Additional Info
- Audio Fileuf_health_shands/ufhs050.mp3
- DoctorsLang Lau, Wai
- Featured SpeakerWai Lang Lau, MD
- Guest BioWai Lang "Winnie" Lau, M.D., is board-certified in internal medicine and nephrology. She is an assistant professor of medicine in the division of nephrology, hypertension and renal transplantation.
Learn more about Wai Lang, MD - TranscriptionMelanie Cole (Host): Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole, and I invite you to listen as we explore IgA glomerulonephritis, a review and update. Joining me is Dr. Wai Lang Lau. She's an Assistant Professor of Medicine in the Division of Hypertension and Nephrology at UF Health Shands Hospital. Dr. Lau, it's a pleasure to have you join us today. Tell us a little bit about IgA glomerulonephritis and IgA nephropathy. Tell us a little bit about what those are, the prevalence. Give us a little background.
Wai Lang Lau, MD (Guest): So, first of all, thank you so much for having me. IgA glomerulonephritis is really one of my favorite diseases. So, in terms of prevalence, globally, IgA glomerulaonephritis is probably the most common form of glomerulonephritis. By incidence, it has its highest incidence in the Asian countries, especially Southeastern Asia. And in fact in Japan, they screen for it in their elementary school children, how common that is. But as we go west on the globe in Europe, the incidence decreases. And then actually as you go further west into the African continent, that's where there's the lowest incidence of IGA glomerulonephritis. And I would say, the United States, I mean, obviously we're a melting pot. We have people from all over the place, but again, looking at the ethnicity, I would say in general, low incidence in African-Americans, highest incidence in Asians and sort of medium incidence in the people of European ancestry.
I IgA glomerulonephritis is really thought to be a deposition of an aberrant form of the IgA immunoglobulin that is galactose deficient, and predominantly this galactose deficient form is produced by the mucosal immune access. And it makes its way into the systemic circulation and it gets deposited in the kidney, predominantly of the glomeruli and that's where it causes inflammation. And that's how it causes this clinical phenotype that we know of as microscopic hematuria, sometimes macroscopic hematuria as well, proteinuria, and sometimes accompanied by renal dysfunction, meaning elevated creatinine.
Host: Dr. Lau, if IgA glomerulonephritis doesn't usually cause symptoms in early stages and can go unnoticed for years, what red flags would you like other providers to keep in mind if their patients present with some of these? You mentioned earlier, microscopic hematuria, will you please let other providers know what you'd like them to be on the lookout for?
Dr. Lang Lau: So, from a subjective standpoint, when you're just talking to the patient and getting the HPI, what you want to hear is whether or not they've ever experienced gross hematuria. Okay. So, that's frank blood that they see in the toilet. Okay. That's a big red flag that they may have this disorder, and I will say, especially around the times of infection, like if they can recall, oh yeah, you know, one time I had this bad strep throat or I had this bad ear infection and then a day or two later, I peed out blood, and it could be self-resolved, meaning it may just happen for a day.
And then the gross hematuria disappears. But nonetheless, that is a big red flag that they may have this condition. But really short of gross hematuria, I mean, there are some rare instances where patients can present with edema, meaning anasarca fluid retention, swelling in their feet and ankles, and they may tell you about that. Ask them about skin manifestations because IgA can be a systemic vasculitis. In addition to being a renal limited, disease, it can be a systemic disease. So, people can have these weird palpable purpura, these little red dots, especially in the lower extremities. But yeah, those are the main things that we ask subjectively in terms of what they tell you, what you might find objectively on exam.
And then of course, you know, in terms of diagnostics, the urine analysis is imperative, right? I mean, anybody can pee into a cup, and all you need to do is do a dipstick on it and that can tell you a lot, if it turns positive for hematuria or proteinuria, then for sure, you've got a big flag right there.
Host: So, Doctor as we're talking a little bit about the histology and the pathological scoring of IgA glomerulonephritis, tell us about the glomerular grading system and how it's useful to predict the natural course of the disease.
Dr. Lang Lau: So, they've come up with what they call the Oxford classification, to describe the histology of the disease. And this came out, I believe in 2000 and 16 and it contains a few elements. It's called the MEST-C score system. So, M in the word MEST-C stands for the Mesangial score, which gives us an idea of how many glomeruli exhibit the Mesangial proliferation that we so classically see in IgA. The E is the score for endocapillary hypercellularity. And this in general gives us an idea of how angry this process is, how proliferative this process is. The S is the segmental glomerulosclerosis score. And that tells us how many of the gloms or the filters have been scarred by this process. The T is for tubular atrophy. And that tells us what percentage of the space in between the glomeruli are scarred, because you know what starts out in the glomeruli, this inflammation, then extends out of the glomeruli into the tubular interstitium and that's where the T score takes into account of.
And then the latest addition to the MEST-C score system is the C, which is just letter C. So, in total, it's actually M-E-S-T-C. So the C stands for how many cellular or fibro cellular crescents are seen on the light microscopy. Now, crescents really are the most angry manifestation that you can see in terms of glomerular inflammation. Because crescents basically represent a blowout of the glomerular basement membrane, where the inflammation has basically blown through the GBM and then extends onto the urinary space in Bowman's capsule. So again, that it's really the most exuberant, inflammatory manifestation of glomerulonephritis of any kind of glomerulonephritis, whether you're talking about ANCA disease or lupus or any kind of GN when you see crescents, you'll have a really angry glomerulonephritis.
Host: So, let's talk about some of the latest treatment options. Tell us a little bit about what you're doing now. What's exciting. And what you feel other providers would like to know.
Dr. Lang Lau: So, the one thing that's sad about IgA is that we don't have good established treatment for it. I mean, it's a disease that we've known about for five decades. Now, I believe in the beginning, it used to be called Berger's disease, of course now we've, we have a better idea of the pathophysiology. But you know, here we are in 2021 and we still don't quite have a handle on how to treat these patients. Certainly most long standing most treatment option is steroids, right, with glucocorticoids, but you know, we all know that glucocorticoids have such severe side effects. And the fact that the epidemiology of this disease is such that a lot of young people get affected. Not too many, 20, 30 something year old people are interested in being on high dose steroids, where they end up having acne and weight gain and stretch marks and all the rest. So, we're really interested in exploring other treatment options. So, what we've recently been involved in, it's called the NEFIGARD study, N-E-F-I-G-A-R-D.
And that uses a drug called Nefecon. It's actually repurposed form a budesonide. It is a glucocorticoid, but it is formulated to release in the part of the small bowel called the terminal ileum. And that's where we think that a lot of the abberant IgA is made. Remember how I said that, what's deposited in the Mesangium of the glomeruli, we think are IgA that is of mucosal immune axis origin. So, the Nefecon is a formulated, a special release glucocorticoid that really gets released in that part of the intestines where we think that this immunoglobulin is being produced. So, as such it's thought to have a lot less side effects than just giving the traditional prednisone, because of its targeted release, and also because of its extensive first pass hepatic metabolism. By the time it goes through the liver, only maybe about 10 to 15% of the drug then gets absorbed into the systemic circulation. So, it's thought to be a lot more tolerable than taking the conventional high dose steroid.
The other things that we're looking to be involved in is the role of complement inhibition. More and more we're understanding that many different forms of glomerulonephritis, perhaps a very basic common pathway, that precedes the glomerular inflammation and clinical disease, is the activation of compliment. And we know that an IgA that occurs in the Mesangium, because we see remnants or fingerprints of compliment degradation products as part of histology when we do the immunofluorescence. So, we are interested in exploring the use of compliment blockade in the treatment of IgA.
And there's a study that is using a lectin pathway inhibitor. It's sponsored by Omeros and I believe they're recruiting for phase three. There's interest with LNP, which it's a small oral molecule blocker of factor B for the alternative pathway that we're anxious to get phase two data on and they are recruiting for phase three.
And we might be a part of that, and then what we're also looking to become a part of is using sort of a non immunosuppressant way of reducing proteinuria, which I think is attractive. It's using endothelin receptor antagonist. It's not a total site targeted therapy, but it's kind of attacks at many different renal cells whether it be Mesangial cells, endothelial cells, Poto sites, tubular interstitial cells, but the end product is that it works to help decrease inflammation and to help decrease proteinuria. And so endothelian receptor antagonists, I think are an attractive arm of treatment that one might look for.
And what's nice about is that it's not an immunosuppressant drug and it can be used as an add-on perhaps to other immunosuppressant drugs. So, I think that's a very attractive arm to look at. Sparsentan is an endothelin receptor antagonist combined with a angiotensin receptor blocker. They will be closing their phase three enrollment. And so, we're all very anxious to see, what the sparsentan data will look like for the IgA group. Because I think that will be a good option. You know, of course, treatment always has to be individualized.
You have to look at the patient, you have to look at their comorbidities, you got to look at their BMI and, and then you also have to discuss the side effect profile of every agent that we have and then between the provider and the patient, you need to decide which agent has an acceptable profile, side effect profile that makes it a positive risk benefit ratio for that particular person. So, one other thing that I just want to mention that how we talk about IgA as being a disease of, deposition of aberrant IgA molecule in the glomeruli, so, you know, what seems a sensible possibility for treatment would be something that might affect the B cells that produce the IgA.
Well, oddly enough, there was a study done in 2017, by Lafayette et al, that looked at using rituximab to treat a group of patients with IgA and surprisingly enough to everybody, it was a negative result. In other words, it did not improve proteinuria or creatinine in these patients. Now, there's been a lot of discussion about what could be the cause of the result and some people claim that well the mean EGFR and the rituximab arm was 40 cc's per minute. So, maybe by that time, the horse is out of the barn already, and there might've been too much scarring. So, it may be just the stage in which we're catching these patients that the drug might have been ineffective. But there've been a few other theories that because again the aberrant IgA, we think that's the culprit, is of mucosal origin; maybe there's a difference between how we need to suppress these particular B cells compared to IgA B cells that are made in the bone marrow or other germinal centers.
So, maybe there's something special about the mucosal immunity. We know that there are genetic predispositions to who forms these aberrant IgA that somehow again, was able to escape the rituximab effect. There's concern that maybe it's more the plasma cells that are involved in producing the abberant IgA.
And of course, rituximab does not hit at the plasma cells. So, there's been a myriad of theories to explain, but for all intents and purposes, for now we do not believe that rituximab is effective for renal limited IgA glomerulonephritis.
Host: Wow. That was an excellent summary, Dr. Lau. So, any final thoughts you'd like to leave other providers with, when you feel it's important to refer, any clinical trials you'd like them to ask you about, just give us little bit of your final thoughts and best advice,
Dr. Lang Lau: Final thoughts and best advice, I would say certainly for all the primary care providers, the people who do physicals, please do urine analyses because a lot of these patients do come in asymptomatic. And if we can catch them early, get the referrals early, get the biopsies done and make the diagnosis and put them on appropriate therapy, then hopefully we can save a lot of these young to middle-aged people from going to ESRD. I would say to our nephrology colleagues, please refer for patients to go on to clinical studies because steroids really are very difficult for patients to tolerate. They are certainly not the answer for everybody. And I would really encourage them to look at the different centers and who's doing what study and make the referrals so that we can catch them because even for clinical studies, we generally like to see them when their EGFR is above 30. So, that unfortunately if you catch them too late, then they may not even be eligible for a study. So, I think those would be my two main ending remarks.
Host: What a fascinating topic we discussed here today. Dr. Lau, thank you so much for joining us and sharing your incredible expertise. Thank you again. And to refer your patient to Dr. Lau or to listen to more podcasts from our experts, you can always visit ufhealth.org/medmatters for more information. That concludes today's episode of UF Health Med Ed Cast with UF Health Shands Hospital. Please remember to download, subscribe, rate and review this podcast and all the other UF health Shands Hospital podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs048.mp3
- DoctorsAl-Mansour, Zeina
- Featured SpeakerZeina Al-Mansour, MD
- Guest BioZeina Al-Mansour, MD, is an associate professor in UF Health’s Division of Hematology & Oncology in the University of Florida College of Medicine.
Learn more about Zeina Al-Mansour, MD - TranscriptionMelanie: Welcome to USF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're exploring advances in malignant hematology. Joining me is Dr. Zeina Al-Mansour. She's an Associate Professor of Medicine in Malignant Hematology, Bone Marrow Transplant, and Cellular Therapy at UF Health Shands Hospital.
Dr. Al-Mansour, it's such a pleasure to have you join us today. Tell us a little bit about the role of precision medicine in malignant hematology practice and some of the things that you've seen over the years as this field has evolved.
Dr Zeina Al-Mansour: Well, thank you, Melanie, for having me today. In malignant hematology, we pride ourselves that precision medicine has really taken off particularly over the past 20 years with the increasing use of molecularly-targeted therapy and all the advances that we have witnessed lately. Precision medicine really uses a broad range of clinical practices in which genetic tests results are used to guide a patient's care.
It is applied to prevention, diagnosis, and the treatment of diseases. And in malignant hematology, we mostly use it for the diagnosis and the treatment of diseases. It is used to improve medical decision-making and delivery of therapies tailored to the patient's sequence of the genetic changes that we see in their cancers. In this way, we believe that we optimize disease control and we improve the chances of curing the patient of their malignancy.
Also, when we apply precision medicine basics, we avoid exposing the patient to medications that have lower efficacy toward their cancer and we also reduce exposure to medications that may expose them to greater toxicity. In malignant hematology, the examples of using precision medicine includes all the targeted medications that we have witnessed their approval over the past couple of decades.
The first one that comes to mind is imatinib or Gleevec, which is basically a revolutionized molecularly-targeted therapy in malignant hematology. It targets the Philadelphia chromosome in chronic myeloid leukemia, which basically transformed this leukemia that used to be life-threatening or fatal within two years, the life expectancy used to be two to three years in this malignancy, to more or less a chronic disease now by blocking this driver mutation in these patients.
So patients now who take this medications basically just has to stay on it, usually for life. And as long as they are tolerating that, they just continue on the medication and continue to control their leukemia in most cases. A smaller fraction of patients may require more aggressive treatments or require change of treatment. But for the most part, continuing on imatinib or some medications of the same family may control it.
Likewise, other molecularly-targeted treatments have transformed the course of many of previously thought to be fatal diseases. For instance, we have the FLT3 pathway, is one of the driver mutations in acute myeloid leukemia. We always say that patients who have acute myeloid leukemia with this pathway, the question is not if it will come back or not, the question is when. But now, we have multiple medications that block these drivers that have changed the course of this leukemia. And by blocking these mutations with these molecules, we have significantly increased the chances of curing the patient of these leukemias.
We currently have two approved medications with multiple ones that are under investigation to be approved. This pathway is known to evade growth suppression, sustain proliferation of this cancer, resist cell death of this malignancy. And blocking this pathway improves the cancer control by blocking all these mechanisms.
Other pathways where we apply precision medicine basics include the JAK pathway, which is identified in multiple myleloid malignancies in terms of deregulating cellular energetics, sustaining proliferative signaling. It avoids immune destruction. It also promotes tumor inflammation and it resists cell death. So we have JAK inhibitors. Jakafi is one of them. And by inhibiting that, it also can control tumor growth by blocking these mechanisms.
And there are multiple other examples from the chronic lymphoid leukemia. For instance, another example, we have in the lymphoid malignancies in which we apply the basics of a precision medicines by using molecularly-targeted therapies that inhibit these driver mutations in these malignancies. With these, we can alter tumor growth or stop it or improve ptosis or cell death to increase the chances of controlling the cancer in these patients.
Melanie: That was a comprehensive answer, Dr. Al-Mansour. Thank you so much. What an exciting time to be in this field, as we're talking about immuno-oncology and the treatment of blood malignancies. Tell us about any novel immune-based therapeutics, BiTEs, CAR T-cell therapy, advances in transplant. Walk us through some of these novel immune-based therapeutics.
Dr Zeina Al-Mansour: This is a topic that is very dear to my heart. So these immune-based therapies come from the bone marrow transplant field and bone marrow transplant is one of the immune-based therapies. In all these immune-based therapies, we are going back to the basics. We are trying to unleash the immune system that was created in the body to fight malignancies. And for some reason, something went wrong and the immune system is now not fighting the malignancy. So with these immune-based techniques, we try to reeducate the immune system, the patient's immune system, to go back and fight the malignancy, either by just changing or modulating the immune system, or by enhancing that with adding some molecules to help the immune system fight the cancer.
For example, when we use what we call the BiTE techniques, BiTE stands for bi-specific T-cell engagers, these are molecules that we infuse into the patient's body. These molecules have usually two binding sites. The first BiTE that was approved was for the acute lymphoblastic leukemia. So we're going to use that for the sake of this example. This molecule has two binding sites. The first site binds the CD-19, which is a common B cell marker. The second binding side binds the CD8 cytotoxic T-cell. So when you infuse this molecule inside the patient's blood, it goes around and binds the CD-19, the acute lymphoblastic leukemia that the patient has and then goes around and binds the cytotoxic T cells that the body has normally, and usually should fight the malignancy.
So when this molecule binds these two together at the same time, again, it binds the malignant cell, the CD-19 malignant cell and at the other site, binds the cytotoxic t-cell. When it brings them together, close to each other, it induces a reaction that causes cellular killing. And by doing that, it enhances the killing of the acute lymphoblastic leukemia.
So this is what we call the BiTE technology, bi-specific T-cell engagers. It has been approved for, B-cell acute lymphoblastic leukemia. it is under investigation for multiple myelomas and acute myeloid leukemias as well. But we believe it's a very promising technology that uses the cytotoxic T cells in the patient's body as long as you find another target that these T-cells can bind and induce cellular killing. So this is one immune-based technology. In BALL, it has been shown to be very, very effective.
The other one that uses immune-based technology is the CAR T-cells. CAR stands for chimeric antigen receptor cytotoxic T cells. And this technology, we basically use it for refractory diffuse large B-cell lymphomas. We take the T-cells from the patient's body that has the refractory lymphoma. T-cells is part of the immune system that is normally supposed to fight the malignancy. However, in that patient, for some reason, it was unable to recognize the patient's malignancy.
So we harvest these T-cells by a process called apheresis. Basically, we collect them from the patient's plasma and then we send them to a specialized lab with a piece of the patient's own lymphoma. And then we re-engineer the receptors on the T-cell in a way that matches the antigens on the patient's lymphoma, so that the receptor and the antigen now can recognize each other. And after that, we culture the T cells in the lab to expand them and make them at enough numbers so that when we re-infuse them back in the patient's body, they can go and re-expand and populate in the patient's body. And then they can circulate around to find the patient's refractory lymphoma.
And at that point, they can recognize the antigen because now they already engineered to recognize it. And at that point, they can interact with each other and then use cellular killing or the tumor killing and fight the malignancy. So that is the second technology, which we call CAR T or chimeric antigen T cell receptor technology. It's currently approved for refractory diffuse large B-cell lymphoma. In pediatric cases, it is approved for our refractory acute lymphoblastic leukemia. And very recently, two months ago, it was approved for refractory multiple myeloma. And it is currently under investigation for acute myeloid leukemias. And in multiple solid malignancies, it's also under investigation. So we also believe it is a very promising technology that is gaining a lot of popularity now.
Melanie: What a fascinating field this is. As we wrap up, what would you like other providers to know about any clinical trials or research for hematologic malignancies that you're doing at UF Health Shands hospital and when you feel it's important they refer?
Dr Zeina Al-Mansour: What I want people to remember, the hematological malignancies is a rapidly advancing field. It is a field that has a potential of a cure. These malignancies, even though they are very aggressive and potentially fatal. They have very high chances of being cured, even the refractory cases. We have multiple clinical trials at UF including BiTE trials. We do all types of cellular therapies, bone marrow transplant, and CAR T-cells at UF, as well as transplant for elderly population. That is also a very rapidly advancing field. So we are happy to see and evaluate patients for any options of treatment that we able to offer them.
Melanie: What a great topic. Thank you so much, Dr. Al-Mansour, for joining us today and sharing your incredible expertise. to refer your patient or to listen to more podcasts from our experts, please visit ufhealth.org/medmatters for more information. And that concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital.
Please also remember to download, subscribe, rate, and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs047.mp3
- DoctorsAl-Mansour, Zeina
- Featured SpeakerZeina Al-Mansour, MD
- Guest BioZeina Al-Mansour, MD, is an associate professor in UF Health’s Division of Hematology & Oncology in the University of Florida College of Medicine.
Learn more about Zeina Al-Mansour, MD - TranscriptionThe University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie: Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're discussing challenges in cancer care in the elderly. Joining me is Dr. Zeina Al-Mansour. She's an Associate Professor of Medicine in Malignant Hematology, Bone Marrow Transplant, and Cellular Therapy at UF Health Shands Hospital.
Dr. Al-Mansour, it's a pleasure to have you join us today. Tell us a little bit about the unique aspects of cancer care in elderly patients. What makes this group of patients unique for an oncology practice?
Dr Zeina Al-Mansour: At this point, it's a well-acknowledged fact that age is the most important risk factor for developing cancer. Approximately about 60% of all newly diagnosed malignant tumors happen in elderly patients and about 70% of all cancer deaths occur in patients over the age of 60 and older. For all malignancies, death rate is disproportionately higher in elderly population. And, most likely, this happens for multiple factors. And due to unique considerations that happens in the geriatric age group.
For example, that are medical aspects that are unique to the geriatric population. For example, there is the age-related organ function decline that happen as people grow older, that contribute to higher toxicity with chemotherapy and cancer treatment. There is also the altered natural history of some cancers that happens in aging individuals. There is the concerns of quality of life that older individuals care about probably more than the duration of life. And there's also the psychosocial aspects of caring for an older individual, including the financial burden of cancer care and the access to healthcare physicians and cancer treatment. And on top of that, in the oncology world, we know that most of the clinical trials that establish the standards of care for cancer treatments, the elderly patients are underrepresented in these trials. So these standards of care that we use to treat these individuals do not necessarily represent them when these are standards of care were established.
So for all these seasons, we now consider geriatric oncology a unique field that has to be studied more and investigated more with the clear emphasis on this age group, with all these unique considerations in mind.
Melanie: What great points you just made, Dr. Al-Mansour. It is such a unique group of patients, as you said. And the mechanisms that link age and, say, body weight to cancer, they're incompletely understood, but recent studies provided evidence that anti-tumor immune response is reduced in both conditions, obviously, as we know the aging body, but while responsiveness to immune checkpoint blockade is paradoxically intact. Tell me a little bit about aging and cancer and aging and immunity and how those go together based on what we've learned.
Dr Zeina Al-Mansour: Let me start first by talking a little bit about immunosenescence. Immunosenescence or the aging immune system is defined as the progressive decline of immune function with aging. And this results from multiple observations that we know about the immune system.
First, we know that both the adaptive and the innate immune system both decline as the body ages with the years. And that results in decline in both their T cell function and the B cell function, as well as the cellular immunity. And these observations has led to increased susceptibility of the human body to developing malignancies, infections and also immune diseases that we clearly observe in the elderly population.
The changes in the T cell repertoire and the B cell function that we see in the human body because of increased exposure is through the years to the antigens that results in increased memory cells and decreased naive cells. This we believe is the reason leading to increased susceptibility to malignancies, infections and autoimmune diseases. That leads to decrease in self-tolerance and increased susceptibility to these conditions in elderly individuals.
The unique aspect or the challenge with this is that all or many of the new cancer therapies are now using immune-based techniques to fight malignancies. In other words, we are trying to unleash the immune system to fight the malignancy and combat cancer. So with elderly individuals, the challenge or the question now comes to mind is that with this aging population, that has declined in immune system that comes with the normal aging process, can we really or efficiently unleash their immune system with these new techniques to fight their malignancy in the same way that we're trying to use with younger individuals?
This question has been gaining a lot of interest lately, especially, with the newer cancer treatment that has been approved. As you mentioned, immune checkpoint inhibitor is one of the newer cancer treatment that has gained approval in a wide range of malignancies, including heme malignancies, like lymphomas, for instance, as well as many of the solid tumors, like lung cancers, melanomas. And I believe many of the gastrointestinal malignancies as well are using immune checkpoint inhibitors.
Just to simplify it for the listeners, it tries to promote self-tolerance or you the basics of self-tolerance by reeducating the immune system to help the body of recognize the patient's malignancy as foreign and help the body to fight this malignancy that the patient has. So by doing that, they try to overcome this malignancy or fight this malignancy. That's the whole basic of using immune checkpoint inhibitor.
So in the aging population, the concern was that we cannot use these technologies or these medications. However, there is a newer data that shows with some of the clinical trials that has been able to include some elderly individuals who were fit enough to be included in these clinical trials, they were also able to get some benefits from using these immune-based therapies. I believe the trials were able to include some patients up to the age of 75. And they were able to derive the same benefit that was seen in younger individuals. The thing that is still unclear is were they able to gain quality of life? With the added years of survival that they were able to gain with this cancer treatment, did it come with quality time?
Melanie: Well, doctor, you've mentioned quality of life a few times, and that's a really important aspect for this population. So tell us about the importance of a thorough assessment of functional status and quality of life consideration when treatments are being considered and the emerging role of comprehensive geriatric assessment in oncology practice for other providers and even for primary care providers. Tell them about this geriatric assessment and why it's so important when they're discussing treatments with their patients.
Dr Zeina Al-Mansour: For geriatric patients, they can be vulnerable to treatment toxicities more so than younger individuals, as we said, the decline in their organ function that puts them at higher toxicity. And for these individuals, cancer cure and longevity may not be the primary goal. Oftentimes, their quality of life is a more important goal for them and their independence and being able to continue with their activities of daily living without necessarily being disabled is their primary goal. So that's why being able to fully and totally able to assess their functional status so that you're able to maintain it for them should be a very important goal to maintain throughout their treatment journey.
What we used to use in the past is the ECOG performance status or the Karnofsky performance status, which is a simple measure of what percentage of time the patient basically spends in bed or sedentary. We found that that simple measure is not enough to assess geriatric patients. In exchange of that, we found that the comprehensive geriatric assessment tool, which is a multidisciplinary diagnostic and treatment process. It identifies medical, psychosocial, and functional, domains of an older individual and can identify frailty or prefrailty areas that an older individual may have so that you can develop a coordinated plan for this patient and modify it throughout their treatment process.
We found that if you use something like that during their oncology treatment, you can basically improve their outcome and improve their quality of life and symptom contro rather than just using a simple measure of how sedentary they are or how much time they spend in bed. And this is gaining popularity and has been validated in multiple settings in oncology and in other fields of medicine. I come from the cellular therapy field of oncology and bone marrow transplant. And it has been used successfully in this population. And it's showing to be a very promising approach in improving the outcome of elderly individuals undergoing this very aggressive approach of cancer treatment.
Melanie: Such an interesting field that you're in, Dr. Al-Mansour. As we wrap up and we're talking about really consideration when we're discussing treatments for elderly patients with cancer, you mentioned it briefly about the multidisciplinary approach. Tell us about that, how that really affects treatment outcomes for better outcomes and what you'd like other providers to know about referral to UF Health Shands Hospital.
Dr Zeina Al-Mansour: What I want everybody to always remember that older individuals are a unique group. They can have very promising outcomes in terms of their geriatric cancer treatment. They can be treated and they can be cured from many of their cancers if they are detected early and if they are cared for very thoroughly. Their treatment has to be very multidisciplinary with thorough care and review of their medications, of their physical status and nutrition and chemotherapy plan at multiple areas and multiple stages of their treatment. Their outcomes can be very promising if it is done in the right way. And here at Shands, we are seeing a lot of elderly individuals and I believe their outcomes are promising and they are being cared of according to all the up-to-date standards.
Melanie: Thank you so much, Dr. Al-Mansour. What an interesting topic in such a burgeoning field, really, anything having to do with the elderly, but cancer care and specifically, and quality of life and geriatric assessments. Thank you so much for discussing all of that.
To refer your patient or to listen to more podcasts from our experts, please visit UFHealth.org/medmatters for more information. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs049.mp3
- DoctorsCrispen, Paul
- Featured SpeakerPaul Crispen, MD
- Guest BioPaul Crispen, MD is an Associate Professor, Urology, University of Florida College of Medicine.
Learn more about Paul Crispen, MD - TranscriptionMelanie Cole (Host): Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole and today, we're talking about improving outcomes for stage I bladder cancer. Joining me is Dr. Paul Crispen. He's an Associate Professor of Urology at the University of Florida College of Medicine. Dr. Crispen, it's a pleasure to have you join us today. Tell us a little bit about bladder cancer and recurrence rates in stage I bladder cancer, specifically.
Paul Crispen, MD (Guest): Certainly. And so, overall they're going to be 80,000 new cases of bladder cancer per year in the United States. Most of these are going to be diagnosed in older patients. The average age of diagnosis across the country is 73 years and there was a about a 3:1 ratio of males being diagnosed compared to females with this. And there's a number of reasons why it's more common in males, including increased use of tobacco, potentially metabolism of carcinogens and different sex steroids. What we do know though is no matter what age you're diagnosed, or if you're a male or female, the majority of patients diagnosed with bladder cancer are going to have stage I bladder cancer, and that's going to represent about 70 to 80 patients of the new diagnoses per year.
For patients with stage I bladder cancer, the chance of the cancer coming back, after the initial diagnosis ranges from 30% up to 80%. So there's a big range there. And the timing of the recurrence can differ dramatically with the type of cancer that's diagnosed and the type of stage I, as there's different types of risk categories of stage I bladder cancer at the time of diagnosis.
Host: So interesting. Dr. Crispen, thank you for that answer. So, tell us about UF Health Shands Hospital's approach to treating patients with stage I bladder cancer. How's it unique? Tell us what you're doing there.
Dr. Crispen: So, we put a great deal of importance on optimizing patients from the onset of diagnosis moving forward. There's a lot of things that we do on a routine basis that I think helps to improve the outcomes of our patients and where we're really trying to decrease the chance of recurrence in our patients on a daily basis. There's a number of things we're doing. The first is avoiding the diagnosis being based upon a biopsy alone. When a patient first comes to see us with a bladder tumor, we want to do more than just take a piece of that tumor out. We want to get a good resection in the operating room where we're removing the entire bladder tumor, any associated abnormalities around it and getting a good look around the bladder to make sure we're not missing anything.
And now that can be difficult to do. There are techniques that are available such as using something called blue light cystoscopy, that we use here at UF Shands Hospital in detecting these tumors. And the blue light cystoscopy differs from traditional cystoscopy, as we put a medicine in the bladder about an hour before the procedure, and this medicine will actually have normal tissue, have a blue color to it, and the tumors light up pink, and this can really help us find other small areas that we may miss with traditional white light cystoscopy.
It does involve an additional procedure to put the medicine in the bladder, but we know from randomized trials that using this type of approach with the blue light cystoscopy can increase the detection rate of stage I tumors up to 40% and has led to a decrease in cancer recurrence in patients by up to 33%. And beyond this, beyond the use of blue light cystoscopy, we also advocate for the use of immediate chemotherapy following the resection of the bladder tumor. And so the chemotherapy that we advocate, isn't the traditional chemotherapy that patients often think of, or providers often think of where we give the chemotherapy in the vein. This is instead a single dose of chemotherapy that we would instill into the bladder while the patient's in the operating room and then drain it.
So, it's a one-time treatment that's done the same day of the procedure. However, by doing that, we can further reduce the risk of cancer recurrence by about 34%. And lastly, something that we're doing routinely at UF Shands Hospital is following up with the recommended, repeat resections in patients that have certain types of stage I tumor that put them at a higher risk of recurrence. And that's something that nationally may only occur in about a third of patients, but our rate of doing these repeat resections when indicated is over 90%.
Host: Wow. That's fascinating. And thank you for characterizing those methods to decrease disease recurrence. And now what are some of the barriers Dr. Crispen to implementing some of these methods and even after the fact for these patients, which you stated were, you know, on the average more males, get this. Tell us about some of these barriers that could improve outcomes.
Dr. Crispen: So, some of the barriers, thankfully we don't have some of these barriers at the UF Shands Hospital is the access to the blue light cystoscopy. That's not widely practiced in a lot of urology centers, in the state or across the country, because it does require specialized medications and equipment to provide that care. Also the routine use of the chemotherapy, isn't always available in every hospital. But we've developed a system here where we can guarantee access to that chemotherapy, no matter where we do the procedure in our hospital. Following those initial resections, patients can have a lot of barriers though to receiving them the next step in care, the next step in the treatment of their stage I bladder cancer.
And that's not something that's unique to any one center. That's a national barrier. And that is too, receiving a medication called BCG and that BCG medication is an immunotherapy that's been used to reduce the risk of cancer recurrence in patients with stage I bladder cancer. We've been using it for over 30 years now. Unfortunately, there is limited ability to produce that medication in the United States with only one FDA approved form of BCG currently, and many patients over the last several years have been unable to get BCG because of this national shortage. And again, that continues to be ongoing and there's very aggressive, active plans to try to overcome that.
One way that we have been successful in overcoming that barrier at UF Shands Hospital is by offering our patients clinical trials where we can get guaranteed access to the BCG. Having that clinical trial open during the past two and a half years, has allowed me to give more patients BCG that otherwise would not receive it. And so then the other amount of BCG that I receive outside of this clinical trial, I've been able to provide the patients who would not qualify for the study. And so I think that's probably the largest barrier for the treatment of patients with stage I bladder cancer, nationally.
Host: While you're talking about clinical trials, is there any interesting research you'd like to let other providers know, maybe genetics or epigenetics? You mentioned briefly immuno oncology. Tell us a little bit about what's exciting in your field and any future research you see coming down the pike.
Dr. Crispen: Certainly. And so when we're talking about improving the care of stage I bladder cancer, one of the most critical needs is improving the care of patients with stage I bladder cancer who no longer respond to BCG therapy. And there've been tremendous breakthroughs through research conducted nationally and through research conducted here at UF Shands Hospital and improving the care of those patients. Right now, there's one particular medication that we've been involved with the clinical trial, looking at using an adenovirus, the common cold virus to be put into bladders to help fight BCG refractory stage I bladder cancer. And that medication is currently undergoing FDA review. And hopefully that could be available not only to our patients here, but across the country, in the near future.
And so everyone, I think who treats stage I bladder cancer is very excited about that possibility. Despite the success of that trial, we're always looking for the next step. And so what happens to patients who don't respond to that therapy? And we've got ongoing trials now at the UF Health Shands Hospital that are addressing that need, and we'll continue to develop those in the future.
Host: Such an interesting topic, Dr. Crispen, as we wrap up, what would you like other providers to know about optimizing effective treatment and bladder health among their patients and the importance of a multidisciplinary approach for these patients?
Dr. Crispen: So, I think one of the biggest things that all providers could improve on is getting patients diagnosed early. There's no standardized screening program for bladder cancer like there are for other cancers like breast cancer or colorectal cancer. And so we often rely on patients seeing their primary care providers and being referred to us to make the diagnosis of bladder cancer. And often we'll see patients coming in late, because maybe some of the signs and symptoms of bladder cancer were overlooked or the patients had blood in the urine and it was attributed to a urinary tract infection where it was actually coming from a bladder cancer. And so I think one of the best things we could do as a healthcare community to improve bladder cancer outcomes, is to do a better job, maybe of recognizing the signs of bladder cancer, to make the diagnosis as early as possible to help drive down the recurrence rates.
Host: What great information, such an informative episode, Dr. Crispen. Thank you so much for joining us and sharing your incredible expertise today. To refer your patient or to listen to more podcasts from our experts, you can always visit UFhealth.org/medmatters for more information. That concludes today's episode of UF Health Med Ed Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs046.mp3
- DoctorsTaylor, Janice;Cheng, Sam
- Featured SpeakerJanice Taylor, MD, MEd | Sam Cheng, MD
- Guest BioJanice Taylor, MD, is an associate professor of surgery in the division of pediatric surgery at the University of Florida College of Medicine. Dr. Taylor earned her medical degree from The Ohio State University in 2003. She then completed her general surgery residency in 2010 at the University of Cincinnati College of Medicine.
Learn more about Janice Taylor, MD
Sam Cheng, MD, PhD, MSc, earned his medical degree and master's degree in clinical investigation from Tongji Medical University in Wuhan, China, and then trained in molecular biology and genetics while being a World Health Organization fellow at the Great Ormond Street Hospital in London.
Learn more about Sam Cheng, MD - TranscriptionMelanie Cole (Host): Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole and we're discussing today the multidisciplinary means management of pediatric intestinal failure. Joining me in this panel is Dr. Janice Taylor. She's an Associate Professor of Pediatric Surgery for the University of Florida College of Medicine and Dr. Sam Cheng. He's an Associate Professor of Pediatric Gastroenterology for the University of Florida College of Medicine. Doctors, thank you so much for joining us today. Dr. Cheng, I'd like to start with you. What is short bowel syndrome? Tell us a little bit about the prevalence and intestinal failure in general in children. What is known about this now?
Sam Cheng, MD (Guest): Short bowel syndrome is when patients require parenteral nutritional support and due to loss of bowel either physically or functionally. It's not a very common condition, but it's a very penetrating condition, according to NASPGHAN, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.
The failure is defined as the need for parenteral nutrition for more than 60 days due to intestinal disease, dysfunction or resection. The recommended definition for short bowel syndrome is the need for parenteral nutrition for more than 60 days after intestinal resection or a bowel length less than 25% of expected. This is not so common, but it's common in our pediatric world. The most common cause of short bowel syndrome and intestinal failure is necrotizing enterocolitis. Account about like 20, 25% and coming next would be gastroschisis, it's a congenital defect, wall defect and that about maybe around 10% to 15% and then the third common reason would be intestinal atresia, named also the malrotation with volvulus. That's another cause of short bowel syndrome in children.
Host: Well, Dr. Cheng sticking with you for a minute. As we're talking about chronic medical management challenges for these kinds of situations in children, do these dominate a child's life by restricting growth, development, productivity, all of these things? Tell us a little bit about the symptoms. Red flags pediatricians should be on the lookout for, as the medical home, working with these children on a regular basis.
Dr. Cheng: Short bowel syndrome, intestinal failure as the name suggests is due to loss of bowel. The main function of the bowel is to you know absorb fluid, electrolytes and provide the nutrition for the whole body. So, when the function is compromised, the first symptoms would be the loss of fluid and so end up a lot of diarrhea and then also malnutrition, maldigestion. So, that's the first thing. This is a long process because it takes a long time for the bowel to adapt. Usually we're not talking about days or months, we talk about years. So, patients usually end up also failure to thrive, poor or retarded growth.
Host: And Dr. Taylor, help us understand some of the surgical and medical options for managing these patients.
Janice Taylor, MD, MEd (Guest): They need to be considered together. A lot of these children because they're not able to absorb nutrition normally, a lot of them will need to have some kind of a feeding tube, like a gastrostomy tube or a gastrojejunostomy tube, depending on the situation. Typically it's a gastrostomy tube. And while we encourage them to eat by mouth, or to take formula or breast milk when they're infants, a lot of times they aren't able to process and absorb feeds normally like any other baby would. And so having a feeding tube, having the access straight into the stomach allows us to say administer some of their feeds in a more slow fashion so that they can have a more gradual way of absorbing their nutrition in what little bowel they have.
So, feeding methods are one important way that we manage these children. Other methods involve various medications that we can use for nutritional absorption. As well as managing what's called bacterial overgrowth. A lot of these babies because and young children, because there are bowel isn't functioning normally, they can get a lot of bowel dilation over time as well, depending on what kind of intestinal surgery they needed that, that got them into this short gut syndrome situation to begin with. They may need to be on oral antibiotics at fairly regular intervals to help control the overall amount of bacteria in their guts to help with that absorption. Some children are also candidates for medications that involve growth factors. So, that's another way that we can manage these children and try to get their intestine to adapt out of the shortgut environment. There are other medications we use to help with fluid production, hypergastronemia in the stomach and in other things that we can do but there's no one perfect thing that works.
And sometimes what may initially start to work on a child ends up not working so great. And we have to move things around. As far as the surgical options for these babies, there are very few specific criteria that they need to fit. Not every baby, just because they have a short length of intestine can actually be a surgical candidate.
The bowel needs to be fairly dilated, typically at least four to five centimeters in diameter in order to be candidates for various types of surgeries to either lengthen the bowel. And is there a sequential or step fashion as we call it or if it's very dilated and if their length is actually not too short if it's actually an okay length, but it's just very wide, then we can do, what's called a tapering, enteroplasty to help the bowel not be so dilated to help move the food contents through.
Host: And Dr. Taylor as we're talking about these types of treatments, help us to understand the importance of multidisciplinary care because you were mentioning a few different modalities and given the complexity and with increasingly complex treatment algorithms that add new options, really to your armamentarium of available therapies, speak about this approach, the multidisciplinary approach, and who's in charge of guiding patients care.
Dr. Taylor: It really is a multi-disciplinary approach that helps these kids do better and have improved outcomes. About 60% of pediatric patients who are listed for intestinal transplant are on that list because they have short bowel syndrome. And it's been shown with some studies looking at either regional groups of intestinal rehabilitation and intestinal failure programs, or even national international groups that if children are involved with these kinds of multidisciplinary care programs, that their outcomes are better, either their outcomes without needing an intestinal transplant or liver transplant are better.
And the liver transplant comes into play because these babies and children need the IV nutrition, the parenteral nutrition. That can cause problems with the liver over time. They either can do better for longer without ultimately needing IV nutrition or if they do end up going to transplant that their outcomes are better because they've been managed more appropriately with the various disciplines that are involved in these children's care.
So, surgeons like me, pediatric gastrologists, like Dr. Cheng also in our group are pharmacists. The neonatologists where a lot of these children will come from here at UF. We've got a core group of neonatologists from our NICU who are involved in the management of these patients, as well as neonatal and pediatric nutrition specialists.
Dr. Cheng: Yeah, I would add that Dr. Taylor we are doing a really good job in working together. A multi-disciplinary short bowel clinic. Most of the time we see patients together as a group and oftentimes, those patients and families not only have medical issues, but also have surgical problems, like a malfunctioning of the feeding tube, occlusion, or damage of the central lines, venous line. Or sometimes they have questions like whether I have an ongoing bowel obstruction, strictures versus stellations or not. So, in those cases, seeing patient separately it's not very helpful, I think that the team approach is really the best way to approach them with the best patient satisfaction.
Dr. Taylor: I agree, and it really allows to streamline their care and make things more efficient. So, they don't feel like they are being bounced around from clinic to clinic. They're seeing everybody in one place. And if I can also add too that we call ourselves in an intestinal rehabilitation program and it's a lot of times synonymous with intestinal failure programs. But I think that we really like to focus on the fact that we are trying to make the bowel adapt and rehabilitate it. You can almost say that it's a focus on the more positive aspects of things and what we're trying to do.
Dr. Cheng: I would also add in that diet is the foundation of all therapies. So, without the diet presently in the lumen, there will be no omtestomal adaptation to occur. I feel also our dietician play a critical role in managing this nutritionally disabling patient. They work together with us, to make sure patients start with right diet in the right time.
Host: Well thank you both. And I was going to ask you about the intestinal rehabilitation program at UF Health Shands Hospital and Dr. Cheng, if you would give us a little bit of a summary of the goals of that therapy. You just mentioned diet and certainly understanding each individual's remaining intestinal function is so important. How does that program work briefly if you would.
Dr. Cheng: Patients with short bowel, if you give sufficient time and support the bowel eventually become adapted and can wean off parenteral support. And without the need of even transplant. So, it's a time and otherwise required by the patient. So, our dietician play a big role and then food, feeding play a critical step. And so we have to initiate diet earlier, gradually as permitted based on the stool output. And then we will change according to the need and also oral feeding as early as possible because the combination of an enteral feeding together with oral feeding produce a greater adaptation and absorption than enteral feeds alone.
Host: And before wrap up, I'd like to give you each a chance for a final thought. So, Dr. Cheng first to you. Give us some strategies for successful outcomes and how the success of therapeutic interventions are working for you. Tell us a little bit about your outcomes at UF Health Shands Hospital.
Dr. Cheng: You know most of our patients right are now doing very well. And we manage more than 25 patients totally. And they only one patient, recently have a referral for transplant evaluations. Most of the patients doing well, on the enteral feeds and some already started on oral feeds, and then we are steadily weaning off the parenteral support. Our patients are in, in the process towards achieving, enteral autonomy. And so that's our goal.
Host: Dr. Taylor last word to you. Tell us a little bit about some future interventions, such as bowel lengthening procedures that could show promise. Tell us a little bit about what you would like referring providers to know about your program at UF Health Shands Hospital and when you feel it's important, they refer.
Dr. Taylor: Sure, I think when a provider has a concern about the absorption, about the weight gain, signs like diarrhea, failure to thrive based on a child's surgical history, or birth history that may have to do with a short length of intestine, or even a normal length of intestine, but acts like it is short gut, then that should be the time at which they should be referred to our program. It's been shown that, based on liver function and other nutritional parameters that the earlier these children get to these multi-disciplinary programs and the better they can do. I would also add that, along with just the assessment, we also work off of our collective knowledge and what we've done to help standardize care and make things more streamlined for these complicated patients that we've developed over the past couple of years, multiple guidelines for how we manage feeds, how we initiate feeds, when we decide to start certain medications to help with their overall outcomes. So, when we first meet a patient and if they haven't had surgery or even if they have, then we will probably do some imaging studies to see exactly what their bowel looks like to see if they would be a candidate for any kind of operative intervention.
Host: Thank you both so much for joining us today. To refer your patient, you can always visit UFhealth.org/pediatricsurgery for more information. Or to listen to more podcasts from our experts, please visit ufhealth.org/medmatters to get connected with one of our providers. That concludes today's episode of UF Health Med Ed Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs045.mp3
- DoctorsPetroze, Robin;Murray, Erin
- Featured SpeakerRobin Petroze, MD, MPH | Erin Murray, APRN
- Guest BioDr. Petroze is an assistant professor in the division of pediatric surgery and joined the UF faculty in 2018. She serves as the assistant chair of global surgery within the UF Department of Surgery and has a joint appointment in the UF Department of Environmental and Global Health.
Learn more about Robin Petroze, MD, MPH
Erin Murray, APRN, FNP, CHES, began her nursing career at UF Health in 2004 as a Certified Nursing Assistant then transitioned to the Pediatric Intensive Care Unit in 2006 after graduating with her nursing degree.
Learn more about Erin Murray, APRN - TranscriptionMelanie Cole (Host): Welcome to UF Health Med Ed Cast, with UF Health Shands Hospital. I'm Melanie Cole and today we're examining the role of bowel management programs in pediatric patients with colorectal conditions. Joining me is Dr. Robin Petroze. She's an Assistant Professor in Pediatric Surgery at the University of Florida College of Medicine and Erin Murray. She's an Advanced Practice Registered Nurse in the University of Florida Division of Pediatric Surgery. Thank you both so much for being here and Dr. Petroze, I'd like to start with you. Tell us some of the common conditions that you treat for children with colorectal conditions.
Robin Petroze, MD, MPH (Guest): So, Melanie, thank you so much for the invitation. And I think that this is a unique topic, for reaching out to some of our referring providers. A lot of people understand that pediatric surgeons treat conditions like Hirschsprung disease and anorectal malformations, but what they don't know is that we're also involved in lifelong management of these children because they do have issues with bowel management and to start, I'll define a little bit about what bowel management is. The easy way to think of it is a spectrum from constipation to incontinence. And so what we do with our kids with potty training, but it becomes a little bit more complicated when we have kids that have anatomic issues. The most common anatomic issue that we see in our bowel management clinic are anorectal malformations. These are things like imperforate anus that may or may not have a fistula. These kids often undergo surgery at an early age, sometimes as a single stage procedure to create an anus, if they weren't born with one, or to move the position, if it wasn't within the muscle complex or the sphincter complex. Many of these kids have associated anomalies, including anomalies that are cardiac, genetic, associated with the urinary system, et cetera. And many of them undergo a staged procedure and have an ostomy and later get their final corrective procedure.
These kids always have issues with constipation or incontinence. And I think one of the important things when I meet with families initially is really helping them to understand that we're building a relationship, to help their child as they grow and to really integrate, but they are going to have a little bit more of a challenge in managing their bowel movements.
The next patient population are those with Hirschsprung's disease, and this is a congenital aganglionosis, or the nerve cells that help send the signal to stimulate stooling for a portion of the rectum are not there. These kids also undergo corrective surgery that more commonly is done in a neonatal or infant period as compared to years ago, but they also can have issues with constipation as well as with something called enterocolitis. All kids with Hirschsprung's have about a 10% risk of having enterocolitis. And so having that connection with a team that really understands them, and the subtleties of their diets and bowel management and, you know, adding medications or other interventions to help them along is really important. Many centers also treat kids that have spina bifida or myelomeningocele, and other anatomic reasons.
And then we do see a certain number of kids that have functional constipation or have kind of a late onset constipation that really has just alluded the ability of the pediatrician and some of our gastroenterology colleagues that, that see us for more aggressive management.
Host: Thank you for that. So, Erin, help us to understand the role of bowel management programs in pediatric colorectal conditions as Dr. Petroze has just described, and while you're telling us about the program itself, tell us about the importance of reviewing the entire clinical history and performing the tests that you need to determine the type of malformation that the patient might have been born with and the potential for bowel control that the patient does have, or will have.
Erin Murray, APRN (Guest): I'm happy to do so. Bowel management was purposely conceived for children born with imperforate anus as Dr. Petroze had mentioned, but it really can be applied to all children with degrees of fecal incontinence or constipation, but it's very patient specific. We tend to run an intensive bowel management program over five to seven days with radiographic surveillance. Typically around the child three to four years old, when they express an interest in potty training or when their peers are out of diapers and they want to be the same. Our program is usually laxative or enema based. And your method depends on, determining a child's potential for bowel control that goes along with their associated diagnosis.
Your potential for bowel control, is usually per a predictive matter on if there is an associated fistula, if there is a presence of a sacrum, or if there's a presence of a tethered cord, there is a predictor for bowel control, such as the sensation of the anal canal, the sphincter control and the ability of the sphincter and the motility of the colon.
When we work up a new patient for bowel management program, we review their associated diagnosis and if they have a fistula associated. We start with a basic abdominal x-ray and then depending on their diagnosis, we may move to a contrast enema or other methods of imaging, such as a Sitz marker study or an anorectal manometry or even colonic motility testing. When we pick our program for a particular patient, once we determine if there is a presence of fistula and if this is true incontinence versus pseudo incontinence, then we consider the patient's potential for bowel control. And consider their predictor for bowel control as well. That guides us in terms of which imaging we're going to order and which therapy we're going to pursue, dwell enema therapy versus laxative therapy.
Host: What an interesting program that you are both doing there. So, Dr. Petroze, tell us about the various options, as Erin's just mentioned, a little bit about the medicational management. I'd like you to expand just briefly and then explore some of the surgical options that are available for pediatric patients with longstanding bowel management needs.
Dr. Petroze: Thank you, Melanie and I think it what Erin highlighted very well, is that, you know, this is really developing a relationship with the family and with the child. And it takes some time for us to get to know them and to really tailor the program to that individual child. And this is really important when we have new patients come to see us. Some of the patients that we see where we performed their initial infant or neonatal procedure, and we've been able to follow, we have some of that information. We've been able to counsel the family and get to know them and really explain the role of bowel management. For a lot of the kids that we see who come to us either a little bit later, or from another center, it really takes that initial exploration that Erin talked about to get to know them and what they had done.
A lot of these families are very frustrated when they come because their kids, you know, have had issues and seen multiple specialists and things that are working or not working. And so the most important diagnostic test as Erin kind of hinted that really is a good history and physical and finding out the details about what the family has been using in the past and what works. And there's a lot of subtle changes to tailor that to a child. And I do think that kind of starting from step one is some of the most important things that we do with these kids. But if they get to the point where that's not working, or they had a repair, they had surgical intervention elsewhere, there is a role for surgery in that initial intervention, just in doing an examination under anesthesia, in terms of looking at the tightness of the sphincter, where is the muscle complex of the anal sphincter located, are there other anatomic abnormalities? Is it a patient that never had a biopsy done to rule out Hirschsprung disease?
All of that is very valid. And I end up doing that in some of the initial kids, as kind of their first surgical exploration or even in some of the children who had repairs previously to make sure that there's not an anatomic reason and to help give us some diagnostic accuracy there. Then we get to the management stage. There were a couple things in the operating room, for Hirschsprung disease and some functional constipation that is useful. One of those is anal sphincter Botox which I tend to use both as a diagnostic modality, as well as a treatment modality to help with our bowel management program.
And this helps to relax the anal sphincter so that kids can really start from scratch when they're starting a bowel management program, if they have an impaired anal inhibitory reflex, or some tight anal sphincter, it helps that relaxation being there's also a social and psychosocial component to it. The next area where surgical management comes in, is really working with people like Erin, who are doing the day-to-day management with the parents on patients that have had a successful enema program, for example, to consider if they don't have the ability to control stooling on their own, do they need a way to do antegrade flushing, meaning to flush the colon from the other side, by creating an appendocostomy to me or a C-costomy.
And this really involves a lot of teaching with the families, and making sure that they have had a successful enama program to make sure that this will work. The goal for kids that don't have function on their own is to keep them clean during the day so that they can go to school, so that they can play, so that they can be as normal as they can be and find something that works for the parents.
Those are the most common things that we're doing from a surgical standpoint. When we get down to the kids that really don't have much tone at all, there are some that are eligible for sacral nerve stimulation and neuromodulation. If the nerves aren't quite firing, occasionally, you know, you can help that along. And these kids, it's really exciting to see a kid that doesn't have control that then does have control. That's a little bit more of a process in terms of really understanding what their past history of control or lack of was and kind of moving down the road for neuromodulation.
Host: So, before we wrap up, I'd like to give you each a chance for a final thought. But Erin, before we do that, as Dr. Petroze mentioned, the rectal flush and teaching families, I imagine this is really a very important part of your job, what are some of the things that you recommend to families that can be done to make it more comfortable? Because it can cause a lot of anxiety for both children and the families. And also while you're telling us some of the things your team does to go above and beyond, what about changes in diet? Have they been useful to these issues or in some cases counterproductive?
Erin: Great question, Melanie. Dwel enema therapy is a little scary. It's scary for the families. It's scary for the patients, if they've never done this before. Sometimes if we have new patients that are a bit older, and have had some sort of enema therapy in the past, they're not exactly excited to partake in another enema therapy program.
What makes dwell enema therapy different from you know, over the counter enema therapy is that it reaches higher in the colon and it's designed to empty the colon and produce a predictable bowel movement for the patient every day. Choosing an enema program versus a laxative program depends on those features that I mentioned earlier, what their potential for bowel control is. If a patient does not have any potential for bowel control and they are incontinent of feces, then they will most definitely require an enema therapy program.
If they have a good potential for bowel control, then they would be a good candidate for a laxative program. When a patient comes to see me to initiate dwell enema therapy program, in person I do this two ways. One way is we can do an in-person visit and I have some therapy model dolls that I let the kids play with and the parents as well. If they are from a distance and can't travel, oftentimes we will mail the supplies and have a Telemedicine visit to discuss how we're going to do this, to help relay some anxieties, and talking to the children and letting them put their hands on the equipment is very important for them to get comfortable and know that this is not going to hurt them.
Diet, incorporation of diet control is also important. We can use a combination of fiber and pectin supplementation for hypermotal colons to help slow things down. For kids with slow moving colons, there's really no special diet, but in anybody that has issues with constipation, we try to avoid constipating foods. We do have a registered dietician that works with us and is willing to discuss with patients and families, dietary measures to prevent constipation, foods that they can choose that would help the elimination process goes smoother for them.
Host: Dr. Petroze why don't you give us some final thoughts on what you see in the future for these patients, the importance of early referral and why you would like providers to refer to the program at UF Health Shands Hospital.
Dr. Petroze: So, I think that's one of the keys with bowel management and particularly in patients who have anatomic abnormalities, anorectal malformations, Hirschsprung disease, myelomeningoceles and spina bifida, is understanding and counseling those families early, that this is a lifelong commitment with their child to a bowel management program.
And that sounds scary initially, but I think what's important is the kids that we know early on and that we have ties to, is we think a little bit outside the box in terms of what is the anatomy, what are the associated malformations? I have the advantage of being able to see that anatomy on the kids that I operate on, that a pediatrician may not have, that adds something special to what we can offer as well as moving towards more aggressive therapies when needed including things like antegrade flushes and sacral nerve stimulation. I think that the key is that a lot of these kids have significant psycho-social trauma from stooling and elimination.
And the families do too. And so, it is a process and a relationship and really getting to know them and to build that trust. And so, the earlier we get to know them, the better it is for the family and for the kids. And we do have, as Erin mentioned, a lot of opportunities to do this through Telemedicine, since a lot of it is you know, related to conversation and that so, I think that dealing with stooling and elimination can be a challenge. And when we read the textbooks about some of these anatomic issues, we don't recognize the need for the lifelong management that these kids and these families have. And I find that the parents that are tied in early do have, they have an extra safety net and being able to reach out to us and especially to reach out to somebody like Erin, who has some of these tricks in her back pocket.
Host: Thank you both so much for joining us. What an informative episode that was. To refer your patient to the bowel management program at UF Health Shands Hospital, please visit UFhealth.org/pediatricsurgery for more information. You can also listen to more podcasts from our experts by visiting ufhealth.org/medmatters. That wraps up today's episode of UF Health Med Ed Cast with UF Health Shands Hospital. Please remember to download, subscribe, rate, and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs044.mp3
- DoctorsIslam, Saleem
- Featured SpeakerSaleem Islam, MD, MPH
- Guest BioSaleem Islam, M.D., M.P.H., is a professor of surgery and pediatrics and director of pediatric minimally invasive surgery in the University of Florida’s College of Medicine. He also is the associate medical director of the pediatric integrated care system (PediCare) in the department of pediatrics at UF and program director of the pediatric surgery fellowship program in the department of surgery at UF.
Learn more about Saleem Islam, MD, MPH - TranscriptionThe University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie: Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're examining neuromodulation for pediatric GI motility. Joining me is Dr. Saleem Islam. He's a professor and Chief of Pediatric Surgery at the University of Florida College of Medicine. Dr Islam, it's a pleasure to have you join us today. Can you start a little bit by telling us the role of the autonomic nervous system in controlling intestinal function for providers that may not really be up on all of that?
Dr Saleem Islam: Sure. It's actually a relatively new concept. We didn't think that the GI tract had either its own intrinsic nervous system or that the nervous system that we have, either the central or autonomic, exerted tremendous control over it. So this is something relatively new over the last maybe two to three decades.
And our understanding has continued to work with this. And it's now fairly well understood that there are many levels of control that the autonomic nervous system, which works below the level of consciousness and kind of just works behind the scenes and as the name suggests automatic in certain ways, it really affects the gastrointestinal tract from the top. If we smell food, we generally start to salivate, that's the autonomic nervous system, to the very bottom where when we're sleeping, we maintain control of our continence and we don't leak out fecal material while we're sleeping. So it really exerts its control from the top to the bottom.
Melanie: What an excellent explanation, Dr. Islam. Thank you. So why are gastrointestinal disorders notoriously difficult to diagnose? We know that functional and motility-related GI problems present with some common symptoms, but why is this a tough diagnosis, especially in children?
Dr Saleem Islam: Well, part of it, Melanie, is that it's not recognized very well. And it's not anyone's fault necessarily. These conditions are only now beginning to be understood. And when I say beginning to be understood, I really mean beginning. A lot of the conditions that we see are in fact termed as functional disorders, which is a nice way of seeing that we don't fully understand why these happen and functional disorders can affect the stomach, can affect the gallbladder and the colon or the large intestine.
And so these functional disorders are things that are very poorly understood in adults, much less in kids. And certainly, if you look at functional gastrointestinal disorders, whether it be gastroparesis, biliary dyskinesia or colonic inertia or what's sometimes called irritable bowel syndrome, they all are more prevalent in adults than in children.
And it's very unfortunate that when we look at the typical child who will present with these symptoms, it's going to be a teenage girl. And the unfortunate part is that it's typically in that patient population ascribed to psychological eating or other disorders, as opposed to likely what it is, is a hormonal pubertal effect that's being exerted on the autonomic nervous system, which is driving these issues. And that's why we see it most often in girls.
Melanie: That's fascinating. So now tell us a little bit about the role of neuromodulation in conditions that are affecting the GI tract. Tell us what it is, how it works, and really, while you're doing that, you can briefly say what has been available to children up until now and what's different now.
Dr Saleem Islam: Sure, Melanie. I mean, that's a great question as well. You know, neuromodulation is a technology that basically acts on nerves. And by doing so, it alters or modulates nerve activity by delivering electrical impulses to a specific target area. And depending upon which area is affected, it exerts different results.
People will most commonly associate neuromodulation when we attach it to the spinal cord for chronic pain issues or to the brain itself as in DBS or deep brain stimulation for Parkinson's disease and things like that.
When we talk about the gastrointestinal tract, however, we really are talking about two different things. And that is gastric electrical stimulation for gastroparesis or functional dyspepsia, which is the sensation of nausea, vomiting, bloating, getting full very quickly and pain after eating or for sacral nerve stimulation, which we use in patients who have a severe constipation with or without fecal incontinence, which is when you can't control the stool and you keep leaking stool out inadvertently. And so those are the two areas of neuromodulation where we use it in the gastrointestinal tract.
And the sacral nerve stimulation works on what's called the S3 or the third sacral nerve root. And from there, it acts on the autonomic nervous system to modulate that, and it actually helps both fecal incontinence and urinary incontinence. And it's used much more frequently in adults than it is in kids.
The gastric stimulator is attached to the stomach wall with leads. And then they're brought out to a device which is then implanted underneath the skin, and that sends constant impulses to the intrinsic gastric nervous system and the cells that are in there and causes the stomach to really start to feel better and to not send those impulse signals, which makes patients feel nauseated, et cetera. And so those are the two things that we've used.
Now, Melanie, you'd asked which of these is available for children. And I kind of have to say that there are no devices that are really developed for kids themselves. We really have to kind of take these devices off the shelf and use them in children in an off-label capacity, because obviously kids do get afflicted with these conditions. And even though the device manufacturer has not expressly made them for kids, we feel that kids deserve the care that all the adults get. And so we've used it and we've used it very successfully in these patients with great relief.
Melanie: Well then, doctor, is there an algorithm by which you're considering referral of patients for neuromodulation if it's not really in the general population? And you're using it in adults with great success, tell us a little bit about referral and when it can be used.
Dr Saleem Islam: So I'm a pediatric surgeon, of course. And I've used this device extensively in children. And if we talk about the gastric stimulator, for example, I've implanted about 154 of these in children. These are permanent devices. But our algorithm consists of, one, trying to do the best medical management that we have available for these functional dyspepsia or gastroparesis patients who frequently have other problems as well that effect the autonomic nervous system.
And once we maximize that and we don't get tremendous benefit, that's when we consider gastric stimulation. And we will do a trial of that gastric stimulation either by putting a special lead through the nose or a special lead through the stomach if they have a feeding tube that's been already implanted. We go through that site and we implant those leads and do a temporary trial for about five to greater than 10 days. And we make sure that that works for these patients.
We do actually an on and off trial in a blinded fashion so that the family, the child and the care team can be very sure that this works for them. We've done this in over 270 patients now, of which 150 eventually get implanted. And that's the largest experience for children in the world actually.
Melanie: And how have been your outcomes with those children that got the implanted neuromodulation?
Dr Saleem Islam: Sure. When we talk about gastric stimulators and the 150 that we've implanted, over long-term results, which have been over a decade now, we have seen really good responses. And 85% to 90% have had long-term success, meaning greater than five years of it continuing to work and provide relief. We see these patients consistently afterwards and they follow up in our clinics. And we monitor the device, we change the settings as needed and then of course, change the batteries, which is just explanting the device and putting a new one in when the battery gets depleted.
When we talk about sacral nerve stimulation, our experience is not as broad, but we've done about 20 patients in that. And when we look at other centers and combine all of our data with them, probably around 250 to 300 children have had sacral nerve stimulators implanted for fecal incontinence and severe constipation. And we've had great results with that. Again, we always do a temporary trial for those patients and we try for up to a month and make sure that this is something that'll work before we implant the device.
Melanie: What an informative episode this has been. As we wrap up, Dr. Islam, what would you like other providers to know about neuromodulation for pediatric GI motility disorders and when you feel it's important that they refer to you at UF Health Shands Hospital, as this is something that you are a leader in?
Dr Saleem Islam: I think that what I really would like the message is that if you have patients who have these chronic symptoms of a very severe nausea, vomiting, getting full very quickly or pain after eating, consider gastroparesis, consider those problems. And, in addition, we didn't talk about billary dyskinesia, which is the problem of the gallbladder, but we can help distinguish between those two and certainly we provide the long-term care for them.
There is an option available for them. These children don't have to suffer or just get a feeding tube and feel that is their life. We feel very strongly that this can really benefit and change their lives around to the point where they become tremendously productive members of society and can fulfill their potential, which we know is immense.
And similarly, I want providers not to feel that if a child has fecal incontinence, that their only ability to get treatment is to either suffer with diapers when they're adolescents or to just get enemas all the time or deal with laxatives of some kind. We do have options and we certainly want to explore them.
Melanie: That's really amazing. Dr. Islam, thank you so much for joining us and telling us about this exciting way to help these children. It's a complex condition and thank you again for joining us.
To refer your patient, you can call (352) 265-8800 or you can visit UFHealth.org/pediatricsurgery to learn more. And to listen to more podcasts from our experts, please visit UFHealth.org/medmatters.
That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please remember to download, subscribe, rate, and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs043.mp3
- DoctorsIslam, Saleem;Beasley, Genie
- Featured SpeakerSaleem Islam, MD, MPH | Genie Beasley, MD
- Guest BioSaleem Islam, M.D., M.P.H., is a professor of surgery and pediatrics and director of pediatric minimally invasive surgery in the University of Florida’s College of Medicine. He also is the associate medical director of the pediatric integrated care system (PediCare) in the department of pediatrics at UF and program director of the pediatric surgery fellowship program in the department of surgery at UF.
Learn more about Saleem Islam, MD, MPH
Genie Beasley, MD, attended medical school and completed her pediatric residency and pediatric gastroenterology fellowship at the University of Florida in Gainesville. She was the recipient of the Pediatric Resident Teacher of the Year Award in 2009, 2010 and 2019.
Learn more about Genie Beasley, MD - TranscriptionMelanie Cole (Host): Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole, and I invite you to listen as we discuss a multidisciplinary approach to pediatric inflammatory bowel disease. Joining me is Dr. Saleem Islam. He's a Professor and Chief of Pediatric Surgery at the University of Florida College of Medicine and Dr. Genie Beasley. She's an Associate Professor in Pediatric Gastroenterology at the University of Florida College of Medicine.
Doctors, thank you so much for joining us today. And Dr. Beasley, I'd like to start with you. Tell us a little bit about inflammatory bowel disease and explain how Crohn's and ulcerative colitis fit into this umbrella term. What's the differences between these two for other providers, please give a little differentiation.
Genie Beasley, MD (Guest): Sure. I'd be happy to. Well, this is a chronic lifelong condition, and it's always been my interest within the field of GI. It involves ulceration and bleeding from the gastrointestinal tract. And we see a lot of both in the pediatric GI world. I would say Crohn's has been more common in our practice. The difference between the two is that Crohn's involves inflammation anywhere in the gastrointestinal tract, anywhere from the mouth, small and large intestine out to the skin. And ulcerative colitis just involves inflammation of the colon. Really, one's not worse than the other, but sometimes the way we approach it, either with medication or surgical options can look different depending on what the diagnosis is.
And that's where our approach in our clinic is really important to kind of help flush out that diagnosis, to determine the next best step for each individual child. I would say that the disease can look really different from person to person. There's this wide range of how it can present from really mild disease to really severe and impairing disease. And I would say we see everything along the spectrum.
Host: Dr. Beasley, just expand a little bit, help us to appreciate and better understand the features and presentation for primary care providers and pediatricians that get these patients into their offices. This is a difficult diagnosis. It's not always easy to diagnose. So, tell us a little bit about red flags, things they might look for. And some serious complications. Parents are worried that it can stunt a child's growth. There are a lot of issues here with these particular conditions. So, speak about that a little bit.
Dr. Beasley: Sure that's a great point. Really inflammatory bowel disease can present in a number of different ways and usually it's the pediatrician that becomes suspicious of the diagnosis. So, it's really important that pediatricians and primary care doctors and emergency department doctors are aware of the different ways it can look. A quarter of people with inflammatory bowel disease present in pediatrics. So, it's actually quite common to present as a child or adolescent. It can look like anything from abdominal pain, diarrhea, and blood in the stool. So, those are the very apparent things that are easier to notice in which case those kinds of symptoms can be easily picked up and then referred to a gastroenterologist. But it can also be more insidious. Kids and teenagers can present with slowing down of their linear growth, that's their height or decrease or plateau of their weight gain.
It can also look like a delay in puberty. And so those kinds of things should be watched on growth charts at the pediatrician or primary care doctor's office. And so when we see slowdowns in that, that's a good reason to refer over to us in GI. It can also look like anemia and it can also look like more surgical problems, which I think we'll get into in just a little bit, such as abscesses around the bottom area. So, when a primary doctor or emergency department or urgent care doctor, sees things like anemia or stomach pain or diarrhea or height and weight problems, that that's where we need to be suspicious for this disease.
Host: Well, thank you for that. So, then Dr. Islam, create a framework for the standard and higher level of therapy for these children with inflammatory bowel diseases. And tell us the role of potential surgical management as we discuss this multidisciplinary team approach.
Saleem Islam, MD, MPH (Guest): Sure. I think that what Dr. Beasley has said is exactly right. It's a challenging disease to take care of. From a surgical perspective, when we look at these, we really divide them and the diagnosis is critical for us to ascertain what the best therapy will be. Now, ulcerative colitis allows us since it's really contained to the colon and the rectum, allows us to consider a potential quote unquote curative approach. And what we mean by that is that we can remove the colon and we can remove the rectum and then we can reinstill the continuity of the intestine so that the children can still have bowel movements through their normal anus by attaching the small intestine down there. That's called an ilial pouch anal anastamosis sometimes referred to as a J-pouch. So, for ulcerative colitis, we can really offer that as a potential curative approach with the understanding of course, that having a normal colon is way better than not having a colon.
For Crohn's disease, the surgical management is a bit more nuanced; 40 years ago, 50 years ago, we used to kind of really be aggressive surgically with Crohn's. And we hurt a lot of patients with that by removing so much intestine that they didn't have enough intestine to be able to absorb nutrients. So, we realized during the course of the last 40 years, or four decades that in fact aggressive surgical approach for Crohn's is the wrong thing. And we operate on children with Crohn's disease when they have a complication that requires to us do so. Dr. Beasley mentioned abscesses or fistulas. So, if those are there, we can certainly surgically manage those conditions. Then if there's a condition where there's a stricture, meaning that things have narrowed down to the point where they're causing a blockage, that's one where we need to operate. And then finally, there's perforation where there's a hole in the intestine. And so in those situations, we do require surgery for Crohn's. But again, it's very important for us to distinguish between Crohn's and ulcerative colitis.
Dr. Beasley: And I would add Dr. Islam that I think we do a great job working together. We've been doing our multidisciplinary clinic for eight years now. And when we have cases where the medical management that I'm trying to do in my clinic, looks like it's not working so well. We see the patients and the families in the room together as a group. And so that's where we start those really patient specific conversations about where we should go next and how surgery can play a role or how, you know, further changes to the medication management might be more important to do first. So, I think that team approach is really the best way to do this.
Dr. Islam: I agree with exactly what Dr. Beasley has said. I'd like to add that, in fact, we've really made it a multidisciplinary approach to managing these patients who are very complicated by including our specialists from radiology, pathology, psychology, nutrition, and other specialties as well in a truly multidisciplinary clinic, which allows us to help our patients in the most broad way possible.
Host: Well, thank you both for that and for telling us about this multidisciplinary approach for these increasingly complex treatment algorithms. And Dr. Beasley, you mentioned just briefly about medicational intervention. And that is the first line that you would try before this approach where Dr. Islam would consider surgical interventions. Speak just a little bit for other providers about some of the exciting medicational interventions for inflammatory bowel diseases that are out there today.
Dr. Beasley: Sure. And it looks like that list is growing. Probably our most common medicines we will use in the treatment of either Crohn's disease or ulcerative colitis are going to be Remicade, which is an infusion. And we have a pediatric infusion center where our patients go to get that under observation. And another similar medication is called Humira, which is a subcutaneous injection that families can administer at home. But outside of that, we have some of our newer medicines such as Stelara, which is an injectable medicine and Intivio, which is a newer infusion medication. And we combine that sometimes with different older oral medications. And sometimes we also combine that with special dietary treatments. The exciting news is that there's additional infusions and shots on the way. It seems like the last decade has been some good years for development of new medicines. So, as soon as new medicines are out on the market, we're pretty quick to get those available for our families.
Host: I'd like to give you each a chance for a final thought for other providers about this complex condition we're discussing today, the inflammatory bowel diseases. So, Dr. Islam, why don't you start? What would you like other providers to know about the multidisciplinary clinic at UF Health Shands Hospital? And really how you all approach this. Tell us a little bit about who's in charge of guiding patients' care and how this introduction of multimodality therapy and the involvement of multiple sub-specialists is really such a great way to work with these patients.
Dr. Islam: Absolutely. Like, Dr. Beasley mentioned, these are really complicated patients and in fact are getting more complicated as time goes on, which behooves us to really include all these specialists so that we can come up with a really well thought out and agreed on plan so that the care is not as siloed if you will. And our multidisciplinary clinic, allows us to do that by getting everybody's opinion and putting it all together and then getting agreement from everybody about what the treatment plan is going to be going forward. This allows us to really, when we tell the family the plan, they can feel comfortable in that all the specialists have weighed in and they all agree what's the best plan moving forward for these children.
And I think that Dr. Beasley should be really congratulated for leading this. She's the one who leads the team and arranges all these meetings and helps us come up with these plans. In the increasingly complex world of more powerful medications and biologics and newer algorithms that have been coming up, that's been really helpful for us. And our goal is the same. Our goal is to provide high-class care to these children who are really complex.
Dr. Beasley: lines, because this is a very unique kind of a set up in clinic. And I think something else that makes it unique is how we involve the patients and the families in the decision making. So, when Dr. Islam and I are talking together or talking with the rheumatologist with the family involved, you know, they hear the entire conversation. So, they're part of us talking out the option and they're part of the decision making process, which I think is important and unique to this disease too.
Host: And Dr. Beasley, as we finish up, what would you like other providers to know about when you feel it's important that they refer to this multidisciplinary clinic at UF Health Shands Hospital?
Dr. Beasley: Sure. I think, if any primary care provider just is suspicious about the diagnosis, sending them to us, we'll help us flush that out and look for it. The disease is progressive. Ulcerative colitis can involve more and more colon over time and Crohn's disease can progress to more surgical problems that Dr. Islam mentioned. So, if this suspicion is there, I think it's fair to perhaps do some basic blood tests, but really just to send to us because a lot of times a colonoscopy is what's needed. It's also good for providers out there to know that we're here to see complex second and third opinions if needed. So, we're always happy to weigh in. Sometimes the family wants to keep their hometown GI doctor, but just come here just to get our thoughts and recommendations. And we're happy to do that. And we enjoy working with other GI providers in the state as well.
Host: Thank you both so much for joining us today. What an interesting and informative episode this was. To learn more about our Pediatric Inflammatory Bowel Disease Program, call 352-273-9350 or visit UFHealth.org. That concludes today's episode of UF Health Med Ed Cast with UF Health Shands Hospital. Please remember to download, subscribe, rate, and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs042.mp3
- DoctorsArcher, Jeremy
- Featured SpeakerJeremy Archer, MD, MS, FAAP
- Guest BioJeremy Archer, MD, MS, FAAP, is board-certified in pediatric cardiology and pediatrics. He joined the UF Health Congenital Heart Center and UF Department of Pediatrics as an assistant professor of pediatric cardiology in August 2020.From 2013 to 2020, Dr. Archer was a pediatric cardiologist at the Billings Clinic in Montana, where he built a pediatric and fetal cardiology practice to serve a wide geographic region in Montana and northern Wyoming. He was the medical director of Pediatric Specialty Medicine, the director of the pediatric echocardiography laboratory and, from 2018 to 2020, the co-founder and co-director of the Pediatric Chest Wall Deformity Clinic. Dr. Archer received his medical degree from UF in Gainesville. He completed his pediatric residency from the University of Vermont in Burlington, where he served as chief resident. Following residency, he returned to UF to complete a pediatric cardiology fellowship, also earning a master’s degree in health outcomes and policy. Dr. Archer’s research has focused on the impact of congenital heart disease in premature infants, and the economic impact of the early detection of congenital heart disease in newborns. Dr. Archer’s clinical interests include developing regional practice systems, sports and exercise testing, fetal cardiology, pediatric chest wall abnormalities and medical education. He is a member of the AAP Section on Cardiology and Cardiac Surgery.
- TranscriptionMelanie Cole (Host): Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole, and I invite you to listen as we examine cardiac complications, sports, and return to play after COVID-19. Joining me is Dr. Jeremy Archer. He's a Clinical Assistant Professor in the Department of Pediatrics at the University of Florida. He practices at UF Health Shands Hospital and at the UF Health Congenital Heart Center in Gainesville, Florida. Dr. Archer, this is such a great topic. Thank you for joining us today. Can you clarify a little more between COVID infection and multi-system inflammatory syndrome or MISC and how it's affecting kids, while not very common. Tell us what you have been seeing.
Jeremy Archer, MD, MS, FAAP (Guest): Thanks Melanie. It's really great to be here. So, that's a great question. COVID-19 of course is the name of the virus and the infection that's caused this pandemic that's affected so many people over the last year and acute COVID-19 disease really refers to the direct effect of the virus on the body. And in both adults and in children, this can affect almost all the organs in the body, from the heart to the lungs, to the brain, to the kidneys and others.
Remember that in children, severe illness and death is much less common than in adults. Children are less severely affected. MISC or multi-system inflammatory syndrome in children is very similar, but it's actually a delayed response to the COVID-19 virus caused by the body's own immune system. And it's seen after infection, sometimes weeks or even longer after. It also affects all organs, but a little bit differently.
Host: Well, thank you for that. So, for other providers, how are patients presenting to primary care, maybe to their pediatricians. What are they seeing in clinic versus someone like you, a Pediatric Cardiologist? What are you seeing and how is this all different?
Dr. Archer: There's such a wide range of ways that patients can present with COVID-19 disease or MISC. The vast majority of children and even younger adolescents are either asymptomatic, meaning they discover they have COVID because a family member has it and they get it tested or somebody at school tests positive and they have to get tested, or they may be minimally symptomatic.
They may have mild cold symptoms, body aches, et cetera for a few days. So, these are the majority of patients that come in to see their pediatrician or primary care doctor. Some of them though, do have more prolonged disease or they may have symptoms that last for quite a while after the disease. They may be fatigued, they may be short of breath, et cetera.
So, those are the types of patients that are coming in to the primary care office. In the Cardiologist Office, we are tending to see the patients who were hospitalized with COVID, who may have actually had MISC. And we're seeing people with persistent symptoms, in particular cardiac symptoms, like chest pain, shortness of breath, et cetera.
Host: Well, then speak a little bit about once diagnosed, give us some EKG or echo cardiologist recommendations for imaging after a child tests positive Dr. Archer. What is the recommended evaluation like?
Dr. Archer: So that's a great question. And after a child tests positive, they really should always start with their primary care physician or other provider. Primary care doctor, pediatrician is the linchpin of post COVID care as they really are of any aspect of pediatric care. And so they are the ones who helps determine if the child needs to see a cardiologist.
That'll generally be if the duration of symptomatic illness was more than about four days, if there's cardiac symptoms or if they were hospitalized for COVID. If they do see a cardiologist, the cardiologists will generally start with an electrocardiogram, an echocardiogram and a troponin level to look for inflammation in the cells of the heart. And then they'll kind of determine if more testing like an MRI and exercise test needs to be done.
Host: Is there any difference with asymptomatic versus symptomatic or age related over under 12? Are there any differences in that evaluation you just spoke about?
Dr. Archer: There's quite a bit of difference. So, the kids who are asymptomatic truly asymptomatic, or if they had mild disease lasting less than four days, they really do not need to see a cardiologist. Those children based on all the published guidelines so far, can be cleared for return to activity by their primary care doctors.
And they ideally would follow a kind of graded return to play protocol, which we'll talk about later, but they don't need excessive testing. They don't need an echocardiogram and electrocardiogram. Whereas the children who are symptomatic, who had symptoms during their disease lasting four days or more, or if they have ongoing cardiac symptoms, those are the folks that need to see a cardiologist.
Those are the folks that are a little bit more risk. Now, the age of 12 is a rough guide to when most children have entered adolescence and the level of sports is more intense. So, we tend to screen those children a little more rigorously, both in terms of COVID and in terms of general sports screening. At this point, it's really important that nobody knows the exact risks of COVID in any age group. So, we're using data from other conditions that we screen for with sports and extrapolating them to COVID.
Host: Such an interesting topic we are discussing here today, Dr. Archer. And while we're discussing all of this, tell us about some of the available therapies and evaluation and one thing I find so interesting is this multidisciplinary approach for these children. So, when you're dealing with primary care providers and cardiologists and respiratory therapists and anyone else who was involved, tell us how that works, how you all work together and really who's in charge of the child's condition.
Dr. Archer: So that's a great question. It can be really complicated as you're pointing out to take care of children with issues with in many different organ systems. In the hospital, for the rare child who's hospitalized with COVID, the hospital pediatrician or pediatric intensive care doctors, are generally in charge, they're coordinating the care.
If the manifestation of the disease is primarily cardiac, the cardiology team will take a larger role. If it's primarily pulmonary, the pulmonary team will take a larger role, but they're really coordinating that. And that's mirrored on the outpatient side. This is a multiorgan disease. So, the pediatrician, the primary care physician is at the helm as they really are and should be with any complicated patient. So, they are making the referrals. They're gathering the referral information. They're ultimately the one that's going to closely follow the patient. And again, if there's a specialist that needs to be involved in a more significant way, they will be involved, but really the pediatrician is coordinating the care here.
Host: Well, thank you for that. So, now let's talk about return to play after COVID-19. Once cleared, how does an athlete get back to play? Apply for us the latest guidelines for return to play after COVID-19 and please place return to play in a broader context of sports pre-participation evaluations.
Dr. Archer: Yeah, absolutely. So, the bottom line is that we're trying to keep kids safe here. And there are a handful of conditions that can cause children and adolescents to collapse or die during sports. We obviously want to avoid that. And for any given child, that risk is very low, but of course, for children who are at risk and where this might be prevented that's the whole reason we have a sports screening infrastructure and program. That's why we do sports physicals. That's why they do screening EKGs universally in some countries in Europe. So, we have knowledge and lessons from this infrastructure from decades of experience with sports screening. Even though we don't know a lot about COVID yet, because it's just too new, we're able to apply that experience and that knowledge and come up with what's a pretty rational screening program for COVID. And so both the primary care physicians and the cardiologists have about seven or eight different published guidelines now to look at. On the one end of the spectrum, the asymptomatic child who tested positive can return to play in as few as 10 to 14 days after infection. On the other end of the spectrum, the child with myocarditis, either ongoing heart inflammation or fibrosis evidence of scarring in their heart, might need to wait six or more months to return to play and have repeated MRIs, exercise tests, et cetera. Once they get cleared to return to play, there's generally a graded progression that is recommended that children follow.
And this can be as little as a one week progression where they start out with maybe walking or light jogging for15 minutes, where they can carry on a conversation easily. If they feel fine, they might progress to 30 minutes of moderate exercise and so forth. For the children, who've had more severe disease, this is a more prolonged return to play and it might actually involve formal cardiopulmonary rehab services.
Host: Dr. Archer, as we wrap up. And due to the lack of evidence about cardiac injury from COVID, I mean, we're still learning so much, right? So, this isn't that common, relatively low number of pediatric cases. However, it's quite important as it is obviously to parents and to providers; so please wrap it up for us with your recommendations that are from your expert opinion in the cardiology department.
Dr. Archer: Sure. I think some of this is going to sound like a broken record to folks, but it's important and it bears repeating every time we talk about COVID. People should be wearing a mask. Everybody who's eligible, should be getting a vaccine. Most children are not eligible for a vaccine because they haven't been tested and approved in children.
So, adults should be getting vaccines to protect themselves and children. People should maintain a social distance from each other. People should stay home when they're sick. And if your child has had COVID make sure you talk to their doctor, for guidance about what to do to get them back to activity, to make sure they're safe. And the one thing I'd like for other physicians and providers to know about referral is that this is a complex disease. We're learning more all the time. So, if you're seeing a patient you're not comfortable with, or you're seeing a patient who's been hospitalized for COVID, call the pediatric cardiologist for advice or send the patient to us, and we'll be happy to work with you to take care of that patient in the best way we can.
Host: Such an interesting topic, Dr. Archer, thank you so much. I hope that you'll come back on as we're learning more and more, please come back on and update us once you get more information. To refer your patient, or to learn more about pediatric cardiology at UF Health Shands Hospital, please visit UFhealth.org/chc. Or you can call (352) 273-7770. Or to listen to more podcasts from our experts, you can always visit UFhealth.org/medmatters. That concludes today's episode of UF Health Med Ed Cast with UF Health Shands Hospital. Please remember to download, subscribe, rate, and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs041.mp3
- DoctorsCampbell, Kevin
- Featured SpeakerKevin Campbell, MD
- Guest BioKevin J. Campbell, MD, is urologist specializing in male reproductive medicine and surgery. Dr. Campbell began his medical education with medical school at LSU Health Sciences Center in Shreveport, Louisiana. He then completed his urology residency at University of Florida in Gainesville, Florida. Following residency, Dr. Campbell underwent fellowship training at Baylor College of Medicine in Houston, Texas. His clinical interests include male factor infertility, erectile dysfunction, sexual medicine, Peyronie’s disease and testosterone management.
- TranscriptionThe University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole: Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole, and I invite you to listen as we examine male infertility. Joining me is Dr. Kevin Campbell. He's an assistant professor at the University of Florida Department of Urology.
Dr. Campbell, it's a pleasure to have you join us today. So tell us a little bit about what you're seeing in the trends and how common infertility in males really is.
Dr. Kevin Campbell: Hi, Melanie. First of all, I wanted to thank you for having me on the podcast. I'm really excited to have the opportunity to be here as well as to discuss a portion of healthcare that I'm really passionate about, and that being men's health and fertility. So getting into a little bit of background on male fertility and the trends, evaluation of fertility in men, it's often a multi-step process for clinicians and patients alike. And infertility can affect approximately 15% of couples who are attempting to conceive.
And when we look at the male factor and how that attributes to these statistics, approximately 50% of infertile relationships have a factor coming from or stemming from the man. Thirty percent of couples have a significant male factor alone and then another 20 combined with male and female factors.
And you may ask, "Well, how do we define infertility?" And I would say infertility is really considered to exist after 12 months of attempted conception without contraception. And so this consideration is in the setting that pregnancy rates by intercourse in couples are approximately 20% to 25% per month and 90% at a year.
So a male who comes in for an infertility workup should be evaluated with the goal of identifying reversible conditions, which can improve a man's fertility as well as irreversible conditions that can relegate candidates to assisted reproductive techniques or identify non-treatable genetic causes. So those was patients with irreversible conditions not amenable to reproductive therapies can also be appropriately counseled.
So currently, it's estimated that approximately 7.3 million couples seek infertility care annually in the United States. So it's certainly on the rise. And although the use of assisted reproductive technology has steadily increased and currently contributes to about 1.4%, 1.5% of all births in the US, the number of male reproductive procedures performed is on the decline. So that's something that we're really looking at in the field of men's health and men's fertility.
Melanie Cole: Well, thank you for that. So tell us a little bit about the evaluation and the initial steps in the workup of male infertility. What tests do you typically run? Who runs them? Tell us a little bit about how that works.
Dr. Kevin Campbell: Certainly, I'd be happy to. So the initial steps in the workup and evaluation of male fertility can really be broken up into a three-part approach. And this is often geared at trying to find the main cause, which can be from a production of too few sperm to fertilize an egg, making sperm that aren't shaped properly or don't move the way that they should or even having a blockage in the reproductive tract that keeps the sperm from getting out.
So the first of these approaches as with many aspects of medicine is a comprehensive history and physical. The evaluation of the history really is structured to uncover all potential causes, including congenital, medical, surgical, environmental, genetic, and even psychosocial etiologies that can be contributing to a couple's inability to achieve a pregnancy.
And really the workup requires assessment of each partner with an appreciation by the physician of the sensitive and anxiety-provoking nature of the process, because you're really delving into the more personal aspects of a patient's healthcare. The interview and the history revolves around relevant, past medical and surgical histories, even those from childhood. So reports of genitourinary anomalies, reconstructive surgery and so forth can really prove important.
So in utero childhood exposures to chemotherapies, radiations, hormones can result in defects in sperm production, and even cryptorchidism and delay in its treatment can be associated with testicular failure, surgery for testicular torsion or pediatric hernia repair can similarly affect future paternity.
So during this workup, we discuss a couple of sexual behavior as commonly there's misconceptions regarding the optimum timing and frequency of intercourse. Often it's not appreciated that semen parameters peak after two to four days of abstinence, but waiting longer than this can actually result in poor sperm quality. So to optimize fertilization rates, intercourse should be performed every other day, beginning about five days expected before ovulation and up to five days afterwards.
So once we get a good history, we then move on to the physical exam, which can give us key information about the patient's overall wellbeing. So this involves the general appearance of the patient and their body habitus and progresses to a genital exam in which the testicles are examined for size, consistency, and location. So depending on the testicular size, their consistency, this can indicate impaired spermatogenesis as normal sperm-producing seminiferous tubules that make up the testicle make up about 85% of that volume.
So also if you have high-riding testicles or their location's in close proximity to the thighs, this can produce insufficient temperatures, which normally is around two degrees Fahrenheit or less between the body and scrotal contents. And that can decrease the amount of sperm production that we normally see. So that's the first part of the workup.
The second part is really looking at the hormonal evaluation of the patient. This tests the hypothalamic-pituitary-testicular axis. So endocrine causes of male fertility are present in less than 3% of cases, but they can be really devastating if they're missed. So the initial hormone assessment should include an evaluation of the FSH, which is the serum follicle-stimulating hormone, which causes your testicles to secrete and produce sperm and testosterone, which is drawn in the morning because testosterone has a well-described diurnal variation throughout the day. Then a more comprehensive evaluation includes the luteinizing hormone, prolactin, estradiol, free testosterone, and even the sex hormone binding globulin. And these can be obtained when abnormalities are present in the initial evaluation.
So lastly, the third part of this in the male workup for fertility is the semen analysis. It's the cornerstone laboratory evaluation in the male undergoing an infertility workup and it really can't be understated. So at minimum, we have two to three semen analyses that should be obtained, and these should be maintained with a similar duration of abstinence for consistency.
The ideal abstinence period is two to four days as we previously said. And shorter periods can affect concentration, whereas longer periods may actually affect the motility of the sperm. And we often evaluate the semen for several key parameters, including the volume of the ejaculate, the concentration of the sperm, motility and morphology among others. And these are based on reference ranges that are set out by the World Health Organization as recently as 2010.
Melanie Cole: Well then, Dr. Campbell, explore for us the medical therapies that could be offered to men to optimize fertility. Please speak about kind of the order that you would do this non-surgical first and then the surgical options that might be available.
Dr. Kevin Campbell: Certainly. There exists a diverse variety of medical options that can be used to augment or induce male fertility. And these agents have to really be selected with the patient's medical history, goals of care and etiology of infertility in mind. So one of these is the anti-estrogen group of medications. Anti-estrogen therapy has been popular due to its safety, its low cost and ease of administration. These are agents like clomiphene or Tamoxifen, which are estrogen receptor modulators, and they have a predominant antagonist activity that blocks negative feedback exerted by estrogens on the hypothalamus and the anterior pituitary. So this results in increased pituitary gonadotropin production, which is the LH and FSH that can both stimulate testicular production of testosterone and spermatogenesis.
Next, we have the gonadotropins, which in many cases of hypogonadotropic hypogonadal men, spermatogenesis can be restored with this hypogonadal gonadotropin therapy. Men can be addressed with agents such as luteinizing hormone or follicle-stimulating hormone. And this acts on the pituitary axis to increase the sperm production in a natural fashion.
So let's say we start with hCG, which is a luteinizing hormone analog. We will often combine this with clomiphene and, after six months of hCG therapy and clomiphene, if no sperms detected, then we'll supplement treatment with FSH and this regimen can take anywhere from six months to two years to achieve its maximum effect on sperm production. And so then we see the sperm count start to rise during that time.
Additionally, there's aromatase inhibitors, which decrease the conversion of androgens to estrogens and that increases serum androgen levels. So the mechanism of increasing testosterone is likely by decreasing that feedback inhibition on the pituitary and hypothalamus. And this affects greater gonadotropin release. So administration of aromatase inhibitors, such as anastrozole restores the testosterone to estrogen ratio to normal, and this has been suggested to significantly increase and improve semen parameters in oligospermic men, including sperm concentration and motility.
Now, if the man has a prolactin-secreting pituitary macro or microadenoma that's been identified, then medical treatment with a dopamine agonist is indicated. So this would be something like cabergoline, which would be taken twice weekly. That's the preferred agent because it's got a high efficacy in normalizing prolactin levels, and then shrinking the prolactin-secreting tumor and reversal of infertility with dopamine agonist therapy occurs in 53% of cases.
And lastly, we also have antioxidant therapy, which infertile men have higher levels of seminal-reactive oxygen species than fertile men in their semen. And high levels of these reactive oxygen species are associated with sperm dysfunction, sperm DNA damage, and reduced male reproductive potential. So this observation has led clinicians to treat infertile men with antioxidant supplements, which can be taken orally or on a daily basis.
Melanie Cole: That was very comprehensive, Dr. Campbell. So for other providers, one underappreciated psychosocial aspect is that both members of the couple need to be involved in the assessment and discussion of the results. Tell us a little bit about the importance of this.
Dr. Kevin Campbell: Certainly. I'd be happy to. So, this is really a dive into a patient's most intimate and oftentimes private aspects of their life. And when we get to see a patient for their fertility issues, it's really a privilege because we're trying to help them conceive and bear a child. And so this isn't an effort that's often undertaken just by one individual. It's the couple. And so if we're able to see the male and the female together and start the work up together, we often have better results because of the communication as well as the followup and achieving a patient's goals.
Also, this conversation that we have can be very important because not all men and women together and couples will be able to have a biologic child without the assistance of assisted reproductive therapy. So goals of care can be important if we're talking about doing something like in vitro fertilization, intrauterine inception, or trying to undergo certain procedures to assist with sperm retrievals. So I really encourage all patients to be evaluated on a couple basis.
Melanie Cole: As we wrap up, Dr. Campbell, what's exciting in your field? Tell us about some recent advances in assisted reproductive technology or techniques in IVF. And what would you like to summarize for other providers and other urologists and healthcare providers? What would you like them to know about treating male infertility and when you feel it's important that they refer to the specialists at UF Health Shands Hospital?
Dr. Kevin Campbell: Certainly. So some of the most exciting options in the treatment of male fertility that I've been part of and able to take part in are largely diagnostic or aimed at those improving sperm production, improving sperm delivery or providing sperm for assisted reproductive therapies. And this would be things such as in-office testicular aspirations, which can be largely diagnostic, but they can be performed in post-vasectomy patients or on those on testosterone therapy to confirm sperm production. And so that can help differentiate between either an obstructive or nonobstructive cause of fertility and also gear us towards our next step, which may be a testicular biopsy to obtain tissue in order for a patient to undergo IVF or a reversible cause of fertility, such as epididymal obstruction, in which case we can do what's called an epididymovasostomy and bypass that obstruction.
So additionally, we're starting to see a lot of improvement in patients following varicocele repairs. Now, varicocele are varicose veins in the scrotum and the most common procedure performed to improve sperm production is a varicocele repair. Common approaches can be inguinal or subinguinal, and so it's like a hernia repair as far as that approach. And we use a microscope to identify these varicose veins and ligate them in an ambulatory surgery setting.
So looking at the data and meta-analysis looking at randomized trials, almost 30 of them shows that the overall pregnancy rate after a varicocele repair was 39%. And this is fantastic looking at men who 80% of which have shown improvements in their sperm concentration and then 72% of which had improvements in sperm motility. And additionally, we see increases in serum testosterone afterwards.
So techniques to provide sperm for assisted reproductive therapy are certainly in the forefront of our goals of care, because we're excited to be able to offer this to patients over at the University of Florida. And so it's not just all men and women going to assisted reproductive therapies or IVF, but oftentimes we can restore that fertility potential that a couple may have thought that they didn't have to begin with.
Melanie Cole: What great information. And it's such an interesting and ongoing topic. Dr. Campbell, thank you so much for joining us today. To refer your patient or to listen to more podcasts from our experts, please visit ufhealth.org/medmatters for more information and to get connected with one of our providers.
That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
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