So talking about condom use, talking about prep, which is pre-exposure prophylaxis for HIV.
The next P is past history of STRs. Most people say no to that question, but many of them have not been tested. So you have to ask, have you ever actually been tested? Has your partner been tested? And then the last one is prevention of unintended pregnancy.
Melanie Cole, MS (Host): Very comprehensive Dr. Boone. And as we're talking about contraception and contraceptive options that are available for teenagers, again, our teens are hearing. Around the country and through social media, that these things that they're being looked at and changed. And there's all this talk. What do you tell teenagers about contraception? The importance of preventing sexually transmitted infections and unwanted teen pregnancies and all of these things, the importance of contraception and what types do you recommend?
Dr. Amy Boone: There's lots of varying questions about contraception and you're right. A lot of that stems from social media and what they hear from friends at school. So medically, many of them are concerned about things like weight gain or changes in their complexion. Many people are worried that contraceptive use for a long time will impact fertility in some way, shape or form. Many parents are concerned that contraception access as a license to have sex and data, very vehemently opposes that notion that has not panned out in any of the studies and the. And other non-medical concerns, teenagers are worried about lack of access. They're worried about lack of access either from the clinic or from restrictions, from political policies that are coming down the pipeline.
They're worried about confidential care, costs of services. There are ways get contraception online and it's legal in labama. One of the barriers is you have to have a digital form of payment to order that. So some co some form of credit card or debit card to place that. And then there's also a pervasive belief that they can't get pregnant. So they don't know that they really need it or that they've had sex several times and haven't gotten pregnant yet. So they're doing okay. And then the last thing is one thing we work on a lot is partner negotiation skills. So how do you have a conversation with your partner asking them to use contraception, to keep you both safe?
Melanie Cole, MS (Host): Yeah, that's really a great point that you just made. And this is such a comprehensive issue. It really is. It's similar in that way to the obesity epidemic. There are so many parameters and so many factors that influence what we see going on in the country today. As we wrap up, what would you like the key takeaway to be about the importance of communication, these discussions, knowledge based discussions, medically based discussions with teenagers and their families for other providers?
Dr. Amy Boone: So one of the important things is there is no restriction on any method of contraception based on age alone. There are lots of great. This is out there for providers who want to learn more about how to safely provide contraception. In 2016, the CDC updated their medical eligibility criteria for contraceptive use. There's a phone app that allows you to stratify risk based on medical conditions history which is really helpful. And then the dual method is the best for everyone, adolescent specifically. So condoms for STI protection combined with a more effective contraception. And the good news is contraceptive use is on the rise with a rapid uptake in LARC use among 15 to 19 year olds in the past five to 10 years.
The Title 10. Federal family planning program clinics exist. There are three within 20 miles of UAB and then 147 of them within 150 miles. So there are resources out there. And then the last thing is emergency contraception is also another widely available thing. So that can provide protection from pregnancy as many as as many as 120 hours after unprotected intercourse. And so the biggest takeaway is, you don't have to prescribe this to everybody. If you don't feel comfortable, but just know who to reach out to. We're always willing to give advice over the phone or to get somebody in to have these complicated conversations.
Melanie Cole, MS (Host): Well, you certainly are. And so knowledgeable. Thank you for such an informative podcast 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 UAB medicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua258.mp3
- DoctorsMaddox, William
- Featured SpeakerWilliam Maddox, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5852
- Guest BioDr. Maddox is a clinical cardiac electrophysiologist committed to delivering exceptional healthcare through dedication to patients and their families. He strives to provide compassionate care, through personalized education and open communication, wishing to inspire hope and well-being in all his patients.
Learn more about William Maddox, MD
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:
William Maddox, MD
Assistant Professor in Cardiology, Electrophysiology
Dr. Maddox has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole: Welcome to UAB MedCast. I'm Melanie Cole. And joining me to discuss current management of ventricular arrhythmias is Dr. William Maddox. He's a cardiac electrophysiologist and an Associate Professor at UAB Medicine.
Dr. Maddox, it's a pleasure to have you join us today. As we get into this topic, speak first about the prevalence of ventricular tachycardia. It could be a dangerous and many times deadly arrhythmia. Speak about what you've been seeing in the trends.
Dr. William Maddox: Sure. Thank you for having me. So ventricular tachycardia is an arrhythmia that we're seeing with an increasing prevalence in our population here, specifically in the population as a whole. As our patients have many comorbid conditions like hypertension, diabetes, and especially coronary artery disease and heart failure, one of the things that goes along with that are ventricular arrhythmias. And so, especially in the south here where we have quite a bit of patients with coronary disease, we see quite a bit of atrial fibrillation. And as the population ages, I anticipate that that's going to continue to get more prevalent.
Melanie Cole: I agree with you. And as we're talking to other providers, speak about the clinical presentation, Dr. Maddox. Some of the symptoms of the hemodynamically unstable ventricular tachycardia, what are they looking for?
Dr. William Maddox: Hemodynamically unstable VT is truly a medical emergency. These patients are many times presenting with chest pain, shortness of breath. It may be with syncope or pre-syncopal symptoms, and usually they're presenting to you in an emergency medical setting. These patients need intervention very quickly or they can decompensate and it can be a life-threatening arrhythmia.
Melanie Cole: Is there screening, Dr. Maddox? And if so, when would that be indicated?
Dr. William Maddox: Screening is tough in these patients. Certainly, we understand that in patients with structural heart disease, there are patients who are at increased risk for ventricular arrhythmia and ventricular tachycardia. And generally, that's going to be patients with ejection fractions of less than 35%, either in the face of coronary disease and ischemic cardiomyopathy or in dilated or non-ischemic cardiomyopathies.
And so in those patients, as you would for management of their heart failure, you're going to get routine echocardiograms as well as EKGs. But screening in the asymptomatic patient isn't something that we would recommend outside of the general EKG that you're going to get in the course of just their general treatment. There certainly are other reasons why people may have ventricular tachycardia, including some of the channelopathies, as well as hypertrophic cardiomyopathy or other things. And in those patients, it can be important to screen the patients either with EKGs or with longer telemetry monitoring, especially if they're having any symptoms of either syncope or pre-syncope or if they're presenting with palpitations at all.
Melanie Cole: I understand, Dr. Maddox, this is a pretty broad discussion that we're having. Whether we're talking about electrical circulatory or structural disorders, I'd like you to give sort of an overview, brief overview, of therapies available. You can start with medical interventions and move on from there. But give us a brief overview of what you do.
Dr. William Maddox: So, VT, which is our acronym in electrophysiology and how we refer to it, there's quite a variety of patients who present with ventricular tachycardia and depending on what their underlying cardiac comorbidities might be, the approach might be very different. In a patient who has what we call idiopathic ventricular tachycardia, which would we be VT in an otherwise structurally normal heart, these patients many times can respond well to medical therapy with beta blockers, calcium channel blockers, particularly verapamil in some patients with right ventricular outflow tract tachycardia. Our antirrhythmic drugs in patients with otherwise normal hearts are pretty wide open. That would include the 1C antirrhythmics like flecainide or propafenone, sotalol, Tikosyn some and, of course, amiodarone is kind of 800-pound gorilla that is pretty darn effective, but has a whole host of long-term problems with multiple organ systems. And so we try to avoid that as we can.
In patients who have structural heart disease, and that's kind of an umbrella term where I'm talking about patients with both non-ischemic and ischemic cardiomyopathy, as well as hypertrophic myopathy, or valvular heart disease that might be significant, those patients generally are at a higher risk of sudden cardiac death with ventricular tachycardia. And our treatment modalities are going to be more important in both primary prevention for patients who are at high risk and in secondary prevention for patients who have already presented with VT or possibly sudden cardiac arrest. That from a medical medication standpoint can certainly include the antirrhythmics. And many times, we're trying to decrease the burden of arrhythmia and stop someone from getting shocked if they have a defibrillator. One of the main stage of treatment for VT in a patient with structural heart disease would be an implantable cardiac defibrillator. This is something that's quite common now and that we see. We have both transvenous systems that can be implanted in either the left or the right subclavicular area on the anterior chest wall. And there's also a subcutaneous ICD that can be implanted in the mid-axillary space under the left arm with a lead that's tunneled under the skin, and then lies just lateral to the sternum.
In patients who have ventricular tachycardia that has been recalcitrant to medical therapy, these patients are excellent candidates for catheter ablation. And this is a therapy that has certainly become more favorable as our tools for being able to map the ventricular tachycardia circuits in the heart have gotten so much better and our delivery tools for energy to the heart to be able to ablate and cauterize these areas that are problematic has gotten better. It's something that's quite common now. And in any given week, I'll probably do three to four VT ablations. I know that I'll do two tomorrow. The success rate of VT ablation can be heterogeneous depending on what the patient's substrate is with success rates as high in the mid to high 90% in patients with idiopathic VT down to patients with infiltrative cardiomyopathies or hypertrophic cardiomyopathy or arrhythmogenic dysplasia, where those patients have a high rate of recurrence.
Melanie Cole: What about secondary prevention of VT?
Dr. William Maddox: So the mainstay of treatment for secondary prevention in patients with any structural heart disease is that we want to get a defibrillator in them. These patients many times have presented with aborted sudden cardiac arrest, either to an emergency setting or occasionally they may show up in our clinics. And we'll intervene acutely on the arrhythmia, but then we want to prevent the next episode. And so these patients will all be offered an implantable defibrillator. And then these defibrillators have the ability to deliver energy and shock the patient out of an arrhythmia should they ever have one. And the transvenous systems also have the ability to be able to use algorithms to pace the patient out of ventricular tachycardia if they have it with a pretty high level of success.
For stable ventricular arrhythmias or monomorphic ventricular arrhythmias, antitachycardia pacing can be successful 50 to 70% of the time. And this limits the amount of shocks that the patient gets. And many times they may have VT and not ever know that they had an arrhythmia and show up in my clinic for routine followup and we note that they'd had an arrhythmia sometimes two or three months earlier.
Melanie Cole: Dr. Maddox, while we've been talking about anti-arrhythmic therapy and implantable cardioverter defibrillators, all of these things you're discussing, these are the, mainstays of therapy and well managed by someone such as yourself, a cardiac electrophysiologist, there are many other facets in the care of these patients, such as heart failure management, treatment of comorbidities that you were mentioning, aesthetic interventions, where expertise of other specialists is really essential for optimal patient care. Can you speak about that coordinated team approach and how it's essential to achieve the best possible outcomes for these complex patients?
Dr. William Maddox: Sure. I think that that's incredibly important in our patient population that seems to be getting more complex by the day. As an example, my clinic is on Tuesdays and Thursdays and two doors down are my heart failure colleagues. And we work hand in hand in treating these patients. And there's many times in clinic that they'll grab me and ask me to come in and interrogate a device and make some changes or make some recommendations on anti-arrhythmic drugs on the other hand.
When I see patients in my clinic and they obviously are having difficulty with fluid management or heart failure symptoms, it's not infrequent for me to find my heart failure colleagues, and talk about seeing them that day and helping me manage their loop diuretics or other things to help manage their heart failure. I think that VT from an electrophysiologist standpoint is an electrical problem, but in the patients in the broader sense, this certainly has everything to do with heart failure management and the hemodynamics to help make sure that the patient doesn't have either more VT or if they do have VT, that they're better able to tolerate it.
Melanie Cole: And that really is the main point, isn't it? So I'd like you to wrap up by telling other providers the importance of early referral for VT ablation, how it can reduce ICD shocks, improve patient outcomes, including mortality. Wrap it up with your best advice and key takeaways.
Dr. William Maddox: Sure. So I think that many times we see VT in my specialty and especially at a tertiary care center, I've seen them and they've been managed with antirrhythmic drugs for a significant amount of time with multiple shocks. And by the time they get to me, they've been shocked multiple times and sometimes has significant hemodynamic consequences from their untreated arrhythmia.
And I'd like everybody to think about the first time that you think about referring a patient to your electrophysiologist for consideration of ablation should be the first time you see VT. And it doesn't mean that your EP is going to take everybody to the lab, but that's the first time I want to start having the conversation with the patient. And there's been recent data that have shown that patients have better outcomes with less shocks and live longer and stay out of the hospital if we intervene on these arrhythmias sooner, rather than waiting until we have failure of multiple anti-arrythmics.
Melanie Cole: That's a great point. And thank you so much, Dr. Maddox, for joining us today, sharing your expertise for other providers with us. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or you can always visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. 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/ua253.mp3
- DoctorsCawyer, Chase;Gould, Sara
- Featured SpeakerChase Cawyer, MD | Sara Gould, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5811
- Guest BioChase Cawyer, MD Specialties includes Maternal and Fetal Medicine and Obstetrics and Gynecology. Learn more about Chase Cawyer, MD
Sara Gould, MD Specialties include Orthopedic Surgery and Sports Medicine.
Learn more about Sara Gould, MD
Release Date: June 10, 2022
Expiration Date: June 9, 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:
Sara Gould, MD
Ambulatory Clinical Director - Highlands Orthopaedics
Chase Cawyer, MD, MBA
Assistant Professor, Maternal and Fetal Medicine & Obstetrics and Gynecology
Drs. Cawyer and Gould have 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 joining me in this panel today is Dr. Sara Gould. She's a Sports Medicine Physician and an Associate Professor and Dr. Chase Cawyer. He's an Assistant Professor and a Maternal Fetal Medicine Specialist in the Department of Obstetrics and Gynecology. And they're both with UAB Medicine. Doctors, thank you so much for joining us today to talk about exercise in pregnancy and the clinic at UAB Medicine. Dr. Cawyer, I'd like to start with you. Can you start with a little bit about the impact of physical activity on course and outcome of pregnancy from pre and postnatal? I'd like you to speak about the most important aspects of exercise. When a woman is planning a pregnancy and beyond.
Chase Cawyer, MD (Guest): Yes, thanks for that question. One of the things that we've noticed with lot of our patients is for whatever reason, they get a little bit nervous about continuing exercise whenever they get pregnant. They get nervous to think that if they overdo anything or go out of their routine, they may end up actually harming the baby, and potentially themselves. But what we know is that women who exercise in pregnancy tend to have better prenatal outcomes, both for maternal health and for neonatal health. This has been studied well in morbidly obese patients and gestational diabetics.
However, there is research to believe that this can be beneficial for all pregnant women, not just those that have medical comorbidities. One of the most common things that we see, for maternal benefit is we see a decreased risk of Cesarean section. We see a decreased development of preeclampsia and a decreased development of gestational diabetes, which in turn improve maternal health during pregnancy and after delivery. And from a neonatal standpoint, we tend to see a decrease in large for gestational age babies, in preterm birth, as well as, some other things that can cause a potential extended NICU stay.
Melanie Cole (Host): Dr. Cawyer sticking with you for just a minute, because you just mentioned that you do see some women that don't, or haven't exercised or are a little bit nervous. To what do you attribute that decreased physical activity levels of pregnant women? Do you think that it's a lack of information? You mentioned just a little bit about nervousness, you know, concern about possible damage to the unborn child. And when you're speaking here to other providers, how would you like them to counsel their patients on just that exact point?
Dr. Cawyer: Yes. I absolutely think the main reason why women are hesitant is there is just not a lot of information readily available to the public as far as what's beneficial and what's harmful. And I'm going to have Dr. Gould chime in about this in just a second and in relation specific to pregnancy and what some studies have demonstrated, but from a pregnancy standpoint, women, immediately once they find out they have a positive pregnancy test, they get really unselfish and they want to do everything they can for their baby, even if it's potentially harmful for them. And what happens is a lot of times they think, well, this exercise could be helpful for me, but if I overdo it or my heart rate gets too high or I get too tired, is that going to harm the baby? And the truth is that it's very, very rare for a woman who has never exercised before, or just exercises somewhat on a regular basis to ever reach a point to where there is even a potential of harm to the baby from overdoing it. And that's something that I want Dr. Gould to just kind of speak about as far as just some of the lack of data, as far as why there's this misperception that potentially too much exercise is harmful.
Sara Gould, MD (Guest): So, that's definitely something that I think is really interesting to talk about. So there was a study done, as far as we know, the most impactful study that has been done was one that was done in, professional athletes, Olympians, in fact, and they were endurance athletes. And, this study did show that there was fetal bradycardia and decreased uterine artery blood flow at around 85th percentile of the maternal maximal heart rate. And so from that study, that's where a lot of our recommendations come. So, there've been a lot of guidelines that have come out.
ACOG has revised and does a great job of periodically updating the exercise in pregnancy guidelines. The most current guidelines are from bulletin 804, I believe. And, basically what ACOG recommends currently is 30 to 60 minutes per session, three to four times a week. And they want you to stay around 60 to 80% of your maximum predicted maternal heart rate. So this is going to be really hard for people who don't have a background in exercise physiology or exercise medicine, cause it's not something that we commonly get trained on in medical school. You know how to calculate maternal heart rates and maximum maternal heart rates.
And so I think we know that because we actually did a survey of obstetricians in Alabama, on their comfort level, and while all of them were familiar with what the guidelines say, putting it into practice because it's time consuming, because it's challenging, we found that not many of them were routinely counseling their women on how specifically to exercise.
And so that's where a lot of our interest comes from is how do we tell women to exercise? There's so many factors that go into it. So many difficult things, we want to tell women what to do and how to do it safely. But sometimes our advice is contradictory. Sometimes it's not feasible. For example, we're in the deep south in Alabama. In the summer, there are rarely any times where, women have access to a thermoneutral environment, especially in rural. So, you know, they don't have the ability to go outside and take a walk because that's not a thermoneutral setting. Now does that actually matter for someone who is acclimated to the heat?
That's whole other topic of controversy in terms of the effect of heat on fetal development. And most of our studies in that aspect have actually come from pathologic conditions. So women who were having fevers and is that the same thing as just being in a hot environment?
One of the most interesting stories that I have about that is I was presenting some research at an international conference once and a Finnish woman came up to me and said, we think it's really funny how all of you Americans are so worried about visiting saunas and your temperature because it's our custom and our habit to continue going to saunas throughout pregnancy and it's part of life and we consider it to be very healthy.
So I think that's a whole other area we have to study, because we are imposing a lot of barriers on women, in terms of our exercise recommendations. So that's what Dr. Cawyer and I are trying to do is put more literature out there and make it more feasible and, and break down barriers to exercise.
Dr. Cawyer: And I would just like to add, I think, from a provider who maybe has a newly diagnosed pregnant patient that they're seeing for other reasons, and they maybe ask a question about, well, what kind of activity can I do? A lot of them, I think, tend to just kind of hesitate and say, well, just take it easy. When I think right answer for most providers is just keep doing what you're doing.
It's likely going to be just fine. And I think even with the very limited data we have, we can feel very confident that a woman continuing to participate in her regular activity, however, that may be is going to be safe and even healthy for the prenancy.
Host: Well, I certainly couldn't agree with both of you more. As I know in graduate school, it was definitely limited. So Dr. Gould, because of the physiologic changes associated with pregnancy, and I find your Finnish story so interesting. As well as the hemodynamic response to exercise, we do recommend precautions. There are some that should be observed. Speak a little bit about contraindications. Dr. Cawyer mentioned gestational diabetes before, are there studies that have shown that exercise improves insulin sensitivity or lipid metabolism, glucose tolerance. And then there are questions surrounding relaxen. And when we talk about strength training or doing what you've done before, if you're an athlete different than if you are a new exerciser or somebody who is just in average shape. Can you speak to those precautions and what are the recommendations right now?
Dr. Gould: Typically, as Dr. Cawyer mentioned, historically recommendations have been it's okay to do what you've been doing. So if you're a conditioned athlete that's okay to keep doing at whatever intensity level you have went at before your pregnancy. For us, we know that obesity is really dangerous. There are all kinds of negative maternal and fetal outcomes associated with obesity. So anything we can do to combat weight gain, excessive weight gain during pregnancy, when we're starting out with an obese state is going to be helpful and important to do. And so, that becomes a real challenge. How do we tell people who haven't been exercising previously that they need to start when all of our guidelines say do what you were doing before. And so, that was actually why we started using this, ultrasound technology that we've developed, for this application, looking at the blood flow through the placenta as an organ, looking at the volume to try to document that there is not shunting of blood away from the placenta with either resistance training or cardiovascular intense exercise. And we've actually published our resistance data. And hopefully that will help guide people to understand that it's okay, that we're not shunting blood away from the placenta with certain levels of resistance training so they can feel comfortable, even if they haven't previously been doing that to start engaging in a program.
Dr. Cawyer: Just to go along with contraindications, really there's very few direct contraindications to exercise in pregnancy. And most of those that are going to be a contraindication, that patient should likely need to be seeing some kind of high-risk physician or an obstetrician who's experienced with medical co-morbidities or obstetrical co-morbidities in pregnancy. So that's something that really, it's pretty rare to tell a patient, hey, you have this condition, you shouldn't be exercising unless you are an obstetrician who has experienc with that.
Host: What a great point. So why don't you, Dr. Cawyer tell us about the Exercise and Pregnancy Clinic at UAB Medicine and why it's so important to seek appropriate prenatal care and discuss those guidelines in case someone is a high risk pregnancy or had a previous high risk pregnancy or is in some way contra-indicated for exercise.
Dr. Cawyer: So those that would benefit from the Exercise and Pregnancy Clinic, are multiple people. You can have those that are pretty active already with an exercise routine and want to make sure that they can safely continue it. That's a very popular patient for our clinic. You also have a woman that wants to try to avoid developing some kind of high risk condition, whether that be gestational diabetes or preeclampsia, and they would like to start an exercise routine because they have either been told to stop it with pregnancy, or they got busy with maybe a younger kid. And so they were unable to continue that, being a busy mom. And then there's also those people that we really want to try to get into clinic are those that have those high risk conditions like obesity, like, previous history of gestational diabetes, or hypertension that would really benefit from an improved exercise physiologic state that they can get with an exercise routine. And then Dr. Gould can kind of talk a little bit more about the clinic itself and how it's structured and why, with our technology that we utilize, how we can show a woman that, hey, what you would like to do can be safely done in pregnancy. And here's the effect that it has on the baby.
Dr. Gould: So, basically the experience that we have set up is it's a multidisciplinary clinic and I think that's really important for two reasons because you get access to both the maternal fetal medicine specialist, as well as someone with a background in sports medicine and exercise physiology. So we kind of start by making sure that women are aware of the benefits of exercise in pregnancy. We've kind of touched on that, but, lower incidence of excessive gestational weight gainthe diabetes, lower incidence of hypertensive disorders, as well as a host of other benefits. And then we kind of talk to them about what their goals are for exercise because, exercise is not a one size fits all.
And so we talk to them about what they desire to be doing, what they've been told they can do. They've been told if anything that they can't do. And then, Dr. Cawyer performs the screening ultrasound and an assessment on their prior pregnancy history. And, through that his evaluation, he then lets me know if there are any contra-indications, any recommendations or restrictions that he has on what I recommend for the exercise portion.
That would be highly individualized to the woman and based on her ultrasound, of course, we also let them know kind of the general warning signs to discontinue exercise while pregnant, like, bleeding, pain, contractions, fluid leaking, things like that. But beyond that, he will very specifically give me recommendations and say either I don't see any reasons that you need to restrict exercise or he'll tell me specifically what he's concerned about. And then I can develop a program. Once we do that, we then perform together an ultrasound, 3D, power flow, color Doppler ultrasound, which allows us to measure the blood flow through the organ, through the placental organ at rest. Once we have that number, we go over to our exercise lab, and we perform a submaximal stress test.
And, once we get to the stopping point, whether that's the patient or physician termination point, we then perform another ultrasound looking at the blood flow through the placenta, and we make sure that there hasn't been decrease in flow, that there's no shunting occurring, that we don't have anything going on at either the fetal or placental level that would make us concerned that the submaximal exercise should be limited. And then based on that, we write an exercise prescription incorporating the woman's goals and perform exercise counseling.
Host: Well, Dr. Gould, what do we know about the relationship between postpartum physical activity, lifestyle parameters and postpartum weight retention or weight gain or weight lost. Can you speak about what happens after the baby is born and how you work with mothers at the clinic in that case?
Dr. Gould: So couple of points, number one, Dr. Cawyer kind of alluded to the fact that pregnancy is a time when women are making a lot of changes, to their behavioral health and their habits. And so, it's an optimal time to adopt an exercise routine. And we know from prior studies, not specifically in pregnancy, but other studies on exercise that if we can maintain an exercise program for a period of time, it's much more likely to be continued. So if we can get women exercising during pregnancy and sustain that, they're much more likely to continue in the postnatal period. Of course there does need to be recovery time and that's going to depend on whether they were vaginal or Cesarean deliveries and what sort of complications, if any, there were during the delivery process.
So it's definitely something that has to be highly individualized and based on a lot of delivery related factors. But in general, we do encourage women to continue exercising to some degree after pregnancy and after delivery. It's also important to note that exercise has been shown to help with PTSD and depression, postpartum depression in particular, something that women can be at risk for. And so, helping them have an exercise regimen already in place and counseling can be really beneficial for those reasons as well.
Host: I'd like to give you each a chance for a final thought here. So Dr. Gould, starting with you, what do you tell women every single day? And you're speaking to other providers here, you're working with these women one-on-one doing the exercise with them, helping them with their questions and their concerns. What would you like to tell other providers about recommendations, counseling their patients when you have a chance to speak to them, what do you say about how they should be speaking to their clients to counsel them on exercise guidelines, recommendations, contraindications, kind of wrap that part of it up for us.
Dr. Gould: Sure. I think that probably the two most useful tools for providers are the ACOG committee bulletins and opinion summaries. They're updated periodically. I believe that number 804 is the most recent, and that has a really good summary. The other tool that can be really, really helpful is the PPAQ, which is a pregnancy activity assessment survey.
And there's a diagram and tools as part of that survey that can talk about FIT principles. So fitness, intensity, time, and basically just kind of lays out for the providers, how to do an exercise prescription. So I think those two resources are going to be the most useful for providers who are looking to incorporate exercise counseling.
I also think that it's important, providers often talk about being very limited on time and their ability to counsel patients. So, I think it's important to document these activities, because you can bill for both your exercise counseling as well as survey administration. So I think those are important things to keep in mind and make it more feasible for providers to actually be able to incorporate this as part of their routine.
Melanie Cole (Host): And Dr. Cawyer last word to you. As you're speaking to obstetrician, gynecologists and primary care providers and medical home, speak to them and tell them the resources that are available at UAB Medicine in the Pregnancy Clinic and why you feel it's so important that they refer to the specialists at UAB Medicine.
Dr. Cawyer: One of the most important aspects of having a healthy maternal obstetrical and neonatal outcome is adequate care. There are very few obstetrical teams that have as much breadth and knowledge when it comes to all areas of obstetrical care, then those providers at UAB. Anytime you're dealing with an area such as exercise and pregnancy, where a lot of providers just don't feel completely comfortable adequately counseling patients; you can find those providers at UAB. The resources are there that Dr. Gould has mentioned. They are online with the American College of Obstetrics and Gynecology website, where providers can get a snapshot to make sure that where they are setting the table for how a patient can approach their pregnancy and how physically active they need to be.
Once they reach that point where they want that individualized care, then a referral to the Exercise and Pregnancy Clinic at UAB is going to be the best case for them, where they can get that multidisciplinary team to make sure they have a optimized care plan.
Host: What an informative podcast this was. Such great information and great points were made. I thank you both for joining us today and to refer a patient to the Exercise and Pregnancy Clinic at UAB Medicine, you can call the mist line at 1-800-UAB-MIST, or you can always visit our website at UABmedicine.org/physician.
That concludes this episode of UAB Med Cast. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua251.mp3
- DoctorsGutnik, Lily
- Featured SpeakerLily Gutnik, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5796
- Guest BioAssistant Professor whose specialties include Breast Surgery.
Learn more about Lily Gutnik, MD
Release Date: May 31, 2022
Expiration Date: May 30, 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:
Lily Gutnik, MD, MPH
Assistant Professor, Breast Surgery
Dr. Gutnik 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 joining me today is Dr. Lily Gutnick. She's a Breast Surgeon and an Assistant Professor at UAB Medicine. And she's here to highlight academic global surgery, an emerging field gaining popularity among trainees and faculty. What is it? Where are we and where are we going? Dr. Gutnick, I love this topic, such an interesting topic. Welcome to the show. There's a large unmet need for surgical care worldwide. We've heard about this and with surgical conditions and treatments being poorly reorganized you and I just did one on Sub-Saharan Africa and breast cancer and resources as public health priorities around the world. Can you tell us a little bit about academic global surgery? What is this emerging field that's gaining popularity among trainees and faculty? Tell us a little bit about that.
Lily Gutnik, MD (Guest): Absolutely. And again, thank you so much for having me here today. First I really want to just start with a definition, right? I mean, we all, when you think about global health and when we talk about global health, people have different sort of thoughts and frameworks in their mind about what that means and what that means for them.
A lot of, I find just in my own personal experience, as I talk to people and say, you know, kind of, this is my academic niche or area of work, people automatically ask if I'm affiliated with doctors without borders. Or if I do sort of short-term mission work. Which that is certainly one aspect of global health and one aspect of global surgery, but it's not really kind of how I view and how most people view and define more of academic global surgery and global surgery as a true sort of field within global health.
And so I'd like to just briefly share this definition. And this was published in the Lancet, at the time when we were working on the Lancet Commission on Global Surgery, we had published a paper sort of saying that even titled Global Surgery Defining an Emerging Global Health Field.
And so global surgery is an area of study, research, practice and advocacy that seeks to improve the health outcomes and achieve health equity for all people who require surgical care with a special emphasis on underserved populations and populations in crisis. It uses collaborative, cross sectional and transnational approaches and is a synthesis of population based strategies with individual surgical care.
And again, one of the things I actually really love about this definition is notice how it doesn't talk about geography, right? So it's not about a group of people going to another place to perform surgery. It's really about focusing on vulnerable populations, which we know exist worldwide rather, you know, even in our own country here in the US we have tons of access to care issues and disparities in our own country.
And then of course, kind of more other lower income countries that kind of have more of these issues that may be a larger scale. And sort of with that definition in mind, I can take you through a, sort of a brief history of this academic global surgery as its own emerging field, because I think it's actually quite fascinating.
So, the first time that global surgery was actually really vocalized and supported in a large public and noteworthy former was in 1980. And at that time, Dr. Halfdan Mahler who's the, was the Executive Director of the WHO had said that the majority of the world's population have no access whatsoever to skilled surgical care and little is being done to find a solution. I beg of you to give serious consideration, this most serious manifestation of social inequity in health care. Right? So that's in 1980. Interestingly in the WHO it wasn't until 2005, where there was actually an initiative within the WHO on essential and emergency surgical care. Following that in 2008, there was a really famous publication, by two giants in global health.
And Jim Kim and Paul Farmer who published a piece in the World Journal of Surgery called Surgery and Global Health a View Beyond the OR, and that was actually where this very famous phrase was coined about surgery being the stepchild of global health. In 2011, the ACGME actually approved international resident rotations.
And then in 2012, there was a first textbook called global surgery and public health which was essentially published by a team of academic general surgeons and urologists. And then fast forward to 2014, there was a first global advocacy group called the G4 Alliance, which was surgical, obstetric, trauma and anesthesia care, which is still a really great and prominent organization, really focusing on advocacy for the neglected surgical patient. And then came 2015 and now 2015 is known as the golden year for global surgery. And that is when the Lancet Commission on Global Surgery came out. The DCP 3, which stands for disease control and priorities three, which is a publication from the world bank, which is really important in terms of sort of economic evaluation and priority setting for ministry of healths around the world.
They now came up with a whole volume on essential surgery. And then the World Health Assembly happened, which adopted the resolution that's saying strengthening emergency and essential surgical care and anesthesia is a component of universal health coverage. In 2016, there's a well-respected Success in Academic Surgery, sort of handbook series and they published a volume called Academic Global Surgery. And then in 2020, the Global Surgery Foundation was formed, which is the first kind of exclusive multiple, you know, public, private foundation that is dedicated to global surgery. So you could see here, you know, most of this work has really been seeing the most rapid rise in the last sort of six, seven years or so.
Host: Wow. That was such a comprehensive description of such a large issue. So as you're telling us that long neglected as a topic within the global and public health arenas, you're describing this increasing awareness of those extreme disparities. Can you speak a little bit how metrics, data, definitions, underlying issues of workforce and training, equipment, infrastructure is huge and funding certainly funding that need to be addressed.
I read that that these may be synthesized around three interdependent pillars, Dr. Gutnick of need access and quality. Can you speak a little bit about that? And some of the barriers to those that you see.
Dr. Gutnik: Yeah, absolutely. So that's a great, great point. And actually one of, sort of the goals of the Lancet Commission was exactly to address that because until that, you know, report and process and everything came up; there was a huge realization that there really is no data. There's no line item. When you look at sort of even big multilateral organizations like budget lines, and which of course correlates their priority setting.
There actually is line items for things like HIV, but there's really nothing for surgery. And one of the challenges in that is because surgery in itself is cross-cutting, it is not its own sort of, you know, disease entity like HIV or malaria or COVID or something. It is a cross cutting discipline that really you know, touches all sorts of other kind of broader disease types. And so a lot of the big goal of the Lancet Commission was to try to synthesize data, have common metrics and have common vocabulary and have it be included in various of these multilateral unilateral organizations. And so one of the things, you know, the Lancet Commission did come up with six indicators. You know, and things like around these topics about access.
So being, you know, number, being able to get to safe and effective surgery within two hours was one sort of indicator. Peri-operative mortality rate is another example of another indicator, workforce density and workforce being you know, both anesthesia, surgical and obstetric provider. The most common surgical procedure performed worldwide is actually a C-section, which you know, kind of here in the US US is within the realm of obstetrics and gynecology. Although in some of these other settings, particularly for example, in Sub-Saharan Africa and in more rural parts, they are really done by clinical officers, which are sort of, you know, skilled surgical technicians that perform a wide range of procedures.
So, those are just some of the examples on it, but I think there's definitely ongoing discussions about what to measure, how to measure it and making sure that there is this sort of common definitions and agreed upon metrics.
Host: Okay then along those lines and if that is what the vision is and what you're looking to do, I feel that this need for this multidisciplinary approach, as you were just talking about providers and as global surgery must engage a multidisciplinary range of individuals. I mean, we're seeing that in our country more and more and more, but including academics and clinicians, politicians, economists and patients at the local, national and international levels. Can you speak about that and how you're bringing these teams together and, and that unmet need?
Dr. Gutnik: Yeah, absolutely. And that's a huge, huge thing. And I think, you know, that even stems back from that famous quote about surgery being the neglected stepchild of global health, right. And global health is really a subsection of public health. And I think we are seeing more and more of this intersection. For example, there are a number of centers for surgery and public health around the country or within global health departments. Within schools of public health, for example, there are sort of surgery niches, or surgery groups, initiatives within these.
There are some institutions that are doing global surgery as for example, Vanderbilt University, their global surgery initiative is a multidisciplinary approach within the school of medicine that engages you know, people that are more public health experts especially within the school of public health, as well, as well as across you know, providers of anesthesia, surgery, obstetrics, and then of course nursing and then other allied health professionals as well.
If you kind of like even think about like, how do you build a surgical system, right? There's a lot of work and interest happening about surgical system strengthening. And again, working very much with health economists and you know, health policy experts, because the concept is you don't want to just perform a surgery. You want to build a safe surgical system around it, which engages all these people from all these different levels. So yes, there's definitely a lot of exciting and interesting work happening around that space right now.
Host: As we wrap up with this fascinating topic, what do you think is involved in implementing improvement? Global surgery has an expansive remet. If you were to let other providers know that are interested in getting involved, in getting more information from you, speak about some of the key parameters that would make a real difference, if someone wanted to get involved, whether it's advocacy, education, research, clinical components that can involve surgeons and anesthesiologists and nurses, allied healthcare professionals, all working together with non-clinicians, including policy makers to really get this thing going. Speak to other providers, give them your final thoughts, key takeaways in what you want them to know if they're interested in getting involved in academic global surgery.
Dr. Gutnik: Absolutely. I think that's great. I mean, I think one approach is definitely a lot of, you know, professional societies whether surgical subspecialties, or even for example, the American College of Surgeons have great initiatives. And I think that is kind of one sort of place to start. I mean, you could start to see what's available within your own institution and then kind of looking to your own professional society, because a lot of them have working groups on global surgery that have various levels of opportunities and involvement.
So that is definitely a great place I would say to start is in your own institution and then turning to your professional societies. The other thing I would just always you know, encourage people to have in mind, as they engage in global surgery activities is to really kind of think about the purpose and who you're partnering with.
And really, you know, particularly if you are working with either vulnerable communities in your own backyard, or if you're working with more vulnerable communities in a different country, it's important to really partner with them and to understand what it is that they need. And how is it that you with your skillset are able to fit their need.
I think, unfortunately I have seen that a lot of that gets lost where people and, and, and from, you know, people are coming from a good place. People are excited. People want to do good. People have a lot of empathy. They want to try to help, but I think the best way to try to help is to first ask the question, what is it that you need and how is it that I could use my skillset and my opportunities to help you.
Host: What an excellent way to end this podcast. Thank you so much, Dr. Gutnick, that was excellent. And so interesting. Thank you. And please come on and update us as things progress in this initiative and let us know what's going on. We would really appreciate that. 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 Med Cast. For more 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/ua255.mp3
- DoctorsWright, Ashley
- Featured SpeakerAshley Wright, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5816
- Guest BioAshley Wright, MD Specialties include Obstetrics and Gynecology. Learn more about Ashley Wright, MD
Release Date: June 28, 2022
Expiration Date: June 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:
Ashley Wright, MD
GYN Ultrasound Director
Dr. Wright has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua252.mp3
- DoctorsZouk, Aline
- Featured SpeakerAline Zouk, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5806
- Guest BioAline Zouk, MD is an Assistant Professor whose Specialties include Pulmonology. Learn more about Aline Zouk, MD
Release Date: June 2, 2022
Expiration Date: June 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:
Aline N. Zouk, MD
Assistant Professor, Pulmonology
Dr. Zouk 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. Joining me is Dr. Aline Zouk. She's a Pulmonologist and an Assistant Professor at UAB Medicine, and she's here to highlight the latest in lung cancer screening guidelines. Dr. Zouk, it's such a pleasure to have you here. As we get into this topic, and this is really a very big field now, and this is such an important preventive screening. What are you seeing as far as incidence and awareness of lung cancer? Are more people smoking or getting the message? Are more providers discussing smoking cessation with their patients? Address the prevalence of lung cancer, as well as to the benefits from screening.
Aline Zouk, MD (Guest): Thank you Melanie for having me. Those are really good questions that you are asking. And we'll start off a little bit by talking about the prevalence and the rates of lung cancer. We just had a report that came out in February of 2022 where lung cancer is now the second most common malignancy in both men and women. It is the third most frequently diagnosed in the United States and we're expecting about 230,000 cases in the year of 2022. So that puts it just behind breast and prostate cancer. It is also, by far the leading cause of cancer deaths in the United States with about 130,000 deaths per year. That's actually more deaths than the next four leading cancers combined. So for men, you have a one in 15 chance of developing lung cancer and for women, it's about a one in 17 chance. The good news that we're seeing is that new cases are decreasing probably, because of the decrease in rates of smoking and also the advances of early detection and treatment of lung cancer which is where the lung cancer screening plays a big role.
We know that survival rate depends on the stage at which the lung cancer is detected or how early the cancer is discovered with the survival rates being much higher in early localized lung cancer versus the disease with distant metastasis. So an early diagnosis or detection is extremely important in this case, especially with lung cancer.
So the recommendation is that we should be using the low dose CT scans. And this recommendation is a consequence of a big trial that was called the National Lung Cancer Screening trial. This trial had about 50,000 participants between the ages of 55 and 74 years old, who were either current or former smokers.
They needed to have a history of at least a 30 pack year history of smoking within the last 15 years. They were divided into two groups, the patients who had early low dose CT scans and patients who had yearly chest x-rays and this was done over three consecutive years. The results of these trials was that the group who was screened with a low dose CT scan had about a 20% decrease in lung cancer mortality. This was because they were able to detect lung cancer at its early stages. And there was also a 7% decrease in overall causes all causes of death. So this study for sure, showed that we should be using a low dose CT scan because it improves the rates of survival along among lung cancer. And this goes back to why is, why is it so important to detect early.
In the case of lung cancer, it makes a big difference to diagnose a lung cancer at early stages. So, the overall five-year survival for lung cancer is about 20%. But this varies dramatically between what based on the stage of diagnosis. So, for example, someone who has an early stage non-small cell lung cancer has a 63% five-year survival compared to a 35% five-year survival if you detect it at a later stage where there's regional involvement. This drops to about 7% if they are diagnosed at an advanced or metastatic stage. For small cell lung cancers, which is the other big type of lung cancer, the five-year survival rate for localized is lung cancer is 27% versus regional, it's 16% and only 3% when it's at a very advanced stage. So you can see here that definitely indeed early detection of lung cancer is very important for the prognosis, but unfortunately only 20% of our lung cancers are diagnosed at an early stage and about 50% are diagnosed at a later stage. And that's really where one of the rationales for lung cancer screening is coming from is can we shift that so that we're finding more cancers at an early stage to try to reduce that mortality, since we have effective treatments at an early stage.
Typically when, by the time we see our patients in clinic, they have come because they've already have symptoms and how that's, how their masses or their lung cancers are found. That's because it's already spread to where it's invading either an airway or it's had a pleural effusion, or it's now outside of the chest. And in those situations, that's where we are identifying patients at a very advanced stage. In other situations where we would identify malignancies earlier is when they are most often found because they've had a CT scan done for some totally other unrelated reason. And that's why screening has become so important is that it has the potential to help in so many patients that would otherwise we would be finding these cancers at a later stage. With screening, we can detect cancers at an earlier stage when they're still a small nodule. We're able to see that lesion or that nodule in the lung and detect it when it's still at a stage where we could have surgery and resect it.
Host: Dr. Zouk this is so interesting. So as you're telling us about the current screening guidelines as set up by the US Preventive Services Task Force. Give other providers, some practice considerations when they're discussing this with their patients. So speak a little bit about those screening guidelines and they've been updated. They're actually getting updated quite often now it's changed a few times. So speak to other providers with some practice considerations for that discussion and why the updated guidelines.
Dr. Zouk: Yes, of course. The recommendations have actually been updated, more recently in 2021. We want to remember that these recommendations is a consensus throughout many different networks and societies, including the National Comprehensive Cancer Network, the American Thoracic Society, the American Society for Clinical Oncology, American College of Chest Physicians and so forth, including the US Preventative Task Force. So the recommendations, that all these organizations, they recommend a yearly low dose CT scan for, to screen for lung cancer in patients that meet certain criteria. So this is not across the board. These are just recommendations for a specific group of high-risk patients.
The recommendations recently expanded in 2021, and now include patients between the age of 50 to 80 years old and patients who are current or former smokers with at least a 20 pack year history of smoking within the past 15 years. So a pack year smoking history is a multiplication of the amount of years that a patient has times the number of packs per day that the patient has smoked. These recommendations have expanded from the prior recommendations. So now we are screening patients as young, as 50 years old and patients who have pack year smoking history. So with these recommendations, the estimated population previously would reach about 8.1 million patients in the US versus now we are reaching about 14.5 million patients in the US and that makes a huge difference for screening.
Host: It does. And if we've gone up in eligible, people that are getting screened, do you have a theory or any sense of why maybe it hasn't even done better? What do you see as some research needs and challenges and about the benefits and data for people in underserved community where smoking and high mortality rates are higher?
Dr. Zouk: I think one of the biggest challenges that we face, is that although we now have these standardized recommendations, unfortunately on a national level, we only about five to 6% of the high-risk patients are actually being screened. And during COVID, in the last two or three years, these numbers are even significantly lower.
One of the reasons for the low number is not because of patient refusal, in fact, there's no real resistance when the patients are offered screenin. Even those who are reluctant to get radiation when they do hear that this is a low dose CT scan, they are much more accepting of it. I suspect that the majority of the low frequency of utilization for the screening is mostly based on the physician's part.
We're probably not ordering it or thinking about it as often as we should. Additionally, there is a lack of patient knowledge that to be asking for these tests, when they go to their primary care physicians.
Host: So interesting. So what happens if something's found on the low dose CT? What do the results show and who reads them? How can providers follow up on these screening findings once they've referred their patients for this screening?
Dr. Zouk: So the radiologists usually read the CT scans and give their recommendations based on how suspicious a lung nodule is. One of the, you bring up a good point because one of the things that we do in our clinic is that we discuss with our patients. We have a, what we call a shared decision-making process with our patients.
We know that while there is a lot of benefits towards lung cancer screening. we also have sometimes something called an indeterminate pulmonary nodule that is seen on the CT scan. These are just incidental findings that, that may represent other benign lesions or different abnormalities in the lung that are not necessarily lung cancer. So it could be anything from a benign pulmonary nodule to fibrosis or bronchiectasis or chronic infections, signs of inflammation, aspiration. Really, there's a broad differential diagnosis here, but, these are benign incidental findings.
And one of the things that we have to keep in mind, is that we have to talk to our patients before we embark on this journey of lung cancer screening to discuss with them that these things may happen. We may see these indeterminate, pulmonary nodules and really it actually happens around more than half percent of the time.
We want to make sure that the patient is aware of this because in certain scenarios, this may trigger other diagnostic testing or intervention such as a PET scan or a lung biopsy to make a final diagnosis. In in other cases we see very suspicious lung nodules that are much more concerning where we would discuss with them about getting a lung biopsy at that point.
Host: So then what would you like to let other providers know? Are the most important key messages or takeaways from this podcast on lung cancer screening and the updated guidelines? What would you like them to know as they're counseling their patients and trying to get patients more involved and even involved in smoking cessation programs? Give us the key takeaway.
Dr. Zouk: Yes. One of the, the biggest key takeaway here is that early lung cancer detection is key because we, it is, it has a concrete impact on patient survival, and we need to do everything we can to detect lung cancer at its early stages. Think about it and discuss with our patients early on. Because we do have strong evidence that a yearly low dose CT scanning is, in the appropriate group can detect lung cancer at an earlier stage and decreased mortality. So we know that we should be using this. Needless to say smoking cessation is also key in this equation because we know that smoking is the main risk factor for developing lung cancer.
And this is where I think prevention ties in with the screening is that we are also opening the doors to more of these discussions about smoking cessation. And then the last message to take home is the updated recommendations for the lung cancer screening guidelines.
Just to remind everyone is that it is for current or former smokers that are in between the age of 50 to 80 years old, who have had at least a 20 pack year smoking history and have smoked for at least the last 15 years.
At UAB, we do have a Pulmonary Nodule Clinic for those patients who have been diagnosed with a pulmonary nodule or lesion based on these yearly low dose CT scans. We have a multi-disciplinary thoracic team, that is composed of our radiologists, radiation oncologists, interventional pulmonologists, thoracic oncologists, and thoracic surgeons, where we work closely as a team to determine what the next best steps are for patients who have been discovered with a lung cancer. And whether that means a lung biopsy or surgery.
Host: Thank you so much, Dr. Zouk. Such a great podcast. Really informative. Thank you again. And a physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST. Or you can always visit our website at UABmedicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua250.mp3
- DoctorsGutnik, Lily
- Featured SpeakerLily Gutnik, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5801
- Guest BioLily Gutnik, MD is an Assistant Professor whose specialties include Breast Surgery.
Learn more about Lily Gutnik, MD
Release Date: May 31, 2022
Expiration Date: May 30, 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:
Lily Gutnik, MD, MPH
Assistant Professor, Breast Surgery
Dr. Gutnik 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. Lily Gutnick. She's a Breast Surgeon and an Assistant Professor at UAB Medicine, and she's here to highlight breast cancer in Sub-Saharan Africa. Dr. Gutnick, it's a pleasure to have you with us. I'd like you to start by telling us a little bit about how advanced stage in diagnosis leads to worse outcomes and higher mortalities when it comes to breast cancer. Speak about the prevalence of breast cancer in Sub-Saharan Africa. And is that cancer burden really on the increase?
Lily Gutnik, MD (Guest): Sure. Thank you. Well, first of all, thank you so much for having me here today. It's a privilege and pleasure to be able to speak with you. FIrst of all, Breast cancer is definitely the most common cancer worldwide for all females of all ages. It's actually made up almost about a quarter of new cancers based on our most recent data in 2020.
But when you look at the incidence data, the incidence is higher in higher income countries, including countries in Europe and in the US but unfortunately the mortality is significantly higher in lower income countries and particularly in Sub-Saharan Africa. It is the second leading cause of death after cervical cancer in Sub-Saharan Africa.
And interestingly, when there was research, looking at something called like a case fatality, when you look at the mortality to incidence ratio, for breast cancer in Sub-Saharan Africa, that's about 48%. Right? So basically what it's trying to show is almost half the women that are diagnosed with breast cancer in Sub-Saharan Africa end up dying from it, which is quite different than what we see here in the US and in general, that kind of index or case fatality measure is about four times higher in Sub-Saharan Africa compared to higher income countries like the United States.
So about seventy seven percent of women present in stage three and four disease in sub-Saharan Africa. And going back a little bit more to your question about incidence being on the rise. That is definitely something we are seeing as well. In fact, when we kind of look at graphs from the United States and other similar higher income countries, like in Europe, we see that the incidence has had a flattened curve for the last few years. And fortunately the mortality curve has been going down. But unfortunately in Sub-Saharan Africa, we see our incidence definitely greatly rising, but we also see that mortality curve rising as well.
Host: We'll then based on that, speaking about the characteristics and determinants of this burden, are they clearly ascertained Dr. Gutnick? And do we know the reason for the advanced presentations? Are certain factors such as westernized diet, urbanization, and possibly even increasing awareness. Tell us about this multifactorial increase in reasoning that we're seeing.
Dr. Gutnik: Absolutely. So, I think there's a lot of reasons for why women present at advanced stages. And it's really kind of, think about it in three buckets. There's the biological, social and systemic determinants of health. And then there's reasons for that in all of that. We do see that in Sub-Saharan Africa, women present at younger ages and have more aggressive tumor biology, particularly the triple negative subtype.
And interestingly, when you look at the African-American population in the US you actually do see similar trends compared to Caucasian Americans. And there has been some very interesting sort of genetics and genomics work done comparing women from various countries in Sub-Saharan Africa and African-American populations. And as well as actually similar work being done in Europe with sort of women of African ancestry in European settings compared to various countries in Sub-Saharan Africa. And you do see some commonalities in the genetics and genomics and increasing in more aggressive subtypes, like triple negative.
But I think that's only one factor. There's definitely another huge factor is lack of screening and early detection. There are no organized screening early detection programs, mammography, which is commonly considered standard of care in high resource settings is virtually non-existent.
And then other measures that we know are actually very effective for screening and early detection, such as doing a robust clinical breast exam is also hard to come by in the region as well. And so there's, and then just another really important thing is lack of knowledge and awareness. I mean, people just don't recognize signs and symptoms of breast cancer or brush it off as it being, an infectious complication or other sort of more unfounded reasons.
And unfortunately not only are these misinformation and lack of knowledge and awareness prevalent among community, but unfortunately, a lot of sort of district level providers, also don't really have enough knowledge about breast health. So even if a woman does come in, let's say she notices a lump, right? And she will come to more of the primary health care post. A lot of countries in Sub-Saharan Africa have sort of a tiered healthcare system where there's sort of a primary level, a secondary level and a tertiary level. So let's say they even come at their primary or secondary health posts. A lot of times the clinician there may not recognize that this could be breast cancer and might mismanage it.
And so we actually have data, even systematic review data that shows that, you know, on average in Sub-Saharan Africa from time of symptom recognition by the patient to the time of actual diagnosis is 9 months. Which you could imagine, in the US just as a comparison, that data is something close to about 45 days.
The other interesting finding is that these patients, they will have on average of four contacts with a healthcare provider before actually reaching that true diagnosis. So there's sort of, again, those kind of more systemic issues. And then again, you know, the social issues, there's a lot of fear and stigma around cancer and especially breast cancer, and especially women's health issues and women's cancers.
Unfortunately, there are community beliefs around that this could be related to witchcraft, or this could be related to a wife being promiscuous and therefore she got breast cancer. And unfortunately there's a lot of times with that fear and stigma comes lack of social support. So there's actually, documented in certain countries, really high divorce rate, after women getting diagnosed with breast cancer or having a mastectomy or their husbands and families leaving them. And so not only are they faced with this terrible disease and often advanced stage, which makes it less treatable and less curable, but they also lose their social support. And so again, that fear and stigma of that causes them to then present late. And it turns into this cycle.
Host: Wow. It's really a multifactorial issue and as I'd like you to tell us about your work on understanding these reasons and developing strategies and interventions to address them with an ultimate goal to downstage. As you're telling us about mammography, are there other strategies? Is there evidence of other strategies specifically and particularly in low resource settings and will this rising burden pose any threat to Sub-Saharan Africa's regional development? Speak about your work and this comprehensive really initiative that we're looking at, because it is so multifactorial.
Dr. Gutnik: Absolutely. No, I'm happy to speak about that. So a lot of my current work does kind of focus on the overall long-term goal of downstaging, right, like I mentioned before, 77% of women present in advanced stages three and four, which obviously negatively impacts morbidity and mortality.
And so if the overall goal is to try to downstage them at time of diagnosis, then hopefully we have, a better opportunity for better treatment and for cure. And so a lot of my work focuses on strategies around screening and early detection. I had spent some time and living and working in Malawi, which is a small country in east Africa, where my research was on training lay women to do screening clinical breast exams and breast health education, in an integrated health system approach and it's one of the large tertiary hospitals in the capital city of the country. And basically what my work found was that this is certainly a feasible approach. These lay women could successfully be trained and could develop the skillset and can perform these clinical breast exams as well as physicians can.
And we had a very high acceptance rate among Malawian women of 82% who were really willing and wanted to undergo the service and have the screening done. Among the participants in our study, there was definitely this strong desire for screening and early detection. And there was this basic comprehension that if you catch something when it's early, it will result to better outcomes. So then in 2014, the WHO put out a position paper on mammography, and they basically say that when possible, they recommend an organized screening mammography approach. However, they recognize that this is often not possible in lower resource settings and that opportunistic mammography, meaning, just woman will walk off the street and to get a mammogram because she feels like it isn't really effective overall cancer control prevention strategy.
And so there's been several organizations and expert opinions, that have put forward additional recommendations. The Lancet Commission on Health Equity and Women's Cancers suggested that a clinical breast exam, is cost-effective and feasible. The WHO even endorsed that we're screening mammography is not possible, again, particularly in that organized population-based approach, that clinical breast exams should be explored. The Breast Health Global Initiative, which is an international group of experts, had come forth and put together all sorts of recommendations, guidelines, and pathways, everything from screening, diagnosis, treatment, and survivorship, based on resource availability. So dividing the country's resources based on their basic or moderate or high resource settings and in the basic or lower resource settings, they also recommend the clinical breast exam would be the best modality. And then the most recently is the NCCN, which is the National Comprehensive Cancer Network guidelines, which we actually use in the US as our sort of backbone of guidelines for everything screening and management of all sorts of cancers.
So they in 2018 has started putting forth again, resource stratified guidelines. For their more basic or lower resource settings, they also recommend clinical breast exam as an effective modality. This has been studied in various settings across the world in south America, in India, in various countries in Africa with clinical breast exam being done by nurses, physicians, trained lay women like I did in my study had been done, community health workers, had been used to, and they all basically come to the same conclusion that this is a very feasible and viable approach. I don't think there's any argument that this is an effective intervention. And then very excitingly about a year ago, published in the British Medical Journal was a 20 year followup of a cluster randomized control trial done in India, in urban slums in Mumbai of clinical breast exam screening intervention versus not or surveillance.
Although both groups did get some sort of breast health education upfront, the intervention arm of course then had ongoing screening clinical breast exams that in that case was actually done by community health workers versus the control arm, which was not. And not only did they find a significant down staging of cancers at 20 years of followup, but they actually showed a mortality benefit by almost 30%, particularly for post-menopausal women or women over 50. And so that's our first and only, large randomized clinical trial and long-term data that really shows the effectiveness of this intervention. Since then there's other really cool emerging technologies in this space.
Something called an IBreast, which is kind of physoelectric tool, that's been developed and tested in India and has now been used in various places around the world as well. But again, another more handheld device that could be used by anyone that's trained, of course, including someone like a community health worker or even an imaging technician to perform this exam.
And it identifies, potential areas of the concern, and then knows who to refer for the women for further followup. There's other technology around thermography or, thermolytics, that's also been developed in India and is currently being tested in various parts of the world that takes thermal images of the breast, which again, can be taught and trained how to use the machine by lower, skilled health workers, as another less invasive approach for that screening tool. So I think there's a lot of excitement and a lot of things going on about that. And of course, understanding.
So that's sort of just one aspect on the screening and early detection intervention space, but of course, there's work to be done in just understanding cultural norms and culturally appropriate context and just awareness, education and dispelling myths, which is definitely critical to this mission. As well as of course, educating providers as well, to make sure that, they understand breast health and basic breast health management.
Host: Well, it certainly is. What a great initiative doctor. 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 you can visit our website at UABmedicine.org/physician. That concludes this episode of UAB Med Cast. For more 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/ua248.mp3
- DoctorsKrick, Stefanie
- Featured SpeakerStefanie Krick, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5767
- Guest BioDr. Krick is an Assistant Professor of Medicine at the University of Alabama at Birmingham (UAB). Following her fellowship training and internships at Jackson Memorial Hospital/University of Miami and Mount Sinai Medical Center, she worked as an assistant professor of medicine at the Miller School of Medicine's Division of Pulmonary and Critical Care Medicine. She has completed training in internal medicine, molecular biology, pulmonary medicine, critical care and vascular medicine.
Learn more about Stefanie Krick, MD
Release Date: May 17, 2022
Expiration Date: May 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:
Stefanie Krick, MD
Assistant Professor, Critical Care Medicine, Pulmonary Critical Care & Pulmonology
Dr. Krick has no 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 today is Dr. Stefanie Krick. She's a pulmonologist in critical care medicine at UAB Medicine. She's an Assistant Professor and the Associate Director of the UAB Adult Cystic Fibrosis Program. She's here to discuss exercise and cystic fibrosis. Dr. Krick, it's a pleasure to have you join us today. Please discuss the role as we get into this podcast of exercise for cystic fibrosis patients, the benefits for the patient. Tell us a little bit about that.
Dr Stefanie Krick: Thank you very much for having me. And the Cystic Fibrosis Foundation really says that regular physical activity provides benefits well beyond better lung function. They state that keeping fit not only helps lung function, but also helps strengthen the bones, manage diabetes and heart disease and improve your mood.
Looking a little bit closer at that though, there are a lot of studies out there, over 83 when I looked at it, looking at over 480 participants, looking really at the role of exercise. But there are no high quality randomized controlled trials. And these are really the ones we need to better define the role of exercise in cystic fibrosis, because like you said, there are a lot of challenges when it comes to cystic fibrosis.
First of all, most of these patients are weaker because they have a chronic lung disease, they have diabetes, they have weaker bones. So what exercise is really right for them? Do they need a specific exercise prescription? Then kids normally don't participate in school sports, because they are more sick than other kids that don't have cystic fibrosis. And same I think in the adulthood, a lot of them do respiratory therapies about three hours on a daily basis and they have a job, so how can they fit in exercise? And they don't age that much. The life expectancy right now of cystic fibrosis patients is about 50 years. But even when they are 30, 40, they are normally more frail than healthy patients. That also poses certain challenges for doing exercise. They cannot do running or hiking and climbing. They, most of the time, have to really change exercise accordingly. So that makes it very challenging. And I think we need to figure out what is best for them, because exercise is important for them to prolong life and keep lung function high.
Melanie Cole (Host): Well, I certainly agree with you. And as we're talking about how cystic fibrosis affects exercise capacity and tolerance, Dr. Krick, let's break down the different types of exercise as part of a wider management strategy. There's a growing body of evidence that's suggesting that exercise and physical activity certainly can lead to improvements in lung function. And so, if it's helping people with cystic fibrosis benefit from enhanced airway clearance and better mucus clearance, can you speak a little bit to the types of exercise when other providers are listening to this with the breathing benefits and the types of exercise that can really help in this regard?
Dr Stefanie Krick: So I think we want to have a comprehensive exercise regimen. So especially coming to airway clearance, it's actually the moderate to vigorous exercise that will help with lung function and really use the whole vital capacity for them and that helps with airway clearance as well. And as a matter of fact, a lot of our patients that do airway clearances and are physically well, they use this vigorous exercise in addition to help clear more mucus. So it definitely plays an important role, but again, like the clinical trials are missing at this point, it's just really more anecdotal.
Melanie Cole (Host): That's so interesting. Well, it gives you something to really look to for a great research trial. And tell us when you're talking about vigorous and moderate, and we're talking about exercise for airway clearance. What about daily life of cystic fibrosis patients, the mind-body relationship, other types of exercise, yoga, meditation, flexibility, functional training? Tell us how these are all worked in for a real comprehensive program for people living with cystic fibrosis.
Dr Stefanie Krick: Yeah. So I think that's a very good point. Yoga is definitely a very good exercise. It again needs to be modified. And that's I think where it comes to cystic fibrosis patients should be in a cystic fibrosis center and seen by a multidisciplinary team. And this team, most of the time, has an exercise physiologist or a physical therapist as part of that team. And they can also help to find the right exercises, because like you said, yoga in general is very good, especially since you focus on breathing, which will help them overall also with airway clearance. But there are some like downward dog, for example, where they have to lean over, which is sometimes tough for patients who bring up sputum or who have shortness of breath in general. So the yoga program needs to be modified according to what they are able to do. Some of them will have feeding tubes because they are malnourished. That's another thing where some patients might not be able to do exercises for their abdominal muscles the way a normal person would be able to do that. So it's good to have a physical therapist like we have at UAB who is part of our program and helps really finding the right exercises.
Melanie Cole (Host): I think it's so important as you point out that you have patient-specific tailored programs and exercise prescription for these patients. Now, what about red flags, Dr. Krick, exercises to avoid? You just mentioned downward dog and how if someone's bringing up mucus, this could be difficult for them. Tell us any other special considerations. How about sweating? Any red flags that you would like for exercise for people that are living with cystic fibrosis?
Dr Stefanie Krick: I think one thing is they should consult with their specific cystic fibrosis team. Some of our patients are underweight and you don't want to do exercise and lose more weight. So it needs to be discussed with a provider, with a dietician and with your physical therapist, what exercise you can do to gain some lean body mass, some muscle mass and not lose weight or adjust your diet accordingly that you, in general, have a weight gain or maintain your weight. That's I think one thing that is very important to take into consideration.
Regarding exercises, I think that again is very individualized. If someone has a feeding tube, they might be able to do some exercises where another one might not be able to do those exercises. Same is with downward dog. Some might do that and actually it will help them expectorate mucus. So there again, it comes to this individualized exercise, prescription and assessment by a physical therapist.
At UAB, we actually are starting some home-based exercise programs where patients can enroll and can start with us, which is also remotely through telehealth. And this is upcoming for the next two years. If they are interested, they should definitely reach out to us. And I think which will help and also includes some behavioral techniques. How can we sustain exercise? Because I think that's the other big issue, because cystic fibrosis patients that live a normal life with having a job and everything they do, their days are pretty packed. So how do I integrate exercise?
And one other thing I think to consider is Trikafta, the new modulators, the CFTR modulators we are prescribing. They change quality of life significantly. So I think we will find basically it's a revolution, because patients will be able to do more. Some of my patients state now that they actually can run again. So they might actually be able in the future to do exercises they were not able to do before.
Melanie Cole (Host): That's so interesting. So it helps really with exercise tolerance. And you're speaking to other providers, as you wrap up, Dr. Krick, what would you like them to know as far as exercise to recommend it in their clinical practice? And when do you feel it's important that they refer to the specialists at UAB?
Dr Stefanie Krick: I think very important really going through the lifespan. With children with cystic fibrosis, they can do exercise and they should participate in school sports. It's not they are the fragile child and cannot do that, I think it's very important to early on integrate exercise and not hesitate. If they are worried, then refer to specialists at Children's of Alabama or to us. And throughout the lifespan, they should not be afraid to recommend exercise, especially when the patient does not have exacerbations. They should be able to try and really challenge themselves how much they can do and just make it a habit that it is part of the life and I think, with being on modulators, probably integrate it more and more.
Melanie Cole (Host): Thank you so much. And it does take a real multidisciplinary approach. So I really appreciate you speaking to that as well. Thank you for joining us, Dr. Krick. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. Or you can always visit our website at uabmedicine.org/physician.
That concludes this episode of UAB MedCast. For the latest on medical advancements, breakthroughs and research, follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS
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