Issues & Developments with Kidney Safety

By Thomas Watson, MD
Nephrology Associates PC


As a nephrologist, I sometimes feel like the annoying little hall monitor who spends his 
days at school telling his colleagues what they can't do. Unfortunately, given that the kidneys are 
susceptible to so many different insults and that patients with chronic kidney disease are unique
in terms of their specific health needs, I am compelled to embrace that role as the so-called
"kidney safety police." I have decided to use this opportunity to participate in the Birmingham
Medical News Blog as a chance to update medical professionals on some of the most common
issues and recent developments in the world of "kidney safety." Many readers are already familiar 
with everything I am about to say, but hopefully, some of the following will lend some clarity:

Antibiotics:

With the ever-increasing incidence of MRSA seen in the ambulatory setting, we in the

nephrology community have noticed a much higher usage rate of oral sulfa antibiotics like

trimethoprim-sulfamethoxazole (i.e. Bactrim). These particular antibiotics, while they generally

have very good efficacy for MRSA, can wreak havoc in patients with chronic kidney disease.

In particular, they can cause both acute renal failure, and severe hyperkalemia. I encourage

outpatient basis. A much less common but present antibiotic side effect involves the use of

quinolones, which can cause interstitial nephritis -- prolonged courses of quinolones in

particular can uncommonly be a problem in this regard. Besides dosing adjustments that may

be required, other oral antibiotics are not generally nephrotoxic.

In the inpatient setting, there remain a number of pitfalls with regards to antibiotics and

kidney function. With newer antibiotics, and newer/safer formulations of some older antibiotics

(anti-fungals like amphotericin, for example), there has been, I believe, a decline in

antibiotic-induced acute renal failure on an inpatient basis. That being said, aminoglycosides

remain predictably nephrotoxic and should be used sparingly and carefully. The original

amphotericin B should be avoided in favor of the new liposomal formulations that have a

reduced incidence of acute renal failure. As always, any penicillin can cause allergic interstitial

nephritis. Daptomycin is a newer antibiotic that is tolerated well, but still has reports of up to

3% incidence of acute renal failure. The toxicity of vancomycin remains controversial.

Low Molecular Weight Heparins (LMWH):

There are two issues here. First, once daily dosing at a slightly reduced dose for DVT

prophylaxis is widely accepted in patients with ESRD and in patients with pre-dialysis CKD.

Not so with treatment doses. There have been no conclusions made regarding the use

of low molecular weight heparins at treatment doses for patients with CKD or ESRD. Studies

have demonstrated both an increase in bleeding events (i.e. overdose) and thrombotic events

(i.e. underdosed), even with the once daily dosing for treatment at 1mg/kg of enoxaparin for

example. Essentially, these findings demonstrate that we have no idea how best to dose

LMWH in patients with kidney disease. Some hospitals have made it possible to follow Factor

Xa levels and thus have a way of monitoring therapeutic efficacy -- in this case, I think the use

of LMWH is probably safe. The alternative is “the old-fashioned way--” i.e. unfractionated

heparin until the patient is therapeutic on warfarin.

Oral Diabetes Medicines:

Metformin: Most are aware of the problems with metformin in kidney disease, but I will

clarify: The problem with metformin is not that it is nephrotoxic (it isn’t). Metformin metabolism

in patients with CKD can lead to lactic acidosis; sometimes it can be severe and

life-threatening. There is some controversy in the literature about what threshold to use when

deciding when to stop metformin. Historically, it has been suggested that a creatinine of 1.5 is

the limit above which no one should take metformin. Using estimated GFR would provide a

more reliable means, and I would suggest using a GFR of 30 as the cutoff below which

patients should not take metformin. If someone has a higher GFR than 30, but has

progressive CKD, I would stop metformin earlier.

Sitagliptin: This is a newer diabetes medicine (DPP-IV inhibitor, trade name Januvia)

that should be given at lower doses for patients with CKD, and has had a few case reports of

actually causing some kidney damage. Dosing recommendations should be available on the

package insert, via Epocrates or UpToDate, or in the PDR.

Linagliptin: This is also a DPP-IV inhibitor (trade name Tradjenta), but it requires no

renal adjustment and has had no case reports of causing acute renal failure.

Pioglitazone: (trade name Actos) This medicine has its own non-renal problems,

although it does cause swelling in some patients. There are no renal issues with this

medicine, but again, its non-renal problems need to be considered as well.

Other oral diabetes medicines are well-tolerated in kidney disease (including

sulfonylureas, meglitinide derivatives, etc), but one should always keep in mind that patients

may require less drug as kidney disease progresses.

Fenofibrate:

Although an uncommon complication of triglyceride-lowering therapy, fenofibrate has

been implicated in the development of kidney damage. I generally take my patients with CKD

off fenofibrate -- unfortunately, palatable triglyceride lowering therapy options are relatively

limited, so I generally don’t substitute anything. The longterm mortality risk associated with

CKD is higher than that associated with hypertriglyceridemia.

IV Contrast:

The risk for acute contrast nephropathy is present for anyone exposed to CT or

angiography-related contrast. The risk factors that increase the likelihood of nephropathy

include underlying CKD, age, diabetes, volume depletion, NSAID use, and type and amount of

contrast used. Many different agents have been studied as potential prophylactic agents, with

disappointing results in general. Limiting the volume of contrast appears to be the most

valuable measure available -- e.g. for cardiac catheterizations, avoiding the unnecessary left

ventriculogram and considering staged procedures. The only other prophylactic measure with

reliable positive data is volume expansion, probably with isotonic bicarbonate-based IV fluid

prior to the procedure. The data for N-acetylcysteine is equivocal at best, but since it is an

inexpensive therapy with no side effects, it is still widely used (the regimen I use is 1200 mg

twice daily on the day before and day of the procedure). Other prophylactic measures that

have been tried but are not effective (and, therefore, not recommended) include dialysis,

hemofiltration, vitamin C, theophylline, and statins.

Gadolinium has been associated with a condition called nephrogenic systemic fibrosis

in a small number of patients with CKD and ESRD. This disease is a diffuse sclerosing illness

that has no obvious treatment and can sometimes be fatal. Consequently, I do everything I

can to help my CKD and dialysis patients avoid exposure to gadolinium. There are some

reports that frequent dialysis immediately after exposure can limit the risk, but it is unclear.

Most of the time, an alternative to MRI with contrast can be found.

Dabigatran:

The use of Dabigatran (aka Pradaxa) is not recommended in patients with CKD/ESRD.

PICC Lines:

The increased use of peripherally inserted central catheters has been a boon to many

patients who have difficult venous access or need longterm home IV therapies. Unfortunately,

PICC lines should be avoided in patients with CKD/ESRD. PICC lines cause permanent

damage to the vein in which they are inserted, thus making that vein impossible to use for

dialysis access in the future. I know that considering dialysis “down the road” must not seem

very important when you have a patient in the hospital who needs access. On the other

hand, we, the nephrologists, see many patients every year who have limited options for

dialysis access (and thus, limited options for life), sometimes due to previous use of PICC

lines. So, we avoid PICC lines as much as possible in patients who have any chance of

needing dialysis in the future.

By no means is this an exhaustive list, but these are the most common issues that we

encounter in our patients. If there is ever a question, a nephrologist is but a phone call away.

Oral and Maxillofacial Surgery

By: N. Ryan Livingston, DMD, MD, and Joshua E. Everts, DDS, MD

Oral and Maxillofacial Surgeon, N. Ryan Livingston, DMD, MD, and Joshua E. Everts, DDS, MD, practice the full scope of Oral and Maxillofacial Surgery with expertise ranging from corrective jaw surgery to wisdom tooth removal. The doctors can also diagnose and treat facial injuries requiring reconstructive surgery, corrective sleep apnea surgery and perform a full range of dental implant and bone grafting procedures.

Wisdom teeth removal

Wisdom teeth are the last teeth to erupt within the mouth. When they align properly and gum tissue is healthy, wisdom teeth do not have to be removed. Unfortunately, this does not generally happen. The extraction of wisdom teeth is necessary when they are prevented from properly erupting within the mouth. They may grow sideways, partially emerged from the gum, and even remain trapped beneath the gum and bone. Impacted teeth can take many positions in the bone as they attempt to find a pathway that will allow them to successfully erupt.

These poorly positioned impacted teeth can cause many problems. When they are partially erupted, the opening around the teeth allows bacteria to grow and will eventually cause an infection. The result: swelling, stiffness, pain, and illness. The pressure from the erupting wisdom teeth may move other teeth and disrupt the orthodontic or natural alignment of teeth. The most serious problem occurs when tumors or cyst form around the impacted wisdom teeth, resulting in the destruction of the jawbone and healthy teeth.  Removal of the offending impacted teeth usually resolves these problems. Early removal is recommended to avoid such future problems and to decrease the surgical risk involved with the procedure.

Dental Implants

Dental Implants are changing the way people live. They are designed to provide a foundation for replacement teeth that look, feel, and function like natural teeth. The person who has lost teeth regains the ability to eat virtually anything, knowing that teeth appear natural and that facial contours will be preserved. Patients with dental implants can smile with confidence.

The dental implants themselves are tiny titanium posts that are surgically placed into the jawbone where teeth are missing. These metal anchors act as tooth root substitutes. The bone bonds with the titanium, creating a strong foundation for artificial teeth. Small posts that protrude through the gums are then attached to the implant. These posts provide stable anchors for artificial replacement teeth.

Implants also help preserve facial structure, preventing bone deterioration that occurs when teeth are missing.

Orthognathic Surgery (Jaw Surgery)

Orthognathic surgery is needed when jaws don’t meet correctly and/or teeth don’t seem to fit with jaws. Teeth are straightened with orthodontics and corrective jaw surgery repositions a misaligned jaw. This not only improves facial appearance, but also ensures that teeth meet correctly and function properly.

People who can benefit from orthognathic surgery include those with an improper bite or jaws that are positioned incorrectly. Jaw growth is a gradual process and in some instances, the upper and lower jaws may grow at different rates. The result can be a host of problems that can affect chewing function, speech, long-term oral health and appearance. Injury to the jaw and birth defects can also affect jaw alignment. Orthodontics along can correct bite problem when only the teeth are involved. Orthognathic surgery may be required for the jaws when repositioning is necessary.

Difficulty in the following areas should be evaluated: difficulty in chewing, biting or swallowing, speech problems, chronic jaw or TMJ pain, open bite, protruding jaw, breathing problems.

Any of these symptoms can exist at birth, be acquired after birth as a result of hereditary or environmental influences, or as a result of trauma to the face. Before any treatment begins, a consultation will be held to perform a complete examination with x-rays. During the pretreatment consultation process, feel free to ask any questions that you have regarding your treatment. When you are fully informed about the aspects of your care, you and your dental team can make the decision to proceed with treatment together.

Phone: 205-208-0137

Fax 800-244-8132

Email: shelbyofs@gmail.com 

Fiscal Cliff Averted? It All Depends

 

by : William O.  “Trey” Whitt, III, CPA

Partner _ Dent, Baker & Company, LLP 

Search the term “fiscal cliff averted” and you’ll get about 57 million hits in a quarter of a second.  Is that proof enough that we did, in fact, avoid a cataclysmic spill over a scary economic precipice?  As a nation, perhaps so.  But if you now find yourself approaching the highest income tax bracket, you may not feel as if you averted anything at all!

The newly enacted American Taxpayer Relief Act of 2012 preserved lower tax rates and other benefits for nearly all households.  But as household income increases, taxpayers may now be climbing a personal tax mountain that feels as daunting as the fiscal cliff the nation just dodged.  Here’s what you need to know. 

Payroll Tax Holiday Sunset

The consequence of the new tax law that affects the most people is actually not in the law at all.  For the past two years employees and self-employed workers have enjoyed the benefit of a two percent reduction in the Social Security tax rate.

The result was an average boost of about $2,200 for the typical taxpayer.  Because this reduction was not renewed for 2013, the Social Security rate returns to 6.2%, and, as a consequence, take home pay will go down.

$250,000 Income Threshold

Additional wage and investment surtaxes enacted with the 2010 healthcare reform legislation took effect at the beginning of this year.  This means that every dollar in wages over $250,000 is now subject to a Medicare tax of 0.9%.  

Once total income surpasses the $250,000 threshold any investment income – dividends, interest, rents, most capital gains and other types of unearned income – is now subject to a 3.8% Medicare tax.

These taxes are assessed on top of the taxes that ordinarily apply to wage and investment income.

$300,000 Income Threshold

At the $300,000 income level, you begin to give back certain tax benefits available to taxpayers at lower levels.  For example, itemized deductions such as charitable contributions, real estate taxes and mortgage interest are reduced up to 80% of the otherwise deductible amount.

Additionally, the value of personal exemptions for you, your spouse and your children will gradually be phased out.

$450,000 Income Threshold

If your income exceeds $450,000, you will likely be subject to the new higher tax rates governing ordinary and capital gains income.  The top rate applying to ordinary income is now 39.6% (up from 35% last year), and the new capital gains rate is 20%.  A capital gains rate of 15% still applies if income is below $450,000.

Business Provisions

Since most businesses are organized as passthrough entities, (business income passes through the entity and is reported by its owners), the new individual tax provisions will have a major impact on business planning.

One encouraging development is the extension and expansion of tax rules that make it easier for businesses and owners to write off capital equipment purchases.  Retroactive to the beginning of 2012, businesses can deduct up to $500,000 in qualifying purchases during the year.

With top income tax rates approaching 40%, this provision represents a significant inducement for businesses to make infrastructure investments. The half-million dollar annual threshold remains in effect through the end of this year.

Is It A Cliff?  Is It A Mountain?

It’s impossible that any financial policy decision – let alone one with the potential impact of that scary fiscal cliff – results in consequences that are “all good” or “all bad.”   No matter howneatly the politicians try to wrap the package, there are always surprises, some welcome and others less so, that straggle out.

My advice for taxpayers is to do your own investigation, or enlist a trusted tax advisor, into what these changes will mean for you.  Only then will you know if you’re falling over a cliff, climbing a mountain or resting easy…at least until the next crisis erupts. 

LAKESHORE PARK PLAZA·2204 LAKESHORE DRIVE, STE 300  ·BIRMINGHAM, AL 35209

(205) 871-1880 ·wwhitt@dentbaker.com

Alabama Sports Concussion Taskforce: A statewide resource for you and your practice (part 1)

Joe Ackerson, Ph.D.

Chair Alabama Statewide Sports Concussion Taskforce

This first of two articles is designed to familiarize the reader with the Alabama Statewide Sports Concussion Taskforce (ASCT) in order to utilize it as a resource for their practice and any public health initiatives. The second part will provide specific information on the recognition and management of concussions for your medical practice. It has been estimated that up to 3.8 million sports- and recreation-related traumatic brain injuries occur in the United States yearly with the highest rates of emergency department visits for sports concussion occurring for young people from ages 10 to 19. Youth athletes appear to be especially vulnerable to the effects of concussion, including cognitive difficulties such as memory and attention problems.

The ASCT was created in 2007 as a committee of the Alabama Statewide Head Injury Taskforce (AHIT) to address the growing problem of Sports Related Concussions (SRC) in Alabama. The members of the ASCT represent healthcare providers, athletes, families, school systems, state agencies, researchers, and policy makers. The ASCT has identified three main area of focus: 1) Education and public awareness for athletes, families, healthcare providers, coaches, schools, and the general public, 2) Clinical guidelines for concussion identification and management, including important return to play and “return to think” decisions, 3) Legislative and policy making endeavors to positively impact the systems of care for athletes and their families. Of course none of this is possible without the ability to fund important efforts and initiatives.

The ASCT is chaired by Dr. Ackerson, a pediatric neuropsychologist with nearly 20 years experience diagnosing and treating youth with traumatic brain injuries (including concussions) as well as diverse brain disorders due to a variety of medical conditions. Dr. Ackerson is currently in private practice but has previously served as Director of Pediatric Neuropsychology at UAB as well as Director of Psychology at Children’s Hospital of Alabama.

The ASCT has five committees, each chaired by an expert in the field. The Education Committee (chaired by Dr. Jimmy Robinson, team physician for the University of Alabama football program and member of the AHSAA Medical Committee) is charged with providing educational resources, including training for physician groups, certified athletic trainers, psychologists, athletic organizations, schools etc. The Public Policy Committee (chaired by Drew Ferguson, ATC, clinical director of UAB Sports Medicine and the Children’s Concussion Clinic) is charged with crafting legislation and public policy initiatives, lobbying for concussion related issues, and fostering cooperation between different agencies and groups. Dr. Michael Ellerbusch (team physician for Hoover High School) chairs the Clinical Resources committee which serves to develop clinical guidelines for the recognition and management of concussion based on the latest scientific reviews as well as clinical expertise of our members. Dr. Jim Johnston (pediatric neurosurgeon at Children’s Hospital of Alabama and Chair of the Children’s Hospital Concussion Taskforce) chairs the Research Committee which is charged with promoting statewide research efforts in Alabama, creation of a clinical database, and reviewing and disseminating the latest research findings to other members of the Taskforce. Finally Marie Crowley (Director of the Traumatic Brain Injury program at the Alabama Department of Rehabilitation Services) chairs the Grants and Funding Committee which serves to help procure grant funding for ASCT initiatives as well as ensuring that our activities remain commercial free.

Enabled by the receipt of MCHA grant monies through the Alabama Head Injury Foundation (AHIF) and the Alabama Department of Rehabilitation Services (ADRS) we have accomplished a number of important goals since 2007. The ASCT has become a clearing house for free, expert information for anyone workingin this area. We have conducted workshops for the Alabama Chapter of the American Academy of Pediatrics, the Alabama Psychological Association, the Alabama Association of Certified Athletic Trainers, and the Alabama Association of School Psychologists and provided important presentation ready information which our members have used at the Alabama Statewide Coaches meeting as well as other venues. We consulted with the Medical Advisory Board for the Alabama High School Athletic Association leading them to adopt on the strictest guidelines in the country for the recognition and management of sports related concussions. We also helped The Children’s Hospital of Alabama and UAB develop their new clinical guidelines for the management of SRC which led to the development of the Children’s Concussion Clinic.

With the assistance of Alabama State Representative Paul DeMarco and the sponsorship of State Representative Ron Johnson and State Senator Greg Reed, and the advocacy efforts and of Steve Savarese, director of the Alabama High School Athletic Association (AHSAA). 2011-541 HB 108 (passed and signed into law in 2011 with a technical amendment added in 2012) helps to prevent the long-term adverse consequences of youth concussions by requiring all schools and athletic organizations to: provide information on sports concussions to all athletic participants and their families; ensure that all coaches have training in the recognition of concussions; the immediate removal of any athletic participant suspected of having a concussion from participation and not allow him/her to return the same day they are injured and until cleared by a physician.

Concussion symptoms can be broken down into 4 major areas. 1) Mental- any change in their usual mental state (feeling woozy, confused, in a fog, disoriented, problems with memory or concentration),  2) Emotional- change in personality, irritability, nervousness, unexplained or sudden sadness, or extreme moodiness, 3) Arousal- chronic fatigue or lethargy, reduced endurance or tolerance for physical exertion, sleep disturbance, and 4) Physical- blurred or double vision, dizziness, problems with balance or coordination, headache, nausea, overly sensitive to light or sound, numbness or tingling. While many times observers may notice that a player has had a concussion when they fail to get up after a hit or fall, it is important to note that you do not have to lose consciousness to have had a significant concussion.

As the awareness of the need to properly recognition and manage concussions has increased dramatically, primary care, sports medicine, and specialty physicians (PM&R, neurosurgeons, neurologists, etc.) need to develop clinical pathways for their practices. The ASTC is a free, expert resource for any physician wanting to learn more about how to integrate this aspect of care into their practice. In the next article I will provide more specific suggestions for how to do this.

(if there is room please include the following ASCT consensus statement)

ASCT Consensus Statement: Sideline or onsite assessment of sports related concussion (SRC) should occur whenever possible. The assessment should include a certified athletic trainer (ATC) and/or an appropriately trained physician. ATC’s receive specific training in the assessment and management of concussion. When working closely with a qualified physician, they provide an important medical function.

Once it has been determined that a concussion has occurred, the on-site professional should also attempt to determine the severity of the injury. No athlete should return to play the same day they have a concussion, and should not return to play or other high risk activity, including activities that involve significant physical exertion, until such time that a physician trained in the assessment and management of concussion can perform an independent evaluation.

In the absence of available medical personnel, coaches must serve the role of recognizing and referring athletes to a physician for further evaluation and treatment. Referees bear the responsibility of protecting players, such as ordering an injured player off the field, notifying the coach of the injury, and preventing their return. Since coaches and referees are not medical personnel it is possible they may not recognize a concussion when it occurs. Coaches and referees should undergo training and certification in the recognition and management of sports related concussions. Neither coaches nor referees should make return to play (RTP) decisions.

Return to play (RTP) decisions should made by a physician trained in the assessment and management of concussion. The physician’s decision regarding RTP may be enhanced by including ATCs, neuropsychologists, and/or other qualified medical experts whose knowledge, techniques, and experience can provide valuable additional information. The final decision regarding the athlete’s ability to return to play should be a medical decision. We recognize that there are many unknown variables and no one, including the treating or consulting physician, can guarantee that the athlete’s return to play would not continue to present a health risk for the athlete. We believe that by following established guidelines, as well as the information and resources developed by this taskforce, the risk of immediate or long-term adverse consequences from the concussion will be significantly reduced.

Given the established need for cognitive rest following SRC, and the fact that young athletes’ most important task is academic achievement, it is increasingly appreciated that in addition to RTP decisions, we need to formulate Return to Think (RTT) protocols. Once an athlete has incurred a concussion, his or her school should be notified as soon as possible in order for proper planning and monitoring to occur, including appropriate accommodations in the academic program. Every school that has an athletic program must provide a designated contact person to receive and disseminate medical and neuropsychological information required to guide RTT decisions in the academic setting. This contact person at each school should have access to a specified neuropsychologist that will be critical for guiding RTT decisions. In more complex cases a neuropsychological evaluation may be necessary.

Any school that provides sports programs, or any community based sports programs, must disseminate information to athletes and their families pertaining to the recognition and management of SRC. 

Counting Calcium: Don’t Forget Foods

Beth Kitchin, PhD, RD
Assistant Professor
UAB Department of Nutrition Sciences

                

    Much of my work as the patient educator in the UAB Osteoporosis Prevention and Treatment Clinic involves counseling patients on calcium and vitamin D supplements and osteoporosis medications. While some patients are not getting enough calcium, some are actually over-supplementing. Somehave been told by their doctors or other health professionals to make sure to take several calcium tablets a day to achieve 1000 to 1500 mg of calcium a day.  But there are some problems with this one-size-fits-all advice:

Ø  Some patients are also getting calcium from their foods. If a patient drinks milk, eats yogurt, cheese, or calcium added orange juice, soy, or almond milk, she or he could be getting at least some of their daily dose of  calcium from these dietary sources.

Ø  Patients may be taking a multivitamin that has quite a bit of calcium in it. Many women’s multivitamins have as much as 500 mg of calcium in one tablet. That’s as much and sometimes more calcium than many calcium supplements.

Ø  Calcium supplements vary in serving size and amount of calcium. If you’ve ever looked at the supplement section in the grocery or drug store you were likely overwhelmed by the sheer number and types of calcium supplements. Add to that the internet shopping options and you’ve got a lot of confusion on both the part of the patient and the clinician.  The amount of calcium shown on the label is for the specific serving size specified on the label. I’ve seen serving sizes on various supplements range from one to six tablets. Patients are often unaware that they need to check the serving size first.

Ø  Excessive calcium is unnecessary and may be harmful. The upper limit for calcium intake is 2000 to 2500 mg a day for adults, depending upon age. Excessive calcium can cause constipationand may lower the absorption of other nutrients although this is not well established.

Ø  To make matters even more confusing, a few supplements like some versions of Tums show you how much calcium carbonate is in the tablet as opposed to just elemental calcium, which is what patients really need to know.  To figure out the elemental calcium you need to know that calcium carbonate is 40% elemental calcium and do the math.  Calcium citrate is 21% elemental calcium but I have not seen any supplements that show the total amount of calcium citrate on the label so this does not seem to be an issue with calcium citrate supplements.

                Because of these issues, patients and clinicians often miscalculate the amount of calcium the patient is getting.I find that a quick dietary assessment of a few key foods that are high in calcium is useful.I ask the patient if she or he eats or drinks the following foods most (5 to 7) days of the week:

Ø  Milk, soy or almond milk, calcium-added orange juice (~300 mg calcium per                                         cup).

Ø  Cheese (~200 mg calcium ounce).  A typical piece of pre-sliced cheese is usually                                                one ounce.  Three dominoes can be used to visualize an ounce of cheese as well.

Ø  1 small carton of yogurt (200 – 300 mg calcium)

Ø  Liquid supplements like Ensure, Boost, or SlimFast (~300 mg of calcium per can)

               

  Answers to these questions give me a rough estimate of how much calcium a patient is getting on an average day.  I then assess how much calcium the patient is getting from their supplements – including multivitamins. This can be a bit challenging if the patient has not brought his or her supplements to their appointment!  I also ask patients if they take Tums for stomach upset. I find that sometimes patients take Tums regularly but do not think of them as a calcium supplement. I then adjust their supplements if necessary.

 

                 I also recommend that patients spread their calcium dose out throughout the day – preferably to three times a day – stressing that foods count as a “dose”. We typically recommend not more than 500 to 600 mg of calcium at one time since fractional absorption begins to decrease after that amount. Research also suggests that split dosing of calcium can help keep parathyroid levels from spiking throughout the day.  I also recommend that patients take calcium carbonate supplements with food since calcium carbonate needs stomach acid for absorption. Right before a meal or within 30 to 40 minutes later should suffice.

                Fortunately, estimating vitamin D intake is much simpler than estimating calcium intake. Since few foods are high in vitamin D and most older patients won’t make enough from UVB rays due to lower levels of 7-dehydrocholesterol in aging skin, simply adding up the total vitamin D from over-the-counter supplements will give you a good estimate of the patient’s  intake. I usually recommend a daily dose of 1000 to 2000 IU’s from over-the- counter supplements to maintain healthy blood levels of vitamin D. Patients who take both a multivitamin and a calcium +D supplement may not need an additional vitamin D supplement. Separate vitamin D supplements are easy to find and come in a variety of doses. Spit dosing is unnecessary since vitamin D is fat-soluble. Some research shows that taking it with food improves absorption.

                Helping patients understand how to get the right amount of calcium from foods and supplements can be challenging.  However, we can help our patients supplement sensibly by asking the right questions and by educating ourselves about calcium sources as well as the issues that confuse patients and clinicians alike.

Dr. Kitchin teaches the Tone Your Bones Osteoporosis Education Luncheonfor osteoporosis patients every Wednesday from 11:00 to 1:00 at the Kirklin Clinic at UAB. The class is open to the public. To register for the class, call 205.801.8187.

Cardiovascular Disease

Seth J. Baum, MD, FACC, FACPM, FAHA, FNLA

Dr. Baum is a medical advisor for Solstas Lab Partners® Cardiovascular Disease Program and the founder of the Foundation of Preventative and Integrative Medicine. He maintains a clinical practice in Boca Raton, Florida. Reach him 1-888-440-FPIM and follow on Twitter @SethJBaumMD. For more information about Solstas Lab Partners, visit www.solstas.com or call 1-888-664-7601.

In spite of the dramatic advances Cardiovascular Medicine has enjoyed over the last three decades, heart disease continues to reign as the king of killers in the western world. Nearly half of us die each year as a consequence of cardiovascular disease (CVD), and, in truth, more women die from CVD than men. (Astonishingly, eleven times as many women die from CVD as from breast cancer!)

How can we reduce these alarming CVD statistics? Prevention.

It is no exaggeration that we see publications of medical trials examining novel cardiovascular risk factors or biomarkers on an almost daily basis. This area of medical research is prolific because it is consequential. Identifying an earlier risk factor enables doctors to implement prevention strategies sooner in the course of cardiovascular disease. An optimal scenario would have doctors consistently identifying risk even before the slightest aberration in the patient’s endothelium. Unfortunately, it appears to be a dream with only distant possibilities. For now, we must rely upon utilizing a combination of established protocols along with cutting-edge tools.

The following hypothetical patient illustrates such an approach:

A 50-year-old woman presents with mild, well-managed hypertension and an LDL-C of 130. She also has a TG of 200 and an HDL-C of 54. You calculate her Framingham risk score (FRS) online. Although you consider her an at risk patient, it is surprising to learn her 10 year risk is only 2%. This exemplifies a flaw in FRS but does not negate its value. Relying upon the 2011 updated AHA guidelines for women, you order a few tests, including an assessment of LDL particles through LipoScience, biomarkers from Cleveland Heart Lab, a Carotid Intima Media Thickness (CIMT), and the most advanced form of cardiac CT scanning as to limit radiation to a single mSv.

What you find is revealing… and disturbing.

Your 50-year-old female patient has extraordinarily high LDL particles, and elevated LpPLA2 and MPO levels signifying inflammation in the vessel wall. She also has five small mixed plaques on Coronary CT and significant thickening of her carotid IM. Your jobs (as the doctor and the patient) have now become far more meaningful. You place her on a statin (which you would not have done without the advanced data you just acquired) and educate her about the importance of Therapeutic Lifestyle Changes (TLC). Now, actually seeing her vascular disease and abnormal biomarkers, she heeds your advice. She exercises daily, eats a balanced diet, and brings her weight down to an optimal level. In short, you have just changed – and probably saved - her life. By digging deeper, you uncovered a smoldering fire that would, ultimately, have become a conflagration and potentially ended her life prematurely. Following this approach you have stepped into the future and joined the evolving field of preventive cardiology. You have amplified your effectiveness, for which your patients will be most grateful.

Solstas® is a registered service mark of Solstas Lab Partners Group, LLC.

New Alabama Appeals Court Decision Restricts Changes of Ownership

By Carey B. McRae
Bradley Arant Boult Cummings

On November 30, 2012, the Alabama Court of Civil Appeals released its opinion in Florence Surgery Center v. State Health Planning and Development Agency, et al. (Docket Number 2110812).  The case involved the change of ownership between two separate and unrelated limited liability companies of a certificate of need (CON) for a single-specialty ambulatory surgery center (ASC) that had been operated at its present location since 1999.  The change was to be effected through a lease of all the assets of the current owner and operator of the ASC (including the building, equipment, real property, and the CON) to the new, unrelated entity.  After execution of the lease, the new owner proposed to obtain a new license from the Alabama Department of Public Health to operate the ASC at the same site.

When the change of ownership filings were made with the Alabama State Health Planning and Development Agency (SHPDA), the agency approved the change and found that the change in ownership did not require the new owner to obtain a new CON.  The agency’s decision was consistent with numerous prior determinations in other similar transactions.

However, a competing ASC in the area objected to the agency’s decision and appealed the matter to the Alabama Court of Civil Appeals.

On appeal, the Court reversed the agency decision, finding that all transfers of ownership require a CON unless a statutory exemption applies.  Referencing two sections of a statute governing the CON program, the Court then went on to describe what is and is not a transfer of a CON.  Interpreting one section (Ala Code section 22-21-270(f) reads: “The transfer of stock in, or change of name or merger of, a corporation which holds a CON shall not constitute a transfer, assignment, or conversion of the certificate.”), the Court concluded that a transfer of stock is not a transfer of a CON.  Interpreting the second section (Ala. Code section 22-21-270(e) reads: “A certificate of need shall not be transferable, assignable, or convertible, other than between members of a parent-subsidiary controlled corporate group as defined in Internal Revenue Code, 26 U.S.C. section 1563(a)(1), and shall be valid solely to the person and purpose named thereon, except to such other member of the controlled group, or by change of name or merger with another corporation.”), the Court concluded that both a merger or an internal corporate reorganization among a parent and subsidiary is not a transfer of a CON. 

SHPDA has filed an application for rehearing with the Court to seek a modification to the restrictive ruling.  That application is currently pending before the Court.  The Alabama Hospital Association, the Assisted Living Association of Alabama, the Hospice and Palliative Care Organization, and the Alabama Nursing Home Association have joined together in an amicus brief supporting SHPDA’s application for rehearing and seeking to modify the Court’s decision to be less restrictive on changes of ownership.

Increasing Colorectal Cancer Screening in Your Practice

By Erica Klevay, MA, Public Information Specialist for the Alabama Department of Public Health FITWAY Colorectal Cancer Prevention Program

Despite the availability of effective screening tests, colorectal cancer (CRC) continues to be the second leading cause of cancer deaths in Alabama. Many Alabamians are not regularly screened for CRC and are only diagnosed with the disease after it has reached an advanced stage, when treatment is more difficult. According to the Alabama Statewide Cancer Registry, from 2006-2010, 42.7 percent of CRC diagnoses in Alabama were made at a late stage (stage 3 or 4 based on AJCC 6). Because most people initiate CRC screening due to the recommendation of a physician, it is imperative that primary care physicians in Alabama make CRC screening a priority. Adding the fecal immunochemical test (FIT/iFOBT) as a test option and tweaking office protocols can improve your standard of care.

Add the FIT to your protocol

FIT/iFOBT is a new type of take-home stool test that is highly sensitive, inexpensive, and does not require diet or medication changes. Both FIT/iFOBT and guaiac FOBT detect occult blood in stool that may indicate the presence of polyps or CRC. However, there are important differences between the two types of stool tests. Some older guaiac FOBT lack the sensitivity required to adequately screen for CRC: only take-home high-sensitivity guaiac tests and the FIT/iFOBT are recommended. Also, while high-sensitivity, take-home guaiac FOBT is recommended, the FIT/iFOBT is superior in several ways:

 FIT/iFOBT is specific to human hemoglobin so there are fewer false positives and no diet or medicine restrictions, making FIT/iFOBT easier for patients to complete.

 Many types of FIT/iFOBT require only one or two samples.

 FIT/iFOBT is specific to lower gastrointestinal bleeding. Therefore, positive FIT/iFOBT results indicate bleeding in the colon or rectum.

 FIT/iFOBT comes in a variety of forms that involve less stool handling than guaiac tests.

FIT/iFOBT screening is covered by major insurers in Alabama, including Blue Cross/Blue Shield of Alabama (BCBSAL), Medicaid, and Medicare. Adding FIT/iFOBT can be cost effective due to the generous reimbursement rates available for FIT/iFOBT. Additionally, CRC screening can be selected to fulfill Centers for Medicare and Medicaid Services Meaningful Use Objectives to earn up to $63,750 in incentives. Several brands of CLIA waived FIT/iFOBT are available to purchase through medical supply distributors and laboratory companies. For free sample tests, call the Alabama Department of Public Health (ADPH) at 334-206-3336.

Give your patients a choice

Dr Allen Perkins, President of the Alabama Academy of Family Physicians, points out that physicians can increase the number of their patients who complete screening by offering several types of screening tests. While colonoscopy is an excellent screening test for CRC that should always be considered, he says that some people are unable to complete a screening colonoscopy. Common barriers to colonoscopy include the cost of the procedure, the time required to prepare for and complete the test, discomfort with bowel preparation and lack of transportation. He cited a recent study in the Archives of Internal Medicine that highlights the benefit of having multiple options for CRC screening. This study found that those offered a choice between colonoscopy and a stool test were more likely to complete screening than those offered only one type of test.*

Make CRC screening a priority

“We can improve screening rates in Alabama by making a concerted effort to identify patients who need screening, recommend screening to these patients and follow up to ensure that patients complete their tests” says Perkins. He points out that chart prompts and electronic health records are effective as physician reminders to recommend screening. Other tools such as emails, letters, or telephone calls can remind patients about scheduled endoscopic tests or to return take-home stool tests. “As practices are updating their data systems,” Perkins said, “please remember to update your office procedures to make CRC screening a routine part of patient care.”

More information about CRC screening and the FIT/iFOBT is available through the ADPH FITWAY Colorectal Cancer Prevention Program. The FITWAY Program is funded with a grant from the Centers for Disease Control and Prevention with a goal to screen 80% of Alabamians 50 and older by 2014. FITWAY focuses on improving CRC screening rates through increasing access to FIT/iFOBT. To learn more, visit the FITWAY website at adph.org/fitway or email erica.klevay@adph.state.al.us. The American Cancer Society also has an excellent resource for clinical quality improvement related to CRC screening at www.cancer.org/aspx/pcmanual/PCM.swf.

*Source: Inadomi JM, Vijan S, Janz NK, et al. Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies. Arch Intern Med.2012;172(7):575-582.