Monday, September 30, 2013

The ABC's of Hepatitis

By: Danika Hickman M.D. @medicalWest

While I don't know if there is any statistical evidence to prove it, but it seemed for awhile that there was an abundance of celebrities that were contracting Hepatitis. TMZ would have some story almost every month it seemed. Whether it was from these stories or if a friend/family member has contracted hepatitis, I thought it would benefit you to know a little more about what the disease is, and how it is contracted.

Hepatitis is inflammation of the liver. The liver is a vital organ that helps filter toxins from your body. Hepatitis can be caused by numerous reasons including viruses, drugs, metabolic disorders and fatty infiltration. In this post, we will focus on viral hepatitis, specifically hepatitis A, B and C. All 3 forms of hepatitis are sexually transmitted and have similar symptoms initially.

Symptoms and Condition:
Some people are asymptomatic but when symptoms are present they can include: fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, and jaundice.

Hepatitis A differs from Hepatitis B and C in that it is self limiting and does not cause chronic disease. Hepatitis A is spread by ingestion of something that has been contaminated with feces of an infected person. For instance: by not washing your hands after using the restroom or changing diapers, then preparing or eating food. 

There is a safe and effective immunization against hepatitis A and B available. The rates of new hepatitis B infections have declined 80% since 1991 when routine vaccination was initiated. Even though hepatitis B infections have dropped significantly, it is still an area of concern for African Americans.  Blacks are almost twice as likely to die from viral hepatitis. Among all ethnic groups in 2006, African Americans had the highest incidence of hepatitis B. 

Hepatitis B and C both can progress to a serious long term (chronic) illness that can lead to cirrhosis of the liver and liver cancer. Hepatitis B and C can be spread by sex with an infected partner, injection drug use, and birth from an infected mother, contact with blood or open sores of an infected person, needle sticks or sharp instrument exposures and sharing items such as razors or toothbrushes with an infected person.

Chronic hepatic C is the most common blood borne infection in the United States and the greatest prevalence of infection is in African Americans. Hepatitis C deaths in the United States have increased by over 100% in the last decade.

As noted earlier - hepatitis damages your liver, reducing its ability to filter those toxins in your body. If your body isn't filtering toxins out to be released from your body, then they are staying in your body. And that's not good. The problems extrapolate from there, as you can imagine.

Hepatitis A & B vaccinations require multiple shots, and it's important to take the shots as scheduled. The immunity (antibodies) will last for a long time, as much as thirty years or more. And if there is any concern - hepatitis vaccines have been given to millions of people all over the world - no serious side effects have been reported. They are safe.

If you are at risk of contracting hepatitis A or B, get the vaccine. The risk factors are fairly obvious - if you work with or are around people with hepatitis A or B, recreational drug use (injections or not), liver diseases, and a few others.

There is no vaccination for hepatitis C. Preventative measures are currently the only protection against it. Don't share needles or other equipment with recreational drugs (or just don't do recreational drugs), don't allow any non-sterilized instruments to pierce you (tattoos, piercings, etc.)

With proper management, people with hepatitis can live complete lives. You need to eat well, exercise - all things that help your immune system stay sharp, as that is a major part of what hepatitis can do damage to. Also, take care when taking any and all medications - follow your doctor's orders to the T.

A lot of the big issues with hepatitis is awareness - from contraction risks to management. The care is available to help you manage the disease and be healthy. Just be sure to make your regular appointments so that in case there is any contraction, you begin management immediately.

My Best,
Dr. Danika Hickman 

Thursday, September 19, 2013


By:  Carol Smith M.D. _ Birmingham Allergy and Asthma

As athletes take to the fields this school year, keep in mind the potential problems for some of our most vulnerable patients. Not only those with asthma, but also kids with a history of anaphylaxis to stinging insects or foods, and even nasal allergies and eczema need a treatment plan to ensure a safe sports season.

  Give the coach a heads up – Alert the coach to any allergic condition, as well as what to do in case of an emergency. Provide detailed instructions on where medications are kept on the field and on how to use injectable epinephrine in case of a severe allergic reaction. 

  Ensure safe snacking – Snacks are the highlight of the game for little ones – except for the child who is allergic to peanuts, milk or other common snack food allergens. Before putting together the snack-assignment schedule, poll parents on children’s allergies to find out if any foods should be avoided. Food allergies can be serious, so if you suspect you or your child suffer from them, see an allergist to get tested and develop a plan.

  Beware of unexpected opponents – Bees, wasps, hornets, yellow jackets and fire ants are some of the different critters that may hang out on or near sports fields that can pack a powerful punch if they sting or bite.  Administer injectable epinephrine and call 911 in the case of a serious reaction, including hives, difficulty breathing and swelling of the tongue. 

  Stock the first-aid kit – Make room in the team first aid kit for latex-free bandages and antihistamines to treat minor allergic reactions. If you know you or your child has a life-threatening allergy, make sure injectable epinephrine is with you at all times.

  Find the right sport – Sports that involve a lot of running – such as soccer, basketball and field hockey – can be tough for kids and adults with exercise-induced bronchoconstriction (EIB), commonly referred to as exercise induced asthma. In addition to using your prescribed daily asthma control medications, use a short-acting, quick relief inhaler at least 20 minutes before exercise and warm up for at least 5-10 minutes before taking the field. If the amount of running is too much, consider switching to a more asthma friendly sport, such as baseball, golf or swimming. An allergist can advise you on asthma treatment options and help you manage EIB, a condition that affects up to 10 percent of the population and 80 percent to 90 percent of those with asthma.

  Stop the sneezing – To help head off a mid-at-bat sneezing fit due to allergies to grass, ragweed and other pollen-producing plants, take allergy medication before the game.  Wash off the pollen by jumping in the shower after the game.

  Keep your germs to yourself – Better not share uniforms and pads if you have eczema, since bacteria can more easily infect a disrupted skin layer.


Find an allergist to discuss long-term treatment plans for the allergic athlete, and help keep the playing field level.


Monday, September 16, 2013

Peptic Ulcer Disease

By: Dr. Murat Akdamar_ Gastroenterology @MedicalWest
Pain is no fun, and you don't need a doctor to tell you that. But as a doctor, I see all different kinds of pains, in terms of severity and cause. There is the pain of a severe cut or bruise, but then there are those pains that stitches and ice can't help with - pains on the inside.

Like… ulcers.

The most common type of ulcers found in the GI tract are called peptic ulcers

Peptic ulcer disease is defined as a defect in the lining of the stomach or the upper small intestine. 

Symptoms of a peptic ulcer:
  • Abdominal pain
  • Bloating
  • Nausea/vomiting
  • Loss of appetite/weight loss
  • And, in bad cases, vomiting blood
  • There can also be bleeding in your stomach/GI tract that will present as black stool

Common causes of peptic ulcers can be medications. Such as Advil, Motrin, ibuprofen, Alleve, Naproxen, Goodies, and others. In addition, a bacteria called H pylori can be found in the stomach which can lead to ulcers.

When these symptoms and pains are present, we'll ordinarily do an upper endoscopy to be sure that a peptic ulcer is what we are dealing with.

Once diagnosed, we'll treat you with acid suppression medications (Prilosec, etc.) to hopefully relieve the area of the stress and allow the body the space (literally) to be able to heal. It's when these things go untreated that they linger that complications can occur such as perforation.

Up front - sometimes these things just happen, and I can't tell you why. An increase in stress - for whatever reason (psychological, physiological, etc.) - that raises the acid levels in your stomach and GI tract puts you at risk.

However, there are a few activities that increase your risk. I'd recommend avoiding these.
  • Smoking
  • Alcohol
  • Overuse of aspirin and/or NSAIDs

Again, pain is no fun, especially when the option simply of "rest it" or "ice it" isn't available to you. (You can't ice your insides.) When you have these symptoms present, PLEASE go see your doctor so that they can get you the appropriate testing and medication your body needs to get you back to living without ulcers.

Thursday, September 12, 2013

Surgery for Sterilization Reversal using the da Vinci Surgical System

By: Robert DeSantis, MD, FACOG – Trinity OB/GYN
Each year in the United States over 600,000 women undergo a permanent sterilization procedure.  Studies show that up to 20% of women will regret this decision within five years of their sterilization procedure.  Approximately 5-10 percent of these women will ultimately decide to have the procedure reversed to have a baby.   Currently most of the reversal procedures are done through an open incision in the belly using microsurgical techniques.  This can include from one, up to several days in the hospital and take six to eight weeks of recovery.  Pain is one of the main issues during recovery.
The procedure has also been accomplished with smaller incisions as an outpatient procedure.  Laparoscopic approaches are reported in the literature and are performed in a fashion similar to open techniques.  The American Society of Reproductive Medicine notes that “only surgeons who are very facile with laparoscopic suturing and who have extensive training in conventional tubal microsurgery should attempt this procedure.”  The procedure requires opening the occluded ends of the fallopian tubes that have been tied and anastomosing them with a fine non-reactive suture material using magnification and microsurgical techniques. 
When faced with a decision for tubal reversal, women also have other options available such as advanced reproductive technology including in vitro fertilization (IVF).  Women must evaluate their options and look at both the pros and the cons.  Women younger than 30 years of age with good tubal length have the best chance of success.  Rates have been reported around 75-80% or better in this group.  Success is also based on sperm count and other fertility factors.  Short tubal length is a con to tubal reversal and your physician should discuss this with you prior to proceeding with any fertility surgery.  IVF has been proven to be a better procedure for short tubes.  Success rates decline significantly after age 43 for various reasons and this should be discussed with your healthcare provider.   There are reports of women undergoing tubal reversal between 40-45 years of age with cumulative pregnancy rates ranging between 41-71%.  Boeckxstaens et al published a retrospective cohort study in 2007 in Human Reproduction on tubal reversal versus IVF and showed a significantly higher cumulative pregnancy rate for women younger than 37 years of age.  However, they did not see any significance in women 37 years or older.  Women undergoing IVF have a higher per cycle pregnancy rate, however, the cumulative rate allows for more opportunities to become pregnant and is more cost efficient.  In fact, studies have shown the average cost per delivery for tubal reversal to be half that of IVF pregnancies. 
As an OB/GYN and a da Vinci surgeon, I have performed over 300 cases on the da Vinci system including tubal reversal. The da Vinci technology allows me to perform sterilization reversals with all the advantages of minimally invasive procedures with far more precision than conventional laparoscopy. This translates into a shorter hospital stay, with most patients returning home the same day as surgery. It also leads to less post-operative pain and a rapid return to normal daily activities.  Most patients are discharged home within hours of surgery and return to work within days of surgery.  They are allowed to begin trying to conceive within 10-21 days after surgery.  Success rates with the da Vinci system are comparable to traditional laparotomy with rates as high as 74-80% viable live pregnancies currently reported.  Other procedures performed by using the da Vinci system include hysterectomy, oophorectomy, myomectomy, sacralcolpopexy for prolapse and excision of endometriosis. 
Rodgers AK, Goldberg JM, Hammel JP, Falcone T. Tubal Anastomosis by Robotic Compared with Outpatient Minilaparotomy. Obstet Gynecol 2007; 109:1375-1380.
Patel SPD, Steinkampf MP, Whitten SJ, Malizia BA. Robotic tubal anastomosis: surgical technique and cost effectiveness. Fertil Steril 2008; 90:1175-1179.

Monday, September 9, 2013

Urology Center Addresses PSA Screening

The physicians at Urology Centers of Alabama would like to clarify some confusion generated by the United States preventative services task force recommendations against PSA screening for prostate cancer.


The United States Preventative Services Task Force has determined that “there is a very small potential benefit and significant potential harm” from PSA screening.  The United States Preventative Service Task Force is a panel composed solely of 16 members, including doctors, nurses, deans, medical directors, chief officers, professors, and researchers and is chaired by a pediatrician.  There were no urologists, medical oncologists or radiation oncologists participating in the development of the recommendation. 


Statistics shows that since the advent widespread PSA screening in the early to mid 1990’s, the ten year survival for prostate cancer has increased from 53% to 97%; simultaneously, the death rate from prostate cancer in the U.S. has decreased by nearly 40%.  During that interval the incidence of prostate cancer has been virtually unchanged.


Therefore, our recommendations are based on scientific studies using a large number of patients, review of the Urology Centers of Alabama data pool, as well as the current “Best Practice Guidelines” from the American Urological Association.  Currently our recommendations include the following: 


Yearly PSA and DREs are recommended for the following by age groups:


Age 40-54 years of age:

1.    Any male concerned about the risk of prostate cancer.

2.    Any African-American male.

3.    Any male with a family history of prostate cancer (father, grandfather, brother, or son).


Age 55-70 years of age.   

 All male patients.


Age 70 years and older: 

1.    Any male concerned about the risk of prostate cancer.

2.    Any male patient with a life expectancy greater than 10-15 years.


(Some recent literature also suggests that checking a PSA and DRE every two years may be appropriate for those patients at low risk who have normal and stable exams).


Any of the physicians at the Urology Centers of Alabama will be happy to discuss this information further.  If you have any questions or need clarification, please feel free to contact us. 


The physicians of Urology Centers of Alabama 

Thursday, September 5, 2013

In Case of Emergency: Is Your Clinic Ready?

By: Allison Adams - Attorney

Physicians are continually reminded about the significance of patient safety.  Malpractice defense attorneys such as myself often speak on the importance of preventing medical errors, effectively communicating with nursing staff and patients, and ensuring proper charting – all with the goal of helping physicians decrease the chances of being named in a medical malpractice lawsuit.  However, safety does not stop at the hospital doors.  The basics of patient safety must be carried back to your clinic office or you risk exposing both you and your clinic to potential litigation.


            Of particular importance to patient safety in the office setting is the ability to effectively and rapidly respond to a medical emergency.  While life-threatening emergencies in the office setting are rare, they can and do arise, and the ramifications of being caught unprepared can be severe.  Some of the more common office-based situations which can lead to a lawsuit include: (1) the lack of functioning equipment and up-to-date supplies; (2) the failure to document maintenance checks on equipment; and (3) the failure to properly train staff on how to respond in an urgent situation.


            Take for instance an elderly patient who comes to your office for a routine check up.  While in the examination room, you notice the patient is having difficulty breathing.  She tells you that she left her oxygen tank at home and cannot seem to catch her breath.  Concerned, you instruct your nurse to retrieve the clinic’s oxygen tank.  The tank is brought into the room, hooked up, turned on, and….nothing.  As your patient struggles for breath, you realize the tank is empty.  Now consider how that situation will appear to a jury in the hands of a skilled plaintiff’s attorney:


Deposition Examination of Defendant Doctor by Plaintiff’s Attorney


Attorney:   Doctor, what did you do when Ms. Patient began experiencing breathing difficulties in your office?


Doctor:      I had my nurse get our oxygen tank and bring it to the examination room where Ms. Patient was located.  I then hooked up the cannula, placed it on Ms. Patient, and turned on the oxygen.


Attorney:   Those actions did not relieve Ms. Patient’s breathing difficulties, did they?


Doctor:      No, unfortunately they did not.


Attorney:   And the reason the oxygen tank did not help Ms. Patient with her breathing difficulties is because there was no oxygen in the tank, correct?

Doctor:      I don’t know if there was no oxygen at all, but yes the tank was low.
Attorney:   It was so low, in fact, that it was not providing oxygen to Ms. Patient at her time of distress, correct?
Doctor:      She was not getting oxygen from the tank, correct.
Attorney:   When was the last time you checked the oxygen levels in that tank?
Doctor:      I am not sure of the exact date.
Attorney:   When was the last time someone on your staff checked the tank’s oxygen levels?
Doctor:      I do not know.
Attorney:   Well, did you have a checklist on the tank which would indicate when it was last checked?
Doctor:      No, not that I am aware of.
Attorney:   Was there a checklist anywhere in your clinic which would show when the oxygen tank was checked last?
Doctor:      I do not believe so.
Attorney:   Now you’re aware that the oxygen in the tank gets depleted over time with use, aren’t you?
Doctor:      Yes.
Attorney:   And you’ve used that oxygen tank in the past on other patients, haven’t you?
Doctor:      Yes, we’ve used it on other patients before.
Attorney:   So you’re telling me that you knew the tank had been used before, you knew the oxygen levels went down with use, and yet you had no plan in place to periodically check the tank to ensure that it was ready to assist the next patient who might need it.  Doctor, wouldn’t you consider it good medicine to make sure your oxygen tanks actually have oxygen in them?
This deposition excerpt is something no physician or malpractice attorney wants to encounter.  With an investment of time and effort, however, this scenario can often be avoided.  Below are some suggestions that are aimed at not only reducing the likelihood of litigation but, more importantly, optimizing patient safety in the office setting. 
Develop an action plan.  Having a predetermined plan of action with personnel trained to carry out the plan in a rapid and efficient manner is essential for managing any emergent situation.  Generally, it is best to have a plan that delineates the specific responsibilities unique to each staff member.  In other words,  make sure that your staff knows who is supposed to be doing what when an emergency arises – i.e., the receptionist will be responsible for calling 911, nurse # 1 will retrieve the crash cart, nurse # 2 will meet the EMS personnel at the entrance and direct them to the patient, etc. 
Train your staff.  Staff education is paramount to implementing an effective response to an urgent clinical situation.  Train your employees, both clinical and non-clinical staff members, on where the emergency equipment is located and how to use it properly.  Update your training as your equipment changes or is upgraded.  In addition, make sure to document any training sessions your staff undergoes in case questions arise as to when and whether a certain employee was aware of the action plan or equipment procedures.  It may also be advantageous to conduct mock emergency drills to allow your staff to practice all the steps in the action plan and become comfortable with the protocol. 
Take an inventory of the medications and supplies on your crash cart.  Pay special attention to the expiration dates on medications.  If a medication is outdated, dispose of it and replace it.  Make sure that the seals are unbroken and that the equipment is clean.  Also check to see if your supplies have all the proper parts and attachments.  Does your AMBU bag have a mask?  Does your intubation box have the appropriate stylets?  The worst time to find out that your equipment is missing connectors or the right attachments is during the midst of an emergency.
Check to ensure that equipment is functioning properly.  Like the oxygen tank scenario posed above, there is nothing worse that having the right equipment, but failing to make sure it is in good working order.  Routine tests and checks should be performed on all equipment to ensure batteries are fully charged, suction devices work, and pressure gauges show an adequate volume of oxygen.
Stock an adequate variety of equipment.  The selection of emergency supplies that will be kept on-site at a clinic will vary depending on your particular type of practice and your clinic’s patient population.  For example, a clinic that sees children and adolescents in addition to adults should generally keep a wider array of equipment sizes on hand than an adult-only clinic setting. 
Document regular maintenance checks.
  The supplies and equipment you keep on hand for emergencies should be inspected regularly and all maintenance checks should be documented.  I recommend keeping a checklist of when each item was inspected, who performed the check, and any findings or actions taken.  Monitor your staff to ensure that these maintenance checks are done routinely, legibly, and correctly.  In addition, it is easy to overlook the restocking of a crash cart in the aftermath of an emergency, so make sure that someone performs a re-check of the equipment and supplies after each use.  Replace any used, opened, or soiled supplies.
The above-referenced suggestions are not a one-size-fits-all solution to office safety.  Each physician must make his or her own determination as to what types of equipment to keep on hand and which policies to implement.  These decisions should be guided by several factors including, but not limited to, the volume of patients seen at the office, the demographics and medical profile of your patients, the complexity and types of procedures performed in-office, and the proximity of your office to a hospital.  In sum, tailoring your emergency plan to your individual clinic needs, devoting the time and effort into ensuring that your clinic is properly stocked with functioning equipment, and adequately training your staff will undoubtedly pay dividends if you are ever faced with an in-office emergency.
Any inquiries can be directed to Allison J. Adams, Esq. at:
            Starnes Davis Florie LLP
            100 Brookwood Place, 7th Floor
            Birmingham, Alabama 35209
            Phone:  (205) 868-6075
            Fax:  (205) 868-6099

Tuesday, September 3, 2013

Health Reform Implications for Primary Care

by: Mark Ricketts, MD
As the Affordable Care Act implementation approaches, primary care physicians in the Birmingham area are becoming increasingly nervous. We are facing several unknowns, including income, access to the latest technologies and our ability to practice autonomously. All these concerns are well founded, because until this legislation actually begins to take shape, our medical community cannot predict how it will affect our practice.


Even with the element of uncertainty, there are several positive changes that will impact primary care physicians. Physicians and patients should be encouraged that pre-existing conditions will no longer be considered for insurance enrollment. This should motivate previously uninsured individuals to enroll, giving them an opportunity to receive treatment on longstanding conditions, and physicians will be given the opportunity to care for them.


The pool of patients will increase, likely resulting in more insured patients walking through the doors of primary care offices. Depending on the volume of patients an office currently sees, this can be viewed as positive or negative.


Another constructive implication is the coverage gap in Medicare Part D goes away. Financially strapped patients with high cost prescription drugs can continue to properly medicate and not deviate from a prescribed medication plan due to cost. The gap had previously forced some patients to under medicate, and there will be less incentive for this to continue under health care reform guidelines.


Our most challenging immediate hurdle for Affordable Healthcare is the implementation process. There are valid concerns around public awareness of the enrollment process. Details about the available plans are still scarce, and enrollment begins on October 1.


The months ahead of primary care physicians are filled with many unknowns. If we can get past the initial struggles of implementing a new process in our business, there is huge opportunity to provide better care for more people.


Dr. Mark Ricketts is a board-certified general internist with Brookwood Medical Center practicing in Vestavia Hills.