Thursday, October 23, 2014

Carotid Stenosis and Stroke - "Once upon a time".

By: Gary S Roubin MD PhD with Cardiovascular Associates, a Brookwood Medical Partner.

There are many “once upon a time” stories in medicine! The extraordinary development of science and technology in cardiovascular medicine has dramatically changed the way life-threatening diseases are treated. We rightly call the recommendations and treatment guidelines, based on rigorous scientific studies and expert consensus opinion, “ Best Practice”. And they are constantly changing! “Once upon a time” – 2 to 3 decades ago, rigorous studies showed that a surgical operation to remove blockages in the neck arteries feeding blood to the brain was effective in preventing stroke.

Then some 20 years ago pioneering work at the University of Alabama at Birmingham provided physicians with a considerably less invasive method of treating the blockages, a procedure that became known as carotid stenting. In 2010 the Federal National Institute of Neurological Diseases and Stroke (NINDS) completed a major 2500 patient, prospective multicenter study comparing Surgery and Stenting. This trial confirmed that these two procedures were equally safe and effective in preventing stroke from carotid stenosis - albeit stenting is done without an operation.

But time and medical science march on! And over the last 20 years we have also seen incredible advances in the medications used to treat this condition. Cholesterol lowering drugs that stabilize the blockages, antiplatelet drugs that prevent blood clot in the blockages and blood pressure medicines that all effectively reduce the risk of stroke. We have also made great strides in reducing tobacco use, managing diabetes, and improving our diet and exercise patterns all of which are known to reduce stroke.

So now physicians have not 2 but 3 options to manage carotid disease in patients with significant blockage but who are quite asymptomatic. (Patients who have specific neurologic symptoms are still best treated with surgery or stenting). Some experts in the field are convinced that surgery and stenting are unnecessary, potentially harmful and unnecessarily costly. Other experts fervently disagree! An expert panel at the NINDS has examined all the available evidence and concluded that given the advances in medicine, stenting and surgery this important question needs to be resolved in a rigorous scientific study. They have commissioned the CREST2 Trial that will begin enrolling patients in the coming months.

All patients in this study will receive the best medical therapy available including advice on medication compliance and risk factor management. Depending on a variety of now well-established factors that determine if a patient is best suited for stenting or surgery; half of the group will be treated with either one of these therapies in addition to the medication program. All treatment strategies will carry a very low risk of a stroke occurring and accordingly patients will be followed with stringent care for a minimum of 4 years. Patients in Alabama are fortunate to have centers participating in this important trial and access to physicians with vast experience in treating carotid disease.

Gary S Roubin MD PhD practices cardiovascular medicine with Cardiovascular Associates, a Brookwood Medical Partner. He is recognized as an international expert in the procedure of carotid stenting and is the lead stenting investigator in the NINDS CREST2 trial. Visit for more information or call (205) 510-5000 to refer a patient.

Tuesday, October 21, 2014

Fighting the Flu!

by Tracy Jacobs, MD with Family Medicine Trinity Medical Clinics – Chelsea

Once again it is flu season in Alabama. To avoid being one of the 1 million people hospitalized annually for this potentially deadly virus, protect yourself with one of the following options:

1. The seasonal flu vaccination. This is the typical yearly "flu shot" that one can get at most pharmacies, primary care and urgent care offices. It can protect against 3 or 4 strains of the flu. If you have had a life-threatening reaction to a flu shot in the past, have had Guillain-Barre Syndrome, or have an egg allergy, talk to your doctor before getting a flu shot. This is approved for everyone 6 months of age and older.

2. The nasal spray vaccination. This is approved for children aged two to adults aged 49. This is a weakened live virus vaccine and those on long term aspirin, allergic to eggs or pregnant females should avoid the nasal spray. Patients with a history of Guillain-Barre Syndrome or immunosuppressed patients should talk to their doctor before getting the nasal vaccine. Children, ages 2 to 4, who have recently taken influenza antiviral medications or have a history of wheezing or asthma, should avoid the nasal vaccination. Despite all of the warnings, there are recent data to suggest that in children ages 2 to 8, the nasal vaccine prevented 50% more cases of the flu than the flu shot. Children, who get immunized against the flu for the first time, will need two doses of either method (nasal spray or shot) at least 28 days apart.

3. Recombinant flu vaccination. This shot is for people, ages 18 to 49, who have had a severe allergic reaction to eggs. This injection is usually administered by a physician with experience in severe allergic conditions. There are fewer doses of this vaccination and the cost is significantly more, so discuss this option with your physician.

4. High dose flu vaccination. This is specifically designed to protect people ages 65 and older who may have a weaker immune system. By giving the individual four times the dose a more robust response is expected. The high dose vaccination has been shown to be 24.2% more effective as compared to the regular flu vaccine. As with all flu vaccines, this is not recommended for those who have had a severe reaction to flu vaccine in the past.

5. Intradermal vaccination. This shot uses a much smaller needle and is injected into the skin instead of muscle. This is indicated for those individuals ages 18 to 64 and has the same precautions as the regular flu vaccination.

The flu vaccine cannot cause the flu! However, one can get a headache, mild body ache and malaise after being vaccinated. This usually lasts only a day or two and is much less severe than the flu. If you feel like you may have the flu, call your doctor’s office. In the meantime, stay hydrated, use acetaminophen or ibuprofen as needed for fevers, and get plenty of rest. Good hand hygiene and wearing a mask if symptoms appear will help prevent spreading the flu to your family and coworkers.

Tuesday, October 14, 2014

What is low vision rehabilitation?

By: Lynne Stevens, O.D., F.A.A.O. Low Vision Optometrist at the UAB Center for Low Vision Rehabilitation

Most of us have family members or know someone who is affected by macular degeneration, glaucoma, or another type of sight-threatening condition. We are lucky to have wonderful optometrists and ophthalmologists here in Birmingham that can treat and manage a wide range of eye conditions. However, having a diagnosis and proper medical treatment often should not be the end of the management of the patient. Even with the best treatments many still have functional difficulties with everyday life activities such as reading, watching television, and driving.

Low vision rehabilitation is not exclusive to only individuals with reduced visual acuities. It also includes those with visual field loss, such as in someone who is 20/20 but has a field cut secondary to a stroke. So there is no criteria to be classified as having low vision. Low vision rehabilitation is for anyone having functional difficulties related to their vision.

There is a vast array of magnifiers and adaptive devices that are available to help patients with their functional difficulties. They range from basic handheld magnifiers to electronic types of magnifiers. Optometrists specialized in low vision rehabilitation can evaluate and prescribe the appropriate amount of magnification and types of devices based on the patient’s goals for rehabilitation. Often times simple modifications to lighting, computer settings, or activities of daily living can make a big impact on one’s daily functioning. Low vision certified occupational therapists can train patients how to implement these modifications and magnifiers into their lives.

There are also resources available throughout the community which can benefit someone with low vision. There are audiobooks, free directory assistance, and cell phone data exemption plans just as a few examples. Alabama Department of Rehabilitation Services offers programs and services to those with disabilities within their homes, schools, workplace, and communities.

Low vision rehabilitation can be instrumental in helping someone see better to manage their diabetes or other medications, which in essence, could help prevent further vision loss. It can also help someone cope with and adapt to their vision loss. If you, a patient, or someone you know is frustrated with their vision despite the receiving the optimal medical treatments consider low vision rehabilitation.


Thursday, October 9, 2014

The HIPAA Risk Assessment

By: Phyllis Drummond, Risk Management Specialist NORCAL Mutual Meaningful use.

The Affordable Care Act. Laws and regulations continue to mount as clinical and administrative mandates multiply. Most recently, the Department of Health and Human Services (DHHS) unveiled additional requirements to existing HIPAA Privacy and Security Rules. Within this regulatory environment, it is important that providers are able to create and follow processes for investigation of possible breaches, and that they develop a breach notification policy.

In order to facilitate compliance with the HIPAA Security Rule, the DHHS has supplied education and assessment resources for covered entities. These can be found in various locations, including the DHHS website: (accessed 3/4/14)

Guidance on preparing for, and conducting a risk assessment can be found at:

The HIPAA Privacy Risk Assessment

In the broadest sense, the risk assessment is an evaluation of the potential risks associated with how an organization collects, manages, uses and discloses its protected health information (PHI). Gap analysis refers to evaluating the organization's information-handling practices in light of the requirements of HIPAA, as well as identifying gaps between current and required practices . Covered entities are required by the HIPAA Security Rule to complete a risk assessment and to create a HIPAA Security Rule Risk Management Program based on their findings.

Conducting an analysis helps covered entities identify potential weaknesses in their privacy and security practices that can subject them to breaches in patient confidentiality or invasions of privacy. Gaps in systems and processes can lead to unintended release of PHI, loss of vital data, or inappropriate alteration of data. Finding these gaps and addressing them will help mitigate liability risk for patient confidentiality breaches, as well as assure that the organization is maintaining compliance with HIPAA and HITECH regulations. Avoidance of increasing fines associated with many breaches is also top of mind when addressing gaps.

Covered entities may choose to conduct their own risk assessment. They know their systems and processes best and usually have the in-house expertise and experience to conduct such an assessment. One individual, such as the Compliance Officer, the Chief Information Officer (CIO), or the Information Technology (IT) Director, can do this. A team approach, often found to be more comprehensive, may include the organization's Risk Manager. It may also include department heads such as directors of Health Information Management, Pharmacy and Lab Services, Clinic or Practice Manager, and/or other key personnel whose responsibilities include managing patient information.

Covered entities may wish to hire a professional with expertise in laws and regulations pertaining to privacy and security practices. This will ensure an objective point of view and will add insight not readily available within a covered entity. Many consultants and vendors can be found with a simple online search. The covered entity might conduct a HIPAA-specific analysis, primarily to meet the analysis requirements, or may wish to take a broader approach and also assess the organization's vulnerability and system weaknesses not addressed by HIPAA requirements.

According to the American Health Information Management Association (AHIMA), some of the goals for an information management assessment (HIPAA and broader) may include: 

  • Identify all areas of noncompliance with HIPAA requirements (technical, procedural, training, administrative, etc.—This is known as gap analysis) 
  • Evaluate weaknesses that have led to past breaches of confidentiality, as documented through claims, lawsuits, occurrence or incident reports, and patient and family complaints or concerns 
  • Identify computerized and paper-based health information system vulnerabilities beyond the scope of HIPAA; e.g. licensing violations, cultural factors predisposing the system to problems, etc.
  • Establish an up-to-date inventory of all hardware and software resources 
  • Map the internal and external flow of protected health information

More information may be found at the AHIMA website: , (accessed 3/4/14)

AHIMA recommends evaluating various approaches to the privacy and security risk assessment, and determining what is likely to work best in your organization. Numerous web-based resources are provided in the article referenced above. These resources include sample checklists and tools for conducting an internal privacy risk assessment.

The Department of Health and Human Services website offers a 7-part series on HIPAA Security, beginning with a primer on HIPAA security for covered entities. The series includes detailed information on administrative, physical and technical safeguards. It also stipulates requirements for organizational policies and procedures related to privacy and security, as well as an entire chapter on the basics of risk analysis and risk management. These resources can be found at:

A variety of sample assessment tools can also be found at the following resources:

• ECRI Healthcare Risk Control:


How Can NORCAL Mutual support your practice’s ability to manage risk in the areas of privacy and security?

We can offer advice to policyholders on practices or policies that may impact the security of their patients' protected health information.

In the event of a possible breach, NORCAL Mutual can provide assistance on how best to handle the situation, as well as information regarding the prevention of future breaches.

Cyber Liability: Reminder

NORCAL Mutual provides cyber liability coverage. For details on this coverage, contact NORCAL Mutual or your agent/broker. To discuss risk management concerns regarding privacy and/or security, call our Risk Management department at 855.882.3412 To report a potential breach, call our Claims department at 844.4NORCAL

To discuss risk management concerns regarding privacy and/or security, call our Risk Management department at 855.882.3412

To report a potential breach, call our Claims department at 844.4NORCAL  

Copyright 2014 NORCAL Mutual Insurance Company. All rights reserved. This material is intended for reproduction in the publications of NORCAL-approved producers and sponsoring medical societies that have been granted prior written permission. No part of this publication may be otherwise reproduced, edited or modified without the prior written permission of NORCAL. For permission requests, contact: Jo Townson at (855)882-3412, ext. 2270.


The information contained in this document is intended as risk management advice. It does not constitute a legal opinion, nor is it a substitute for legal advice. Legal inquiries about topics covered in this document should be directed to an attorney. Recommendations contained in this document are not intended to determine the standard of care, but are provided as risk management advice. Recommendations presented should not be considered inclusive of all appropriate risk management strategies or exclusive of other strategies reasonably directed to obtain the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the individual physician/healthcare provider in light of the individual circumstances presented by the patient.



Wednesday, October 8, 2014

The Flu_ Time to Take It Seriously

By: Mohannad Azzam, M.D. at Medical West

Sometimes when we are consistently exposed to something, we can become numb to it. Whether it be foul language, good manners, tragic news coverage - all kinds of things in our lives where the more we see of it, the less of an impact it seems to make, and the less attention we give to it.

I think that this may have happened with the flu.

For a long time, we’ve been exposed to the flu through television commercials, conversation, news coverage, on and on. And in my experience, I’m not seeing the appropriate level of concern over the flu that it deserves. While many times the flu can be a mild illness, there are the cases where it develops into a much more severe situation, resulting in hospitalization and even death. Yes - people do die from the flu.

Influenza is respiratory illness caused by flu viruses, and it is contagious. When a person has the flu, they’ll commonly have fever or feeling chills. Accompanying that is the combination of runny noses, coughs, and sore throats - and muscle and body aches. Headaches are common, as well as feeling fatigued.

Anyone can get the flu. And that’s something that adds to the dangerousness. You can be perfectly healthy, but once you’re body is exposed to a virus it has not encountered before - you can still get sick. And oftentimes, those healthy individuals believe that they are so healthy that they can handle any sickness naturally - and that’s where they can get in trouble.

Influenza, when not treated, can roll into something much worse: bronchitis, pneumonia, and sinus and ear infections. And before many people realize, they have a very serious situation on their hands.

The best protection against the flu is vaccination. Stay up to date with your shots! The CDC recommended a yearly flu vaccine - which may seem like its too often, but because of the viral nature of the flu, staying up to date with the changes the viruses may make is important.

Also, be sure to do the smart things everyday to avoid the flu - like, avoid sick people. And if you become sick, don’t spread it around. Avoid touching your eyes, nose and mouth - this is how germs spread, and of course - wash your hands often!

And when you get sick - see your doctor, and do what they tell you to! If you are prescribed medicine, take as instructed. And if your doctor tells you to stay home, do it!

While you may feel like you hear about it all the time - the flu is more serious than you may think. Don’t get numb to it! Anyone can get the flu, healthy or sickly individuals - we’re all at risk. Get your vaccinations and take action if you’re feeling the symptoms.

Take Care, Dr. Azzam