The Watchman Left Atrial Appendage Occlusion Device:The alternative to blood thinners

By: Anil Rajendra, MD, FACC Cardiac Electrophysiologist Alabama Cardiovascular Group Grandview Medical Center

Background


Atrial fibrillation (afib) is the most common arrhythmia and affects over 3 million Americans. It is an irregular, unorganized heart rhythm originating in the top chambers of the heart (atria). When people are in afib, there are electrical signals originating from numerous locations in the atria, causing the atria to fibrillate or “quiver” rather than contracting normally.

While afib is not a fatal arrhythmia, it does carry an increased risk of other issues, of which the most concerning may be strokes. Because the atria “quiver” rather than contracting normally, blood may pool in certain areas of the atria and form a clot. This clot can then dislodge or break and cause a stroke. Patients with afib have a 5 times increased risk of stroke. To minimize this risk, patients have traditionally been placed on anticoagulation (blood thinners) to prevent these blood clots from forming in the heart.

The overwhelming majority of these blood clots form in the left atrial appendage. The appendage is an outpouching in the left atrium and is a vestigial structure; i.e., it does not have a real purpose in normal heart function.


What is your risk of stroke?

As mentioned, the risk of stroke in patients with afib can be at least 5 times higher than patients without afib. The risk of stroke varies depending on other medical problems and risk factors. There are a few risk scores that are used to determine a patient’s risk of stroke. The most commonly used risk score is called the CHA2DS2-VASc score. 1 to 2 points are assigned to the following risk factors: congestive heart failure, hypertension, age > 75 (2 points), diabetes mellitus, previous stroke (2 points), vascular disease, age 65-74, female sex. According to current recommendations, patients with 2 or more points should be on anticoagulation (blood thinners) to lower the risk of stroke. The higher your risk score, the higher your risk of stroke.

How do we prevent strokes in these high risk patients?


The first line and most common modality to reduce the risk of stroke is the use of anticoagulation (blood thinners). Warfarin (Coumadin) is the oldest of the blood thinners, having been used for many years. Because warfarin has been around for a long time, it is relatively inexpensive. However, it does require frequent blood monitoring as well as diet restrictions.

More recently, newer anticoagulants have become commercially available, namely dabigatran (Pradaxa), rivoraxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa). These newer drugs performed well in clinical trials comparing their efficacy against warfarin, and all gained FDA approval for stroke prevention in patients with afib.

However, many patients cannot take blood thinners due to high risk for bleeding or previous bleeding. In addition, some patients just do not want to take blood thinners long term. Until recently, there was not an option for stroke prevention in these patients. Now there is a device, called the Watchman left atrial appendage closure (LAAC) device that is an alternative to oral anticoagulation for stroke prevention.

The Watchman device


The Watchman LAAC device gained FDA approval in the spring of 2015 after being studied extensively in 2 separate clinical trials and 2 subsequent registries. As mentioned previously, the left atrial appendage is the location where the majority of clots form in the heart. This device is implanted in the opening of the left atrial appendage, with the heart muscle growing over the device and permanently sealing off the appendage. The Watchman device was studied against warfarin in 2 large studies and proved to be as good as warfarin at preventing strokes.

The Watchman is shaped like a parachute and has a nitinol frame with a mesh covering over it. Using a minimally invasive technique through access in the femoral vein in the groin area, the device is implanted in the left atrial appendage. Ultrasound and fluoroscopy (x-ray) are used to position the device in the proper location. After the procedure, patients remain in the hospital overnight and are discharged home the following day. Patients remain on blood thinners for 45 days after implant. At 45 days, they have another brief ultrasound to ensure the device is still in good location and a good seal has formed. If that ultrasound shows a good seal, then patients can discontinue blood thinners at that time.

My partners and I with Alabama Cardiovascular Group at Grandview Medical Center were the first to implant the device in the state of Alabama. We have successfully implanted the device in over 40 patients and have had outstanding results. Our patients who have undergone the procedure have been able to discontinue their blood thinners and still be protected against stroke.

Conclusion


Atrial fibrillation is a very common, complex arrhythmia that increased the risk of stroke in patients afflicted with the disorder. Traditionally, anticoagulation has been the only modality available to reduce the risk of stroke in those patients. For patients that cannot take anticoagulation, however, the Watchman LAAC device is a very viable and effective treatment option to reduce the risk of stroke without the need for long-term anticoagulation. If you have afib and cannot take blood thinners, inquire if you are a candidate for the Watchman device.

How to Recognize a Dangerous Phishing Email

By Thomas Kane, CEO Keep IT Simple

How do you know that that rogue email from American Express about an unpaid invoice is real? How about the email from BestBuy, Costco or FedEx? Or the slew of other unsolicited emails you receive daily? Individual consumers are not the only targets made by cybercriminals. Businesses and medical practices are very often targeted by hackers and cybercriminals with emails that are designed to look completely legitimate and real as a form of introducing ransomware, malware, viruses, and trojans to your computer and practice network. You are often asked to click a link, download an attachment, or provide some personal information or credit card information. This type of scam is called phishing, and is becoming a very real threat to your medical practice.

There are 5 things to look for when reviewing incoming email that can help keep your office and your data safe.

1. Real companies will use your name.

Legitimate emails from legitimate companies in which you have an actual account will always use your name. Emails that start with vague introductions such as “Dear Customer” or “To Whom it May Concern,” or similar context should immediately alert you to something suspicious.

2. Safe emails will come from a registered domain email address.

If you receive an email from a company such as American Express, it should specifically be from someone@americanexpress.com, which reflects a registered domain email address. Emails from non-registered domain email addresses, such as americanexpresscustomerservice@gmail.com, are almost always dangerous, should be highly avoided, and quickly deleted.

3. Spelling and Grammar

A real email, from a real company, for a real reason, will always be spelled correctly and use proper grammar. For example, if you receive an email from someone@support.americanexp.com that uses a subject line like “You have missed a invoice,” this is considered to be very suspicious and should be promptly deleted. Sometimes the spelling is correct, but the grammar doesn’t quite make sense. If the email seems off and you can’t put your finger on it, it is probably a phishing scam.

4. An actual company will never ask for sensitive information.

Companies that you do business with will never contact you via email to ask for billing information or personal information about you. Never send your credit card number to anyone via email or give any specific personal information about yourself. Once you click send, it’s out in cyberland and will be too late to stop a hacker. If an email you receive asks for any credit card, billing, or personal information without requiring you to sign in to an account you already have set up, stay far away.

5. Legitimate companies will never send you an unsolicited attachment.

Lots of medical practices are receiving emails that look and feel exactly like an email they would normally get, but may include an attachment. There usually isn’t an attachment from a legitimate company. Proper invoices and company information will always be available through a secure portal on a legitimate company website.


It is imperative that you and your office staff begin implementing these critical items into your daily email checks to prevent phishing attacks via email. The number one cause of dreaded ransomware, where your office data is encrypted and the only course of action is to reformat and restore from a backup, is a phishing email. The nastiest virus known to be circulating right now may be sitting in your email inbox waiting for you to mindlessly click that link. Once you click, there’s no turning back. Take the time to educate yourself and your team on how to identify these types of vulnerabilities. If you ever have a doubt or a question about an email, immediately delete it and call the company in question to inquire about the noted issue. If they have no idea what you’re talking about, congratulations, you just avoided what could have been the worst virus infection your office has ever seen.

Just 30 Minutes

By: Raymond Workman, MD, Cardiologist at Medical West UAB

Sometimes, when it comes to getting in shape, the hardest part just starting. There are so many different ways to exercise now (CrossFit, pilates, old-fashioned running, on and on…), that it can be overwhelming as we look for what is most appealing to our lifestyle - and what will give you results.

Whatever your plan - DO IT. (Consult with your doctor, of course.) Get over that hump of getting started - set a plan, make time for it, and be accountable.

And when I say plan - put it in your schedule, your calendar, your iPhone app… whatever it is use to organize your day. Thirty minutes is set aside for you to exercise, nothing else. And set aside this thirty minutes five to seven days each week. Maybe get a friend to jump in with you and help keep each other accountable.

Exercise is a catalyst for so much in our lives. Not only are you in better shape, losing excess weight, etc. - but it also makes you more productive. The chemicals released into your body when you exercise make you sharper mentally and you are more productive. You are also less stressed, and people who are less stressed are more rested and - believe it or not - not sick as often. (Stress is a big hit to the immune system.)

And of course, there are all the physical benefits of lowered blood pressure and lowered cholesterol, which roll over into so many reduced risks of more serious diseases and events.

In short, a moderate amount of exercise and a moderate diet can almost completely turn around most health issues for a person. Of course, there are the exceptions of conditions that may arise in some people, but if you play the numbers, your healthy will more than likely be better with a moderate amount of exercise.

A happier, healthier life - and all you need is thirty minutes a day.

Do it!! -

Ray Workman

Neck rejuvenation

By: Dr. Marian Northington with Shelby Dermatology


One of the most important concerns for patients interested in facial rejuvenation is the aging jawline and neck. We now have more tools to improve the aging neck ranging from injectables to surgical options. When selecting which treatment is best for your patient, it is important to identify if texture and dyschromias are an issue or if it is skin laxity, excess adipose tissue or a combination. It is also important to identify patient expectations, concerns and what their tolerance is for social downtime. The most effective way of improving skin laxity is a surgical lift. However, some patients do not want the risk or downtime associated with surgery. It is exciting that we have nonsurgical effective options for these patients.

One subtle and easy way to improve the neck with little to no downtime is with botulinum toxin. Botulinum toxins can soften platysmal bands and relax the downward pull of the platysma by injecting along the platysmal muscle. This is known as the Nefertiti lift. Additionally, soft tissue fillers are effective in adding volume and recreating a defined jawline by injecting along the mandibular angle and along the jawline and chin.

Energy devices are another tool we have to improve the appearance of the aging neck. Lasers can be used to improve the discoloration of the neck as well as texture. A variety of lasers are available to address these issues. Noninvasive tightening devices include radiofrequency devices such as thermage or microfocused ultrasound such as ultherapy. It is important to emphasize that these devices will not eliminate skin laxity or remove excess fat like surgery, but they will improve skin laxity and give a natural improvement which improves over time due to wound healing processes. These are excellent options for people who do not want the downtime or risk of surgery. I recommend noninvasive tightening procedures to be done on an annual basis for maintenance and for preventative purposes and like these as an adjunctive treatment to other procedures like liposuction. I also advise patients to start treatments with early signs of laxity to attempt to prevent laxity as much as possible. Cyrolipolysis is another device which induces apoptosis of the fat cells with cold temperatures. A new neck applicator is available to eliminate unwanted neck fat and improve laxity through the wound healing process. The treated fat cells are permanently destroyed. Kybella is another permanent removal of unwanted fat and is an injection of deoxycholic acid in the submental area. Again, the fat cells are permanently destroyed and laxity improves over the next few months. This treatment does have some downtime such as swelling for a week and possibly temporary numbness in the treated area.

Neck liposuction with the tumescent technique is my favorite procedure for neck rejuvenation. The tumecscent technique takes away the risks of general anesthesia. Patients are awake and comfortable. The adipose tissue is anesthetized with a dilute form of lidocaine. It is the most predictable procedure for fat removal and tissue tightening occurs as the area heals. Downtime with this procedure includes bruising, swelling, tenderness, and patients wear a neck strap/garmet for a week. Many patients wonder if they should lose weight before the procedure, but neck fat is not an area that responds well to weight loss and so is not necessary. first. Neck rejuvenation is important part of improving an aging appearance. It is exciting that there are so many options available for our patients.

Celebrate Doctors’ Day in Alabama

On March 30, Gov. Robert Bentley will sign a proclamation declaring March 30, 2016, Doctors’ Day in Alabama. Doctors’ Day in Alabama formally recognizes Alabama’s more than 9,500 licensed physicians serving millions of residents through private practice, in hospitals, in research, and in other health care facilities.

 

Doctors’ Day in Alabama, a project sponsored by the Medical Association of the State of Alabama and the Alabama Department of Public Health, will be held in conjunction with National Doctors’ Day to celebrate physicians of all specialties serving in our communities.

 

“The practice of medicine is a special calling,” said Mark Jackson, executive director of the Medical Association. “Physicians study and train for many years, work long and unpredictable hours, and cope with often conflicting demands of work and family life to serve the needs of their communities.”

 

Although they are healers first, Alabama’s physicians not only contribute to patient health but also the state’s economy. According to a study by the American Medical Association, each Alabama physician supports an average of 10 jobs – contributing to 83,095 jobs statewide – for an average of $1.3 million in positive economic input and a total of $11.2 billion in economic impact statewide.

 

“Physicians often lead patients and families through some of life’s most challenging moments,” Jackson said. “We wanted to have one day to thank our physicians for the work they do each day to make the health of our residents and our state better. If you see your physician on March 30, help us celebrate Doctors’ Day in Alabama by telling your doctor how much he or she means to you.”

 

For more information about Doctors’ Day in Alabama, contact Lori M. Quiller, APR, at (334) 954-2580 or lquiller@alamedical.org.

 

 

A growing concern; Obesity, metabolic syndrome and cancer risk

By: Saritha Uppala, M.D. Internal Medicine Grandview Medical Group


Common chronic diseases include Diabetes, stroke, cancer, heart disease & Osteoporosis. Cancer and cardiovascular disease is the major cause for morbidity and mortality worldwide, with cancer expected to results in 571,950 deaths per year in US. Most common leading cause of cancer continues to be related to tobacco use. Evidence shows that obese men and women are at greater risk of developing cancer and worsening of chronic conditions than non-obese.

Obesity is defined as body mass index (BMI > 30Kg/m2) or greater. In the past 30 years, its prevalence increased worldwide, more than 35% of adults and 20% of children are currently obese in United States. Majority of these obese individuals meet the criteria for metabolic dysfunction characterized by increased waist circumference, insulin resistance, hyperglycemia, hypertension and hypertriglyceridemia.

Which cancers link to obesity, diet or physical activity?

In 2007 AICR (American Institute of Cancer Research) expert report examined the evidence linking various lifestyle factors including diet, physical activity and body weight to cancer at 17 body sites using systematic literature review. There is strong evidence lifestyle linked to more than 12 cancers in men and women, including colon, rectal, pancreatic, gallbladder, renal, malignant melanoma, breast, endometrial cancer, non-Hodgkin’s lymphoma, esophageal, leukemia, multiple myeloma, thyroid cancer, liver prostrate etc. Another comprehensive report complimented to these findings is meta-analysis ( Dobbins et al )of 98 studies done 18 countries from 1985 to 2011 -revealed 8 tumor sites in men and 5 in women has strong association between obesity and cancer . Another 16 year prospective study done in 900, 000 US population done from 1982 till 1998, revealed risk of mortality from these cancers high in men and women with BMI higher than 35. In individuals with colon cancer , BMI greater than 40 has higher risk of mortality than others

 Higher the BMI, higher the risk of colon and rectal cancer in men and colon cancer in women. It was shown a risk association of 9% increase in colon cancer for every 5 Units of BMI increase as compared to individuals with normal BMI , similar impact was seen in pancreatic cancer and increased abdominal fat and waist circumference .


Are there possible mechanisms linking obesity and cancer?

Excess body weight can elevate insulin levels, high triglycerides leading increased levels of metabolic hormones like IGF -1 , leptin and adiponectin. Especially in insulin resistance , disrupted glucose metabolism leading to enhancements in chronic, low grade inflammatory state may contribute to growth signaling , vascular signal , cell enrichment for cancer susceptibility , tumor initiation and invasion and metastasis , poor prognosis. These inflammatory markers include interleukin-1beta, IL -6, TNF –alfa, MCP -1. PAI -1 , a serine protease inhibitor is also produced by visceral adipose tissue , increase levels commonly found in obese people associated with risk of atherogenesis, CVD risk and caner.

The magnitude of the association between cancer and obesity risk is noteworthy and could be avoided with reduction in obesity.


Does weight loss improve outcomes?

Weight loss itself has been shown to decrease cancer risk and when we add other life style modifications including exercise has beneficial affect -by altering metabolism thereby slowed tumor growth.

In 2001 International Agency for Cancer Research Committee reports looked at levels of evidence and physical activity and their data supports physically active life style lowers colon cancer risk and also substantial evidence in decrease in breast cancer up to 20 -40% in most active women compared to sedentary women.

Up to 12% decrease in colorectal cancer in individuals who did 30 minutes of recreational physical activity which is equivalent to brisk walking. Increase in physical activity reduces insulin resistance , chronic inflammatory state and also releases circulatory myokines which are anticancer (SPARC and calprotectin)

 Patient who achieved weight loss demonstrated significant improvement in a variety of metabolic conditions such as hypertriglyceridemia, Diabetes, HDL 40% decrease in longterm mortality from any cause.

Ran•som•ware

By: Jeremy Beck, Director of Sales and Business Development at Integrated Solutions

noun: ransomware;

1. a type of malicious malware/software designed to block access to a computer system until a sum of money is paid.


Recent Cases

The Tewksbury, Mass. police department was taken over by CryptoLocker. Their most recent back-up on an external hard drive was also corrupted, and their most recent non-corrupted back-up was 18 months old.

The Tewksbury P.D. enlisted the help of the FBI, the Department of Homeland Security, the Massachusetts State Police, and private info-security firms — all to no avail. After nearly five days of unsuccessful attempts to decrypt the locked systems, they decided to pay the attackers roughly $500 in Bitcoin.

Tewksbury Police Chief Timothy Sheehan told the Tewksbury Town Crier, “It was an eye-opening experience, I can tell you right now. It made you feel that you lost control of everything. Paying the Bitcoin ransom was the last resort.”


How much will ransomware cost me?

The demanded costs to unlock your files can vary greatly. The prices can range from $25 up to $1000 or more. It is also important to note that paying the ransom does not guarantee that you will ever get your files back.

How does ransomware infect my system?

Ransomware usually infects a system in one of two ways:

1. Your system may become infected by visiting malicious or unsecured websites.

2. Ransomware infections also come through email attachments or links from untrusted emails or emails that have been hacked.

What can I do to prevent ransomware?

1. Have and maintain a firewall. - Your first line of defense is a strong and well maintained firewall.

2. Use Anti-virus software. - While no Anti-virus protection is good enough to catch everything….the combination of firewall and AV protection is your best combination for protection.

3. Make sure your pop-up blocker is enabled and working. - Many ransomware infections come in the form of a pop-ups that end users click on, thereby unknowingly downloading a virus.

4. Only go to trusted websites. - Make sure everyone in the office is aware of this policy and state clearly what types of websites are not to be visited under company policy.

5. Only open links and attachments from trusted senders. - If there is any question about the authenticity of the sender, call them to verify that the email is legitimate.

6. Make sure your backups have “multiple restore points.” - One of the most important tips is to make sure your backups can be restored from multiple restore points. Some of the most common backup solutions can only restore to the last known backup. For example, if you leave work today at 5:00pm and at 7:00pm your system is infected with Ransomware and your backups run at 10:00pm….you now have a backup of your data, but unfortunately the backup is of corrupted data.


What should I do if I become infected?

1. Shut down your computer and disconnect it from the internet immediately.

2. Call the authorities.

3. Call your trusted IT professionals, Integrated Solutions.