Let's stop heart disease!

By Andrew P. Miller, M.D., FACC, FAHA, FASH

Cardiovascular Associates

3980 Colonnade Parkway

Birmingham, Alabama 35242

Office (205) 510-5000

www.cvapc.com

From a study done across the world, 90% of your risk for a heart attack can be determined by a simple clinic visit and inventorying 6 common risk factors.

These are:

1.     Physical inactivity. Everyone should get 30 minutes of aerobic or symptom-limited activity 5 days a week or 150 minutes per week. If formal exercise is difficult, a pedometer can guage your activity level. The American Heart Association suggests 10,000 steps per day.

2.       Overweight/obesity. You should know where you stand with body mass index. This is your body weight divided by surface are of skin. The correct ratio is 25 or less. A body mass index over 30 qualifies as obese. It is predicted that in Alabama in 2030, 62% of our population will be obese. If you are in this category, a formal dietary intervention is worthwhile (such as weight watchers).

3.     Tobacco use. If you smoke or are around second-hand smoke then you are depleting your heart artery reserves and battering the artery walls with a risk factor that is most likely to take the young, productive members of this world from us. It is important to set a quit date. The number one indicator of whether you will quit is how many times you have tried. You must get smoking out of your environment. Then set a date that is at least 7 days away and not further than a month away and do your best. If you slip, you will have the experience of temporary success and it will be easier next time. Keep working on it.

4.         Hypertension. The ideal blood pressure is 115/75. For every 20 points on top and 10 points on bottom that you go up, your risk of stroke (and heart attack and death) is doubled. When you are over 50, it is the top number that is most important. So, when your blood pressure is 195 on top, your risk of stroke is 16-fold higher. The average number of pills it takes to control blood pressure in the US is 3.2. So, it might take some work, but simple medication for blood pressure might be the most important intervention we have to improve cardiovascular health in Alabama. You should have your blood pressure checked and get it controlled.

5.     High cholesterol. You should have yours tested and often treated with medications if it is high and you have other risk factors on this list or have had a prior heart attack or stroke.

6.     Diabetes. A fasting blood sugar can give you a good guage of your risk for it and diagnose it. Treating it is valuable for preventing heart attack, blindness, and the need for dialysis.

Each of these risk factors doubles or triples your risk for a heart attack. Unfortunately, together they are more potent at causing havoc, such that 3 wrong makes your risk 13-fold higher and 4 wrong makes your risk 42-fold higher.

It really takes a comprehensive strategy for inventorying and then controlling each of these risk factors to prevent heart disease and stroke, and keep you functionally able and independent for as long as possible.

How MRI Works

By Hailey Gothard
Medica Stand Up Imaging

MRI, or Magnetic Resonance Imaging, is based on physics. MRI uses the magnetic field, your protons and neutrons, along with radio frequencies to create images of your body. More specific to protons and neutrons, MRI uses the hydrogen atoms in the body to create images. The human body consists of 60 percent water, which makes it easy to image the human body. When the body is put into the magnetic field, your hydrogen atoms either line up with the direction of the magnetic field or against it, which cancels them out completely, but there is always ONE hydrogen atom left. This is where the radio frequencies come in – MRI is able to run different sequences to look at your tissues (Fat vs. Fluid) by using different radio frequencies. By using radio frequencies to create images, no radiation is used in MRI.

Many MRI patients ask: what is that knocking noise? It is the gradients and radio frequency coils switching to make your images. MRI takes pictures of the patient's body in three planes: axial, sagital, and coronal. Imagine three slices of bread. This is why the patient never has to move. Compare to X-ray pt moves for every x-ray. Another important fact to know is you must hold still during your MRI to get the best image possible. Exams last between 30 minutes to an hour.

Why would my doctor choose an MRI?

• Looks at tissue and NOT bone like X-ray and CT (Structural: is anything out of place)
• Exams:
• Multiple Sclerosis
• Tumors of brain
• Torn ligaments (ankle, knee wrist)
• Shoulder injuries
• Soft tissue masses
• Herniated discs in spine
• Early Stage Strokes

MRI Safety: Show screening form

• No pacemakers, aneurysm clips
• Remove hearing aids, dentures
• Remove all metal (blue jeans if having lower back hips done) (bras)
• Heart stints: Good after 6 weeks
• Surgical metal ok (I.e. knee, hip replacement) but if scanning that area could cause an artifact
• No cell phones, watches, wallets (magnetic field erases credit cards)

Stand-up MRI

• History: Dr. Damadin, who 1^st discovered the basis of MRI, designed the Stand-up MRI

What makes Medica Stand Up different?

·         Only one in the state

·         Positional scanning: flexibility of scanning sitting, standing, lying down, reclined and even bending and flex/ext views of the spine (i.e.) pt back really hurts when they bend over we can image that

·         Weight-bearing scans – No other MRI can offer

·         Comfort: It is truly open, great for claustrophobic people and watch TV

·         Accommodates up to a 500LB pt and 60 inch waist

·         Important for your Doc: stronger than most open MRIs around .6 vs. .2 tesla

Prevention:

• No real advantages to getting MRI early
• Obviously need to have a problem first
• If you do have a problem go ahead and see the doctor and don’t fear an MRI
• Putting it off could make it worse
• MRIs aren’t as scary as they used to be:  come sit and watch TV with us!

The Alabama Graduated Driver License Law

By Kathy Monroe, MD
Emergency Medicine Physician, Children’s of Alabama

We all like surprises, right?

Recently I was surprised that a friend did not know that Alabama ranked second nationally in teen driving fatalities.

In the Emergency Room at Children’s, caring for kids who have been involved in motor vehicle crashes (MVCs) is an all too common occurrence. As a member of the Alabama Safe Teen Driving Coalition, Children’s is reaching out to pediatricians and family practice physicians this month to raise awareness of the Alabama Graduated Driver License Law.

The law, passed in 2002 and refined in 2010, was intended to keep teen drivers safer on our roads, yet many physicians (and parents and teens, even some in law enforcement) are unaware that this law even exists.

The members of the Alabama Safe Teen Driving Coalition believe that empowering physicians to help educate teen drivers and their parents about the risks faced on the roads they travel is key. While knowledge of the law is only the first step in helping parents and teens decrease the number of these deaths, we want to help physicians initiate the conversation.

In addition to raising awareness about the law, we encourage all doctors to know the leading contributors to teen driver crashes and engage teen drivers in conversation about these topics:

• Not wearing a seat belt

• Distractions inside the car

• Driving while using alcohol or drugs

• Speeding, aggressive or reckless driving

• Driving after dark

• Too many passengers in the car

• Talking on cell phones while driving

• Texting while driving

• Eating or drinking while driving

• Adjusting the radio, CD player, temperature controls, etc.

• Loud music in the car or wearing headphones

The Alabama Graduated Driver License Law places restrictions on young drivers to help ensure their safety. Parents should know the law and enforce it with their teen drivers. If you are a pediatrician or family practice physician, you can help us educate parents and teens by sharing the teen driving educational materials available at www.childrensal.org/healthcareprofessionals or www.alaap.org. 

Tick bites: A common cause of IgE antibodies to alpha-gal

By Carol Smith, MD

Birmingham Allergy & Asthma Specialists, PC

www.birminghamallergy.com

Two novel forms of anaphylaxis have been defined recently: 1) acute reactions during the first infusion of cetuximab and 2) delayed anaphylaxis to red meat.  In each case, these reactions were shown to be occurring in patients who had IgE antibodies to the oligosaccharide galactose alpha-1,3-galactose, which is a mammalian blood group substance.

In a study published in the April 2011 issue of The Journal of Allergy and Clinical Immunology (JACI), Commins et al have now reported evidence that tick bites predominantly from the Lone Star Tick cause these IgE antibodies. The evidence includes prospective data on three subjects, a strong association with a history of tick bites, a good correlation (r=0.67, p<0.001) between IgE antibodies to tick extract and IgE antibodies to alpha-gal, and finally extensive epidemiological evidence that these IgE antibodies are only found in areas where tick bites are common. These IgE antibodies are common (i.e., 15-20% of adults) in an area that includes TN, NC, AR, MO and VA.

These results are important clinically because the cases of anaphylaxis starting 3-6 hours after eating beef, lamb or pork can be very confusing. The history usually includes prolonged pruritic reaction to ticks. The diagnosis becomes probable with positive skin tests to mammalian extracts and can be confirmed by blood test for IgE to alpha-gal.

This comes from the website of the American Academy of Allergy, Asthma and Immunology. These novel forms of delayed pruritus, urticarial and/or anaphylaxis have been elucidated, primarily through research done in the Allergy Department of the University of NC, Chapel Hill. We have diagnosed several cases here at the Birmingham Allergy & Asthma Clinic, but many more cases likely go undiagnosed. Please let us know if you have any patients with delayed or unexplained anaphylaxis, or questions about this very interesting phenomenon.

CAROL SMITH, MD

Birmingham Allergy & Asthma Specialists, PC

www.birminghamallergy.com

Employment Discrimination in the Medical Profession

 

by Daniel J. Burnick, Attorney at Law

Sirote & Permutt, P.C.

Over the years, I have been involved in numerous cases involving employment discrimination.  The claims involve all types of workplaces, including accounting firms, insurance firms, manufacturing plants, automobile dealerships, law firms and even in the medical profession.  No industry or profession is immune from allegations of discrimination.  The types of claims involve sexual harassment, racial discrimination, pregnancy discrimination, disability discrimination and family medical leave discrimination.  No position is immune from claims of discrimination:  I have handled claims against presidents and other officers of corporations, human resources directors, supervisors and co-workers.

A recent case out of New York has received a lot of publicity.  ABC News reported last month that Sandra Morris, a hospital technician at Mount Saint Sinai Hospital in New York, worked in an operating room where Dr. Ahmet Cercioglu, a Cardiovascular Perfusionist and her immediate supervisor, allegedly watched X-rated movies on his cell phone while he was operating equipment that keeps patients alive while undergoing bypass surgery. Dr. Cercioglu also allegedly called her a “dumb Jew bitch” and a JAP, short for Jewish American Princess, in front of co-workers at a farewell party. Ms. Morris also alleges that Dr. Ricardo Lazala, a Cardiothoracic Surgeon and a secondary supervisor, stated that she could not work on some cases “because she doesn't have a dick” and that they would “never hire a woman again.” On July 31, 2012, Ms. Morris filed a lawsuit against the hospital and Dr. Cercioglu, alleging sex and religious discrimination; allegations of a hostile work environment in which other Perfusionists “routinely joked about his behavior;” and that she was not paid the proper amount for overtime. She was fired after being off work for six months on unpaid leave as the result of an on-the-job injury, but is not challenging this decision. 

At this time, the lawsuit contains only allegations against Dr. Cercioglu and the hospital, and the hospital issued a statement that the hospital “maintains strong policies prohibiting discrimination and harassment in the workplace and does not tolerate behavior that violates these policies.  Mount Sinai is confident that Ms. Morris will not prevail on her claims.” 

Notwithstanding the denial, what impact has this lawsuit had on Dr. Cercioglu and the hospital?  First, there is bad publicity, not only in New York, but around the United States and even the world.  A quick Google search shows that this story has been picked up by the Huffington Post, the Daily Mail in the United Kingdom, and by YahooLifestyle, in which the headline reads “Sex Scandal Hit US Hospital Accused of Horny Grey’s Anatomy-Like Ambiance.” Second, a great deal of time and effort will be spent interfering with the daily activities of the hospital, doctors and employees due to the investigation by the attorneys, preparing for and attendance at depositions, reviewing records and trial testimony, if the case gets that far.  Third, the expense of defending a claim such as this will be in the hundreds of thousands of dollars, if not more based on rates charged by attorneys in New York City.  Finally, one can only hope that no patients suffered any complications and/or passed away as the result of surgeries that involved Dr. Cercioglu.  If so, it is likely that these allegations will factor into the malpractice claims as well.

 

Although the lawsuit has just been filed and there has been no finding of any wrongdoing at this time, the damage has already been done.  It is important to realize that at work, any improper conduct can ultimately result in a lawsuit being filed.  Media outlets look for sensational stories, and I imagine that if this happened in Birmingham, Ala. it would be on the front page of the Birmingham News, the lead story on TV stations, and discussed on talk radio.  To quote Sgt. Phil Esterhaus from Hill Street Blues, “Hey, let’s be careful out there.” 

 

Iron Deficiency and Restless Leg Syndrome

By Joanne Rossman, MD

Restless leg syndrome sufferers have unpleasant sensations in the legs. These sensations usually occur at night or after periods of inactivity. They are commonly described as creeping, crawling, pulling, throbbing, gnawing, burning, or pain involving the legs. The discomfort is worsened by stress and emotional upset. The discomfort lessens or is relieved by stretching, walking, jiggling the affected limb, exercising, or pacing.(1) Patients with restless leg syndrome are awakened by these symptoms and move frequently in order to alleviate their pain. Several patients experience limb jerking with sleep disruption. As a result, restless leg syndrome patients tend to suffer from severe insomnia. They experience many side effects from their insomnia including daytime fatigue, depression, anxiety, and slowed thought processes.

Approximately 20% of restless leg syndrome patients are actually suffering from iron deficiency. New data suggest that a serum ferritin of less than 80 is associated with iron deficiency induced restless leg syndrome. The symptoms of iron deficiency are similar to those seen in severe insomnia. They include fatigue, slowed thought processes, depression, muscle aches, dizziness, and cold intolerance. Physical exam and laboratory evaluation by a physician can determine if your symptoms of restless leg syndrome are due to iron deficiency. Treatment with iron infusion can rapidly correct these symptoms and return a night of restful sleep.

Joanne Rossman, MD practices at Medical West.

For more information please read the following article:

Diego Garcia-Borreguero, et al. Algorithms for the diagnosis and treatment of restless legs syndrome in primary care.  BMC Neurology 2011 Feb 27; 11:28.

Care of the Diabetic Foot

By Rodney Snow, MD

Diabetes is a major problem that we deal with in the United States and Alabama is certainly one of the states near the top of the list with a large percent of the adult population that are diabetics. In the U.S. it is estimated that up to 17% or more of the adults are diabetics. Close to 14% of all US health care expenditures are related to diabetes and its complications with about half of the cost related to complications such as heart attacks, strokes, kidney failure including dialysis, degrees of blindness (diabetic retinopathy) and diabetic foot ulcers (DFU) with various levels of amputation.

Human nature is such that most do not even think about their feet unless an issue developed that causes pain or some other issue that gets our attention. We just take our feet for granted and move along. Any diabetic that develops a foot ulcer (DFU), no matter how small or simple can result in that person losing their leg. It is estimated that the lifetime risk of the diabetic getting diabetic foot ulcers or other foot complication is up to 25%; therefore 25 out of 100 diabetics are going to get a foot ulcer that can lead to loss of their limb.

Diabetic peripheral neuropathy is the main factor that leads to diabetic foot issues with risk of ulceration and then possible limb loss along with peripheral arterial disease. To prevent peripheral neuropathy controlling of one’s blood sugar is vital. Elevated blood sugar leads to the development of neuropathy in various ways, which causes damage to the nerves. It usually develops first in the feet, distally in the toes progressing up into the legs and later into the hands. However, all nerves in the body can and will be damaged over time. The neuropathy leads to damage of the sensory nerve function so there is gradual loss of sensation or feeling in the foot that’s why it’s is so important in protecting the foot from injury. We all learn to not do something when it causes us pain, such as touching a hot stove in which we learn not to repeat that behavior. The loss of protective sensation in the foot from the diabetic neuropathy allows trauma and injury to occur. In addition, the motor nerve function is also damaged so there is weakness in the muscles and the muscles get smaller especially in the foot. This allows deformities in the foot such as hammer toes or claw toe deformity to have more pressure in one location over another on the bottom of the foot allowing callus formation. In addition, neuropathy affects the nerves that regulate the sweat glands and regulates the micro blood flow in the skin. The diabetic foot becomes dry leading to cracks and scaling of the outer layer of skin. With the deformities, shoes will not fit properly leading to areas of pressure and or friction that leads to blisters and calluses. The blister can open, getting infection and or causing an ulcer to develop.  A crack can occur in the callus which can get infected leading to an ulcer. Without protective sensation, even minor trauma can lead to issues because with no pain the trauma is overlooked until it is noticed from bleeding or infection.

When the diabetic patient sees his primary care provider he should go ahead and take his shoes and socks off at each visit for foot inspection.  At least once each year a complete examination of the feet should be done. The diabetic patient should ask for the foot exam each year. In addition, blood flow to both feet should be assessed. When sensory function is altered, different foot ware should be considered.  Shoes should be wide and deep enough to allow for custom inserts, to distribute the pressure on the bottom of the foot more evenly. With the mechanical wear and continuous changes that occur in the foot, shoes and inserts need reevaluation at least every six months.

The diabetic patient should be educated and understand their responsibility to check their feet daily and take proper care of them, if the individual wishes to keep them over time, along with blood sugar control, diet, and not smoking, which accelerates artery damage. One should avoid activities that can injure the feet such as walking barefoot or even in sock feet, using a heating pad, hot water bottle, or putting ones feet on a furnace vent or near a space heater. Do not step into a bathtub or soak ones feet without testing the water temperature. Do not spend extra time on ones feet looking for other ways to ambulate or exercise. Trimming nails and other bathroom surgery that leads to breaks in the skin on the feet should be avoided, allowing Podiatry or other healthcare providers to do even the minor procedure. Feet need to be washed daily in lukewarm water with a mild soap (such a Dove®) and apply generously moisturizing lotion or cream. Because of the dryness it will require application of the lotion or cream more than once daily. The diabetic must check the entire surface of both feet for skin breaks, blisters, swelling, or redness, including between and underneath the toes where damage may be hidden. Use a mirror, if it is difficult to see all parts of the feet or ask a family member or caregiver to help. Select cotton socks that fit loosely, and change the socks every day. Select shoes that are snug but not tight, and break all new shoes in slowly to prevent any blisters. When blisters develop, do not open them and get pressure off that area to allow the blister to heal.  The top layer of skin comes off on its own. Keeping calluses soft as possible and filed down, prevents the build of additional callus and development of a blister underneath or cracking. Most diabetic foot ulcers develop from blister or calluses.

If an ulcer develops, the time to get it healed is when it is first noticed. Seek medical attention and keep in mind antibiotics alone will not heal the ulcer. Remember that one should not be able to walk without pain with an ulcer on their foot. This is the problem, the lack of the pain from the neuropathy. For the ulcer to heal, the pressure must be taken off of the ulcer so the patient must not walk on the ulcer or some method must be provided to relieve that pressure.  If not, the ulcer will not heal and will get larger and deeper, with infection developing at some point. The price for healing must be paid and with the lack of pain, our mind must guide us to accomplish the appropriate things needed for healing, to prevent a greater price that could be prevented.