Monday, August 24, 2015

Ambrosia artemisiifolia "This Ambrosia was definitely not the food or drink of the Greek gods"

By: H. Wayne Shew, Ph.D. Birmingham-Southern College, Department of Biology in conjunction with Alabama Allergy and Asthma Centers 

A. artemisiifolia is the scientific name of common ragweed, the bane of many hayfever sufferers. Ragweed is the leading cause of allergic rhinitis in the U.S., affecting some 75% of allergy sufferers. It is a fall flowering weed that is a particular problem in the Eastern and Midwestern regions of the country where it can be found in abundance in rural areas, and in locations of soil disturbance due to construction, gardening, land clearing, etc. There are 17 species of Ambrosia, all of which trigger allergic rhinitis, but two species are of most importance in triggering allergy symptoms due to their widespread distribution throughout the eastern half of the country.

Common ragweed is not recognized by most people since it is typically small (height of about six inches to two feet, but may reach six feet) with green, unimpressive flowers. As a result, you may have the plant growing close to where you live and work and never realize it may be the trigger of your allergic rhinitis attack. Giant ragweed, A. trifida is more likely to be noticed because of its size, typically 1-4 meters (3 to 12 feet) in height, and having 3- lobed but occasionally 5- lobed leaves, which are 3-12 inches long. The flowers of giant ragweed are like those of common ragweed however, green and relatively inconspicuous. The pollen production by ragweed flowers is anything but unimpressive or modest. Some estimates are that a single plant can produce one million pollen grains in a single day, and some estimates put the number of grains produced at close to a billion over the growing season of a single plant.

You should to learn to recognize and avoid ragweed plants, but if you have this allergy it is impossible to escape contacting the pollen during ragweed season. The pollen produced by ragweed is small, light, and easily transported in the air. Ragweed pollen has been collected as far as 400 miles out-to-sea, and at altitudes of two miles. Ragweed plants typically begin flowering in the northern part of Alabama in late August and continue until sometime in October, usually till frost. Since the pollen travels great distances as part of the aerospora, you might find yourself experiencing symptoms in early to mid-August due to pollen produced in southern areas of the state or Florida. If you suffer from ragweed allergy, you should try and avoid outside activities as much as possible on warm, dry days during the late summer and early fall. Most of the pollen is shed in the morning to early afternoon, but during the peak of the season (mid- to late-September) you will potentially find that there are high levels of pollen present in the air throughout the day.

Ragweed is one of the plants that make up the flora in early successional stages following clearing of land, and in fields following cultivation, if the field is left unattended or if the edges aren’t treated with herbicides or mowed routinely. Hence, if you live near a site of disturbed soil due to land clearing, construction, or cultivation, you may find a lot of ragweed plants growing nearby. This could result in a higher ragweed pollen count in your local vicinity. If you suffer from ragweed allergy, you should avoid areas where large numbers of ragweed plants are growing which could help reduce the likelihood of an allergy attack. However, as mentioned above once ragweed begins flowering in the fall the pollen counts will increase everywhere and it will be impossible to avoid breathing in some of the pollen. Follow your physician’s advice regarding methods to reduce your allergy symptoms.

One additional note, ragweed pollen is also associated with oral allergy syndrome. This is a condition in which proteins in certain foods that resemble the proteins in the ragweed pollen grain lead to the immune system treating the food as a foreign invader, that is, the food proteins show cross-reactivity with the pollen proteins. "Ragweed, in theory, cross-reacts with bananas and melons, so people with ragweed allergies may react to honeydew, cantaloupe, and watermelons, or tomatoes," says Warren V. Filley, MD, from the Oklahoma Allergy & Asthma Clinic in Oklahoma City. You can add zucchini, sunflower seeds, dandelions, chamomile tea, and echinacea to the list of plants that can show cross-reactivity with ragweed allergens.

(Photos below, except for pollen grain, from USDA Plant Database,

Common ragweed plant in flower

Common ragweed plant prior to flowering

Common ragweed pollen grain        

Giant ragweed plant


H. Wayne Shew, Ph.D.

NAB certified counter

BSC/AAAC Collection Station—Birmingham, Alabama


Alabama Allergy and Asthma Center

Thursday, August 20, 2015

Workflow is Key for ICD 10 Readiness


By: Tammie Lunceford, CPC BSHA with Warren Averett CPAs and ADVISORS
It is now less than 40 days until the implementation of ICD 10 on Oct. 1, 2015. Most medical entities have completed training but not assessed provider documentation for improvement goals. Many providers and billing offices are completely relying on their electronic medical record to code diagnoses for them.

While conducting training sessions, I have encouraged practices to assure they are able to view ICD 10 coding in their current EMR workflow. They should walk through the ICD 10 options on at least one or two patients a day and let the billing office review the electronic superbill. If there is not consistent use of the EMR, the physicians may not be fluent in using the diagnosis coding option in the EMR. Many physicians utilize voice recognition or continue to dictate to avoid clicking through the EMR. These physicians likely rely on a paper superbill or handwritten descriptions to list diagnoses.

Allowing a “Burger King Have it Your Way” workflow for physicians can create multiple problems for ICD 10 implementation. The billing office will deal with different workflows related to charge capture for each physician, if it is a group practice. One practice removed all the ICD 9 codes to force the physician to write in diagnoses, but the physicians were not specific enough in the description to code a valid diagnosis, which then caused the staff to refer to the documentation. The physicians are not going to write multiple diagnoses needed for risk adjustment.

Practices without an EMR are dealing with more workflow issues. There are resources to code through an electronic app or crosswalk but those who elected to not implement an EMR are not likely to look for technology to assist them.

What Should You Do?

• Reach out to a consultant for assistance

• Look for options to create an electronic superbill – EMR or other source

• Assess the number of provider workflows- discuss with your physician champion

• Review provider documentation and benchmark for improvement goals

• Review clinical best practices with your EMR vendor

• Prepare or obtain a top 50 diagnosis crosswalk as a quick reference for workstations

While CMS has offered some leniency, other carriers have not. It will cost commercial carriers if the risk adjustment is not accurate. The risk adjustment relies on ICD 10 for accuracy and specificity, which is why ICD 10 was not delayed. There are tools and resources to assist in your success, don’t wait, and get prepared now.

Sports Hernias – All Hernias Are Not Created Equal

By: Benton A. Emblom, M.D. , Andrews Sports Medicine and Orthopaedic Center

When it comes to athletic injuries, the mind turns to broken bones and torn tendons. Yet one of the more common injuries I see in my practice as an orthopedic sports surgeon is sports hernias. But the name misleads many an athlete. The true name of a sports hernia should be core muscle injury or athletic pubalgia.

Probably the least understood of all injuries experienced by pro, collegiate and high school athletes, as well as active adults, the sports hernia is a whole different ballgame than the commonly known hernia with the tell-tale bulge.

What is a Hernia?

A traditional hernia stems from a weakness or hole in the muscular wall that keeps abdominal organs in place. With these hernias, a visible bulge or pooch sticks out in the lower abdominal region and makes the diagnosis fairly straightforward. Most primary care physicians are able to diagnose and treat these hernias without surgery.

What is a Sports Hernia?

Sports hernias most often occur during activities that require sudden changes of direction or explosive twisting movements, such as in football, hockey, soccer and tennis. The outcome can be a tear in the muscles in the lower abdomen, especially where the tendons attach the oblique muscles to the pubic bone. The tendons that attach the thigh muscles to the pubic bone (adductors) are also often stretched or torn. This group of muscles are responsible for stabilizing the pelvis and moving the leg towards the midline of the body.

What are the Symptoms of a Sports Hernia?

With a sports hernia, groin pain becomes more pronounced when straining in the abdominal area, especially in explosive-type activities or twisting. Doing a sit-up or flexing the trunk against resistance will be painful.

Any athlete — or extremely active adult, even in workouts — whose chronic groin pain is aggravated by sports or aggressive workouts, but relieved by rest, should strongly be considered to have a sports hernia.

Why are Sports Hernias Difficult to Diagnose?

Sports hernias mimic the symptoms of a traditional hernia, but without the visible bulge or pooch under the skin. This makes a definitive diagnosis difficult.

It is not uncommon for athletes with sports hernias to be diagnosed with a groin strain and be told to rest until the problem goes away. And it does for a while. But the pain associated with a true sports hernia will return with a vengeance once the ibuprofen wears off and activity resumes.

What is the Solution?

Some sports hernias can be treated with physical therapy or injections. However, with athletes or active adults, I recommend surgery.

The procedure repairs the torn tissue through a small open incision in the upper part of the groin. The acquired adductor contracture is released and the lower rectus muscle is reattached to the pelvis. This restores normal biomechanical movement to the pelvis. In essence, the procedure rebalances the disruption that has taken place in the pelvis to compensate for the loss of support from the injured area.

More than 90 percent of patients who go through non-surgical treatment and then surgery are able to return to sports activities. At our clinic, we’ve had football players’ return to the rigors of full play four to six weeks after surgery. Without treatment, this injury can result in chronic, disabling pain that prevents you from resuming sports activities.

Benton A. Emblom, M.D., specializes in sports medicine and arthroscopic treatment of the shoulder, elbow, hip and knee at Andrews Sports Medicine and Orthopaedic Center in Birmingham, AL. Dr. Emblom serves as team physician for the University of Alabama, Samford University and Hoover High School.

For more information, contact Andrews Sports Medicine and Orthopaedic Center at 205.939.3699 or visit

School is back in –--hope teachers stay out of trouble…

By: Carleen F. Ozley, M.S. CCC-SLP Voice Therapist and Endoscopist with Excel ENT

Teachers represent the largest number of professionals who use their voice as their primary tool of trade. (Titze, Lemke, and Montequin, 1997). Occupational voice users, such as teachers are defined by Carol and colleagues (2006) as those “who, due to the vocal demands of their work and acoustically poor environment, injure their voice or acquire compensatory habits.” As school reopens this year, many teachers will find themselves with a “less than optimal voice” to perform the many vocal tasks required during a regular school day. It is estimated that at least 50% of teacher experience voice problems (Roy, Merrill, Thibeault, Gray and Smith, 2004). As teachers begin to create individual student goals in various areas of education, it is hoped that teachers will have a game plan for themselves to achieve and maintain a problem free voice.

Some of the contributing factors that constitute a voice disorder or voice problem for teachers may include: Poor classroom acoustics that contribute to increase levels of noise, echoes, and reverberation that make listening more difficult and encourage the teachers to use a louder voice; upper respiratory infections and airborne irritants; requirement for extended and extensive speaking times; poor hydration; ambient noise with poor room insulation; increased number of students requiring increased vocal volume; lack of amplification systems within classroom; and lack of teacher awareness for vocally abusive speaking patterns.

These conditions have contributed to teachers and other occupational voice user experiencing hoarseness, voice breaks or vocal arrests, intermittent voice loss, and vocal fatigue. Other related physical complaints may include shortness of breath, throat dryness, throat discomfort and tightness and effortful speaking. If these conditions are left untreated and teachers continue to experience chronic voice problems they are susceptible to laryngeal irritation and edema and even benign vocal fold lesions including vocal fold nodules, polyps and hemorrhages (Dejonckere, 2001; Vilkman,2004).

Vocal problems interfere with job satisfaction, performance and attendance, causing 18% of teachers to report missing work on a yearly basis. (Roy, Merrill, Thibaut, Gray et al., 2004) More than one third of teachers complain that their voice does not function as it usually does or as they would like it to for more than 5 days of the school year. (DaCosta, Prada, Roberts and Cohen, in press). Studies have also indicated that voice problems can lower a teacher’s job performance and quality of life (Smith, Gray, Dove, Kirchner and Heras, 1997; Yiu & Ma, 2002)

Prevention is obviously the best course of action. As school begins, teachers will be better able to serve their students and preserve their voice if they engage in the following suggestions:

*Have adequate daily hydration: body weight divided by 2.2 equal number of ounces for an average speaker. Teachers may need to increase that amount since their speaking demands exceed average.

*Reduce ambient noise in classroom.

*Check body posture during voicing.

*Be sure to power the voice with inhaled breath support and STOP talking when air supply has been exhausted

*Eliminate coughing and throat clears.

*100% compliance for identified diagnoses of LPR/GERD, sinusitis, allergies and asthma.

*Get plenty of rest and manage stress with good physical exercise and healthy foods.

* Check body for signals/signs of tension and contraction – especially in the neck and shoulder region.

*Decrease overall volume.

*Give your voice periods of “vocal rest” throughout the day.

*If hoarseness last for more than 2 weeks, a thorough voice evaluation and endoscopic evaluation by an ENT should be scheduled.

As school resumes this year speak up for a teacher and encourage them to take good care of their voices. Hopefully teachers will impose their own “time out” and give their voices a much needed rest and apply good vocal hygiene measures to insure a “happy, healthy school year.” 

Tuesday, August 18, 2015

The Digital Imaging Revolution – What are you waiting for?

By: Jarrod Stiff, VP of Operations at Capital X-Ray

The digital imaging revolution. You’ve heard about it. Read about it. Thought about it. Forgotten about it. Thought about it again. Researched pricing…and forgotten about it again. Well, the verdict is in and it’s time you thought about it once more. However, this time you’ll want to remember.

You knew digital imaging was the next big thing. As we’ve seen with every industry, once things go digital there’s no turning back. At first, some providers saw digital radiography as a neat, but unnecessary, luxury. Entry-level costs were too high for private physicians to justify making the transition.

But today, computerized radiography and direct-digital radiography solutions are aggressively priced and come with more features than in the past. Let’s look at a few key points in the justification argument for going digital.

1) Eliminate film and chemistry

This argument has always been a no-brainer. The monthly bills for various film sizes and stinky processing chemicals: gone. In years past, one could argue that the film and chemistry costs were still less than a digital conversion, but have you seen consumables’ pricing lately? It’s not getting any cheaper. Meanwhile, digital prices have fallen. Significantly. Have a qualified imaging partner look at your current variable costs within your imaging department and see for yourself. Return-on-investment calculations used to strain to show a break-even. Now, most facilities recognize financial savings in the first year. And financial savings aren’t the only perk.

2) Processing time DOWN = Productivity UP

It’s only logical. If you cut your processing time in half, you now have the ability to perform twice as many exams. What if I told you that newer digital systems are faster than that? With even tabletop CR (computerized radiography) units now clocking in with processing speeds north of sixty-five 14” x 17” plates an hour, its no wonder that even single-physician practices are quickly seeing benefits.

3) Better images AND lower radiation dose to the patient

Complex algorithms, grid detection and suppression, digital editing, contrast/brightness adjustments: all of these tools are made available with digital imaging. The end result is fewer retakes and less radiation dose to the patient.

4) Reduced archival woes

How many file jackets stuffed with x-ray films are littering your practice? Have you had to resort to dedicating an entire room to film storage? Reclaim that space! The majority of today’s digital systems offer some sort of “mini PACS” (Picture Archive Communication System). This allows for quick and secure storage of patient images and allows you to easily find the images for follow-up visits and comparison studies. Cloud-based backups assist in disaster recovery scenarios furthering the argument for digital imaging. How many copies of your patients’ x-rays do you currently have? What happens if there is a fire? Yep. That’s what I thought.

These are just the tip of the iceberg when it comes to the benefits associated with digital imaging. Reduced chemical waste, less environmental damage, faster overreads, space saving - the list goes on and on.

Capital X-Ray is happy to provide more information upon request.

Jarrod Stiff is Vice President of Operations for Capital X-Ray. Captial X-Ray is a full-service radiology partner providing digital image solutions to medical professionals across the southeastern United States.

Friday, August 14, 2015

Children's Cancer

By: Dr. Avi Madan-Swain, Division of Pediatric Hematology-Oncology at Children’s of Alabama

Most people know that the Alabama Center for Childhood Cancer and Blood Disorders at Children’s of Alabama provides cutting-edge cancer treatments. But our care goes well beyond the lifesaving surgeries, chemotherapy and radiation therapy. Since 2008, our Hope and Cope Psychosocial Program has been providing support and services from diagnosis onward using a family-centered approach, where the family and health care providers are partners working together to best meet the needs of the patient.

Our interdisciplinary Family Support team, consists of skilled and compassionate specialists, including social workers, child life specialists, pediatric psychologists, pediatric neuropsychologists, chaplains, hospital-based teachers, school liaisons, art and music therapists, as well as a rhythm drumming specialist to provide emotional, psychological and spiritual support and also assist with concrete needs. Theyfocus on identifying family strengths and resiliency factors, as well as risk factors, and provides evidence-based interventions. Some families need emotional help. Some need financial help. Some need spiritual help.

To ease the stress and distress from frequent hospitalizations or lengthy outpatient visits, the Hope and Cope Psychosocial Program offers a variety of emotional health and well-being activities including: Art/Music/Drumming and Rhythm Circle, Beads of Courage, Gardening on the Terrace, group school or bedside instruction, STAR (School/Social Transition & Re-entry), Hand in Paw Animal-Assisted Therapy, Hand of Hope Volunteers, individual therapy for patients or family members to help with specific individual challenges being faced, Parent 2 Parent Mentoring, as well as a weekly inpatient Caregiver Dinner Support Group to give families a break from hospital food. Many of these activities are made possible through partnerships with local community businesses and organizations.

Many of our diversionary activities are popular and fun. For example, our rhythm drumming attracts entire families and allows them to express themselves through music. We plan on soon adding drama therapy, and hope to have all of our patients work together on a theatrical production describing their medical journey.

On the more practical side, our STAR initiative focuses upon the often complex educational needs of childhood cancer patients. School is one of the most important parts of a child/teen’s life. Focusing on school helps the child/teen look to the future and is a step toward returning to a more normal lifestyle. We believe that when a child/teen diagnosed with cancer or a blood disorder is medic ally able, they should return to classroom. It is important to keep children on track with their education, because it sends a strong message about our confidence in their continued growth and development. We offer group school daily in the hospital, along with bedside instruction when the child is medically unable to attend.

Our STAR team school liaisons work with education systems to help cancer survivors successfully transition back to school. The school liaisons work closely with the family and serve as a link to provide ongoing communication between the hospital and school. When the child/teen is ready to attend school regularly, the school liaisons work with the child/teen, parent and school personnel to develop an individualized school re-entry plan to ensure a smooth transition.

STAR school liaisons also teach parents how to navigate the educational system. They learn about their child’s learning difficulties that are associated with the cancer diagnosis and treatment, their child’s educational rights and how to successfully advocate on their behalf. Sometimes our school liaisons attend school meetings to help ensure that educational accommodations are included in the child’s educational program. The school liaisons advise parents on what is reasonable to expect from schools and connect them to resources that help ensure those expectations are met.

Childhood cancer survival rates have risen dramatically in recent decades, but not all children win their battle against cancer. The Hope and Cope Psychosocial Program has designed activities to assist children with a terminal diagnosis. For instance, our art therapist works with the patient and their family to create a “legacy” piece of art that serves as a remembrance after the child’s death. Additionally, we host an annual “Honoring Their Journey” memorial service for families who have lost their child to cancer or blood disorder in the past year. It is a time for families to reconnect with staff and share memories.

It’s important that parents become active participants in their child’s medical care; after all, no one knows their child better than they do! Parents are equal partners on their child’s care team, and their voices needs to be heard during family-centered rounds. Through sharing information openly and honestly, the medical team, patient and family work collaboratively to develop daily goals as well as discharge goals. Parents need to be engaged and empowered. They need to feel comfortable asking questions and providing input during daily inpatient rounds or outpatient visits.

Childhood cancer knows no boundaries. It can strike young children and older children. It can strike the wealthy and the impoverished, black or white. Similarly, the needs of a family are boundless, too, and vary widely. Until childhood cancer is eliminated, the Hope and Cope Psychosocial Program is here to empower young people and their families to foster a sense of healing throughout the medical journey.

Dr. Avi Madan-Swain, is an associate professor of pediatrics and director of the Hope and Cope Psychosocial Program in the Division of Pediatric Hematology-Oncology at Children’s of Alabama. She has worked extensively with children diagnosed with cancer and other blood disorders and their families in both inpatient and outpatient settings.

Tuesday, August 11, 2015

Pregnancy Dos and Don’ts

by James Brock, MD

If you just found out that you’re pregnant, you probably have a lot of questions? Should you at shellfish? What about drinking a cup of coffee, soft drink or glass of wine? Here are a few tips to help you and your baby stay healthy for the next nine months.

Do see your doctor for regular prenatal checkups. Ask about stopping any medications you are currently taking and starting any new ones. Make sure health problems, such as diabetes or high blood pressure are treated and kept under control.

Do eat plenty of fruits, vegetables, grains, calcium-rich foods and lean meats. It’s okay to have up to 12 ounces of fish per week, but avoid fish such as swordfish, mackerel or tilefish that are high in mercury and can cause serious nervous system damage for your baby. Instead, opt for canned light tuna, shrimp, salmon or catfish. Also stay away from unpasteurized milk and soft cheeses, because they may contain listeria, a bacterium linked to miscarriage, premature birth, stillbirth or fetal illness. Remember to drink plenty of water every day to prevent constipation.

Do get at least 400 mcg of folic acid every day to lower the risk of birth defects. It’s also a good idea to take folic acid before you become pregnant. Also be sure to get enough iron to prevent anemia and reduce the chances of preterm birth and a low-birth weight baby. Your doctor may prescribe prenatal vitamins during your pregnancy.

Don’t smoke, which can raise the risk of miscarriage, preterm birth and infant death; drink alcohol, which can cause irreversible birth defects; or use illegal drugs, which are dangerous for you and your baby. Avoid exposure to toxic substances and chemicals, such as cleaning solvents, certain insecticides and paint.

Don’t gain too much weight. Excess body weight can increase the chances of developing gestational diabetes, pre-eclampsia, stillbirth and preterm birth. In general, a woman who is normal weight should gain about 25 pounds during her pregnancy.

Don’t change or clean out your cat’s litter box and avoid contact with pet rodents, such as guinea pigs and hamsters.

Don’t take very hot baths or use a hot tub or sauna, which can be harmful to the fetus. Also avoid douching or using scented feminine hygiene products, which can increase the risk of infection.

In short, stay healthy and get at least seven to nine hours of sleep each night. Reduce your stress levels and make sure to see your doctor for routine checkups.

James Brock, MD, is an OB/GYN with Brookwood Women’s Care.

Monday, August 10, 2015

The Opiate Escalation Trap: Why some patients fail opiate pain management

By : Ty Thomas, MD, with Alabama Pain Physicians

When a patient is prescribed high doses of opiate medication for chronic nonmalignant pain, most providers cringe and view that patient in a negative light. The provider then might go a step further and asks, “Who in their right mind prescribed this?”

In our current medical climate with opiates considered an epidemic, the practice of prescribing opiates for nonmalignant pain is dicey. The state board has done a good job educating providers about the basics of opiate prescribing and its associated rules and regulations. First on that list is “make sure you have a damn good reason to prescribe these first.” Second on that list is “not everyone with a good reason should get opiate medications.” The third thing is “if you do it, you better make sure you monitor them.” I paraphrase a bit, but, if you have been to any of these education sessions, this is how the message is delivered. I agree wholly with that message. However, that “good reason” often goes assumed and rarely fully interrogated to warrant a solid, soon to be extinct, 5 digit ICD-9 diagnosis code.

The purpose of this article is to take those 3 rules and add a caveat for those patients on high doses. When I see these patients, I ask, “Why did they require such an escalation for this?” High dose opiates are rarely indicated for nonmalignant pain at any stage. Tolerance is often the reason most providers and patients give when asked why. This makes sense to a degree. Mr. Smith has been suffering this pain for 15 years now. A little increase here and there adds up over time. However, there are medication management techniques to avoid this.

One of the escalation traps I see providers get stuck in is when the patient correctly or incorrectly perceives euphoria for pain relief. “Doc, this pain med just isn’t working as well as it used to.” Trying to explain the distinction between euphoria and pain reduction to someone can be like trying to recite beautiful poetry with a mouthful of marbles. It just doesn’t come out right. Besides, the euphoric feeling of an opiate sure goes a long way when trying to overcome the suffering of a perceived terrible pain. Tolerance to euphoria does develop quite quickly in some. This is the trap. As a provider, this distinction of euphoria vs. absence of pain is always in the decision making process when it comes to escalation or perhaps opiate cycling.

So this is my thought process: First, it is my policy to never escalate someone over 120 mg morphine equivalents daily for nonmalignant pain. Anything more increases the risk for serious adverse events by at least 6 fold depending on the study. So how do I overcome this? I start by making sure I have a solid diagnosis warranting an opiate as one of many tools to use to manage pain. I then make sure the patient is a solid candidate to responsibly take these medications--this is a topic in itself and complex. I monitor for patient compliance as much as I can (insurance changes have made this much more difficult lately—again, another topic). Then, I explore why someone might be incompatible for a specific opiate or delivery method. I also look for other reasons why someone might fail standard opiate therapy (requiring escalation beyond 100mg morphine equivalents daily).

These include:

• Opioid malabsorption

• Genetic defects

• Neuroinflammation

• Hormonal Deficiencies

In summary, most patients do not need or require high doses of an opiate for chronic nonmalignant pain management. If they do, patient aberrance is not usually the reason. Instead, there has likely been a failure to differentiate euphoria from pain relief leading to euphoria tolerance and or a failure to recognize why a patient has failed standard opiate dosing therapy as listed above. While complicated, time consuming, emotionally draining and frustrating at times, good, responsible, comprehensive pain management is possible even in this health care environment. If in doubt, refer the patient out—I will be happy to see these patients.

Barrett’s Esophagus: Diagnosis and Treatment

By: Mark R. Janich, MD, Birmingham Gastroenterology Associates

With an estimated 20 percent of American adults affected by Gastroesophageal Reflux Disease (GERD), both Primary Care Physicians and Gastroenterologists are daily diagnosing and treating patients with this disease. While the symptoms of GERD are troublesome, an estimated 10-15 percent of these patients will develop a serious complication, Barrett’s Esophagus.

Barrett’s esophagus is a condition in which the lining of the esophagus changes and it becomes similar to the tissue that lines the intestines. While frequency and severity of GERD does not affect the likelihood of Barrett’s, it is more likely to occur in patients who developed GERD at a young age or have had a longer duration of symptoms. Dysplasia, a precancerous change in tissue, can occur in any Barrett’s tissue. Endoscopy is utilized to diagnose Barrett’s. Biopsy confirmation is required for a definitive diagnosis, but the tissue is visible during endoscopy.

Radiofrequency ablation can safely and effectively remove the abnormal cells before they become cancer. During the procedure, a gastroenterologist inserts an endoscope down the esophagus of a sedated patient. The endoscope has an electrode pad attached to the tip that delivers short automated pulses of energy to destroy the Barrett’s tissue that lines the inner surface of the esophagus. Birmingham Gastroenterology Associates utilizes the HALO system for this procedure.

The key to this technology is the fact that the Barrett’s epithelium is approximately ½ millimeter thick, and the HALO system can deliver bipolar energy that consistently ablates to a depth of greater than ½ millimeter, but less than 1 millimeter. HALO ablation removes the Barrett’s cells, but limits damage to the surrounding healthy tissue. The superficial ablation results in an extremely low complication rate. The patient has an outpatient procedure and is home the same day.

It is recommended that patients with longstanding GERD (longer than 5 years) should undergo screening for Barrett’s. If a patient has Barrett’s without dysplasia, they should have a surveillance endoscopy every 3 years to monitor for dysplasia and early cancer. Patients with Barrett’s esophagus and dysplasia will require more frequent monitoring.

Data shows that annually 2 patients in 1000 with simple Barrett’s will progress to esophageal cancer. This number increases significantly with progressive forms of dysplasia, so the use of radiofrequency ablation for any form of dysplasia is appropriate.

Birmingham Gastroenterology Associates ( was the first group in Birmingham to utilize HALO for Barrett’s Esophagus and continually pursues the newest and best evidence-based therapies available.