The Battle of the (Hernia) Bulge

By: Matt Reed, M.D. _General surgery at Medical West Hospital

Pressure in your groin area doesn't always mean that you've got to go to the bathroom. Sometimes something can be out of place, causing discomfort. If you've experienced pressure or weakness in your groin, or noticed a bulge on either side of your pubic bone - you could have an inguinal hernia.

In general, a hernia is a protuberance of an organ through a cavity wall in the body. Inguinal is the medical term for the groin area. Inguinal hernias can be felt when bending, coughing, or lifting heavy objects. And they don't feel good - usually a burning, aching sensation.

Guys - remember getting those sports physicals as a kid? This is what they were checking for.

There is no singular cause of inguinal hernias. As you may know, heavy lifting, constipation, excessive coughing, etc. can be contributing factors. Family history can also be an indicator.

Besides the discomfort, there some serious complications possible with inguinal hernias:

1) Put tension on tissues around the hernia. If not repaired, inguinal hernias can get larger, resulting in pressure being placed on tissue/organs in the area. This causes further pain and swelling in the area.

2) Stangulation can occur, where blood flow has been greatly diminished or even halted completely to the protruding area of the organ. Because of the lack of blood, this tissue may in fact die, creating a serious, life-threatening situation. Surgery would be needed immediately.

TREATMENT:

There are two most common treatments for an inguinal hernia:

1) Open Repair. A simple explanation is that an incision is made in the groin and the surgeon pushes the protruding organ back to where it should be. Then he/she sews up the tear.

With an open surgery, surgeons can opt to use a surgical mesh to reinforce the torn area. Most of the time patients do very well and recover quickly. Complications can arise, rarely, including intestinal adhesion to the mesh, but the risk of this is usually outweighed by the risk of hernia recurrence if mesh is not used in the repair.

2) Laparoscopic Treatment. Instead of a one big incision, the surgeon will make three to four incisions, each about one centimeter in length. The surgeon then inserts a tiny camera into the area through one opening while the surgical instruments are inserted through other incisions. The video camera then guides the surgeon through the operation. The surgical mesh is always used here.

There's less discomfort for the patient with laparoscopic treatment, and they are even quicker to return to their routines. However, laparoscopic treatments can lead to a slightly higher rate of recurrence of the hernia compared to open surgery. 

RECOVERY:

It can depend on how bad the hernia was, of course, but in general, the patient has to take things relatively easy for about a month. Immediately after surgery, rest is important as the patient has been under anesthesia. It is also during this time that pain killers may be required.

Stitches take a little more than a week to dissolve, so the patient shouldn't be involved in any activity that will risk the stitches opening up.

And eat right. For real, it's important. For two weeks after surgery, the patient will need to be heavy on fiber, fruits, and vegetables and avoid constipation. And for at least a month - NO HEAVY LIFTING.

About 10% of the time, the hernia will have to be repaired again. The tissue will either heal poorly or the area experienced trauma from the procedure.

Inguinal hernias are something that needs to be quickly addressed. Should you ever experience the symptoms or suspect that you have a hernia - GO SEE YOUR DOCTOR. This is one of those things that doesn't need to wait until the next checkup. Call their office and go.

Live pain-free and win the battle of the bulge.

- Matt Reed, M.D. http://www.medicalwesthospital.org/doctor.php?cn=561 

                     

The recognition and management of concussions

By: Joe Ackerson, Ph.D.

Chair Alabama Statewide Sports Concussion Taskforce (ASCT)


This second of two articles is designed to 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.

 

However most concussions occur OUTSIDE of organized sports such as football, soccer, and basketball and can affect athletes in all sports, including cheerleading, volleyball, and lacrosse. Therefore it is important that all primary care physicians, as well as specialists in Sports Medicine, Physiatry, Neurosurgery, Neurology, and Psychiatry, familiarize themselves with the proper recognition and management of concussions. Dr. Ackerson and the rest of the ASCT have provided concussion training for physicians, psychologists, schools, coaches, athletic trainers, nurses, teachers, school administrators, athletes, and parents. We have helped the Alabama High School Athletic Association, The Children’s Hospital of Alabama, the University of Alabama at Birmingham (UAB), Andrew’s Sports Medicine Clinics, and numerous school systems and athletic teams develop their guidelines and clinical procedures for the recognition and management of concussion.  

 

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 was passed and signed into law in 2011 (with a technical amendment added in 2012). This law 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.

 

As a result of this law many physicians are seeing a dramatic increase in the number of concussion cases presenting for medical evaluation and management. Concussion symptoms can be broken down into four major areas. 1) Mental- any change in their usual mental state (feeling woozy, confused, in a fog, disoriented, problems with memory or concentration, declining school performance),  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. It is critical to point out that loss of consciousness IS NOT required to make a diagnosis of concussion and in fact occurs in less than 10% of all cases. In the vast majority of cases neuroimaging (CT, MRI) will yield normal results. Use of a standardized approach for assessment of post-concussive symptoms, such as the SCAT-3, is highly recommended.

 

Once it has been determined that a concussion has occurred, the physician should also attempt to determine the severity of the injury. Any hard neurological signs should generate a referral to the appropriate medical specialist (neurologist, neurosurgeon, etc.). However for the routine concussion the most important element is to prevent an additional concussion before the individual has fully recovered from their current brain injury. During the post-concussive period the patient remains especially vulnerable to additional neurological injury and possible long-term complications. Therefore 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.

 

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. 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. However, we (the ASCT) 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 or brain rest following concussion, 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, and the treating physician, should have access to a neuropsychologist that will be critical for guiding RTT decisions. In more complex cases a neuropsychological evaluation may be necessary.

 

Neuropsychologists are trained in the diagnosis and treatment of brain disorders, including concussion. While they are licensed and operate at an independent level, they often work closely with physicians in the diagnosis and treatment of brain injury. While it is up to the physician’s individual discretion regarding whether and when to refer to a neuropsychologist, many will choose to do so if their patient seems to be taking longer than typical to clear, there are pressing academic needs and challenges that require an expert, the patient has a complicated premorbid history (such as ADHD, psychiatric illness, or learning problems), or other factors that may place them at higher risk for a complicate or prolonged recovery.

 

It is also important to distinguish between the comprehensive evaluation, management, and treatment services offered by a neuropsychologist and the brief, computerized cognitive testing (such as IMPACT) that are sometimes erroneously referred to as a neuropsychological assessment.  Some physicians utilize baseline (and follow-up) computerized cognitive testing to enhance their practice, and some have found this approach can be quite useful. However physicians are rarely trained in the intricacies of interpreting neuropsychological test results and can make significant errors if they over-rely on such measures without the benefit of a consulting neuropsychologist.

 

While brain rest and time to allow for full recovery are the primary treatments for concussion, there are other interventions that can be considered. We often encourage the adoption of a healthy lifestyle to promote brain wellness, including following an appropriate diet, light exercise (such as walking), and engaging in low key pleasurable activities (such as arts and crafts or pursing a favorite hobby). Medications such as amantadine, amitriptyline, stimulants, anti-depressants, migraine medications, etc. are sometimes employed to target specific symptoms that persist past the expected time for recovery, but are usually reserved for those cases that are sent to a specialist experienced in concussion management. Finally psychological interventions can be particularly useful for managing chronic pain, dealing with the sense of loss/depression/anxiety, addressing family dynamics, the acquisition of healthy behaviors, and promoting general recovery.

 

Peyronie’s Disease: An Uncomfortable Truth, but New Hope

 

By: Dr. Brian Christine, 

Director of Erectile Restoration, Prosthetic Urology, and Male Genital Aesthetic Surgery

 

Every clinic session in my schedule invariably includes several new patients who have been referred or who have sought me out themselves to address curvature of their penis during erection.  Most often these men suffer from a condition called Peyronie’s disease (occasionally I will see a young man who has congenital curvature of the penis, but we’ll save that for another blog).  First described in 1741 by the court physician to King Louis XV of France, this condition is believed to affect 9% of the men in the U.S., but exact demographics are difficult to confirm due to likely under reporting by men who are embarrassed about their condition.  The curvature of the penis is often so severe as to make sexual intercourse painful or impossible.  While Peyronie’s disease is not life threatening, it most certainly has a negative impact on the patient’s quality of life.

 

In Peyronie’s disease, the elastic fibers of the tunica albuginea of the penis are replaced by collagen during an initial inflammatory process. This process is in response to injury to the tunica during sexual activity; occasionally, there is a single dramatic event that starts the disease but more often the inflammation and collagen replacement are brought about by repeated micro injuries.  The tunica albuginea must stretch to accommodate the increased blood flow into the penis during an erection, and the fibrous tissue mass of Peyronie’s disease (referred to as a “penile plaque”) has much less ability to stretch. The result is an erection that is curved, most often dorsally.  Even a moderate curve can cause buckling of the penis during penetrative intercourse.  Curve of any degree is often times regarded as a disturbing disfigurement by the patient leading to emotional distress. 

 

A number of forms of non-surgical treatment have been used in Peyronie’s disease.  Oral or topical vitamin E, oral and topical steroids, and trans-dermal iontophoresis have all been tried, but there is no controlled data on efficacy that supports their use and none have FDA approval.  Surgery has been the most effective treatment to date, with high success rates; incision of the peyronie’s plaque or plication of the tunica albuginea offer good functional and aesthetic outcomes. 

 

Recently, the FDA approved the use of collagenase for the treatment of Peyronie’s disease.  Marketed under the name Xiaflex (Auxilluim Pharmaceuticals, Inc), this drug has already been used to treat Dupuytren’s contracture.  The collagenase enzyme is injected into the peyronie’s plaque during a series of treatments in the urologist’s office, and the patient is instructed how to manually stretch the penis in a process called modeling.  In a large, multi center study about 65% of Peyronie’s patients experienced significant improvement in their curvature with a low rate of adverse effects. 

 

I am really very excited that Xiaflex has been approved.  It is being released to a limited number of urologists, and I have patients who have been waiting for its arrival.  The first patients will be treated in January. For patients with Peyronie’s disease, indeed, there is new hope around the corner. 

 

 

 

Dr. Brian Christine is with Urology Centers of Alabama, Director of Erectile Restoration, Prosthetic Urology, and Male Genital Aesthetic Surgery

 

 

Princeton NAPBC Accreditation

By: Gregory L. Bearden, M.D. F.A.C.S.,  James C. Walker, MD and  Pamela D. James, CRNP, MSN, ONC, MCS

 

 

  We are pleased to announce that the National Accreditation Program for Breast Centers has awarded the Breast Care Center at Baptist Princeton Medical Center a full 3 year National Breast Center Accreditation. This achievement highlights our commitment to providing comprehensive, high quality care to the women in our community in a compassionate and patient centered environment. 

 

Breast cancer screening and the care of patients diagnosed with breast cancer continues to evolve rapidly.  As diseases of the breast become more complex and treatments more specialized dedicated centers have been developed to meet this growing need.  In 2005 the American College of Surgeons initiated the National Accreditation Program for Breast Centers in order to identify and promote breast centers committed to excellence.

 

 In order to apply for recognition a breast care center must demonstrate seamless cooperation and are required and held accountable by MQSA law (state and FDA) to implement and maintain standards among the varied medical professionals who participate in the care of women with breast cancer. At our weekly Multidisciplinary Breast Cancer Conference Radiologists, Surgeons, Pathologists, Oncologists, Nurses, Physical Therapist , Mammography and Ultrasound Technicians, Social workers and Navigators come together to discuss every patient with a new diagnosis of cancer. This ensures smooth collaboration and the creation of a comprehensive treatment plan that encompasses the time from the initial biopsy to the completion of therapy and transition through Survivorship. We are continuously delighted at the level of support and participation our conference enjoys and we are convinced that this conference directly improves patient care. 

 

In an effort to promote high quality care, the NAPBC mandates that centers of excellence adhere to nationally accepted evidence based guidelines.   The standards set by the NAPBC are ambitious and sweeping and cover every topic from imaging to rehabilitation through Survivorship.  For example, the standards dictate that a patient navigation process be in place to assist patients through this complicated process.  Our patients benefit from an attentive and caring staff who accompany them each step along the way.  Other examples include standards that relate to maintenance of certification in image guided biopsy, availability of a plastic surgeon for reconstruction, and community outreach for education and early detection.

 

Early in our application process as we sat down and read through this exhaustive list we realized that our staff and our nurses and our physicians already did most of these things simply because they as individuals were committed delivering high quality care to their patients.  At that point all we had to do was provide organizational structure, pull the disparate elements together, tweak a few areas, and fill out a really long application that included twenty seven standards.  We are extremely proud of all the staff of the Princeton Breast Care Center, and the members of the Steering Committee for working so hard and so long to make this happen and very thankful to Administration for allowing us to participate in this venture.  As of this writing there are only two accredited centers in the state of Alabama.  The people who benefit the most from our achievement are the women who use Baptist Princeton for their health care needs.  From the moment a woman steps into a mammogram suite she experiences anxiety.  From the moment a woman receives a notification she needs a biopsy she faces an uncertain future.  Because of the commitment to excellence that resulted in the NAPBC awarding our center full accreditation a woman who seeks care here will find peace in knowing that she is receiving the best care possible from the best people around.  A woman who seeks care at the Princeton Baptist Breast Care Center, (a National Accreditation Center of Excellence), will find comfort in knowing that our staff is doing everything we can to help her live a better quality of life.

 

 

Gregory L. Bearden, M.D. F.A.C.S.

Co-director of National Accredited Breast Care Center at Princeton Baptist Medical Center

 

James C. Walker, MD

Co-director of National Accredited Breast Care Center at Princeton Baptist Medical Center

 

Pamela D. James, CRNP, MSN, ONC, MCS

Manager, of National Accredited Breast Care Center at Princeton Baptist Medical Center

 

 

 

 

 

 

 

Update on Polio

By: Kelli Tapley, MD

 

A long maligned foe has returned to the forefront in pediatric news: Polio.  While I have never seen a case, nor have most practicing pediatricians in the United States, I can remember learning about the structure of the enterovirus and its crippling effects. However, as recently as 1952 there were 57,000 cases in the US.

 

Why is it returning? All of the circulating polioviruses can be traced to one of three countries: Nigeria, Pakistan, and Afghanistan, where the viruses are endemic. These viruses have spread to places like Syria. Embroiled in civil war, Syria, a country that currently spends only 3% of its GDP on health care, pre-conflict boasted 90% immunization rates. Currently it is closer to 65%. Already 17 children have been diagnosed with paralytic polio in Syria, and there have been 3 cases in Cameroon. The Middle East, specifically Egypt, Iraq, Jordan, Lebanon, and West Bank and the Gaza Strip, Syria, Turkey and Cameroon have declared a polio emergency because of the concern that the viruses will spread across their borders.

 

There are efforts underway in Syria, Jordan, and Iraq to vaccinate children and prevent transmission of polio. UNICEF has 1.35 billion doses of oral polio vaccine and hopes to have 1.7 billion doses by the end of the year.

 

 Our role is to ensure all of our patients are up to date on polio vaccines, especially those travelling to areas where it polio is circulating. The CDC is recommending a one-time polio booster for travellers going to Syria, Egypt, Iraq, Jordan, Lebanon, and Turkey, Cameroon, Central African Republic, Chad, Republic of Congo, Equatorial Guinea, and Gabon and Nigeria. For a full listing see www.cdc.gov/travel/notices/alert

 Dr. Tapley is with Birmingham Pediatric Associates

Wasted Opportunities

 

By: Bill Cockrell, at Cockrell and Associates, LLC

 

In a time where healthcare providers feel squeezed, significant opportunities for improving the patient experience, and provider revenues, are going unachieved.  To make matters worse, the opportunities will be increasing over the next few years and there appears to be a lack of urgency on the part of providers to take advantage of the opportunities.  Whether it’s wanting to blame something  / someone else (typically the Accountable Care Act or “Obamacare”) or other, outside influencers or hoping for some big change of unknown origin or just wanting to hunker down and cut away, there seems to be little effort to be proactive.  Some seem to feel that the ACA will go away and we’ll go back to the fee for service days off old or that there are no ways to make things better.

To address the ACA going away, how are you going to unwind many of the provisions (eliminating pre-existing issues, extended coverage for dependents, or the thousands of newly covered individuals since October 2013) that are now in effect?  Will elected officials really take things away from voters?  And there is significant support for not eliminating, but modifying the ACA.  For example, “The U.S. Chamber of Commerce has accepted that the Patient Protection and Affordable Care Act is here to stay and, rather than continue calling for its complete repeal, will work this year to change what it sees as flaws in the 2010 law, the business group's president and CEO said Wednesday.” Modern Healthcare, January 8, 2014.

As for other changes, here’s what Medicare, independent of the ACA, is planning.  Three month delay in cuts most likely replaced by:

—  A 10 year period of stable fee updates (at 0% per year),

—  A value based performance program that consolidates and enhances several existing incentive programs

—  Incentivizes the development of, and participation in, alternative payment models

—  Make other changes to Medicare physician payment policies.

 

And as for other payers:

—  United Healthcare

—  July 10, 2013

—  UnitedHealth Group on Wednesday announced that it expects to double its accountable care contracts over the next five years across employer-sponsored, Medicaid, and Medicare plans.  Currently, more than $20 billion in United Healthcare reimbursements to hospitals, physicians, and other providers are paid through contracts linking pay to quality and efficiency measures. Those contracts include more than 575 hospitals, 1,100 medical groups, and 75,000 physicians nationwide.

—  Humana

—  May 17, 2012

—  Humana has begun working with providers on several new, collaborative delivery system models that already have yielded successful results, the insurer told a Senate panel Wednesday.  “the insurer is working toward aligning payment and care through its different accountable care organizations (ACO) and patient-centered medical homes (PCMH).”

 

And finally, what about Blue Cross?  They may not have an ACO strategy (at least called that) but they do have an existing, and easily expandable Value Based program that offers a 20% bonus (effective this year) on cognitive care to many providers. Is that significant?  For the average primary care physician, a 5% increase in cognitive care payments from Blue Cross is around $7,500 so 20% is $30,000, annually.  So a four physician primary care practice is looking at an additional $100- 120,000 per year.  Not bad.  In 2013 about 1,000 physicians achieved the 5% level and around 100 physicians achieved the 15% level.  That’s a missed opportunity.  Achieving a Level Three Patient Centered Medical Home (PCMH) designation in 2014 is a 10% slam dunk in this program.  To put it in other terms, providing good care, making a few operational changes, having an EMR, and documenting all of it, gets you that PCMH level.  Of course, there are details involved you have to address, but, compared to other options and ideas, this is an easy objective.

Back to Medicare and other payers, that “Incentivizes the development of, and participation in, alternative payment models” section is referring to programs such as ACO’s or the PCMH concept.  That means, instead of a 0% increase in the fee schedule for 10 years, by 2017 those participating in these models might be looking at a 5% increase in cognitive payments from Medicare.  For a practice with a 50% Medicare base, that’s good money.  If a practice has a 25% BCBS patient base and the 50% Medicare patient base, do the math.  In addition, other models, such as Shared Savings Plans (an ACO is an example) and the Medicaid Regional Care Organizations (RCO’s) in Alabama, are going to have an impact in the next 2 – 3 years in Alabama.

So, for providers who are retiring in the next couple of years, you deserve a hearty congratulations.  For those who plan to be around for a while, it might be a good idea to see how much money you are leaving on the table.  A wasted opportunity for one is a golden opportunity for another.

 

The Normal Heart Rhythm

 

By Dr. Jose Osorio, Cardiac Electrophysiologist

 

The Electrical System of The Heart

The heart is a muscle that contracts to pump blood to the body. The heart has two upper chambers – the atria and two lower chambers – the ventricle.

Atria and Ventricles are separated by heart valves that are meant to allow blood to only flow forward. The ventricle is the more muscular part of your heart and responsible for over 80% of the blood flow. The atria are thinner, but also very important to help with blood flow.

The atria and ventricles contract in an organized sequence which is very efficient. That sequence is controlled by the electrical system of the heart: the sinus node, AV node and His-Purkinje system.

Sinus Node

Your heart has a specialized electrical system that essentially tells the muscle when to beat or contract. The electrical impulse begins in the Sinus node. The Sinus node is located in the right atrium, and is your own natural pacemaker – telling the heart when it is time to beat. It controls the rate and increases it as needed – for example during exercise.

When your heart is in normal rhythm, it is called sinus rhythm because the sinus node is controlling when each heart beat is going to happen.

After the Sinus node start the contraction in the right atrium, the electrical activity travels through the right and left atrium causing that part of the heart to contract, pushing blood forward, into the right and left ventricles.

The atria is not nearly as important as the ventricle in terms of heart pumping function. However, it is very important in regulating the normal heart rhythm (via the sinus node). The atria is also the origin of many heart rhythm disorders, such as atrial fibrillation or other so called supraventricular arhythmias.

AV node

After the activity starts in the sinus node it goes into the AV node. The AV node is best described as a wire that connects the upper and lower chambers, sending the electrical impulse that started in the sinus node into the ventricle, telling it to contract.

His-Purkinje System

The impulse then travels from the AV node via specialized cells that act as wires that will send the signal to contract to the right and left ventricles.

When the normal sequence is followed

1.       Impulse originates in the sinus node and quickly spreads into the right and left atria

2.       Atria will contract causing blood to flow into the ventricles

3.       The electrical impulse will goes through the AV node, which causes a small delay, allowing the ventricles to fill with more blood

4.       Electrical impulses are then conducted quickly via the His-Purkinje system into the entire right and left ventricles

5.       As the electrical impulses reach the heart muscle, the right and left ventricles will contract

6.       When the ventricles contract the mitral and tricuspid valves will close causing the blood to be ejected forward, into your lungs or you body.

Jose Osorio. MD

Cardiac Electrophysiologist

St Vincent's Hospital

Birmingham, AL