Thursday, August 25, 2016
by: Karen Vines, MD
Board Certified Family Medicine Physician Grandview Medical Group –Hoover/Trace Crossings
Shingles are caused by the varicella-zoster virus (VZV). This virus causes two clinically distinct forms of the disease. The primary infection of this virus results in varicella (chickenpox), which is characterized by skin blisters on the face, trunk, and extremities. The other clinical form that this virus can cause is herpes zoster, also known as shingles. This results from reactivation of VZV infection. This clinical form of the disease is characterized by a painful, unilateral vesicular (blistering) eruption, which usually occurs in a restricted skin region. The mid and lower backs are the most commonly involved sites of shingles.
Approximately 32 percent of people in the United States will experience shingles. This equates to one million individuals annually. Incidence rates progressively increase with age, presumably due to the decline in VZV-specific cell-mediated immunity.
Shingles is usually characterized by rash and acute pain. The rash starts as red skin lesions that evolve into grouped skin blisters. Within three to four days, these blisters can bust open. In most people, the lesions crust by 7 to 10 days and are no longer considered infectious. Pain is the most common symptom of shingles. The pain may be constant or intermittent and can precede the rash by days to weeks. Most patients describe a deep "burning", "throbbing", or "stabbing" sensation. Some individuals describe the pain only when the involved area is touched, whereas others complain primarily of itching sensation.
While the shingles vaccination is licensed to be used in immunocompetent individuals ages > 50 years of age, the CDC recommends the vaccine for immunocompetent adults over the age of 60. The reason being that the duration of protection may not last until the later decades when the vaccine is needed the most.
The management of shingles includes antiviral therapy, which speeds up the healing process of the skin lesions. The antiviral therapy also decreases the duration and severity of pain. The most clinical benefits are seen in patients who receive the antiviral within 48-72 hours of rash onset. So it is Pain control is very important in the treatment management of shingles. Pain control options include NSAIDs, acetaminophen, and tramadol in the acute phase. Patients may develop post-herpetic neuralgia, which is nerve pain. This nerve pain is due to nerve damage caused by the varicella zoster virus. Post-herpetic neuralgia can last 3 months or longer. First line treatment for post-herpetic neuralgia includes tricyclic antidepressants, gabapentin, and pregabalin.
1. Dworkin RH, Johnson RW. Breuer J. et al. Recommendations for the management of herpes zoster. Clin Infect Dis 2007: 44 Supple 1:S1.
2. Straus SE. Ostrove JM. Inchauspe G. et al. NIH conference. Varicella-zoster virus infections. Biology, natural history, treatment and prevention. Ann Intern Med 1988: 108:221.
3. Oxman MN. Immunization to reduce the frequency and severity of herpes zoster and its complications. Neurology 1995: 45: S41.
Wednesday, August 17, 2016
By: Michael Ellerbusch, MD with Southlake Orthopaedics Sports Medicine & Spine Center, PC
Fall is not only a time of beautifully changing colors in the trees and the return to school, but it is also a very busy season for various types of sporting activities. Perhaps the most well-known of these sports in the South is football; however, there are many other activities going on including, volleyball, cheerleading, soccer, cross country, and even baseball, softball, and other year-round sports. With all of these sports, there comes a variety of different types of injuries. Most studies will tell you that the highest number of youth related sporting injuries in the fall occur in football. According to the Consumer Product Safety Commission (CPSC) in 2013 in athletes ranging from ages 5-13:
• Approximately 881,700 football-related injuries
• Nearly 434,000 were treated for soccer injuries
• 99,884 were treated for cheerleading-related injuries
• More than 94,000 for volleyball related injuries
Below is a table from the CDC’s website from Kerr, et al, December 11, 2015, looking at various injury rates in popular collegiate sporting activities:
Competition and practice injury rates per 1,000 athlete-exposures and competition/practice rate ratios, by 25 championship sports — National Collegiate Athletic Association Injury Surveillance Program, United States, 5 academic years, 2009–10 through 2013–14
− a diminished blood flow and oxygen supply to the muscle associated with pain and spasm
− stress on tendons which may cause inflammation or scarring of the tendons
− nerve injury due to pressure or tension on the nerve, possibly leading to ischemic damage
− damage to bone due to repetitive pressure or tension on the bone
Different sporting activities are associated with different types of injuries. Although there certainly can be crossover, contact sports such as football are more associated with traumatic injuries; while non-contact sports, such as cross country and volleyball, typically result in repetitive stress injuries. For these reasons, as with most clinical interactions, it is very important to obtain a thorough history including the possible mechanism of injury and sports played in making an accurate diagnosis. The history and physical examination may lead to various types of diagnostic procedures if needed: including x-rays, CT scans, MRIs and other testing modalities. Once an accurate diagnosis has been made, a proper treatment program including likely activity restrictions/modifications may be necessary.
Now, all of this information is very important after the injury has occurred, but what if we can take steps to prevent the injury from taking place altogether? Although not all injuries can be prevented, we may be able to reduce the incidence of some of these injuries with the 10 steps listed below. These are found on the American Academy of Orthopaedic Surgeons’ Website:
PRE-SEASON SPORTS SAFETY TIPS FROM THE AAOS
1. Have a pre-season physical examination and follow your doctor’s recommendations.
2. Warm-up and cool down properly with low-impact exercises like walking or cycling.
3. Consistently incorporate strength training and stretching. A good stretch involves not going beyond the point of resistance and should be held for 10-12 seconds.
4. Hydrate adequately to maintain health and minimize muscle cramps. Waiting until you are thirsty is often too late to hydrate properly.
5. Keep an eye out for unsafe play surfaces. Playing grounds should be in good condition.
6. Don’t play through the pain. Speak with an orthopaedic sports medicine specialist or athletic trainer if you have any concerns about injuries.
7. When participating, wear protective gear such as properly fitted cleats, pads, helmets, mouth guard or other necessary equipment for the selected sport.
8. Play multiple positions and/or sports during the off-season to minimize overuse injuries.
9. Pay attention to weather conditions such as wet, slippery fields that can lead to injuries.
10. Avoid the pressure to over train. Listen to your body and decrease training time and intensity, if pain or discomfort develops. This will reduce the risk of injury and help avoid “burn-out.”
Some experts recommend a dynamic stretching program before activities and reserving static stretching, as listed above, following activities while the muscles are warm. In addition, the importance of the playing conditions cannot be stressed enough to help in the prevention of often devastating injuries. For those who watch the NFL, this was exhibited in the NFL Hall of Fame Game on August 7, 2016, between the Packers and the Colts when portions of the painted surface became hard and slick leading to the cancellation of the game just minutes before kickoff. On this same field in the 2015 Hall of Fame Game, the Pittsburg Steelers’ kicker, Shaun Suisham, sustained a season ending knee injury which he attributed to poor field conditions. These recommendations, along with a preseason conditioning program and proper fitting equipment and other tips as listed above, may be very helpful in the prevention of many on the field injuries. As physicians who treat athletes, we need not only to be well trained in how to treat injuries after they occur, but also to be able to relay information to the athletic trainers, parents, and athletes that may help them reduce the risk of injury before they occur so that they may have a more enjoyable sporting experience.
Michael Ellerbusch, MD Subspecialty Board in Sports Medicine Board Certified Physical Medicine and Rehabilitation Subspecialty Board in Neuromuscular Medicine Southlake Orthopaedics Sports Medicine & Spine Center, PC
Thursday, August 11, 2016
South Carolina Hospital Pays $17 Million to Resolve Stark, False Claims Act Claims Filed By Whistleblower
By: Zachary D. Trotter with Waller
On Thursday, July 28, 2016, the United States Department of Justice announced that it had reached a settlement in which the Lexington County Health Services District d/b/a Lexington Medical Center, a 428-bed hospital that serves the South Carolina Midlands area, agreed to pay $17 million to resolve allegations that it violated the Stark Law and the False Claims Act. According to the government press release ( https://www.justice.gov/opa/pr/south-carolina-hospital-pay-17-million-resolve-false-claims-act-and-stark-law-allegations ), the United States alleged that Lexington Medical Center violated the Stark Law and the False Claims Act by inflating asset purchase agreements for the acquisition of physician practices or employment agreements with 28 physicians that were not commercially reasonable or provided compensation in excess of fair market value.
"This case demonstrates the United States' commitment to ensuring that doctors who refer Medicare beneficiaries to hospitals for procedures, tests and other health services do so only because they believe the service is in the patient's best interest, and not because the physician stands to gain financially from the referral," said Principal Deputy Assistant Attorney General Benjamin C. Mizer, head of the Justice Department's Civil Division.
This case continues the long line of cases in which a former employee turns whistleblower. Here, Dr. David Hammett, a former physician employed by the medical center, filed the lawsuit in federal court in Columbia, S.C. under the qui tam, or whistleblower, provisions of the False Claims Act before the Justice Department chose to join the suit. As part of the settlement, and in accordance with the whistleblower provisions, Dr. Hammett will receive approximately $4.5 million dollars of the recovered funds.
Lexington Medical Center did not admit fault as part of its settlement. Instead, in a quote to The State newspaper ( http://www.thestate.com/news/local/article91389192.html ), the medical center stated that the settlement “allowed the medical center to avoid continued costly litigation that could have lasted for several years.” Former U.S. Attorney Bill Nettles, knowledgeable of this particular case, stated that the medical center’s potential liability was far greater than the $17 million settlement value. “That $17 million is nothing compared to what it could have been if it had gone to trial.”
In addition to the monetary settlement, Lexington Medical Center agreed to enter into a Corporate Integrity Agreement (“CIA”) with the Department of Health and Human Services - Office of the Inspector General (“HHS-OIG”) to ensure implementation of measures designed to avoid or promptly detect potential violations of the sort raised by Dr. Hammett. This CIA oversight, which often includes onerous and costly reporting requirements, will last for five years. The CIA may be found here ( https://oig.hhs.gov/fraud/cia/agreements/Lexington_Medical_Center_07202016.pdf ).
This settlement is yet another of numerous cases illustrating the Justice Department’s and HHS-OIG’s crack down on alleged violations of the Stark Law and the False Claims Act. The government’s Health Care Fraud Prevention and Enforcement Action Team (“HEAT”) initiative, originally introduced in May 2009 by the Attorney General and the Secretary of Health and Human Services, has used the Stark Law and, particularly, the False Claims Act as a powerful weapon against health care providers. Since January 2009, the Justice Department has recovered more than $30 billion through False Claims Act cases, with more than $18.3 billion of that amount recovered in cases alleging fraud against federal health care programs.
Fraud enforcement may be the only government initiative with truly bipartisan support in Washington, DC., and with the Justice Department’s current winning streak and record-breaking settlements, there’s no reason for health care providers to think that enforcement actions won’t remain a high priority for the government in the future.
By: Giovanna Rodriguez, MD
Endocrinologist with Brookwood Baptist Health, Specialty Care Network, located in the Brookwood Medical Plaza, Suite 400
The pregnancy hormones such as estrogen, progesterone, prolactin, human placental lactogen, along with increased levels of cortisol and weight gain during pregnancy affect glucose levels.
In a pregnant woman with Gestational Diabetes, the cells become ‘insulin resistant’ and the post prandial blood glucose levels stay elevated due to the cell’s inability to absorb the glucose. The hyperglycemia that ensues crosses the placenta and affects the fetus. Women with gestational diabetes may have larger babies that may be wedged in the birth canal, sustain clavicular fractures or require c-section. The baby may also suffer from preterm delivery, respiratory distress, hypoglycemia at birth or even Type 2 diabetes and obesity later in life.
Therefore it is of utmost importance for mothers diagnosed with gestational diabetes to be educated about the condition and to have strict glycemic control. If referred to an endocrinologist, we target fasting levels below 95 mg/dl, 1-hour postprandial less than 140 mg/dl and/or 2-hours postprandial: 120 mg/dl or less as per American Diabetes Association. However, since glucoses above 130mg/dl cross the placenta and affect the fetus, some may choose to target less than 120mg/dl one hour post prandial.Some patients do well after thorough education and strict low carb diets, however some require the initiation of insulin therapy, particularly in the third trimester when the above mentioned hormone levels are highest.
Once patients deliver, the insulin requirements return to pre-pregnancy baseline and patient is able to either stop the diabetes medication completely or require less medications. The main focus post-partum is to avoid the progression from gestational diabetes to type 2 diabetes.
Wednesday, August 10, 2016
by: Robert Cooper with White Arnold and Dowd
Opioid abuse and misuse is an urgent, nationwide public health concern, and Alabama is no exception to the growing trend. In 2015, Alabama had 1.2 opioid prescriptions per capita—the highest rate in the nation. The Executive Director of the Alabama Board of Medical Examiners recently noted there are currently 496 pain clinics in Alabama. While the nationwide average of abusers of patients receiving opioids is 4.5%, a recent study by Castlight Health, a national insurance information company, identified Anniston, Alabama as having the highest percentage of abusers of opioids in the United States: 11.6%. Anniston shared the top spot with Wilmington, North Carolina. Two other Alabama cities— Gadsden (ranked seventh) and Tuscaloosa (ranked eleventh) – were also identified by the study.
Methadone has been a frontline treatment in the fight against opioid addition. Alabama currently has 24 opioid treatment centers, sometimes called “methadone clinics.” However, methadone is also subject to abuse and must be monitored closely. In 2013, Alabama’s Certificate of Need Review Board imposed a moratorium on the opening of any new clinics for three years, apparently to assess the efficacy of the treatment and outcomes. While the moratorium has since been lifted, the Alabama Department of Mental Health is employing a new geographic formula that prevents a new clinic form opening within 50 miles of an existing clinic, effectively blocking new facilities in any Alabama county except for Lee.
On a national level, in response to this issue of primary concern President Obama signed Senate Bill 524 into law on July 22, 2016. Known as the Comprehensive Addiction and Recovery Act of 2016 (“CARA”), the bill enjoyed bipartisan support and passed both houses of Congress with a wide margin: 407-5 in the House and 92-2 in the Senate.
CARA is wide-ranging and seeks to address the opioid abuse and misuse issue on several fronts. A section-by-section analysis can be found on the website of the National Association of State Alcohol and Drug Abuse Directors. Some of the highlights are:
- Enhancing healthcare professionals' use of opioid risk reporting tools and state prescription drug monitoring programs in Department of Veterans Affairs (“VA”)facilities, as well as strengthening education and training on pain management and safe opioid prescribing practices for practitioners, mandating the establishment of clinical teams to coordinate pain management therapy for patients with pain that is unrelated to cancer;
- Creating a pilot program to support family-based services for pregnant and postpartum women with a primary diagnosis of a substance use disorder, including opioid use disorders;
- Studying the prevalence of neonatal abstinence syndrome (“NAS”), as well as the care settings in which infants with NAS are treated, encouraging “best practices” for treating infants born addicted to opioids, the reimbursement methodologies and costs associated with such treatment, and other related issues;
- Authorizing multiyear funding for the Department of Justice to issue grants to states, local governments and Indian tribes to be used to develop or expand treatment alternatives to incarceration programs, train law enforcement officers and other first responders in the use of naloxone to reverse an opioid overdose;
- Authorizing the Department of Health and Human Services (“HHS”) to establish grant programs to support co-prescribing opioid overdose reversal drugs for patients who are at increased risk for overdose, including those who are taking prescription opioids, and to develop standing orders for use of opioid overdose reversal drugs for pharmacies and encourage pharmacists to dispense the drugs pursuant to such orders;
- Allowing partial filling of opioid prescriptions where not prohibited by state law; Modifying existing regulations to permit nurse practitioners and physician assistants to administer medication-assisted treatment for opioid use disorder in collaboration with or under the supervision of a qualifying physician (where state law requires such physician oversight).
- Directing HHS, together with the VA, the Department of Defense and the Drug Enforcement Administration, to convene a task force composed of representatives from the public and private sectors -- including physicians -- to review, modify and update best practices for pain management and prescribing pain medications.
Now that CARA has become law, healthcare professionals engaged in the delivery of care for patients with chronic pain issues or for those patients struggling with opioid abuse or misuse should anticipate continued close monitoring by the attendant regulatory boards. While significant, the treatment funding aspects for CARA were not close to the $920 million sought by the Democrats supporting the legislation; further discussion and efforts for increased funding in fiscal year 2017 and beyond are anticipated. Healthcare professionals will need to watch carefully for new rules on implementation, regulations, and grant opportunities.
 Yurkanin, Amy, “During opioid epidemic, Alabama cracked down on treatment centers,” June 7, 2016, available at http://www.al.com/news/index.ssf/2016/06/during_opioid_epidemic_alabama.html (last visited Aug. 8, 2016).
 The cited study by Castlight Health identified abusers “as those who received more than a 90-day supply and had received opioid prescriptions from four or more providers in five years, excluding cancer patients and others near the end of life.” Yurkanin, Amy, “Study: Alabama city leads in opioid abuse among workers,” April 20, 2016, available at http://www.al.com/news/index.ssf/2016/04/study_alabama_city_leads_in_op.html (last visited Aug. 8, 2016).
 Yurkanin, Amy, “During opioid epidemic, Alabama cracked down on treatment centers,” June 7, 2016, available at http://www.al.com/news/index.ssf/2016/06/during_opioid_epidemic_alabama.html (last visited Aug. 8, 2016).
 Public Law 114-198.
 See http://nasadad.org/wp-content/uploads/2016/07/CARA-Section-by-Section-July-2016-1.pdf(last visited Aug. 8, 2016).
Tuesday, August 9, 2016
Mike Goodlett grew up in Moulton, Ala., dreaming of being a sports star…or at least being able to hit a home run or run for a touchdown. That life wasn’t meant for him. Little did he know such a humble beginning would lead him to The Plains as the team physician for the Auburn Tigers.
“I was a very asthmatic child,” Dr. Goodlett explained. “Had my mother not been a nurse, I probably would have died several times before I was 12 years old. One night I was already pronounced dead in the emergency room when my mother called Dr. Robert Rhyne to the hospital. Dr. Rhyne came into the room and squirted some epinephrine down my tube and saved my life. I wouldn’t wheeze very much. I’d just turn black. The resident on call in the ER looked at my color and decided I was already gone. Dr. Rhyne saved my life that night.”
Dr. Goodlett never forgot that night in the emergency room, or Dr. Rhyne Years later, after tearing his ACL, he found himself in the famed Hughston Clinic for Orthopaedics and Sports Medicine and in the care of Dr. Jack Hughston. Now, his path was set.
“I had always wanted to play sports. And, ending up in Dr. Jack Hughston’s clinic…I just thought he was so cool! I really wanted to be a combination of Dr. Robert Rhyne and Dr. Jack Hughston. I wanted to be able to do what they did every day!” He laughed. “So, I did.”
Dr. Goodlett went to the University of South Alabama College of Medicine, and he specialized in family medicine at UAB affiliated Gadsden Baptist Memorial Hospital. He worked with Drs. James Andrews and Lawrence Lemak to gain expertise in sports medicine. In 1993 while en route to a family vacation, he got the surprise of a lifetime delivered in the most unusual way.
“My family and I were driving to Destin for a vacation when we were stopped by a State Trooper,” Dr. Goodlett said. “He said he didn’t know who I was but handed me a piece of paper and asked me to call the number on it. That’s how I found out we had just gotten the Auburn Tigers job. There went our vacation that summer, but what a trade off!”
Dr. Goodlett wasn’t exactly sure just how much his life was about to change that day, but he knew one thing was certain…change it would. He was about to become the team physician for about 600 athletes in all 21 of Auburn’s athletic programs. For the first 22 years, he was the only full-time physician. Now, there are two more full-time partners that are also VCOM professors and sports-trained physicians as well as a fellow.
“Every day has been an adventure since that first day. It has been a true pleasure taking care of these student athletes. It’s a unique practice to say the least,” Dr. Goodlett said.
While he doesn’t necessarily travel with the team to every away game, there is a lot of behind the scenes safety preparations that go on between Dr. Goodlett’s staff and the medical staff of the opposing team. There are no secrets here. The conversation is always about safety, or a “medical time out.” Procedures are discussed to make sure everyone is comfortable with equipment, entrances, exits, use of the medical cart, etc. Then, it’s game time.
The roar of the crowded stadium is nothing compared to the adrenaline pumping through the veins of the players, staff and media on the sidelines. As the players don their helmets and rush the field, it’s game on for the Auburn Tigers, but for Dr. Goodlett those aren’t players on the field. Those aren’t fans in the stands. Those aren’t officials on the sidelines. Those are patients.
“About four years ago, they put a heart rate monitor on me. Before the game, my heart rate was like 140, but when the game started it was like 60. To me, it’s one player, one patient. Everything slows down on the field during the game, and I just have to take care of that patient. When a player goes down, it’s stark silent in the stadium. That’s scary. But, I’m constantly talking. The trainers tell me I’m constantly talking to my sports medicine team and to the patient. It’s all about the patient. You never know what you’re going to find when you get to that player. Sometimes when a player goes down on the other sideline, because of the slope of the field, you don’t have a visual or you didn’t get to see the play, you don’t know exactly what you’re going to find when you get across the field,” Dr. Goodlett said.
In 1996 when fire broke out just outside Jordan-Hare Stadium, Dr. Goodlett’s medical team rendered aid to the fans and firefighters affected by the smoke and flames. Dr. Goodlett said had the wind shifted drawing the flames, smoke and debris into the crowded stadium, disaster would have overtaken the day’s festivities in just a few minutes in what he called “one of the scariest days I’ve ever worked at the stadium.”
In the field of sports medicine, there are as many challenges as rewards. Dr. Goodlett said the most difficult part of his job is to disqualify a player because of an injury. Players want to play and sometimes feel that’s why they are there. But, with the awareness of sports injuries becoming more prevalent, players are coming around to more of an advocacy point of view by policing themselves better for healthier play.
“I always feel bad to a degree if I have to disqualify a player because of an injury or because of health reasons, but ultimately it’s for that player’s health. On the other hand, the most rewarding part of my job is when former players come back and say thanks for taking care of me during those times. That means so much to me!” Dr. Goodlett said.
Dr. Goodlett’s legacy with Auburn University will also be felt in the classroom. He was one of the original individuals approached by Auburn University President Jay Gouge in the early stages of the creation of the Edward Via College of Osteopathic Medicine – Auburn Campus.
“I’m very proud to be one of the three individuals that President Gouge enlisted to assist him in the creation of VCOM at Auburn. It’s incredibly important these medical students are exposed to rural settings and are trained in the State of Alabama, so hopefully some of them will want to stay in rural Alabama. This is an opportunity to keep our young physicians here in Alabama, and I’m very happy to be a part of it,” Dr. Goodlett said.
Monday, August 8, 2016
By Christopher A. King, MD, FACC
Cardiologist with Alabama Cardiovascular Group an affiliate of Grandview Health
From a patient’s perspective, few events are more devastating than the loss of a limb. Moreover, critical limb ischemia is associated with increased mortality, decreased functional capacity and diminished quality of life. Approximately 25 percent of newly diagnosed patients will require an amputation within one year and the average survival after diagnosis is approximately two and a half years.
The technology for endovascular limb salvage has advanced at a rapid pace over the past few years. Operator experience has followed. The impact that timely treatment of critical limb ischemia can have should not be underestimated. A multidisciplinary approach to critical limb ischemia can result in a marked decrease in amputation in this patient population.
The standard endovascular approach for treatment of chronic limb ischemia utilizes catheters, guidewires and balloons to increase blood flow to the impacted limb. In many cases, critical limb ischemia is caused by the below the knee vessels which are roughly the same size as the coronary vessels. Hence, treatment of these vessels borrows strongly from paradigms for treating coronary vessels. This, however, is not always fully effective as the vessels may react differently than the coronary vessels.
Refinement of technology for atherectomy, angioplasty (in addition to the development of drug coated balloons) and stenting have allowed us to approach the disease in ways which only a few years ago would have not been possible. Specific angiosomes may be targeted to allow optimal wound healing when a limb is at risk. Pedal access has allowed us to cross lesions that we were once unable to cross. Ultrasound can be utilized in the catheterization lab to minimize radiation and fluoroscopy as well as increase the success of the procedures. Early recognition of peripheral artery disease (PAD) prior to the development of critical limb ischemia may further reduce the risk of amputation as well as identify patients at risk for coronary artery disease and stroke.
Alabama Cardiovascular Group and Grandview Medical Center have developed a comprehensive center for advanced disease management which includes a limb salvage discipline to treat those who are most at risk. Our physicians are experts at diagnosing and treating peripheral arterial disease in patients prior to the development of critical limb ischemia and in utilizing cutting edge techniques to salvage a limb when there is risk of limb loss. The Center for Advanced Disease Management at Grandview will also coordinate with endovascular and endovenous specialists, wound care experts, surgeons, endocrinologists and primary care physicians to help insure that a patient’s needs are fully addressed.
For more information please call Alabama Cardiovascular Group at 205-971-7500.