Monday, December 21, 2015

Staying Sober During the Holidays

By: Terry and Sherry Pouncey, with ARCpoint Labs of Birmingham at Greystone

The holidays can be one of the most difficult times during the year to stay sober. For some, it’s the excess of food and drink and merriment. Attending parties and being surrounded by people eating and drinking to their heart’s content can make staying sober difficult, as no one wants to be left out of the party. And of course, there’s the stress of planning for the holidays, cooking the food, hosting a family gathering, and being forced to spend time with those family members that you may normally try to avoid. All that stress can make it tempting to use just one little drink to relax. Unfortunately, that one little drink tends to turn into two, and then three, and even more. These tips will help you stay strong and stay sober this holiday season.

Plan Non-Alcoholic Drinks Ahead of Time

If attending a holiday meal or other holiday party where most of the other adults will be drinking alcohol, make sure to bring your own non-alcoholic alternative beverage. Rather than just drinking water, consider bringing something that you enjoy drinking, whether that’s Diet Coke, non-alcoholic apple cider, or juice. Bring some sparkling grape juice for a more festive drink that you can even slip into a wine glass to feel more included in the holiday toast. Being prepared with a tasty alternative will give you something to sip on while others are downing glass after glass of wine.

Connect with a Support Group

As the holidays approach, it may be a good idea to connect with a sober support group, if you don’t already have one. Before entering any kind of high-risk situation, like a holiday party, attending a support meeting or talking with a sponsor or mentor will help give the support and resolve you’ll need to help you stay sober.

Recruit a Sober Buddy

Invite a sober friend to attend the Thanksgiving meal or holiday party with you, or ask a close family member to help you by remaining sober with you. Having someone by your side who you can trust to remain sober with you can be an enormous help. It’s much less tempting to drink if a friend is not drinking and that friend can also keep an eye on you to help keep you from slipping up.

ARCpoint Labs provides drug and alcohol testing to promote a sober and healthy workplace. Find the nearest ARCpoint Labslocation today.

Can Esophageal Cancer Be Prevented?

By: Brian A. Brunson, M.D., Gastroenterology Associates of North-Central Alabama, P.C.

Esophageal adenocarcinoma, or cancer of the lower portion of the esophagus, is one of fastest growing cancers in our country over the last several decades, with the number of new diagnoses growing six-fold from 1975-2001. It carries a poor prognosis, with a 17% five year survival once diagnosed. A condition known as Barrett’s Esophagus (BE) is the primary risk factor for the development of esophageal adenocarcinoma. Up to 1.3% of the general population is affected by BE, although this number is higher in patients seen in a typical gastroenterology practice (up to 5-10%). Barrett’s esophagus is thought to result from prolonged acid exposure in the esophagus, leading to replacement of the normal lining (squamous epithelium) with a specialized lining called intestinal metaplasia. Gastroesophageal reflux disease (GERD), therefore, is the primary disorder that puts a person at risk for BE. It’s most common symptom is heartburn which affects up to 10% of the population on a daily basis and up to 44% of the population on a monthly basis.

While there are no definitive recommendations for screening, most gastroenterologists will perform an upper endoscopy, or EGD, in patients over age 50 who have a history of GERD. This allows direct visualization of the lining of the esophagus and biopsies if there is suspicion for Barrett’s. Multiple studies have suggested that the risk is highest in males over the age of 55 who are overweight or obese. It is not clear, though, if we should screen patients with acid reflux who don’t meet those criteria, although this is still routinely done. Once Barrett’s Esophagus is confirmed by a pathologist, the gastroenterologist is then faced with the decision on how often to repeat the endoscopy to assess for progression towards cancer.

The progression of Barrett’s esophagus to cancer occurs in a stepwise fashion. Reflux of acid, bile, or other intestinal contents into the esophagus results in injury to the esophageal lining. This then leads to inflammation and, in some cases, transformation (metaplasia) into a specialized intestinal lining. In some patients, this will continue to progress to dysplasia, which is a change in the cells of the lining that is much more likely to lead to cancer. Many factors determine which patients develop this higher risk change, including ongoing inflammation and genetics. Treatment of the acid reflux with a class of medicines called proton pump inhibitors (PPIs) does decrease the risk of progression to cancer, but does not completely eliminate it. Therefore, once BE is diagnosed, patients are placed in a standardized protocol for follow up endoscopies and biopsies. After the initial diagnosis, a repeat endoscopy with biopsies is typically performed one year later. If no dysplasia is found at that time, then a surveillance exam is performed every 3 years. Unfortunately, studies have not shown surveillance to be very good at preventing cancer formation, particularly in patients who have dysplasia which is much more likely to turn into cancer.

Surgically removing the esophagus previously was the only true preventative option in patients at high risk for cancer. This surgery carries significant risks and typically requires a prolonged recovery and long-term dietary modifications. Thankfully new techniques to actually treat and eliminate Barrett’s Esophagus have been developed over the last decade. Initial therapies using a laser or a technique called photodynamic therapy brought mixed results and a high risk of complications such as stricture formation.

Newer therapies developed and tested over the last five years include radiofrequency ablation (or RFA) and cryotherapy ablation. Ablation is a technique where tissue is heated or frozen until it is no longer alive. RFA (or the “Halo” procedure) has become the most widely utilized technique in our country and can be performed by gastroenterologists or surgeons with a special interest and training in this field. This procedure is performed during a standard upper GI endoscopy. Special balloon catheters can be used to treat or “ablate” large circumferential segments of Barrett’s tissue. Smaller focal areas can be treated with a catheter with electrodes mounted onto the tip of the endoscope. Clinical trials have shown that RFA completely eliminates the dysplastic or pre-cancerous tissue in greater than 90% of patients at average followup of 2.5 to 3 years. A followup study showed this response persisted out to 5 years in 92% of patients. Depending on the length of the Barrett’s segment, it usually takes at least 2-3 treatment sessions to completely eliminate the abnormal area.

RFA is now recommended by all the major endoscopy and gastroenterology societies for the treatment of all patients with Barrett’s and high grade dysplasia, and in patients with low grade dysplasia confirmed by 2 expert pathologists. Some patients with long segments of Barrett’s tissue without dysplasia may also be candidates, especially young patients (under age 40) or those with a family history of esophageal cancer. The risks of the procedure are very low; less than 1% cumulative risk of developing esophageal strictures and less than 1/1000 risk of perforating the esophagus during the procedure.

In summary, heartburn and gastroesophageal reflux can put you at risk for Barrett’s Esophagus and esophageal cancer. Therefore it is recommended that all patients with symptoms of reflux be evaluated by a gastroenterologist to assess the risk of Barrett’s and need for endoscopy. New low risk, non-invasive and highly effective therapies have been developed to treat and eliminate the pre-cancerous Barrett’s tissue and prevent progression to esophageal cancer.

Tuesday, December 15, 2015

A Dose of Our Own Medicine – Exercise During the Holidays

By: Ricardo E. Colberg, M.D., Andrews Sports Medicine and Orthopaedic Center

As healthcare professionals, all of us know the importance of a healthy diet, staying physically active and getting a restful night’s sleep. On a daily basis, we treat many patients with chronic medical conditions that are a direct result of a sedentary lifestyle.

Even though we continually remind our patients about the need to make better lifestyle choices, we too are human and struggle with the same temptations. With the holidays, cooler months, and shorter days, the need to practice what we preach increases exponentially; otherwise, we become patients too. The American Heart Association recommends that we perform 30 minutes of exercise, five times a week, all year long. If you are having a hard time getting motivated to exercise during the winter months, here are your MUST READ reasons and recommendations.

“Why Should I Work Out?”

1. It is Easier to Keep Weight Off Than to Try Losing It

With the colder weather, our basal metabolic rate decreases, which means our bodies build fat easier. Staying physically active during the colder months keeps our metabolic rate elevated, allowing us to enjoy our holiday feasts without the guilt of packing on a few pounds. Considering that it takes one week to lose one pound of excess weight, it is easier to keep weight off than to gain weight during the winter and try losing it in the summer.

2. We are More Productive When We Work Out

With the colder mornings and later sunrise, we are all tempted to hit the snooze button more often. However, studies have shown that exercising in the morning increases your energy level and productivity throughout the whole day. There is also better compliance with the exercise program since it is the first activity of your day, so you are less likely to skip exercising due to running late with other commitments.

3. “Feel Good” Hormones are Produced When We Exercise

With the long, dark, and cold days of winter, we are more susceptible to seasonal affective disorder and depression. Staying physically active is a great way to produce endorphins, which are the "feel good" hormones in our bodies. This goes a long ways in keeping us energized throughout the day making those dark days of winter more enjoyable. Most importantly, it keeps us emotionally stable.

4. Exercise Stimulates the Production of Joint Fluid

Our joints tend to get stiffer during the winter due to the colder temperature causing peripheral vasoconstriction. Exercise stimulates increased blood flow to our extremities, which promotes the production of healthy joint fluid and helps preserve the joint’s full-range-of-motion. In the long run, this leads to decreasing the risk of developing osteoarthritis, specifically of the hips and knees.

5. Staying Active in the Winter Decreases Injuries in the Summer

Exercising during the winter keeps our bodies in shape, maintains our strength and flexibility, and keeps us ready for spring time. This decreases the risk of injuries when the warmer weather comes and we are more inclined to go outside and participate in sports and recreational activities.

“How Can I Stay Compliant?”

1. Schedule Workouts

Rather than leaving your workout up to chance, you can be proactive and schedule dedicated time to exercise, ideally in the morning.

2. Recruit an Accountability/Training Partner

While it may be hard to motivate yourself to get going on cold mornings, it is easier if you are not alone. Find a workout partner to stay motivated. You will be less likely to press the snooze button if there is someone else you are leaving hanging.

3. Exercise at Home and at Work

If you can't go to the gym during the holiday season, you can still get a great workout at home. There are many workout videos that you can play on your TV or tablet that do not require special equipment. In addition, make an effort to park at work farther from the building and to take the stairs more often. This forces you to exert your body more frequently during the day in order to maintain a higher basal metabolic rate.

Ricardo E. Colberg, M.D. is a sports medicine & non-surgical orthopaedic physician at the Birmingham & Pelham offices of Andrews Sports Medicine and Orthopaedic Center. Dr. Colberg has a special interest in treating acute and chronic musculoskeletal injuries, including bone, joint, ligament, muscle and tendon injuries. He performs various treatment modalities in the clinic that assist the patient in their recovery from the injury, among them diagnostic musculoskeletal sonography, ultrasound-guided injections, and platelet-rich plasma therapy. For more information, contact Andrews Sports Medicine and Orthopaedic Center at 205.939.3699 or visit

Tuesday, December 1, 2015

Access is Key in Patient Engagement

By: Tammie Lunceford, Healthcare Consultant at Warren Averett LLC.

Patient satisfaction is an ever growing aspect of medical service in the last few years. Physicians are acutely aware of competition in many forms; urgent care, Uber medicine, and telemedicine to mention a few. Even in rural areas, physicians complain that their patients will not call to schedule with them when they are sick because it is simply too easy to go the urgent care, close by. Recent radio advertisements reveal a telemedicine product designed to treat twenty common ailments without leaving home. Even if you need to see a healthcare provider face to face, Uber medicine will send someone to your home with the personal touch of the 1950’s. Busy patients simply want to receive treatment fast and spend their time on other aspects of life. Basically, patients want healthcare to be as easy as picking up their dry cleaning.

What does this mean for physicians in private practice? It means we can’t stop the way medicine is changing so we must make adjustments to keep the patient relationship strong. Unless you are a specialist known for your expertise, you may have to revise your schedule to accommodate immediate access. Consider a mid-level provider to accommodate walk-in or patients who call to be seen. Train your staff to meet the patient’s needs and to monitor no shows. How many patients who booked appointments today, also no showed today? If they could be seen more conveniently elsewhere, they went elsewhere! Another way to meet the needs of the patient is to stagger staff and providers during lunch so patients can be seen on their lunch hour. You can stagger the physician and the mid-level for early and late access. Be sure to market your changes so patients will know you are available.

I recently reviewed physician schedules to find new patients could only be seen during one appointment slot a day, one specific time of the day. We must adopt open access scheduling to meet the needs of busy professionals, working moms, etc. The only decision should be the number of patients your office can accommodate each day, then let the schedule fill. Your referring physicians will appreciate your flexibility. Your patients will recommend you to their friends.

Another Head on the Hydra Metabolic Syndrome and Low Back Pain

By: Matthew Smith M.D. with Alabama Pain Physicians

“Modernity’s double punishment is to both make us age prematurely and live longer.” - Nassim Nicholas Taleb, The Bed of Procrustes

The developed world is facing an insidious healthcare epidemic. Via a confluence of medical breakthroughs, primarily in neonatology and infectious disease, we have benefitted from a jump in life expectancy since the early 1900s. Yet, these advances have been deceptive. Our success in addressing some of the most immediately preventable causes of death have masked the fact that morbidity has been gradually increasing over the last century and a half, with a rapid increase over the last twenty years. Today, the average elderly male spends 7.7 years in increasing medical dependency before death and the average female over 10 years. Moreover, there is a steadily increasing progression of morbidity prior to these years of dependency.

The main reason why our society has been getting progressively sicker despite our medical advances is because of the widespread development of a constellation of interrelated diseases known as the metabolic syndrome. The metabolic syndrome is classically defined as a disease whose primary manifestations are a dysregulation of glucose and insulin metabolism, dyslipidemia, hypertension, and suboptimal excesses of visceral adipose tissue. It is well known that the metabolic syndrome is strongly associated with, and causative of, many instances of gout, polycystic ovary syndrome, myocardial infarction, stroke, and dementia. To borrow from Greek mythology, its disparate manifestations are like a many-headed hydra, with each head representing a different “disease” but with each head attached to the same body of pathology.

Yet this hydra has at least one more head. And while this head is less well known than the others, it is no less important. It is common knowledge that the metabolic syndrome causes gout, diabetes, and heart disease. It is less well known that the metabolic syndrome is also the cause of many cases of osteoarthritis, or the type of arthritis more traditionally thought to be only from “wear and tear.” The metabolic syndrome appears to not just cause arthritis in the weight bearing joints, where bad mechanics can play a role, but in the hands, elbows, and every other non-weight bearing joint of the appendicular skeleton. And there are now numerous studies showing that osteoarthritis of the spine (also known as spondylosis) is also often caused by the metabolic syndrome.

This new understanding of how a vast amount of arthritis and pain are caused is a game changer. We now know that the pain and debility associated with osteoarthritis has at least as much to do with physiology as it does with mechanics. Perhaps the most salient physiology linking the metabolic syndrome to arthritis involves the visceral adipose tissue (VAT). VAT is the “white” adipose tissue that is in the viscera, as opposed to the white adipose tissue under the skin. The main purpose of VAT was previously thought to be just to store extra fat. We now know that our previous understanding was not just incomplete but misleading. VAT is actually an important endocrine organ that has the capacity to produce inflammation and cause profound destructive systemic effects. VAT is one of the primary generators of such pro-inflammatory cytokines as interleuken-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha). VAT leads to a decrease in the anti-inflammatory cytokines IL-10 and adiponectin as well. It also causes an increase in phospholipase A2. Regarding the latter, note that corticosteroids, still one of the mainstays for injection therapy for numerous arthritides, works by inhibiting phospholipase A2. VAT is thus akin to the anti-corticosteroid injection. But this is not the end of the ways that the metabolic syndrome destroys joints and causes pain. The vascular diseases associated with the metabolic syndrome, including small vessel occlusion and venous stasis, predisposes individuals to subchondral bone ischemia and poor nutrient and gas exchange in the joint cartilage.

The problem of the metabolic syndrome from too much visceral adipose tissue is compounded by a general lack of muscle, or sarcopenia, that is also becoming ever more prevalent in our patient populations. Robust skeletal muscle mass is an excellent insulin sensitizer and acts as a “glucose sink”, stabilizing the metabolic abnormalities that are part and parcel with the metabolic syndrome. Skeletal muscle also acts on the periosteum on a cellular level, establishing a normalization of metabolic function and improving bone density, chondrocyte health, and other factors implicit to bone and joint health. A lack of adequate skeletal muscle is therefore not just bad mechanically, but it worsens the destructive potential of the metabolic syndrome physiologically. Thus we now know of many ways in which the metabolic syndrome wrecks havoc on bones, joints, and their surrounding tissue. Above are a few of these ways and this is by no means an exhaustive list.

The physiological causes of osteoarthritic pain from the metabolic syndrome are important as they explain why so many more people are now experiencing arthritic pain, particularly of the low back. Back pain has been with us since time immemorial. Even Otzi, the tattooed mummy unearthed in the Alps and thought to have lived about 6,500 years ago, had some spondylosis. Spondylosis is nothing new and, like wrinkles of the skin, seems to usually be a normal part of the aging process. And, like spondylosis, some degree of back pain has been with humans since the very beginning of our species. Back pain has classically been the second most common reason to visit the doctor, just after upper respiratory tract infections. Yet, while spondylosis and back pain are part of the human condition, the prevalence and severity of back pain has been increasing tremendously in recent years, in lockstep with the tremendous increases with the other manifestations of the metabolic syndrome.

In order to appreciate the magnitude of the problem, it is helpful to look at some of the numbers. Low back pain has a direct cost in the United States of 70 billion dollars annually, with an indirect cost of up to $130 billion. Nearly 150 million workdays in the United States are lost every year because of low back pain. The worldwide incidence of back pain is 5% a year, with recurrence in one year ranging from 24-80%, depending on which study is favored. And the problem continues to get worse. European studies have shown a quadrupling of low back pain workdays lost over the late twentieth century with similar trends in the United States.

And consider this in correlation with the astronomical rise in obesity over the last two decades. According to the CDC, in both 1994 and 2010, Alabama was the second most obese state in the union. Yet, if you took the percentage of Alabamians who were obese in 1994 and transferred them to 2010, Alabama would be the leanest state in the union. And things have only worsened over the last five years.

These findings are important for three reasons. The first reason is that it shows that arthritic pain is an incredibly important disease whose etiology now looks to be vastly more complicated than previously appreciated. The second reason is it shows that in many ways the Pain Physician is treating manifestations of the same pathology as Cardiologists, Endocrinologists, Nephrologists, and General Practitioners. The third reason is that it gives us guidance as to the optimal treatment of our patient’s chief complaints.

Since the primary way by which the metabolic syndrome leads to pain and osteoarthritis is physiological, this opens up opportunities to treat some of these conditions pharmacologically and interventionally. As mentioned earlier, this is already done somewhat with treatments such as corticosteroid injection therapy. Visceral adipose tissue produces phospholipase A2, which leads to the production of pro-inflammatory cytokines. Corticosteroids inhibit phospholipase A2. Likewise, the metabolic syndrome is associated with an increase in TNF-alpha. There is some preliminary evidence that TNF-alpha inhibitors may help with osteoarthritic pain. While TNF-alpha inhibitors have classically been associated with the treatment of autoimmune pathologies, it thus makes sense why these could work with the much more common osteoarthritides. Leptin, adiponectin, and other cytokines may also be targets for pharmacological intervention. Furthermore, as the metabolic syndrome is associated with a variety of hormonal and neurohormonal issues (hypogonadism, etc), we may be able to leverage our better understanding of this pathology to address these as well.

While pharmacological advances and procedural interventions are exciting, the most obvious guidance that this new knowledge gives us is the importance of addressing the root cause of the metabolic syndrome in general. The most important take away is that there is simply no substitute to a healthy lifestyle, including the diet and activity necessary to ensure that our patients are appropriately lean and well conditioned. Of course, the problem is this requires a tremendous amount of patient buy in. And it can be really difficult to get this buy in. But not all hope is lost. Smoking used to be vastly more prevalent than it is today. Yet due to a change in societal norms, including the advice of doctors, tobacco use has decreased dramatically. Hopefully, with enough time and perseverance, we can change the lifestyle factors that are the root cause of the metabolic syndrome and the increasing incidences of arthritic pain as well. In the meantime, perhaps we can also utilize our new and fuller understanding of the ultimate cause of many types of pain to design better interventions for those for whom lifestyle changes are not enough.

Further Reading:

Conaghan PG, Vanharanta H, Dieppe PA. Is progressive osteoarthritis an atheromatous vascular disease? Ann Rheum Dis, 2005, 64: 1539–1541.

Gandhi R, Woo KM, Zywiel MG, Rampersaud YR. Metabolic Syndrome Increases the Prevalence of Spine Osteoarthritis. Orthopaedic Surgery, 2014, 6: 23-27.

Goodson NJ, Smith BH, Hocking LJ, McGilchrist MM, Dominiczak AF, Morris A, Porteous DJ, Goebel A. Cardiovascular risk factors associated with the metabolic syndrome are more prevalent in people reporting chronic pain: Results from a cross-sectional general population study. Pain, 2013,

Alam I, Lewis K, Stephens JW, Baxter JN. Obesity, metabolic syndrome, and sleep apnoea: all pro-inflammatory states. Obesity Reviews, 2007, 8: 119-127.

Katz JD, Agrawal S, Velasquez M. Getting to the heart of the matter: osteoarthritis takes its place as part of the metabolic syndrome. Current Opinion in Rheumatology, 2010, 22:512-519.