UF Health Shands Hospital

Colorectal Cancer in Young Adults

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Audio Fileuf_health_shands/ufhs040.mp3
DoctorsRamnaraign, Brian
Featured SpeakerBrian Ramnaraign, MD
Guest BioBrian Ramnaraign, MD is an assistant professor of medicine in the division of hematology and oncology at the University of Florida College of Medicine.

Learn more about Brian Ramnaraign, MD
TranscriptionMelanie Cole (Host): Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole and join us as we examine colorectal cancer in young adults.

Joining me is Dr. Brian Ramnaraign. He's an Assistant Professor of Medicine in the Division of Medical Oncology at the University of Florida. Dr. Ramnaraign, it's a pleasure to have you join us today. Just start with by telling us a little bit about the prevalence of colon cancer in young adults. What do you see in the trends as far as that?

Brian Ramnaraign, MD (Guest): Sure Melanie and thanks for having me. So, colorectal cancer is actually much more common in older patients. However, since the 1990s at the very least, older patients have actually had decreasing rates of colon cancer. The numbers are actually going down, but in the younger population specifically in those under the age of 50, the rates are going up. And In fact, it is increasing at about 2% per year, the number of cases of colorectal cancer in this age group. So, it's definitely something we're very concerned about and something that we really want to shed more light onto.

Host: Why do you think that this is happening? And while you're telling us that, tell us some of the risk factors you can identify.

Dr. Ramnaraign: So, no one knows for sure exactly why the incidence of colorectal cancer is increasing in the under age 50 age group. But we do know that some of the risk factors for colorectal cancer have been getting worse, especially in younger patients. With regards to the risk factors for colorectal cancer, one of the big factors is genetic risk. However, that of course has been stable, over the decades, and that really only constitutes about 10 to 20% of the cases of early onset colorectal cancer. The most common genetic syndromes are Lynch syndrome or a FAP, familial adenomatous polyposis.

With regards to the actual risk factors that are, that are more common that we look out for; there are risks with regards to diet, risk with regards to weight, specifically a sedentary lifestyle. It gives you an increased risk of colorectal cancer and smoking. What we do see are increasing rates of obesity in this country, especially in younger patients, and a poor diet, a diet that lacks high fiber foods, a diet that is heavy in red meat are both risk factors that are going up and are seen in a younger patients, and may play a role in why these patients have higher rates of colorectal cancer.

Host: So, Doctor, we know that we have screening protocols from the US Preventative Services Task Force and other organizations, as far as screening for colorectal cancer in those 50 and older. I know myself, I've had many colonoscopies, but for young adults, what would indicate the need for screening? Are there symptoms that you've had patients come across? Is it just based on genetics? Tell us a little bit about clinical indications for screening colonoscopy in young adults.

Dr. Ramnaraign: Sure. So, anyone who's age 45, at average risk, should begin getting regular colonoscopies. Now the question is who should get a colonoscopy sooner.

Of course, if you do have some complaints, specifically blood in your stool, a change in your bowel movements, if you have abdominal pain; these could be symptoms of colorectal cancer and are definitely symptoms that you should bring up to your right primary care provider. However, these symptoms are very vague and non-specific, and could be you know for example, related more towards hemorrhoids, but they are definitely symptoms that shouldn't be ignored. And if these symptoms do persist, of course, a colonoscopy may be needed irrespective of how old the patient is. Of course, whenever a patient is seen in their primary clinic with their PCP, a thorough history, a family history, is needed. And if the patient has a first degree relative, so, that is you know mother or father, brother, sister, they should begin screening for colorectal cancer 10 years before that patient was diagnosed with their colorectal cancer or by age 40, whichever comes first.

With regards to the treatment for colorectal cancer, everyone is familiar with chemotherapy and the toxicities of chemotherapy, but here at the University of Florida Health Cancer Center, we're looking at other new options and investigational agents to tackle this disease. A lot of patients are interested in immunotherapy. And immunotherapy is actually a very good treatment option for patients. Right now, immunotherapy is approved by the FDA for the treatment of colorectal cancer, but that's only if a patient has a particular set of mutations that would predict a response. And we refer to these mutations as the microsatellite stability status or the mismatch repair deficiency status.

And patients who are microsatellite unstable or mismatch repair deficient, which really only account for 5% of these patients, are the ones who are eligible for immunotherapy. However, here at the University of Florida Health Cancer Center, we're looking at ways we can enhance the patient's immune system so that they can better benefit from immunotherapy. Studies are ongoing looking at clinical trials at this right now. We're also sending off patients' biopsies and tissues for next generation sequencing where we can look for specific targeted mutations that we can potentially target with specific drugs that bind to or block proteins from genes that may or may not be expressed in that particular patient, based on their genomic profile.

Host: So, now let's talk about treatments. Once you have diagnosed a younger person with colon cancer, what are some of the treatment options? Tell us a little bit about the difference that you might find between treating somebody younger versus treating someone older.

Dr. Ramnaraign: So, what we have noticed too, with younger patients with colorectal cancer is that a lot of them are presenting at more advanced stages. And this is probably because a lot of their symptoms are going ignored and are taken for more common things like hemorrhoids. With regards to treatment options, regardless of how old the patient is, it's usually a combination of surgery, chemotherapy or radiation therapy. When we discover that the patient has colorectal cancer, which is usually on biopsy of a tumor that's found in the colon or rectum, staging procedures are done. Staging images are done with CAT scans, commonly. If it is a very early tumor which is the whole point of getting screening colonoscopies; then surgery and only surgery is needed. However, if the tumor is more advanced, meaning that there's deeper invasion into the colorectal tract or if there's any suspicious lymph nodes that we see on imaging; the patient may need chemotherapy and radiation in addition to surgery.

And unfortunately, a lot of these patients are presenting with stage four disease and stage four means that the cancer has spread to distant organs or distant sites. If that is discovered, then the only treatment that we have is chemotherapy, and that's palliative chemotherapy. Chemotherapy meant to slow the growth of the tumor, of the cancer and to potentially give the patient more life expectancy than they otherwise would have. But once the tumor is stage four, chance of cure is low.

Host: Wow. That's quite a statistic. So, tell us a little bit about prognosis, if it's not stage four and also for some younger people as primary care providers and other gastroenterologists are working with these patients, fertility preservation may come up depending on the treatment regimen and how young they are. So, kind of tie a lot of this together for us as far as what you would like other providers to counsel their patients about when going through these kinds of treatments and diagnosis.

Dr. Ramnaraign: I think the most important thing for primary care providers and even gastroenterologists, when they see younger patients is to encourage healthy living, encourage your patients to have a diet that's rich in fresh fruits, vegetables, high fiber and of course limit the red meat intake. And for our patients who are overweight to encourage weight loss and even maybe refer them to a nutritionist or a dietician to help with such things. When it comes to treating the disease, and what the prognosis actually is; the lower the stage, the better the chances of cure and the better the chances of long-term remission. Staging in colorectal cancer, like other solid tumors, ranges from stage one, two, three, and four. Four, as I mentioned, I as someone who has a metastatic disease. Disease that has spread to other organs and distance sites.

Stage three is commonly when the tumor has spread to the lymph nodes and with rectal cancer, we can determine that based on getting a rectal MRI before surgery, however, with colon cancer, usually we have to wait until the patient has had their surgery in order to determine the lymph node involvement. And then stage one and two colorectal cancer is a tumor that is just limited to the gastrointestinal tract and it hasn't invaded into other lymph nodes or organs.

Host: So as a summary, Dr. Ramnaraign, tell other providers what you'd like them to know about patients, younger patients with colorectal cancer, and when you feel it's important that they refer to the specialists at UF Health Shands Hospital.

Dr. Ramnaraign: I think the most important thing for providers to know is that the incidence of colorectal cancer in this age group is increasing and is increasing at an incidence at about 2% increase per year. With regards, to the symptoms that could be explained by colorectal cancer, such as a blood in the stool, a change in bowel movements, abdominal pain or the discovery of iron deficiency anemia, shouldn't be ignored and these patients should be considered for a colonoscopy, if other more common things like hemorrhoids are excluded. Providers should also know that the recommendation to begin screening colonoscopies for the average risk patient is now at age 45, not at age 50 anymore.

So, your patients who are younger 45 should be considered for a screening colonoscopy. As well, it's always best to catch these cancers as soon as possible because the sooner we catch it, the more the likelihood of a cure is, and the better the outcomes with less need for potentially toxic therapy such as radiation therapy and chemotherapy. Providers of course, should always counsel their patients on living an active and healthy lifestyle. And as I mentioned, weight, diet, encouraging exercises are all very important things, right? In addition to smoking cessation if your patients are active smokers.

Host: What great advice in such an interesting topic that we examined here today. Thank you so much, Doctor, for joining us. And 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 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/

Is Your Challenging Epilepsy Patient a Candidate for Stereo-Electroencephalography (SEEG)

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Audio Fileuf_health_shands/ufhs039.mp3
DoctorsKalamangalam, Giridhar
Featured SpeakerGiridhar Kalamangalam, MD
Guest BioGiridhar Kalamangalam, MD, DPhil, is a Wilder Family endowed professor and the Division Chief of Epilepsy at the UF College of Medicine and he practices at UF Health Shands hospital.

Learn more about Giridhar Kalamangalam, MD
TranscriptionMelanie Cole: Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole and I invite you to listen as we ask the question is your challenging epilepsy patient a candidate for stereoelectroencephalography?

Joining me is Dr. Giridhar Kalamangalam. He's a Wilder Family-endowed professor and Division Chief of Epilepsy at the UF College of Medicine and he practices at UF Health Shands Hospital. Doctor, it is a pleasure to have you join us today. So tell us a little bit about the prevalence of epilepsy in the general population and how really surgical indications have evolved over time to encompass a wider variety of epilepsy types and applying surgery to more patients that have medically refractory epilepsy.

Dr. Giridhar Kalamangalam: Good morning, Melanie. Yes, epilepsy affects about one in 200 people on the whole, all across the world. There are some changes depending on which part of the world you're exactly in, but that's a reasonably accurate figure. Now, while that proportion might not seem much, you just have to compute that percentage over, say, the population of the state of Florida. And then you realize the numbers of patients that are in this state. There are tens, in fact, hundreds of thousands of patients with epilepsy.

Over the years, treatments have evolved. The condition of epilepsy, of course, has been recognized since antiquity. This was a Hippocrates' sacred disease after all. And treatments have evolved such that, in today's day, we can treat most epilepsy patients satisfactorily after a good diagnosis, an accurate diagnosis, has been made in about 60%, maybe 70% of patients. That is a large proportion, but again, considering the numbers of epilepsy patients there are, even a small proportion, like 20%, 30%, 35% of patients who don't do that well with standard medications require more advanced treatments. And these are the patients that we call refractory patients, refractory because they don't respond satisfactorily or sufficiently to first-line medications.

And this population has been recognized also for a very long time. And indeed, the challenges of epilepsy management largely have to do with trying to help this 30%, 35%, 40% of patients on the whole. And a very important treatment for these patients is some kind of surgery.

Epilepsy surgery used to be thought of as some operation on the brain for epilepsy. And that in fact is true, but it's not the whole truth. These days, we have a large, really quite a menu of options available for patients who don't get satisfactory control of their seizures with medications. And those are the patients we deem surgical candidates. And in a center like ours, for instance, we see large numbers of such patients because these patients are referred in from the community.

And the options, the surgical options, for patients have really increased over the past couple of decades and especially in the past 10 years or so has really dramatically increased to include several novel options, all of which are available at our center. So these patients have always but the options, the treatments that are available for them have become really expanded in recent years. And it's now more important than ever that, you know, a positive attitude is taken on behalf of these patients by all providers, such that these options can be presented and patients visit and get treated at specialized centers.

Melanie Cole: As we're talking about medically refractory epilepsy, tell us about the current indications for surgical intervention. And please tell us about SEEG and identify the patients who may benefit from this type of monitoring.

Dr. Giridhar Kalamangalam: Yes. That's actually a very relevant question in today's practice of tertiary epilepsy. Like I just mentioned, surgery for epilepsy can take many forms. The most important one and perhaps the most effective one are brain surgeries that operate on some part of the brain to disconnect or remove a portion of brain that is diseased and is causing epilepsy.

I should say, you know, while we're talking about brain surgery, there are many other surgical treatments. of them are not removal of brain, but perhaps more disconnective procedures. And those have been used for a long time, just like resective procedures for epilepsy in addition to other surgical treatments such as VNS, the vagal nerve stimulator. And in recent years, other stimulators that are implanted directly into the brain.

These are not strictly thought of as surgical treatments, but in a way they are because technically they involve a surgery, but they don't involve removing, disconnecting portions of brain, but rather stimulating parts of the brain or, in the case of VNS, one of the cranial nerves that enters the brainstem.

So those are neuromodulatory treatments that require a surgery, but let's just stick to brain surgery for epilepsy that, as I said, it remains really when successful the most effective frequent there is and the effectiveness can be pretty dramatic and, you know, in well-chosen patients, really long lasting.

The challenge, of course, of doing a surgery on the brain for a patient with epilepsy is to really do the right thing. And that might seem like an obvious statement, but many times this is a challenge. What exactly is the problem? Where exactly is the problem? What kind of surgery does the patient need?

And when we say what kind, it means what would be the most effective surgery for this patient, but also extremely important, what is the surgery that will do or carry the least amount of with it? Not an intraoperative risk, but a risk of or risk of things getting worse or something occurring that the patient didn't have before, like a weakness or a problem with eyesight or some difficulty with speech.

These are all problems that we ponder. These are very important issues that we consider when we offer patients epilepsy surgery. And to do this correctly, to do this as effectively as possible, we use several techniques. And an emerging one in the United States over the past decade or so is the technique you just mentioned, which is SEEG or stereoelectroencephalography.

This is a method by which we explore the brain in a very targeted and precise way with electrodes that are implanted into the brain. In this way, we study the epilepsy at close quarters. We actually get right up to the face of epilepsy. We go right there knocking at its door, explore it where it starts, where it spreads to, how it involves various brain regions. We actually understand the epilepsy as it exists within the brain.

And based on that understanding, we come up with a plan for that patient, which we hope most of the time will involve removal or disconnection of part of the brain, because that remains the most effective treatment for epilepsy, surgical treatment for epilepsy.

But sometimes, the SEEG tells us that there is no such strategy available, and we wouldn't have known that unless we actually did that SEEG. And then we move on to other kinds of treatments, which also may be surgical, which may be stimulatory modulatory treatment for epilepsy.

So SEEG has become really good de facto method of exploring complex epilepsies. Not every patient needs it, but many patients do, especially in our practice where we get a relatively large proportion of complex, not just refractory patients, but refractory patients who are complex, where it's unclear where seizures start or which is the bad area and how the epilepsy is organized within the brain.

And so these are the patients that require this more in-depth exploration. I mean, in-depth is both literal and figurative. It's a depth electrode in the brain, but it also gives us a deeper look at the process of seizures that are occurring in that patient. So that, if you like, is a broad overview of what SEEG is.

Melanie Cole: So tell us a little bit about some of the limitations that you're seeing and really else might this be beneficial besides finding that location as you just described in the brain where these seizures occur. How else might intercranial monitoring, how else might SEEG be used during the evaluation for epilepsy?

Dr. Giridhar Kalamangalam: Right. The role of SEEG is really, there's only one role and now that role has different parts to it. So when you put electrodes into the head of something to the brain of somebody through the head, through the skull, your objective is to identify everything that you can with that data. That means understanding the epilepsy, like I just said, which is to understand, to recognize the primarily diseased areas, recognize secondarily diseased areas, which are areas where seizures propagate to. And therefore then obtain a map, if you like, or grade of disease. If you like. And then that maps out an area of brain that needs to be targeted for surgical removal or disconnection.

Equally, our job is to make sure that this procedure that we contemplate is safe for the patient, right? So I mentioned risks to normal brain areas, and we call that a risk of a deficit or the risk of incurring something that the patient didn't have before, such as, say, a weakness. And that can happen when the epilepsy area, the area to be operated on is very close to, say, an important area for strength, which we call motor eloquent areas. And so when we operate on the brain, we want to make sure that we stay away from those areas.

And this is our job as epileptologists, to provide this information to our epilepsy neurosurgeon, who then performs the procedure and performs the procedure in such a way that disease areas are maximally targeted and normal areas, where the patient might incur a deficit if they were encroached on, are minimally interfered with. So we have to maximize the yield of disease and we have to minimize really the risk. And if you like, those are the two things that we have to do with SEEG.

And if you do that successfully, then we have a plan and the electrodes are then taken out. And all of these data presented at our joint conference. Neurosurgery is a very important partner. But really the, epilepsy surgery as the name might indicate, you know, has two parts to it. It's got the epilepsy part of it and the surgery part of it. And so we have a team here which then considers all the data and, providing they're all convinced that we've identified the area accurately with SEEG and that area has also been identified, those areas that we think of operating on have been identified as not being a risk to that patient, if they are removed, we then have a plan. And that plan is then executed by our surgeon. So those are the two roles.

And when you talk about limitations, of course, every technique has limitations. First of all, I should say that most patients don't need SEEG, most patients require an accurate diagnosis. So we have a lot of patients who come to our outpatient clinic who will never need SEG or any kind of brain surgery. They do need an accurate diagnosis of what exactly that epilepsy problem is. They need good medications to be given to them, effective medications. We need to keep them free of side effects as much as possible and we need to reduce seizures to a minimum, hopefully no seizures.

So, SEEG is used for the more complex patients. There is a limit to what it can achieve. In some patients, we have the risk, it's not really a risk, but, if you like, the fundamental difficulty of the epilepsy is such that you do an SEEG thinking that you would confirm something that you are thinking as the cause of the patient's seizures or the areas of the brain regions that are causing seizures. And we go in and we find it's actually much more complicated than we thought and that no clear area emerges from that data, that is, if you like, no clarity. That can happen. And that is a limitation and that limitation arises because the disease itself is very complicated.

Obviously, if an SEEG is not done with the care that it really should be done with, then of course one can get data that isn't helpful, but that is because the technique hasn't been carried out, if you feel like, optimally. But with the optimal technique, with the optimal thinking behind an implant, one might still have a situation where the data is too complicated to be, if you like, parsed or, put into a classification so that we clearly have a distinction between abnormal areas and normal areas. So that's the limitation and that comes from the fundamental complexity of disease in some patients.

Obviously, you know, there's a number, there's a limit to how many electrodes one can put into the brain, too. And so some epilepsies cannot be, if you like, explored sufficiently. So that can be a problem too where, you know, you're just unable to explore everything you want because there's a limit to, the number of electrodes that can be put in safely.

So those are some limitations. There's a set of other limitations that have to do with the technique itself and I won't go into those necessarily. Those are interpretive challenges and that takes us kind of deep into the field of SEEG data analysis, which I think would be inappropriate to talk too much about.

But there are certain challenges at, if you like, the data interpretive level that we deal with. And it's an evolving field. We don't know everything about it. Not at all. We are learning about it. We're discovering things about it. We're learning from our patients, from our experience and from other people. And so that remains a challenge too.

I won't talk about the technical challenges. I'm not a neurosurgeon, but a neurosurgeon would tell you what challenges there are in actually implanting these electrodes, the actual procedure itself and what the risks are and where things can go wrong, and so forth. So there are those challenges too, but on the whole, it's a safe technique. It's being increasingly recognized as the de facto method, the best single method for exploring the brain for patients with refractory epilepsy.

So it's seen very wide acceptance very quickly in this country, I should say, in the same breadth that it's been known about for decades. It's been practiced in other parts of the world for decades, but it has recently taken off in North America for many reasons. But it's now here to stay. Everybody wants to do it. A lot of tertiary centers, over a hundred centers in this country do it. And all of this has happened literally in the past five years.

So it's an emerging, rapidly exploding field of knowledge and something that is on the whole safe for patients as far as surgery on the brain goes and extremely a dramatic impact on the treatment of epilepsy in a very short time. And, it's our job to be able to provide that kind of knowledge out to the community so that people know, patients know and providers know that they have options.

Melanie Cole: As a final thought and a wrap up for this episode, where do you think SEEG is going in the future? Give us a little blueprint. Or really what's exciting? And why do you feel it's important that providers refer?

Dr. Giridhar Kalamangalam: The answer to that actually is in two parts. And I will tell you the more important part first, which is I think where SEEG is going, is it's going in the direction of greater visibility. That is perhaps the single most important thing. I think everyone who deals with epilepsy patients should know that there are options available for refractory patients. There are options available that are less invasive than in years gone by, and that, at experienced centers, a patient can get a thorough evaluation, an intracranial evaluation with SEEG that will really lead to an advanced understanding of their epilepsy and give them options that they didn't have. I think that is the single most important thing about the future of SEEG.

There are of course scientific and medical advances that we have to make. We have to understand the data better. We have to understand how to do the technique better and so forth. And that's incremental. And that will go on, I guess, for decades. But a greater awareness, I think, can make a dramatic impact on the treatment of epilepsy in a very short time. And it's our job to be able to provide that kind of knowledge out to the community so that people know, patients know and providers know that they have options.

Melanie Cole: Wow. Thank you so much for joining us and sharing your incredible expertise. What a fascinating topic. Thank you again.

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/

Surgical Repair of Bicuspid Aortic Valve

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Audio Fileuf_health_shands/ufhs038.mp3
DoctorsArnaoutakis, George
Featured SpeakerGeorge Arnaoutakis, MD
Guest BioGeorge J. Arnaoutakis, MD, is an assistant professor in the division of thoracic and cardiovascular surgery at the University of Florida College of Medicine. He is also the director of the physician assistant residency program, surgical director of the transcatheter valve program and the associate director of the UF Health Aortic Disease Center.

Learn more about George Arnaoutakis, 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 examine surgical repair of the bicuspid aortic valve. Joining me is Dr. George Arnaoutakis. He's an Assistant Professor in the Division of Cardiovascular Surgery at the University of Florida College of Medicine.

Dr. Arnaoutakis, I'm so glad to have you join us today. Help us to understand the epidemiology and clinical features of bicuspid aortic valve syndrome. Is there a heritable component to this disease? Tell us a little bit about it.

George Arnaoutakis, MD (Guest): Well, good morning, Melanie. It's nice to be here this morning. Sure. Bicuspid aortic valve disease is actually a very common condition. It's technically the most common congenital abnormality, but it is seen so frequently in about one in a hundred individuals that I consider it a normal variant. It affects, as I said, one to 2% of the general population and is associated with other conditions like ascending aneurysms, coarctation of the aorta, and even a higher incidence of bacterial endocarditis.

Host: Well, then give us a little evolution on the history of bicuspid aortic valve repair. What's happened over the last 10 to 15 years?

Dr. Arnaoutakis: So, bicuspid aortic valve repair has kind of followed a similar trend that was seen in mitral valve repair, which was pioneered by a French Surgeon, Dr. Carpentier. And many of the techniques and principles that he established for mitral valve repair have been applied to bicuspid aortic valve repair over the last one to two decades, where we adopt many of the same principles toward approaching the aortic valve in terms of aortic leaflet pathology, as well as aortic annulus pathology.

Host: What an interesting topic we're discussing here today. So, let's speak about diagnosis, Doctor. How and when is this usually found and what region of the aorta is most effected by aneurysm in patients with bicuspid aortic valve syndrome?

Dr. Arnaoutakis: So, many patients with bicuspid aortic valves will be identified based on a physical exam at their general practitioner, their internist or cardiologist office when a murmur is heard. Other patients will often be identified because they have a strong family history as this is a heritable condition. And patients with bicuspid valves can develop either aortic stenosis or aortic insufficiency. Many patients will also develop pathology of the ascending aorta, where they develop a concomitant ascending aortic aneurysm. The interesting feature about patients with bicuspid valves, is that the rest of the aorta is most frequently normal, such that the main component involved is the ascending aorta.

Host: Wow. So, then review for us the current guidelines for surgical intervention. What are the clinical criteria? Tell us a little bit about how that discussion comes about.

Dr. Arnaoutakis: So, when a patient is found to have a murmur, oftentimes this is followed up with an echocardiogram, which evaluates the function of the aortic valve, as well as the other valves in the heart. And in addition, the function of the left ventricle and the other chambers of the heart. Now, if patients are symptomatic, such as shortness of breath or lower extremity edema, presyncope even angina or chest discomfort, and it's attributable to aortic stenosis, then those patients meet the highest strength recommendation for surgical intervention, a class I indication. But other patients may be asymptomatic. And that's where the conversation becomes even more nuanced about the decision regarding timing for surgical intervention. If patients start to exhibit any signs of ventricular dysfunction, such as a low ejection fraction or dilation of the ventricular dimensions on echo, that's also an indication for intervention to address the aortic valve. Which if the valve is stenotic or calcified, most often requires replacement. When patients have an incompetent or insufficient valve, that's where the discussion arises regarding options for valve repair.

Host: Well, I think one of the most important messages or aspects of our conversation today is patient selection for aortic valve repair. So, speak about patient selection and what's the most common orientation of the fused leaflets in patients with bicuspid aortic valve.

Dr. Arnaoutakis: So, there's many different anatomic variants for bicuspid valves. This is referred to as the Sievers classification of the anatomic arrangement of the bicuspid valve. Most patients will have a fused leaflet. Some patients, actually a minority of patients with bicuspid valves will have no fused leaflets and truly have just two leaflets. And that's a Sievers type 0. Patients with Sievers type 1 is the most common variant and there's most commonly fusion of the left and right coronary cusps. And that's the most common variant that we see for bicuspid valves. Now, patients who have good leaflet tissue, no calcification, those are the patients who are the ideal candidates for a valve repair.

In addition, when we consider a patient for a valve repair, it's not just the anatomic criteria of the valve, but also the patient's underlying physiologic condition. So, elderly patients with multiple co-morbidities need a more straightforward operation with a definitive outcome at the first attempt in the operating room. And so in those patients, we often undertake performing a replacement right off the bat. But patients who are younger, in better physiologic shape, are better able to tolerate longer periods under anesthesia and on cardiopulmonary bypass because the elaborate repair techniques often take a bit longer. And so those are the patients that we typically pursue repair on.

Host: Well along those lines, then give us an overview of technical aspects and predictors for successful aortic valve repair. Are there any technical considerations you'd like to share with other providers for better outcomes? Or do you have any valve preferences you'd like to discuss?

Dr. Arnaoutakis: Sure. So, patients, as I said, who have really good leaflet tissue, now they may have what's called leaflet prolapse, where one of the leaflets is longer than the other and hangs below it into the left ventricle outflow tract. And is what leads to the valve leakage. Now there are techniques such as leaflet plication where we can shorten the length of the leaflet and make it equal with the other leaflet. So, that way they meet or co-opt in the center and render the valve competent. Patients with that pathology have been found to have very good long-term durability with freedom from reoperation greater than 90% at 10, 15, 20 years out from operation. Now, one of the predictors of a failed repair, is patients who have calcification on the leaflet or patients who require any kind of a patch repair due to a defect in the leaflet. Those have been predictors of a poorer long-term outcome. So, if we encounter any of those conditions at the time of surgery, that's usually an instance where I would elect to perform a valve replacement. Now, the discussion about what kind of valve to replace the aortic valve with has also evolved over the last decade with the advent of TAVR technology, where valves can be replaced through the groin. Especially if someone has a prior bioprosthetic valve. Typically in patients 65 or younger, who can take a blood thinner like Coumadin, we recommend a mechanical valve. Patients 65 or older, the typical recommendation would be for a bioprosthetic valve.

Host: Tell us about your outcomes, doctor.

Dr. Arnaoutakis: Yeah. So, here at UF Health, we have great outcomes with bicuspid aortic valve repair. As I mentioned, one of the common techniques is leaflet plication. Many patients with bicuspid valves will also have concomitant aortic aneurysm. And one of the techniques that was actually devised here at UF Health by one of my partners, Dr. Thomas Martin is called the Florida Sleeve Technique where part of the aneurysm at the aortic root is buttressed by a Dacron graft, Valsalva graft on the outside of the aortic root. And sutures are placed underneath the annulus to anchor that graft in place and perform an annuloplasty. Then we reattach the aortic wall to that Dacron graft and that accomplishes what's called valve resuspension.

And so we've have a very long experience with bicuspid valve patients who undergo this Florida Sleeve Technique. And it's been found to be a very durable technique for bicuspid valve repair. This is an added tool in our armamentarium to address patients with bicuspid valve pathology. Other options for bicuspid valve repair are what's called a David reimplantation or a valve sparing root replacement, where we preserve the valve leaflet, but replace the entire aortic root.

Host: Well, then tell us about some promising new therapies. Are there any game changers in your field right now?

Dr. Arnaoutakis: Well, one of the newest technologies over the last decade, as I just mentioned a moment ago, is TAVR technology. And this is really predominantly reserved for patients who have stenotic aortic valves. And it was initially felt that the atomic configuration of a bicuspid valve would preclude safe TAVR performance in a patient with a stenotic bicuspid valve.

However, we have experience here at UF Health as do many other institutions around the country and world, in fact, with performing TAVR procedure in patients with bicuspid valve. What we've found is that to accomplish a safe TAVR procedure, we have to pay a little bit more attention to some of the different measurements that we use on our preoperative CT scan to look at the orientation of the valve leaflets, the native valve leaflets, that is. We also find that we more commonly perform what's called a balloon valvuloplasty before we deploy the TAVR valve. That's to allow the TAVR valve to sit more nicely in the aortic annulus and lead to very low rates of paravalvular leak as well as good hemodynamics on the valve. In fact, our experience with bicuspid valve TAVR patients was one of the first publications regarding this topic in the literature, on TAVR.

Host: Absolutely fascinating. As we wrap up Doctor, what would you like other providers to take away from this episode and your experience at UF Health Shands Hospital?

Dr. Arnaoutakis: Well, I'd like for others to know that patients who have incompetent bicuspid valves that are severely regurgitant are very commonly candidates for repair. And there's a lot of benefits to repair. Always preserving one's own native leaflet tissue, we feel is better than any kind of a prosthesis, whether it be mechanical or biologic. The rates of endocarditis are much less in a repair situation than in a person who has a prosthesis in place. And so many patients are candidates for repair techniques. These techniques are elaborate and not performed at all centers. And so we have a vast experience with bicuspid valve repair here at UF Health. And so I would just advise providers to consider that patients with incompetent valves may be candidates for repair and our bioprosthesis options are also evolving rapidly. There's new INSPIRIS technology, which has an anticalcification property. And there's some feeling that that valve may be a biologic, but more durable than the currently most widely implanted ones. And so, technology is continuing to evolve in terms of our techniques for repair, as well as the bioprostheses and mechanical prostheses that are being implanted.

And so it may be the case that someday in the future, patients with a mechanical valve don't require Coumadin as they previously have. So, there's lots of exciting developments. We have a comprehensive bicuspid aortic valve program here at University of Florida College of Medicine in Gainesville, where we offer patients the benefits of genetic counseling, cardiologists with vast experience with bicuspid valves, genetic testing and counseling for patients and families as well, as well as a very robust experience in treating patients with aneurysms throughout the entire aorta.

Host: Thank you so much, Dr. Arnaoutakis for joining us today and sharing your expertise. 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 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/

Continuous Glucose Monitoring in Clinical Practice

Additional Info

Audio Fileuf_health_shands/ufhs036.mp3
DoctorsLeey, Julio A
Featured SpeakerJulio A Leey
Guest BioJulio Leey, MD, MsC. assistant professor in the College of Medicine at University of Florida and he practices at UF Health Shands Hospital.

Dr Leey focuses in all clinical aspects of diabetes mellitus. He has clinical expertise in diabetes technology, type 1 and type 2 diabetes, Cystic Fibrosis-related diabetes. He participates in clinical studies related to the previously mentioned areas.
TranscriptionMelanie Cole (Host): Welcome to USF Health Med Ed Cast with USF Health Shands Hospital. I'm Melanie Cole and I invite you to listen as we discuss continuous glucose monitoring in clinical practice. Joining me is Dr. Julio Leey. He's assistant professor in the College of Medicine at University of Florida and he practices at UF Health Shands Hospital.

Dr. Leey, it's a pleasure to have you with us today. There's so much technology happening in the world of endocrinology and diabetes. How is this technology useful and how are you finding it very exciting in your clinical practice?

Julio A Leey (Guest): Thank you for having me here. Yes, there is a lot of progress in diabetes technology. Essentially diabetes technology describes all the hardware and software that is used to manage blood sugar levels, to minimize complications of diabetes and to improve the quality of life of our patients. In a sense we can group diabetes technology in four groups.

One group will be all the advances made in insulin delivery, like insulin pumps, insulin pens. The second group will be all the progress made in sensing blood sugars like regular meters or with continuous glucose monitors. The third group is the combination of the first two, which is the glucose responsive insulin delivery.

And that includes the artificial pancreas or pressure suspend systems that can decrease the dose of insulin when the blood sugar trends down and the fourth group is the so-called data management progress. And that includes all the apps, all the wearables, devices that patients can wear. And also the programs and the software that many, many providers use to help patients in managing their diabetes.

Host: Well, then tell us about the Endocrine Society Guidelines for continuous glucose monitoring. Speak a little bit about the clinical indications for CGM and insulin pumps and what you're seeing right now.

Dr. Leey: The Endocrine Society released guidelines for diabetes technology in 2016 and it specifically, and they address the insulin pumps and continuous glucose monitor systems. At that time, they described in the guidelines that essentially the majority of patients with Type 1 diabetes would benefit from continuous glucose monitoring systems those that are called real time. There are two different types of CGMs or continuous glucose monitor systems. And one is the so-called real time or personal CGM. And the other one is the professional or retrospective CGM. What they are referring here is the first one that real-time CGM that patients can wear this device all the time and seeing their glucose level changing over time and that can helps preventing hypoglycemic events. And that can also help patients understand what type of food or what type of physical activity can have the greatest effect on their blood sugar level.

And something similar happening also in patients with Type 2 diabetes more so if they are using insulin injections and those are the two main groups. More recently, the American Diabetes Association has also released guidelines about the use of CGM systems and essentially adults and youth population with diabetes can benefit similarly in their statements. And whether they are using the CGM for personal use in real-time or intermittently due to some limitations in COVID as perhaps. They are still able to recognize the patterns and they are still able to change their treatment if needed, looking at the downloads of their CGM systems.

Host: Well, what do you feel it's important for other endocrinologists and indeed other providers that are helping their patients with diabetes that may be using CGM or insulin pumps? What do you feel it's important to note when you're interpretating this real-time data as it comes in?

Dr. Leey: Yes. Essentially when the blood sugar is measured constantly, we're able to see subtle patterns that typically we don't see just pricking the finger and getting blood sugar intermittently. When we have a continuous glucose monitor or a real-time glucose monitor the thing the patient can see their blood sugar changing over time and over the office visit with their provider. They can download the device and see the pattern over weeks and can tackle a particular issue with either a dose of insulin that is insufficient or a dose of the insulin that is too high and they can also address a particular food pattern if they are eating maybe too much or too little, or if this is associated to exercise. Exercise can also play a big role in hypoglycemia and having a continuous glucose monitor on board can help prevent the many of those events as well.

Host: Well, it certainly can. Speak about some of the significant barriers that you've seen to the use of self-monitored blood glucose, and as far as the from the patient's perspective and for the clinician that is helping the patient to learn to use this and adapt to this new lifestyle. What have you seen as some of the challenges?

Dr. Leey: Well, some of the, the main challenge is the financial barrier. This system, obviously involves an additional cost. And when patients are monitoring or checking their blood sugar frequently, the approach of doing finger pricks equals or gets closer to the cost of using or wearing a continuous glucose monitor system. In that sense, the Medicare has released guidelines as to when they are going to cover a continuous glucose monitor. And one of those situations is when patients are using insulin in multiple injections, when they are checking their blood sugar four times or more per day? And in that setting, Medicare has decided that this is a cost effective approach and that they are going to pay for that service.

Now, for people who doesn't have that criteria, or for people who is only using insulin once a day, even though they might not qualify for the personal CGM or real-time CGM, they can still have intermittent measurement pattern with the CGM. It's called the professional CGM. And once in a while, they can get that data and identify a pattern that can be fixed and can be improved with additional therapy or maybe lowering the dose of insulin. So, those are the two, the two approaches.

Host: Do you have the ability Doctor to download and share a lot of this data electronically and keeping the current pandemic in mind, how can sharing this data remotely make a Telehealth visit, maybe more meaningful? Have you implemented modules to help your staff upload tools to look at that insulin pump data and the CGM? Tell us how you're using all of this information with your staff and possibly other providers.

Dr. Leey: Well because patients with diabetes have a lot of information in blood sugar levels if they are using fingerprick or from the continuous glucose monitoring systems that are being downloaded, our practice has assigned a clinic that specializes in these issues. And with the current pandemic, we now have developed and expanded the Tele-medicine clinics. And in that setting, we have now the capability of accessing the glucose monitors and the CGMs, as long as the patient also has access has access to internet and can upload their information and then via Telemedicine, our clinic can download that information and see that patient via video conference and then address also the glycemic patterns and propose the changes to the patient that are needed to prevent hypoglycemia events. And also attention needed to improve the glucose control in case they are feeling weak, unusual dietary patterns that are now more common in pandemic.

Host: Well they certainly are and isn't it amazing the technology today? Dr. Leey, what final thoughts do you have for endocrinologists, other providers? What would you like them to know about the topic we're discussing here today, continuous glucose monitoring in clinical practice? What are some points we may have missed that you feel are really important to point out to other providers?

Dr. Leey: Well, CGMs are extremely useful for the management of diabetes, not only the Type1 diabetes, but also Type 2 diabetes. And the amount of information that these systems can provide is very, very and we need a particular pattern to analyze the data. And most of the systems now have a standardized report that allow us to do the interpretation. But these systems that now we have available, over time will continue improving and the cost will go down over time. And it will become more accessible to more and more people. So, they all can enjoy the benefits of assessing their blood sugar especially if they are using insulin where it is celebrate its benefit.

Host: It's really great information and what a fascinating topic and an exciting time to be in your field. Dr. Leey, thank you so much for joining us today. To refer your patient or to listen to more podcasts from our experts, please visit USFhealth.org/medmatters for more information and to get connected with one of our providers.

That concludes today's episode of USF Health Med Ed Cast with USF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other USF Health Shands Hospital podcasts. I'm Melanie Cole.
HostsMelanie Cole, MS
Post Test URLhttps://cme.ufl.edu/mededcast/

Clinical Trajectories of Acute Kidney Injury in Surgical Sepsis

Additional Info

Audio Fileuf_health_shands/ufhs037.mp3
DoctorsBaslanti, Tezcan Ozrazgat;Bihorac, Azra
Featured SpeakerTezcan Ozrazgat Baslanti, Ph.D | Azra Bihorac MD, MS, FCCM, FASN.
Guest BioDr. Tezcan Ozrazgat Baslanti is a Research Assistant Professor of Anesthesiology at the University of Florida. She earned her Ph.D. degree in Statistics at the University of Florida.

Learn more about Tezcan Ozrazgat Baslanti, Ph.D.

Dr. Bihorac is an internist, nephrologist, general and neuro-intensivist with a career-long clinical and research interest in postoperative complications, more specifically sepsis and acute kidney injury.

Learn more about Azra Bihorac MD
TranscriptionIntro: The 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 I invite you to listen as we examine the clinical trajectories of acute kidney injury in surgical sepsis. Joining me in this panel are Dr. Tezcan Ozrazgat Baslanti, she's a Research Assistant Professor at the University of Florida College of Medicine, and Dr. Azra Bihorac, she's the R. Glenn Davis professor in the Division of Nephrology, Hypertension, and Renal Transplantation at the University of Florida College of Medicine. Doctors, thank you so much for joining us today. Dr. Bihorac, I'd like to start with you to tell us a little bit about sepsis-associated acute kidney injury and their correlations. Tell us about how it's associated with increased healthcare costs, mortalities, anything you'd like to share about that.

Dr Azra Bihorac: Thank you for having us on your program. So as many of your listeners know, sepsis is one of the most common, expensive and inadequately managed syndromes in the modern medicine. Every year, about 1.5 million individuals in the United States are affected by sepsis, one out of the three hospitals deaths because of the sepsis and more than $20 billion is spent annually on treating patients with sepsis.

Now, the sepsis is really infection that affects other organs and can cause dysfunction of the organs that are not related primarily to infection. One of those organs is obviously kidney, among patients with sepsis, almost 60% of them will experience during the course of the sepsis acute dysfunction of the kidney, meaning that the kidney will not work properly and filter waste products of the metabolism in up to 60% of the cases with sepsis.

We also know that organ dysfunction with sepsis is associated with worse survival. And we also have demonstrated before in our work that among the patient with sepsis and acute kidney dysfunction, inability to recover from the kidney dysfunction can lead to worse survival. And that association was shown by other groups too.

So our interest was really to understand better whether certain trajectories of renal recovery affect outcomes with patients with sepsis and investigate these in more details.

Melanie: Thank you for that. So, Dr. Baslanti, how do you define and classify trajectories of acute kidney injury? And tell us a little bit about the prevalence of persistent AKI and AKI without renal recovery after sepsis.

Dr Tezcan Ozrazgat Baslanti: So we define AKI using KDIGO criteria with the changes in serum creatine compared to baseline. And recent guidelines key criteria, introduces us to use other dimensions, just the severity, how high the creatinine goes, but also duration and renal recovery. They define the rapidly reversed AKI by recovery of AKI within 48 hours of AKI episode start. And persistent AKI is characterized by persistence of AKI more than 48 hours, which may end with or without renal recovery at hospital discharge.

In our cohort, we have seen that 52% of the patients have AKI within the first 48 hours and then, overall 62% had developed AKI. Among those, one third was rapidly reversed AKI, the rest was persistent. So in the all sepsis cohort, prevalence of persistent AKI without renal recovery was 24%. We have seen the worst outcomes, both hospital outcomes and long-term outcomes, being in the persistent AKI group specifically persistent AKI without renal recovery group.

Melanie: Well then, Dr. Bihorac, as you're telling us how important early recognition is as crucial to provide supportive treatment, limit further insults, is there evidence that you can speak to on the fundamental mechanisms that may play a role in the development of sepsis AKI, microvascular dysfunction, inflammation, tell us what we know as of now.

Dr Azra Bihorac: I think we still do not know precisely why acute kidney injury occurs in sepsis. It's postulated that it's multifactorial, that it's a combination of the effect of inflammation and microvascular changes as you have implicated in your question that contributes to this.

I think that, overall, I would like to think about AKI in sepsis as a combination of both susceptibility and exposure. In other words, in other AKI models, we know that underlying kidney health predetermines in many ways how you're going to respond to acute stress of acute illness as an example of sepsis. So for the patients who are older and who have underlying impairment in kidney held, especially among elderly and those with chronic kidney disease, the susceptibility will be much higher, thus resilience will not be the same.

The insult by itself, in another words, how severe sepsis is in terms of infection itself is another mechanism that contributes to the development of AKI. In that sense, the inflammation and persistent immunosuppression that we know now is happening in the early stages of sepsis will be determining the framework of the development of AKI.

Melanie: Such an interesting correlation here. So Dr. Bihorac, sticking with you for a second. Speak about the clinical characteristics, resource utilization in hospital and long-term outcomes. How do they all differ between sepsis patients from different trajectories of acute kidney injury?

Dr Azra Bihorac: So, what we really were interested to understand is within the first 48 hours, most of our intervention for sepsis occur. That is our golden time. Forty-eight hours, we have to administer antibiotics to give fluid therapy. And we were interested to see whether in this first 48 hours, we can distinguish patients with the different trajectories.

And interestingly, we have seen that on the sepsis presentation, almost half of the patients already has some indications of acute kidney injury. Part of this cohort that has early sepsis, we think is due to inadequate resuscitation, meaning not receiving adequate fluid and will be very irresponsive to fluid therapy, will respond quickly and will implicate that their course might be less severe than others. This rapidly reversed AKI group actually show themselves in the first 48 hours. Those are the patients that we can recognize as early recoverers, maybe not put any more further invasive strategies of treatment to them and then focus on the group that does not recover within 48 hours. And those are the persistent AKI group.

Among those groups, we have demonstrated that inability to recover from renal dysfunction by the time of the discharge will be associated with need for renal replacement therapy. Almost half of these patients will need dialysis or CVVH and the mortality of 40%. So meaning that patients who do not recover their renal function to their baseline, half of them almost will die by the hospital discharge. Those are the short-term outcomes. These patients will require prolonged ICU admission, will require more mechanical ventilation, more use of vasopressor and so on.

In terms of the long-term function, we also see that amongst survivors, the ability to recover renal function at the time of the discharge will determine what happens to you a year from the discharge and whether you die or develop chronic kidney disease.

Melanie: Wow. So Dr. Baslanti and the message for this particular podcast, how can you translate the findings that you both are discussing today into potential treatment strategies and add to the promising pharmacologic approaches that are being developed and tested in clinical trials? Take this from research to bedside.

Dr Tezcan Ozrazgat Baslanti: So the key points of this research was that we have observed one out of two sepsis patients develop AKI. So the clock starts ticking at the moment of the sepsis protocol being initiated. And after that, two out of the three patients with AKI develop persistent AKI after three days. So this tells us that the initial effort needs to be focused on earlier reversal of AKI. And one out of two with persistent AKI did not recover their kidney function by the time of discharge. And one out of two with persistent AKI without renal recovery died in hospital. And one out of two of the survivors died or had severe functional disability one year after discharge. So this really shows the importance of preventing the AKI development, if not preventing the AKI to be persistent, and if not, try to help the patients recover before they're discharged, because we see that enhancing the kidney recovery is really important and top priority in sepsis research.

Melanie: Can you prevent sepsis-associated acute kidney injury? Do you see that happening in the future?

Dr Azra Bihorac: I think we are in the beginning of these efforts. As of now in our own institution, we have focused a lot of our work on early recognition of AKI and risk stratification of patients who present with acute kidney injury in terms of who is at the risk of developing persistent AKI.

As of now, we have strategies to ameliorate secondary insults in patients who present with AKI within 48 hours of sepsis. That means we can adjust our antibiotic therapy, not to use medications that have potential to induce further kidney toxicity. We also know that too much or too little of the fluid is not good for AKI progression. So we have to develop precision in the way how we resuscitate these patients. And for that, we use some well-proven strategies, like dynamic assessments of volume responsiveness and so on.

But the most important thing here I think is understanding the prognostic enrichment that AKI has in the course of sepsis. In other words, if you can identify a patient who has one of these malignant phenotypes, meaning patients with AKI early is at more risk of having worse outcomes. Three days from sepsis onset, patients who have AKI and is not recovering is now really the most malignant clinical phenotype. And we really need to focus enrolling those patients in clinical trials, as well as using strategies of monitoring or avoiding secondary insult in this specific group of patients.

Melanie: What an interesting study we're discussing today. And I'd like you each to have a chance for final thoughts. So Dr. Baslanti, to start with you, what would you like other providers to take away from these studies and clinical trials and the testing that you're doing and really sepsis associated acute kidney injury, what would you like them to know about this?

Dr Tezcan Ozrazgat Baslanti: I think it's very important to identify AKI and not only severity, but all different dimensions of AKI and trying to take preventive measures as early as possible is the key point. So sometimes the AKI goes undetected easily, so we've been developing some algorithms that can do that and help assist doctors. And I think that would become more common soon and that would help. And I think a really important part is to be aware of the trajectory of the patient and take preventative measures as early as possible.

Melanie: That's a great point. And Dr. Bihorac, last word to you, what would you like other providers to know and to take away from this really interesting episode?

Dr Azra Bihorac: I think that I would summarize this in awareness recognition and precision, meaning increase the awareness among primary providers in ICUs and hospital, awareness of importance of AKI in determining outcomes of sepsis patients. Recognition would be recognizing AKI at any stage of sepsis as early as the time of admission to hospital, very important. And precision means not only to recognize the acute kidney injury and isolated moment of time, but tracking dynamically trajectory of AKI as a complication and understanding which of malignant trajectory your patient is assuming early enough so you can reverse the course and change the outcomes.

Melanie: Thank you so much doctors for joining us today and sharing your incredible expertise in this research. To refer your patient or to listen to more podcasts from our experts, please visit UFHealth.org/medmatters for more information and to get 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/

Cardiovascular Disease in Women

Additional Info

Audio Fileuf_health_shands/ufhs035.mp3
DoctorsPark, Ki;Freeman, Kirsten
Featured SpeakerKi Park, MD | Kirsten Freeman, MD
Guest BioKi Park, MD, is a clinical assistant professor of medicine in interventional cardiology. In addition to her professorship role, she is the director of women’s cardiovascular health at UF Health.

Learn more about Ki Park, MD

Kirsten Freeman, MD is an assistant professor with the division of cardiovascular surgery at the University of Florida.

Learn more about Kirsten Freeman, 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 I invite you to listen as we discuss cardiovascular disease in women. Joining me in this panel is Dr. Ki Park, she’s an Assistant Professor in Cardiovascular Medicine at the University of Florida College of Medicine, and Dr. Kirsten Freeman, she's an Assistant Professor in Cardiovascular Surgery at the University of Florida College of Medicine. Doctors, I'm so glad to have you with us today. And Dr. Park, I'd like to start with you. If you could just tell us what you're seeing in the trends. Define common cardiovascular diseases that you're seeing most these days.

Dr Ki Park: Thank you for much for this opportunity. I'm excited to be here and talk about cardiovascular disease in women. I think overall there's been a trend in our field, more towards focusing on specific gender-related risk factors for cardiovascular disease in relation to auto-immune disorders and pregnancy conditions, which are associated with long-term cardiac risk.

We also are seeing better appreciation for the differences in a wide variety of cardiovascular conditions by gender. We know that women have different presentations in regards to acute coronary syndromes, valvular disease. Really sort of anything that you name within the spectrum of heart disease has some difference noted in women. So I think we're understanding that women are not just smaller versions of men and that this is particularly important when it comes to cardiovascular disease.

Dr Kirsten Freeman: I just wanted to add that in surgery, we tend to notice that women tend to present sometimes later than men, because sometimes the symptoms can be similar to other types of symptoms and slightly different than men with common, crushing chest pain of a heart attack.

Sometimes women have symptoms that are more like shortness of breath or that feel like reflux disease rather than the sort of typical angina-type symptoms. And so sometimes we see later presentations in women than we even do in men.

Melanie: Dr. Freeman, I'd like to expand on that for just a minute. As you've pointed out that the signs and symptoms can be very different, do you, in your opinion, feel that women as caregivers to everybody else that we do, we tend to put off some of those symptoms and brush them away and think they're stress or anxiety or a panic attack? While men are more difficult to get into a doctor, women, we sometimes don't look at our symptoms enough and realize what we have to do for ourselves.

Dr Kirsten Freeman: I think that's very accurate. I think that oftentimes women are making sure that family members are set up and they are in a role of what I call a house manager of sorts. And sometimes, by the time you get through all the normal lists of day-to-day activities, your own health may be at the bottom.

And so I do think that sometimes women push their symptoms off, men also push their symptoms off, but they often are encouraged by family members or spouses to seek treatment. Wherein sometimes women are not pushed by anyone other than themselves to then seek treatment because they often keep their symptoms to themselves.

Dr Ki Park: Yes. And I would just add on top of that, that I think those issues are compounded by the fact that as Dr. Freeman mentioned, women sometimes can have different types of symptoms than men do with the same type of condition. So for instance, I see a lot of women in my university clinic. We have a dedicated women's heart health clinic at University of Florida who have what's known as microvascular disease. So this is disease within the small microvessels, the arteries within the heart that are not amenable to stenting or bypass. And a lot of providers are also not aware of that condition.

So these women present repeatedly for evaluation for chest pain. They undergo multiple heart caths and often their conditions aren't recognized because providers sometimes don't understand that that condition exists. So I think the sort of issues surrounding the whole topic are so multifactorial.

Melanie: Well, they are. And, Dr. Park, because of what you just said and the presence possibly of microvascular disease, so many of the symptoms that we've started discussing here today are similar to stress and anxiety. For providers that are going to see those women, whether they're primary care or gynecologists, whoever the women are seeing, how do we know the difference? Does it take diagnostic tests in the cath lab and such? How do we know whether it's an anxiety attack or stress? Because so many of these symptoms mimic so many others.

Dr Ki Park: Yeah, it's a very important question. I think when we look at a patient overall, you know, we start with the symptoms. So how sort of classic are they? Are they atypical? But then we're also looking at the patient overall, you know, how old is the patient? What kind of risk factors do they have? I think, for a primary care provider and even for sometimes us as cardiologists, it is very challenging to tease all that out.

However, I think that in most patients, depending on the initial assessment, you know, at least some basic testing is likely warranted. We have a wide spectrum of testing that can be done from very minimally invasive such as a treadmill stress test, of course, to the most invasive, which is cardiac catheterization and trying to tease out what's right for which patient is something that's something within our area. But the initial step is to at least recognize that some evaluation is warranted. And again, that sort of depends on the patient's risk profile and oftentimes patients also appreciate some degree of testing at least to ensure that the overall structure of their heart is normal. And that there's nothing else grave that is being missed.

Melanie: Dr. Freeman, let's get into intervention criteria because we've discussed a bit about symptoms. We've discussed a bit about diagnostic criteria a bit, but I'd like to get into some of the intervention that you would try. Please characterize when a disease process needs some sort of intervention and where you come into that picture.

Dr Kirsten Freeman: So as far as intervention criteria goes, for each different pathology we have basic criteria. So when we're talking about coronary artery disease, it has to be of a significant blockage in order to warrant crossing into the risk benefit of either percutaneous intervention versus surgery itself oftentimes related to symptoms and the percentage of blockage for coronary artery disease.

In women, sometimes the size of the vessels can be an issue, meaning that they often are quite small and sometimes the ability to do a bypass surgery may be more difficult purely because of size. Other issues with aortic pathology also is due to size. Women are on the whole smaller than men and so we typically intervene sooner with an aorta. Men, we often wait until an ascending aorta is over five and a half centimeters. In women sometimes, depending on their size, we may want to intervene even earlier. Because we know that the larger the size of the aneurysm, the higher the risk of rupture.

And then there's valvular pathology, and often issues with your valves including most commonly the aortic valve and the mitral valve, they're all wrapped around the type of symptoms you're having, whether they're lifestyle-limiting, can they be controlled with medications? And on an echocardiogram, do they meet certain criteria that put them into a severe category? Usually, the reasons to do interventions are based on symptoms and severity of disease. And then once you get into a scenario of symptoms and a severe disease process, then we can look at the risk-benefit profile of the intervention.

Melanie: Then Dr. Park, as we're talking about the differences, when treating women with cardiovascular disease, speak a little bit about the multidisciplinary approach that's so important when you're working with women, whether it's valve issues or coronary artery disease, whatever the problem is. As you two work together, tell us how this works and who else might be involved because there's a whole cache of healthcare providers that can help women when they have cardiovascular disease.

Dr Ki Park: I think that's a really important point. In fact, Dr. Freeman and I were discussing a patient together this morning. You know, as she mentioned, when we look at a patient, we're considering a lot of different factors. There's anatomic factors, you know, can we actually do the procedures that we want either from a surgical end or from a minimally invasive percutaneous end? Sometimes we need our imaging colleagues to help us determine whether we need other additional imaging to better look at a valve particularly, now that we have transcatheter options. And so that's always important, I think, multidisciplinary care when you look at complex patients.

I think that this is particularly important also in women, as Dr. Freeman mentioned, and the anatomy is different, the sizing of a valves, those types of factors have to be discussed as to what is the best long-term result for the patient.

I also see women in my clinic, who are either pregnant, with a variety of cardiovascular conditions are considering becoming pregnant with known conditions, particularly valvular disease is something that comes up often. And so we need to discuss those patients as to what is the best planning in regards to future pregnancies, what types of valve is most appropriate for those patients? And so there's a really wide spectrum of folks within the team, both within surgery, interventional cardiology, imaging that really need to be involved in order to get the best outcome for the patient.

Melanie: And Dr. Freeman, I'd like to give the first last word to you. As we wrap up, what's exciting in your field in cardiovascular surgery, that you would like other providers to know that you're doing at UF Health Shands Hospital? Kind of give us a rundown or a summary on what you feel is exciting or what you're looking forward to in the future.

Dr Kirsten Freeman: I think what's exciting that we're doing at University of Florida is we're on the cutting edge of all the technologies. So all the new trials, we're just about to start a new trial for mitral valve interventions and doing them in a more and more minimally invasive way. There's a standard open operation that we use most of the time for complex aortic problems, aortic dissections, aortic aneurysms. But we also do all the way down to minimally invasive, where we're using a stent graft inside the aorta to treat aneurysms. So all the way from maximally invasive to minimally invasive, we have available at our fingertips.

You know, treating coronary artery disease sometimes can be done in a standard open coronary artery bypass grafting. Sometimes it can be done using percutaneous interventions. And then sometimes we have to do a hybrid. It just depends on the anatomy. Additionally, our valvular pathologies, more and more, our aortic valve stenosis are being treated by minimally invasive means namely through the TAVR. But there's always the availability for a standard open-heart operation 24/7 at University of Florida. So if for some reason, there is an inability to do something minimally invasive, we can transition very easily with our huge team of people that we use to accomplish complex operations.

Melanie: Dr. Park, last word to you. What would you like other providers to know about the differences between men and women when it comes to cardiovascular disease, the difference in symptoms? And really, and this is your advice to other providers, the importance of listening to their patient and hearing those complaints and taking them seriously and helping their patient figure out what's going on.

Dr Ki Park: I think you sort of hit the nail on the head with the last comment in terms of listening to your patient. As was mentioned earlier in our discussion, women are very busy. They're very caught up in managing the family and everything else. Perhaps at the home and children and whatnot. And I think it's important to recognize that women really deserve full attention when they're in our clinics seeking evaluation. They've taken a lot of time out of their other demands and whatnot to come and see us.

And often the symptoms can really be very subtle. We're always taught that patients with coronary disease have sort of classic, you know, crushing elephant on the chest type discomfort, whereas in women oftentimes, they just have subtle signs of some shortness of breath, or they only have jaw or shoulder discomfort or just some upper abdominal type nausea, those types of subtle symptoms, however they're very persistent. And if they're at the point where they're coming in to seek evaluation, we really need to take time and listen to them and not just say that we can excuse it as either stress or anxiety or some other psychologic condition.

Melanie: Thank you, doctors, so much. What an important episode we've just recorded here today. Thank you so much for joining us. 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/

Nonalcoholic Fatty Liver Disease

Additional Info

Audio Fileuf_health_shands/ufhs033.mp3
DoctorsCusi, Kenneth
Featured SpeakerKenneth Cusi, MD
Guest BioKenneth Cusi, M.D., F.A.C.P., F.A.C.E. is a Professor of Medicine, on Staff, Malcom Randall VAMC and Chief, Division of Endocrinology, Diabetes and Metabolism.
TranscriptionMelanie Cole: Welcome to USF health med ed cast with USF health Shands hospital. I'm Melanie Cole, and I invite you to listen. As we discuss non-alcoholic fatty liver disease, the overlooked complication of obesity and type two diabetes. Joining me is Dr. Kenneth KUSI. He's a professor and chief in the division of endocrinology, diabetes, and metabolism in the department of medicine at the university of Florida.

He practices at USF health Shands hospital and is on staff at the Malcolm Randall VA medical center in Gainesville, Florida. Dr. KUSI. It's a pleasure to have you join us again today. Tell us a little bit about non-alcoholic fatty liver disease. What's the prevalence and what are you seeing in the trends?

Kenneth Cusi, MD (Guest): Well, thank you, Melanie. Again, it's always a pleasure be part of your program. Well, and again, we're really excited also and worried because the epidemic has been growing since the last time we spoke last year, I mean, we were able to publish a study showing that the problem is bigger than we anticipated. But what it is, is basically in the setting typically of individuals being overweight or obese or having type 2 diabetes, the liver tends to collect more triglycerides, more fat than we appreciated. And we didn't think that this was a main problem, but now we know it damages the liver. Causes scarring and fibrosis of the liver and is the number one cause of liver transplantation in the United States. So we think we need to be very proactive in identifying these patients early on and treating them.

Host: Thank you so much, Dr. Cusi. So, expand a little more for us on the importance for PCPs and endocrinologists in identifying early patients with non-alcoholic fatty liver disease.

Dr. Cusi: Well, that is really the key question. So thank you, Melanie. I mean, what happens is that in the majority of people who are overweight or obese, and particularly if they have type 2 diabetes or there's a family history of fatty liver disease, they have insulin resistance. In other words, their body doesn't respond normally to insulin. And the problem is that with excess weight, that adipose tissue behaves in an abnormal way. And it does not hold on to the stores of energy of fat that you have and to release it into your circulation. And this fat finds a home in tissues that are very poorly adapted to this fat. So, the liver collects fat. The hepatocytes, the liver cells feel that this is toxic to them. They send signals that activate this scarring, this fibrosis. Now the real problem is that we know now that if you screened for fatty liver disease, every individual with diabetes or obesity between half to 70% of people have too much fat in the liver.

And we have looked at that. The real problem is when this inflammation gets started, which we call steatohepatitis, a hepatitis induced by fats, steato in Latin is fat. And when that happens, you go down a path of fibrosis, okay. So, primary care doctors are at the forefront of this. They take care of 90% of the patients with obesity and diabetes, they have been proactive identifying complications, like eye disease, kidney disease in people with diabetes. And that's why the rates of those complications have decreased in the recent decades. But now it's time to add this to the list of things that they have to look at. And there's simple ways to do that. So, primary care doctors and also endocrinologists that deal with more complicated patient with diabetes should be doing this. And there is a big movement in that direction.

Host: Well then let's stand the mechanisms that lead to non-alcoholic fatty liver disease and the role of obesity and type 2 diabetes. Why is diabetes such a major risk factor? Explain a little bit about those mechanisms of progression.

Dr. Cusi: Well, as I said, one mechanism is that when you're overweight or obese, that excess adipose tissue is sick. Adipose tissue normally it serves as a reserve of excess energy for times in between meals. So, overnight we break down some of that fat those triglycerides into free fatty acids that feed muscles and all tissues of the body. But when you're overweight and obese and have insulin resistance or the metabolic syndrome, this release of energy happens around the clock. And then other tissues get bombarded with this. And this affects the normal metabolism of the person leading to fat accumulation.

Also it promotes the liver to make more fat. And what we know is that when the liver cells are distressed, they begin working in trying to repair this, and on a chronic basis, it does lead to progressive cirrhosis. So, just for primary care doctors who may be listening, out of 10 individuals that are obese or have type 2 diabetes, now we know six or seven have too much fat in the liver and they qualify for the definition of non-alcoholic fatty liver disease. About half of them have the inflammation component, what we call steatohepatits. So about 30%, three out of 10, and advanced fibrosis, the degree of fibrosis that we know left alone will lead to cirrhosis, happens in about one or two out of 10 patients.

That's a lot of people. Think that we have 30 million individuals with type 2 diabetes in the country. So, that means, you know, 20% of that, we have five, 6 million people who are heading to cirrhosis unless our primary care doctors and endocrinologists identify them beforehand, where we can do something about it.

Host: Wow. It's quite a statistic, Dr. Cusi. So, what do you want doctors to do? How should they screen for this and what are some of the diagnostic difficulties regarding it?

Dr. Cusi: That's a - every challenge comes with an opportunity, man. Good words of wisdom there? So, I think that what we have to do is begin thinking about it, because again, you'll never going to diagnose something that it's not in your mind. So first step, remember that your individuals that are overweight or obese or have type 2 diabetes are at risk of fatty liver disease. Second thing, we typically have looked at liver enzymes, but the cutoffs for liver enzymes that we use are high, are 40 international units per liter for AST or ALT. We need to lower those down to 20 in women and 30 in men. So, above those numbers, we begin having, knowing that there's too much fat in the liver. There's also a very simple biomarker or diagnostic panel better said called FIB-4, F-I-B-4, and it is because it's made out of four.

It's a fibrosis index, and it's based on four tests, the AST, ALT a, which are the liver enzymes we most commonly measure. Age and platelets. So, you just type in any web browser, FIB-4, and it gives you a calculator and that helps you start with assessing what the risk of that individual is. If that is above a number, we call 1.3, that person can be at risk. And if it's 2.6 twice that number, it is very, very likely that person already has cirrhosis. So, the second diagnostics test to do is an imaging study. So, we can do in the clinic, what we call elastography the most commonly used by hepatologists called FibroScan, like fibrosis scan, but FibroScan.

And then if you don't have it in your clinic, you can order it. Then get the result by the next visit and between those two tests, you will probably be in a good place to detect 90% of the patients that need to be seen by a liver doctor.

Host: Wow. So, then let's talk about some of the current treatment modalities and thank you so much for telling us about screening, but what is the role of available diabetes medications? Tell us how those all go together.

Dr. Cusi: That's a great point. So, once you have a patient with elevated liver enzymes, elevated FIB-4 or imaging suggestive of high fibrosis, then you typically would bring in the liver doctor who would do a further evaluation and some of them will require a liver biopsy. Others may be ruled out of not needing it, but if the patient has NASH with fibrosis, you know, with this scarring, there are A, lifestyle, weight loss of about five to 10% reduces the inflammation and may even improve the risk of fibrosis and cirrhosis, bariatric surgery does the same thing or one diabetes medication that has been studied the most is pioglitazone known in the past as Actos. This is a very inexpensive medication. It's a generic now, should cost less than five to 10 dollars, the generic in any regular pharmacy. And about 50% to 60% of patients have a complete resolution of that inflammation. And there can be a modest improvement in fibrosis. So, that is the drug that has been recommended in the current liver guidelines and guidelines across many countries and societies. And that should be the first choice. Another choice is a drug that, we've published three papers on pioglitazone and others have done similar studies.

The other option is an injectable medication called semaglutide, which is the brand name is Ozempic. That's a weekly formulation. We participated in a study that was published in the New England Journal of Medicine on November 13th of 2020, and we showed that again between 40 to 60%, almost 60% of patients, 59% of the patients with the higher dose had a complete reversal of the inflammation.

Although the scarring didn't get much better. The progression over the 72 weeks of the study was less with that medication. Now, the only thing is that we should clarify to the audience, none of these drugs are FDA approved to treat NASH. There are no FDA approved drugs, but if you're treating somebody with diabetes, these medications are available to treat diabetes. So again, those are the two main options. In addition to of course, to lifestyle weight loss that can improve, not only the liver disease, but diabetes, blood pressure, lipids, you know,

Host: Well, thank you for telling us about lifestyle, because that would have been my next question and this potential for disease co-management, which I think is going to be such an important part. And as we look to the future, Dr. Cusi, tell us what you see as future directions and developments in this field. What are you excited about?

Dr. Cusi: Well, I'm excited about number one, primary care doctors are now realizing their key role in preventing cirrhosis, and they can do it in a very simple way. So, that has been very exciting because now we know from the success that primary care has had in decreasing diabetes complications, that the same can be done with the liver complications. So, that's exciting. I'm also excited that we have relatively inexpensive medication like pioglitazone to do this. And typically I tell them, start with the lowest dose, 15 milligrams, and then you bump it up to the intermediate dose of 30 milligrams. I'm also excited that there are a number of new drugs in the pipeline that are going to help us treat these patients.

I can say that a lot, about 30 medications that are being tested in phase two and a few in phase three that will become available in the next two to three years. So, in the meantime, we can't let our patients drift into cirrhosis. Do them a favor. Pay attention to fatty liver disease, do these simple tests to make a diagnosis. And you can really save a life. I've identified many patients, and I've seen the difference between patients at the end of the road with cirrhosis and decompensated cirrhosis needing a liver transplant and those who have been stable for more than 10 years, because we identify them in time. And thank you, Melanie, because this time may have saved somebody who will do that for a patient or a neighbor or a family member. So, this is a great opportunity.

Host: Thank you so much, much Dr. Cusi. What a wonderful thing to say. And I can hear the passion in your voice for the great work that you're doing. Thank you again for joining us today. And to refer your patient, to UF Health Shands hospital, please visit usfhealth.org/medmatters to get connected with one of our providers and to listen to more podcasts from our experts.

That concludes today's episode of USF 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/

Chronic Total Occlusion Percutaneous Coronary Intervention (CTO PCI)

Additional Info

Audio Fileuf_health_shands/ufhs032.mp3
DoctorsChoi, Calvin
Featured SpeakerCalvin Choi, MD, MS, FACC, FSCAI
Guest BioCalvin Choi, MD, MS, FACC, FSCAI is an Associate Professor of Medicine in the UF Division of Cardiovascular Medicine and specializes in Interventional Cardiology.

Learn more about Calvin Choi, MD
TranscriptionMelanie: 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 chronic total occlusion percutaneous coronary intervention or CTO PCI.

Joining me today is Dr. Calvin Choi. He's an Associate Professor of Medicine in the UF Division of Cardiovascular Medicine. Dr. Choi, it's a pleasure to have you join us today. Explain a little bit about chronic total occlusion for us or complete blockages of the coronary arteries. Tell us the prevalence and the pathway of this CTO and when is a blockage considered a CTO?

Dr Calvin Choi: So chronic total occlusion is a fairly common problem. When we perform a coronary angiogram, depending on the patient population, we see this in 10, maybe up to 30% of the time. And, this is a different than acute coronary syndrome or MI or a myocardial infarction. In the setting of acute coronary syndrome or myocardial infarction, the coronary artery blockage is an acute event, namely through a plaque rupture. Chronic total occlusion is different because progression is insidious and it develops over weeks and months. So oftentimes patients may not be acutely aware of the disease process or the symptoms that may come along with it.

But over time, patients often do develop symptoms. So there's different processes involved in chronic total occlusion and acute coronary syndrome. Acute coronary syndrome, as I said, is an acute process, and this is what we typically consider a heart attack. And these are the problems that patients may get acutely ill or even die from. On the other hand, chronic total occlusion is a chronic problem that develops over prolonged period. And the development is insidious and, not necessarily something someone may acutely get sick from or die from, but certainly it can cause a lot of symptoms such as angina, shortness of breath.

Melanie: then what have been the treatment options for CTO? Have they traditionally, Dr. Choi been limited due to the complexity of opening up completely blocked arteries using catheter based techniques? How has the treatment evolved over the years? And how does an understanding of the histopathology of these lesions help provide insight into the development of new revascularization strategies?

Dr Calvin Choi: So as an interventional cardiologists, we do a lot of, angioplasty and stent placement. Chronic total occlusion has been a difficult disease process to manage in the cath lab with angioplasty or stent placement, namely because often these blockages been there for a long period. They do have a lot of calcium involved. So wiring these blockages, or placing a balloon or stent, have been very difficult. Traditionally, these lesions have been treated either with medications for symptom management or if patient has other reasons to have a bypass surgery, they would be referred to our cardiothoracic surgeons for coronary artery bypass grafting.

And that's the traditional way of managing our chronic total occlusion. However, over the past decade or so, we've really made tremendous progress in percutaneous management of chronic total occlusion. Namely because of the technology, advances in technology and also advances in technique in what we do.

In a typical angioplasty, we would wire the artery and use a balloon or stent to open the artery. In a chronic total occlusion setting, just wiring a vessel is extremely difficult using the traditional strategy and technique. So one of the ways we've learned, is that rather than going through the artery, per se, we've learned that we can go all around the blockage, while staying inside the vessel itself, we go through the vessel wall rather than the vessel lumen itself. And that has really tremendously improved our success rate. And today, we're able to have a successful coronary CTO, intervention, up in the ranges of about 90% success rate. Historically, that number has been in the ranges about 50% or even less. So both techniques, as well as equipment, advances in equipment have significantly improved our odds of a successful revascularization involving chronic total occlusion.

Melanie: you for that. And you got to my question about how that radiologic imaging has augmented your therapeutic capabilities for this. So tell us about some widely accepted best practices for CTO PCI. What are the clinical indications Dr. Choi? Give us some indications and what factors the decision to pursue this depends on.

Dr Calvin Choi: So there are a number of reasons why we would pursue or recommend a CTO PCI. One of the reasons is, and probably the most common reason is for symptom management. A lot of patients as mentioned before, have chronic total occlusion, and historically we've offered medical therapy for symptom management and some patients do just fine with medical therapy, some patients, because of other reasons, say they have valve disease or they have multi-vessel coronary artery disease, and they're in need of a coronary artery bypass grafting, so they'll be referred to a surgeon for coronary artery bypass grafting. But those who are not a candidate for bypass surgery because of their comorbidities or other reasons, or patients who are refractory to medical therapy, in other words, medication is just is not enough to control their symptoms and they have debilitating or refractory symptoms despite adequate medical therapy; in that population, CTO PCI is an appropriate treatment option and indicated. But I think the first line therapy would be at least a medical trial of medical therapy. If that fails and patient remains refractory, then CTO PCI is indicated and that will be the primary indication for CTO PCI. That is the symptom management.

Now there are some anecdotal data and also some information that suggest that CTO PCI may improve overall heart function. But I think that's more of select group, not, something that can be applied to a general population with a CTO or chronic total occlusion.

Melanie: Well then since this is such a complex procedure that requires expert care from highly experienced physicians, as you described a little bit about the procedure doctor, do you have any technical considerations you'd like other providers to know, share any contemporary strategy and technique for CTO PCI that you would like other providers to know about?

Dr Calvin Choi: Sure. So, as I've mentioned, we've had a tremendous advance in technique and technology. Regarding technology, to do, to perform CTO PCI successfully, the operator, the physician needs to be fully trained and aware of the use of these equipment. That is critical component of a CTO program. Second is the operator experience. Even with the advances in technique and technology is still a challenging procedure. It takes a lot of experience and time to learn this technique and skill set. If the patient needs a CTO PCI, identifying programs that have a lot of experience in CTO intervention, I think is the first step.

Not every interventional cardiologist is comfortable or facile with CTO PCI, identifying, your experts at an established CTO PCI program, I think is very important. In terms of the skills that's involved for a CTO PCI, one, as I mentioned, rather than trying to go through the blockage itself in the lumen of the vessel, we've learned over the years that you can actually go around the blockage and go through the vessel wall, as opposed to through the lumen of the vessel and in fact, that is a safer and more effective way of opening a chronically occluded, coronary artery. That is one strategy. The other strategy is using collateral vessels. So collateral vessels are these tiny vessels that the heart develops to improve profusion to an area, where the blocked artery is.

And these are small vessels and, may not be big enough to accommodate our traditional balloons and stents, but there are equipments, specialty wires and specialty microcatheters that can be used in this setting to get to the blockage and also use these equipments to successfully open the chronically occluded coronary arteries.

Melanie: Really fascinating, Dr. Choi. So what kind of support do patients need after the procedure? If your program has a focus that engages multidisciplinary teams to best treat the patient, what does that look like for your team? Speak about this approach and why it's so important for these patients.

Dr Calvin Choi: Having a CTO program involves, as you say, multidisciplinary team, surgeons, interventional cardiologists, support staff and nursing technologists. We need to identify first and foremost, who are the patients who are going to benefit from the procedure and what is the best way to treat this patient. And that involves multiple, sub-specialists, cardiac surgeons, interventional cardiologists, imaging specialists. So without that team effort, it will be very difficult to identify that right patient who will benefit from this procedure. And as mentioned before, this is a complex procedure. So I think it's important to identify the patients who will benefit and the best way to do that is to have a multiple sub-specialists engage in a meaningful dialogue and discussion to come up with the best treatment option for the patient. And for that reason, surgeons, imaging specialists, interventional cardiologists, nurses, technologists, and cath lab staff are involved is critical for the success of a CTO program and intervention.

Melanie: Well it certainly is. As we wrap up, Dr. Choi, looking forward to the next 10 years of the field. Tell us about any promising new therapies. Are there any game changers you'd like to mention for chronic total occlusion? Anything you'd like to talk about? Give us a little blueprint for future research that you know about.

Dr Calvin Choi: So recently they've noticed a very promising treatment option. And if you think about the kidney stones, it shouldn't for long time, urologists have used ultrasound to, break kidney stones with lithotripsy. And that's what it's called and recent application of this technology in coronary artery has revealed some very promising results, particularly because of chronic total occlusion involves arteries that a lot of calcium in it, and that really makes the procedure extremely difficult and challenging. And having an ability to address these challenges with lithotripsy, I think is a very promising treatment option going forward. And, I think that it's very promising, to improve a procedural success and two, to be able to perform procedure safely utilizing the technology.

Melanie: When do you feel it's important for other providers to refer to your team of specialists at UF Health Shands Hospital?

Dr Calvin Choi: I think, a trial of medical therapy is critical. I think patients need a trial medical therapy to see if they'll respond. Because if the patients do respond to medical therapy and they get satisfactory symptom management, then there really is no particular reason for patients to go through an invasive procedure because invasive procedures at the end of the day do carry risks. Patients ought to have a conservative management and if they respond well to that, then really no reason to pursue anything further, or anything invasive per se. There are exceptions, but in general, I think that's the strategy I would hold.

If however, patient is refractory to medical therapy and they're not a good surgical candidate for coronary artery bypass grafting, then that is the patient I think would benefit from having a discussion for possible CTO PCI.

Melanie: Thank you so much, Dr. Choi. What an interesting episode and a fascinating procedure. Thank you so much for joining us today. To refer your patient, please visit ufhealth.org/heart for more information, or to learn more about other healthcare topics at USF Health Shands Hospital, 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/

Hybrid Treatment Approaches for Atrial Fibrillation

Additional Info

Audio Fileuf_health_shands/ufhs034.mp3
DoctorsMiles, William;Beaver, Thomas
Featured SpeakerWilliam Miles, MD, FACC | Thomas Beaver, MD, M.P.H.
Guest BioDr. William Miles is Professor of Medicine and Silverstein Chair for Cardiovascular Education. He joined the faculty at the University of Florida in 2005. Prior to his current appointment, he was on the faculty at Indiana University from 1983-1998 where he was Professor of Medicine and Director of the Electrophysiology Laboratory.

Learn more about William Miles, MD, FACC

Dr. Thomas Beaver is The Grant and Shirle Herron Chair and Professor and Chief of The Division of Thoracic and Cardiovascular Surgery at The University of Florida College of Medicine.

Learn more about Thomas Beaver, MD, M.P.H.
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 I invite you to listen as we examine hybrid treatment approaches for atrial fibrillation. Joining me is Dr. Thomas Beaver, he's a professor and Chief in the Division of Cardiovascular Surgery at UF Health Shands Hospital; and Dr. William Miles, he's a professor in the Division of Cardiology at UF Health Shands Hospital.

Gentlemen, it's a pleasure to have you join us today. Dr. Miles, I'd like to start with you. Tell us what you're seeing in the trends for atrial fibrillation. And while you're doing that, please review the types of AFib, including paroxysmal and persistent, and which ones you're seeing more commonly.

Dr. William Miles: Well, we feel like we are seeing a lot more atrial fibrillation recently and we think it's probably because the population is aging. There's a fair amount of chronic illnesses like hypertension and diabetes in the population, which predispose to atrial fibrillation, being overweight predisposes patients to atrial fibrillation. And we now know that sleep apnea and other sleep disorders make patients are very prone to have atrial fibrillation to the point that almost every patient that comes in with atrial fibrillation we now screen for sleep apnea and send a lot of them for sleep evaluation.

Patients can have either persistent or paroxysmal forms of atrial fibrillation. We think the paroxysmal form is sort of in most patients an earlier iteration than the persistent forms. The paroxysmal forms are a little bit easier to treat. The paroxysmal atrial fib is atrial fib that starts and stops spontaneously. The patient may have one or two episodes a week or a month or may have many episodes in a day, but each episode stops on its own and thought to be maybe earlier stages of the progressive progress that atrial fib goes through.

Persistent atrial fib is atrial fibrillation that doesn't stop on its own. That can go on for hours and days until we give a drug or we cardiovert or we do some type of ablation. For the paroxysmal forms, we often start with drug therapy or ablation therapy, catheter-based ablation therapy as the first option and we leave more complicated things for patients who don't respond.

The really interesting area these days is persistent atrial fibrillation where the therapies are much more difficult and so procedures that we're interested in that combine catheter-based with some minimally invasive surgical-based techniques may be advantageous in those particular types of patients.

Melanie: Thank you so much Dr. Miles, for that answer. So Dr. Beaver, we're going to get into this hybrid treatment options and approaches, but before we do, is there anything exciting in diagnosis for AFib? Tell us what you're doing.

Well,

Dr. Thomas Beaver: I think Bill as a cardiologist sees more of the patients on the frontline and as a surgeon, I work closely with him to treat these more difficult patients. But Bill can comment more, but I think people now have iPhones and iWatches and electronics and probably are bringing their AFib to him in the office. Bill, have you been seeing that?

Dr. William Miles: Yeah, we certainly have, and it's actually been very useful. You know, pulse monitors when people would bring in pulse tracings, they are very inaccurate and they're not really particularly helpful in most cases. But the new apps that have an actual electrocardiographic tracing and they can be very high-quality EKG tracings, they are very useful. And you can usually look at those and tell whether is this atrial fibrillation? Sometimes it's artifact that has to be distinguished from atrial fib. Is it atrial flutter? Is it PVCs or just PACs, premature atrial or ventricular contractions?

So we think these patient-based apps are very useful. They don't completely substitute for 24-hour monitors or two-week or a month-long monitors, but they're very useful to help guide us in diagnosis and therapy. It may help us tell whether someone has paroxymal atrial fib or persistent atrial fib, for example.

Melanie: Well then, Dr. Beaver, as oral anticoagulants are really an important therapy, we know that, but they come with limitations and many patients need an alternative. Tell us about some of these treatment approaches and what you're doing at UF Health Shands Hospital. Speak about the hybrid approaches that we've briefly mentioned.

Dr. Thomas Beaver: Well, I think as Bill can comment further when you have atrial fibrillation, there's really two concerns. So one is the concern about the actual heart rhythm affecting the blood pressure and the way people feel. And then there's also the huge component of stroke risk. And that is why patients, of course, are on the blood thinners to prevent strokes, from forming an atrial appendage predominant site where strokes would form.

For over 10 years now, we've been doing a clip that we can put minimally invasive via thoracoscopic between the ribs and that clip essentially isolates out the atrial appendage, and the procedure takes about 30 minutes. And patients that are good candidates for this-- I actually saw a patient yesterday, who they're tried on trials of some of the novel oral anticoagulants or warfarin itself, the traditional anticoagulant, and then they don't tolerate them. For example, some people have stomach bleeding or some people have hematuria or most commonly radiation proctitis from history of maybe radiation to their prostate. So these patients are ideal candidates for these new therapies. There's also the endocardial approach, and they can be put in the cath lab, which is the Watchman device. But I've seen a few patients. In fact, one earlier this year with an atrial appendage that is actually too large for the Watchman, and they're referred for this clip, which is really tolerated very well by patients.

Dr. William Miles: if I can jump in the other patient that I think the left atrial minimally invasive clip is an advantage for is a patient who has an absolute contraindication to anticoagulation. Because to clip the appendage with minimally invasive surgery, the patient doesn't have to be anti-coagulated at all either before or after the procedure. Whereas if you implant a left atrial appendage occlusion device, there needs to be a period of full anticoagulation currently usually about 45 days after implantation of the device.

So if the contraindication to anticoagulation is just relative you can get away with that. But if they have a very serious problem with any anticoagulation, a left atrial clip might be the better therapy for that particular patient. So we try to customize what type of procedure we do to each individual patient's needs.

Melanie: And Dr. Miles, speak a little bit more, expand on the post-procedure drug regimen for us. What happens after one of these procedures or the hybrid procedure or the Watchman, as you mentioned, any of these, are they still using those anticoagulants? What are they doing? What are you doing for them now?

Dr. William Miles: Yeah. So we think that the procedures for atrial fibrillation are not perfect because atrial fibrillation is a progressive process and also a multicentric process that can come from almost anywhere in the left or the right atrium. So once you get rid of atrial fibrillation or minimize atrial fibrillation with any type of ablation procedure currently, we think most of those patients, if they have a high stroke risk score or to begin with, anticoagulation needs to be continued.

So again, one of the advantages of a hybrid procedure that Dr. Beaver does with thoracoscopy, minimally invasive thoracoscopy, is that he can take the left atrial appendage. And once that's done, once the left atrial appendage is clipped, we think that the risk of stroke, of a clot originating from the left atrial appendage is minimized to a point that patient may do okay without anticoagulation.

In general, though, if a patient has a catheter-based atrial fibrillation procedure or drug therapy for atrial fibrillation without occlusion or clipping of the left atrial appendage, if they have a high stroke risk to begin with, they still need anticoagulation afterward.

So again, the two major things that we have to address in every patient with atrial fib is it causing symptoms or is it causing left ventricular dysfunction, number one? And number two, what have we done about the stroke risk?

Dr. Thomas Beaver: I think I might just jump in here, Bill, and just to highlight what the new approaches are. So paroxysmal, as you know, Bill, you've been doing it for years, the catheter approach is actually very successful, especially with the new cryoballoon, but really where I think you find it challenging is the patients that have the persistent AFib for several years, perhaps they've had a catheter ablation in the past and that they still have AFib that's symptomatic for them.

And that's where these newer hybrid procedures, actually they've been around for some time, but I think what's generated interest is the American Heart Association, the clinical trial results from the Convergent procedure, which is one of the two approaches was presented and that clinical trial showed there was a very significant benefit combining a surgical pericardial window, so to speak, where a catheter could be used to ablate the posterior left atrium in tandem with your catheter isolation of the pulmonary veins. And that was proven to be about 70% effective in restoring patients to normal sinus rhythm.

And by the way, we can also put a clip on in that patient if we do that in the operating room to eliminate the stroke risk from the appendage. So that's a very new procedure that we've been doing over the last couple of years here at UF Health. But this is in addition to, as you mentioned earlier, the thoracoscopic approach, which you've also been doing probably over 10 years, which is also in a separate clinical trial, by the way, here at UF Health. It's called the DEEP trial, dual epicardial and endocardial procedure. A clinical trial, which again combines the thoracoscopic approach where we can isolate the pulmonary veins, put a clip on the appendage and then actually create additional ablation lines in the posterior left atrium, which appears to be real driver of atrial fibrillation in the patients with persistent AFib.

And then Dr. Miles can come in and then map those patients. And we have now enrolled three patients in that clinical trial and they're all in sinus rhythm. So we're very excited about the promise of that clinical trial, which is still ongoing. Maybe, Bill, you could comment on the mapping that goes along with those patients, because we've also had some pretty nice maps patients.

Dr. William Miles: Yeah. The principle here is that the cornerstone of atrial fibrillation ablation is isolation of the four pulmonary veins where most atrial fibrillation originates. But as atrial fibrillation progresses from the paroxysmal to the persistent forms, more and more the atrial fibrillation drivers and rotors, the things that generate the atrial fib are located on the posterior left atrial wall. We can address those with catheter ablation, but I'm very jumpy about it because right behind the posterior wall is the esophagus and a very, very life-threatening complication, although rare, can occur if you try to do radiofrequency ablation in those areas.

There are a lot of physicians who do that and they dance around the esophagus and try to avoid it. But I think that a safer way of approaching the posterior wall of the left atrium in people with persistent atrial fib is to do this pericardial access called the Convergent procedure and the maps that we get show very extensive and, for us, very beautiful voltage maps of ablation of the posterior wall by pericardial scope access, the Convergent procedure, with very little worry at least on my part. I don't know how much you worry about it, Tom, but very little worry on my part about damaging the esophagus. So we know where everything is. We control the direction of the heat. We get good posterior wall ablations epicardially and endocardially without risking esophageal injury.

Dr. Thomas Beaver: Well, I think the key is when we have that at epicardial approach, Bill, we're able to direct the ablation catheter towards the left atrium, which is in the 180 degrees opposite the esophagus and also similarly in the thoracoscopic approach. So rather than if you would will in the endocardial procedure where you're actually directing towards the esophagus, we're going the other way. So I think we feel pretty safe.

Melanie: Absolutely fascinating, doctors. I'd like to give you each an opportunity for a final thought. And Dr. Beaver, why don't you start in what you find most exciting for the future of stroke reduction in AFib patients, any procedures you see upcoming, equipment, you know, advances in diagnostic radiology, anything you'd like to discuss as your final thoughts?

Dr. Thomas Beaver: Well, I think what we're excited about and we know that patients that have AFib and actually that have already had a stroke are at significantly higher risk for a repeat stroke. And we've already proven in a small clinical trial that was funded by the NIH here at our center, that we can essentially reduce that risk with these procedures, by putting a clip on.

We followed patients out one year with a follow-up MRI and we had 12 patients in the surgical arm, and none of them had strokes whereas a couple in the medical arm did in fact have a repeat stroke. So these procedures are not only for the general population, but particularly for patients that have had a stroke in the past with AFib. It's a wonderful procedure in my mind. We'll need more trials and more clinical trials, which are ongoing. In particular, I mentioned the deep trial, but I think it's an exciting time and at UF Health. I've appreciated working with Bill over the last 10 years, and we have significant amount of experience taking care of these patients.

Dr. William Miles: Well, I can just say two things very quickly. One, there are new energies other than radiofrequency energy that are being developed, that probably may be able to limit collateral damage such as the esophageal or phrenic damage. One of those is called electroporation, and I think that that's showing some promise. And the other thing is sort of mundane, but the new anticoagulants that are substituting now for warfarin are so much easier for patients to use no monitoring. They're safer from an intracerebral bleeds standpoint. I think that's really a large step forward on the pharmacologic therapy for the prevention of stroke. So those are two things I could mention that I think are steps forward and exciting.

Melanie: Thank you, gentlemen, so much for such an interesting discussion about atrial fibrillation and hybrid treatment approaches to refer your patient, please visit UFHealth.org/heart for more information. Or to learn about other healthcare topics at UF Health Shands Hospital, you can visit UFHealth.org/medmatters to get connected with one of our providers.

And 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/

Burn Care for Pediatric Patients

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Audio Fileuf_health_shands/ufhs030.mp3
DoctorsLarson, Shawn;Indelicato, Lauren
Featured SpeakerShawn Larson, MD, FACS | Lauren Indelicato, DNP, APRN
Guest BioDr. Shawn Larson, an associate professor of Pediatric Surgery, focuses on all aspects of the field, with special interest in pediatric trauma, pediatric burn care, neonatal surgery, and gastrointestinal surgery (including minimally invasive pediatric surgery). Dr. Larson serves as the medical director for the UF Health/Shands Children's Hospital Pediatric Trauma & Burn Program.

Learn more about Shawn Larson, MD

Lauren Indelicato, DNP, APRN, has been a nurse practitioner with the UF Division of Pediatric Surgery since 2007. She focuses on all aspects of pediatric surgery, but has a special interest in pediatric burns and trauma. She is double board-certified as a nurse practitioner in pediatric primary care and pediatric acute care by the Pediatric Nursing Certification Board.

Learn more about Lauren Indelicato, DNP, APRN
TranscriptionMelanie Cole: Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole and I invite you to listen as we discuss burn care for pediatric patients and the principles of pediatric burn management. Joining me in this panel are Dr. Shawn Larson, he's the medical director of the UF Health Shands Children's Hospital Pediatric Trauma and Burn Program, and Lauren Indelicato, she's a nurse practitioner at the University of Florida in the Division of Pediatric Surgery. Thank you both so much for joining us today. And Dr. Larson, I'd like to start with you. Tell us why pediatric trauma and burn injury is such a significant public health issue. What are you seeing in the trends and why are burns so common?

Dr. Shawn Larson: Well, thank you, Melanie, for having us. That's a very good question. So pediatric trauma is the leading cause of death of children from the age of one all the way up to the young age of 44 years of age. A lot of those mechanisms of injury, including burn injury, are preventable. When we're talking about pediatric burns and being preventable, it really, a lot of times, comes down to adult supervision of the children, making sure that they don't have access to chemicals and common household and garage things like gasoline and diesel fuel. We live in North Central Florida, which is a kind of a combination of suburban as well as rural areas, and we have a lot of our families that burn trash, burn leaves, burn brush, and will sometimes use things like gasoline or diesel fuel as an accelerant, which are really, you know, not the best choice because of the flashback burn that they get.

The other thing that we often see too is scald burn. Scald burns are very common in children for a host of reasons, including ramen noodle burns from scalds. These are easy access for a lot of children. They can be put in the microwave. They're easy to cook. And they're also very easy to spill when they're extremely hot and cause some pretty significant injuries. So, that's what we see very commonly here at UF Health.

Lauren Indelicato: And one thing I wanted to add, another common one that we see is people will often burn their trash, so they don't have to pay for trash pickup. And we see kids that run through hot embers, because it's Florida and they run around in their bare feet. They run across an old fire pit that they thought has been out for a long time, but the embers actually stay hot for five days. And we see lots of foot burns from that mechanism as well.

Melanie Cole: Dr. Larson, can you discuss the reasons for us why children require a specialized approach and resources for burn injury? Help us to understand local and systemic physiologic changes caused by burns so that other providers can best understand the therapeutic options available.

Dr. Shawn Larson: Again, another great question. We, in the pediatric community, often will say that children are not small adults. And obviously what does happen a lot of times with a pediatric trauma and pediatric burn injury is that people will extrapolate adult treatment and adult responses to trauma and burns.

There's been some great research that's been done lately, but when you get a burn wound, you have a very large, well, potentially a large surface area of injury, and the effects of that injury are not just at the time of injury, but are ongoing. So children will get a number of different physiological responses to them and you need providers, doctors, nurses, and other hospital personnel that are familiar with dealing with children to recognize, you know, how best to treat that physiological response. When a child comes in, you know, the first thing we do is we do something called the advanced trauma life support protocol, which is from the American College of Surgeons. To ensure that there are not other injuries that are involved, we assessed the child from head to toe very quickly and make sure that there are no life-threatening injuries and then initiate that treatment.

Well, the first thing you got to do with a burn wound is to stop the burn. And then the second thing is to try to prevent is secondary injury from the continuing injury going on at the cell level. So what does that mean? Well, you got to get rid of the dead cells and the dead skin. We got to get some treatment on there. And that. When you think about it, the skin is the largest organ in the body and is an important protective barrier for infection. So we have to get that covered, preferably cleaned and sterilized, or at least some sort of antibiotic treatment and then address the special needs of the children. I'll let Lauren kind of talk us through how a child comes through the peds ER and then through the inpatient stay.

Lauren Indelicato: Yeah. So once the kid arrives in the ER, ER attending physicians usually assess the patient. They give us a call right away. So we come down there fairly quickly. We have the burn nurses who are all specialized burn nurses. They come down and, with the collaboration with the ER staff, that patient usually gets a conscious sedation. And then, the burn nurses go ahead and clean up the burns. They debrid them. They apply the dressing that we usually tell them to whether it's an antibiotic ointment or a silver-impregnated pad called Mepilex. The patient kind of recovers down there. We speak to the family and then they usually will get admitted to the floor.

Once they are on the floor, we follow them very closely, whether they're in the pediatric ICU or on the regular floor. We are very involved with the family. We get Child Life involved who helps with medical play and distraction. We have social work involved with all of our patients to help the families kind of work through this traumatic experience as well as help them with dressing supplies when they're discharged. We also have physical therapy and occupational therapists who are also specialized with burn care to work on range of motion and just kind of getting back to normal life. And then, we also have specialized burn nurses who have been trained on how to do pediatric burn care and dressing changes.

Dr. Shawn Larson: Just like to add, taking care of a pediatric burn, there's some basic principles of first aid that are involved. And a lot of providers can obviously take care of the burns, but when you start getting into the bigger burns or the sicker child, what is most important is the team. And that team is a multidisciplinary team that would approach this just like a cancer diagnosis or other type of injury. And having therapists present and the social work as Lauren indicated are incredibly important for making sure that these kids have the best long-term outcomes.

Melanie Cole: Well, thank you both for that. And Lauren, please expand a little bit on that, the importance of how awareness of those long-term physical and emotional outcomes can be enhanced through participation in burn aftercare programs, scar management, occupational and physical therapy, all of these accesses to burn reconstruction and emotional counseling, and peer support. Tell us about the importance of that and how you help at UF Health Shands Hospital.

Lauren Indelicato: Right. So I run the outpatient pediatric burn clinic, which again is another great multidisciplinary clinic. It is myself with specialized burn nurses. We have Child Life who comes up as well, who helps with the distraction for dressing changes. And then, I also have a physical therapist in clinic who does a great job assessing range of motion issues. She also measures for burn garments, which we provide our patients for scar management through grants that we get through the Children's Medical Network as well as the UF Medical Guild. It is an ongoing process. I see them, you know, through their stages of healing. And I usually follow up with them weekly until they are healed. And then I will see them periodically for about every three months for the first year and a half while they get their scars under control. And then after that, once their scars have matured, I will see them yearly for scar checks for several years.

Melanie Cole: Dr. Larson, as we're talking about future research and putting translation into practice, are there some gaps in the evidence-based knowledge that we have? Tell us of any emerging, unique interventions and challenges that you've noted and what you'd like other providers and pediatricians to do to help their patients prevent burns at home.

Dr. Shawn Larson: Again, another excellent question. There are major gaps in the research that's been done, because we don't know all of the different stages depending on the child's age of their physiological response. And that's one thing that our center has been working towards getting some answers by doing translational research. We've also participated in clinical trials for various treatment, novel treatments for burn wounds.

So one of the things that has always bothered me about caring for burn wounds is that many times the main tool that we have for deep burns and big burns is skin grafting. And while that's some pretty awesome technology, it still ends up creating twice the size of the burn wound. For instance, you have a child that comes in with a 10% burn wound that needs skin grafting. Then in order to cover that area of 10%, we've essentially created a 20% wound. And that child is then going to have to undergo a lot of metabolic changes to heal that 20% wound in addition to the burn injury. And so I think, you know, are there ways that we could use stem cell treatments, or by taking a few cells of skin and potentially growing that.

And we've participated in a number of different trials. We were one of the first institutions in the state of Florida to actually use a system by where we grew a patient's skin to graft. We also have participated in some clinical trials to evaluate new or novel ways to treat burn wounds from using, you know, medicines that could be applied to the burn wound to do the debridement process rather than proceeding to the operating room.

Another clinical trial that were participating in or will be participating in is a way of taking a few cells and expanding those cells literally within one-hour period of time and then putting those cells back onto the wounds to allow them to grow the new skin that we need. We've also participated in a-- It wasn't a clinical trial, but it was a compassionate use, which is the FDA allows us to use experimental type treatment under very careful guidance, to basically take some skin samples from a patient and then grow their own skin in a laboratory, and then use that as part of the autografting process.

So one of the things that we do here at our center is to continuously look for new ways to treat children, whether it be with the debridement process or removing of the injured skin, whether it's the autografting process and then even beyond that where we're looking at ways to better manage scars and the longer-term effects of that. You know, for the pediatricians and the folks that would be referring the patients to our center, that's something that I would like them to know. This is an academic process for us. What do I mean by that? You know, we see the problem and then we try to continuously almost every single day of the year get up and come up with a newer and better way to help these kids.

As far as the pediatricians out in the community who are really obviously the frontline providers and an important first line with this is to discuss fire safety at home. Discuss how are the kids getting burned in the community? Well, in our community, it's the use of scald burns. In the rural communities, it's the use of accelerant on fires and open fires. And then as Lauren had pointed out, there's also a large number of people that do fire pits or burn trash, and to make sure that these fires are properly extinguished. So again, prevention is very important and, you know, there is good evidence out there that when the pediatricians and providers get involved in making sure that children are safe, that that really does help to educate parents and children about the various dangers within the home.

Melanie Cole: And Lauren, last word to you. What would you like other providers to take away from this segment and your multidisciplinary approach to pediatric burn management?

Lauren Indelicato: I think just awareness about what we do here. It seems to be like an ever-evolving process that just gets better and better. I've been here a long time and I've personally seen it evolved into the multidisciplinary clinic. We refer patients out as well, if we need, to other specialties, such as pediatric hand plastic surgeons. Sometimes they need some orthopedic help. It just kind of depends on what's best for the patient. We also are starting to get a little more of the psychosocial aspect of things involved, which I think is a huge part of burns that kind of gets ignored as the patient’s kind of go on with their life. So it really is an evolving process that is moving forward in the right direction more and more.

Melanie Cole: Thank you both so much for joining us today. What an informative segment and such an important topic. To refer your patient, please visit UFHealth.org/pediatric surgery to get connected with one of our providers. Or to learn more about other healthcare topics at UF Health Shands Hospital, please visit UFHealth.org/medmatters.

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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