Thursday, August 29, 2013

Opioid Malabsorption Syndrome

By: Ty Thomas M.D.
Most of us have seen patients who just do not make sense.  How can a 300 lb woman need 15 mg of morphine while the 100 lb man requires 200 mg?  The answer is usually multifactorial and includes pharmacogenetics, pharmacokinetics, and pharmacodynamics.  However, opioid malabsorption may also be in that mix explaining why some opiates work for some but not others. 

Most oral opiates are absorbed  in the small intestine and travel to the liver where they are metabolized.  Opiates are mostly metabolized via the cytochrome P450 enzymes and glucuronidation. Some opiates begin metabolism via CYP450 enzymes before the opioid crosses the intestinal wall.  We know genetic polymorphisms exist in the CYP450 pathways which can explain some variability in opioid response.  Next to the liver, the small intestine has the second highest concentration of CYP450 enzymes.  So it is reasonable to posit that without adequate CYP450 function, opioids may not metabolize in the small intestine and subsequently fail to absorb into the bloodstream.  The role of opiate receptors in the small intestine is not well understood.  Perhaps the receptor enzyme complex plays a significant role in signal processing and transport resulting in a malabsorption syndrome explaining why there are such variances in opioid response and tolerance.

Opioid Malabsorption Syndrome should be considered any time a patient reports failure of multiple oral opiates.  These patients may be a candidate for opioid tolerance testing. 

Monday, August 26, 2013

Affordable Care Act Will Squeeze Profits – So What Can You Do?

By Lisa Kianoff, CPA.CITP, CGMA

Lost in all the media hype about “affordable care” is the coming squeeze on profit margins for providers of health care under the playing field called Obama Care. Regardless of how final rules play out, informed medical practitioners must have in-depth information on the internal elements and costs of their practices to function effectively and profitably today.

                                                    Lots of Moving Parts
This new health care environment presents a particular challenge to a multi-faceted practice: multiple doctors and nurse practitioners, multi specialties, locations or multiple stakeholders. The challenge: track all revenues fromstandard and ancillary services, determine who generates those revenues and properly allocate them to the rightprofit centers. Lots of moving parts; particularly challenging if the growth of the medical practice is outpacing a QuickBooks-type accounting system.
That was the challenge for Northside Medical Associates, P.C., a growing practice in Pell City, a quick 30 minutes east of Birmingham. The timing seemed right for the clinic to offer an onsite pharmacy, extend in-house diagnostics, recruit additional sub-specialistsas part-time tenants and provide an opportunity for them to grow their practices in a secondary location. The problem: Northside’s physician shareholders had no comprehensive reports on the health of their practice to demonstrate to potential lenders or service providers.
What the practice did have was Mike Brennan, CPA, recruited as CFO by Dr. Rock Helms, the physician president of Northside, who recognized the necessity of better financial reporting to manage the business side of the Practice. Brennan was anexperienced business administrator, ableto orchestrate and administer the implementation of the multiple ancillary profit centers and the latest Electronic Billing systems. In a previous position Brennan had seen what decision-driving information about the practice he could get by upgrading to Microsoft Dynamics GP, an integrated business management and accounting system which could be used to design Practice-specific reports. He made the case that Northside needed a system like that capable of producing the information essential to the successful management of such a practice. We helped them implement that.
Brennan’s approach was to make each of the physicians, nurse practitioners and ancillary services a profit center. The result was12 profit centers, each generating appropriate reports. There was a P&L statement for each doctor and nurse practitioner throughout the year, reporting on all the lines of business, including X-ray, urgent care, Lab and Ultrasound; and a precise measurement of each physician shareholder’s contribution to the Bottom Line.

Parts All Moving Together

The system now produces 28 monthly management reports, compiling information available month-by-month and on a comparative annual basis. Some of their favorites:

1.    Individual Profit Center:Comprehensive Monthly Reports of Earnings in each area.

2.    Nurse Practitioner: Monthly performance of each professional by location where employed.

3.    Physician:Gross fees generated and net contribution to profit by each physician.

4.    Comparative: Month-to-month comparison of each profit center.

5.    Overhead Allocation: Total administrative overhead, by profit center.

6.    Revenue: Percentage of revenue and Net Profit generated by each Profit Center 


Dr. Helms says the Practice Partners/Shareholders find the reports easy to understand. “It allows us to decide whether to bring in another piece of diagnostics, expand the lab, or hire a more qualified and highly compensated employee for a profit center. It also allows us to know how to properly compensate people contributing to those profit centers,” he said.

Last year the reporting helped justify a further investment in Ultrasound equipment; not much for profit but great for patient care.
“Ultrasound is invaluable to have at your disposal when treating patients,” said Dr. Helms. “When a patient walks into your office with a swollen leg, for example, it sure is nice if you can tell them right away if it’s a blood clot, without having them walk to the hospital, at the risk of that clot breaking off and going into their lungs.”
Reporting also showed that X-ray could justify a 2nd machine in a more easily-accessed area, with a quicker return on investment, and helped make the case for adding 16,000 square feet to accommodate more specialists and that onsite pharmacy.
“There’s no way they could have opened the pharmacy without this system,” said the CFO. “The doctors wanted it, not so much as an additional revenue source, but as a way of effectively tracking feedback from patients about timely use of prescribed medications and making sure they were getting their refills.”
So it is again, that access to the right information is the barometer on how successfully the business side of any medical practice will be coming out of this next squeeze from the government. Northside’s new system will grow with the practice, so its owners will receive the best information on a timely basis, enabling them to make more effective business decisions.  These manager-physicians now see trends early and react if they see a business unit start to decline or identify areas where it becomes necessary to expand services.

Measure the Value of the Practice


“As profit margins tighten up, you’re required to be more efficient,” said Dr. Helms. “To be more efficient, you’ve got to have a very clear picture of where you are financially. This type of precise and accurate reporting allows us to do that and, to improve our financial position for the long run.

 One of the most essential elements of a strong accounting and reporting capability is the ability to measurethe value of a Practice. Ultimately,older shareholders will want to retire and sell their interest in the Practice to their youngerpartners. It is essential, when an older shareholder reaches that point, that they have not only built a successful business but have a strong business management system that can readily demonstrate that success. 

Lisa Kianoff, CPA.CITP, CGMA, is the founder and president of L. Kianoff & Associates, Inc. a 27-year old consulting services company that specializes in performance strengthening for businesses. A growing part of its business is helping health services companies with complex business structures strengthen their business performance using L. Kianoff developed Best Practices for multi-location, multi-specialty and/or multi owner medical companies. The company is a Microsoft Gold Certified Partner and authorized VAR for Microsoft Dynamics GP, Sage100, Sage 500, and Intacct. E-mail

For the full case study on this health care provider, go to

Friday, August 23, 2013

Diabetes Camp: A place to have fun, make life-long friends and learn.

Dennis J. Pillion, Ph.D., Professor (retired), Dept. of Pharmacology & Toxicology, UAB

Diabetes camps were first started in the 1930’s by physicians who felt that their young patients with Type 1 diabetes mellitus would benefit from the physical challenges and social interactions that are found in the camping experience.  Young persons with diabetes were often not able to experience a night away from home, since their diabetes required continuous attention, usually provided by their parents.  Diabetes camps allowed children with Type 1 diabetes an opportunity to stay away from home for days or even weeks, in a rural setting, under the supervision of physicians, nurses, dieticians and camp staff/counselors, many of whom had Type 1 diabetes themselves.  The camp experience provided a welcome vacation from daily diabetes care for parents of children with diabetes and allowed the children a unique opportunity to meet others with the same health care needs. 

Today, advances in diabetes care, particularly blood glucose monitors that allow instantaneous measurements of blood glucose concentrations, have allowed greater freedom for children with Type 1 diabetes to lead a more normal lifestyle.  Nonetheless, the experience of attending camp with dozens or even hundreds of other children with diabetes can be a tremendous benefit to children who battle daily to manage a chronic illness and who assume important responsibility for their own health care at a young age.

Alabama has a long history of providing some of the largest and most widely respected diabetes camps in the world, with Camp Seale Harris and Camp Sugar Falls providing high-quality diabetes camping programs for more than 50 years.  Camp Seale Harris is named after one of the founding fathers of the camp, Dr. Seale Harris, a Birmingham physician who treated patients with diabetes for many years.  Camp Seale Harris has provided week-long residential camping experiences in the summer since 1947. Camp Seale Harris has used the outstanding facilities at Camp ASCCA (Alabama’s Special Camp for Children and Adults) on Lake Martin in Jackson’s Gap, AL since 1992.  Before 1992, Camp Seale Harris operated diabetes camping programs at several other locations around the State of Alabama.  Now operated by a 501c3 non-profit, Southeastern Diabetes Education Services (SDES), with a main administrative office in Birmingham, Camp Seale Harris and its sister Sugar Falls Day Camps and Sugar Falls Community Programs currently serve over 1500 people annually, including 600+ children with diabetes and their siblings and family members.   SDES programs are offered throughout Alabama and Northwest Florida, serving families from throughout the Southeast.  Each year, over 375 volunteer staff members, including physicians, nurses, pharmacists, diabetes educators and activity leaders, give their time to provide unparalleled medical care and supervision.  A second SDES residential camping location has now been established in Mobile, AL.  In addition to the residential camp experiences, SDES offers day camps and community programs in multiple cities, including Birmingham, Dothan, Tuscaloosa, Montgomery, Cullman, Guntersville, Huntsville, Auburn/Opelika, Mobile, and Pensacola.  SDES programs are funded completely through donations from individuals, foundations, and local civic organizations, including the Lions Clubs of Alabama and many others.  SDES is an independent 501c3 non-profit, providing services directly to local children with diabetes.  SDES has no research or policy agenda or lobbying efforts, and receives no funds from national research and advocacy organizations.  All funds are
used for local statewide programs.  Children with Type 1 diabetes are eligible to seek financial assistance to attend SDES camp programs and no child is denied access to the program because of financial need.  SDES camps are accredited by the American Camping Association, meeting over 300 safety requirements.

A child with Type 1 diabetes who is newly diagnosed, or who has never experienced a residential camp program, can attend a day camp program or a family weekend event to be introduced to the diabetes management program that Camp Seale Harris and Camp Sugar Falls have used over the past 56 years, focused on frequent monitoring of blood glucose levels, increased physical activity, and nutritional support geared to balance blood glucose levels, under the supervision of both medical professionals and older campers skilled in diabetes care.  Control of blood glucose levels and learned independence in diabetes self-care have been the cornerstones of diabetes management at camp since its very beginnings, but the benefits of the camping experience go far beyond simply maintaining the status quo and keeping children safe. 

Education occurs at camp in thousands of “teachable moments” every day.  As one younger camper watches an older camper using a new type of equipment, such as an insulin pump or a continuous glucose monitor, he or she opens the door to new possibilities in his or her own care and management.  Positive peer pressure and positive role models become an essential part of the camping experience.  Selection of older campers to serve as counselors- in-training and counselors is an important and careful process.  These older campers sleep in the cabins with the younger campers and oversee their glucose monitoring and insulin administration, as well as serving as a liaison to the camp medical staff.  For campers, diabetes education occurs in both formal classes and in programs that raise awareness, among campers and their parents, of the causes of diabetes, current treatment options, research efforts underway to find a cure for the disease, and chat sessions or skits that address the emotional aspects of living with a chronic disease, including guilt, anger, depression, difficulty in finding good medical care, medical insurance issues and many other topics that concern young people with diabetes and their parents.  It is common that a camper will comment at the end of a week at camp that he or she learned so much at camp, just by watching and listening.  An underlying goal of the diabetes camp experience is that every camper comes out of camp with a wealth of new knowledge about how to manage their disease.  Parents of children with diabetes will comment on how much their children have learned at camp and how much more self-confidence they display in taking charge of their own diabetes management.  Many children have given themselves their first insulin injection at camp, something that their parents or caregivers had to do in the past.   These experiences can play an essential step in growing the self-confidence of a young person with diabetes and helping them when it comes time to leave the nest and live independently.  Parents often go through anxious moments when their children with diabetes first go off to camp, but the process pays huge dividends a few years later when these same children become young adults capable of managing their diabetes care on their own.

Life-long friendships are another benefit of diabetes camp participation.  The camping experience often requires that children with diabetes participate in activities that they have never done before, including ropes courses, ball games, dances, talent shows, campfire songs and skits.  These types of new activities foster team-building and friendships that can be incredibly important for children who previously may
have felt excluded from such activities because of their chronic illness.  Younger campers often appreciate the chance to share a week with cabin members their own age, as well as spending time with the older counselors-in-training and counselors.  The young campers often have never spent time shoulder-to-shoulder with someone who has faced the same challenges that they have faced and who have succeeded in dealing with the many challenges that Type 1 diabetes can present to a student in elementary school, middle school and high school.  For many children with diabetes, they are the only student in their class at school with the disease.  Here at camp, everyone has diabetes. Many campers comment that they hate their diabetes, but they love the fact that it gave them the chance to go to diabetes camp and make these special friendships.

A third benefit of the diabetes camp programs is the opportunity they present for students and health care professionals in the fields of medicine, nursing, nutrition, pharmacy, teaching and counseling. Health care professionals and students who serve on the medical staff are immersed in a community of young persons with diabetes. Volunteer medical staff members may see more insulin delivered, more insulin pumps used and more blood glucose monitoring take place in a week at camp than in a year at another setting.  Volunteers also have the opportunity to watch and learn from leaders in diabetes care who serve as the senior members of the camp medical staff.  Amazingly, SDES recruits several hundred volunteer medical staff every year.  The physicians, nurses, nutritionists, pharmacists, diabetes educators and social workers, who oversee the care of campers, serve at camp without compensation.  Their only reward, albeit a precious one, is the increased knowledge that they carry home with themselves on the latest advances in diabetes management.  But the intangible rewards of service at diabetes camp run deep, as many camp staff volunteers continue to return for 10, 20 or even 30 years.

Rhonda McDavid serves as the Executive Director of SDES, overseeing the operations of Camp Seale Harris and Camp Sugar Falls.  According to Mrs. McDavid, “Sending a child with diabetes to camp is the best thing you can do for their independence, confidence and long-term health managing diabetes.  As a mother of a child with Type 1 diabetes, I am confident and thrilled that we have the best diabetes camping programs in the country right here in Alabama.”

Sugar Falls Day Camp Birmingham is held at the Lakeshore Foundation in Homewood annually during the last week of July.  Day-campers participate in a variety of physical activities, including tennis, swimming, archery and shooting,   Plans are underway for Camp Seale Harris weekend family and teen leadership programs in the fall of 2013 and winter months of 2014, and week-long residential camps next June.

For more information about the SDES diabetes camping programs, or to make a donation to sponsor a child in need, call 205-402-0415; email:; or visit the website at


Thursday, August 22, 2013

Infertility Treatments and Financial Options: Sharing the Risks with Patients to Achieve Success

By: ART Fertility Program of Alabama, Drs. Honea, Houserman, Long and Allemand

Some people never seek fertility care because they are overwhelmed by the fact that they have infertility and by the vast array of therapies available. Only about 20% of couples need the advanced therapies of IVF or Egg Recipient cycles.

One of the biggest stresses on couples with infertility is the fear of needing fertility services that are not covered by insurance. Most services are covered to some extent except IVF and Egg Donation. Every patient who comes into the ART Fertility Program of Alabama meets with a financial counselor to understand what their insurance covers.

One of the more important contributions we have made at the ART Fertility Program of Alabama is developing our Shared Risk Refund Program for IVF and Egg Donation. This Plan is ultimately the most successful way for qualified couples who need IVF or egg donation to have a baby.  It has been well studied that most couples with infertility need two or three cycles to have a baby. Couples often stop pursuing fertility care because they are so devastated if they do not become pregnant the first cycle; or if they become pregnant and miscarry; they are overwhelmed and give up. Couples need a plan that is bigger than one cycle.  They need a plan to achieve a live birth. At least 75-80% of couples have a baby (or two) with the Plan or receive a significant refund.

The Shared Risk Refund Plan is offered for both IVF and egg recipient patients.  The Plan guarantees that if a qualified couple does not achieve a live birth, the refundable portion of the plan fee will be returned so that other alternatives can be pursued. If attempting a single cycle, couples feel that everything depends on the outcome of that one cycle. With the Shared Risk Refund Plan, the pressure is off. Couples know they can do multiple IVF or egg recipient cycles and use their frozen embryos until they achieve the outcome that they desire or have a good alternative.

It is important to point out that while the Shared Risk Refund Plan is available for egg recipients as well as IVF, they are structured differently. There is an additional fee for egg donor expenses if a second cycle is needed.  For egg recipient patients using the Plan, the process provides a similar peace of mind because they are not thinking of it as only one procedure.  They are thinking of it as a process.  And that is how you have to think about fertility.  It often takes multiple tries as shown in the Shared Risk Refund Plan.

What are Patients’ Options?

With the Shared Risk Refund Plan, couples receive the first cycle and any frozen embryo cycles if needed.  If they do not become pregnant or miscarry, they receive the second cycle and any frozen embryo cycles. This fee includes ICSI, embryo freezing and thawing and laser hatching of embryos if indicated.  If the course of care changes as a result of the findings from the first cycle, alternatives may be available to complete the Plan; for example, using donor eggs or sperm if there is a problem
identified. If they do not have a baby, they get back at least 60% of the refundable portion of the cycle. They can then use the refund to pursue another appropriate infertility direction or other options they desire. (Embryo or egg donation for failed IVF, adoption, gestational carrier). 

There is also a three-cycle Shared Risk Refund Plan for certain patient situations, which gives them three opportunities.  Certain criteria must be met to be eligible for these Plans. Those eligible must have a good number of eggs, be in a fertile age range (less than 35 unless using donor eggs), and usually must complete the Plan before they turn 35 for two cycle and 36 for three cycle.  Some are required to do the three-cycle Plan due to other specific fertility factors as their chance of pregnancy is slightly lower each cycle.

If insurance covers IVF or egg recipient services, they cannot use the Shared Risk Refund Plan. The counselor will discuss whether financial help is needed if services are not covered.  For those who do not have insurance coverage, our financial counselor will meet with them to guide them to resources that may help them with financing.  We offer counseling for all of our patients on financial issues and the different options to consider before starting any process.

We’re Here to Offer Patients a Path

Many patients don’t know about the Shared Risk Refund Plan before they walk in the door. They don’t see a clear path.  It is our job to show them their options, review expected outcomes for their unique issues and help them weigh the risks and benefits so they can choose the best path for them. And when most couples succeed in having their baby -- that is a better path!



Tuesday, August 20, 2013


By: Gregory P. Bourgeois MD
Summertime always brings about thoughts of vacations at the beach or laying out by the pool and basking in the glowing heat of the sun by the water.  We all know that common cancers of the skin are caused from harmful UV rays from the sun, often accumulated over many years of exposure.  Along with skin cancer, the signs of aging (wrinkles, brown spots, loss of skin elasticity) are due mostly due to the UV energy from the sun.  Yet we seek out the sun because it’s our nature to do so.
Sunscreen is the most potent product that can prevent skin cancer and aging.  In June 2011 the FDA announced a series of requirements for sunscreens in order to ensure they are being marketed to consumers with correct information for sun protection. 
-The term “broad spectrum” is now used to label a sunscreen that can effectively block both UVB and UVA. This goes further than the SPF value, which reflects the ability of the sunscreen to block the UVB spectrum only (the cause of sunburns).  A sunscreen must pass a test the FDA implements to measure UVA transmission in order to be designated “broad spectrum”.  A broad spectrum sunscreen with SPF of 15 or greater can claim to reduce the risk of skin cancer and early skin aging (used with other skin protection measures) while non-broad spectrum sunscreens with SPF values between 2 and 14 can onlyclaim to help prevent sunburn.
-No longer can sunscreens be called “sunblock” or “waterproof” or “sweatproof” because this overstates their abilities.   They also cannot claim to provide protection from the sun for greater than 2 hours without reapplication or claim to provide immediate protection after application without supporting data.“Waterproof” will be replaced by “water resistant” and also indicate whether the sunscreen is effective for 40 minutes or 80 minutes while swimming or sweating based on testing. No sunscreens are waterproof because they eventually wash off!
-The standard “drug facts” label that we are all accustomed to seeing on any OTC drugs will now be placed on sunscreen bottles.
One can find that most sunscreens sold today contain the above labeling as these changes have been implemented over the last year.  Hopefully, these changes will bring the public’s attention to the long-term risks from sun damage and how to enjoy being outside in the sun safely. 
People often ask me, “Well, which one should I use?”  I recommend the sunscreen ingredients zinc oxide or titanium dioxide because they are physical sunscreens that deflect the sun’s rays and tend to be more photostable than chemical sunscreens.  These have been “microsized” to particles that are nanometers in size, so their application is very smooth without an opaque, white appearance; gone are the days of the lifeguard with white paste on their nose. Chemical sunscreens such as avobenzone, cinnamates, and ecamsule among others absorb the sun’s UV rays and convert that energy into heat that is quickly dissipated.
I hated putting sunscreen on as a kid – so greasy, sticky on your clothes and fingers, stings in your eyes and on your face, and didn’t seem to last long.  Industry has come a long way to address these concerns and has developed more elegant and robust vehicles so that those with sensitive skin won’t feel the stinging and that greasy feeling is gone.  At Shelby Dermatology we offer a wonderful line of sunscreens
by Elta MD that are all broad spectrum and have been formulated to fit the preference of any patient.  You can find more information at

Gregory P. Bourgeois MD is with Shelby Dermatology, PC
1022 First Street N Ste 201 | Alabaster, AL 35007| ( Office: 205.621.9500 | 7 Fax: 205.621.9507 |

Monday, August 19, 2013

Tornadoes tested imaging information technology at Children’s

By: Stuart A. Royal, M.S., M.D., is Radiologist in Chief at Children’s of Alabama. He holds the Harry M. Burns Endowed Chair in Pediatric Radiology, and is past president of the Society for Pediatric Radiology.
Most of us remember April 27, 2011, the day 62 tornadoes ripped through Alabama. Those violent storms killed 248 people and injured 2,219, many of them children. We at Children’s of Alabama still have vivid memories of that terrible tragedy, and we remember what helped us deal with the flood of trauma victims that day.

There were many medical professionals and working parts of the Children’s system that allowed us to bring top medical care quickly and efficiently to scores of injured patients, and new imaging information technology was one of the keys to coping with the crisis. This technology represents a huge advance for radiology, which translates into better, faster and less expensive care for patients. But we never thought we’d have to use it to that scale.

Typically, radiologists at Children’s perform 10 to 15 CT scans in an overnight period; after the tornadoes, we did 152 CT scans, 10 times the normal flow. Despite the flood of patients, these scans were done accurately, analyzed immediately and sent quickly to the specialists who needed to see them. Our system, which is made by Siemens, functioned perfectly.

Scanning the patients was one thing, but distributing the images was something else entirely. Information technology for CT scans comes in two parts—the RIS (Radiology Information System) and the PACS (Picture Archiving and Communications System).  RIS essentially handles the textual content of scans, and PACS distributes the images to places where they are critically needed, like the ICU, operating room or emergency department.

A single CT scan can produce 1,000 or more images for a single patient. Each image contains about 250,000 pixels. All those pixels have to be moved around in the computer network, and it’s essential that the information stays connected to individual patients. We had the potential for massive information overload since we were handling 10 times our normal load of data. The system handled it without crashing.

Our job during the tornado was further complicated by the fact that we didn’t know the names of some injured children who were rushed to us by people who found them alongside the road. We had to assign temporary identification. There were no mix-ups.

All this shows that you can blend cutting-edge technology into a critical medical situation and make it work.

Of course, an information system like ours is not static; it evolves. We started 10 years ago with our RIS-PACS system, and we have constantly updated it since then. Most recently, we have been connecting to clinics and hospitals within our referral network. This allows us to share CT scans between doctors, medical institutions and even other types of imaging systems that typically are unable to exchange
information because of different, proprietary software. Children’s has contracted with a cloud-based company called SeeMyRadiology. It is basically a website that allows institutions and doctors to upload CT scans into a system where they can be shared, even on iPhone and iPad apps.

For example pediatricians in Birmingham can view CT scans for patients who have been referred from hospitals in Huntsville where the scans were made. In the past, those scans were sometimes transferred with the patient by CD or not at all. Thus, CT scans often had to be repeated, and patients were exposed to more radiation, something of particular concern for children who are much more sensitive to radiation exposure than adults. The system gives physicians at Children’s immediate access to a patient’s CT scan history.

Our cooperation with healthcare professionals and facilities around the state has been cooperative in getting studies uploaded and downloaded properly. It’s extremely efficient and low cost. We use it many times a day because of the acuity of our patients and the large number of referrals we get. In addition, we use the system within our network of pediatricians for a peer review of CT scans, documents and diagnoses. It’s just another way that this new technology allows us to be more accurate and efficient—and most importantly, help patients.

Thursday, August 15, 2013

Is There a Voice Doctor in the House?


By: Carleen F. Ozley, MS, CCC-SLP
Voice and Swallowing Therapist and Endoscopist
If you break a bone an Orthopedic is the physician you are looking for to help you. If you have joint aches and pain, a Rheumatologist is the one you need to see.  Vision problems – ophthalmologist; headaches – neurologist; heart problems: cardiologist. But who do you see if you have a voice disorder? An Ear, Nose and Throat (ENT) physician and Voice Specialist is the medical team that can best diagnosis and provide a voice plan of care for you. Today’s advanced technology in visualization of the larynx (voice box) through a quick and simple nasal or oral endoscopy examination provides the complete picture for the Voice Team to accurately assess your problems. The endoscopy exam along with a complete voice evaluation and perceptual and acoustical analysis of your voice provides the needed information for intervention and correction of the voice problem.

What is a Voice Disorder?

Most people give very little thought to how they produce their voice and even less attention to the health of their voice on a daily basis until their voice interferes with communication in their day to day lives. Voice problems have a direct effect upon occupation and personal and work relationships. Voice disorders may be accompanied by pain or discomfort in the throat area, and may have an effect upon swallowing and/or breathing. In addition to these physical and functional limitations there are also emotional constraints that voice disordered people experience. Isolation, aggravation and overall frustration may also be experienced as one attempts to communicate with a less than efficient vocal production. As a general rule, any change in voice (hoarseness/ reduced pitch range/ change in ability to raise or lower volume) or discomfort in the throat that lasts for more than two weeks should be evaluated by a team of voice care professionals.

What Causes Voice Disorders?

There are many causes of voice problems and most often the cause is multifactorial. Listed are a few of the possible causes of voice disorders:

*upper respiratory infection

*inappropriate pitch- too high or too low

*speaking too loud

*speaking for extensive periods of time

*improper breathing techniques

*chronic throat clearing and /or coughing

*excessive dryness due to poor hydration or side effects from certain medications


*Gastroesophageal reflux disease

*Laryngoesophageal reflux disease

*psychological stress

*laryngeal cancer

*hormonal changes

*other more serious neurological problems or medical conditions

What Are Some Signs of a Voice Disorder?

*Hoarseness, roughness or rapines

*Chronic throat clearing or coughing


*Vocal arrests – voice cuts off

*Inability to control vocal volume – too loud, too soft

*Feeling of lump in throat

* Pitch changes

*Decreased vocal range- can not reach higher or lower pitches

*Increased effort to talk – voice gets tired as you use it


*Throat pain or discomfort after speaking or singing

Who has a Voice Disorder?

Anyone at any age may have a voice disorder. Occupational voice users (teachers, pastors, singers, speakers, etc.) are at a higher risk of developing voice disorders because of their extensive daily vocal use and their increased perception and awareness of vocal variations that may negatively affect their ability to perform their jobs. According to Ingo R. Titze, Ph.D., at the National Center for Voice and Speech, he reported a study which comprised 123,060,000 U. S. worker evaluated for voice disorders.  Interestingly, the occupation with the highest percentage of voice disorders (factory workers at 14.53%) comprised only 5.6% of clinic case load. Teachers with a prevalence of 4.2% for voice disorders comprised 19.6% of clinic case load for vocal treatment intervention. Additional occupations reported the following percentages of voice disorders: Salespeople: 12.97%;Clerical workers: 10.57% and Teachers: 4.2%.

What is the Prevalence of Voice Disorders?

There is some variation in study results but it is generally reported that as age increases there is an increase in voice disorders. Ages 45-70 years old report a 6.5% incidence (Leeks, 1982 and Marge, et al. 1985).  Often mild hoarseness or intermittent vocal changes or throat discomfort goes untreated for several years until a more persistent voice problem develops. Approximately 28million workers in the U.S. experience daily voice problems(Verdolini, K., & Ramig, L.O. (2001) Review: Occupational Risks for Voice Problems. Logopedics, Phonetics, Vocology, 26 (1):37-46. A second study estimates that 5% to 10% of the U.S. workforce would be classified as heavy occupational voice users. (Roy, N., Weinrich, B., Gray, S. D., et al. (2003,June).

How is your Voice?

Take this simple and quick quiz and find out!

*(Adapted from several validate questionnaires use in voice clinics: See Voice Handicap Index (VHI), Jacobson et al.; Voice-Related Quality of Life (V-RQOL), Hogikan & Sethuraman; Laryngo-pharygneal Reflux Symptom Index (RSI),Belafsky et al.

Answer YES or NO to the following questions based on symptoms within the last month (other than times when you’ve had a cold:


1. I have trouble talking loudly or being heard in noisy situations.

2. I feel a lump in my throat, like extra phlegm or something sticking there.

3. I have trouble doing my job or practicing my profession because of my voice.

4. Talking or singing takes effort/makes me tired.

5. I have to repeat myself to be understood in normal conversation.

6. My throat feels sore or achy even though I’m not sick.

7. My voice sounds higher, lower, or less flexible in pitch these days; I’m losing notes at the top.

8. I feel anxious or frustrated because of changes in my voice.

9. I have trouble being heard/understood on the telephone.

10. I have to strain, change now I use my voice, or compromise my vocal technique in order to sound the way I should.






Take care of your voice….TODAY!
Carleen F. Ozley, MS, CCC-SLP
Voice and Swallowing Therapist and Endoscopist
ExcelENT of Alabama
Birmingham, Alabama

Wednesday, August 14, 2013

Skin Care Should Begin Before the Onset of Wrinkles

By: Dr. Kelli H. Tapley

Good skin care should begin in infancy and continue throughout life. As children age, especially upon entering the hormone-riddled tween/teen years, their skin care needs change and the need to treat and prevent acne becomes as important as sun protection.

            Step one is teaching parents to avoid sun exposure in their infants. Sun-related skin changes occurring as early as the first year of life may lead to melanoma and other forms of skin cancer later in life, according to a review in July 2011 issue of Pediatrics. The “best” sunscreen depends on patient age and other factors such as level of activity. But it doesn’t work if it’s not applied and re-applied frequently. The AAP does not endorse any sunscreen in children under six months, but it can be used as a last resort when exposure cannot be avoided.

            The Environmental Working Group, an non-profit, non-partisan organization, publishes yearly reviews on the best sunscreens on its website.  Their recommendations are based on products that do not contain oxybenzone, retinyl palmitate, combination sunscreen and bug repellents and are not “spray on.”  I advise parents to look for products that provide coverage from UVA and UVB rays and contain zinc oxide, avobenzone and Mexoryl SX. Some of my favorites are: CVS Baby Sun Lotion Broad Spectrum SPF 50, Aubrey Organics Natural Sun Screen Sensitive Skin Children (available at Whole Foods), Vanicream Sunscreen Sport (available on Amazon), Blue Lizard Australian (available locally at Dermatology and Laser of Alabama), Badger Kids Sunscreen (available locally at Village Dermatology). Parents should be advised to avoid sun exposure in their infants, especially during the hottest hours of the day (between 10am-4pm), seek shade when they are outside, dress in loose protective clothing and hats, and hydrate appropriately.

            Step two begins when those same children enter tween/teen years. Our focus should expand to include daily regimens aimed at prevention and treatment of skin disease, namely acne.

            Acne treatment is a business, and business is booming. While pharmaceutical reps for prescription acne medications are abundant, I have only met one who detailed products targeted at providing solid foundations for skin health. As physicians, we are left with the same resources parents are left with: media. Forbes estimated in 2010 Guthy-Renker (the makers of ProActiv) took in $800million in revenue from ProActiv alone. With celebrities such as Justin Bieber and Katy Perry claiming ProActiv improved their acne, teens and their parents credit cards are often sold on promises of clear complexions and bleached white smiles. As I tell my children, “just because you saw it on television, doesn’t make it real.” Often those same patients come in frustrated and several dollars lighter complaining about irritation and less than satisfactory results.

            The effects of acne reach beyond just the monthly credit card statements. Affecting over 50 million Americans, the scars left behind by acne are often deeper than just physical findings. Teens with acne report higher incidence of depression, suicidal ideation, anxiety, psychosomatic symptoms, including pain and discomfort, embarrassment and social inhibition. Effective acne treatment improves self-esteem, affect, body image, social assertiveness and self-confidence.

            While the number of OTC and prescription acne medication regimens are vast what we often overlook is basic skin care essentials. Think of it as mise en place. Adequately cleansing, moisturizing and protecting the skin are important weapons in our arsenal against acne in addition to the various prescription choices. Many patients will require topical antimicrobials and/or combination products, some will need more in depth treatments such as Accutane or procedural therapies which are usually administered in a Dermatologist office. But we can start the conversation during our routine visits and we can familiarize ourselves with the various options for good skin care foundations in our patients.

Dr. Kelli H. Tapley is with Birmingham Pediatric Associates

Monday, August 12, 2013


By: William A. Thompson, III, MD, FACS
For Stage I and II breast cancer, lumpectomy provides equivalent survival to a mastectomy, provided adjuvant radiation is employed.  According to the American College of Surgeons, greater than 25% of patients in the United States who need radiation following a lumpectomy did not undergo radiation. In Alabama, this number is greater than 40%. Traditionally, high energy radiation is delivered externally 5 days a week for up to 7 weeks.
Within the past 10 years, it has become apparent that select patients can forgo extended whole breast radiation in favor of partial breast irradiation delivered twice a day through a percutaneous catheter that the patient would wear for about one and a half weeks to 2 weeks. The optimal patients are older than 45, have a tumor less than 3cm, have negative margins of excision, and ideally would be node negative. This is certainly more convenient than 6-7 weeks, but does add the discomfort of additional surgical procedures with catheter insertion, keeping the area dry for greater than a week, and having a medical device protruding from the breast for 1 to 2 weeks.
The most recent advance is a single dose of radiation delivered in the operating room while the patient is under anesthesia. The INTRBEAM system is a small portable electronic X-ray source that delivers radiation via a spherical applicator immediately after the lumpectomy following pathologic margin assessment. The duration of therapy depends on the volume of the applicator used, typically between 25 and 50 minutes. The lifestyle advantages are obvious. Daily radiation therapy for an employed patient is inconvenient at best, and for a more infirmed or rural patient may be completely untenable.
This exciting new therapy is supported by a  greater than 2000 patient  multicenter trial presented at the American Society of Clinical Oncology meeting in Chicago 3 years ago and published in the prestigious journal, The Lancet in July 2010. A follow up presentation at the December 2012 San Antonio Breast Conference showed no breast cancer 5 year  survival benefit to receiving 6 weeks of therapy compared to a single dose intraoperatively. In fact, there was a trend for improved overall survival in the INTRABEAM arm due to fewer non-breast cancer deaths.
Currently, Trinity Hospital is the only hospital in the state and one of about 40 facilities nationwide to use the INTRABEAM.  These hospitals include Georgetown, NYH-Cornell, Florida-Gainesville, and USC-Los Angeles. A clear impediment to wider state wide use has been reimbursement. Despite a willingness to pay thousands of dollars for catheter based therapy which has far weaker data, Blue Cross/Blue Shield of Alabama has refused to pay the several hundred dollars for the INTRABEAM. That deterrent however has not prevented Trinity surgeons and radiation therapists from delivering this treatment to Alabamians many who would not have had radiation therapy otherwise.
 William A. Thompson, III, MD, FACS