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UAB Study Shows Additional Antibiotic for C-Sections Reduces Infection A UAB study shows that dosing with an additional antibiotic during non-elective C-sections drops the infection rate by 50 percent ... 6

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UAB first in Alabama to Use FDA-Approved PFO Occluder By Jane ehrharDt

Around one-fourth of all American adults have a patent foramen ovale (PFO). Although present in all humans at birth, this small flap-like opening — the foramen ovale — in the wall between the right and left upper chambers of the heart, usually closes during infancy. Normally, a PFO creates no health problems in adults. In some, it can cause cryptogenic strokes. “There is no data on the subset of those who have strokes with PFO, but we do know that they have strokes and we cannot find any other reason — no blockage and the heart is perfect, but they have PFO,” says Massoud Leesar, MD, UAB professor of medicine and section head of interventional cardiology. “In these patients, it is indicated to close that PFO.” The strokes occur because a blood clot, such as in a leg, migrates to the heart, travels through the PFO from the left to the right side of the heart (CONTINUED ON PAGE 14)

Massoud Leesar, MD discusses the occluder procedure with a PFO patient.

New Long Acting Injectable Helps Chronic Low Back Pain By ann B. DeBellIS

A novel drug, Probuphine, was approved last year by the FDA as the first and only buprenorphine implant to treat opioid dependence. Probuphine implants, placed in the arm, give up to six months of continuous release of a low-dose buprenorphine that helps prevent withdrawal symptoms and cravings. The same pharmaceutical company that brought this drug to market is working on a buprenorphine-based injectable for moderate to severe chronic low back pain. “Fifty million Americans have chronic back pain,” says Ty Thomas, MD, of Alabama Pain Physicians. “Chronic pain patients are often prescribed opiate pain killers to manage Brookwood Baptist Health this pain.” 2001, the Joint Commission rolled out its Pain Management StanSurgeryIn Center–Gardendale 2213which Decatur Highway dards, helped grow the idea of pain as a fifth vital sign. Given the Gardendale, AL time 35071that pain was undertreated, the standards required perception at the Ty Thomas, MD, of Alabama Pain Physicians talks with a patient Brookwood Baptist Health Main: 205-418-6021 about low back pain. Surgery Center–Gardendale 2213 Decatur Highway Gardendale, AL 35071 Main: 205-418-6021 Fax: 205-418-6025

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HEALTHCARE SPOTLIGHT

Monheit Establishes Legacy in Dermatologic Surgery By Cara D. Clark

Gary Monheit, MD learned from the best. And that impetus to achieve high standards has driven his surgical dermatology practice for 40 years. His work at the University of Wisconsin Hospital as a Fellow with innovative cancer researcher and surgeon Frederic Mohs, MD gave Monheit insight into the premier method of treating skin cancers, particularly on the face. By removing only tissue where cancer exists, the Mohs technique combines a very high cure rate with preservation of normal skin, a critical aspect of the treatment. “I saw the value early in how this procedure could take care of cases in which people didn’t think there was a good end point or cure,” Monheit said. “It is the most precise method of treating skin cancer, utilizing surgical removal and microscopic mapping as one removes it. The procedure can take care of early skin cancer and limit the extent of treatment necessary. “I was fortunate to be involved in the early development of this and to rub shoulders with pioneers who championed dermatologic surgery. I’m a past president of the American Society for Dermatologic Surgery. Now there are 3,000 members, but I remember our first meeting with just 15 people. They were pioneers of surgical and cosmetic procedures who laid the groundwork for all of the things we do today.” In appreciation of what Monheit learned from his early mentors and collegues, he has since shared his experience in teaching 22 dermatologists and plastic surgeons during their one year fellowship in Mohs and dermatologic surgery. They, in turn, have paved the way by training their own fellows. Monheit calls these his grand fellows, and feels paternal pride at their accomplishments. He has also closely followed the evolution of cosmetic dermatology from the beginning chemical peels and the early development of laser treatments in removing blemishes and rejuvenating skin. He has been active in the development of botulinum toxin, and has done research for the FDA to verify the safety and efficacy of filling materials and toxins. Monheit has pioneered a namesake peel that has been well-accepted worldwide as a safe treatment for pigmentation, scarring and wrinkles. He began as a solo practitioner in 1977. Since then, Total Skin and Beauty has grown into one of the most wellrespected dermatology practices in the nation with four physicians involved in medical treatment of skin diseases, surgery, preventative treatment, along with cosmetic care. And in addition to the Fellowship Program, the practice has

Monheit and Heidi Nugent, PA-C in surgery.

Gary Monheit, MD with his staff.

a research center that conducts clinical trials for new and innovative drugs and devices. Monheit operates in the surgical center four days a week. He spends one day a week at Callahan Eye Hospital to handle cases in the critical area on the eyelid and around the eye, working with ocular plastic surgeons as a team to approach these difficult problems. He also

serves as an assistant professor in UAB’s Department of Dermatology, and is fellowship director of the American College of Mohs Surgery, teaching residents dermatologic surgery. His work requires him to travel frequently, which gives Monheit and his wife the opportunity to indulge their interest in history. His greatest professional satisfaction

comes from working with patients. “It’s rewarding to see results with patients,” he said. “I’m seeing the third generation of people I started with. It’s gratifying to know we are spreading the word about what we can do. People should be taking care of people. Over the years, I have treated each patient personally with respect while providing the best care possible. I have also made many close friends. The human touch is still the most important part of being a physician. “To me, it’s a calling. We all stand on the shoulders of giants. I know I did. There are people standing on my shoulders now, and to have them following in my footsteps is a great feeling.”

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WOMEN’S HEALTH

Birth Hour Is Important Time for Mother and Baby skin-to-skin time. “We help mothers with positioning and the correct way to feed,” she says. “When Scientists who have studied the you educate mothers while they are birth process have deemed the first breast feeding, it encourages them hour after birth a momentous time and gives them more confidence for baby and parents. Staff at Brookthat they can maintain it.” wood Baptist Medical Center have Beginning to breast feed in that recognized the importance of this first hour also can make a difference bonding time and have developed in the mother’s milk. “Early feeding clinical best practices for newborns has an impact on milk supply. The delivered in their hospital. Skin-tosooner you start feeding, the better skin contact between mother and the milk supply,” Dickerson says. baby, immediately after delivery, is “A mother will tend to have a beta major part of the bonding process ter milk supply in the first two weeks and offers many physical and psyif she starts breast feeding in the first chological benefits. hour.” “We put the baby on mom’s Over the years, nursery rechest immediately after birth so they source nurse Kim Massey has been can begin bonding. That process part of the changes in the birth proalso stabilizes the newborn’s respiracess at Brookwood. “Initially skintion and oxygenation, stabilizes gluto-skin care, focusing on bonding of cose levels, and warms the infant,” the mother and baby and feeding says Glenda Dickerson, Women’s during that first hour, was a culSupport Services Manager. “Jointure change in our community. We ing mother and baby immediately found after we implemented these is important because the mother’s Brookwood Baptist Medical Center encourages skin-to-skin bonding for changes that the patients loved the estrogen and oxytocin are at their mothers and babies. new focus. When they are educated highest level which helps bonding. about the process, it is overwhelmIt also impacts the father, because things to make the birth experience more ingly positive,” she says. “The sooner she emits those hormones and encourages intimate, such as a clear C-section drape you get moms and babies together, the them to bond as a family.” so the mother can see the baby being lifted more confidence they have when they go Skin-to-skin contact also colonizes out if she wants to,” she says. “We also home.” baby with the mother’s skin. “That prowarm the operating room to keep mom Another clinical practice is screening vides immunity benefits to the baby. It and baby comfortable. A nursery resource new mothers for signs of postpartum dealso decreases discomfort after the birth for nurse helps make mom and dad part of the pression, a condition that affects one out both mother and baby,” Dickerson says. birth.” of seven women. New mothers complete Nurse Educator Lynn Jeter says that The birth hour is also the best time the Edinburgh Postnatal Depression Scale skin-to-skin time is encouraged for both to begin breast feeding, and skin-to-skin survey while they are in the hospital. “In vaginal and C-section births. “Our goal contact helps facilitate that process as well. addition to this assessment, we also watch is to provide the same care regardless of Ali Hardy, a nursery resource nurse, says mothers for cues such as tearfulness, not how the baby is delivered, so we keep Cright after delivery baby will find its way to wanting to hold the baby, or wanting us to section mothers and babies together durits mother’s breast on its own during the care for the baby,” says Sandra Brewton, ing the birth hour. We have implemented By ann B. DeBellIS

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Labor & Delivery Director. “Postpartum depression usually occurs in the first week after delivery and can last throughout the first year, so it is important that we educate the family about signs of this condition.” During discharge, the father is included in discussions so he will recognize symptoms. “We tell fathers to watch for mom’s disinterest in caring for herself or her baby or feeling overwhelmed. If symptoms come and go, that’s normal. If they come and stay, that’s when we need to be careful,” Brewton says. Cindy Jones, Director of Inner Path, Brookwood’s outpatient psychiatry program, says it is not unusual for “baby blues” to affect mothers. “70 to 80 percent of mothers experience baby blues, a milder form of postpartum depression,” she says. “Those feelings resolve themselves, but actual postpartum depression lasts longer and can become prolonged.” Jones says the quicker postpartum depression is diagnosed, the better. “If it lasts more than three weeks, it can affect the mother’s ability to bond with her baby. She is overwhelmed, and it is important that we get them back to a balanced place so she can take care of herself and her baby,” she says. The most serious form of the condition is postpartum psychosis, a state of mind where the mother might harm herself or her baby. “These mothers feel completely disassociated and can’t care for themselves. They are delusional and cannot cope at all,” Jones says. “It is a rare disorder but a serious one.” Inner Path provides treatment that allows mothers to talk with people who are supportive, including some who have experienced some form of postpartum depression themselves. Anyone can self-refer online or by fax. “We provide an environment where mothers can better understand their problem and put it all in perspective. Inner Path offers hope,” Jones says. If a patient needs additional therapy when they leave Inner Path, the staff will refer her to a psychiatrist or therapist. “It is important to know that there is help out there, and there are ways to get the support you need on an outpatient basis, whether it is through Inner Path, a support group, a psychiatrist or therapist,” Jones says.

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WOMEN’S HEALTH

UAB Study Shows Additional Antibiotic for C-Sections Reduces Infection By Jane Ehrhardt

A UAB study shows that dosing with an additional antibiotic during non-elective C-sections drops the infection rate by 50 percent. “Infection during the postpartum period is a major health problem for both mom and baby, and a common underlying cause of death,” says Alan T. N. Tita, MD, PhD, a professor in the UAB Division of Maternal-Fetal Medicine, director of the Center for Women’s Reproductive Health, and principal investigator of the study. The study, published last September in the New England Journal of Medicine, covered a clinical trial of 2,013 women in the United States from across 14 hospitals. The participants were more than 24 weeks into their pregnancy and required a C-section during labor or after a membrane rupture. “The strongest risk of infection is when a woman undergoes labor and then gets a C-section, because labor or a membrane rupture allows bacteria from the lower genital tract — which is colonized by many organisms — to ascend to the upper genital tract where there is less contamination,” Tita says. With these nonscheduled Cesareans, the risk of infection runs as high as 12 percent. “12 percent corresponds to a substantial number of infections, considering there are millions of cesareans,” Tita says.

Alan T. N. Tita, MD, PhD talks with a patient.

Infections remain in the top five causes of maternal death, and C-sections cover one-third of all births. The surgical procedure ramps up the risk of infection for the mother five times over a vaginal delivery. In the study, which was conducted from 2010 through 2014, half of the participants received the standard antibiotic regimen of cefazolin during their C-section. The other half received cefazolin along with 500 milligrams of the macro-

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lide antibiotic, azithromycin. “Azithromycin is not a new antibiotic for use during pregnancy,” Tita says. “It has been used for other reasons, like chlamydia and preterm membrane rupture.” Azithromycin was chosen because it fights anaerobic and ureaplasma organisms, which studies found to be the primary cause of post-partum infections. “Those bacteria are not covered by the standard antibiotic we use during C-sec-

tions,” Tita says. “When our group first developed the idea that a second antibiotic could help reduce infections for these women, we found reassurance in the fact that some patients who have preterm premature rupture of the membranes receive two antibiotics to help reduce infection and prolong pregnancy,” Tita says. The study reported that azithromycin-dosed mothers were less likely to have positive cultures for any bacteria and for antibiotic-resistant organisms. Infectionrelated complications also dropped in participants who had received azithromycin, including wound complications, wound hematoma, and wound breakdown where the wound opens without any clear sign of infection. Study participants who took the additional antibiotic reported notably fewer hospital stays for any reason. Their emergency room visits dropped by 40 percent over those who only received the cefazolin, and readmissions fell by 45 percent. The readmissions specifically for infection dwindled by 64 percent. The data from the 14 hospitals, analyzed by UAB’s department of biostatistics, found that the additional azithromycin did not increase the risk of adverse events in the babies. They were tracked up to three months after birth. “We looked at selected outcomes, such as admission to neonatal ICU, and there was zero difference,” Tita says. With the babies, the future currently still holds an unknown. “The concern is that antibiotics may influence the initial makeup of germs that are normally part of body surfaces and may expose them to longer-term problems,” Tita says. “We need to follow these babies over several years to see that they’re not doing poorly compared to those who did not get the azithromycin.” They plan to check all the babies at around five to ten years of age. For the mothers, the strong positive health outcomes should also translate to lower expenses. “There are significant costs associated with infections,” Tita says. “The reduction in readmissions, visits, fevers, and overall antibiotic use due to the intervention was higher than we expected, and translates to reduced healthcare costs.” This breakthrough means less suffering for mothers having undergone unexpected C-sections, and appears to have identified a simple and inexpensive way to reduce the most common complication associated with cesarean delivery.


WOMEN’S HEALTH

Fighting Breast Cancer with New Research, New Tools By CINDY SANDERS

Although many more will die from heart disease and lung cancer, breast cancer remains the most feared diagnosis for many women. The bad news is it is the most common cancer among U.S. women with the exception of skin cancer. The good news is that death rates have dropped over the years and new treatment options continue to come online. The American Cancer Society estimates about 252,710 new cases of invasive breast cancer and 63,410 new cases of carcinoma in situ cases will be diagnosed in 2017. Additionally, the ACS estimates 40,610 women will die from breast cancer this year. The second leading cause of cancer death in women, the death rate declined by 38 percent from a peak high in 1989 until 2014 (the last year for which figures are currently available). The ACS “Cancer Facts & Figures 2017” attributes the drop, which cumulatively translates to almost 300,000 fewer deaths from breast cancer, to improvements in early detection and treatment.

Localized cancer, which makes up more than 60 percent of newly diagnosed cases, has a five-year relative survival rate of 99 percent. Invasive breast cancer has a 90 percent five-year survival. Today, there are more than 3.1 million breast cancer survivors in the United States.

Primary Prevention: Diet Matters A study released earlier this year in Cancer Epidemiology, Biomarkers & Prevention, a journal of the American Association for Cancer Research, found poor diet in adolescence and early adulthood is linked to an increased risk of premenopausal breast cancer. Specifically, the study pointed to a diet associated with chronic inflammation that was low in vegetables and high in carbohydrates, refined sugar, and processed meats as being a culprit for significantly increased risk, according to Karin Michels, ScD, PhD, lead author and Karin Michels professor and chair of the Department of Epidemiology at the UCLA Fielding School of Public Health.

“Because breast cancer takes many years to arise, we were curious whether such a diet during the early phases of a woman’s life is a risk factor for breast cancer,” she said. The research team used data from 45,204 women in the Nurses’ Health Study II who had previously completed food frequency questionnaires about diet during high school and later questionnaires about eating habits at various stages of adulthood. Michels and colleagues then assigned an inflammatory score based on the women’s adolescent diet and created five groupings. During 22 years of follow-up, 870 women were diagnosed with premenopausal breast cancer. Those who were in the top inflammatory score group from adolescence had a 35 percent higher risk for premenopausal breast cancer than those in the lowest score group. The researchers then used the same method to score early adulthood diet based on the later questionnaires. When the analysis was run using that data, women in the highest inflammatory score group had a 41 percent higher risk for premenopausal breast cancer relative to those in the lowest score group. “Our results suggest that a habitual

diet that promotes chronic inflammation when consumed during adolescence or early adulthood may indeed increase the risk of breast cancer in younger women before menopause,” said Michels. Recognizing each woman’s breast cancer risk is different based on a host of factors from demographics to genetic predisposition to lifestyle choices, Michels said this study points to poor diet as yet another potential factor to consider. While not definitive –Michels noted the study had several limitations including the fact that adolescent diet was recalled at a later date by participants and that researchers did not have access to adolescent and early adulthood measurements of blood markers of inflammation – she noted consuming a healthier diet when young appeared to afford some protection. Michels concluded, “During adolescence and early adulthood, when the mammary gland is rapidly developing and is therefore particularly susceptible to lifestyle factors, it is important to consume a diet rich in vegetables, fruit, whole grains, nuts, seeds, and legumes and to avoid soda consumption and a high intake of sugar, refined carbohy(CONTINUED ON PAGE 18)

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Increase in Death Rates among Middle Age Whites with Little Education By Laura Freeman

“Death of hope” may not be listed on many coroners’ reports, but if you are trying to identify the killer causing an alarming increase in mortality and morbidity in middle-aged white Americans with a high school education or less, it’s a prime suspect. Mental health affects physical health, and there is a lot for this population to be depressed and anxious about—with few resources to change the outlook, and nowhere left to move to look for better opportunities. In an April report releasing a deeper analysis of their disturbing 2015 study, Princeton economists Anne Case and noble laureate Angus Deaton found that the problem goes beyond the lethal increase in deaths from drugs, alcohol and suicide. Deaths from all causes are up in both men and women—but only in the United States. “Life expectancy has been the pulse we use to tell us how a country is doing. Judging by the vital signs we are seeing in this report, the U.S. has a problem” UAB sociologist Nyesha Black, PhD, said. “The increase in deaths isn’t happening in other affluent countries with large populations of European descent. They faced the same economic challenges from a world- Nyesha Black, PhD wide recession and job displacement from globalization and automation, but their mortality rates are improving.” A case in point is the divergence in U.S. and German death rates. 15 years ago, mortality rates in less educated middle-aged caucasians in the two countries were virtually the same. Today, those in America are 45 percent more likely to die before their time. Out of every 100,000 in population, there are 125 more deaths in the U.S.

What is killing so many Americans? In the preliminary report that came out in 2015, the study authors identified the three most obvious increased causes of death as drug overdoses, diseases related to alcoholism, and suicide. However, of the 125 additional deaths cited above, only 40 could be attributed to the big three. The remaining 85 were more difficult to explain. The authors of the study are working with a model of cumulative disadvantage to make sense of the numbers. What this demographic group has in common is long-term unemployment, underemployment, and lack of resources. This

economic instability has translated into a difficulty forming stable relationships that could provide emotional support. This segment is waiting later to marry and start families, and if they do marry, their relationships are less likely to survive. Economics are a big part of the equation, but it’s about more than money. White men in low skill jobs still earn 36 percent more on average than their black counterparts, but death rates in black people have declined to the point that rates in the two populations have converged. Years of disappointment take their toll. When people reach middle-age and realize their lives aren’t turning out as they hoped, and they see no way to change the outlook for the better, they may either give up hope or turn to other ways to ease the pain that aren’t healthy. The same stresses that lead to drugs, alcohol and suicide also influence the immune system, heart disease, cancer and obesity-related disorders like diabetes and hypertension. Without insurance benefits from a job or the income to buy insurance or pay for basic care, diseases are less likely to be detected early. Even with good insurance, a colonoscopy can cost $400 or more out of pocket. For people who can’t find a job, choosing between a health screening and feeding their children is no contest. A lack of resources is also making bad problems worse. As UAB psychiatrist and addiction recovery specialist Cayce Paddock, MD, pointed out, drugs can kill in more than one way. “We’re seeing people drop left and right from drug overdoses here in Birmingham,” she said. “According to coroner’s reports, between January and September of last year, heroin/Fentynal deaths were double the suicide rate in Jefferson County. However, people are also sharing needles and we’re seeing a spike in hepatitis C infections. HIV rates could also go up. When people inject, they aren’t thinking about clean conditions. They are thinking about not feeling bad. The germs they inject can cause abscesses, sepsis, and endocarditis that may send them into heart failure.” Though drug deaths are happening in every demographic group, those with only a high school education or less are particularly at risk. They often work in jobs where accidents, back injuries and repetitive motion injuries cause pain. A hospital stay or visit to the doctor may come with a prescription for an opiate. “A while back, doctors were criticized for not adequately treating pain,” Paddock said. “So they started prescribing more of the newer drugs that didn’t seem to have the same side effects as older drugs. As we know now, some of these drugs were more (CONTINUED ON PAGE 16)


BEHAVIORAL HEALTH

Study Highlights Higher Death Rate for Young People Experiencing an Incident Episode of Psychosis By CINDY SANDERS

A study published last month in the journal Schizophrenia Bulletin found the death rate in young people during the year following a first episode psychosis incidence was much higher than anticipated. Analyzing claims data on approximately 5,000 young people ages 16-30 with commercial insurance who had received a first observed psychosis diagnosis, researchers from the National Institute of Mental Health (NIMH) found the group had a mortality rate of at least 24 times higher than the same group in the general population in the 12 months following the index psychotic episode. With abundant clinical evidence from the United States and other countries showing a correlation between mental illness and decreased life expectancy, the NIMH research team expected there would be elevated mortality for this group but were still surprised by the findings. “I wasn’t surprised by the direction of the effect. I was surprised and shocked by the scale of the effect,” said Michael Schoen-

baum, PhD, senior advisor for Mental Health Services, Epidemiology and Economics for NIMH who led the research project. He added, “We were so shocked when we first did this analysis that we bent over backwards to check it and make sure we hadn’t used the data wrong and made

a mistake.” After recalculating, the team concluded they hadn’t missed the mark … and, in fact, reported the figures using the most conservative assumptions. “To find a group in the U.S. general population with mortality as high as our conservative estimate for these young people, you have to look at Americans over age 70,” said Schoenbaum. “The upper end estimate is more than a 7 percent mortality rate in a year. In the general U.S. population, you wouldn’t expect to see that rate until people are in their 80s.” In addition to mortality, the study also looked at the healthcare treatment those ages 16-30 received in the 12 months following the initial psychosis diagnosis. That analysis uncovered the group had low rates of medical oversight and only modest involvement with psychosocial treatment providers. According to the report, “In the year after index, 61 percent of the cohort filled no antipsychotic prescriptions and 41 percent received no individual psychotherapy. Nearly two-thirds (62 percent) of the cohort had at least one hospitalization

and/or one emergency department visit during the initial year of care.” Schoenbaum said the NIMH has made it a strategic priority to not only discover new treatment options for those with a diagnosed mental illness but to also develop and test better ways to deliver existing treatments. “This is a devastating thing to happen in Michael people’s lives,” he noted. Schoenbaum, MD “We’ve had data for a long time that suggests historically there has been a long gap in time between when a person experiences psychosis for the first time and when they receive meaningful care.” This new analysis, he said, helps confirm that suggestion and shows there is much room for improvement. The study, which looked at 2008-2009 commercial payer data, was made possible through a multi-payer claims database built by the Department of Health and Human Ser(CONTINUED ON PAGE 12)

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BEHAVIORAL HEALTH

Helping Those with Autism Build a Better Life By Laura Freeman

“There’s a classic saying, and it’s true - if you’ve met one person with autism, you’ve met one person with autism. Although some symptoms are commonly found in people with Autism Spectrum Disorder (ASD), every individual is different. The combinations that occur and the degree of severity differ widely from one person to another,” DevelopmentalBehavioral Pediatrician Justin C. Swartz, MD said. “Researchers are working in many areas of inquiry related to the causes of ASD and how it works in the brain. It may take a while to get definitive answers to some questions and generalize them to such a diverse population,” he said. “In the meantime, the key to maximizing a child’s developmental potential is early diagnosis. Each child comes to us with a unique combination Justin C. Swartz, of strengths and weakMD nesses. By getting an early start on a program that builds on strengths and works on improving weaknesses, we can make a difference in the person’s quality of life at any age.” Swartz, an assistant professor of pe-

diatrics at UAB, is part of the team in the Developmental Medicine Clinic at Children’s of Alabama. In the rare specialty of developmental-behavioral pediatrics, he is equipped to evaluate children from both a medical and behavioral perspective. “Several physical issues are common in people with autism, particularly the genetic syndromes, but we don’t really have objective biometrics we can rely on for diagnosis,” he said. “It’s very much behaviorally based. Our team evaluates hearing, speech, nutrition and specific issues like sleep and unusual behaviors. Children are often referred to us if their communications skills are delayed, they display repetitive behaviors, or they avoid

interaction. They may have trouble gathering information from the world around them or difficulty with fine motor skills. I like to talk with the child’s family to get a sense of what they are seeing. Spending time with the child, observing and interacting, tells us whether ASD is the correct diagnosis and where we should start with interventions.” On special projects, Schwartz works with Sarah O’Kelley PhD, an assistant professor at UAB who works with autistic children, teens and young adults through the Civitan-Sparks Clinic. “In making an evaluation, we keep in mind that there are a number of things that may suggest autism that could actually be something else. A child may simply be introverted, which could explain hesitancy to make eye contact,” O’Kelley said. “Hearing and speech issues can be related to communication delays. Anxiety, depression and a variety of other conditions may look like ASD until you look closer. There’s also an area of thought that suggests some cases of ASD may simply be an example of human diversity. “I like to get the long view from the family who sees the child every day. Then I observe how children respond to me and to others. Do they engage in an age appropriate way, how do they talk about their interests and do they pick up on fa-

cial cues?” When a diagnosis of ASD is confirmed, Schwartz says Intensive Behavior Intervention can be valuable in using motivation reinforcement to work on specific targets like improving eye contact, responding to name, expanding diet and learning new life skills. “It can be helpful even to older children and adults. It isn’t readily covered by insurance, but the Alabama legislature is now working on legislation that could change that,” Schwartz said. For teens and young adults interested in building social skills that can help them make and keep new friends, O’Kelley trained at UCLA to be able to offer their highly regarded PEERS group program here in Birmingham. “The program is 14 weeks for teens and 16 for young adults. It has been very popular with both the patients and their families. There is so little offered for this age group, and this is a time in their lives when expanding their social contacts may be especially important to them,” O’Kelley said. “We teach them how to identify people who may share their interests, and how they can invite or accept invitations to spend time together. We also teach them how to deal with negative situations like teasing. It depends, of course, on where each person started, but by (CONTINUED ON PAGE 12)

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Study Highlights Higher Death Rate for Young People, continued from page 9 vices using funds from the stimulus package following the financial crisis. “That dataset did two things we couldn’t easily do before this,” explained Schoenbaum. “First, it was a really large sample.” He said having access to this commercial payer information was critical since most young people in the United States have commercial insurance … if they have coverage … at the time of symptom onset. While Schoenbaum said a limitation of the study was that the team couldn’t definitively say it was each individual’s first episode of psychosis without having lifelong data, they did single out only those young people who had no sign of psychosis in the 12 months prior to the documented episode. “The second innovation in this dataset is that it also contained information on mortality,” he continued. “In this country, it is relatively rare to link information

on people’s health and healthcare on the one hand with death and mortality on the other.” There are, of course, exceptions. Schoenbaum said there is really good mortality data available for cancer and cardiovascular surgery. “But there is no place in mental health where we do that right now,” he noted. “You have to know there’s a problem before you can fix it. If we can’t study patterns of mortality, we don’t know if there’s a problem and what kind of problem it might be.” Going forward, Schoenbaum said he would like to see if their findings are replicated in other U.S. samples and to have access to more specific mortality data. The database used listed all cause death without specifying if mortality was a result of suicide, homicide, accident, or other. “It would be really valuable to not just know that they died but how they died.” He also said it’s important to imple-

ment the clinical practice guidelines that already exist more consistently and then measure the impact on mortality. Despite being identified with early psychosis, Schoenbaum said the analysis highlighted the next critical step of effectively connecting these patients to models of care didn’t routinely happen. “This is a highly vulnerable population. We just didn’t realize how vulnerable,” Schoenbaum said of the study’s results. “We want to connect them to effective services. One hope is that people recognize that these individuals aren’t just at risk of suffering … their lives are at stake.” On the positive side, he continued, “The relatively low levels of care that we observed here underscore the potential value of the new models for treating first episode psychosis, specifically what’s called coordinated specialty care.” Congress has earmarked 10 percent of SAMHSA mental health block grant fund-

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ing go to states for coordinated specialty care programs for first episode psychosis. “By 2018, all states are expected to have at least one such program, and some states will have multiple programs,” Schoenbaum said, adding such programs are measurement-based and are engineered to analyze results and make adjustments as needed. Schoenbaum’s other hope is that the study will help launch larger conversations about mental health and mortality. “Together with the national increase in suicide rates and the national epidemic of deaths from opioid overdose, I think this paper underscores the importance of tracking mortality as an outcome for people with behavioral health problems,” he said. “In the meantime, this study is a wake-up call telling us that young people experiencing psychosis need intensive, integrated clinical and psychosocial supports,” Schoenbaum concluded.

Helping Those with Autism, continued from page 10 the end of the program most of the participants are showing improvement. They get together more often and the quality of the time together changes as they get to know each other. We’re getting great feedback from families.” Other work at UAB is helping ASD patients improve their ability to interact with the rest of the world. “We have a monkey robot that is great at building interaction skills with children who aren’t quite ready to interact with adults,” O’Kelley said. “One of our colleagues also has an autism driving program that is getting national attention. People with autism tend to like to follow rules, so that can be helpful in making them good drivers. When other people don’t follow the rules or when multitasking is involved, that’s where the driving program can help. “People with autism can often benefit by being taught specific skills that other people just pick up as a routine part of life. Learning those skills can make a difference,” O’Kelley said. Neurological research at UAB is also using PET scans to look at differences in the neural connectivity of the brain in autism. There is also research into what appears to be multiple causes of the disorder. Schwartz said, “A combination of genes and environment may be involved. Some families seem to be at increased risk of autism in a second child, and there have also been studies showing an older mother or father can increase risks. That suggests some of those genetic changes could happen over time. Several possible environmental triggers are being investigated. We may eventually find that autism is a symptom of another process that is going on. “Work is also being done to map brain activity, eye movement and other early indicators that could help us identify autism sooner so we can help ADS children grow up to live fuller lives.”


Revocation Of Enrollment In The Medicare Program- A powerful Weapon In Medicare’s Arsenal by

Angie C. Smith

In 2014, CMS issued a final rule related to 42 CFR 424.535, which gave CMS expanded authority to impose penalties on providers. Although the rule is several years old, the first version published in 2006, the rule has been expanded over the years, and CMS’s use and enforcement appears to be increasing. Therefore, it is important to understand the basis of revocation and the implications for providers who receive notification from CMS or its MAC contractor regarding revocation. The regulation allows CMS to revoke a provider’s billing privileges under the following circumstances: • Noncompliance with enrollment requirements; • Provider or supplier conduct - being barred or excluded from Medicare; • Felony convictions in the past 10 years which would be detrimental to Medicare or its beneficiaries; • False or misleading information the provider certified as true false or misleading information when enrolling in the Medicare program or to maintain enrollment in the program;

• On-site review - if during onsite review, CMS determines the provider is no longer operational or does not meet provider enrollment requirements; • Grounds related to provider screening requirements - failure to submit an application fee or CMS is unable to deposit funds submitted for the application fee; • Misuse of billing number - knowingly sells or allows another to use its billing number (does not include assignment of billing number); • Abuse of billing privileges - submitting claim for services that could not have been furnished (i.e., beneficiary is deceased) or pattern and practice of submitting claims that do not meet Medicare requirements; • Failure to report changes in location, ownership or adverse legal action; • Failure to document or provide CMS access to documentation; • For a home health provider, failure to meet initial reserves operating fund requirement; • Medicaid termination; • Prescribing authority - suspension or revocation of DEA number or state revocation or prescribing authority;

• Improper prescribing authority - a provider has a pattern or practice of prescribing Part D drugs that fails to meet Medicare requirements or is abusive or is a threat to the health and safety of Medicare beneficiaries. When a provider’s or supplier’s billing privileges are revoked, the Medicare provider agreement is also terminated. The revocation results in a bar from participating in the Medicare program from the date of the revocation until the end of the re-enrollment bar. This is not the same as being excluded or “debarred” from Medicare. The re-enrollment bar begins 30 days after CMS mails notice of the revocation and can last from one to three years. The period of the bar is supposedly based on the severity of the basis of revocation. If after the bar on enrollment ends, a provider or supplier seeks to re-establish enrollment in the Medicare program, it must re-enroll in the Medicare program as a new provider or supplier through the completion and submission of a new enrollment application and applicable documentation. Certain providers and suppliers will be resurveyed and recertified.

If the revocation was due to adverse activity (sanction, exclusion, or felony) against an owner, managing employee, or an authorized or delegated official, or a medical director, supervising physician, or other personnel of the provider or supplier furnishing Medicare services, the revocation may be reversed if the provider or supplier submits proof that it has terminated its business relationship with that individual within 30 days of the revocation notification. When a provider or supplier is revoked from the Medicare program, CMS automatically reviews all other related Medicare enrollment files that the revoked provider or supplier has an association with (for example, as an owner or managing employee) to determine if the revocation warrants an adverse action of the associated Medicare provider or supplier. Except for home health agencies, a revoked provider or supplier must submit all claims for items and services furnished before the date of the revocation letter within 60 calendar days after the effective date of revocation. A revoked home health agency must submit all claims for (CONTINUED ON PAGE 16)

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UAB first in Alabama to Use FDA-Approved PFO Occluder, continued from page 1 and then on to the brain, where it causes a stroke. “Stroke in patients younger than 60 years old is probably related to PFO,” Leesar says. Patients older than 60, should have more common causes ruled out, such as atherosclerosis and atrial fibrillation. The treatment for those suffering strokes from PFO has commonly been a blood thinner. Another option was to insert a device called an occluder to plug the hole. Leesar has performed over 100 of these procedures in the last 10 years. “But there was no guidelines or FDA approval,” he says. That was because studies on the occluder had produced mixed results. However, those trials had included PFO patients who had never had a stroke. “But the RESPECT study fixed that,” Leesar says, and the results changed everything. Published last November, the RESPECT study (Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment), showed a strong advantage for implanting an Amplatzer PFO Occluder in PFO patients who had experienced strokes. “That approved the device,” Leesar says. “It’s the first time a study clearly showed that patients who had prior strokes benefited from this device.” The long-term study stated that after six years, participants showed a 45 percent relative risk reduction in preventing any recurrent ischemic stroke, and a 62 percent relative risk reduction for preventing recurrent ischemic stroke from an unknown mechanism (cryptogenic). In January, UAB was the first in Alabama to use the newly FDA-approved

Top left: echocardiogram shows PFO flap-like opening in heart. Top right: Occluder has closed PFO. Below left: The occlude device.

occluder. “Our first patient did very well and was discharged the day after the procedure, since the echocardiogram showed complete closure of PFO,” Leesar says. The procedure is done in the cath lab. First an imaging device — a special echo device — is inserted through the vein in the groin area to the heart, so the surgeon can see the hole. Then surgeons advance the PFO Occluder through the other vein in the groin area. “We deploy it into the hole, then release the device, and it stays in the heart,” Leesar says. When open, the occluder resembles

a double-decker, woven-mesh disk. When travelling through the vein, it looks like a closed umbrella. In the heart, the smaller disk inserts through the hole and unfurls flat. The bigger disk remains on the other side of the hole, completing the closure. The pressure of the from both sides keeps the disks in place. “It gradually gets covered by cells, and stays there forever,” Leesar says. Like stents, the occluder is composed of metal nitinol resulting in zero antigen effects. During the three months it takes the cells to cover the device, the patient takes Plavix to thin the blood. After that, patients take a daily aspirin to keep the blood thin in case some area may not be completely covered. Complications can occur in the deployment. “It can cause stroke if not done perfectly, because air bubbles can go to the brain or, rarely, a device can fracture or, very rarely, a device can move and separate from hole,” Leesar says. But the only bad experience Leesar has heard of with the device was due to a nickel allergy

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in the patient. “There’s a mixture of nickel in nitinol,” he says. This device is not new; nor is the procedure. “But now we have guidelines and a defined group of patients who will benefit most,” Leesar says. “And the occluder should be used. Deploying the device is a very reasonable approach to preventing future events.” He expects that with the new FDA approval, UAB will soon be performing the PFO occluder procedure two to three times a month.

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What Patients Say, What Doctors Hear by Danielle Ofri, MD; $24.95; 242 pages The examination wasn’t bad. The hospitals have, simple might seem conidea of it, perhaps, was worse. trary but Ofri says that listening, from a Your doctor took your vitals, looked doctor’s standpoint, is not just a matter in your mouth, felt of hearing a list of comaround your jaw, and plaints. It’s “a diagnostic thumped your back. He tool and a therapeutic asked questions, you antool” requiring the work swered, got down from of two to be effective. the table, got dressed, Because body language and got your prescripcan speak volumes, listion. In and out in fiftening is also sometimes teen minutes but what done by the eyes. just happened? After But listening goes reading the new book both ways and the What Patients Say, What words a doctor says and Doctors Hear by Danielle they way she says them Ofri, MD, the answer “can have a potency may be “not enough.” comparable to the medWhen you’re sick, ications we prescribe.” your doctor might order Patients must closely an MRI, CT, PET, listen to what their EKG, good old X-rays, doctor says in order to Danielle Ofri or any of dozens of new self-care and heal at medicines. That alphabet soup of diagnoshome. Here, Ofri believes, is where body tics may give you pause, especially when a language comes in: sometimes, patients simpler thing may work just as well. may give nonverbal clues or reasons for With the advanced technology that noncompliance. Perhaps they are embar-

rassed or fearful; can’t afford care or don’t have access to it; can’t read instructions or don’t understand them. They may not know their diagnosis, or even their doctor’s name. Listening, Ofri says, can help when conflicts arise and mistakes are made. It can give patients a better outcome. Good communication will ensure that everyone understands what is about to happen, and it helps a doctor break bad news. “Taking a history” is one of the first things physicians learn in med school. And, says Ofri, “It can sometimes mean life or death.” What Patients Say, What Doctors Hear is a book that makes you want to hang on every word. Obviously, Danielle Ofri, MD is good at communicating, even though she admits that there were times when she wasn’t. That’s one of the best parts of this book: Ofri not only uses herself as an

example, but she spent months interviewing doctorpatient pairs in order to understand the importance of listening in a medical setting. Readers get real-life stories to illustrate the points Ofri makes, told in language that’s authentic but that doesn’t require a PhD to grasp. We’re also given subtle advice on getting (and giving) the best care possible through listening and communicating. This is the book you want to read in the waiting room at your next doctor’s appointment. It’s the one you’ll want to take to the next medical conference. In both cases, it could make a difference. With What Patients Say, What Doctors Hear, it’s your listening skills you’ll be examining. Terri Schlichenmeyer is a professional book reviewer who has been reading since she was 3 years old and she never goes anywhere without a book.

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Diseases of Despair, continued from page 8 addictive than we may be even more realized, and some difficult. people can become To understand addicted much faster what is going on, two than others. Doctors things a sociologist are now cutting back would likely examon writing prescripine are how the sotions for opiates. In cial structures differ patients who arenâ&#x20AC;&#x2122;t where this problem is already addicted, happening and what that could be the best was going on in the decision. However, society just before the Cayce Paddock, MD when addicts are cut problem began. off from prescription drugs without alterâ&#x20AC;&#x153;Though other countries where mornatives, feeling so bad sends them to the tality rates continue to go down have streets for relief. the same gene pool and the same global â&#x20AC;&#x153;Here in Alabama, heroin is being economic influences, they have different cut with manufactured Fentynl which is forms of government, different healthcare 20 times stronger. Pills that look just like systems and different social safety nets,â&#x20AC;? a Percocet can be so much more powerful Black said. â&#x20AC;&#x153;We need to understand what that people can easily overdose and die,â&#x20AC;? is working for them that isnâ&#x20AC;&#x2122;t working for Paddock said. us. â&#x20AC;&#x153;Another problem is that it has been â&#x20AC;&#x153;There is usually a delayed impact on very difficult to get in-patient coverage populations as macro changes in policy for opiate rehab because detoxing doesnâ&#x20AC;&#x2122;t and economics ripple through a society. usually outright kill you, though you may Mortality rates began to rise in 1999. So wish you were dead. But what happens what was happening just before then? when we only detox people who donâ&#x20AC;&#x2122;t Globalization and the transition from an have the resources to cover rehab themindustrial society to a technological society selves is that they are left without anything were beginning. An upswing in automain their tool box to fight backâ&#x20AC;&#x201D;and their tion makes more low skill jobs obsolete tolerance is lower, A dose they could have every year. Mining jobs disappeared as handled before can now be deadly,â&#x20AC;? Paddemand for coal fell. Most of all, our govdock said. ernment made the decision that our country needs high paying technology jobs, not How did we get here, and why is low skill, low paying factory jobs that can it only happening in the U.S.? be done by anyone, anywhere. In short, itâ&#x20AC;&#x2122;s complicated. Even the â&#x20AC;&#x153;Trade agreements were made based authors of the study say they are perplexed on this decision. The thinking at the time by the many influences that contributed was that some of the profits from moving to this trend. Finding a way to reverse it manufacturing to cheaper labor markets

would be reinvested through tax policy to retrain citizens displaced by the decision so they could move to technology jobs. That didnâ&#x20AC;&#x2122;t happen.â&#x20AC;? Now the problem has spread to every region in the United States. The geographic divide is between rural and urban locations. The greater the distance from an urban center, the higher the death rates are becoming. Isolation and distance from resources may figure into this.

What next? Though a college degree has been protective so far, there are subtle signs that what is happening in high school educated populations is only the first wave of more to come. â&#x20AC;&#x153;We hope college will have given people skills to make them better at adapting and retraining, but there is already pressure in the job market. Recent graduates are having a harder time finding jobs,â&#x20AC;? Black said. â&#x20AC;&#x153;We know that lawyers in India are training in American law so they can offer basic legal services online. Advances in medical technology may affect jobs in health care.â&#x20AC;? With telemedicine, doctors can see patients across town, or from a whole hemisphere away. New York trading firms are already using computer algorithms to make trades highly-paid stockbrokers were making last year. The health of a society is only as good as the health of its people. It is like an organism. If the left leg isnâ&#x20AC;&#x2122;t getting enough blood flow to carry adequate oxygen and nutrients, the muscle begins to die. If nothing is done, the leg dies, and the entire organism is in jeopardy.

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â&#x20AC;&#x153;We have to get together and get expertise from every discipline so we can follow up on the data and get a consensus on how we are going to solve this. It isnâ&#x20AC;&#x2122;t going to be fast or easy,â&#x20AC;? Black said. â&#x20AC;&#x153;We have to start a comprehensive conversationâ&#x20AC;&#x201D;policy makers, economists, sociologists, health professionals, and the people who are our society. We need to start talking about what we have to do to get all segments of our society healthy again.â&#x20AC;?

Revocation Of Enrollment In The Medicare Program, continued from page 13 items and services within 60 days after the later of the effective date of the revocation or the date that the home health agencyâ&#x20AC;&#x2122;s last payable episode ends. If you receive a revocation notice, you have 60 days from the postmark on the letter to file a redetermination request. This is a review by an independent reviewer who was not involved in the initial determination. The reviewer has 90 days to make a redetermination, and the revocation date is not tolled pending the appeal. If the redetermination request is not successful, the provider may appeal the decision to an administrative law judge and, ultimately, to the federal courts. Pursuant to this review schedule, your appeal at the administrative level can take several months; whereas, the revocation takes place 30 days after you receive notification of the revocation. In a recent case, Medicare revoked the billing privileges of a large supplier of diabetic supplies, Arriva Medical, LLC. The basis of revocation was abuse of billing privileges (42 CFR 424.535(a)(8)(i)). According to CMS, Arriva had billed Medicare for testing supplies for Medicare beneficiaries who were deceased. Out of 5.8 million claims over a five year period, CMS focused on 211 claims submitted by Arriva, 0.003 percent fall claims submitted. Because of the length of time it takes for the administrative appeals process to play out, Arriva filed a lawsuit in federal court seeking to enjoin CMS from revoking its billing privileges, which was denied. Arriva received notice of revocation in October 2016 with an effective date of November 4, 2016. On March 17, 2017, the federal district court issued an order denying Arrivaâ&#x20AC;&#x2122;s request for a preliminary injunction of the revocation, which would have stopped the revocation until Arriva had exhausted its administrative remedies. The administrative appeal is still pending at the Departmental Appeals Board. Angie C. Smith is a partner in Burr & Forman LLPâ&#x20AC;&#x2122;s Birmingham office practicing in the Health Care Industry Group.


BE WELL AND VITAL

Nutrition is at the Heart of Wellness By Dale Short

Editor’s note: This is Part One of our FourPart “Be Well and Vital” series. Is nutrition a complex subject or simple? A keystone of good health? All of the above, according to Micah Howard, MD of Decatur, who practices integrative medicine - a mix of conventional and non-conventional treatments tailored to each particular patient. Howard says that proper nutrition is at the center of wellness. “We know two things there isn’t much debate about,” he says. “The modern American diet causes chronic disease, and studies show that in different countries you can track the growth of those diseases by how quickly they’ve adopted a diet containing refined sugar and processed flour. In the 1700s the annual per-capita sugar consumption in the U.S. was five pounds per person. By 1900 it had grown to 70 pounds, and today the average is 152 pounds. “ The Industrial Revolution brought many Micah Howard, MD changes to the American diet, including the processing of foods, such as refined wheat flour, that separate the germ nutrients from the wheat. “We cre-

ated flour that wouldn’t spoil, and learned to refine sugar the same way,” Howard says. “Likewise, we replaced olive oil, a good source of Omega-3 fatty acids, with oil from soybeans which contains Omega-6 that causes inflammation. This is important because research has shown time and time again that high levels of inflammation are at the center of many diseases. “Together, cardiovascular diseases, various cancers, and diabetes account for almost 70 percent of deaths in the United States, and the common link among all of these is inflammation.” Advances in manufacturing also made possible the creation of imitation or ultraprocessed foods that didn’t exist a century ago, from which average Americans get 58

percent of their calories. Congress passed regulations in the 1930s requiring such foods to be labeled “imitation,” but those policies were dropped in the 1970s. There are many ways the health of our gut affects our wellness, Howard says: “There are more neurons in your gut than in your brain, and the number of symbiotic microorganisms total in the trillions; more bacteria than the number of cells in our bodies.” An estimated 80 to 90 percent of the serotonin in your body is manufactured by the nerve cells in your gut, and gut-associated lymphatic tissue represents 70 to 80 percent of the body’s total immune system.” In explaining the simplest way to eat healthy, Howard cites food writer Michael Pollan who says to (1) Eat food, (2) Not too much, and (3) Mostly plants. “Another way to put it,” Howard says, “is ‘don’t eat foods that don’t spoil.’” These facts conflict with much of the common wisdom about dieting. “Even the word ‘diet’ has, over time, become an almost obscene word that has the connotation of failure,” Howard says. “At its best, it’s something you do for a short while and then go back to what you were doing before.” For instance, many people gain weight on a low-fat diet. The “good fat” is an important part of a healthy diet and has the added benefit of helping to curb cravings. “The first thing most diets tell you is to

cut calories,” Howard says. “But all calories are not the same. If you eat 2,000 calories worth of Snickers bars versus 2,000 calories of kale, you obviously have a very different outcome. Every type of food hits different metabolic switches.” Another important factor is variety in foods. “Thomas Jefferson grew more than 150 species of fruit and some 330 vegetables in his garden at Monticello. But today there are four crops that account for two-thirds of the calories we eat: corn, soy, wheat, and rice,” Howard says. He adds that factory farming of animals has had a serious effect on the quality of meat. “Before we started factory-farming, animals had lots of good fats and high-quality properties. But farmers started using growth hormones to grow livestock bigger and faster, and then they switched the feed from grass to grain which was cheaper. And finally, because this diet is making the livestock sick, they’re given antibiotics. So quality has worsened.” The most important first step for achieving nutritional health, Howard says, is eliminating the “poisons” from what you eat: “For instance, broccoli is great for you, but eating it will only get you so far. You can’t eat enough broccoli to balance out cupcakes. You’ve got to eliminate refined flours and refined sugars first, or you’re spinning your wheels.”

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New Long Acting Injectable Helps Chronic Low Back Pain, continued from page 1 healthcare providers to ask every patient about their pain. Since that time, the U.S. has experienced a surge in opioid prescriptions and, subsequently, an increase in overdoses and deaths tied to opiate pain killers. “I began to see the consequences of these standards when I started my pain practice in 2009,” Thomas says. “Many patients were given opiates to treat pain without adequate education. I see this manifest clinically when patients describe a history of needing more pain medication to control their pain. I believe patients often confuse euphoria for pain relief, especially if expectations were never defined when starting opiate therapy. It is not surprising to see this evolve into a crisis when so many patients have become dependent on opiates.” Thomas uses buprenorphine for his patients, because it does a good job of removing euphoria. “We have been using it for addiction for many years. Recently, it was approved for pain in low doses,” he says. “I like this molecule for pain, because it acts at the mu opioid receptor and provides analgesia. At the same time, it has a ceiling effect which makes it relatively

safe.

Traditional opiates lack a ceiling effect which means more of the drug produces more results. If that result of pain relief is confused for more euphoria, more opiate is required to achieve a similar benefit. However, the side effect of traditional opiates is respiratory depression. This is what happens in many accidental overdoses, resulting in death.” Thomas prescribes buprenorphine for both dependence and pain. “I have seen great results in patients who are taking very high doses of opiates. For these patients, it is necessary to get them off opiates to determine what is going on so we can begin to figure out where the pain originates. Buprenorphine has been a good tool for this. Most of the time, the patient hurts less, thinks more clearly, and functions better,” he says. Thomas would like to see buprenorphine used more for moderate to severe pain. “I think we are seeing this happen with products like Butrans and Bellbuca. I like the idea of implanting long-acting forms of medication for disease states like chronic pain. The benefits of improved compliance, safety, and convenience are

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great,” he says. “The reduction or elimination of oral and/or fast-acting opiates can only help reduce the reinforcements associated with a cycle of addiction. I think it is a great idea, and I think we need more options like buprenorphine available.” The FDA has announced an action plan to help reverse the opiate trend. The plan takes a detailed look at the benefits and risks of using opiates in non-malignant chronic pain. Buprenorphine has benefit while reducing risk. “I think we will see more pharmaceutical companies get in this arena. We already see how the changes made by the Alabama State Medical Board regarding opiate prescribing have affected practice patterns,” Thomas says. “Two to three

Fighting Breast Cancer with New Research, New Tools, continued from page 7 drates, and red and processed meats.”

HER2 Treatment Targets Moffitt Cancer Center researchers in Tampa, Fla., have reported promising clinical activity with a HER2-targeted dendritic cell vaccine. Since deregulation and inhibition of the immune system help cancer develop and proliferate, researchers worldwide have focused energies on therapeutic strategies to re-stimulate the immune system and get it to recognize and destroy cancer cells. Previous research has shown immune cells are less likely to recognize and target cancer cells that express HER2 as the breast cancer progresses to a more advanced stage. The vaccine being studied targets the HER2 protein on breast cancer cells using dendritic cells harvested from each patient for a personalized vaccine and led to regression of early-stage breast cancer with minimal toxicities. Moffitt researchers performed the clinical trial in 54 women who had HER2expressing, early-stage breast cancer. After

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years ago, it was common for patients to come to our clinic taking more than 120 mg morphine equivalents daily. Now, we rarely see those amounts prescribed in the community. I think we are on the right track in addressing the opiate epidemic. Legislation and policy changes, combined with safer medications, can help significantly.” Alabama Pain Physicians is participating in a Phase III, double-blind, placebo-controlled, multicenter study to evaluate the efficacy and safety of a long-acting buprenorphine injectable product. To qualify for the study, participants must have chronic back pain and be prescribed at least 60-80 mg of morphine equivalents daily. Participants will be reimbursed for their time and travel.

isolating each woman’s dendritic cells and exposing them to fragments of HER2 protein, the women received an injection of their personalized vaccine weekly for six weeks into a lymph node, the breast tumor, or both. Assessing the vaccine’s effectiveness by seeing how many of the women had detectable disease in surgical specimens after resection, researchers found 13 patients achieved a pathological complete response (pCR). Of that group, patients with ductal carcinoma in situ (DCIS) achieved a higher rate of pCR than those with early-stage invasive disease, and those who achieved a pCR had a higher immune response within their local sentinel lymph nodes. Brian J. Czerniecki, MD, PhD, chair of the Department of Breast Oncology at Moffitt, said, “These results suggest that vaccines are more effective in DCIS, thereby warranting further evaluation in DCIS or other minimal disease settings, and the local regional sentinel lymph node may serve as a more meaningful immunologic endpoint.” In other news, the U.S. Food and Drug Administration approved a new drug in March from Novartis Pharmaceuticals for the treatment of postmenopausal women with HR-positive, HER2-negative advanced or metastatic breast cancer. Ribociclib (Kisqali), a cyclin-dependent kinase 4/6 inhibitor, was approved in combination with an aromatese inhibitor as initial endocrine-based therapy based on interim results from the international MONALEESA-2 trial. In the randomized trial, those receiving ribociclib plus letrozole (the aromatese inhibitor) reduced the risk of progression or death by 44 percent compared to those receiving letrozole alone and demonstrated tumor burden reduction with an overall 53 percent response rate. Novartis has since reported information from a subsequent analysis with additional follow-up and progression events that showed a median progression-free survival of 25.3 months for ribociclib with letrozole compared to 16 months for letrozole alone.


Cannabidiol Reduces Frequency and Severity of Seizures For epilepsy patients with frequent, often severe seizures that traditional medications fail to control, everyday life can be an ordeal. That’s why the Alabama legislature voted to approve Carly’s Law, which allowed research into whether cannabidiol (CBD oil), a derivative of the cannabis plant, could effectively and safely help to ease intractable seizures. That decision is paying off. Researchers from UAB and Children’s of Alabama delivered 11 abstracts at the 70th annual meeting of the American Epilepsy Society, detailing findings that show not only a reduction in both the frequency and severity of seizures in a majority of cases, but also additional positive changes that have been observed. The research team involved in the ongoing study is being led by co-primary investigators Jerzy Szaflarski, MD, PhD, professor in the Department of Neurology and director of the UAB Epilepsy Center, who works primarily with adult patients, and Martina Bebin, MD, professor of neurology, who focuses on pediatric patients at Children’s of Alabama. Jerzy Szaflarski, “A month after beMD, PhD ginning oral doses of CBD oil, the majority of our 81 patients were experiencing fewer seizures,” Szaflarski said. “Approximately nine percent were seizure free. More than onethird of the patients had Martina Bebin, MD a reduction in seizures of more than 75 percent, which included nine percent who were seizure-free. At least 58 percent of the group saw their seizures reduced by half or more. Adding those who saw at least a 25 percent reduction in seizures brings the total number of participants who saw a good to excellent response to 68 percent. “Equally important is that approximately two-thirds of our patients reported a drop of more than 50 percent in the severity of seizures. That included some patients whose number of seizures may not have declined as dramatically, but the reduction in severity improved their quality of life.” More than a third of the patients had a reduction in seizures of more than 75%, which included 9% who were seizure-free. At least 58% of the group saw their seizures reduced by half or more. Adding those who saw at least a 25% reduction

“Researchers have also expressed interest in the potential of CBD oil in pain syndromes, brain and muscle disorders, migraine headaches, Parkinson’s, depression, PTSD and other disorders. It will require research, time and funding to determine whether the oil will be effective in some of these other neurological conditions,” Bebin said. “There are more than 100 active compounds in the cannabis plant, and it has been used in traditional remedies for a wide variety of conditions for hundreds of years, particularly starting in the 18th Century,” Szaflarski said. “The specific compound we’re investigating is cannabidiol, which is extracted by a pharmaceutical company and blended in sesame seed oil. It only contains trace amounts of THC. The cannabidiol concentration is standardized, which allows us to collect data to determine an optimum range for a starting dosage.” Bebin said, “Every patient responds individually, so finding the most effective dosage for a specific patient may require careful adjustment. However, we have found that a good starting dosage range for the oil we use is between 20 and 25 mg/kg/day to help patients achieve maximum benefits. Outside this range, the benefits may not be seen and symptoms can © Boris Zerwann

By Laura Freeman

in seizures brings the total number of participants who saw a good to excellent response to 68%. Bebin said, “One difference we noted in how adults and children respond was that pediatric patients seem to be more likely to experience a reduction in the number of seizures. We think that may be related to a difference in the etiology of the disorder. Epilepsy often has a genetic basis in children whereas the seizures in many adults began with a tumor or brain injury. Other positive changes included an improvement in mood that was independent of the extent of seizure reduction. Some patients also showed improvement in cognitive functions that were associated with corresponding fMRI signal changes.

actually become worse.” The dosage range for the standardized concentration cannot be generalized to other oils which have come on the market since Leni’s Law went into effect, allowing oils derived from cannabis to be produced in other states and marketed online. “Some patients who are not part of the study are ordering the oils online and each brand has a different formulation and different concentration of ingredients,” Szaflarski said. “This can complicate the care plan. CBD oil can interact with warfarin and with several epilepsy medications, which may require dosage adjustments to avoid an overdose.” The study at UAB and Children’s of Alabama is ongoing, and a few slots remain open for new participants. “We’re continuing to gather and track data,” Szflarski said. “It’s still uncertain exactly how CBD oil works, but as we learn more about it, it could unlock areas of investigation that could lead to new approaches to treating epilepsy. When sufficient information is available for FDA review, we hope to see CBD oil as a standardized medication available to treat all patients who could benefit.” “Families tell us that CBD oil has made such a difference in the quality of life for their loved ones,” Bebin said. “They say patients are more interactive, less moody, have better concentration and are generally healthier. We hope other patients will be seeing the same benefits soon.”

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The Perfect Colonoscopy and How to Get It By ChrIStoPher P. ShaVer, mD

A colonoscopy is an endoscopic examination of your large intestine. The primary indication for the procedure is colon cancer screening. However, it is also an effective diagnostic tool for the evaluation of chronic intestinal symptoms including abdominal pain, diarrhea and rectal bleeding as well as unexplained anemia. I perform more than a thousand endoscopic procedures every year with colonoscopy topping the list. I have also been on the receiving end of the c-scope. This makes me uniquely qualified to present to you my top four colonoscopy essentials: 1. A complete endoscopist. Whether gastroenterologist or surgeon,

expect experience and attention to detail. One of the primary goals of colonoscopy is to significantly reduce the risk of colon cancer in the patient. This goal is accomplished by identifying cancer precursor lesions called polyps. These lesions are often flat or otherwise subtle and require patience and time to identify and remove. The art of colonoscopy involves the detection of elusive polyps and their subsequent safe and complete removal. Sizeable flat lesions often require removal using a technique known as endoscopic mucosal resection (EMR). This technique requires advanced training and carries increased risks. A lack of skillful EMR may lead to unnecessary complications, extra procedures and even unnecessary surgery.

I call screening colonoscopies “polyp hunts.” While some polyps are inevitably missed, the goal is to kill them all. The complete endoscopist understands this and works mercilessly to eliminate them. 2. A clear prep; absolutely essential. We can’t remove what we can’t see. A couple of key points here include the following: A split-dose colonoscopy prep is preferred. Everyone orders it a little differently, but this clean-out strategy gives a clearer view of the colon, particularly on the right side. Yes, it’s different from the last time you did it. And yes, there’s an extra step. But since the right side of the colon is where flat and aggressive polyps love to set up shop, it’s a small price to pay to improve the accuracy of your exam. Patients with chronic consti-

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pation or taking medications that slow bowel function may require enhanced bowel prep techniques. 3. Clean sedation. The endoscopic journey from anus to cecum is rarely a straight shot. More typically, the procedure is a series of sharp turns, loop reductions, twists and torques. The resulting bowel stretch along with air insufflation is well-known to be uncomfortable to patients. Safe and appropriate sedation improves the quality of the experience and promotes a more complete and efficient procedure. 4. A first class environment. The backdrop for your colonoscopy is key. From the front desk check-in process to the wheelchair ride to your getaway car, expect to be treated with professionalism and compassion. The thought of having your intestinal tract broadcast on a large-screen, high definition monitor elicits responses ranging from nervous laughter to paralyzing fear. Don’t expect fuzzy slippers but do expect a friendly and comfortable environment; one that you want to come back to for your next perfect colonoscopy. Christopher P. Shaver, MD practices gastroenterology with Birmingham Gastroenterology Associates.

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Recycle Electronics and Keep Your Practice Safe By Blake Perry

Recycling electronics is a great way to help conserve and reuse valuable materials found in many gadgets, including glass, plastics, and metals such as copper, gold, palladium, and silver. Many electronics, especially computers and televisions, contain toxic materials such as cadmium, lead, and mercury. Recycling and reusing electronics helps to keep these toxic materials out of our landfills and water supply. Even more importantly, recycling electronics is a great way to help keep your practice safe and data secure. Many companies, in addition to medical practices, have unused IT equipment in their office with unsecured data-containing electronics. A situation like this violates numerous federal regulations. Protect your practice as you transition with new equipment and be aware of protecting your data as you choose to recycle. Instead of tossing your old or unused gadgets containing sensitive information to the trash, choose to recycle with a company that is HIPAA compliant and will destroy old data before hauling your supplies away. Having old hard drives destroyed first is imperative when recycling your practice’s old devices. Keep IT Simple recently spent time learning about data security while recycling. Danny Skinner, owner of Protec Recycling in Birmingham, explained the benefits of electronics recycling as a twopronged approach to conserve resources. It recovers valuable materials to use in making new electronics, and reduces the use of raw elements. If you decide to recycle, be sure you work with a company that abides by Alabama State Laws for electronics recycling, and with HIPAA Compliance.

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RESEARCH NOTES

Preterm Babies Benefit from Moms’ Receiving Steroids Prior to Delivery

UAB Study Shows Link Between Microbiome in the Gut and Parkinson’s

A new study from UAB suggests that women at risk of preterm delivery should receive corticosteroids due to strong associations with a lower rate of death and serious illness for their babies. The study says that very premature babies seem to benefit the most from the steroids, even those born at 23 weeks of gestation. “The benefits of antenatal corticosteroids were substantially larger for infants born at the lowest gestations, including less than 28-week infants,” said Wally Carlo, director of the UAB Division of Neonatology. A team of researchers analyzed data for 117,941 infants born between 23 and 34 weeks of gestation at 300 neonatal intensive care units across the United States. Death or major illness was analyzed by gestational age and exposure to antenatal corticosteroids, adjusting for factors such as birth weight, sex, mode of delivery and multiple births. The researchers found that exposure to antenatal corticosteroids was associated with a significantly lower rate of death before discharge from hospital at each gestation compared with infants without exposure. They also found that the number of infants needed to treat with antenatal corticosteroids to prevent one death before discharge increased from six at 23 and 24 weeks of gestation to 798 at 34 weeks of gestation, suggesting that infants born at the lowest gestational ages benefit most.

There is growing evidence showing a connection between Parkinson’s disease and the composition of the microbiome of the gut. A new study from UAB researchers shows that Parkinson’s disease, and medications to treat Parkinson’s, have distinct effects on the composition of the trillions of bacteria that make up the gut microbiome. The findings were published in February in Movement Disorders, the journal of the International Parkinson and Movement Disorder Society. “Our study showed major disruption of the normal microbiome in individuals with Parkinson’s,” said Haydeh Payami, PhD, professor in the Department of Neurology in the UAB School of Medicine. Payami says, at this point, researchers do not know which comes first. Does having Parkinson’s cause changes in an individual’s gut microbiome, or are changes in the microbiome a predictor of Parkinson’s? What is known is that the first signs of Parkinson’s often arise as gastrointestinal symptoms such as inflammation or constipation. “The human gut hosts tens of trillions of microorganisms, including more than 1,000 species of bacteria,” Payami said. “The collective genomes of the microorganisms in the gut is more than 100 times larger than the number of genes in the human genome. We know that a well-balanced gut microbiota is critical for maintaining health.” Payami’s team studied 197 patients

Haydeh Payami, PhD

with Parkinson’s and 130 controls. The researchers found that some species of bacteria were present in larger numbers in Parkinson’s patients than in healthy individuals. Other species were diminished. Different medications used to treat Parkinson’s also appear to affect the composition of the microbiome in different ways. “It could be that, in some people, a drug alters the microbiome so that it causes additional health problems in the form of side effects,” Payami said. “Another consideration is that the natural variability in the microbiome could be a reason some people benefit from a given drug and others are unresponsive. The growing field of pharmacogenomics — tailoring drugs based on an individual’s genetic makeup — may

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need to take the microbiome into consideration.” The study subjects came from three regions, the northeast, northwest and south. The research team detected an unexpected difference in gut imbalance as a function of geographic site, which may reflect the environmental, lifestyle and diet differences between the three regions. Another function of the microbiome is to help the body rid itself of xenobiotics — chemicals not naturally found in the body often arising from environmental pollutants. The study found evidence that the composition of bacteria responsible for removing those chemicals was different in individuals with Parkinson’s. This may be relevant because exposure to pesticides is known to increase the risk of developing Parkinson’s. Payami says the study of the microbiome is a relatively new field, and a better understanding of macrobiotics may provide unexpected answers for Parkinson’s disease and other disorders. “This opens up new horizons,” she said. “There are implications here for both research and treatment of Parkinson’s. Therapies that regulate the imbalance in the microbiome may prove to be helpful in treating or preventing the disease before it affects neurologic function.” However, Payami cautions against grand conclusions until more data are available. Another study is underway at UAB with individuals with Parkinson’s and healthy individuals in an effort to replicate and confirm the results. “The present findings lend support to the notion that the composition of the gut microbiome may hold new information for assessing efficacy and toxicity of Parkinson’s medications,” Payami said. “Additional studies are needed to assess the effects of those drugs, with larger numbers of treated and untreated patients as well as individuals who do not have Parkinson’s.”


RESEARCH NOTES

Findings Suggest Underdiagnoses of Age-Related Macular Degeneration Approximately 25 percent of eyes deemed to be normal based on dilated eye examination by a primary eye care ophthalmologist or optometrist had macular characteristics that indicated agerelated macular degeneration, according to a study published by JAMA Ophthalmology. Approximately 14 million Americans have AMD, and age-related macular degeneration is the leading cause of irreversible vision impairment in older adults in the United States, yet little is known about whether AMD is appropriately diagnosed in primary eye care. David Neely, MD, of the UAB Department of Ophthalmology, and colleagues conducted a study that included 644 people 60 years or older with normal macular health per medical record based on their most recent dilated eye examination by an ophthalmoloDavid Neely, gist or optometrist. PresMD ence of AMD was based on imaging (color fundus photography). With an average age of 69, 75 percent of the participants had no AMD, in agreement with their medical record while 25 percent had AMD despite no diagnosis of AMD in the medical record. Among eyes with undiagnosed AMD, 78 percent had small deposits (drusen) under the retina, 78 percent had intermediate drusen, and 30 percent had large drusen. Undiagnosed AMD was associated with older patient age, male sex and a less than high school education. Prevalence of undiagnosed AMD was not different for ophthalmologists and optometrists. The authors note that the eyes with undiagnosed AMD that had AMD with large drusen would have been treatable with nutritional supplements had it been diagnosed. “The reasons for AMD underdiagnoses in primary eye care remain unclear,” Neely said. “As treatments for the earliest stages of AMD are developed in the coming years, correct identification of AMD in primary eye care will be critical for routing patients to treatment as soon as possible so that the disease can be treated in its earliest phases and central vision loss avoided.” Neely said that detailed fundus examinations for patients are still a good way to be screened for AMD, especially for those paitents with the common risk factors like older age, family history of AMD, hyperopia and others. He said while AMD is not necessarily hard to diagnose, the early forms, which show pigmentary changes and few small drusen, can be very subtle and require a very detailed fundus examination. “Fortunately, the advanced forms, like exudative or wet AMD, are more readily diagnosed and sent promptly to vitreoretinal subspecialists for intervention,” Neely said.

GRAND ROUNDS

UAB Expands Cancer Navigation Program Nationally The University of Alabama at Birmingham and Guideway Care have announced a partnership to expand the reach of UAB’s cancer navigation program, Patient Care Connect, to patients nationally. The UAB Patient Care Connect program was funded by a $15 million Center for Medicare and Medicaid Innovation grant to help create a national model for improving outcomes while reducing unnecessary health care utilization, as well as decreasing the cost of cancer care. The national implementation of the program will be led by Guideway Care, which provides knowledgeable cancer care guides, processes and technology to assist cancer patients, especially during the periods in between clinical visits. “Building on the proven methodology created at UAB, Guideway Care provides patient guidance beyond navigation,” said Craig Parker, CEO of Guideway Care. The UAB Patient Care Connect program succeeded locally by using nonclinical resources to resolve barriers patients encounter during their cancer journey. Results during UAB’s program implementation include: 55 percent reduction in hospitalizations: Hospitalization rates dropped from 35.8 percent to 16.1 percent in the navigated patient population. 29 percent reduction in ER visits: ER visits decreased from 30.7 percent to 21.8 percent in the navigated patient population. 60 percent reduction in ICU admissions: ICU admissions dropped from 10 percent to 4 percent in the navigated patient population. 45 percent reduction in overall cost: In terms of Medicare claims, there was

a reduction of overall cost in the navigated patient population from $15,091 to $8,269 per patient per quarter, which is a Medicare savings of $6,822 per navigated patient. Cost in the last six months of life decreased from $23,735 to $16,764 in comparison to the nonnavigated group that increased from $13,418 to $15,544. The UAB team reported an estimated potential 10 to 1 return on investment of the UAB cancer navigation program. These cost savings are important. “Bundled payments are coming — transferring risk and financial burden to providers,” said Edward Partridge, MD, director of the UAB Comprehensive Cancer Center. “It is necessary to transition from fee-for-service thinking, and prepare our physicians and hospital delivery systems for performance-based payment models. “The Guideway Care program positions cancer centers to be on the forefront of this movement while differentiating themselves with an outstanding patient experience.”

In fact, the Centers for Medicare and Medicaid Services’ independent third-party assessors found a significant improvement in satisfaction among patients.

TekLinks Named No. 1 Healthcare MSP ChannelE2E.com’s Top 100 Vertical Market MSPs list has ranked TekLinks the world’s No. 1 managed services provider (MSP) for the healthcare industry. Overall, TekLinks ranked No. 2 on the Top 100 Vertical Market MSPs list for the second consecutive year. The list identifies and honors the top 100 managed services providers in healthcare, government, financial services, manufacturing and additional vertical markets. Rankings are based on ChannelE2E’s Q1 2017 readership survey. “Being named to this list is an honor that has taken a lot of work and dedication to the healthcare market,” said TekLinks’ Vice President of Managed and Cloud Services Chris Hoscheid.

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GRAND ROUNDS

Princeton Baptist Neuroscience Technologist Honored Carrie Ford, neuroscience technologist at Princeton Baptist Medical Center, has been inducted into the Tenet Heroes Hall of Fame, Tenet Healthcare Corporation’s highest honor for employees. Ford partnered with Kerri Kasem, daughter of Carrie Ford famed disc-jockey Casey Kasem, to help prevent abuse and isolation of elderly patients in Alabama. When Casey Kasem’s story of elder abuse was publicized, it captured Ford’s attention because her father faced the same circumstances. When Ford learned that Kerri Kasem was working to pass visitation legis-

lation in every state, she contacted Kasem and began working towards passing this legislation in Alabama. She gained support through an online petition, and subsequently authored and lobbied for the passing of the Robert G. Ford Casey Kasem Visitation Act, which gives individuals the right to visit family members who are involuntarily isolated, and requires that relatives be notified when a loved one is admitted to the hospital or moved to another facility.

RTMD of Birmingham to Partner with Emory Emory University School of Medicine has entered into an agreement with RealTime Medicare Data, LLC (RTMD), a Birmingham-based healthcare analytics company that specializes in Medicare Fee-for-Service paid claims

data. Under the agreement, RTMD will provide Emory with key Medicare claims data to enable its researchers to assess the utilization of Medicare preventive services across Georgia. “We are excited to partner with Emory,” says Gina McWilliams, CEO of RTMD “With the largest privately held collection of Medicare Fee-for-Service paid claims data in the U.S., we can provide a valuable resource to researchers at leading institutions like Emory.” Historically, Medicare has concentrated on treating beneficiaries’ diseases rather than emphasizing preventive care. In recent years, however, that focus has been changing. In 2011, with the goal of increasing the provision of preventive healthcare to the elderly and the disabled, Medicare began paying for health screenings

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Birmingham Medical News

in the form of an Initial Preventive Physical Examination (IPPE) and an Annual Wellness Visit (AWV). These services provide free co-payments for eligible patients to receive health screening and counseling, including a review of family and medical history, immunizations, blood pressure, and screenings for depression, cognitive impairment, and functionality. “These IPPE and AWV services have a great deal of potential in the early diagnosis of diseases that Medicare beneficiaries, due to their age, are at greater risk of contracting,” says McWilliams. Although these IPPE and AWV services are provided at no charge to the beneficiary, providers are reimbursed for the service at favorable rates, particularly if the services are not wholly performed by a physician. Despite the potential benefits of IPPE’s and AWV’s, there are still questions as to how widely healthcare practitioners are offering them and whether utilization rates vary across geographical areas. Emory launched the research project to investigate this. “When Emory approached us about this project,” RTMD Research Director Curtis Spraitzar says, “we were able to query our vast Medicare claims database to give them both the breadth and depth of data they needed.” Through the use of quantitative analysis of RTMD’s data, Emory will be able to determine the geographic variation in completed IPPE’s and AWV’s in the state of Georgia, as well as the penetration rate among Medicare beneficiaries and providers. RTMD’s data will also allow Emory researchers to gain a very detailed perspective on which providers in Georgia have completed and which ones have not completed IPPE’s and AWV’s in their practice. Insights gained from this initial data analysis will inform the project’s next phase in which they plan to design an educational intervention.

Cyber Security Lunch and Learn FBI Special Agent to Speak

Integrated Solutions is hosting a lunch and learn on cyber security on Wednesday, May 31 at 11:30 at the Wynfrey Hotel. The keynote speaker is FBI Supervisory Special Agent Darren Mott, who is the Supervisory Special Agent for the Counterintelligence Program for the Birmingham Division of the FBI. Cyber Security is a paramount issue facing all businesses. Companies can address current network challenges with a future-proof cybersecurity strategy for 2017 and beyond by integrating the correct processes, procedures, standards and technology. For more information, visit www.it4theplanet.com.


GRAND ROUNDS

Prameela D. Goli, MD Joins Grandview Prameela D. Goli, MD, FACR has joined the Grandview Medical Center medical staff. Goli specializes in Rheumatology and has joined Grandview Medical Group. She is Board Certified in Rheumatology. Goli, who has been in private practice in Birmingham for 25 years, completed her residency in internal medicine at Texas Tech University Health Sciences Center. She completed a Fellowship in Rheumatology at Oklahoma University Health Sciences Center. Goli is a member of the American College of Rheumatology, American Medical Association and the Alabama Society of Rheumatic Disease.

CVA University Community Education CVA is hosting a series of community educational forums on a variety of topics related to cardiovascular health. The programs, which are free of charge, are held on the CVA campus in the Green Room. Upcoming presentations include: High Blood Pressure with Dr. Andrew Miller – Tuesday, May 16 at 5:30 The Truth about Cholesterol with Dr. Saema Mirza – Tuesday, June 20 at 5:30 Diabetes Management – Tuesday, July 18

Princeton Baptist First in Southeast to Offer New Technology in Treatment of Severe Aortic Stenosis The Structural Heart Program at Princeton Baptist Medical Center became the first center in the southeast to implant the newly FDA approved CoreValve™ Evolut™ PRO TAVR for the treatment of severe aortic stenosis for symptomatic patients who are at high risk for open heart surgery. Recently unveiled clinical data showed high survival, low rates of stroke, minimal paravalvular leak (PVL) and excellent hemodynamics for the self-expanding valve. Aortic stenosis occurs when the heart’s aortic valve narrows, restricting blood flow from the heart to the aorta, which can severely weaken the heart muscle. If left untreated, it can lead to heart failure and even death. Mustafa Ahmed, MD, Director of the Structural Heart Disease Program at Princeton Baptist Medical Center, Clifton Lewis, MD, cardiac surgeon at Princeton, and their team have perThe Princeton Structural Heart Program Surgery Team formed several hundred cases involving TAVR . The Evolut PRO device features a unique valve design with an outer wrap that adds surface area contact between the valve and the native aortic annulus to further advance valve sealing performance. The biocompatible porcine pericardial tissue wrap, in addition to other design elements, is incorporated to address the occurrence of blood leaking through the sides of the valve. It is both recapturable and repositionable, so accuracy in placement and control during the procedure is increased. The Evolut PRO System is delivered through the EnVeo™ R Delivery Catheter System and is indicated for vessels down to 5.5 mm. The EnVeo R system features an InLine Sheath that makes it the lowest delivery platform currently on the market. It also provides a greater opportunity to treat patients with smaller vessels through the preferred transfemoral access route.

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MAY 2017 • 25


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Physician and nurse attendees listen to a panel discussion.

Urology Centers Hosts CME Conference The Urology Centers of Alabama CME conference “But I’m Not a Urologist! Urology for the PCP” was held in April at the Grand Bohemian Hotel in Mountain Brook. Dr. Mark DeGuenther, Dr. Brian Christine, Jason Biddy and Marcie Prescott served as the conference planning committee. The event was attended by over 90 physicians, mid-level providers and nurses and was kicked off with a reception for physicians, attendees, and exhibitors on the Friday evening prior to the conference. “The physicians at Urology Centers of Alabama are proud to be leaders in the field of Urologic care and used this conference as an opportunity to educate PCP’s regarding a broad range of topics affecting patients from Alabama and beyond every day,” DeGuenther said. “In addition, we were able to share our passion for excellence and our commitment to offering our community the most up-to-date, compassionate Urologic care possible.” “The conference was geared towards our primary care colleagues,” Christine said. “The goals were to give information of value and of practical use helping PC physicians diagnose and, when appropriate, treat common urologic problems. We wanted to help primary care practitioners understand when to refer and to enlighten our audience as to current trends, and controversies, in urology.”

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American Sports Medicine Institute to Host Sports Medicine Conference for Sports Agents

Children’s Names Dimmitt as David E. Dixon Endowed Chair in Pediatric Gastroenterology

The American Sports Medicine Institute and Chairman, Dr. James Andrews, have announced ASMI’s Inaugural Sports Medicine for Sports Agents Conference, which will be held June 9th and 10th at the Ritz-Carlton, Buckhead in Atlanta, GA. “The mission of ASMI is to improve the understanding, prevention Andrews, and treatment of sports- James MD related injuries through research and education”, Andrews said. “This conference provides us with the opportunity to further this mission by gathering some of the country’s premier sports medicine specialists and sports agents to better educate these agents on the latest advancements in sports medicine – injury prevention, treatments and surgical procedures.” Dr. Andrews and conference cochairs, Drs. Lyle Cain and Jeff Dugas, selected highly-respected sports medicine physicians, surgeons and physical therapists who have collectively treated thousands of professional athletes to share their knowledge and expertise.

David E. Dixon, a long-time member of the Children’s of Alabama Board of Trustees, has been honored for his service with the establishment of an endowed chair in his name. Dixon began his volunteer leadership service at Children’s in 1998, serving on the Board’s Research and Education Committee, Executive Committee and as an officer of the Alabama Children’s Hospital Foundation. His family foundation has a strong partnership with the UAB Department of Pediatrics, including its support of the Dixon Fellowship Training program. Reed Allen Dimmitt, MD is the first

Grandview Medical Center’s Inpatient Rehab Unit Ranks in Top 10 Percent Grandview Medical Center’s Inpatient Rehab Unit, known as Easy Street, has been recognized as one of the top 10 percent of inpatient rehabilitation facilities (IRFs) in the United States. Easy Street is one of 781 units that qualified to be ranked in the IRF database of Uniform Data System for Medical Rehabilitation (UDSMR) in 2016. Grandview received a 94 percent composite score. Easy Street, a 17-bed unit, uses a multidisciplinary approach to provide individualized care to patients needing medical care as well as a more intense regimen of therapy. A team of physicians, nurses, therapists, social worker and dietician provides comprehensive rehab services. This is the eleventh year that UDSMR has issued these awards. The data used for this report was based on 12 months of 2016 data, drawn from both Medicare and non-Medicare patients. Number of patients discharged to the community as well as functional improvements in walking, dressing, grooming, eating and other activities of daily living were collected in the data.

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EDITOR & PUBLISHER Steve Spencer VICE PRESIDENT OF OPERATIONS Jason Irvin CREATIVE DIRECTOR Susan Graham STAFF PHOTOGRAPHER April May CONTRIBUTING WRITERS Ann DeBellis, Jane Ehrhardt, Laura Freeman, Lynne Jeter, June Mathews, Cindy Sanders GRAND ROUNDS CORRESPONDENT Frank Sinatra Birmingham Medical News 270 Doug Baker Boulevard, Suite 700-400, 35242 205.215.7110 • FAX 205.437.1193 Ad Sales: 205.978.5127 All editorial submissions should be mailed to: Birmingham Medical News 270 Doug Baker Boulevard, Suite 700-400 Birmingham, AL 35242 or e-mailed to: editor@birminghammedicalnews.com —————————————————— All Subscription requests or address changes should be mailed to: Birmingham Medical News Attn: Subscription Department 270 Doug Baker Boulevard, Suite 700-400 Birmingham, AL 35242 or e-mailed to: steve@birminghammedicalnews.com Birmingham Medical News is published monthly by Steve Spencer ©2017 Birmingham Medical News, all rights reserved. Reproduction in whole or in part without written permission is prohibited. Birmingham Medial News will assume no reponsibilities for unsolicited materials. All letters sent to Medical News will be considered Medical News property and therefore unconditionally assigned to Medical News for publication and copyright purposes. ——————————————————

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GRAND ROUNDS holder of the David E. Dixon Endowed Chair in Pediatric Gastroenterology. Dimmitt is a professor in the UAB Department of Pediatrics, the Reed Allen director of the Division of Dimmitt, MD Gastroenterology, Hepatology and Nutrition, and the medical director of Childrenâ&#x20AC;&#x2122;s Intensive Feeding Program. In addition, Dimmitt will serve as the president of the Childrenâ&#x20AC;&#x2122;s of Alabama medical staff and chair of the medical executive committee beginning in January 2018. Dimmittâ&#x20AC;&#x2122;s research includes mucosal immunology, the role of intestinal microbiota in the pathogenesis of injury, and the causes of intestinal failure associated liver disease. â&#x20AC;&#x153;Dr. Dimmitt is one of our very best. He cares deeply about the children of Alabama. His leadership in all areas, but particularly in intestinal rehabilitation, intensive feeding and eosinophilic gastrointestinal disorders has distinguished UAB and Childrenâ&#x20AC;&#x2122;s of Alabama,â&#x20AC;? said Mitchell B. Cohen, M.D., Chair, UAB Department of Pediatrics and Physician-InChief, Childrenâ&#x20AC;&#x2122;s of Alabama.

UAB Named Center of Comprehensive MS Care

The University of Alabama at Birmingham Multiple Sclerosis Center has been designated a Center for Comprehensive MS Care by the National Multiple Sclerosis Society. This is the highest designation in the system developed by the NMSS. UAB is now one of only seven such centers within a 200-mile radius of Birmingham. To achieve this status, an organization must offer a multidisciplinary model of care to address the needs of persons with MS, and to offer access to a full array of coordinated medical, psychosocial and rehabilitation services. â&#x20AC;&#x153;The needs of patients with multiple sclerosis are varied and complicated, and need, comprehensive management,â&#x20AC;? said Khurram Bashir, MD, professor in the Department of Neurology and Khurram Bashir, MD director of the UAB MS Clinic. â&#x20AC;&#x153;Our focus is exclusively on MS.â&#x20AC;? The UAB Comprehensive Center for MS Care has expanded its already extensive services with more nurses and staff members trained in MS care, along with expanded offerings. The comprehensive designation reflects the collaboration between the adult UAB MS Clinic and the Center for Pediatric-Onset Demyelinating Disease in the UAB Department of Pediatrics, which treats children with MS. The CPODD, housed at Childrenâ&#x20AC;&#x2122;s of Alabama, provides care for children across a broad range of medical specialties. More than 2.3 million people have MS. Most are diagnosed between the ages of 20 and 50. At least two to three times more women than men are diagnosed with MS.

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