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Fusion Technology Improves Detection of Prostate Cancer By Ann B. DeBellis
Beekeeping physician creates buzz at local hospital A typical workday for Jim Boogaerts, MD doesn’t usually include rescuing homeless animals. But one day last April, he was called upon to round up some strays; thousands, in fact. And furthermore, he provided them with a lovely new home in his own backyard ... page 3
New technology that fuses magnetic resonance imaging (MRI) and ultrasound is improving the detection of prostate cancer and helping to avoid unnecessary biopsies. Bryant Poole, MD, of Urology Centers of Alabama, says the technology has been available for about four years but has become more widespread over the past six months. Urology Centers of Alabama is now using the UroNav® system to do MRI/ultrasound fusion biopsies of the prostate. “In the past, we were doing 12-template biopsies, six on each side, and they were just random biopsies,” Poole says. “Studies have shown that some significant cancers have been missed by doing it that way, and our cancer detection rate using the 12-template biopsy is about 32 percent. The MRI/ultrasound fusion will allow us to identify these cancers more specifically, and we will be better able to determine who needs to be treated and who doesn’t.” Poole says that the overall cancer detection rate
Surviving Sudden Death Therapeutic Hypothermia Becoming Standard of Care in Cardiac Arrest For fans of TV medical dramas, reality can come as a shock. Week after week, they are accustomed to seeing defibrillators restoring flat lined heartbeats to happy ever afters ... page 7
(CONTINUED ON PAGE 12)
Bryant Poole, MD, of Urology Centers of Alabama, reads MRI results.
UAB Regrows Bones Using Living Membrane By Jane Ehrhardt
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Jason Lowe, MD
A motorcycle accident in December left the soldier on leave from Afghanistan with a broken shin. The bone had punctured through the skin. A month later, the bone became infected despite treatment, and the soldier arrived at the UAB Division of Orthopaedic Surgery. “It had been so severely injured in the crash that over five inches of the bone was dead,” says Jason Lowe, MD, a fellowship-trained orthopedic trauma surgeon at UAB. He is one of only three in the Birmingham area. Lowe used the Masquelet procedure on the soldier’s leg. It requires no external or internal apparatus, braces or screws. Within two months, the soldier had grown back enough new bone to bear full weight. By October, Lowe announced the soldier fully healed. He had been back on active duty since June. “With the Masquelet technique, they’re usually weight-bearing within two months after grafting, and the bone is fully incorporated in three to four months,” Lowe says. The soldier took longer to grow the missing section of bone, because at 14 centimeters, it had been twice the average length for bone regenera(CONTINUED ON PAGE 8)
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AT THE 10 YEAR MARK 4,000 PAGES & COUNTING I began working on the Birmingham Medical News in the fall of 2004. My first step was to find advertisers – without advertisers there are no funds for all the expenses that go into a business. Without advertisers, there is no Birmingham Medical News. Somehow, I managed to get several important people on the phone, and was soon driving from Jackson, Mississippi, my home at the time, to Birmingham where I had meetings with Chris Kimble and Colin Luke of Balch & Bingham, Howard Bogard of Burr Forman and Gerry Kassouf of Kassouf & Co. They all agreed to advertise with me even though I had no newspaper to show, little more than an idea. Their companies have advertised with us every single month since the first issue. The credibility of these firms was invaluable in helping to establish the Birmingham Medical News. Other advertisers started with us that first year who remain today. Trinity Medical Center, then Baptist Montclair, joined us in the second issue in March 2005; Medisys started that April. Healthcare Workers Compensation Fund, Image South, Medica Stand-Up (now Open MRI), AL MGMA, ART Fertility Program, UAB, Jefferson County Medical Foundation, The Maids, Management Resource Group and Warren Averett all joined us during the first 12 months and all still advertise with us today. Since that first year, we’ve become partners with so many outstanding companies. Most have stayed with us for years. That kind of loyalty is rare in the publishing world. We can’t thank you enough. Once I had enough advertisers for the first issue, I still needed content, which meant writers. My family and I had moved here in mid-December, and with layout for that first issue scheduled just weeks away, I was scrambling to find writers. You can imagine my stress – moving to a new city; starting a new business, uncertain it would succeed, with a deadline looming, and at that point, nothing but blank pages. Fortunately, I heard about Alabama Media Professionals, a local group for writers. I attended their luncheon where I met three writers who provided us with great material for that first issue. And in the following months, I connected with the talented writers whose work would become the heart of the Birmingham Medical News. Ann Debellis started with us in October 2005, going on ten years now. Laura Freeman has been with us for eight years. Jane Ehrhardt has been with us for seven years and a few years ago, Jane started handling our ad traffic, which has been a fantastic time-relief for me. Dale Short, the
newest of the bunch, has been with us for four years. These writers have a unique challenge. Imagine you were a journalism major. You didn’t take pre-med courses. And now you have to interview doctors to write articles for medical professionals who know more about the topic than you ever could. That’s tough. And our writers have done a great job with it. Of course, as good as the writers are, there still must be a story to write and people to interview. I want to thank all the healthcare professionals who have helped us find story ideas over the years, and especially thank the hundreds of physicians, practice administrators and other healthcare professionals who have taken time out of their busy schedule to speak with our writers. And there is layout and printing. Susan Graham has laid out all 4,000 pages of the Birmingham Medical News in a tasteful style befitting our audience. Katy Barrett-Alley, Amy Gomoljak and Christie Passarello design some creative ads that they turn around quickly. And Franklin Web prints a beautiful newspaper on thick, bright-white paper. The final piece of the Birmingham Medical News puzzle was put in place in August 2005, just months after the first issue. I was trying to do everything, which meant working every waking hour. I knew I needed help, and a lady who advertised with us recommended Jason Irvin. Jason joined us, initially as a salesperson. It didn’t take long to find out that he was capable of much more than sales and it’s not easy to imagine where this newspaper would be without him. Jason, who is now Vice President of Operations, has always gone far beyond the call of duty for customers. In years past, he has helped customers set up lunch-and-learns with physicians. He has become a maestro at bringing people together. I can’t keep count of all the advertisers he has introduced to each other when he found that one company needed the services another could provide. Jason has created and managed all the extra programs we offer: our blog; our relationship with FOX TV; and recently he started a networking event for practice administrators. So these are all the parts that have helped create the Birmingham Medical News. But regardless of the advertisers, the content, printing and anything else that goes into the paper, none of it matters if no one reads it. So our biggest thanks has to be to the medical community for reading the paper, and for supporting us. Over the past ten years, I have received so many nice emails and letters from physicians commenting on stories. This, really, is the circle of life for our publication. Advertisers took a chance on us, but they have stayed with us because the medical community has been gracious enough to make us a part of their lives.
Steve Spencer, Owner Birmingham Medical News
2 • FEBRUARY 2015
Birmingham Medical News • 10 Year Anniversary
THANK YOU ALL
HEALTHCARE SPOTLIGHT
Beekeeping physician creates buzz at local hospital
Boogaerts spritzes sugar water onto the surface of the swarm cluster at Trinity.
By June mAtheWs
A typical workday for Jim Boogaerts, MD doesn’t usually include rescuing homeless animals. But one day last April, he was called upon to round up some strays; thousands, in fact. And furthermore, he provided them with a lovely new home in his own backyard. A cardiologist with Cardiovascular Associates of the Southeast, Boogaerts is known among his friends and colleagues as a hobbyist beekeeper. So when a nomadic swarm of honeybees showed up at Trinity Medical Center and set up temporary quarters underneath a canvas awning, he seemed the logical person to call for help. Boogaerts received an early morning text that day informing him of the winged visitors. He first suggested calling the Jefferson County Beekeepers Association (JCBA) and getting an expert in swarm removal involved. But later, though he had never before captured a swarm, he decided to give it a try. Besides helping rid the campus of a perceived threat, he could likely get some more bees for his garden apiary out of the deal. So he took along his bee suit, and armed with a smoker and a spray bottle filled with sugar water, Boogaerts approached the scene. Despite concerns of hospital personnel to the contrary, he knew the bees would likely be harmless. “When they swarm, they’re very docile,” he said. “They’ve just left a hive in search of another one, so they don’t have a hive or honey or brood to defend, and they’re exposed and not interested in being aggressive. They’re just hanging out, trying to figure where they’re going to go next.” The relocation process, he said, is fairly simple. A few spritzes of sugar water onto the surface of the swarm cluster keeps the bees occupied licking it off and decreases their flying around. After that, it’s just a matter of preparing the bees for transport. “Basically what you do is take a box, and then you just prod the bees a bit and they fall into it,” he said. “Put a lid on the box, then you carry them and put them into an empty hive and you’ve got a new colony of bees that sets to work right away, establishing themselves in their new hive structure.” Boogaerts first became interested in beekeeping in 2009. After attending a few JCBA meetings and taking some courses in beginning beekeeping, he purchased his first “nucleus” (10,000 bees with an associated queen) from a local beekeeper. He started out with one hive; he now has three. “And that’s where I’ll stop,” he said. “I’m into beekeeping for reasons other than just honey production. I’m attracted to the aesthetics of the apiary and the interesting and docile behavior of these small social
Jim Boogaerts, MD animals. In addition, I have fitted my hives with removable windows, to allow viewing and photography of the combs inside.” Boogaerts partially attributes his interest in bees to his scientific bent. “I work in biology, and I have a PhD in physiology in addition to being an MD cardiologist, so I’m a geek on that side of things,” he said. He also finds that bees provide fasci-
nating material for practicing macrophotography, another of his hobbies. “Within a field of view, you can have any number of subjects – bees at work on the wax cells, the geometries of the comb, the ongoing replication,” he said. “You can get many interesting shots from a single hive.” Boogaerts further incorporates his love of bees into writing essays, emulating
the style of Lewis Thomas, a prominent physicianscientist who for nine years, starting in 1971, published a column titled “Notes of a Biology Watcher” in the New England Journal of Medicine. Thomas’s essays were later compiled into a number of books. “There are so many interesting facets of honeybees, they’re pretty easy to write about,” Boogaerts said. “I try to make the essays interesting and informative, while still focusing on a particular aspect of honeybee biology.” Boogaerts’s essays appear in JCBA’s monthly newsletter, often accompanied by one of his photos. Samples of his photography and writing are also published on his imagessays.com website. With all he knows now, would Boogaerts recommend beekeeping as a hobby? “If you’ve got the time and the interest, it’s easy and inexpensive to do,” he said. “It can be less than a hundred dollars for a hive. I don’t spend as much time as I (CONTINUED ON PAGE 16)
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CARDIOLOGY FOCUS
Cardiologist Aims to Prevent Amputation of Lower Extremities By Ann B. DeBellis
Direct revascularization through targeted angiosomes is proving to be successful in the treatment of critical limb ischemia (CLI) and peripheral artery disease (PAD), particularly in wound healing for patients suffering from diabetes and end-stage kidney disease. Studies show that revascularization through a source artery to the angiosome often results in better wound healing and limb salvage rates, according to Christopher Huff, MD, of Cardiovascular Associates in Birmingham. The angiosome concept defines the human body in threedimensional areas of tissue that are fed by arteries and vessels. These areas are angiosomes. “As technology has evolved, our understanding of PAD and CLI has Christopher Huff, MD, of Cardiovascular Associates in Birmingham evolved, and more research has been directed toward how we can Similarly, there are three arteries below the successfully heal wounds and thus prevent knee that run to the foot. Those three arteramputation,” Huff says. “The angiosome ies are responsible for different areas of tisconcept makes a lot of sense if you think sue to the foot, and if you lose one of those about it from a coronary artery standpoint. arteries, the other arteries have to take over If a patient’s stress test shows ischemia in and make up for the lost blood flow.” the LAD territory, we don’t solve the probHuff points out that diabetics and lem by fixing the right coronary artery.
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patients with end-stage kidney disease don’t compensate well when an artery is blocked and can’t form the natural bypasses required for adequate limb perfusion. That is especially problematic if they have a foot wound. “There may be enough blood flow to prevent tissue loss from ischemia, but there is not enough blood flow for healing should the patient develop a wound from an external injury,” he says. For example, if a patient has a wound on the bottom of the foot and there is blockage in both the anterior and posterior tibial arteries, it is the posterior tibial artery that needs to be fixed, since it is the artery that supplies blood flow to the bottom of the foot, Huff says. “It seems simple enough, but not everyone approaches CLI in this manner, which may be why some patients don’t have successful wound healing after revascularization. To maximize wound healing, you need direct blood flow from the aorta all the way to the wound. Using our knowledge of angiosomes, we revascularize the artery that supplies blood to that area and the wound heals.” Though the angiosome concept for revascularization is relatively new, Huff is
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Birmingham Medical News • 10 Year Anniversary
confident that its application can reduce amputations. However, he says that physicians need to know who is at risk for CLI and be aggressive about referring patients with wounds to a CLI specialist, even if the referring doctor feels the patient has adequate blood flow. “If the patient has no claudication and the doctor feels a pulse on the top of the foot, they assume there is good blood flow so they don’t see the need to refer them to a specialist. The problem is that 40 percent of PAD patients don’t have claudication (1), and a palpable pulse on the top of the foot doesn’t mean there is adequate blood flow to all areas of the foot,” Huff says. “Without referral, they will not get appropriate testing and subsequently won’t get an intervention to correct the problem.” According to Huff, data shows that 90 percent of amputations can be prevented with intervention (2), but only 50 percent of these patients have an angiogram prior to the amputation (3). “Furthermore, patients who undergo a below the knee amputation have a five to 10 percent chance of dying before discharge from the hospital, and mean survival in a diabetic patient after major amputation is 27 months (4-7). So saving the leg not only improves quality of life, but it actually prolongs life,” he says. Application of the angiosome concept has not been embraced broadly, and Huff believes it is due to a lack of education. “Things have changed a lot over the past five years in terms of peripheral intervention. We have more tools and more advanced techniques that allow us to be successful. I think there are a lot of wound care doctors and primary care doctors who don’t realize what we can do,” Huff says. “When I trained at the Cleveland Clinic, we worked hand-in-hand with podiatrists. We coupled wound care with revascularization and had fantastic outcomes.” Huff says this team approach is necessary in order to be successful. “I can do a revascularization in a few hours, but it may take four weeks for the wound to completely heal. You need a team that can perform successful revascularization and then follow that up with aggressive wound care. Both are equally important,” he says. “There are a lot of people in health care who don’t understand this concept. To be honest, before I did a dedicated year of CLI training, I didn’t completely understand the importance of early and aggressive revascularization. There is a misconception that a patient should fail wound care and then be referred for revascularization as a last resort. This is the worst way to handle CLI, as it allows time for infection to propagate, often making amputation necessary regardless of whether revascularization can be performed. CLI is a ‘heart attack’ in the leg and should not be managed conservatively. I think we need to do a better job educating our patients with (CONTINUED ON PAGE 8)
Dr. James Sprague
Chris Kabel
Brian Castrucci
(CONTINUED ON PAGE 18)
Congratulations to the Birmingham Medical News for serving our medical community for ten years. 10 Year Anniversary • Birmingham Medical News
FEBRUARY 2015 • 5
CARDIOLOGY FOCUS
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Birmingham Medical News • 10 Year Anniversary
Surviving Sudden Death
Therapeutic Hypothermia Becoming Standard of Care in Cardiac Arrest By Laura Freeman
For fans of TV medical dramas, reality can come as a shock. Week after week, they are accustomed to seeing defibrillators restoring flat lined heartbeats to happy ever afters. Few would guess that until recently, only around six percent of cardiac arrest patients revived in Alabama survived to recover fully. “Now we’re seeing 40 to 50 percent of revived patients at St. Vincent’s East walk out of the hospital with little or no neurological deficit,” Birmingham Heart Clinic cardiologist Jason Thompson, MD, said. “Some of that improvement is from more people learning CPR, Jason and now more schools, Thompson, churches and other MD places where people gather have automatic external defibrillators. However, the one change I’ve seen that is making the biggest difference is therapeutic hypothermia.” Also known as targeted temperature management, the therapeutic hypothermia protocol cools the bodies of patients revived after cardiac arrest to between 32 °C (90 °F) and 34 °C (93 °F). A recent study found benefits in even more moderate cooling at temperatures as high as 36 °C (97 °F). Hypothermia as a therapy following cardiac arrest is not a new idea. It was attempted in the 1950s with less than favorable results, primarily because the more profound cooling to much lower temperatures created its own complications. There was a resurgence of interest in the 1990s using much milder cooling. “I was at Johns Hopkins when we were getting encouraging reports from Australia and Europe,” Thompson said. “When we started using the protocol and saw the results, we were enthusiastic, too.” Without cooling, cardiac arrest often causes widespread cerebral ischemia leading to severe neurologic impairment. Hypothermia seems to improve survival by not only reducing cellular metabolism rates and the demand for oxygen, but also reducing reperfusion injury and damage from a cascade of reactions and inflammatory immune responses. “Cooling the body and gradually rewarming helps to prevent damage,” Thompson said. “The sooner cooling can begin, the better—ideally within fifteen minutes if possible, but even up to six hours after an arrest, we see some benefits.” When Thompson joined Birmingham Heart Group and started spending
much of his time at St. Vincent’s East, one of his first priorities was making sure the protocol was available for his patients. “We launched the program at St. Vincent’s East in January of 2009, just after UAB launched theirs. Now this therapy is available at every hospital in Birmingham,” Thompson said. “The challenge is if you have a heart attack in a rural area where a small local hospital isn’t likely to be able to offer the protocol. “It takes both cooling and a 24-hour cath lab where you can clear the blockage to improve survival rates. As of now, Medicare doesn’t cover cath labs unless a cardiac surgeon is available if surgery is required. There simply aren’t enough cardiac surgeons to staff every hospital, and we can’t graduate enough, even if every small town had a population large enough to sustain a practice.” Access to therapeutic hypothermia is likely to expand with time, but as of now the takeaway message for clinicians is to make sure patients understand the importance of exactly what Thompson and the other ten cardiologists at Birmingham Heart Clinic tell their patients. “If you’re having heart symptoms, call 911 and get EMS involved. They know which hospitals have the hypothermia protocol and a cath lab available that isn’t backed up,” Thompson said. “So many people with a heart emergency arrive at the hospital in a car, either driving themselves or having a family member drive them. Maybe they are afraid they will be embarrassed if it turns out to be nothing, or that they can’t afford to spend money on an ambulance they may not need. “What they don’t realize is that up to a third of people experiencing an acute heart attack will arrest before they reach the hospital. You can’t do CPR on yourself, and it’s hard to do it on someone else in a car and do it long enough to reach a hospital. It’s exhausting work. Worse yet, if you get there and they have to send you elsewhere, you lose vital time waiting for them to get an ambulance.” For hospitals considering a therapeutic hypothermia program that may be reluctant because of budget concerns, Thompson has this advice. “There are several techniques for cooling that work. If you have the budget, you can purchase equipment that cools and monitors temperatures for you and requires less staffing. But the old-fashioned way works, too. It can be as simple as saline and ice packs. The key is controlling temperature—not too cold, not too warm. That takes more staff if you don’t have automatic monitoring. “What’s important is to just do it. Therapeutic hypothermia saves lives.”
CARDIOLOGY FOCUS
Affairs of the Heart Americans & Cardiovascular Health By CINDY SANDERS
Perhaps it should come as no surprise that there is a major divide between what Americans should do and what is currently being done when it comes adopting healthy cardiovascular lifestyle habits. Based on data from the Framingham Heart Study – the landmark research project founded in 1948 by the National Heart, Lung, and Blood Institute – a recent multi-institutional study found few in the United States hit the mark … or even come close … in terms of scoring well on the American Heart Association Cardiovascular Health score (CVH score). “Ideal Cardiovascular Health: Associations with Biomarkers and Subclinical Disease and Impact on Incidence of Cardiovascular Disease in the Framingham Offspring Study,” which initially published online in Circulation late last fall, Dr. Thomas J. investigated the correlaWang tion between the seven lifestyle factors used to calculate the CVH score and cardiovascular disease (CVD) incidence. Multiple past epidemiological
studies have shown the correlation between the risk factors and cardiovascular events. The seven factors used collectively to calculate the CVH score are: 1) non-smoking status, 2) body mass index, 3) physical activity, 4) diet, and a favorable profile of 5) serum cholesterol, 6) blood pressure, and 7) blood glucose. “The better your score, the lower your cardiovascular risk as evidenced by less subclinical atherosclerosis and a lower risk of future cardiovascular events,” noted Thomas J. Wang, MD, director of the Division of Cardiovascular Medicine and physician-in-chief for the Vanderbilt Heart and Vascular Institute in Nashville and a co-author of the study. “We know a lot of the health practices that are associated with better cardiovascular outcomes, but there seems to be a disconnect,” added the professor of Medicine at Vanderbilt University Medical Center. Of the main findings, Wang continued, “The number of individuals who had ideal cardiovascular health scores was low meaning the number of individuals who adhered to five or more of these healthy lifestyle practices was low.”
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In fact, he added, only 1 percent of the Framingham participants included in the data (mean age 58 years; 55 percent women, no overt signs of CVD) had optimal marks for all seven. “Fortunately, having zero healthy lifestyle practices was also uncommon at about 1 percent of people. Most people did at least one thing associated with good cardiovascular health,” Wang said. However, more than 8 percent did fail to meet the ideal CVH score for at least six of the seven lifestyle factors. “The vast majority of people were at four and below … 18 percent fell between five and seven,” he continued of scoring well on the seven benchmarks. “The fact that such a small number of people actually meet all of the cardiovascular health criteria highlights that there is still a big gap with current lifestyle practices,” he stated. The group studied originated with the Framingham Offspring cohort participants attending the sixth examination cycle (1995-1998) when a routine assessment of subclinical disease was performed along with assays of multiple biomarkers. From the original group of 3,532 potential participants, more than 850 were excluded
for a variety of reasons ranging from prevalent CVD to unavailable concentrations of biomarkers. While Wang said none of the final sample of 2,680 participants had overt heart disease at the beginning of the study, during the 15 years the cohort was followed after the baseline examination, a significant number of them developed cardiovascular events. He noted those who developed a CVD event tended to have lower CVH scores at baseline. “I think people feel as if we’re making a lot of progress with cardiovascular disease, which is true … but it’s still the number one cause of death in America,” Wang stressed. “Physicians could probably do a better job of encouraging their patients to adhere to these healthy practices and give them strategies for adherence, and patients need to do a better job of adhering to them. I think, as with all things in medicine, it is a joint effort,” Wang said. While the study findings might seem intuitive to some extent, Wang pointed out, “It is important to continually remind physicians about the fundamental importance of healthy lifestyle factors in lowering the risk of cardiovascular events.” He (CONTINUED ON PAGE 12)
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Spring Allergies Are Fast Approaching With the changing of the seasons comes an increase of pollen and mold in the environment, which means a lot of people are going to be sneezing. Spring pollen season here should begin in February, although weather can sometimes alter the start and end dates. If your patients are already dreading the return of sneezing, sniffles, headaches, stuffiness and itchy, watery or dry eyes, they can take steps to help keep allergy symptoms from activating their immune system. Encourage your patients to see a Board-Certified Allergist before spring allergies start. We should start seeing pollen in trees in early February. Once patients have been allergy-tested and
their allergy triggers have been identified, they should start medications and follow their allergist’s recommendations beginning early in the season, before pollen peaks in March and April. Even if previous attempts at treatment weren’t successful, there are newer treatments and combinations of therapy that may offer renewed hope for feeling better. For the daily certified pollen report, visit our website at www.aalabamaallergy.com. Bookmark it on your computer for easy daily access. If you prefer to use a weather app that also provides pollen and mold count reports, try the Weather Channel app.
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UAB Regrows Bones Using Living Membrane, continued from page 1 tion procedures. “There are a couple of options to salvage these limbs, but about 40 percent often end in amputation,” Lowe says. Using the Masquelet technique, he and the other two orthopedic trauma surgeons at UAB — Emily Keener, DO, and Candice Dubose, MD — have a high rate of success. “Essentially where there is no bone, we create an environment which tricks the body into regenerating bone,” Lowe says. The procedure starts by cutting away the dead bone, like in any bone-regenerating technique. A stabilizing rod is inserted between the two healthy bone sections to span the empty space. Then the surgeon packs a layer of polymethylmethacrylate (PMMA) — commonly called cement spacer — around the rod and over the native bone for 1.5 centimeters. “In about four to six weeks, we come back and the body has formed a mem-
brane around the cement, and that membrane is very biologically active,” Lowe says. “Under a microscope, it looks like the periosteum — the normal outer surface of bone.” Because of the overlay of the PMMA onto the normal bone, the membrane is firmly attached at both ends, forming a living sheath. “We chisel or scoop out the cement spacer, and what’s left is a sleeve of tissue, like on a hotdog,” Lowe says. “We cut that membrane open, put in the graft, and close it up.” The bone graft, ground from the pelvis or other large bones, resembles coarse sand. When the patient puts weight on it, the stress signals the body to make the graft pieces into a solid mass and incorporate it into normal bone. The membrane was first discovered about 15 years ago while utilizing PMMA’s other notable benefit of being able to re-
lease large doses of antibiotics over time. “So they put these antibiotics beads into wounds, and they found that if you left it for weeks, then this fibrous membrane formed around the beads,” Lowe says. “That membrane is a living thing. In grafting procedures, it helps support new bone growth.” The largest section Lowe has replaced using the Masquelet technique ran along the tibia for 17 centimeters, about eight inches. The most complex was in the arm. “They’re a little more cumbersome and tricky then legs, especially in the forearm because it rotates,” he says. A few years ago, he replaced eight centimeters in both bones of a woman’s forearm. “We grew back all 16 centimeters of her bone,” he says. It was one of the first reported case for successfully using the Masquelet method on both the radius and ulna simultaneously.
Like the woman’s forearm, most of the Masquelet cases at UAB derive from vehicular accidents. “Most of the force in a crash comes up through the floorboard, so we see a preponderance of lower limb trauma,” Lowe says. Arms generally get severely injured only during rollovers or if someone has their arm out the window. Other primary reasons Lowe and his colleagues have used the Masquelet technique over the last five years include gunshots and infection. “We’re the acute Level 1 trauma center for the state, so our practice is called to treat those fractures that don’t heal, healed badly or are infected,” he says. “People send us their problems, and we pride ourselves on being available to the community.”
Cardiologist, continued from page 4
diabetes and end-stage kidney disease. In addition we need primary care doctors, wound care specialists, and podiatrists who can recognize this problem and refer patients for urgent evaluation.” Huff suggests that physicians start by looking at their patients’ feet. “I am sure there are a lot of patients who don’t routinely have their socks and shoes taken off in the exam room. The first thing I do with every patient, regardless of what they are seeing me for, is touch their feet. For me, it’s just as important as listening to the heart,” he says. “But we need to recognize that the physical exam has limitations and be suspicious for CLI in our patients with diabetes and/or end-stage kidney disease who have a foot ulcer. CLI carries a five-year mortality rate of 67 percent, which is greater than MI, stroke, breast cancer and colorectal cancer (8-12). It’s a bad problem. If we don’t evaluate our patients appropriately and miss their CLI, we underestimate their risk of amputation and cardiovascular death.”
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Birmingham Medical News • 10 Year Anniversary
1) Rosinberg, A. (2011). Hemodynamic Evaluation of Peripheral Arterial Disease. In I. Casserly, R. Sachar, J. Yadav, Practical Peripheral Vascular Intervention (p. 8).Philadelphia, PA: Lippincott Williams & Wilkins. 2) Henry AJ, Hevelone ND, Belkin MB, et al. Socioeconomic and hospital-related predictors of amputation for critical limb ischemia. J Vasc Surg. 2011;53:330-9.e1. 3) Goodney PP, Travis LL, Nallamothu BK, et al. Variation in the use of lower extremity vascular procedures for critical limb ischemia. Cardiovasc Qual Outcomes. 2012;5:94-102. 4) Hasanadka R, McLafferty RB, Moore CJ, et al. Predictors of wound complications following major amputation for critical limb ischemia. J Vasc Surg. 2011;54:1374-1382. 5) Belmont PJ, Davey S, Orr JD, et al. Risk factors for 30-day postoperative complications and mortality after below knee amputation: a study of 2,911 patients from the national surgical quality improvement program. J Am Coll Surg. 2011;213:370-378. 6) Aulivola B, Hile CM, Hamdan AD, et al. Major lower extremity amputation: outcome of a modern series. Arch Surg. 2004;139:395-399. 7) Stone PA, Flaherty SK, Hayes JD, et al. Lower extremity amputation: a contemporary series. W V Med J. 2007;103:14-18 8) SEER Stat Sheets: Breast. National Cancer Center Institute Web site. http://seer.cancer.gov/statfacts/ html/breast.html. April 24, 2013. 9) SEER Stat Sheets: Colon and Rectum. National Cancer Center Institute Web site. http://seer.cancer. gov/statfacts/html/colorect.html. April 24, 2013. 10) Weitz JI, Byrne J, Clagett GP, et al. Diagnosis and Treatment of Chronic Arterial Insufficiency of the Lower Extremities: A Critical Review. Circulation. 1996;94:3026-3049. 11) Hartman A, Rundek T, Mast H, et al. Mortality and cause of death after first ischemic stroke: the NorthernManhattan Stroke Study. Neurology. 2001;57:2000-20005. 12) Ljungman C, et al. Eur J Vasc Endovasc Surg. 1996; 11:176-182.
OPHTHALMOLOGY FOCUS
Eye Cues
Signs of disease may be detectable in the eye years in advance By Laura Freeman
Shakespeare said the eyes are windows to the soul. They can also give a pretty clear indication of health issues that may be developing in other parts of the body. A patient’s primary physician and eye care provider may not cross paths all that often, but a closer working relationship could possibly unmask disorders earlier when they are more treatable. The classic case is diabetes, which may first present in an eye exam chair with a patient complaining of blurred vision. High blood sugar can attack the vascular system of the eye, and it can eventually lead to early cataracts or diabetic retinopathy, a leading cause of blindness. Unfortunately, economically disadvantaged people, who tend to have an elevated risk of diabetes, are also less likely to have eye exams. A UAB study published in JAMA Ophthalmology found that low socioeconomic status is a risk factor for visual impairment because of decreased preventive services and poor continuity of care, which can delay diagnoses and increase
Chronic illnesses can have an impact on vision, making coordination between healthcare and eye care providers is important.
complications. Paul McLennan, PhD, lead author of the study, said “Our results show that frequency of eye care was low, just 33 percent within the first year, and only 45 percent within two years.” A second UAB study looked at the value of using Telemedicine for dia-
betic eye screenings in underserved communities. One in five patients examined had early stage diabetic retinopathy, and nearly half of the mostly minority populations screened had additional vision conditions such as glaucoma or cataracts. Encouraging diabetics to get regular
eye exams is an area of collaboration between health professionals that can have a positive effect on patient health. Looking into a patient’s eyes can also reveal early signs of heart and vascular conditions, hypertension, and autoimmune and metabolic disorders. Dry, red eyes may suggest it’s time to see an allergist, but they can also be a sign of Sjogren’s syndrome or other disorders related to arthritis. Eyes may be where emerging symptoms of thyroid disorders such as Graves Disease first show themselves. Recent research shows that early evidence of Alzheimer’s can sometimes be found in the eye years before more obvious symptoms appear with the detection of an amyloid protein in the lens and fluid of the eye. Changes to the eyes may also help diagnose the onset of frontotemporal dementia, the second most common form of dementia. Scientists from UAB, Gladstone Institutes and the University of California found that individuals with a genetic mutation associated with FTD showed a significant thinning of the retina before any cognitive signs of dementia (CONTINUED ON PAGE 10)
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Eye Cues, continued from page 9 were present. This thinthat may first show up in a ning is not present in primary care physician’s people who do not have office that warrant an exthe mutation. pedited referred to an eye “We can use the specialist. Retinal detachthinning of retinal cells ments are a vivid example. as a marker for this type When patients complain of of dementia,” UAB neuflashes of light, a dramatic rologist Erik Roberson increase in floaters, shadows said. “Further studies in peripheral vision or loss of may also help determine central vision, it could be an whether the changes emergency requiring immein the retina can be a diate assessment and treatmarker of disease proment by a retina specialist to gression or a means of preserve sight. gauging the effectiveness Fortunately, for such of new therapies.” emergencies and for eye inAnother area where juries, Alabama has the naprimary physicians, spetion’s first designated eye cialists and eye care pro- Eyes are the windows to health, where signs of systemic diseases can be directly visualized. trauma center at the Calviders can work together lahan Eye Foundation Hosfor better outcomes is in pital in Birmingham. Open scattered and did not focus on the retina making sure that patients whose vision 24 hours a day, it is the only emergency properly. Rosenstiel prescribed a hard, has been impaired by systemic diseases department totally dedicated to eye emergas-permeable lens which created a new know about and have access to advances gencies in Alabama and one of only two spherical refractive surface on the front of that could improve their sight. in the Southeast. The department’s rethe eye which allowed light rays to focus Jeff Henson of Heflin was legally cent renovations feature a new optical accurately on the retina. She piggybacked blind from the effects of arthritis and incoherence tomography system to capture it with a soft contact lens Henson could flammation. three-dimensional images of the eye. wear underneath the hard lens to tolerate “I didn’t have any vision at all,” Perhaps a good resolution for it better. With his contacts, Henson’s vihe said. “I was running into doors and the coming year would be for primary sion in his left eye is now nearly normal. walls.” physicians, specialists and eye care proEye movements and pupil reactions Carol Rosenstiel, OD is the chief of viders to work more closely. It might be a can also signal the possibility of brain the contact lens service in the UAB Degood idea to ask patients who their other tumors, stroke and other neurological partment of Ophthalmology. She spehealth care providers are and keep conconditions as well as the presence of traucializes in using contact lenses to correct tact information on file. matic brain injuries. Such findings dursevere vision issues, particularly in cases And next time patients come ing an eye exam would likely result in an like Henson’s, where surgery or eyeglasses in for a checkup, it might be helpful to immediate referral for follow up with a are not an option. ask when they last had an eye exam. And physician. Henson’s cornea was badly scarred how did it go? There are also eye emergencies from inflammation. Light entering the eye
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The Blinding Disease By Shilpa Register, OD, MS, PhD, FAAO, FNAP
Glaucoma affects over 2.2 million people, but only half of them are aware that they have the disease. If left untreated, glaucoma will lead to blindness, making it the 2nd leading cause of blindness in the world. Glaucoma comes in many forms, but most are marked with high eye pressures and subsequent damage to the optic nerve and vision loss. Because there is no pain, irritation, redness, or other noticeable symptom, it is important that all adults obtain comprehensive eye exams on an annual basis. Most people do not notice any vision changes until a substantial portion of their vision has been lost. Any vision loss cannot be regained. Adults over age 40 should be tested every two years, while those over 60 should be tested annually. Glaucoma affects people of all ages with older adults being at the highest risk. Those individuals who are at-risk for certain types of glaucoma include older individuals, African Americans, Asians, and Latinos. Those patients with a positive family history of glaucoma are at higher risk. Diseases that affect your body also increase their risk of glaucoma including the presence of diabetes, poor perfusion or the presence of vasospasms. During the annual eye exam, optometrists can identify additional ocular risk factors such as high or asymmetric intraocular pressures, optic nerve enlargement, optic nerve asymmetry, high myopia, thin central corneal thickness, and visual field defects that could be indicative of glaucoma. Optometrists will perform necessary tests to diagnose and monitor glaucoma. He may prescribe eye drops or recommend surgical intervention to stabilize the eye pressures and reduce further ocular damage. Shilpa Register, OD is an Associate Professor in the UAB School of Optometry and sees patients at UAB Eye Care.
New Procedure Delivers Drug Via Balloon To Help Repair Leg Arteries By Dale Short
Repairing heart arteries that become clogged with plaque--a condition known as atherosclerosis--has become a familiar medical procedure in recent years. Somewhat less well-known to the public is the field of peripheral artery disease in the legs and feet, or PAD. But a new breakthrough in PAD surgery, involving drug delivery via a tiny balloon, is making a dramatic difference in success rates. Most patients with heart disease also have some buildup of plaque in their legs, says cardiologist Robert Foster, MD of St. Vincent’s East. And traditionally, arteries affected by PAD have been roughly twice as likely to re-narrow, or re-occlude, after a procedure as those Foster, in the heart, according to Robert MD Foster. The new treatment uses a balloon, similar to those used for opening heart arteries, to deliver the drug paclitaxel after the artery has been cleared, which improves blood flow and reduces the rate of artery re-occlusion from about 60 percent to 20 percent. “Many people underestimate the seriousness of PAD,” Foster says, “but if you follow the progress of untreated cases, they actually have worse outcomes than breast cancer, as patients are likely to die from a complication of cardiovascular disease such as a stroke or heart attack. It can also result in amputation, and the need to wear a prosthesis. Maintaining one’s mobility is critical for survivors. “And when you look at the data on amputees, people in their 60s, 70s, and 80s in whom the disease is particularly advanced, fewer than 20 percent ever walk again--generally because their other leg or their arms aren’t strong enough. That has a great impact not only on the patient, but on family members.” Formerly, treatment for PAD often involved the insertion of stents, as in heart surgery but with less success. What physicians discovered, says Foster, is that “putting a foreign body into a leg artery doesn’t respond like the heart. The nice thing about balloons is that, unlike the stent, they don’t leave anything behind after the plaque has been cleared out.”
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“St. Vincent’s is excited to be the first in our market to offer our PAD patients a life-changing technology,” says Michael Korpiel, president and COO of St. Vincent’s East. “We have a longstanding reputation for providing innovative vascular care to our patients. This new technology builds on that commitment to offer our patients the latest and most effective treatment options to improve their outcomes.” The primary reason the hospital is the first to offer the new balloon technique is its familiarity with PAD procedures, says Foster. “Our volume of cases is probably the highest in the state. We’re the training center for a lot of these devices, because we’ve established a reputa-
tion for peripheral work. More than half the procedures in our cath lab are peripheral. In addition, we’ve established relationships with the provider companies we see at meetings when we do presentations around the country. When there are new developments in the technology, the companies typically seek out the sites with the highest volumes of surgeries. “Most companies do their initial research in Europe because there’s less regulation and the approval processes are faster. So by the time a technology comes to the U.S., it’s a second or third generation product and is a better device because of it.” The new PAD device is known as the Lutonix Drug Coated Balloon PTA Cath-
eter, though Foster says several other companies are entering the field. Another reason the breakthrough is used first in a high-volume center, says Foster, is that “peripherals are different from the heart, more complex, and so the procedures are a bit more operatordependent to have good results. I started doing peripherals in 1999 and the equipment was pretty simple, but the progression and improvement now makes many of the procedures non-surgical. “We can open the leg non-surgically, put in a little stitch, and the patient is ready to go. Keeping patients walking is important, and generally they’re up walking the same day.”
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Fusion Technology Improves Detection, continued from page 1 with the MRI/ultrasound fusion biopsy is 54 percent. “But if you stratify that for the lesions that are highly suspicious, then it’s 80 percent so this technology increases the sensitivity and the specificity. Not only is this technique more accurate, we think we can reliably detect the cancers that look more aggressive on the MRI as well.” The first step in the biopsy process is to send the patient for a multi-parametric MRI. “They use three different parameters, a T2 weighted image, diffusionweighted imaging, and dynamic contrast enhancement. They use the three parameters of the MRI to calculate a score of one to five to assess how worried they are about a lesion that might be cancer. We do biopsies on the ones that are three or higher,” Poole says. “The radiologist uses the MRI to identify the lesion, marks a circle around it, and that becomes our target.” In a follow-up appointment, the patient will return to the doctor’s office for a real-time, three-dimensional ultrasound, and the MRI is fused with the ultrasound image. “While we do the ultrasound, we can see the target that was marked on the MRI so we know where to direct our needle,” Poole says. With the more specific readings from the MRI/ultrasound fusion, physicians also are more able to determine when cancer is not a threat. “There are two problems with doing the 12-template biopsy,” Poole says. “One is that we may not be catching the significant lesions or significant cancers that need to be treated, and the other problem is that we may be catching too many cancers that don’t need to be treated. I think the MRI will allow us to stratify who needs to be treated and who doesn’t. “If you do the MRI and you don’t identify anything that looks suspicious, that patient may not need a biopsy at all. As urologists and radiologists gain experience with the MRI, we will find a comfort zone where we can determine when a lesion looks like it’s suspicious and definitely needs a biopsy or when we can forego a biopsy on one that doesn’t appear to be a threat. That’s a huge advantage.” Poole hopes that this new technology also will end the controversy about whether prostate-specific antigen (PSA) screening does more harm than good in the prediction and treatment of prostate cancer. “We believe the PSA screening needs to be done, because it helps us do a better job of determining which patients need to be treated and which ones don’t, so we can’t say that PSA screening is the problem” Poole says. “We have always maintained that the screening is not the issue; it’s the treatment of the prostate cancer, so the idea of putting your head in the sand and not doing PSA screenings any more doesn’t make sense. The problem is not finding the cancer, the problem is developing better treatments for the cancer. This MRI fusion is the first step in getting better treatment for prostate cancer. It is going to help us diagnose the cancer more accurately.” Poole adds that there has been dis-
Birmingham Medical News • 10 Year Anniversary
cussion of whether it is cost effective to do the MRI fusion on all patients. “We would do the test on people who have had a negative biopsy in the past but their PSA continues to rise. At some point, we may do all prostate biopsies this way” he says. The MRI can also be used to monitor patients who have been diagnosed with a low grade cancer and have elected to do active surveillance. “We would not be treating the cancer, we would just be watching it so we could use the MRI to monitor the prostate and make sure there is nothing there that could develop into a more aggressive cancer.”
Currently, insurance companies do not cover the added cost of the MRI fusion, but Poole believes catching cancers earlier and recognizing cancers that don’t need to be treated will save money in the long run. His group will use the fusion screening regardless of the insurance coverage because it is better for their patients. “I believe this fusion technology will revolutionize the treatment of prostate cancer,” he says, “and it is a major priority for our group to offer this to patients. This is just the first step in the fight against prostate cancer. There is more to come.”
Affairs of the Heart, continued from page 3 added, “It also serves as motivation for the scientific community to better understand the biological mechanisms linking lifestyle factors such as diet and exercise to lower cardiovascular risk.” Wang recognized medical interactions occur in very tight timeframes these days, which makes it difficult for providers to cover the full spectrum of useful information with patients. However, he noted, there are a number of organizations at the national level – including the
American Heart Association and National Heart, Lung, and Blood Institute – that offer excellent tools and resources that can be printed or accessed online to help patients better understand the importance of healthy lifestyle strategies. “It’s clear that a better lifestyle would not just be associated with better cardiovascular outcomes but also with less death from cancer and other diseases, as well,” Wang concluded of the critical need to change American habits.
AHA Releases Updated Worldwide, U.S. Heart & Stroke Statistics Last December, the American Heart Association/American Stroke Association released updated heart and stroke statistics in the United States … and, for the first time in the 50 years such information has been provided, added a global perspective with health data compiled from nearly 200 countries. Key findings from “Heart Disease and Stroke Statistics 2015 Update” include: • Heart disease remains the No. 1 global cause of death with 17.3 million deaths annually. The annual death toll is expected to rise to more than 23.6 million by 2030, according to the report. • Stroke, which has fallen to the No. 4 cause of death in the United States, remains the No. 2 cause of death in the world. Although the number of deaths per 100,000 declined worldwide between 1990 and 2010, the number of people having a first or recurrent stroke increased each year, reaching 33 million in 2010. • In the United States, nearly 787,000 people died from heart disease, stroke and other cardiovascular diseases in 2011. Nearly 2,150 Americans die daily from cardiovascular diseases … or one person every 40 seconds … accounting for approximately 1 in every 3 deaths in this country. • Additionally, about 85.6 million Americans are living with some form of cardiovascular disease or the after-effects of stroke. • The AHA estimates direct and indirect costs of CVD and stroke in this country to be more than $320 billion. • Breaking heart disease out separately from stroke in America, heart disease remains the number one killer in the United States with more than 375,000 dying annually … or about one person every 90 seconds. • Nearly half of all African-Americans have some form of cardiovascular disease and more than 39,000 died from heart disease in 2011. On the plus side, the death rate from heart disease fell about 39 percent between 2001 and 2011. The physical and cost burden, however, remain incredibly high. About 735,000 people in America have heart attacks each year (accounting for approximately 120,000 deaths), and cardiovascular procedures and operations increased around 28 percent between 2000 to 2010.
Freestanding Emergency Departments to Benefit Patients in Hoover and 280 Corridor By Ann B. DeBellis
Overcrowded emergency rooms and ambulance diversion are problems around the country, and Birmingham is no exception. Recent approval for the construction of freestanding emergency departments (FEDs) in the Birmingham area may begin to help the problem, especially in high traffic areas of the city. About 30 states currently have FEDs, but the two FED projects in Birmingham are the first in Alabama. Medical West has broken ground on its FED at Highway 150 and Interstate 459, and Brookwood Medical Center is expecting an August completion of its FED at the intersection of U.S. 280 and Highway 119. The two entities have worked together on the development of these projects. “This has been a collaborative effort between Brookwood and Medical West, because we want the same things. We hope these new freestanding emergency room facilities coming to the market can take some of the load off of hospital emergency rooms,” says Stephen Preston, Vice President of External Affairs for Brookwood Medical Center. “With the construction of this new FED, we are taking emergency care to patients, and response time is critical. Our FED should help al-
Rendering of proposed Brookwood Freestanding Emergency Department
Rendering of proposed Medical West Freestanding Emergency Department
leviate some of the overcrowding.” The Medical West FED will offer the same quality of service provided by its existing emergency room and emergency physicians in Bessemer, including convenient outpatient diagnostic services. Hospital officials project between 12,00015,000 emergency visits per year at the new facility which is slated for a spring
2015 opening. “This facility will allow us to provide emergency care for area residents closer to home, and the location will provide easier access to care,” says Keith Pennington, Chief Executive Officer and President of Medical West. “We are proud to take the leadership role in being the first to offer this new service which will expand
healthcare access to the growing Hoover community, the largest community in Alabama without acute healthcare access.” Brookwood filed for its Certificate of Need for this project in 2009, but the project was opposed by Trinity Medical Center, which is relocating to a new facility on Highway 280. Trinity argued
10 Year Anniversary • Birmingham Medical News
(CONTINUED ON PAGE 22)
FEBRUARY 2015 • 13
New Tool for Early Detection of Lung Cancer By Bibb Allen, Jr., MD FACR
About 450 Americans die every day from lung cancer. Lung cancer kills 160,000 people every year - more than any other type of cancer; more than breast, colorectal, prostate and pancreas cancers combined. But we know that if we can catch lung cancer in its earliest stages, it can be cured. The problem has always been how to find it early because for the vast majority, by the time lung cancer causes symptoms, it is already in an advanced stage and much more difficult to treat. That is about to change. We now have a tool that will actually save lives in lung cancer patients by detecting the disease in its earliest stages. Recent scientific studies show we can lower the overall mortality of lung cancer by 20 percent through early detection of the disease in high-risk individuals. Tobacco use continues to be the highest risk factor for lung cancer, and by targeting this group of individuals for early detection, we can save 50 lives a day. A study sponsored by the National Cancer Institute and the National Institutes of Health conclusively demonstrates that screening for lung cancer in high-risk individuals with low dose computed tomography would save 10,000 to 20,000 lives each and every year. Early detection through screening high-risk patients will save more lives than the decades of work we have spent on new ways of treating lung cancer.
14 • FEBRUARY 2015
Who should be screened? Current or former smokers who smoked a pack of cigarettes per day for 30 years or more are considered at high risk for lung cancer. Our veterans, rescue workers, firefighters and construction workers are unfortunately over-represented in this group. Even former smokers who have quit smoking in the last 15 years remain at risk and should be screened as well. So beginning at age 55, these individuals should be screened for cancer every year until they are 80. This is the recommendation of the United States Preventative Services Task Force and because of this recommendation, insurance carriers are required by the Affordable Care Act to provide coverage and we expect this to happen beginning in 2015. How does screening work? We use standard computed tomography (CT) equipment, and the CT scan takes less than 10 seconds to perform – no medicines, no needles. Although the CT scan uses x-rays to look at the lungs, the examination is considered very safe. We use the lowest possible amount of radiation for satisfactory examination, and it is an amount similar to that used for a routine screening mammogram. Considering the overwhelming benefits, risk of radiation exposure should not deter highrisk patients from being screened. How good is screening? When an early lung cancer is detected, patients have a 93 percent chance of being cured, and while that’s exciting news, no test, including CT
Birmingham Medical News • 10 Year Anniversary
screening for lung cancer, is perfect. Sometimes patients can have a cancer or other medical condition that will not be detected by the screening examination. Sometimes, the screening examination detects an abnormality that could be cancer, but is not. In order to make sure these findings are not cancer, patients may need to have some follow-up tests that will only be performed after consultation with the patient. Usually, this may be short interval follow-up CT scan to make sure a likely benign finding is not changing. Sometimes, more invasive procedures are required to determine a diagnosis including bronchoscopy and/or biopsy. Finally, in five to ten percent of cases the screening CT examination may detect abnormalities in areas of the body adjacent to the lungs including the kidneys, adrenal glands, liver or thyroid. These findings may not be serious, but sometimes need to be examined further. Overall, about one out of four lung screening exams will find something in the lung that may require additional evaluation, and usually these findings are lung nodules. Lung nodules are small collections of tissue in the lung that are quite common, and 97 percent of the time they are not cancerous. Most are small areas of scarring from past infections. But less commonly, lung nodules are cancer. If a small lung nodule is found to be cancer, the cancer can be cured in the vast majority of cases. But to distinguish the large number of noncancerous nodules
from the few nodules that are in fact cancer, we may need to get more images before the next yearly screening exam, usually in about six months. If the nodule has suspicious features (for example, it is large, has an odd shape or grows over time), patients are referred to a specialist for further testing. At Trinity Medical Center, we have put together a Lung Cancer Screening Program that is a multi-specialty effort between radiology, pulmonary medicine, medical and radiation oncology, thoracic surgery and primary care. We offer all of our enrollees a smoking cessation counseling to help them stop smoking. Our equipment specifications exceed all of the minimum standards for lung cancer screening, and our personnel are trained to perform and interpret the examinations. We have a structured reporting system that ensures standardized management and multi-specialty follow-up of abnormalities detected in the examination. As a radiologist, who for years has seen mostly advanced lung cancers, it is an exciting time to finally be able to help the people by offering a way to make a dent in mortality from our country’s largest cancer killer. My hope is that the people in our state will take advantage of this opportunity to beat lung cancer. Bibb Allen, Jr., MD FACR is a diagnostic radiologist at Trinity Medical Center.
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10 Year Anniversary • Birmingham Medical News
FEBRUARY 2015 • 15
Benefitting from ‘Health Information Handlers’ The not-so-new role is gaining traction, as time and money savings highlight submissions process By JULIE PARKER
Five years ago, the 400-bed Boca Raton Regional Hospital in Florida faced a crush of Medicare audits and penalties. The 47-year-old, not-for-profit hospital made a significant change resulting in a complete turnaround by employing an entity with which many healthcare providers remain unfamiliar: the health information handler (HIH). “According to hospital officials there, the previous process had been cumbersome, and meant printing, sorting, packaging and mailing documents to Medicare to support claims and to adjudicate their bills,” said Lindy Benton, CEO of Norcross, Ga.-based Medical Electronic Attachment/National Electronic Attachment (MEA/NEA), a certified HIH that has electronically delivered and tracked patient medical records for healthcare providers nationwide via CONNECT, an open source health information exchange software that serves as the National Health Information Network’s (NwHIN) transmission mode for esMD (electronic submission of medical documentation). “Since one patient record can fill a box or more, hospitals are left paying for all materials, labor and shipping involved … enormous financial considerations for every organization.” Because the Boca Raton hospital is now able to submit documents electronically via an HIH, the Medicare audit process has dramatically improved and denials related to untimely submission of records have disappeared entirely, Benton noted.
Benton explains: “For example, Medicare allows 45 days from the date of request for hospitals to respond, but Medicare still sends documentation requests by paper. Typically, by the time the request arrives at the proper hospital department, more than 10 days has elapsed. Managing the entire process requires a very strict time requirement and hospitals often fail to return records to Medicare on time, which blocks hospitals from making appeals. By automating the process and securely depositing electronic attachments to Medicare’s official information portal, Boca Raton Regional Hospital has prevented the loss of at least $350,000.” What exactly is a health information handler? The Centers for Medicare & Medicaid Services (CMS), which manages the HIH program, defines an HIH as “any organization that handles health information on behalf of a provider.” HIHs are often referenced as claim clearinghouses, release of information vendors, and health information exchanges (HIEs), and most also provide esMD gateway services. “esMD is still a work in progress, an ongoing experiment, spearheaded by CMS to support electronic exchange of information between health systems and Medicare audit contractors,” explained Benton. “Prior to esMD, providers had just two ways in which to respond to documentation requests from Medicare review audit contractors – mail or fax. esMD fixed that problem.” The esMD gateway isn’t set up like a
typical website, Benton pointed out. “Not everyone wanting to submit information via the gateway can simply jump on, upload files and press the ‘send’ button,” she noted. “To interact with CMS through esMD, organizations need access to the portal. The gateways are costly to develop and maintain so hospitals and providers turn to HIHs to facilitate the exchange process. HIHs build and service an esMD gateway for multiple provider participants and submit electronic documentation on a provider’s behalf. As more providers use HIHs to simplify their audit processes, electronic health information exchange also will increase in usability.” Slated improvements are poised to further streamline this process. The HIH program has been effective for more than three years – phase 1 went into effect on Sept. 15, 2011 – and phase 2 will allow providers the ability to receive electronic documentation requests when their claims are selected for review … when CMS launches it. “From a business and enterprise perspective, the move by CMS to launch the program has meant the growth of a number of HIH firms like ours that offer a variety of services and skill sets,” said Benton. “In addition to providing exchange capabilities, some allow for capture of information, scanning, storage and transmission in a secure manner. The HIHs also track data sent, and acknowledge and verify that it’s been received by auditors through the gateway … are considered business associates of the organizations they serve, and are required by CMS to follow HIPAA rules.”
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“There are hurdles to widespread implementation as hospitals resist using the solutions because they’re overwhelmed with current technology,” she said. “They’re already so invested in other projects that many are unable to see the benefits of bringing on additional solutions and being able to exchange information with CMS. A prevailing thought is that those managing hospital IT departments simply are overwhelmed and growing ever more nonchalant about the idea that technology is going to save them or their employers any more than already has been promised. “In fact, recent reports have begun to surface claiming that CIOs at struggling health systems have little faith that new technologies, on top of recently implemented systems like EHRs, will do much good for them since these other solutions – the EHRs – had such little positive effect on their organizations’ bottom lines. Simply put, they’re sensing a bit of personal doom and growing tired of all the hype. It’s unfortunate.” Also, for payers, despite the obvious benefits of encouraging HIH relationships with physicians, esMD and electronic exchange aren’t top priority, considering all the issues being managed, including the current federal insurance overhaul. “Perhaps time will change this, but for the foreseeable future, esMD isn’t likely to gain the traction it needs to become an industry standard,” observed Benton. “What’s fortunate is that service providers like HIHs are having a positive impact on the healthcare environment and are bringing down some pretty mighty horses, while also helping bring about better workflows, improved efficiencies and increased profitability. Despite the lack of awareness surrounding these healthcare partners and their impact across the sector, many are still unaware of HIHs’ purpose and the very term by which they’re defined.”
continued from page 3
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Birmingham Medical News • 10 Year Anniversary
would if I were trying to maximize honey production. To do that, you have to inspect the hives more frequently and pay closer attention to details, to have everything ready for the timing of the spring and summer blooming season. So for me, maintenance is not really a big deal.” But, he cautioned, if harvesting honey is your motivation for beekeeping, knowing what you’re getting into is key. “There’s a saying that people get into beekeeping because of the bees, and get out of beekeeping because of the honey,” he said. “Working large numbers of hives for honey yield can be hot, heavy, sticky work. Amateur backyard beekeepers can end up with more honey than they can give away.”
The Literary Examiner BY TERRI SCHLICHENMEYER
Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner by Judy Melinek, M.D. and T.J. Mitchell, c.2014, Scribner; $25.00 / $29.99 Canada; 258 pages Everybody’s good at graduation from UCLA something. medical school, she deYou may have an apcided to become a surtitude for numbers. You geon. That specialty might be a master at chess, turned out to be a bad multitasking, organizing, fit for Melinek, so she reor people skills. Your real signed from her residency talents could be hidden, position and turned inor maybe the whole world stead to a medical branch knows how good you are. that also intrigued her: foAuthor Judy Melinek, rensic pathology. M.D. loved doing surgery, Forensic patholobut it had its drawbacks. gists, she says, investigate And besides, as you’ll see “sudden, unexpected, or T.J. Mitchell and Judy in “Working Stiff” (with violent deaths by visitMelinek, M.D. T.J. Mitchell), her real ining the scene, reviewing terest lay just this side of six feet under. medical records, and performing an auFrom the time she was very small, topsy” while gathering evidence for posJudy Melinek’s father shared with her a sible legal reasons. You learn a lot about fascination with the human body. He was the human body when you’re a forensic a doctor. Melinek dreamed of becoming pathologist and if “you knew how much a doctor, too, and making him proud but hardware some of your fellow citizens are she never got the chance. He committed toting around in their knickers, you might suicide when she was just thirteen. see the world as a stranger place.” Still, she forged ahead and, upon Forensic pathology only barely re-
sembles what you see on TV. “Everyone thinks ‘murder’ when you say you work as a medical examiner,” she says, “but homicides are rare.” Still, in her career, she discovered evidence of them. She also investigated overdoses and mis-doses, though “alcohol is the deadliest drug.” She helped police solve a crime in which a driver swore he didn’t hit-andrun. She gave comfort to the loved ones of the deceased she autopsied, and she learned why you want to brew coffee when investigating a long-dead body. And on September 11, 2001, she got a call to help investigate “the largest mass murder in United States history.” Visit your local library or bookstore and you’ll find a very long, long shelf of books by medical examiners. “Working Stiff” is one of the better ones. Part of the reason for that, I think, is what you won’t see in this book: author Judy Melinek, M.D. doesn’t write about
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celebrities’ deaths. Her work was performed on regular people who likely would’ve lived long, anonymous lives but who died under circumstances that needed investigation. The other appeal here is what you will see: interesting stories of crime, death, the human body, and the ways they might intersect. Melinek (with T.J. Mitchell) is perfectly willing to share stories of that intersection, which is exactly why I loved this book. Be aware that this is probably not something you’ll want to read at lunch. It can be gruesome and detailed but oh-sofascinating, so if you’re strong-stomached and up for a slice-of-life book on slicing at death, then “Working Stiff” is a good one.
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10 Year Anniversary • Birmingham Medical News
FEBRUARY 2015 • 17
Big Data Analytics and an Evolving Standard of Care By
GilliAn eGAn
IBM’s Watson, the natural-language processing computer perhaps most famous in popular culture for obliterating its opponents on a January 2011 evening of Jeopardy!, has more recently been making news in the healthcare industry. A growing number of care providers are buying or renting Watson’s computing power to assist their medical professionals and staff with decision-making. The possibilities for using big data to improve outcomes for patients are myriad and exciting. With these new tools come new responsibilities. As contextual computing devices become more widely available and, presumably, less expensive and more conveniently sized, how will health providers’ standard of care change in response? How can the healthcare industry use this technology to improve care and save lives, but also manage the potential exposure to liability that comes with reliance on massive amounts of data from myriad sources that no single human
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brain could ever contextualize or verify? Many important questions spring from this change - questions revolving around patient privacy, managing inputs, ethics in research, data protection and the potential for breach, and how to use the cold numbers of statistics to assess and improve the unquantifiable goal of “better quality of life.” For health systems’ risk management and in-house counsel, innovation also brings concerns for management of potential liability. The availability and use of big data analytics injects uncertainty into some already slippery concepts, including the “duty of care.” A court’s determination of the standard of care in a medical malpractice action today varies from jurisdiction to jurisdiction, but generally revolves around the court’s analysis of what a reasonably prudent doctor would do. This concept is fluid, and for good reason - the reasonably prudent doctor in 2015 obviously makes different choices from the reasonably prudent doctor of 1955, and the court system can use expert testimony and common sense to allow the standard of care to evolve as quickly as medicine evolves. The availability of systems like Watson will necessarily change the standard of care in medical malpractice actions: eventually, large health systems may be required to engage the use of contextual computing in order to provide the bare minimum of good care, especially as it becomes cheaper and easier to use. That’s virtually certain. What is harder to define
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Birmingham Medical News • 10 Year Anniversary
is how human practitioners should engage with the technology. To what degree will a doctor be allowed to disagree with the computer? Although not much is yet known, given the infancy of contextual computing, some concepts can be extrapolated. For example, a reasonably prudent doctor generally must read the patient’s chart and consider the full range of available information when making treatment decisions. In Breeden v. Anesthesia West, P.C., 656 N.W. 2d 913 (Neb. 2003), an anesthesiologist familiar with a patient’s chart failed to check the nurse’s latest notes just before putting a patient under anesthesia, and missed an important notation that may have changed his decision-making. The patient suffered brain damage and sued, and the anesthesiologist pointed the finger at the nurse, arguing that she should have brought the new notes to his attention. The court disagreed, holding that the anesthesiologist’s duty to check the chart could not be delegated to another healthcare provider. It is possible that this conclusion could be extended to non-human, healthcare providers - in other words, a court could one day hold that while a doctor can use contextual computing to improve his treatment decision making, he can’t blame the computer if it makes a mistake that the doctor could have prevented through reading paper charts or asking questions of the nursing staff. In other words, a doctor could use a computer but would not be permitted to delegate to that computer the duty to know
the patient’s pertinent, available medical information. On the flip side of the coin, a large health system already has a duty to ensure that patient charts are complete. In one case, labs were ordered and yielded concerning results, but those results were never put into the patient’s chart. The patient later died. Johnson v. Hillcrest Health Center, 70 P. 3d 811 (Okla. 2003). The court held that this failure to put pertinent information into a chart could signify a breach in the standard of care. The hospital had a duty (in this case, a duty described by an Oklahoma statute) to put test results, services rendered, and other relevant information into a treating patient’s chart. In this instance, the hospital tried and failed to evade liability because it had a policy and training program in place that should have been followed. The court rejected this defense - the data was available, it was not hooked up with the patient’s chart, and the hospital could not shield itself from liability with its good policies and procedures. One day this concept could be extended to incorporate a duty to include (and analyze) all of the massive amounts of data that is becoming available on most Americans. Already some large health systems are using consumer data gleaned from credit card transactions and public records to create risk profiles on certain patients, and introduce lifesaving interventions earlier based on predictive models. As data brokers now offer data sets that can provide a complete picture of the “whole patient”, it may become harder for a “reasonably prudent” doctor to exclude that information from the patient’s digital “chart” and fail to take it into account when treatment decisions are made. The “standard of care” in medical malpractice is often defined in court by experts in the field. As healthcare providers grapple with the integration of contextual computing into their care models, different jurisdictions will have to adapt the definition of the reasonably prudent doctor, based on what those experts decide. It is possible that one day a natural language processing computer like Watson may itself be the expert called to assist a court in determining a standard of care. Watson’s move from the Jeopardy! podium to the witness stand is not inevitable, as juries may continue to prefer the human witness. What is inevitable is contextual computers’ move into the treatment rooms and health centers of America. As health systems integrate these computers into patient care models, the concept of the reasonably prudent doctor must remain in the forefront in their risk management decision-making. Gillian Egan practices in Burr & Forman’s Mobile office in the area of labor and employment.
Blood Sugar Control: From Kitchen Experiment to Commercial Success By JULIE PARKER
ST. LOUIS – When Francine Kaufman, MD, was completing an endocrinology and metabolism fellowship at the Children’s Hospital of Los Angeles, part of the University of Southern California (USC) School of Medicine, she became intrigued with finding a clinically proven way to control blood sugar for six to nine hours for patients who have trouble managing blood glucose. “During my fellowship in the late 1970s, I watched my patients with diabetes convert from having a tremendous amount of high glucose all the time to experiencing significant hypoglycemia,” said Kaufman, a world-renowned pediatric endocrinologist and former president of the American Diabetes Association. “Back then, we didn’t have evidence that showed how controlling glucose even mattered. It wasn’t scientifically validated until 1993.” Dr. Francine Also in the early Kaufman 1990s, scientists were beginning to use uncooked cornstarch to treat glycogen storage disease, a very rare ailment in which glucose values cannot be controlled because the liver blocks stored glucose from being released. “Children with glycogen storage disease are profoundly hypoglycemic all the time,” she said. “We were feeding them grams and grams of cornstarch four to six times a day. So I began thinking there must be some way to use a little bit of very complex starch to be slowly released in combination with protein.” In the late 1990s, when final evidence validating the importance of controlling glucose was published, Kaufman began experimenting in her own kitchen to come up with a complex carbohydrate formula in food form for diabetes and weight management. “I thought many of my patients didn’t have adequate meat or dairy protein, so I embraced an alternate form,” said Kaufman, an early advocate of soy protein. The first food product she developed, adding protein to the sugar-free pudding concept, was something her children jokingly called a “vanilla pudding brick.” The key ingredient was uncooked corn starch, a low-glycemic carbohydrate that metabolizes slowly and helps to control blood sugar for longer than anything else on the market. “The cornstarch made it quite thick,” she said, with a good-natured laugh. “At that point, I wasn’t concerned much about taste. To me, it was just a big science project. A bonus was that my family learned I could cook, which nobody really believed!” That “vanilla pudding brick” served as an “a-ha” moment for Kaufman, who
recognized that using a more mature and scientifically validated formula could translate to mass production. Kaufman received assistance through USC’s commercialization program on securing patents and worked on scientifically validating the product. Kaufman also teamed up with a former Eli Lilly associate, who saw the potential for launching the product nationwide, even though the marketplace was quickly becoming flooded with “nutrition bars.” Together, they established Extend Nutrition and collaborated with food scientists to finalize the formula, find the correct level of heat to cook the cornstarch, and prepare the products for mass production.
One problem lingered: how to improve the taste. “Stevia was a great idea for us, as well as adding some vitamins to the gluten-free product,” said Kaufman. Today, Extend Nutrition features four product categories: bars, crisps, drizzles and shakes. Last November, the company rolled out two new products in tandem with National Diabetes Month: all-natural protein bars- chocolate and caramel, and cookies and cream flavors. The bars contain 130-140 calories, 22 carbs, and 10 grams of protein. “Our new formula is better than anything we’ve ever done,” she noted. As a result of six clinical studies and
17 international patents, Extend Nutrition products have been verified and proven to be effective in helping to control blood sugar and limit hunger. The products are now available through Target, Walgreens, Kroger, Publix, CVS Pharmacy and other national chains. The products are also online at online at Amazon.com and directly from www.ExtendBar.com. Medical and healthcare professionals can contact the company at 1-800-8872919 or email comments@extendnutrition.com to receive samples. “We’re always in discovery,” said Kaufman, who’s been very pleased with the results. “A good company never runs on their laurels.”
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10 Year Anniversary • Birmingham Medical News
FEBRUARY 2015 • 19
Experts Predict Another Year of Robust Healthcare M&A By CINDY SANDERS
After a record-setting year of mergers and acquisitions in the healthcare sector for 2014, a recent survey by U.S. audit, tax and advisory firm KPMG LLP indicates 2015 will offer more of the same. A number of considerations ranging from cash-rich balance sheets to changing business models driven by the Affordable Care Act to easier access to capital are expected to fuel the continued feeding frenzy for those looking to enlarge their corporate footprint. Conversely, for those facing increasingly tight margins and regulatory oversight, the timing could be right to take the money and run.
“We are seeing a convergence of factors facing providers, health plans, and drug and device makers that are forcing them to make tough decisions about strategy,” noted Bill Baker, the national partner in charge of transaction services for KPMG’s Healthcare & Life Sciences Practice. He added those hard decisions sometimes include selling their business or practice. Texas-based Baker, continued, “Technology, regulation, consumerism and pushback from employers and government payers are reshaping all facets of healthcare, forcing companies to review all of their options. The capital markets – low interest rates and strong valuations –
are creating favorable conditions for those considering selling or divesting assets.” The Year That Was The Associated Press recently reported 2014 was one of the most active years for healthcare M&A activity in the last decade. KPMG noted that through the first three quarters of 2014, deal value across all industry sectors reached nearly $1 trillion, returning the United States to pre-recession levels. Irving Levin Associates, a leading healthcare market intelligence firm based in Connecticut, seconded the sentiment with data showing similar transaction increases specific to the healthcare industry.
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In nine of 13 healthcare industry sectors, there were an increased number of deals for 2014 in comparison to 2013. Through Dec. 19, 2014, Levin’s The Health Care M&A Information Source had captured 1,208 deals across healthcare, which was an increase of 17 percent over 2013. Spending also was up significantly for deals in 2014 v. 2013 at $386 billion compared to $163 billion. Leading the way in transactions was eHealth (up 65 percent in 2014) and biotechnology (up 50 percent). Long-term care, managed care, pharmaceuticals, rehabilitation and other services also had double digit increases in deal activity for 2014 over 2013. Behavioral health and medical devices had more modest gains at 6 percent and 4 percent, respectively. However, transactions are anticipated to be strong in the coming year. Nashville-based Acadia Healthcare led the way in the behavioral health market with a fourth quarter announcement the company would purchase CRC Health Group out of Cupertino, Calif., which has more than 140 programs treating 44,000 patients daily. The transaction, estimated to be valued at nearly $1.2 billion, is expected to close in the first quarter of 2015. 2015 M&A Outlook Survey Looking ahead, KPMG, in collaboration with SourceMedia’s Research Practice Group (publisher of Mergers & Acquisitions), surveyed 738 M&A professionals in the United States last fall about anticipated activity across a broad spectrum of industries. Survey participants work in senior management at companies advising an array of industries including healthcare, energy, financial services, technology, manufacturing, and consumer products. Of those surveyed, a full 82 percent said they were planning at least one acquisition in 2015 and 10 percent said they expected to do 11 or more deals this coming year. Perhaps not surprisingly, deals touching the healthcare industry, which is in the midst of transformative change, were predicted to lead the way with 84 percent of the experts saying they expected heavy healthcare activity. Almost half of respondents (47 percent) expect technology companies, including those tied to the healthcare industry, to be the most active individual industry sector for mergers and acquisitions. Coming in second, nearly one-third of the professionals anticipate pharmaceuticals and biotechnology to be the most active M&A sector in 2015. Expiring patents for a number of leading drugs plus the need to hone product portfolios to build ‘franchises in key treatment categories’ are two factors behind the anticipated jump in activity for the pharma/biotech industry. Additionally, 27 percent of the ex(CONTINUED ON PAGE 22)
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10 Year Anniversary • Birmingham Medical News
FEBRUARY 2015 • 21
Freestanding Emergency Departments to Benefit, continued from page 13 that a Certificate of Need should not have been approved for Brookwood back in 2010 because at that time, the concept of a freestanding emergency room did not exist in the state health plan. Trinity’s opposition was overruled after five years, giving Brookwood the go-ahead to begin the project. Brookwood has made a commitment to the Highway 280 corridor, an important area that has few options for emergency care. Congestion in this area can cost time when emergency services are needed, and the FED will make earlier treatment possible. Preston says the FED also will complement Brookwood’s existing primary care services as well as urgent care facilities along the corridor. Brookwood’s Cardiovascular Associates heart clinic is also in
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the area near the Colonnade. Brookwood’s $19 million FED will be a 24,000-square-foot facility with 11 exam rooms and a trauma room. It will be available 24 hours a day, seven days a week and will have 24-hour fully staffed laboratory services, as well as pharmacy and diagnostic services including CT, MRI, X-ray and ultrasound. In addition to ambulances stationed at the FED, a helipad will also be available for emergency air transfer, a requirement set forth by the Alabama Department of Public Health (ADPH). Protocols will be set for stabilization and immediate transfer of patients who require specialized hospital care. Medical West’s facility will be similar and will also meet ADPH requirements. “We have worked closely with the Alabama Department of Public Health which developed stringent rules that will guide these facilities in our state. Doctors who work at these FEDs must be board certified in emergency medicine. These rules are more stringent that those regulating traditional emergency departments,” Preston says. “Our FED Stephen will be staffed by the Preston same physician group that is in our emergency department at Brookwood Medical Center, maintaining constant communication with the hospital if a patient in the FED needs a specialized
procedure or admission.” Pennington points out that the Alabama facilities will operate similarly to others in the U.S. One major difference mandated by the ADPH requires that FEDs in Alabama be owned and operated by an existing hospital licensed in the state and can be no farther than 35 miles from the hospital that oversees it. “This makes the Alabama facilities unique,” he says.
Preston agrees and adds that the provider-based requirement is an important one. “One of the most important aspects of the rules is that freestanding emergency departments in Alabama must be provider-based,” he says. “I think that’s a real safeguard for citizens in Alabama, knowing there is a relationship between the freestanding emergency department and the host hospital.”
Experts Predict, continued from page 20 perts think healthcare providers are ripe for consolidation and cited forces tied to the ACA as being the primary driver of such moves. However, regulatory factors are expected to play an increasingly prominent role in decision-making on the front end considering the Federal Trade Commission’s scrutiny of several large deals last year. Among those being surveyed, some due diligence issues were seen as a bigger factor within the healthcare industry than in other sectors. In addition to how a merger or acquisition might impact the competitive landscape, healthcare providers also are perceived as being more concerned about cultural shifts when joining forces. The experts cited the cultural assessment as being a larger factor for healthcare companies in comparison to all industries (32 percent v. 28 percent). “Mergers and acquisitions are never
easy for everyone involved,” Baker pointed out. He added that negotiating a favorable and mutually acceptable transaction is just the first step. “Managing the various stakeholders of ownership, employees, customers and vendors during an integration process can be daunting … and, if not executed properly, can destroy the very benefits the transaction was modeled on generating,” Baker said. Another due diligence issue expected to factor prominently in healthcare transactions is volatility of future revenue streams, which was cited as a key issue among respondents for healthcare companies at a rate of 58 percent as opposed to ‘all industries’ at 51 percent. Interestingly, ‘quality of earnings,’ while still a key due diligence factor for the healthcare sector, trailed industry averages at 29 percent for healthcare companies compared to an average of 42 percent for all industries.
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Birmingham Medical News • 10 Year Anniversary
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Overcoming an Abundance of Adversity By Julie PArKer
When Beverly Smallwood, PhD, was making the rounds discussing her candidly written book and video training program, This Wasn’t Supposed to Happen to Me: 10 Make or Break Choices When Life Steals Your Dreams and Rocks Your World, based on many adversities she and others had overcome, she admittedly thought most of her woes were behind her. However, life stopped Smallwood in her tracks on Aug. 25, 2014, a typical Monday packed with clinical client appointments. “I’d received a call from the jail of a neighboring county, asking if I could come and evaluate an inmate that was causing all kinds of problems by behaviors as extreme as smearing feces on the wall,” recalled Smallwood, a psychologist specializing in counseling trauma survivors. “As you might imagine, they were quite eager to get him transferred to a hospital for mental treatment. I agreed to help.” Around 5:45 pm, Smallwood was in the midst of the 30-minute journey on a state highway, traveling 55 mph in the right lane. “Suddenly, there was a loud crash, the sound of breaking glass, and chaos as the car was Dr. Beverly tossed this way and that,” Smallwood she recalled. “Then the vehicle came to a stop, smoke coming into the car. The airbags were all deployed, and my seatbelt was still intact.” Smallwood’s Nissan Murano was totaled; the Jaws of Life were needed to pry her from the twisted metal. Her left hip was broken in two places, along with other painful injuries that would keep her in the hospital for five weeks. Smallwood later learned a woman driver with only minimal liability insurance had sped across two lanes from the opposite side, never slowed down in the median, and plowed directly into her SUV. “That was the beginning, but not the end of the ordeal,” recalled Smallwood, who endured surgery and had begun the lengthy rehabilitation process when another family tragedy occurred. “Ten days after my accident, the unthinkable and unimaginable happened. My beloved oldest grandchild, Joseph, committed suicide. It was a total shock. Joseph was a wonderful Christian boy who’d never given his parents a minute’s trouble.” In addition to the unspeakable grief of losing her grandson, Smallwood felt the additional pain of being unable to be there to comfort her daughter, Amy, son-in-law and Joseph’s two brothers. “The shock, grief, and every emotion
in the human psyche have been almost unbearable,” she said. “But I knew that I had purpose and that I still had work to do. So I hung on.” Then, just before Christmas, Smallwood’s family suffered another devastating loss when news broke that her former brother-in-law had been found dead, apparently from foul play. At press time, the case remains under investigation. “In all of these experiences, I’ve had to be absolutely in submission to and dependence on God and to put the ‘10 Choices’ to work as never before,” said Smallwood. She still uses a walker and a cane to move around, just returned to the driver’s seat in December, remains unable to sit for more than 45 minutes without significant pain, and refuses or minimizes potentially addictive pain medication. “I’d experienced tragedy and trauma before in my life, and walked through horrific places with thousands of others in my clinical practice at The Hope Center and in my seminar audiences,” she said. “But these experiences, piled on top of each other, were definitely dream-stealers and world-rockers. It hasn’t been easy.” Smallwood took her own advice and turned her worries over to a higher power.
“So many amazing things have happened that can only be attributed to God’s mercy,” said Smallwood. “I remember being in the hospital after hearing the news about Joseph when the bank called, saying I was in the hole and needed $4,500 that day to cover overhead expenses. I wasn’t in a position to work, obviously, so I told the banker I’d call her back. I put the situation in God’s hands. That afternoon, my assistant pulled a check from the mail for $5,000 from a forensic case that was considerably past due. The timing! That’s just one example. It’s happened over and over.” Smallwood’s also learned afresh the power of social media. Her continuous candid and hopeful Facebook updates have received thousands of thumbs up from friends, family, and supporters. “I’m not sure exactly where all this is taking me, but it’ll continue to center around my life’s mission to help bring out the best in people,” said Smallwood, who acknowledged the physical limitations and rehabilitation process have spurred her to consider work she might not have done otherwise. While she will still do some counseling and coaching of other therapists at The Hope Center, she’s also implementing new ways of helping people. For instance, she’ll soon co-launch an online leadership training program, Leading in Good Faith, with fellow leadership expert Barry Banther. Additionally, she and her daughter Amy, Joseph’s mother, will unite as consultants and team developers with Rodan & Fields, an anti-aging skin care program developed by two world-
renowned dermatologists. “Even when you experience losses that rob you of physical abilities or important relationships, you don’t quit,” Smallwood said. “As long as you’re breathing, you have purpose. Sometimes, it just requires a little adjustment to figure out how you fulfill your purpose in a changed life situation.” In the last six months, Smallwood has reached a deeper realization that everything in life can shift and change in an instant, often through no fault of one’s own. “I can remember lying flat of my back in that hospital bed, unable to move or get up on my own, and humbly dependent on healthcare workers for the most embarrassing and intimate of personal care,” she said. “I’ve found that every source of security other than God can be taken away. In my case, I lost my health, my ability to work, my independence, and even the ability to live out the strong value of family support. But I didn’t lose my faith. What you learn in the valley far surpasses what you typically learn on the mountaintop.”
Psychologist Beverly Smallwood, PhD, established The Hope Center in 1984 for counseling and evaluation services, and Magnetic Workplaces ™ for corporate leadership and teambuilding programs. A frequent motivational speaker, her audiences are worldwide.
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10 Year Anniversary • Birmingham Medical News
FEBRUARY 2015 • 23
OLLIF Spine Procedure By steVen r. niChols, mD
The words “back surgery” and “spinal fusion” are never easy to hear—regardless of whether a patient has been diagnosed with a herniated disc, degenerative disc disease (DDD), spondylolisthesis, and/or spinal stenosis. In the past, the open anterior and posterior approaches were more commonly used. The anterior approach also includes the use of a general surgeon in conjunction with the spine surgeon for exposure. These approaches required a longer hospital stay and longer post-operative recuperation time. In the past decade, advances in surgical technologies have shortened surgeries, hospital stays, and recovery times for spinal fusion procedures. While several
different approaches to spinal fusion are available, many spine specialists are increasingly recommending oblique lateral lumbar interbody fusion (OLLIF), when appropriate, because of its inherent advantages of being minimally invasive which means less disruption to the patients’ lifestyle. Because the hospital stay is notably shortened, patients are able to resume normal activities much faster than those with traditional surgical fusion. The OLLIF is a procedure in which the spine surgeon approaches the lumbar spine through four or five small incisions more toward the side instead of the midline posterior approach. This is different from an open anterior or posterior approach, which is more surgically invasive. In the traditional “open” approaches,
RESEARCH NOTES the surgeon has to retract and/or dissect major muscles, blood vessels, ligaments, and bones which can often lead to more post-op pain and a longer recovery period. The OLLIF is minimally invasive because of the small incision size, which causes less trauma to the tissues surrounding the spine. The indications for this procedure include conditions like a herniated disc, degenerative disc disease (DDD), spondylolisthesis, and/or spinal stenosis with spinal instability. Steven R. Nichols, M practices orthopaedic and spinal surgery with Andrews Sports Medicine.
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Birmingham Medical News • 10 Year Anniversary
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Brain Inflammation a Hallmark of Autism While many different combinations of genetic traits can cause autism, brains affected by autism share a pattern of ramped-up immune responses, an analysis of data from autopsied human brains reveals. The study, a collaborative effort between UAB and Johns Hopkins, included data from 72 autism and control brains. It was published online in the journal Nature Communications. “There are many different ways of getting autism, but we found that they all have the same downstream effect,” said Dan Arking, PhD, an associate professor in the McKusick-Nathans Institute for Genetic Medicine at the Johns Hopkins University School of Medicine. “What we don’t know is whether this immune response is making things better in the short term and worse in the long term.” The causes of autism are a frequent research topic for geneticists. But Arking noticed that studies of gene expression involved too little data to draw many useful conclusions about autism. Unlike a genetic test, which can be done using nearly any cells in the body, gene-expression testing has to be performed on the specific tissue of interest; in this case, brains that could be obtained only through autopsies. To combat this problem, Arking and his colleagues analyzed gene expression in samples from two different tissue banks, comparing gene expression in people with autism to that in controls without the condition. All told, they analyzed data from 104 brain samples from 72 individuals, the largest data set so far for a study of gene expression in autism. While previous studies identified autism-associated abnormalities in cells that support neurons in the brain and spinal cord, the UAB-John Hopkins study was able to narrow in on a specific type of support cell known as a microglial cell, which polices the brain for pathogens and other threats. In the autism brains, the microglia appeared to be perpetually activated with the genes for inflammation responses turned on. “This type of inflammation is not understood well, but it highlights the lack of current understanding about how innate immunity controls neural circuits,” said Andrew West, PhD, an associate professor in the UAB Department of Neurology and co-author of the study. “Given the known genetic contributors to autism, inflammation is unlikely to be its root cause,” Arking said. “Rather, this is a downstream consequence of upstream gene mutation.” The next step would be to find out whether treating the inflammation could ameliorate symptoms of autism.
RESEARCH NOTES New Research Finds Baby’s Genes, Not Mother’s, May Trigger Some Preterm Births Some babies may be genetically predisposed to being born too soon, and variants in the DNA of the fetus — not the mother — may be the trigger for some early births. That is the finding of research conducted by Joseph Biggio, MD, professor and director of the UAB Division of Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology, and his colleagues from the Eunice Kennedy Shriver National Joseph Biggio, MD Institute of Child Health and Human Development Genomics and Proteomics Network for Preterm Birth Research. The March of Dimes will present its award for Best Research in Prematurity to Biggio for this work during the annual Society for Maternal-Fetal Medicine meeting in San Diego, California. Biggio’s research analyzed the number of copies of certain segments of DNA in the blood or saliva from hundreds of babies and their mothers. “These findings open a whole different arena for us to look into as we think
about preterm birth,” said Biggio, who was assisted by William Andrews, PhD, MD, professor in UAB’s Department of Obstetrics and Gynecology in UAB’s School of Medicine, and others. “It causes us to think more critically about the role of the fetus in causing preterm birth. We’ve always thought about preterm birth as a maternal issue, but these data change the paradigm. It may be the fetus who has the underlying predisposition, not the mother. “This still is very preliminary, and more investigation is needed, but the research clearly identified genetic regions associated with an increased risk of preterm birth.” No link was established between the number of copies of the mother’s genes and the risk of preterm birth. However, there was a two to 11-fold increase in preterm births before 34 weeks of gestation among infants in whom any of four genes was duplicated or any of seven genes was deleted. “These findings may help explain what triggers early labor in some women even when they’ve done everything right during pregnancy and there’s no obvious cause for an early birth,” said March of Dimes Chief Medical Officer Edward R.B. McCabe, MD “The hope is that this finding may one day lead to a screening test to help identify which babies are at a
higher risk of an early birth.” The preterm birth rate in the United States dropped more than 10 percent between 2006 and 2013, with most of the improvement focused in late preterm births (those between 34 and 37 weeks of pregnancy). Today’s research findings focused on early preterm births — births before 34 weeks of pregnancy — in which there has been little improvement in recent years. More than 450,000 babies are born too soon each year in the United States, and Alabama has one of the highest rates of preterm birth in the nation, at 15.1 percent. Preterm birth is the leading cause of newborn death, and babies who survive an early birth often face an increased risk of a lifetime of health challenges, such as breathing problems, cerebral palsy, intellectual disabilities and more. Even babies born just a few weeks early have higher rates of hospitalization and illness than full-term infants. It is a serious health problem that costs the United States more than $26 billion annually, according to the March of Dimes. While the differences in the number of copies of the genes may not directly cause a preterm birth, they may make a baby more susceptible to infection or reacting to other harmful environmental factors that trigger early labor, Biggio says.
“We don’t know exactly that it’s the genes in these areas,” Biggio said. “It may be something else. But these changes are in the areas of these genes, and that’s certainly the first place to start looking.” It may also help explain why treatment with progesterone, a naturally occurring hormone in pregnancy shown to prevent some preterm births, works for only about one-third of women. “We think we are treating the mother with progesterone, but perhaps we are actually treating the baby or changing the fetal-immune response,” Biggio said. The Eunice Kennedy Shriver National Institute of Child Health and Human Development funded this research, which Biggio says emphasizes the importance of genetics and informatics to scientific discovery. This also reinforces the importance of UAB’s investment in data infrastructure and its hiring of renowned expert James Cimino, MD as the inaugural director of the UAB Informatics Institute. “Genetics and informatics are going to be a key to our understanding of complex disease, and preterm birth is a prime example,” Biggio said. “If we can begin to understand the complexity of preterm birth and can work to prevent it, we will be able to avert significant health care expenditures and morbidity.”
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Grand Rounds Danberry Issued CON To Add Memory Care Beds The Alabama State Health Planning & Development Agency has issued a Certificate of Need to Danberry at Inverness to convert 24 Assisted Living Beds to Spe-
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BE PREPARED IN 2015 FOR ICD-10, MEANINGFUL USE, PQRS, BCBS VBP, CMS VALUE MODIFIER, CHRONIC CARE & MORE! 26 • FEBRUARY 2015
Birmingham Medical News • 10 Year Anniversary
Gandhi Joins Birmingham Infectious Diseases at Trinity Trinity Medical Center is pleased to welcome Anurag Gandhi, MD, to its medical staff. Anurag Gandhi, MD, who specializes in Infectious Diseases, has joined Birmingham Infectious Diseases, PC, in association with William Lapidus, Anurag Gandhi, MD MD, and Eima Zaidi, MD on the Trinity Medical Center campus. Gandhi received his medical degree from St. John’s Medical College, Rajiv Gandhi University of Health Sciences in Bangalore, India. He completed his internal medicine residency at Upstate Medical Center, State University of New York in Syracuse, NY and his clinical infectious diseases fellowship at Strong Memorial Hospital, University of Rochester in Rochester, NY. Gandhi is board certified in internal medicine and infectious diseases. He is an associate member of the Infectious Diseases Society of America, served as Chief of the Department of Medicine at Gadsden Regional Medical Center, and is a former board member of the Etowah County American Red Cross.
St. Vincent’s East Announces New Advisory Board Members Joe Freeman, Bonnie Hicks, and Foster Ware III have joined the 11-member St. Vincent’s East Advisory Board. Joe Freeman brings more than 10 years of financial experience and currently serves as the principal at his firm, E.F. Joe Freeman Joseph, LLC. Freeman is involved in a wide range of community organizations, including Camp Smile-AMile and the Birmingham Irish Cultural Society. Bonnie Hicks Bonnie Hicks has more than 27 years of experience as realtor, currently working at Re/Max MarketPlace. She is involved in a variety of community organizations, including Foster Ware III the St. Vincent’s Foundation Board, Eastern Women’s Committee of Fifty, and the Trussville Chamber of Commerce. Foster Ware III has a diverse range of experience, including health care consulting, government affairs, sales management, and engineering. He is currently the area manager for the North Region of Alabama Power’s Birmingham Division.
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RESEARCH NOTES UAB, Industry Partnership Could Lead to First Rapid Test for Bacterial Meningitis
Barnum’s work with bacterial meningitis dates back 20 years, when his team was looking at production in the brain of proteins in the complement system, a critical part of the immune system. They found
Meningitis research efforts two decades in the making could soon come to fruition through a partnership between investigators at UAB and a medical device startup, with assistance from the UAB Institute for Innovation and Entrepreneurship. Laboratory test results to diagnose this infection, particularly if bacterial meningitis is suspected, lose precious time and often are inaccurate, says Scott Barnum, PhD, professor in the UAB Department of Microbiology. Theresa Ramos, PhD (L) and Scott Barnum, PhD (R) “Viral meningitis genthat many complement proteins were proerally is not serious and often is treated duced by several cell types in the central symptomatically, while bacterial meningitis nervous system, including neurons. requires immediate intervention and treat“When we looked at the levels of ment with antibiotics because of the serious complement proteins in the cerebrospinal nature of that infection,” Barnum said. fluid of patients with confirmed bacterial Yearly in the United States, from meningitis, we found that certain proteins 2003-2007, about 4,100 cases of bactewere markedly elevated compared to the rial meningitis occurred, resulting in 500 levels found in aseptic meningitis (menindeaths, according to the Centers for Disgitis caused by a virus or other pathogen),” ease Control and Prevention.
28 • FEBRUARY 2015
Birmingham Medical News • 10 Year Anniversary
Barnum said. “We patented this observation with the aim of developing a diagnostic test for discriminating between the two types of meningitis.” Now Barnum’s team has partnered with Kypha Inc., a St. Louis-based company focused on complement proteins and lateral flow assays, which are diagnostic tests similar to a pregnancy test, to bring that goal to a reality. “A test that could rapidly discriminate between bacterial and viral meningitis would be a valuable tool for the emergency room physician,” Barnum said. “We would love to see the test be used in underdeveloped parts of the world where limited resources prevent timely and accurate diagnosis of most diseases. This is the kind of test we are working to develop in partnership with Kypha.” With Kypha’s help, Barnum says the original scope of the project has expanded and opened other doors at UAB that have led to new collaborations that are mutually beneficial. Kypha has funded Barnum’s postdoctoral researcher, Theresa Ramos, PhD, dubbing her a postdoctoral entrepreneur for the company. “This is a unique position that Kypha
developed. Postdocs like Dr. Ramos will spend 50 percent of their time in the lab and 50 percent of their time learning about the business side of science through interaction with Kypha,” Barnum said. “This is a great opportunity for someone thinking about moving into biotechnology or pharmacology after their postdoc. For Dr. Ramos, this will be a great experience and will significantly enhance her resume.” “After Kypha CEO Chad Stiening visited UAB and witnessed the breadth of research and collaborations that occur here, he and his team decided to make UAB a betatesting site for their new device, the COMP ACT System,” Ramos said. “It has been a match made in research-entrepreneurial Chad Stiening heaven.” Stiening says they were impressed with UAB’s clinical research infrastructure, and with the level of responsiveness of faculty, clinical staff and administrative leaders. “This was important given the broad potential clinical utility of Kypha’s products and our desire to conduct several clinical studies in parallel across multiple indications,” Stiening said. “Perhaps the most pleasant surprise was the level of
RESEARCH NOTES institutional support for industry partnerships — and a recognition of the value and unique challenges that startups bring to the equation.” Several layers of support exist for this project at UAB, says Ramos, including the Department of Microbiology, UAB Hospital’s Emergency Department, the Institutional Review Board, and most notably the Institute for Innovation and Entrepreneurship. “We couldn’t move our project forward without the help of the IIE and Kypha. The speed and scale of what we can do with the partnership take the effort to a whole new level,” Barnum said. “It’s a synergy that all universities and biotech startups could benefit from. I hope that it is the first of many partnerships that UAB and the IIE develop.” IIE Managing Director Kathy Nugent, PhD says the IIE is the nexus for UAB innovation and applied research. “Our mission is to broaden the impact of UAB’s contributions by facilitating collaboration with industry and providing greater opportunities for researchers and entrepreneurs,” Nugent said. “UAB is at the forefront of scientific and medical innovation, and Dr. Barnum’s research is an excellent example of the game-changing breakthroughs that the IIE is helping to bring forward.” Nugent says the IIE is excited to be working with researchers like Barnum, and they are committed to ensuring that the public has ongoing access to the newest, most effective scientific and health care innovations, products and procedures. “We are fortunate to be located in Birmingham with such a vibrant academic and medical ecosystem to support this type of innovation,” Nugent said. “We have been very fortunate to have the support of the IIE, my chairman, Frances Lund, PhD and Kypha as well,” Barnum said. “It’s a great validation of our original basic science and in our plans to develop this finding into a rapid, point-ofcare test that we hope will have worldwide clinical utility.”
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Birmingham Medical News • 10 Year Anniversary
Zenko Hrynkiw, MD is a 2014 Healthcare Community All Star, an award given by Safety National, a provider of excess workers’ compensation coverage to self-insured employers nationwide. Each year, Safety National names three Community All Stars who have done something extraordinary in terms of philanthropy or acts of kindness. Alabama Retail Comp, the workers’ compensation fund that serves Alabama Retail members, nominated Dr. Hyrnkiw for the heroic efforts he made during the debilitating snow storm that hit BirmingZenko Hrynkiw, MD receives award. ham in January 2014, bringing the city to a standstill. Realizing he would be unable to travel by car, Hrynkiw walked more than six miles through the snow and ice to Trinity Medical Center to perform emergency surgery on a patient with a traumatic brain injury. Each Community All Star category winner is awarded $10,000 in the form of a scholarship endowment or donation to a charity of his or her choice. Hrynkiw requested the donation on his behalf go to Operation Smile, which performs cleft lip and cleft palate surgeries on children.
BCRFA Donates to UAB Cancer Center The Breast Cancer Research Foundation of Alabama presented $650,000 — its largest donation to date — to the UAB Comprehensive Cancer Center, for a total exceeding $5.1 million since BCRFA’s inception in 1996. “We are thankful for this generous gift. Without the help of the community, none of this would be possible,” said Edward Partridge, MD, director of the UAB Comprehensive Cancer Center
UAB Named to National Pulmonary Fibrosis Care Network UAB has been added to the Pulmonary Fibrosis Foundation Care Center Network as part of a major expansion of that network. The PFF Care Center Network, which now boasts 21 sites in 20 states, comprises the leading medical centers with specific expertise in treating interstitial lung diseases and pulmonary fibrosis, a group of lung disorders including idiopathic pulmonary fibrosis (IPF), that often are difficult to manage and that are associated with survival rates of less than five years following diagnosis in certain diseases. The UAB Division of Pulmonary, Allergy and Critical Care Medicine, under the leadership of division director Victor Thannickal, MD, has become a leading research and clinical care site for pulmonary fibrosis. The division’s research programs include multiple NIH-funded grants that have grown to almost $4 million per year. The Interstitial Lung Disease clinic in The Kirklin Clinic now follows as many as 500 patients, with an estimated 200 new patients per year.
EDITOR & PUBLISHER Steve Spencer VICE PRESDIENT OF OPERATIONS Jason Irvin CREATIVE DIRECTOR Susan Graham STAFF PHOTOGRAPHER Clark Sanders CONTRIBUTING WRITERS Ann DeBellis, Nancy Dorman-Hickson, Jane Ehrhardt, Sharon Fitzgerald Laura Freeman, Kathy Hagood Dale Short, Cindy Sanders 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 ©2015 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 Kinney is President-Elect of the Jefferson County Medical Society F. Cleveland Kinney, PhD, MD is the new President-Elect of the Jefferson County Medical Society. Kinney, who serves as Professor Emeritus of Psychiatry and Behavioral Neurobiology at UAB, attended UAB to earn his PhD in anatomy in 1976 and his medical degree in 1985, and joined the UAB Hospital as a staff psychiatrist in 1990 after completing his F. Cleveland psychiatry residency and Kinney, PhD, MD fellowship in geriatric psychiatry at UAB. In 1968, after earning his BA at Birmingham-Southern College, Kinney joined the U.S. Navy and was stationed at Headquarters Allied Forces Northern Europe in Oslo, Norway until his honorable discharge in 1972. Kinney, who has been listed in the Best Doctors in America, has been chosen for a number of honors, including the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill; an Argus Society Award for Excellence in Teaching; and Outstanding Faculty Teacher by the UAB Psychiatry Residents Association. He finds that his academic training in both anatomy and psychiatry work hand-inhand when looking at MRI scans to determine whether brain lesions are correlating with changes in geriatric patients’ behavior. In his new role with the Jefferson County Medical Society, Kinney hopes to raise money for local medical school scholarships.
Heslin Elected Chief of Staff at UAB Hospital Martin J. Heslin, MD, Chief of the Section for Surgical Oncology at UAB and Senior Scientist at the UAB Comprehensive Cancer Center, has been elected for a five-year term as Chief of the Medical Staff at UAB Hospital. Heslin is also the Associ- Martin J. Heslin, MD ate Director of Clinical Programs at the Comprehensive Cancer Center. Heslin has been on UAB’s staff since 1996 after completing his post graduate training at Memorial Sloan-Kettering Cancer Center and NYU Medical Center. He specializes in the research and treatments of gastrointestinal cancers and soft-tissue sarcomas. He is the director of the Multidisciplinary Gastrointestinal Oncology Clinic, which was created to provide all gastrointestinal cancer patients with a multidisciplinary approach to the treatment of their disease.
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10 Year Anniversary • Birmingham Medical News
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