Monday, September 28, 2015

Children’s of Alabama Expands Child Maltreatment Services

By: Dr. Michael A. Taylor with Children’s of Alabama and professor of Pediatrics at the University of Alabama at Birmingham (UAB)

Child maltreatment is a significant public health problem in Alabama, as it is in all states. The most recent statistics available show there were nearly 20,000 reports of child abuse or neglect during 2013 in Alabama, with about 9,000 children confirmed as victims. And that is just the tip of the iceberg, with cases often going unreported and under-reported. Studies indicate that about 1-in-8 children nationally are victims of serious abuse or neglect by the time they reach their 18th year.

Children’s of Alabama is responding to this widespread problem with the creation of a new Child Abuse Pediatrics Division. It will expand the current services provided by the Children’s Hospital Intervention and Prevention Services (CHIPS) Center.

Child maltreatment encompasses a wide variety of conditions, including physical abuse, sexual abuse, caregiver fabricated illness (previously referred to as Munchausen syndrome by proxy), neglect and psychological/emotional abuse. Thus, child abuse pediatricians must work within medical, child welfare, law enforcement and judicial systems. We are often called to testify in court.

The CHIPS Center has provided forensic medical evaluations, psychosocial assessments, play therapy, counseling, case management services, prevention education, court support and expert court testimony in cases of suspected child abuse. Drs. Melisa Peters and David Bernard have provided medical care to maltreated children at Children’s for many years through the CHIPS Center and the Emergency Department (ED); however their availability to provide care has been stretched between these two services.

The UAB Department of Pediatrics and Children’s created the new Division of Child Abuse Pediatrics along with a full-time director, a position I am honored to hold. This division will provide oversight for existing child maltreatment services being offered through Children’s and UAB. This includes The CHIPS Center, the pediatric sexual assault nurse examiner (P-SANE) program, which operates out of the ED, and other physical abuse and neglect services. Drs. Bernard and Peters have invaluable experience serving maltreated children and are both board certified in general pediatrics, child abuse pediatrics and pediatric emergency medicine. They will continue to play key roles with Dr. Bernard as the medical director for the SANE program and Dr. Peters as the medical director for The CHIPS Center.

These actions are moving Children’s to the advanced tier of services for child maltreatment. Over the next five years we will move to develop at Children’s a “Center of Excellence,” the top tier as defined by the Children’s Hospital Association (CHA). This expansion will involve an extended regional presence, larger child protection teams, an accredited fellowship, research initiatives and increased family intervention and prevention services.

I have a special affection for Children’s, having served my pediatric residency here and serving as a long-time pediatrician at the University Medical Center in Tuscaloosa. And I am passionate about providing medical services to our most vulnerable children.

Children’s has a Level 1 Trauma Center, a Burn Center, a large Emergency Department, a nationally known neonatal intensive care unit, pediatric cardiovascular services, the Alabama Center for Childhood Cancer and Blood Disorders and many other top organizations within top organizations. Children’s is now becoming a leader in the recognition, management and prevention of child maltreatment.

Dr. Michael A. Taylor is director of the newly created Division of Child Abuse Pediatrics at Children’s of Alabama and professor of Pediatrics at the University of Alabama at Birmingham (UAB). He is board certified in general pediatrics and child abuse pediatrics. He has extensive experience in providing medical services and support to abused and neglected children.

Thursday, September 24, 2015

GERD - When to Treat and When to Scope

By: Brent Barranco M.D. with Gastroenterology Associates, N.A. P.C.

Gastroesophageal Reflux Disease (GERD) is a very common problem facing both primary care physicians and gastroenterologist a like. It is estimated that 20 percent of American adults are affected by GERD, which means that we will likely be faced with diagnosing and treating this on a daily basis. And while the symptoms of GERD can be bothersome, it is estimated that 10-15 percent of these patients will go on to develop more serious complications from reflux.

I think it is helpful to define exactly what GERD is. When you talk about gastroesophageal reflux (GER - not disease), it is defined as the passage of gastric contents into the esophagus and is considered a normal physiologic process. Most episodes are brief and do not cause any clinical symptoms or even injury. However, when patients do have symptoms and they present to their primary care physician, they are labeled as having GERD. Gastroesophageal reflux (GER) does not becomes a disease (GERD) until it either causes damage to the esophagus as seen on EGD or it causes symptoms that significantly reduce the patients quality of life. So please keep in mind that every patient who presents to your office with heartburn does not necessarily have GERD.

GERD can be classified into 2 varieties based on the appearance of the esophageal mucosa at the time of upper endoscopy:

Erosive esophagitis that is characterized by endoscopically visible breaks in the esophageal mucosa.

Nonerosive reflux disease which is characterized by the presence of troublesome symptoms of GERD without breaks in the esophageal mucosa.

The most common symptoms that patients will present to the office with will be heartburn, regurgitation, or dysphagia. While these are the 3 most common symptoms, there are several other less common symptoms that health care providers need to be aware, as they may be a manifestation of more serious acid reflux disease. These include dysphagia, odynophagia (pain with swallowing), globus sensation (there is a lump in the throat), chest pain, chronic cough, asthma, nausea, and dyspepsia. Some of these symptoms are more serious than others, and it is the more serious symptoms that we call alarm symptoms of reflux disease. The alarm symptoms of reflux disease warrant a more aggressive means of work up and treatment. They include: dysphagia, odynophagia, non-cardiac chest pain, gastrointestinal bleeding, anemia, weight loss, and recurrent vomiting.

So the most common challenge facing the primary care physician is whom do you treat with medicine only and who do you send for endoscopic evaluation. Below is a guide to how to approach and manage these people who present to you with what you may think is gastroesophageal reflux.

In patients with mild and intermittent symptoms (fewer than two episodes per week) begin these patients on a combination of lifestyle and dietary modifications for reflux disease and either an H2 Blocker (i.e. Pepcid, Zantac, ect..) or an OTC PPI. This therapy should be continued for 8 weeks. If after 2 weeks of therapy the symptoms are still present, then change the patient over to a prescription strength PPI either once or twice a day, whichever is required to achieve good symptom control. If they are asymptomatic at 8 weeks, then give them a trial off of the medication. If the symptoms recur within 3 months, then refer them for endoscopic evaluation.

In patients with more frequent symptoms (two or more episodes per week) and/or severe symptoms that impair quality of life, a more aggressive approach needs to be taken. In these patients start them out on lifestyle and dietary modifications as well as once daily prescription strength PPI therapy. If after 2 weeks of therapy their symptoms still persist, then increase the dose of PPI to twice a day. This therapy should be continued for 8 weeks. If they are asymptomatic at 8 weeks, then give them a trial off of the medication. If symptoms recur within 3 months, then refer them for endoscopic evaluation.

If patients with typical GERD continue to have symptoms after 8 weeks of therapy, then they need to be referred for endoscopic evaluation. In patients who present with heartburn and alarm symptoms of reflux disease (see above), begin lifestyle and dietary modifications for reflux disease and start them on acid suppression therapy with a proton pump inhibitor once daily. These patients need to be referred for endoscopic evaluation immediately.

In Men over age 50 with chronic GERD symptoms (symptoms for more than five years) and additional risk factors for Barrett's esophagus (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, and tobacco use), refer these patients for endoscopic evaluation.

In patients with severe erosive esophagitis (Los Angeles classification Grade C and D) on initial endoscopy, a gastroenterologist should be managing their care and they should undergo a follow-up endoscopy after a two-month course of proton pump inhibitor (PPI) therapy to assess healing and rule out Barrett's esophagus.

Gastroenterology Associates, N.A. P.C. ( has 3 locations (Brookwood Medical Center, Shelby Baptist Medical Center, and St. Vincent’s East Medical Center) and is comprised of 13 board certified gastroenterologists and 9 nurse practitioners. We will gladly partner with you to help manage and care for your patients.

Tuesday, September 22, 2015

DOJ’s Continuing Focus on Stark Whistleblower Cases Leads to Large Settlements

By Zachary Trotter

Recent press releases from the Center for Medicare and Medicaid Services (CMS) indicate that the Department of Justice (DOJ) continues its focus of holding health care providers accountable for Stark Law violations. In just the past few weeks, three settlement agreements have resulted in more than $225 million in penalties paid to the government by various health care providers for allegations that the providers violated Stark and other federal laws.

Since August 13th, the DOJ has announced that providers in North Carolina, Florida, Georgia and Missouri have agreed to pay $115 million, $69.5 million, $35 million and $5.5 million to settle allegations that the providers violated the Stark Law by paying for referrals, which in turn led to the submission of false claims to the government in violation of the False Claims Act. In just the last two weeks, the DOJ has announced two record settlement amounts. The $115 million settlement with Adventist Health System represents the largest Stark settlement ever reached without litigation, outpacing the $69.5 million settlement with North Broward Hospital District announced only last week, according to Modern Healthcare.

Notably, all four cases arose from lawsuits filed by whistleblowers. Three of the settlements identified above were originally filed by a physician offered an employment agreement that allegedly violated Stark, by a former hospital executive and by a physician employed by one of the defendants.

Since the 2009 creation of the Health Care Fraud Prevention and Enforcement Action Team initiative by the Secretary of Health and Human Services, the DOJ has recovered a total of more than $24.9 billion through False Claims Act cases, with more than $15.9 billion of that amount recovered in cases involving fraud against federal health care programs. Recent statements by officials in both the DOJ and HHS indicate that this heightened focus on health care organizations will continue for the foreseeable future.

“Health care organizations paying physicians based on referrals undermines public trust in medical institutions and the financial integrity of federal health care programs,” said Special Agent in Charge Gerald T. Roy of the U.S. Department of Health and Human Services Office of Inspector General. “We will aggressively pursue organizations that engage in conduct detrimental to taxpayers and government health programs.”

These “settlements demonstrate our continuing vigilance to ensure that health care referrals are based solely on the medical needs of the patient and that health care providers bill the government only for the care they provide,” said Principal Deputy Assistant Attorney General Benjamin C. Mizer, head of the Justice Department’s Civil Division. “Healthcare providers who seek to profit at the expense of taxpayers will face serious consequences.”

“The type of conduct alleged puts access [to services] at risk,” said U.S. Attorney Michael Moore of the Middle District of Georgia. These settlements demonstrate “the Department of Justice’s commitment to make sure that hospitals and physicians who commit violations of federal law are held to account, and that [the DOJ] continues to have appropriately functioning health care providers accessible to the wide array of communities they serve.”

Fraud enforcement may be the only government initiative with truly bipartisan support in Washington, DC., and with the DOJ’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.

Zachary Trotter is an associate with Waller where he practices health care law.

Wednesday, September 9, 2015

Ten Tips for HIPAA Compliant Technology

By : Josh Cantrell technology writer with TekLinks 

It’s a bull market for black market health records. A single patient health record can earn cybercriminals 10 times the price of a stolen credit card number. The Office of Civil Rights is auditing small and large healthcare providers alike, imposing multi-million dollar fines in some cases. Meanwhile, the same electronic storage, mobile devices, and cloud-based applications that patients, doctors, and healthcare staff want to use often compromise a practice’s ability to keep that patient data safe.

In light of all this, it is obvious that HIPAA compliant technology practices are more important than ever. Using the ten tips outlined here, you can make sure you are using technology in a way that supports your HIPAA compliance goals and keeps your patients’ health records secure.

1. Analyze and manage risk. Before any other steps can be taken, perform a documented risk analysis to determine where electronic protected health information (ePHI) is being used and stored. Use the findings of this analysis to identify the possible areas where HIPAA violations may occur. Then, work to implement measures to reduce any risks to an acceptable level.

2. Encrypt ePHI. Robust data encryption is the first line of defense against improper disclosure of electronic protected health information. When ePHI is properly encrypted, it is protected even when physical controls are not properly followed and a piece of hardware is misplaced or stolen. Endpoint encryption is often regarded as one of the cheapest and easiest ways to reduce the risk of most ePHI data breaches. Click here to learn more about endpoint encryption.

3. Store ePHI on secure servers or in a secure cloud environment. In addition to being encrypted, servers on which ePHI is stored should be kept secure, both physically and virtually. Servers and data should not be accessible to staff without authorization, and servers should be protected with passwords or public key authentication. If your ePHI will be stored in a cloud computing environment, carefully evaluate the cloud provider’s approaches to management, security and accountability.

4. Avoid storing ePHI on disks or thumb drives. If a laptop can be misplaced or stolen, a thumb drive, disk, or external hard drive can be, too – and often far more easily. Misplaced thumb drives and storage disks are one of the most common causes of HIPAA violations. This problem can be completely eliminated simply by prohibiting the use of these devices. If you must use a thumb drive, make sure they it is encrypted, that there is a record of its chain of custody, and that it does not leave the facility.

5. Use clearance levels to limit access to ePHI. Individual access to workstations, transactions, and software should be limited by authorization and clearance levels. Employees should only be granted access to ePHI when it is critical to their ability to perform their job, and they must be properly trained on HIPAA compliance procedures in order to be approved for access.

6. Consistently update IT security measures. IT security can only be robust when it is regularly updated. Security updates are essential to identifying and fixing bugs, and patching vulnerabilities that could lead to improper access of ePHI. Employee authentication credentials (passwords) should also be regularly updated and never shared.

7. Regularly train staff on improper disclosure of ePHI. Improper access, disclosure, or transmission of ePHI by employees is a major cause of HIPAA breaches – and more often than not, it’s accidental. Staff must be thoroughly educated about protecting health information, and participate in periodic trainings to remind them of its importance.

8. Use and review audit reports. Audit reports are logs that track activity on hardware and software. These allow security officers to easily find the cause or source of any breaches, improper access, or improper disclosure of ePHI. All staff should have a unique, authenticated name and/or number so that audit reports can correctly identify users.

9. Perform periodic evaluations. Periodically review your business practices and changes to the law to determine whether your HIPAA compliance procedures need to be updated. Regularly evaluate systems’ security measures to ensure they are current.

10. Have contingency plans. Make sure that all ePHI is backed up, that backups are accessible, and that procedures are in place to recover any lost data. Establish procedures that will enable critical business procedures to continue operating in the event of an emergency.

Technology on its own cannot make a healthcare practice HIPAA compliant. With forethought, regular employee education, and relevant policies, however, any practice can leverage the best that technology has to offer while securing patient data.

About the Author
Josh Cantrell is a technology writer with IT services company, TekLinks.

Bringing hope to men with metastatic castration-resistant prostate cancer

By: Dr. Vincent Michael Bivins with  Urology Centers of Alabama

Prostate cancer is the most common (non-skin) cancer in American men.  Approximately one in every seven men will develop prostate cancer in his lifetime and about 220,800 men will be diagnosed with prostate cancer this year. Prostate cancer is usually curable, but can spread outside the prostate requiring additional treatments. 

Prostate cancer growth is fueled by the male hormone, testosterone.  Lowering testosterone levels will usually result in significant decrease in the growth of the cancer.  Once the cancer has spread to other parts of the body, the first line of therapy used is hormone therapy.  This involves lowering the patient’s testosterone levels and can be done surgically by removing the testicles or chemically through medications.  The initial response to these treatments is usually favorable, but unfortunately, the median duration of response is 18-24 months.  Metastatic castration-resistant prostate cancer is the term used when the cancer has spread outside the prostate and is able to grow despite treatments to lower the amount of testosterone.  A few years ago, the only other option for these patients was chemotherapy.  Fortunately, there are now several treatment options for this group of men.  For the most part, these therapies are tolerated very well and offer promising results.

What’s available? 

Provenge (sipuleucel-T)

Provenge is immunotherapy that uses a patient’s own immune cells to fight the prostate cancer.  It is used for patients with a rising PSA on hormone therapy who are asymptomatic or minimally symptomatic and have good functional status.  Research data shows there is a 13 month survival advantage if Provenge is completed before the PSA reaches 22.  The treatment requires only 6 appointments and is completed in about a month.  Patients first go to a blood center for cell collection (leukapheresis) and then those cells are made into a dose that is specific for them.  Patients return to the physician’s office about three days after cell collection to have their cells reinfused through an IV.  This process is done three times, spaced a week apart.  The procedures are usually tolerated very well with minimal, if any, side effects. 

Oral Oncolytics

The approval of oral oncolytics, before the use of chemotherapy, has been a major step forward in treating metastatic castrate resistant prostate cancer.  The standard hormone therapy we use targets testosterone produced by the testicles; however, testosterone-like hormones are also produced by the adrenals and the tumor itself.  Zytiga (abiraterone) and Xtandi (enzalutamide) are two oral agents that block testosterone signaling or production outside the testicles.   These drugs each have roughly a four month survival advantage over placebo.  Furthermore, they delay disease progression on imaging studies and delay the beginning of chemotherapy.  As with any oral medication, there are potential side effects, but most men deny significantly bothersome symptoms and are capable of continuing on with their daily living while on either of these medications.

Xofigo (Radium 223)

Xofigo is used for patients with metastatic spread to bones who are experiencing bone pain symptoms.   When cancer invades the bones, it stimulates the bones to accelerate calcium uptake.  Radium 223 is structurally similar to calcium; therefore, it is absorbed by the bone cells and concentrated in areas of the bones where the cancer is most active.  Although it can improve pain symptoms, it is not just a palliative treatment.  The primary role is to use it as another form of treatment to actually fight the prostate cancer.  Xofigo, administered by an intravenous injection, is given once a month for a total of 6 months.  It has been shown to increase overall survival by 3.6 months compared to placebo and delay time to first symptomatic skeletal events, such as pathologic bone fracture, spinal cord compression, tumor-related orthopedic surgical intervention, or need for external beam radiation to relieve pain.


Chemotherapy, of course, continues to be an option for metastatic castrate-resistant prostate cancer.  Docetaxel (Taxotere) is the first chemo drug given in most cases.  Treatment usually consists of 6-10 total treatments.  The word “chemo” can be very frightening to many patients, but thankfully, docetaxel is tolerated much better than most other forms of chemotherapy.  Patients might experience some side effects, including fatigue and loss of appetite, but it generally does not cause the severe degree of toxicity associated with other chemotherapies.  Recent studies have also shown increased benefit in early chemotherapy intervention and many are proceeding with this even before they become castrate-resistant. 

Bone-Targeted Therapies

Another important component in treating these patients is addressing bone health.  Hormone therapy alone puts patients at risk for loss of bone density and muscle mass.  Once the cancer has spread to the bones, patients are even more susceptible to bone related complications such as fractures.  Fortunately, there are therapies that can effectively decrease the risk of these complications.  Denosumab, zoledronic acid, and Fosamax are commonly used bone supportive treatments that decrease such events.  Years ago, nothing was being done on this front, but we now have more knowledge and ways to decrease bone complications, which gives patients longer quality of life.

It should be noted that the treatments above are additive.  The months of survival advantage and delay in disease progression of one therapy adds to the next therapy, and so on.  The combination of treatments gives patients a significantly extended live expectancy.  Perhaps more importantly, since most of these treatments have minimal side effects, patients can also expect to maintain a good quality of life.  When compared to the options just a few years ago, this is very exciting for metastatic castration-resistant prostate cancer patients.  There are also several new treatments that are expected to be released in the near future that will build on what we already have available.  There is certainly reason to have hope!

Urology Centers of Alabama has developed a specialized clinic combining all of these options with comprehensive care involving a nutritionist, pastoral services, and physical fitness.  We would love to have you or your loved one as one of our patients.


Tuesday, September 8, 2015

A better way to a healthier community

By: Anne-Laura Cook, MD, FACP, MHCM Medical Director, Population Health Management & Primary Care Innovation Baptist Health Centers

Many of us struggle to make our own health a priority. It’s easy to put everything else first – work, finances, social life. Health seems like something remote, something you can always deal with later when you have the time, or when you are forced to pay attention to it. Maybe health seems too hard, too expensive or simply out of your control.

You can’t do much about your genes or family history, but there some things that you can control and that have a tremendous impact on your health.

Five Modifiable Risk Factors to Prevent or Control Chronic Disease:

• Tobacco Use

• Diabetes and Pre-diabetes

• High Cholesterol

• High Blood Pressure

• Excess Weight and Physical Inactivity

In this post, we will discuss the first two risk factors:

Tobacco Use

Lung cancer is now the leading cause of cancer death in the United States for both men and women, and is the most preventable form of cancer death in the world. Tobacco use causes 87 percent of lung cancer deaths in men and 70 percent of lung cancer deaths in women. (Source: Cancer Facts & Figures 2014) Do you know that more than one in every five people in Alabama still smoke cigarettes?

Nicotine, which is found in all tobacco products, is a highly addictive substance. Only about four to seven percent of people are able to quit smoking on any given attempt without medicines or other help. Baptist Health System, via the Be Well program – focusing on workforce health, will begin its first intensive Tobacco Treatment program this October. We will use a proven, evidence-based approach modelled after the University of Mississippi’s ACT Center Tobacco Treatment program. Our program includes the use of a variety of medications to counter nicotine addiction as well as group counseling sessions that help participants get the skills they need to quit and stay quit.

Diabetes and Pre-diabetes

Alabama frequently boasts about being in first place. Did you know that Alabama has the highest percentage of people with diabetes – 13.8 percent - higher than any other state in the country? What’s worse, one in four people with diabetes do not even know they have the condition.

Adults, especially those who are overweight or who have a family history of diabetes, should have their blood sugar tested to screen for diabetes either at a doctor’s office or a workplace health screening. Once you know that you have diabetes, it is time to get educated. Baptist Health System has a Diabetes Self-Management Education program, accredited by the American Diabetes Association. Our program teaches people with diabetes the skills they need to take care of themselves, including:

• Healthy eating • Being active

• Monitoring

• Taking medication

• Problem solving

• Healthy coping

• Reducing risks

Have you ever been told that your blood sugar is “borderline”? That could mean that you have prediabetes. One in three adults in the United States have prediabetes; nine out of 10 people with prediabetes do not know they have the condition. Without lifestyle changes to improve their health, 15 percent to 30 percent of people with prediabetes will develop type 2 diabetes within five years. (Source: National Diabetes Statistics Report, 2014). So what can you do?

1. Have your blood sugar tested. Find out if you are one of the 86 million Americans with pre-diabetes.

2. Lose five to seven percent of your body weight. For a 200-pound person, that is 10 to 14 pounds. Can you lose more weight than that? Sure! However, losing just five to seven percent of your body weight will significantly decrease your risk of developing diabetes.

3. Be active. Getting at least 150 minutes of physical activity each week (that’s 30 minutes a day, five days a week, of an activity such as brisk walking) reduces your risk of developing diabetes.

Do you know that the YMCA of Greater Birmingham has a Diabetes Prevention Program? The 12-month program consists of 16 one-hour, weekly group sessions, followed by monthly sessions led by a trained lifestyle coach. To qualify for the program, you must be at least 18 years old, overweight (BMI>25) and at high risk for developing type 2 diabetes or have been diagnosed with pre-diabetes.

Baptist Health System wants to change the way you think about your health. We want to prepare you to take better care of yourself and help you prevent chronic illness. We want you to spend more time doing the things that matter to you – we want you to Be Well.

Look for future posts on the remaining Five Modifiable Risk Factors to Prevent or Control Chronic Disease in the coming weeks.

Struggling young readers may have a subtle, treatable, eye muscle coordination disorder.

By: Dr. Kristine Hopkins is an Associate Professor of Optometry at UAB

As another school year begins, we must once again think about children’s vision and their visual needs at school. This means much more than just whether or not a child can discriminate the letters on a distance visual acuity chart. Children spend 75 percent of their school day reading and doing close work. It is important for us to consider how a child’s eyes work together while reading. For comfortable reading, the eyes must both point at the text to prevent double vision and the focusing system of each eye must adjust focus to make the print clear. For most children, this is effortless but not for all of them.

Up to 6% of school aged children have an eye muscle coordination disorder called Convergence Insufficiency (CI). For children (and adults too) with CI, it is difficult to accurately converge the eyes toward the nose. While reading across the page, a child with CI must work to keep both eyes pointed on the text. If one eye drifts outward, the text becomes double and the child must work to make the print single again. As reading continues and the child fatigues, the double vision and often times blur become more frequent and reading becomes a chore. This struggle can cause a child to read more slowly, lose his place frequently, be inattentive, or avoid reading all together. This can lead to homework battles for parents and frustration for our young students who don’t understand why it seems so easy for their peers.

Unfortunately, most vision screenings are designed to detect the need for glasses (which is important) but they do not look for eye muscle coordination or focusing disorders. In the scope of a screening setting, these disorders would be difficult to detect. A comprehensive eye exam when possible is the best way to detect the need for glasses, test eye teaming, and rule out ocular pathology. In a primary care setting, often asking the right questions will go a long way in identifying children who may be struggling with convergence insufficiency. The Convergence Insufficiency Symptom Survey (CISS) is a well validated tool for detecting CI. It’s a 15 question survey about how a child’s eyes feel while reading. It uses a Likert scale that assigns each response a score. If the sum of the symptom score exceeds 16, the patient is suspected to have CI with 96% sensitivity (88% specificity). A copy of the CISS may be found at . In lieu of a formal survey, health care professionals can ask questions regarding common symptoms of CI that may also be very helpful in identifying children at risk. Children with CI are likely to exhibit the following symptoms while reading or doing near work:

• Tired and/or sore eyes

• Headaches

• Double vision and/or blur

• Difficulty maintaining concentration

• Frequent loss of place

• Avoidance of reading

Fortunately there are well studied, effective treatments for convergence insufficiency. In a multi-center, randomized clinical trial supported by National Institutes of Health, office based vision training was shown to eliminate CI related symptoms in 75% of the children assigned to office-based training. The children receiving home based pencil push-up training and those receiving in-office placebo training had success rates of 33% and 35% respectively. While this study showed that treatment was effective at reducing CI related symptoms and improving eye muscle coordination, it’s still unclear how this affects reading and attention (both suspected of being affected by this disorder). While preliminary studies have shown improvement in attention and reading after the successful treatment of CI, large scale studies are underway.

Children and parents of children with CI often don’t consider that difficulties with reading may be a vision problem. Asking the right questions will often uncover an eye teaming problem like convergence insufficiency and help children receive the treatment they need. Assessments for reading difficulty should begin with a comprehensive eye examination.

1. Borsting EJ, Rouse MW, Mitchell GL, et al. Validity and reliability of the revised convergence insufficiency symptom survey in children aged 9-18 years. Optom Vis Sci 2003;80:832-8.

2. Barnhardt C, Cotter SA, Mitchell GL, Scheiman M, Kulp MT, Group CS. Symptoms in children with convergence insufficiency: before and after treatment. Optom Vis Sci 2012;89:1512-20.

3. Convergence Insufficiency Treatment Trial Investigator Group. A randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol 2008;126:1336-49.

4. Scheiman M, Mitchell GL, Cotter S, et al. A randomized trial of the effectiveness of treatments for convergence insufficiency in children. Arch Ophthalmol 2005;123:14-24.

5. Borsting E, Mitchell GL, Scheiman M, et al. Treatment of symptomatic convergence insufficiency improves attention In school-aged children In: ARVO. Ft Lauderdale, FL; 2011. (presentation)

Dr. Kristine Hopkins is an Associate Professor of Optometry at UAB specializing in clinical care and research of pediatric vision, amblyopia, and binocular vision disorders including convergence insufficiency. She is the site Principal Investigator for the NIH/NEI sponsored Convergence Insufficiency Treatment Trial – Attention and Reading Trial (CITT-ART) currently ongoing at UAB.

Tuesday, September 1, 2015

Vulnerability Management – ‘Do unto yourself before others do unto you’

By: Susan Pretnar, President at KeySys Health LLC

Not a perfect translation from the law of the prophets, but a meaningful aphorism for managing electronic information system security risks. For those who really have no idea what vulnerability management means, very simply stated, it means ‘hack’ your own systems before you become the ‘hackee’.

The idea of finding and killing your own snakes makes perfect business sense in the ever expanding online and internet saturated environment that healthcare entities are operating in today. Unfortunately, the industry is only recently awakening to the realization that their networks, databases and information systems are vulnerable to attack from external malicious threats, regardless of their size or specialty.

Based on security readiness surveys and breach statistics, one could assume that practices using electronic systems really don’t value investment in infrastructure and data security. Healthcare is notorious for taking eons to change direction, but rather than paint everyone with the same brush, let’s take the position that most just don’t understand what is needed, or they’re distrustful of the advice offered by their vendors. The recommended solutions invariably cost money: penetration tests, system scans, continuous monitoring.

There are several actions that need to be accomplished to design a solid vulnerability management process for the digitized protected health information that you create, maintain, share or transmit. Although not all inclusive, here are some basic fundamentals:

a.) Identify all applications, servers, and devices that make up your IT network and operations, and identify business partners that extend your risk. Assure your software licenses and security certificates have not expired;

b.) Define your endpoints or ‘perimeter’: where is PHI data coming from, where it is going and where and how is it maintained or archived. The old, forgotten backup files are snakes that have bitten several;

c.) Determine the effectiveness of your identity management process, especially ‘privileged user‘ access to operating systems, databases, networks, etc. Review your basic authentication procedures for new users and ongoing access control;

d.) Review the standards used for your device and server configurations and the effectiveness of your patch management process;

e.) Organize your IT systems into groups (routers & hubs, servers, firewalls, applications, etc.) and determine what automated tools you have in place to monitor them.

If you contract for IT support, establish an IT Security Audit Plan with them and modify it when you change your network or introduce new technology. Include periodic ‘scanning’ of network servers and devices, reflecting the status of patches to all devices and applications, and conduct a penetration test (recommended by NIST at least once every 3 years) to satisfy HIPAA requirements. Sadly, a penetration test is costly and only a snapshot at one point in time. Do the penetration test after you are satisfied that you have built the best network you can afford, then monitor with frequent scans of your IT network and information systems to assure it stays secure.

Vulnerability management is a constant need in healthcare as with any line of business. It should be designed to assure regulatory compliance, but more importantly, to protect your business operations as well as the patient protected health information you generate continuously. There are many tools to assist the monitoring process, but don’t underestimate the obvious vulnerabilities of weak passwords and poor security training that results in human failures to recognize phishing expeditions by the bad guys.

PAD Month

By: Michael Simpson, MD Cardiologist at Birmingham Heart Clinic

September is National Peripheral Arterial Disease (PAD) Awareness Month. One in 20 Americans over the age of 50 has PAD, and though it is a common and treatable disease, it is largely unknown, often unrecognized, and its symptoms are commonly attributed to old age.

Peripheral arterial disease is caused by plaque build-up or blockages in an area of the body outside of the heart such as the legs, neck or arms. The blockages keep extremities and organs from receiving oxygen-rich blood. And just like clogged arteries in the heart, blocked arteries in the legs raise the risk of cardiovascular events, such as heart attacks and strokes. Ultimately, PAD can reduce mobility and be fatal if left untreated.

Many people lose limbs each year due to peripheral arterial blockage, but BHC believes that early diagnosis and treatment can prevent disability and save limbs and lives. BHC has extensive experience in interventional procedures to save limbs.

Symptoms of PAD include:

• open ulcer/wound on the bottom of your foot that does not heal
• pain in the feet or legs that goes away with walking

• severe cramping in your calf after exercising that goes away immediately when stopping

• discoloration of the legs/feet

• numbness or coldness in legs/feet

• pale, shiny skin

PAD is caused by the same risk factors that lead to heart disease. Those at risk include anyone over the age of 50, especially African Americans; those who smoke or have smoked; and those who have diabetes, high blood pressure, high blood cholesterol or a personal or family history of vascular disease, heart attack, or stroke. A simple, painless ultrasound can test the blood flow in your legs to determine your risk of PAD. Consult with your doctor if you think you may be at risk, or call BHC to learn more at (205) 856-2284.