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Comprehensive Hip Care Concept Provides Specialized Treatment Nowhere is efficiency more important than in the practice of medicine. Orthopaedists at the Andrews Sports Medicine & Orthopaedic Center have embraced that philosophy through specialty care in its Hip Center ... 3

Hugh Kaul Precision Medicine Institute A Healthcare Revolution In less than two centuries, medical science has accomplished miracles— vaccines, anesthesia, antibiotics and now even heart and face transplants. It has saved millions ... 10

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In May, UAB has opened a new autonomic testing lab that will assist physicians to more definitively diagnose disorders of the autonomic system and determine an effective treatment plan. The autonomic nervous system controls involuntary functions of the human body, including heart rate, breathing, and sweating. Sweating – or more accurately, not sweating – is one of the keys to diagnosing conditions affected by the autonomic nervous system. The comprehensive testing lab, which includes a tilt table and an autonomic chamber for performing a thermoregulatory sweat test, is the only such facility in the southeast, and one of only seven in the U.S. “This is very important in the era of precision medicine,” said Mohamed Kazamel, MD, assistant professor in the Department of Neurology at UAB. “We try to make more accurate and more specific diagnoses for (CONTINUED ON PAGE 8)

Mohamed Kazamel, MD in the autonomic testing lab.

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send a blood sample for analysis to learn more about which genes and mutations are involved, what the cancer’s drivers are and In the past, tumors were often treated where those targets might be vulnerable to based on where they first presented. In the treatments that may already be available,” lung, they were treated as lung cancer. In Eddy Yang, MD, PhD, deputy director of the prostate, odds were that a prostate canUAB’s Hugh Kaul Precision Medicine Incer protocol would offer the greatest hope for stitute, and director of the UAB Molecular a cure. Tumor Board, said. The difficulty with starting treatment Eddy Yang, MD, PhD A relatively new concept, precision based on location, however, is that not all oncology is changing how cancer care is tumors follow the same road map. Now that provided. It uses the genetic signature of the tumor to determine opgenetic profiling of cancer cells can be done with a blood test, the reatimum therapy. sons some tumors don’t respond as expected are becoming clearer. “Tumors shed cells and DNA into the blood stream. We can (CONTINUED ON PAGE 10)

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ORTHOPAEDICS

Comprehensive Hip Care Concept Provides Specialized Treatment By Ann B. DeBellis

Nowhere is efficiency more important than in the practice of medicine. Orthopaedists at the Andrews Sports Medicine & Orthopaedic Center have embraced that philosophy through specialty care in its Hip Center. Physicians at The Hip Center at Andrews Sports Medicine have embraced a comprehensive hip care concept where treatment is specialized for each patient. The treatment approach recognizes the variety of disorders, the diversity of the patient population, and the full spectrum of contemporary treatment options. “There is a shift from general orthopaedic care, where one doctor takes care of all problems, to a more specialized model. Our vision was to create a concept that provides ultra-specialty care for our patients,” says Benton Emblom, MD, an orthopaedic surgeon at The Hip Center at Andrews Sports Medicine. “We use a team approach to see patients, evaluate them, and treat them appropriately in a streamlined fashion.” The Hip Center physicians’ priority is to establish an accurate diagnosis and to develop treatment plans that are customized to the diagnosis and precise needs of each patient. The physicians treat specific disorders which allows for specialized care. “Our group reached a mutual understanding that has made this concept workable,” Emblom says. “It is a onestop shop for the hip that allows us to be more efficient and to foster superior outcomes.” Team members have the expertise to diagnose and deliver the full spectrum of both non-surgical and surgical solutions for hip injuries, disorders, and disease. “Hip disorders are classified in two categories –non-arthritic/hip preservation and arthritic,” Emblom says. “We want to foster a super specialty organization with the utmost experience in specific hip problems. We don’t want to be ‘just a hip guy.’ “Arthroscopy has been a great tool for non-arthritic hip problems and soft tissue injuries around the hip. The procedure is geared toward young, active patients, and we repair the problem to prevent progression of arthritis. With the improvement of MRI scanning and arthroscopic surgery, we have been able to identify the disabling sources of hip pain that has gone untreated for so long.” David Moore, MD, an orthopaedic surgeon and joint replacement specialist at the Hip Center, says he recognizes the value of the continuum of care concept and believes it provides for successful treatment of hip problems. “With the

Benton A. Emblom, MD, talks with a young, non-arthritic patient during a post-surgical visit.

expertise and technology available to us, we can encompass the entire spectrum for hip disorders. At the end of the day, however, we are going to deliver thoughtful, cutting-edge care no matter the problem,” he says. The center’s technology helps physicians to deliver state-of-the-art care. In August 2017, Andrews surgeons began utilizing Stryker’s Mako Robotic-Arm Assisted technology with hip replacement surgery. The system employs robotic technology that transforms the way joint replacement surgery is performed. It enables surgeons to have a more predictable surgical experience with increased accuracy. “Leg lengths can be uneven after hip

replacement surgery, because we don’t have a precise way to measure the leg while the patient is asleep. The Mako technology allows us to place implants more quickly and precisely with the robotic arm, and it gives us the right fit every time,” Moore says. Moore has been doing hip replacements for over 22 years, and he says the Mako technology is the biggest improvement in hip replacement surgery he has seen. “It is great for surgery, because we have more confidence that we will be accurate with every patient,” he says. “Our goal is for our patients to be happy with their surgery and that it lasts as long as possible.” With the continuum of care treat-

K. David Moore, MD

ment model and state-of-the-art technology, physicians at The Hip Center at Andrews Sports Medicine are poised to provide high-tech care to patients. “I use an analogy to explain,” Emblom says. “You don’t take a Toyota to a Chevrolet dealership for service. Chevrolet doesn’t have the parts or experience needed to make the repairs. The Toyota dealership will have the parts and the experience and will do it faster and better. Orthopaedics has the same concept. In our hip center, we can save time and get better outcomes. That’s the ultimate goal.”

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ORTHOPAEDICS

Non-Surgical Treatments Can Delay Joint Replacement By Ann B. DeBellis

As we age, the cartilage in our joints begin to deteriorate. Years of use will gradually wear down the cushion provided by cartilage and can lead to inflammation, swelling and, finally, arthritis. While joint replacement may be required eventually, Daryl Dykes, MD, of Alabama Bone and Joint Clinic offers several non-surgical options for patients to help them avoid surgery for as long as possible. “Osteoarthritis is the most common cause of joint pain, and trauma and obesity tend to accelerate that process,” he says. “If you have a history of those issues, your joints tend to wear out at 60 to 70 years of age.” Both medical management and lifestyle changes can help reduce pain and manage symptoms. “Weight loss of as little as 10 percent of body weight can lead to a significant decrease in pain,” Dykes says. “NSAIDs, physical therapy, steroid injections and hyaluronic acid injections are the primary non-operative treatments that I use if other measures fail.” When a patient reaches the point where none of these treatments work, Dykes will recommend surgery. “I tell patients they will know it’s time for surgery when they can’t sleep at night because of pain or they can’t travel or do basic things with the family,” he says. “When patients

Daryl Dykes, MD, right, performs joint replacement surgery.

begin to have sensations of the knee or hip giving way, they become prone to falling which can have huge ramifications for their lives. A new joint can help them maintain their independence.” When surgery becomes necessary, better implants and advanced treatments are making the procedure easier for patients. “Multimodal pain management is

becoming a popular way to keep surgical patients comfortable,” Dyke says. “I use a regimen of spinal adductor canal blocks and intracapsular blocks to numb the joint, along with anti-inflammatories and pain medicines that block nerve impulses. I rarely see a patient distraught from pain. Most are comfortable and their pain is manageable. In my opinion, this is the best

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innovation in the past two years.” There is a constant evolution of implants, metallurgy, and plastics used in joint surgeries. “The plastics are denser, they wear better, and they are less likely to de-laminate,” Dykes says. “I use a plastic that is infused with Vitamin E. It prevents breakdown of the plastic, so the patient gets more longevity from the implant. I think we will have much more than 20 years of use with these new implants.” An innovation in wound care management is making recovery from these surgeries easier for both patients and doctors. The Prevena™ Incision Management System is a negative pressure wound therapy device intended for use on surgical incisions that continue to drain following sutured or stapled closures. It prevents fluid accumulation under the skin which can increase the risk of infection. “I like this system because the patient can do rehab, flex, extend and shower with this wound dressing system. This has been a great device for patients,” Dykes says. “Patients have enjoyed the convenience of the system because they don’t have to wait days to shower, and the dressing decreases the hassle of wound care following surgery. While most people will see an orthopedist when they begin to have problems with a joint, Dykes says that most primary care physicians can manage the nonsurgical care of these patients and help to postpone referrals to an orthopedist if they are comfortable with intra-articular injections. He adds that the physicians also can improve surgical outcomes by optimizing the patient’s medical conditions. “Primary doctors also can provide weight-loss counseling, physical therapy, and anti-inflammatory medicines. Many of these patients just need reassurance,” Dykes says. “The doctors can help maximize the health of these patients by trying to control their overall physical condition. For instance, studies show that a hemoglobin A1C level greater than seven and a body mass index (BMI) higher than 40 can increase the risk of infection and wound problems significantly. Medical doctors can help improve a patient’s overall health which will make them better surgical candidates.”

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ORTHOPAEDICS

Treating Your Back Pain Without Surgery By Ann B. DeBellis

Back pain is one of the most common reasons people go to the doctor, but not all back problems require surgery. Most causes of the pain can be treated with non-surgical methods in a doctor’s office. “Back pain can be caused by a number of different factors. Most often it can be attributed to irritation or degenerative changes in the discs or the joints in the back, the facet joints, or the joints of the pelvis, including the sacroiliac joints and hips,” says William Craig, MD, a Physical Medicine William Craig, MD, evaluates a patient with back pain. and Rehabilitation Specialist with Southlake Orthopaedics. Mechanical means the source of In his practice, Craig focuses on inthe pain may be in the spinal joints, discs, dividuals who may not be candidates for vertebrae, or soft tissues. “Acute mechanical surgery or who may not be ready for a back pain without neurological involvement surgical option and want to try a more or ‘red flags’ such as fever, unexplained conservative treatment approach. He speweight loss, or pain unrelated to movement, cializes in epidurals for pain block, ultrahas a favorable natural history,” Craig says. sound-guided injections, physical therapy, “Up to half of patients with uncomplicated and oral management, among other treatmechanical back pain recover  within two ments, for both chronic and acute meweeks, and up to 90 percent will improve chanical back pain. within three to four months.”

Treatment options for acute mechanical back pain include reassurance and education related to the natural course of the back pain. “I also may recommend activity modification, ergonomic and lifestyle changes, chiropractic care, physical therapy and medications,” Craig says. “When using oral medications, I tend to favor the NSAIDs and acetaminophen. In patients who do not respond to these medications or whose pain is severe, I suggest limited use of muscle relaxants and select opioids, such as Tramadol.” Pain that persists for more than 12 weeks is considered to be chronic mechanical back pain, which also has basic goals for its evaluation and treatment. “First, we rule out malicious causes of pain, such as an infection, a tumor, or a fracture,” Craig says. “Next, we localize the source of pain with a comprehensive medical history, examination, diagnostic imaging and diagnostic injections. Diagnostic injections are helpful in determining the primary pain generator when history, examination and diagnostic imaging are inconclusive. The injections include medial branch blocks

for facet mediated pain, discography, sacroiliac joint injection or ultrasound-guided hip injection.” Treatment for chronic mechanical back pain includes therapeutic injections in addition to the treatments commonly used for acute mechanical back pain. “Therapeutic injections include, but are not limited to, radiofrequency ablation for facet or sacroiliac joint-mediated pain, epidural injection for discogenic pain, and corticosteroid injection of the hip or sacroiliac joint,” Craig says. “For patients who do not respond to conservative techniques, I typically refer them to my surgical colleagues for consideration of fusion.” Sometimes, however, the techniques may not work for people who have certain physical conditions or diseases such as Cauda Equina symptoms, cancer, tumors, or a malicious lesion in the spine that appears unstable. “In those cases, getting pain relief may require surgery,” Craig says. “If someone has a pinched nerve with significant weakness, I often advise them to consider surgery, but it is not always inevitable. The main issue with back pain patients is getting them through the door. Once they are in the office, either I or my surgical partners do a thorough history, exam and imaging to try and identify the problem. At that point, we can decide what a patient needs.”

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It’s news no athlete wants to hear … a torn anterior cruciate ligament most always means the season is instantly over with surgery and months of rehab to follow. “The scope of the problem is there is anywhere between 250,000 to 300,000 ACL injuries every single year,” said Trent Nessler, PT, MPT, DPT, the founder and developer of the ACL Play-It-Safe Program™. “Right now it’s about a $5 billion healthcare cost for the primary injury only, and 79 percent of those who tear their ACL will have Wearable technology helps evaluate movement before starting the ACL osteoarthritis within 12 years,” Play-It-Safe protocol. he added of the impetus to makes wearable sensor technology. “We identify and reduce risks. basically integrated our movement assessFor athletes at the high school, colment with their technology,” Nessler said legiate and professional level, an ACL of the partnership that led to ViPerform injury comes with long lasting effects, inAMI™ – the 3D wearable technology cluding increased risk of re-injury. Nessler now used for the ACL protocol. noted a study published earlier this year Over time, the assessments have that focused on NFL players with torn grown to include a number of additional ACLs found athletic performance was reexercises to gauge quality of movement duced for up to two years after the athletes on both the left and right sides. “In total, returned to play. “In addition,” he said, the test consists of 83 reps and three verti“they reduce their professional career by cal tests. It’s very physically challenging, two years on average.” Nessler also noted but we’re testing athletes,” he said. The ACL injuries have a high re-injury rate of idea, Nessler continued, is to see how the 20-30 percent within two-five years after athlete moves when fatigued since many primary reconstruction. non-contact ACL injuries occur as the Nessler – who is the national director athlete tires. of Sports Innovation for Select Medical, The wearable technology allows one of the largest rehabilitation companies trainers to evaluate an athlete’s movement in the nation with 1,600 centers across the and put them on a strength and conditionUnited States and more than 800 athletic ing protocol from level one to four … with trainers on staff –said the vast majority of four being for athletes who move really ACL injuries don’t happen as the result of well and level one for those with the higha direct hit. He pointed out 70-80 percent est risk of injury due to engrained patterns of ACL injuries are non-contact, typically of incorrect movement. occurring when a rapid change of direc“When you improve the biomechantion ruptures the ACL. ics of the lower kinetic chain, what you see is the kinetic energy transfer across Program Development the system is much better,” Nessler said. His quest to create an effective ACL “When we identify those athletes who injury prevention program began 18 years are at greater risk and put them on the ago when he had a physical therapy pracprogram, we found we not only reduce tice in Phoenix, Ariz. In a fairly short span ACL injuries but all non-contact lower of time, Nessler had 21 kids come to his extremity injuries – ankle, knee, hip and office to rehab torn ACLs. “I was seeing low back,” he continued. certain patterns that I knew intuitively Even the best movers have benefitwere putting them at risk for re-injury,” ted from the exercise protocol and seen he recalled. “I knew if I could assess it, I enhanced vertical jump and sprint speed, could treat it.” both measures of explosive power that are Nessler began videotaping specific particularly appealing to athletes. Nessler movements including a single leg squat said improving performance also prevents and single leg hop. “If an athlete’s knee injuries to create a win/win for athletes moves in towards midline too much, we and coaches. knew that was a risk factor. We suspected Having been around sports medicine that if the knee had major movement, his entire career, Nessler knew it was key faster, there was greater risk.” to keep the protocol short. “If a program To quantify the magnitude of moveis greater than 20 minutes in duration, ment, Nessler’s research led him to dorsaVi™, an Australian company that (CONTINUED ON PAGE 12)


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UAB Now Offers Autonomic Testing with a Comprehensive Lab, continued from page 1 each patient and make individualized treatment plans according to these diagnoses. “Before our lab opened in May, we had to diagnose clinically or send patients all the way to Nashville or Jacksonville for testing.” But those labs don’t include the sweat lab, or autonomic chamber, the feature that places the UAB lab in an elite group. One reason there are so few autonomic chambers is that they must be customized and therefore are not commercially available. When UAB decided to build one as part of their autonomic lab, they contacted Case Western Reserve University in Cleveland, Ohio, and arranged to work with the engineer who built three of the other six chambers. “Many people have a vague diagnosis of dysautonomia that says you have a disorder of your autonomic nervous system, but it doesn’t really tell you what the disorder is or what it entails,” Kazamel said. “This lab is going to be able to help patients get an accurate diagnosis and hence a plan of treatment.” The patient must refrain from caffeine and alcohol for a short time prior to being tested in the sweat lab. On the day of the test, the patient lies on a hospital bed in the chamber and is coated with alizarin powder, which is yellow to begin with and changes to purple when exposed to sweat. The temperature and humidity are raised slowly as the technicians collect body temperature information. The areas

A patient is tilted on the table for testing.

where the patient doesn’t sweat are key to a specific diagnosis. “If the patient’s toes and feet don’t sweat, that indicates peripheral nerve issues,” Kazamel said. “If one leg doesn’t

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sweat, they have a lesion in the spinal cord. And if the whole body doesn’t sweat, this is more of a central nervous system issue like multiple system atrophy.” While the sweat lab measures the distribution of sweat, another test will measure the amount a patient sweats. The response of the heart rate to one minute of deep breathing, and heart rate and blood pressure responses to the Valsalva maneuver also provide important information for autonomic diagnosis as well. In addition, the facility contains a tilt table that measures various cardiac functions. The patient is tilted at a 70-degree angle, head above feet, for 10 minutes. “This provides a challenge to the heart to see how the heart rate and blood pressure respond to the decreased blood volume, because the blood accumulates in the feet,” Kazamel said. “This is very important in cases of syncope and transient loss of consciousness. We can see how patients react to that position and challenge.” The new lab will be available to referring physicians across Alabama and the region. Kazamel anticipates that most referrals will come from neurologists, cardiologists, gastroenterologists, primary care and internal medicine physicians. Physicians can access referral forms at the UAB Autonomic Testing Laboratory website. ‘We are excited to offer such a new service to Birmingham and the whole Southeast,” Kazamel said.

Conditions diagnosed at UAB Autonomic Testing Laboratory Amyloidosis Autonomic peripheral neuropathies Diabetic autonomic neuropathy Hereditary sensory and autonomic neuropathy (HSAN) Lambert-Eaton myasthenic syndrome (LEMS) Lewy body disease Multiple system atrophy (MSA) Neurogenic syncope Orthostatic intolerance Orthostatic hypotension Postural orthostatic tachycardia syndrome (POTS) Pure autonomic failure (PAF) Reflex sympathetic dystrophy (RDS), or complex regional pain syndrome (CRPS) Small fiber neuropathy Sweat disorders (anhidrosis/ hyperhidrosis) Vasovagal syncope

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New Pathways to Success for ACOs by

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In the eight years since the Affordable Care Act (the ACA) became law, there has been no shortage of developments related to the law and its implementing regulations. Some of these developments were planned by the ACA’s architects; others represent more of a shift or redesign of the law’s original intent and form. In early August 2018, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would amount to a redesign of one prominent feature of the ACA by revamping the Medicare Shared Savings Program. The redesigned program would be labeled “Pathways to Success,” and would introduce several significant and wide-ranging changes applicable to Medicare’s Accountable Care Organizations(ACOs). This initiative purports to advance five goals: Accountability, Competition, Engagement, Integrity, and Quality, and if finalized would institute changes worth the attention of ACOs and those who contract with them. Among the several new models advanced for delivering health care throughout the country and within our state by the passage of the ACA are ACOs. These organizations embody one of the aims of the ACA in the shift away from a pure feefor-service model by taking responsibility for the quality and total costs of care for an assigned population of Medicare patients (although traditional fee-for-service

payments are not eliminated). ACOs are formed by health care providers, including physicians, hospitals, post-acute facilities, and most of them operate under the Shared Savings Program, a voluntary program established by the ACA and launched in 2012 that has three different tracks (effectively representing different tiers of risk-reward) that an ACO can choose from. According to CMS, this program promotes accountability, coordinates items and services for beneficiaries, and encourages health care providers’ investment in services that are both high in quality and efficient by allowing the ACOs the regulatory relief needed to innovate and rewarding them with the savings they achieve. However, as CMS noted in its announcement of the “Pathways to Success” proposed rule, ACOs—including those in the Shared Savings Program—may not be receiving strong enough incentives to truly innovate health care delivery pathways, nor do they tend to face real financial consequences if the cost of health care for their populations increases. Indeed, the Shared Savings Program has, rather than saved taxpayers’ money, shown an increase in net spending, arguably due to the fact that 82 percent of the ACOs do not assume risk for cost increases. The Pathways to Success initiative seeks to change that perceived weakness of the program by redesigning the participation tracks available. Such alterations are intended

to encourage more ACOs to move to options where they will both receive (a larger portion of) savings and be accountable for losses. Based on CMS’ experience with the Shared Savings Program, these so-called “two-sided” models lead to significant savings for the Medicare program. Among the significant changes proposed by the Pathways to Success is, first, a reduction in the time period that an ACO can remain in the Shared Savings Program without assuming the risk of increased costs to two years, or possibly less—a sharp decrease from the current six year period. This would greatly lessen the opportunity for ACOs to enjoy the advantages of savings earned from their innovations without the dangers of those innovations in fact failing to increase savings for Medicare. Also included as a proposed change is a requirement related to the adoption of the 2015 edition of Certified EHR Technology to promote interoperability. CMS also proposes policies to deter gaming of the program by, among other features, limiting more experienced ACOs to higher-risk participation options and labeling certain ACOs re-forming under new legal entities as “re-entering ACOs” so as to treat these ACO as more experienced rather than new ACOs. The changes are not all burdensome to ACOs; as a voluntary program, the Shared Savings Program needs buy-in from participants, and one of the incentives CMS offers through the Pathways

to Success is an increased flexibility for participants, including around telehealth. Additionally, CMS’ proposal would attempt to increase beneficiary engagement through educating them about ACOs and also by allowing incentives to be paid to beneficiaries who take certain positive actions related to their health care. Pathways to Success also proposes broader access to the program’s current SNF 3-day rule waiver for ACOs assuming greater risk. Changes to the program would also usher in more sensitivity to spending variations in local markets. Taken together, these changes are anticipated to provide new mechanisms for greater coordination and interoperability, increase beneficiary engagement, and incentivize ACOs to assume greater levels of risk with the hope of greater flexibility and savings. Sensitive to the time needed to implement any final rules from CMS, CMS has in its proposed rule offered a six-month extension for the agreements of current ACOs and a mid-year start date in 2019. Comments on the proposed rule are due by October 16, 2018. The form the final rule takes bears close watching, as does the readiness with which ACOs respond to the various changes implemented. Chris Thompson is an attorney at Burr & Forman LLP practicing in the firm’s Health Care Industry Group.

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PERSONALIZED MEDICINE

Hugh Kaul Precision Medicine Institute A Healthcare Revolution By Laura Freeman

In less than two centuries, medical science has accomplished miracles—vaccines, anesthesia, antibiotics and now even heart and face transplants. It has saved millions. The difficulty arises when what has worked for millions doesn’t work for the one person sitting in front of you. Until recently, the tools of science have been geared toward large statistical samples, bell curves and average responses of cohorts in clinical trials. Unfortunately, there is no such thing as an average patient. Every person comes with a unique family and medical history, environmental and lifestyle risk factors, and an array of DNA variations so vast that unless you are a twin, there is probably not another person on earth with the same combination. When the diagnosis or treatment that fits most people doesn’t fit you, the odyssey to find the right answer can be frustrating for both the patient and the physician. Fortunately, the new tools of medical science are changing the focus from the average to the individual, making finding answers easier. The era of precision medicine is dawning. “Precision medicine is a whole new way of doing health care. It seeks out the root molecular causes of diseases and tailors individual treatments optimized to fit the patient’s unique data.” Matt Might, PhD, director of UAB’s Hugh Kaul Precision MediMatt Might, PhD cine Institute, said.

10 • SEPTEMBER 2018

“We start with tools like genomics and informatics to build a comprehensive view of the individual’s unique genetics, history, and environmental and lifestyle risk factors. Once we identify the genes and molecular processes involved, we use pharmacogenomics to look for existing drugs active against similar targets that we might be able to repurpose to help patients now while any clues gathered from what we’ve learned can be directed toward new drug development. “Ultimately this approach will contribute to virtually every area of healthcare, from rare and undiagnosed diseases to cancer, cardiology and orthopedics to common chronic conditions.” The institute has been active in proof of concept testing using genetic profiling of unresponsive tumors to detect which treatments might be most effective and to identify existing drugs that might be repurposed. In cardiology, researchers are verifying the effectiveness of genetic predictors of blood thinner response in cardiac catheterization. The institute is also helping patients with undiagnosed diseases look for answers. A similar personal odyssey led Might from his work as a professor of computer science to teaching at Harvard Medicial School and being recruited by President Obama as a White House strategist for the Precision Medicine Initiative. Might’s son was born with an unknown neurological condition that experts failed to identify. Might used his knowledge of computing, social media and search engine optimization to look for someone who might be able to find the genetic basis of his son’s illness. Finally, a very rare HGLY1 deficiency was detected, but with that answer came another ques-

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tion. There were no known treatments. Might again used his computer and data analysis training to identify two over the counter drugs that show activity in helping to relieve symptoms. “When I was recruited to lead the institute last year, I saw a tremendous depth of expertise at UAB and the great potential opportunities of being able to call on the genetic computing power of HudsonAlpha Institute of Biotechnology in Huntsville and the drug development and testing capabilities of Southern Research Institute,” Might said. Another area where the institute’s precision medicine efforts are already showing results is in psychiatric diseases, particularly depression. “Depression has such a tremendous impact on so many lives. Finding the most effective medication to relieve symptoms can be especially challenging. All too often, it can be a long process of trying one medication after another to find the one that works for that patient. But with precision medicine tools, we can identify predictors of what type of drug is likely to be most effective,” Might said. The institute is working with all heath care specialties at UAB to begin applying the principals of precision medicine in all areas of care. Physicians in training are also learning the techniques used in precision medicine to provide personalized care. “Five years from now, I’d like to see precision medicine becoming the standard of care throughout UAB Medicine,” Might said. “We hope to continue building our expertise and capabilities to make the institute a world-class leader in this new way of doing medicine.”

Precision, continued from page 1 “Precision oncology uses a great deal of informatics to help us understand not only the genetic profile of the tumor, but also other factors that may influence what is happening, from environmental risks to diet and family history.” Yang said. “Mutations are common, but in healthy people repair systems are in place to correct those errors. When those repair systems stop working, we need to understand why. The more we know about that particular tumor, the more effective we can be in stopping it.” In a current proof of concept trial, precision oncology researchers are seeing some exciting results. One of these success stories is about Mickey Nunn, a patient from Gadsden who has been fighting prostate cancer since 2008. “After dozens of rounds of radiation and chemo, plus another treatment with some painful injections, my PSA’s had gone all the way up to 99. We were out of anything else to do, out of savings and we didn’t know where to turn next,” Nunn said. “Then I saw a story about this on NBC news. My wife was going to call New York the next day to see if I could get information on a trial. But about 15 minutes before she could call, UAB called and told me I fit the criteria for that same trial they were doing here. The timing was like an answer to a prayer.” Yang said, “The precision oncology proof of concept trial is open to cancer patients who haven’t responded well to standard therapy, but who are still strong enough to benefit. In this case, one of the differences we saw between the genetic profile of these cells and typical prostate cancer cells was the presence of a gene that is often found in women who develop breast or ovarian cancer. After studying the drivers and molecular factors involved, we identified a drug approved for ovarian cancer that looked like a strong possibility. Olaparib, marketed under the name Lynparza, is designed to work on a similar target.” “I was the first man who had ever taken it,” Nunn said. “The first month, my PSA numbers fell from 99 to 64. Last time it was checked, I was down to around 10. I went from hurting all the time and not being able to do much of anything for years, to mowing the yard and washing my truck. Dr. Yang and everyone on the team have been wonderful.” In the future, profiling the genetics of a patient’s cancer cells is likely to become the standard of care and one of the first steps in treatment. “The simple blood draw, or ‘liquid biopsy’, isn’t as invasive as a surgical biopsy, so we can repeat it as needed. We can look for key mutations or changes in the copy number of cancer driver genes and then turn to medications that are known to target these mutations,” Yang said. “As treatment continues, we can track how well the patient is responding with follow up blood tests.” Soon, precision oncology will be saving cancer patients from the delays, side effects, pain and economic burden of treatments that aren’t likely to work and moving them more to treatments that will probably be more effective. It should be a game changer that will save many lives.


Practicing with Precision

Barriers, Resources to Integrating Precision Medicine By CINDY SANDERS

Precision Medicine. The very name neatly sums up providers’ universal hope to dispense medicine in the most efficient, effective, precise manner possible to the benefit of a patient based on that person’s individual profile. Yet, integrating the discipline into practice is often anything but an exact science. A number of barriers – from a barrage of new discoveries to difficulties with authorization and reimbursement – have hindered physicians as they seek to offer patients the best option to treat a range of conditions and illnesses. The American Medical Association (AMA) has taken a leadership role in working with stakeholders, from researchers and colleagues to payers and policymakers, to address a number of key issues cited by physicians on the frontlines of care. Already critical to the delivery of patient-centered care in a variety of specialty areas including oncology and rare disease, the discipline is only anticipated to grow as new discoveries come online daily. To enable that growth, the AMA has recognized physicians need readily available resources to learn about the rapidly changing field and its impact on patient care.

The national organization has developed a number of educational resources, including the “Precision Medicine for Your Practice” series, which includes online modules to enhance awareness of physicians and healthcare providers of the different ways genetic testing can be incorporated to improve health outcomes for patients. According to the national organization, “The modules – developed by the AMA in partnership with Scripps Translational Science Institute and The Jackson Laboratory – cover specific topics in genomics and precision medicine, including expanded carrier screening, prenatal cell-free DNA screening, somatic cancer panel testing, cardiogenomics, neurogenomics and pharmacogenomics. The modules offer CME free of charge and can be found on the AMA’s website.” Currently, those modules are available online at education.ama-assn.org/precision-medicine.html. However, the AMA is updating their Education Hub so the address will likely change as that transition occurs but should be searchable in the association’s new education section. The AMA is also supporting continued research as a formal partner in the National Institutes of Health “All of Us” research program, which is building a large research cohort for precision medi-

cine. The goal of the initiative is to better understand genomic influences and how they interact with lifestyle and the environment. More information on the largescale project is available at allofus.nih.gov. While precision medicine holds great promise for the future, current payment systems have proven to be a significant barrier to clinical integration. Additionally, more work is needed on the clinical decision-support front to assist providers in identifying and deploying appropriate testing. On a related note, the AMA said there is a widespread shortage of medical geneticists and other clinicians with specialized knowledge to help drive broad clinical integration. “The AMA is working on several fronts to address these barriers. For example, the AMA has advanced several priorities to expand coverage and payment and access, as well as educational initiatives and support for research and clinical validation,” the organization said to Recipeideas in a statement. While efforts to ensure coverage and payment for clinically validated precision medicine continue, the AMA noted, “An ongoing challenge has been the rapidly evolving coverage and payment policies of government and commercial health insurers that have not necessarily kept pace with innovation and clinical validation in

genetics and genomics. There are some commercial insurers that are imposing either prior authorization requirements or other utilization management policies due to their fixed capacity to keep pace with the change, which impacts and challenges patient access and clinical integration.” At the beginning of 2017, the AMA joined with 16 other organizations representing the continuum of care to release the Prior Authorization and Utilization Management Reform Principles, calling for an array of improvements in utilization management including addressing the key issues of clinical validity, transparency, fairness, timely access, continuity of care, alternatives and exemptions. “The release of these principles spurred important conversations between provider and health plan organizations on the need for prior authorization reform. An important initial outcome of those discussions was the January 2018 release of the Consensus Statement on Improving the Prior Authorization Process,” stated the AMA. The consensus statement from six national organizations representing physicians, hospitals, pharmacists, practice managers and payers reflected an agreement between providers and payers to (CONTINUED ON PAGE 14)

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SEPTEMBER 2018 • 11


Playing it Safe, continued from page 6 coaches won’t do it,” he noted. ACL PlayIt-Safe incorporates a five-minute warmup followed by the normal practice led by the coaching staff and then about 15 minutes of a series of seven exercises specific to the Play-It-Safe level assigned to each individual athlete. Other unique attributes include having a video, which is available via an app tied to the program, to show exact technique for each movement at every level. “It creates a standardized instruction in the individual exercises,” Nessler said. Each athlete also has their own equipment that comes in their personalized bag so that someone at one level doesn’t grab a stability trainer, cuff or resistance band meant for someone at a different level.

Researching Effectiveness “To date, we’ve done over 8,000 assessments nationwide on athletes and put

over 4,000 kids on the ACL Play-It-Safe Program,” Nessler said. Despite amassing plenty of field evidence the program worked, he recognized the need to study the impact of the program in a more methodical way. To measure data and quantify outcomes, Nate Bower, PT, DPT, SCS, served as lead physical therapist in the ACL Play-It-Safe study with the women’s soccer team at Samford University in Birmingham, Ala. Bower, who is residency trained and a board-certified clinical sports specialist, serves as market manager for Champion Sports Medicine, part of the Select Medical Outpatient Division. He noted that over the last five years, the soccer team had averaged three to four ACL tears per season. “That’s pretty high when considering the team has about a 20-woman roster,” he said. “The athletic trainer came

to me and asked, ‘Do you know of any programs we can implement now to hopefully prevent these injuries in the future?’ That’s essentially where we started.” He added the ACL Play-It-Safe protocol focuses on strength, flexibility, balance and plyometrics. “All of the exercises are targeting areas that should be part of any injury-prevention program,” Bower pointed out. Working closely with the athletic trainer, he said the first step was to get a baseline performance measure on each specific movement test in July 2017, about six weeks prior to the start of the soccer season. After identifying areas where there was room for improvement, such as poor landing mechanics, the athletes were assigned to a level and provided education to improve areas of weakness throughout the season. Two of the key metrics being studied were any reduction in injuries and time

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lost from competition and practice. “A third thing we wanted to see is if we were able to reduce the medical cost associated with these injuries,” Bower noted. During last year’s season, there was one ACL contact injury. “We did not see any non-contact ACL injuries,” said Bower. “As far as lower extremity injuries, we saw a 50 percent decline. As for the amount of time loss from these injuries compared to previous years, it was 40 percent less, and there was almost a 40 percent reduction in medical costs.” While the data collected to date bears out what Nessler envisioned when he developed the program, there are more questions to be answered. Bower said the goal is to enroll another 100-120 athletes at the Division I level. “The soccer study is still ongoing. We want to collect longterm data. The second cohort of the PlayIt-Safe protocol was just implemented,” he said. “In 2018, movement testing was done for women’s volleyball, women’s basketball, and men’s basketball,” Bower added of additional baseline assessments at Samford. In addition to long-term ACL outcomes, Bower said a future goal is to ascertain whether or not an assessment score is predictive of on-field performance or if there is a correlation to risk for injury.

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12 • SEPTEMBER 2018

Nate Bower works with an athlete on a series of exercises tailored to improve quality of movement and lessen risk for ACL injury.

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SEPTEMBER 2018 • 13


Wading into the Pool of Risk Bearing Reimbursement Models By Joni Wyatt, MHS

Many Alabama providers participated in the Quality Payment Program in 2017, under MIPS (Merit Based Incentive Program). A handful participated in a MIPS APM (Alternative Payment Model), which is a baby step towards alternative payments, but still left the participants free from downside risks. As we pass the half-way point for the 2018 performance period, exploring risk bearing programs is on the rise. The Alternative Payment Model for which I get the most questions is the Bundled Payment for Care Improvement (BPCI) model. This model requires formal contracts for participation, and the deadline to confirm participation in this model was August 8th, 2018. Historical performance data was recently released and interested parties are scrambling to review all contract options. The BPCI performance period begins October 1, 2018.

BPCI Highlights In the BPCI model, shared savings occurs when total cost for an attributed episode of care is less than the CMS established target price for the specified clinical condition. The target price is set by CMS annually and reflects historical costs. Tar-

get price is standardized by region and may be adjusted to reflect patient acuity. The total cost for an Episode of Care includes all charges to Medicare for services from the date of procedure/visit (initiation of the Episode) to 90 days post discharge/procedure, regardless if the service is directly related to the initial procedure or provider of care. If total cost for an Episode of Care is less than the target price, then CMS will pay out the savings (less three percent) to the group or provider for which the episode is attributed. Likewise, if an episode of care is more than the target price, then CMS will expect a payback. In addition to cost, quality metrics are also assessed, and there could be additional adjustments to payout based on quality performance. Physician Group Practices, Hospitals and any other providers can participate and determine the level of risk they are willing to take on. It goes without saying, the bigger the risk, the bigger the reward. In many cases a non-provider will act as a convener for a group, and will be responsible for managing the cost, quality of care, and overall apportionment of savings and/or risk. Conveners will often charge a fee for their services, as well as take a portion of the savings (risks) based on the

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aggregate of all episodes. BPCI is considered an Advanced APM, therefore if a provider meets the qualified provider threshold, they could receive the five percent lump sum bonus in addition to shared savings, and be excluded from MIPS. BPCI seems complicated – why would anyone want to do this? The release of historical cost data allows providers to compare historical performance against the target price and determine if they are already generating savings. Providers may identify ways that they can reduce costs, and therefore realize savings. The shared savings payments to providers is in addition to any Quality Payment Program incentives - so the upside is two-fold if the conditions are favorable. However, there are a few negatives to consider. Often, the cost margins are tight and a small savings identified could convert to a loss with just one poor outcome. Also, convener fees can cut into savings, thereby reducing the potential for additional payment. The probability of meeting the qualified provider threshold is low. Most providers will still report MIPS under the MIPS APM standard, or can choose to opt out. If they choose to opt out, they won’t receive a penalty, however, they won’t receive a bonus either. Once in the program, there is one “out” in March 2019. Beyond that, you would be subject to the program until January of 2020. If you are interested in BPCI and missed the deadline- no worries, you can choose to participate in the next round which starts in January 2020.

Practicing with Precision, continued from page 11

meaningful address the process impacting the delivery of cutting-edge care. With the shortage of medical geneticists and specialized clinicians deploying precision medicine … and with those who do possess that specialized knowledge and skill set often clustered at major academic centers … the AMA has focused on increasing access to genetic and genomic consultations through the utilization of telehealth and e-consults. Strong supporters of using technology to expand access and knowledge, the organization hailed a proposal to allow the Medicare program to cover interprofessional e-consults beginning Jan. 1, 2019. “This is very important news for physicians and patients who will be able to obtain patient-specific medical genetic consultations more rapidly and without constraints of geography, while ensuring care coordination and care delivery by the primary care provider,” the AMA stated. “With all of this optimism and promise, consistent coverage policies that reflect the evidence base remain a critical factor in the successful implementation of precision medicine, as well as the infrastructure to support widespread clinical decision-support for the right patient, right test at the right time,” noted the AMA. Although excited about forward movement in terms of expanding access through e-consults and the work to address prior authorization impediments, the national physician group said additional challenges remain, including concerns over affordability and accessibility. A growing concern is the potential impact of efforts that could limit the number of clinical laboratories offering testing due to payment cuts. “The AMA is committed to addressing these challenges though advocacy efforts, investing in a number of educational initiatives, as well as promoting continued discovery and innovation through the All of Us campaign.” Additional information and links to resources to assist in implementing precision medicine at the practice level are online at BirminghamMedicalNews.com.

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Finding Balance

Retraining the Vestibular System to Prevent Falls By Laura Freeman

One 80-year-old fractures a hip, which triggers a physical decline that leads to an early death. Another octogenarian still enjoys golf and tennis. What is the difference? Staying healthy--and a big part of that is maintaining healthy vestibular function. Half of elderly people who fall have vestibular deficits. Falls are the number one cause of fractures and are associated with 40 percent of all nursing home admissions. However, vestibular disturbances shouldn’t be considered an inevitable part of growing older. The elderly also aren’t alone in dealing with these problems. Young athletes with concussions, survivors of traffic accidents and other head injuries can struggle to regain a sense of where they stand in relation to the world around them. “The neuroplasticity of the brain allows the vestibular system to be retrained,” Carl Stephenson, MD, of Tuscaloosa Ear Nose & Throat Center, said. “Our physicians begin with a detailed diagnosis and examine other factors that may be contributing to balance and vestibular issues. Then we work with FYZICAL Carl Stephenson, MD Therapy and Balance Center next door to design an effective therapy plan to address the individual patient’s specific problems.” The center is part of a national group of centers that offer specialized therapy in balance as well as other physical therapy services. FIZCAL’s patented protocols are aimed at helping patients improve faster in a safe environment where they can build the confidence to do more as they rebuild both their balance and their physical condition. Dustin Clary, PT said, “The physicians at Tuscaloosa ENT use some advanced testing methods, and the results give us a clear picture of the patient’s overall health and the deficits we need to correct. That guides us in designing a therapy plan Dustin Clary, PT to achieve the best outcomes. “It’s important to create an environment where patients can feel safe. We have a patented overhead safety support system so they don’t have to worry about falling as they relearn the mechanics, correct their posture and work to improve. “So often, balance problems develop

after an earlier fall. People become apprehensive and stop challenging their balance centers. They lose strength, their posture changes and their sense of where their center of balance is changes with it. They become more inclined to fall. If they fall and get a vestibular concussion, this adds more balance issues.” Stephenson said, “Our ENT’s see patients with everything from vertigo to Meniere’s, stroke damage and injuries to balance centers. We also have to consider things like possible side effects from medication and problems with muscles, joints and bones.” Therapies to rebuild neural connections between eye, ear and the balance centers of the brain may include biofeedback and 3D virtual reality techniques. Retraining muscles, joints and posture includes physical therapy to improve strength and endurance, as well as gait training and coordination. “We’ve been seeing more young athletes to help them regain their balance and coordination after injuries,” Clary said. “There can be vestibular problems after concussions that need to be corrected. Otherwise, the athlete’s sense of balance and coordination can be affected. It can throw off their playing skills and make them feel clumsy, which can put them at risk of more injuries.” Vestibular disturbances can also be linked to other health issues that may not be immediately apparent. Stephenson said, “My wife was one of our first success stories. She had headaches that didn’t seem to be linked to any of the usual causes. It got so bad that when she was driving she had to pull over. Dustin asked me if she had been tested for eye-vestibular mismatch. That turned out to be the problem. After therapy to retrain her eye and vestibular coordination, the headaches were gone.” “This is similar to the eye-vestibular mismatch that occurs in motion sickness,” Clary said. “Some people begin to depend more on their eyes than their vestibular system. Receiving two different inputs can be difficult for the brain to process. But people can be retrained to trust their vestibular system again.” The physicians at Tuscaloosa Ear, Nose & Throat Center frequently identify patients who are at risk of falling or are in the early stages of developing balance problems. “They often refer patients for our BodyQ evaluation,” Clary said. “It can help people of all ages identify and track issues related to balance, fall risk, and overall fitness. Even in middle age, people can begin developing problems with strength, flexibility, posture and balance that can be corrected so they don’t turn into bigger problems later.”

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Virtual Care In Alabama: Greater Access and Lower Cost By Beth Pitman JD, CHPC Waller, Lansden, Dortch & Davis LLP

Telehealth hit a bump in its road to progress when the Office of Inspector General released the April 2018 Audit reporting errors in telehealth claims. This bump, however, should not create a detour away from a cost-effective healthcare delivery model. In today’s Medicare reimbursement structure, appropriate implementation of telehealth may help physicians improve MIPS scores, increase reimbursements and provide Alabama patients with greater access to quality care. Telehealth are healthcare services delivered through audio-video telecommunicating technology or patient-facing portals rather than the typical in-person encounter. Telehealth may include applications such as live videoconferencing, store-andforward videoconferencing, remote patient monitoring, mobile health, and virtual check-in. Medicare has expressed a commitment to expanding reimbursement for telehealth services. “CMS is committed to modernizing the Medicare program by leveraging technologies, such as audio/ video applications or patient-facing health portals, that will help beneficiaries access high-quality services in a convenient manner,” said Administrator Verma. The 2019

Physician Fee Schedule proposes reimbursement for virtual check-ins, evaluation of patient-submitted photos, and telehealth services for prolonged preventive care such as chronic care management. In addition, CMS/OIG Waivers for certain payment programs provide availability for reimbursement of telehealth services in urban centers as well as Health Professional Shortage Areas (HPSA) and for additional services typically paid as if an in-person encounter. Alabama’s large concentration of rural and HPSA designated areas makes telehealth an attractive option for providing rural areas with access to quality primary care and specialty medical treatment and reducing costs. Reimbursement structures are available through federal and private insurers and self-insured plans, licensure barriers are lower, and development of HIPAA compliant technologies has increased significantly. Alabama was among the first states to adopt the Interstate Medical Licensure Compact (“IMLC”) in 2017. IMLC expedites multi-state medical licensure for Providers among participating states (24 states, 1 territory and 31 Medical and Osteopathic Boards as of August 2018), offers Alabama providers opportunity for care delivery outside of Alabama for which they

can be reimbursed, and provides access to specialty consultation and care from outof-state Providers. Physicians must hold an unrestricted license in the Compact state of residency or employment. IMLC defers to each state board for review of the IMLC license application and approval. The Alabama Board of Medical Examiners issued 33 licenses in 2017 and 22 letters of qualification issued to other states. Prior to IMLC, Alabama physicians were limited to providing telehealth services within the state. Government and private payors, such as BCBS, designate a specific set of services for telehealth that are coded and reimbursed as if provided in an inperson encounter. Most payors have some common features in the conditions for reimbursement: synchronous (realtime face-to-face) communication using a HIPAA compliant technology originating from a payor specified location, such as a physician office, clinic or hospital, in the presence of a licensed provider and with medically necessary care delivered by the remote provider. There are some distinctions that increase opportunities for reimbursement. Recognizing the value of communication technology-based services using asynchronous and non-face-to-face modalities,

such as a phone call or pre-recorded videos, CMS proposes new HCPCS codes to separately reimburse these non-face-to-face services which do not fall into the statutory definition of telehealth services (face-toface real time encounters). The proposed additional services would: (1) pay clinicians for virtual check-ins which are brief, non-face-to-face assessments via communication technology; (2) pay Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for communication technology-based services and remote evaluation services that are furnished by a RHC or FQHC practitioner when there is no associated billable visit; (3) pay clinicians for evaluation of patient-submitted photos or recorded video; and (4) expand Medicare-covered telehealth services to include prolonged preventive care. Prior to its proposed changes in the 2019 Physician Fee Schedule, Medicare acknowledged that telehealth fits squarely into its Innovation programs which focus on reducing costs and implementing the use of technology while improving performance and quality. Certain of the CMS and OIG Waivers for bundled payment and shared saving programs expand opportunities for telehealth by permitting delivery from alternative origination sites, (CONTINUED ON PAGE 17)

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Urology Centers Invest in Employees through Wellness Program By Marti Webb Slay

Jason Biddy, CEO of Urology Centers of Alabama, and Alisa Pugh, director of human resources, had a problem. Insurance costs for the practice were climbing and the health of the 185 employees was not as good as they wanted to see. So they put their heads together and developed a wellness program that is designed to improve the health of employees, while ultimately saving the practice money. “The main reason we started a wellness program was because we have a concern for our employees’ wellness,” Pugh said. “We have people who have had heart attacks and strokes. The top two diagnoses in our group were diabetes and heart disease. Loaded with that information, we knew where we needed to start.” They named the program Urolive & Well and kicked off in January. The first activity was to ask everyone to make New Year’s resolutions they thought they could keep. “Wellness is not just about weight,” Pugh said. “There are other things that play into wellness. One is stress relief. Another is making sure you get enough sleep. Another is financial

Virtual Care, continued from page 16

such as home or a dialysis facility, permitting telehealth in previously unavailable geographic areas, such as metropolitan areas, and permitting use of asynchronous technology for teledermatology and teleopthamology. Successes at organizations that provide services to rural areas has demonstrated the value of telehealth. Intermountain Healthcare in Utah conducted a study assessing the cost, quality and performance of telehealth delivered services as compared to similar care delivered at primary care office, urgent care, and ERs and the outcome was that the quality and performance metrics were substantially the same while telehealth resulted in greatly reduced costs. After a 14 years of providing health care services through telehealth, in 2017 The University of Mississippi Medical Center earned the designation of National Telehealth Center of Excellence after implementing a telehealth platform connecting the health system with more than 200 healthcare sites across Mississippi and more than 500,000 patient visits in 69 of the state’s 82 counties. With barriers reduced and reimbursement options enhanced, implementation of telehealth as an additional method for delivering healthcare to patients in Alabama - and elsewhere - is on the horizon. Beth Pittman is of counsel with Waller.

Urology Center held a health fair for employees.

wellness. It involves every aspect of your life.” The program has a different focus each month, with three or four big activities over the year. In March, a health fair that included nine vendors provided information for the employees on a variety of topics. Four gyms offered a drawing for free passes, and Birmingham Internal Medicine spoke to the group. A mortgage broker, dental group, 401K advisors and Homewood Pharmacy rounded out the vendors who talked to the employees. In addition to providing information through the monthly focus about health issues ranging from heart health to skin wellness or osteoporosis, the practice has a nurse practitioner in-house to offer urgent care for employees. As an incentive to promote regular care, the practice offered baseline blood draws: free checks of glucose and cholesterol that weren’t billed

to insurance. People with abnormal results were given referrals. The in-house nurse practitioner also sees employees who may have strep throat, ear infection, UTI, sinus infections or other common illnesses. “We do these sick visits to help keep employees at work,” Pugh said. “You want your employees to go to the doctor when they are sick and not spread germs around. This way they don’t have to go to the doctor for every little thing that pops up. “We discovered that 80 percent of emergency room visits are things that can be taken care of in urgent care facilities. A lot of health insurance claims are people going to the ER for something that is not an emergency. We are hoping to address that by offering this service.” “With the sick visits, we can have a healthier population,” Biddy said. “People can show up to work when they are sup-

posed to, and they can use their vacation time to really get away. That’s a big deal for some people. If they are constantly out sick, their whole time off is eaten up with that, and it doesn’t make for a good work/ life balance.” Before the wellness program began, Urology Centers provided canned sodas for staff at no cost. “That was a significant expense on one hand,” Biddy said. “But also it wasn’t conducive to a wellness program. So we took that out, gave everyone a water bottle and got nice water coolers in every area of every office. That pushed the idea of hydrating.” While the impetus for the wellness program was the health of the employees, the cost of insurance also played a role. “This is pretty much a break-even initiative,” Biddy said. “We aren’t sinking a ton of money into this, and when you look at the things we’ve cut out like soft drinks, it’s budget neutral. That’s not the primary goal, but often there’s a stigma that a practice can’t afford to do this. This has not been costly, and we hope in the long run it will be something that proves to be a return on our investment with healthier employees.” Urolive & Well is still relatively new, but most employees seem to be embracing the changes and participating in different aspects of the program. “We’re changing the culture,” Biddy said. “So it won’t happen overnight. Lifestyle changes take time. The employees know now that we are serious about this. My hope is that as we go forward, we’ll be able to offer lower premiums for health insurance or different incentives, and they’ll begin to see the value.” “It will take five to eight years before we have the data to see that,” Pugh said. “But if we save one person from a heart attack or diabetes, it’s been worth it.”

Welcomes Dr. Njeri Maina Dr. Maina, with a Fellowship from UAB Allergy & Immunology, brings her patients years of experience from around the world and a devotion to educating them about their treatment and conditions. Understanding forms a vital part in providing excellent and lasting good care for her patients.

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New all-in-one GI Endoscopy Center opens at St. Vincent’s Birmingham By Marti Webb Slay

With the opening of its new GI endoscopy center, St. Vincent’s Birmingham now boasts a 20,768-square-foot facility with all general and interventional endoscopy services in one location. “There’s nothing better than having a state-of-the-art facility to practice gastroenterology in,” said Craig Philpot, MD, medical director for GI Services at St. Vincent’s. “The facility offers every type of GI service. The equipment is new, the facility is new, and it makes it much easier to give patients a satisfactory experience in a comfortable environment while we do our job.” Previously housed on two different floors, but with much of the same staff, the former layout could be confusing for patients and difficult for staff to coordinate. “We’ve added space, and our therapeutic rooms are now twice the size, which allows us more capabilities on our procedures,” Jamie Lawson, GI Center manager. “We were thoughtful from the beginning about taking the patient’s perspective into consideration,” Shannon Scaturro, St. Vincent’s Birmingham vice president of operations, said. “We chose this location because it would have front door drop-off and pick-up service. It’s convenient, with

The St. Vincent’s Birmingham GI Services team.

an outpatient look and feel to it. “We even took into consideration the environment patients were coming into. They are greeted immediately by a receptionist in the waiting area. And we planned out the flow through the center to move patients efficiently through the system.” “We have installed a new imaging system to better enhance our ability to care for therapeutic biliary and pancreatic cases,” Lawson said. “We purchased a top-of-the-line Omega Interventional En-

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ers.” The center offers on-site pathology readings for many endoscopic procedures. “We often give the patients a result before they leave the GI lab,” Philpot said. “Usually there’s a 24-hour turnaround on other procedures.” “The on-site pathology readings are not available at many other systems,” Lawson said. “It’s a commitment of our pathology department here. Patients are already nervous, and they want answers.” “It also minimizes the number of biopsies we have to do,” Philpot said, “because we already have a diagnosis, and we don’t have to just hope we got it. It’s a quality feature for both the patient and the physician.” After patients receive state-of-theart treatment at the center, they are sent home with customized, printed patient findings, education information and care instructions.

doscopy Fluoro System, which is the gold standard in therapeutic imaging.” “The Omega system is state-of-theart for colonoscopy and endoscopy,” Philpot said. “We also have a dedicated endoscopic ultrasound room. Endoscopic ultrasound is used for some of our more complicated procedures and biopsy of pancreatic masses and other GI cancer staging and evaluation. And we have a dedicated ERCP (endoscopic retrograde cholangiopancreatography) room and a new fluoro system that’s dedicated just to ERCP. It revolutionizes the visualization of the procedure and is the best that’s available for looking at the biliary tract and pancreatic duct.” Equipment at the center includes high resolution manometry and Bravo studies. The Omega Interventional Endoscopy Fluoro System for therapeutic imaging. “We have advanced technology to diagnose gastroesophageal reflux disease (GERD) and the “We have nine full-time gastroenterfunctioning of the esophagus to help conologists and six colorectal surgeons here,” trol GERD,” Scaturro said. Philpot said. “It’s a full staff dedicated to “We are an end to end center,” Lawproviding GI services to our patients.” son said. “We do outpatient diagnostic and gastroenterology emergency or therapeutic cases, as well.” The new GI New guidelines for colorectal screenEndoscopy Center ing were taken into account as the facility was being planned. “As a system, we can see patients have a commitment to colorectal cancer with a variety of screening,” Scaturro said. “The guidelines gastroenterological which came out just reduced the age to 45, so we needed to invest in our GI services issues, including: to account for growth. We are investing in our community’s health by building the Irritable bowel syndrome (IBS) center out to be able to take care of that Inflammatory bowel disease population.” In addition to quality of care and Biliary disease patient convenience, St. Vincent’s considUlcers ered safety issues when designing the facilLactose intolerance ity. “Radiation exposure is a safety issue we always have to address,” Scaturro said. Reflux “This equipment helps reduce the amount Crohn’s disease of time a patient is exposed to radiation. Ulcerative colitis And by nature of design of the equipment, it helps reduce it, because of lead barriPancreatitis


The Literary Examiner BY TERRI SCHLICHENMEYER

The Doctor Will See You Now by Cory Franklin, MD; 2018, Academy Chicago; $16.99; 271 pages The appointment was made months

bad. Studies show that computerized record use sometime results in less face-time That gave you plenty of time for anand personal attention from caregivers. ticipation, to think about whatever news There are also issues of medical privacy inyou might get; to volved, the strength ponder the discomof which wanes as fort; to think about computerized rehealth care in gencord use increases eral, while you sit and Big Tech dips in your physician’s its toe into medical waiting room. And record-keeping and if you take The Docresearch. tor Will See You Now Ah, and studby Cory Franklin, ies. Needless to MD, you’ll have a say, they’re often lot more to think flawed. They may about while you’re ignore the very Cory Franklin waiting. young or the very So you’ve walked in and taken a seat. old, or even half the population (women). Are you in a hospital clinic or private Read them, try to understand them, but practice room? Franklin says that it’s likely take them at face value. Most importantly, the former because federal rules and regudon’t use them as an excuse to skip your lations have made it “prohibitively expenappointment or any tests you need. sive” for anyone to start a private practice. Overall, be your own patient adThat you’re in a larger clinic setting vocate. If you feel overwhelmed, take means it’s likely that the facility uses comsomeone with you to help make sense of puterized records. That’s both good and what’s going on – and that goes doubly ago.

d to cardiothoracic care, to your patints

for a hospital admission, ER visit, or if you have cancer, and especially on holidays and weekends. Know how to tell a charlatan’s advice from real medical knowledge, and don’t put blind faith in what you see on TV. Remember that medicine is a business, and it sometimes expands into questionably ethical territory. And finally, remember that whatever happens outside in the world affects what’s inside your body. ACA, Obamacare, insurance rates, Medicare, Alphabet Plans. It’s enough to make your head spin, which is why you’ll appreciate reading about a physician’s POV in The Doctor Will See You Now. At first look, though, this book may

appear to be a lot of common-sense information. You already know about flawed studies, questionable diseases, and HIPAA rules broken, but author Cory Franklin, MD helps sort things out, even though his observations sometimes get messier as the facts pile up in subsequent chapters. Happily, those sections that delve deeply into serious matters are separated by lighter thoughts: Franklin does a wonderful job enlightening readers about unsung and little-known heroes and heroines in medical history, and he lauds them in words that leave no doubt as to whom we owe our health and gratitude. Be aware that this bandage-ripping book may raise your blood pressure with its dip into politics and controversy but you owe it to yourself to be educated. If you value your health (or need to be healthier), The Doctor Will See You Now is a book you should make an appointment with. Terri Schlichenmeyer is a professional book reviewer who has been reading since she was 3 years old and she never goes anywhere without a book.

Let our family care for your patients.

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UAB Researcher Hopes to Standardize Coma Use for Epileptic Patients Status epilepticus (SE), a dangerous condition in which epileptic seizures follow one another for a duration of five or more minutes without the victim regaining consciousness between them, is the second most common neurological emergency in the United States, with around 150,000plus cases per year. In 60-70 percent of cases, the patient responds to antiepileptic medications and benzodiazepines. However, up to 44 percent of status epilepticus cases progress to refractory status epilepticus, where the patient doesn’t respond to these drugs, and more extreme treatments are required. “These emergencies require prompt and effective treatment,” said says Wolf-

gang Muhlhofer, MD, an assistant professor of neurology in the UAB Epilepsy Center. “The longer SE is going on, the higher the chances of brain damage or the body’s being unable Wolfgang Muhlhofer, to compensate for the MD trauma, leading to other complications like cardiac arrest or kidney or heart failure.” The main treatment for RSE patients is inducing an artificial coma, where the patient is placed on a sedating or anesthetic agent and is intubated and put on

a ventilator. “The idea is to hit the reboot button on the brain, sedating the brain to a stage where there is no seizure activity,” Muhlhofer said. While artificial coma is the agreedupon treatment for RSE patients, Muhlhofer says there isn’t an evidence-based consensus on how long patients should be kept in this state, and recent studies have shown that the longer a patient is kept in an artificial coma, the more likely they are to have complications during their hospitalizations, or worse, permanent problems with physical and cognitive functions. Muhlhofer wanted to analyze RSE patients in a more systematic way, with

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the hopes of determining more specific guidelines regarding the lengths of the artificial coma. He designed a study of adult patients, admitted to UAB or University of California, San Francisco Medical Center during a seven-year period, who were placed in a coma and who had a seizure recurrence within the first 48 hours of lightening the patient’s sedative medications. Particularly of interest to Muhlhofer are complications patients’ experience as a result of artificial coma, such as urinary tract infections, hospital-acquired or ventilator-associated pneumonia, deep vein thrombosis or pulmonary embolism, and strokes, among others. He also is studying whether the patient was discharged with a disability or need for physical rehabilitation or long-term care. Muhlhofer began with 42 patients from UCSF that fit his criteria. He then worked with the UAB Center for Clinical and Translational Science’s Enterprise Data Warehouses to add about 100 more patients. When he paired those two collections with UAB’s access to i2b2, a self-service application that enables researchers to access de-identified patient data, he was able to double his sample size. Muhlhofer plans to use the preliminary data to apply for grants that will enable him to conduct a randomized clinical trial to look at different durations of artificial comas and review health outcomes, primarily sustained seizure control. “Do patients slip back into seizing the moment you take away the medications?” he asked. “We would also like to find out whether there are issues during the hospital stay. And are there any complications right after discharge? Up to a year after? The answers to these questions could help solidify clinical standards for what the best treatment plans are for RSE patients.” This preliminary analysis, which i2b2 helped him create, gave Muhlhofer a better idea of potential sample sizes and how to calculate sample size for future study proposals. His goal is eventually to have a multi-centered clinical trial across the United States. “I think it’s an intuitive way of using different filters and criteria to narrow down a patient population, especially for creating preliminary data sets for applications,” Muhlhofer said. “It’s an excellent tool, and they are continuously improving it and making it more user-friendly. I think i2b2 will continue to be a very beneficial tool.”

Follow us on Twitter @bhammedicalnews


Fighting Slow PC Performance By Matthew Brannan

One of the most frustrating things PC users can experience is slow performance or freezing while using their normal programs. It can make even the simplest tasks take several times longer, slowing down your work day and impacting patient care. While it will sometimes mean there could be hardware issues and your PC needs an upgrade, there are several steps that you and your IT support can take to speed up the performance of your PC through cleanup tools, antivirus and anti-malware scans, or optimizing settings. The first thing to check is how long it has been since your PC has been restarted. Do you restart your PC once a week or do you only reboot your PC every few weeks? Restarting your PC is a great first step to allow your PC to clear out old processes and refresh itself. Some users will opt to set a schedule for their PC to reboot over the weekend, or at night. If a simple restart doesn’t resolve the slowness, you can try running your antivirus or anti-malware program to see if there are any potential threats hiding away inside your hard drive. If you’re not sure of how to run these scans, you should be able to reach out to your IT support technicians. These scans will ideally be set on a schedule to run nightly or weekly, but if you open the software on your PC, you can run a manual scan as well. If your PC detects any malicious items, you can them Quarantine them to prevent them from affecting your PC any further. If your PC takes a long time to boot up when you power it on, there may be lots of programs trying to start that are slowing down the bootup time and preventing you from seeing a usable desktop. Ask your IT support to help you disable any unneeded startup programs on your PC. There are several other methods and tools you can utilize to help speed up the performance of your PC from registry re-

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pair software, clearing out temporary files and running a Disk Cleanup. I suggest that you get your IT Support technicians to perform these items for you. Performing these cleanup methods and monitoring your computer’s performance can help your IT Support in developing a plan for resolving the issue for you. Let’s say all the above was completed but you are still having issues with your PC performing slowly. The next step is to analyze your PC’s age and hardware to make sure it is able to keep up with the ever-increasing demands of your software. Normally you will want to make sure that both the physical memory, processor, and hard disk in your PC are powerful enough to handle many different software programs and processes without bottlenecking and restricting the speed of your PC. For memory, the typical software requirement is about 8GB. This allows your PC to handle more processes at once without restraining your operating system. If your PC only has 2GB or 4GB, your operating system will need to use a majority of that amount to just run idle without any programs open, and your PC will struggle to handle anything else. Once the memory usage gets above a certain threshold your PC will struggle to swap between software

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programs, resulting in slowness and freezing issues. Sometimes your PC’s hard disk will suffer and will struggle to perform. There are several scans that can be run against your hard drive and logs that your IT Support can analyze to evaluate the health of your hard drive, and then the drive can either be repaired or replaced as needed. If the drive ends up needing to be replaced, you simply need to know what type of drive to replace it with. You can obtain either a standard hard-disk drive (HDD), or a much faster solid-state drive (SSD). An SSD offers much faster speeds and will greatly improve the time it takes to boot up your PC. The downside to SSDs are that although they are becoming more available and the price is coming down, they are still expensive compared to normal HDDs, but if speed is the main issue then the investment would be worth it in the long run. All in all, there are many causes that could be the determining factor in why your PC is running slowly or freezing up. It could be a software fix that could be repaired without much trouble, but if there are hardware issues that can quickly become a more daunting project to take on unless you have good PC hardware

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By Theresa Dudley, Healthcare Programs with Spectrum Enterprise in Technology

One of the greatest challenges currently facing the healthcare industry is finding a way to service the approximately 50 million Americans (17 percent of the US population) who have limited access to quality healthcare because they live in rural communities. Rural healthcare has a unique set of issues, including not only geographic but also economic and lifestyle factors. Let’s begin with geography and the fact that American’s rural population is spread out over wide distances and served by fewer doctors and specialists than urban areas. As a result, if rural resident has an accident or gets injured, they may have to travel farther to reach the specialized trauma or emergency services they need. Compounding this is that fact that typically, rural populations tend to have less healthcare coverage than urban populations. When you also consider that rural youth are more likely to use tobacco products leading to long-term healthcare issues, it is easy to see the need to overcome these healthcare access limitations. Unfortunately, the exact opposite is happening. According to the Washington Post, between 2010 and 2015, 48 rural hospitals closed and that number has continued to grow over the last two years, which means many patients in rural communities now have to travel greater distances to access healthcare, requiring more time and money. It is not as though healthcare providers don’t recognize this untapped market. In fact, a recent Healthcare Priorities, IT Impacts and Plans1 report showed that 73 percent of healthcare providers view rural healthcare as a priority but they face a challenge in how to effectively reach and treat people. This is where technologies like telehealth and Cloud services can come into play. The history of telehealth solutions in rural communities started with treating high risk patients, most often post-heart surgery patients and stroke victims. The goal was to use telehealth solutions like remote monitoring or virtual consultations so that high risk patients could checkin with the specialist and have their vital signs monitored to ensure that they stick to their treatment plan and lower the chance they would need to be readmitted to the hospital. Today, telehealth has evolved to include additional patient care groups including mental health, maternity and even primary care. This trend is also echoed in the Healthcare Priorities report which showed that 70 percent of healthcare decision makers indicated that the use of telehealth solutions was a priority, and 43 percent indicated that they have already

implemented video solutions for physician consultation and collaboration. Internet access and Ethernet services, delivered over a fiber network, provide high bandwidth, reliability, and minimal latency required to enable real-time video, voice, and other collaborative features that can help improve patient outcomes. These networks are not being created in a vacuum. The Federal Communications Commission has published guidelines around recommended bandwidths for clinics and hospitals, and the FCC is also funding broadband connectivity in both rural and urban areas. As noted above, these remote solutions are not just a future vision; they are already in place in many communities. For example, Spectrum Enterprise has a health system client that deployed fiber-based Ethernet and Internet access to expand the reach of their stroke network across the state. Known as eICU, this was one of the first telehealth applications deployed to treat stroke victims. The eICU telehealth solution provides two-way audio, two-way video, and access to imaging to connect the onsite responders treating a stroke victim with trained stroke neurologists within the critical ‘Golden Hour.’ Let’s take telehealth connectivity one step further and into the cloud. Decision makers at many hospitals and large medical practices are facing a key choice - do they allocate their limited budgets on improved clinical space or on new IT infrastructure? Most often, healthcare providers will choose to spend their IT budgets on clinical space and choose to outsource their datacenters to the cloud. This model includes cloud datacenter solutions for storage of patient data and secure mobility solutions for the viewing of the data. Cloud services are also a good fit for newer telehealth solutions like tele-burn, tele-psych and trauma services that require minimal latency. The increasing number of telehealth applications clearly shows that with the proper bandwidth and secure connectivity, geography no longer needs to be a barrier to the delivery of high-quality healthcare. Theresa Dudley is with Spectrum Enterprise.


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SEPTEMBER 2018 • 23


RESEARCH NOTES

Researcher Finds Risk of Later Death after Donor Blood, Marrow Transplant in Childhood While blood and marrow transplants can save the life of a pediatric cancer patient, research out of the UAB found that those patients may be at an increased risk of premature death years or even decades after the procedure as compared with the general population. Smita Bhatia, MD, MPH, professor of pediatric oncology at UAB, served as the senior author of findings from an observational study in the Journal of the American Medical Association Oncology. The study analyzed data regarding Smita Bhatia, cause of death for nearly MD, MPH 1,400 patients who lived two years or more after undergoing an allogenic blood or marrow transplant in their childhood between the years of 1974 and 2010. Leading causes of death in the patient cohort were infection and chronic graft-vs-host disease, patients’ primary disease, and subsequent cancers. The data also indicated that the rate of later death among these transplant patients has decreased over the last three decades. The authors say it is promising to know that mortality rates have dropped, and the research gives more insight as

to what causes late mortality in this population, and how to help other patients moving forward. “This study shows that, while we are able to save the life of the child during their cancer treatment, we need to continue to provide proactive followup care with these types of patients throughout the rest of their life, as they are still an at-risk population,” Bhatia said. “The high intensity of therapeutic exposures at a young age lends itself to cause morbidities and organ compromise once they reach adulthood.”

Drug Slows Brain Damage in Multiple Sclerosis Results from a clinical trial of more than 250 participants with progressive multiple sclerosis revealed that ibudilast was better than a placebo in slowing down brain shrinkage. The study was supported by the National Institute of Neurological Disorders and Stroke, part of the National Institutes of Health, and was published in the New England Journal of Medicine, and involved researchers across 28 clinical sites, including a team from UAB. “This is a landmark study in patients with progressive forms of MS, which have been difficult to treat,” said Khurram Bashir, MD, director of the Division of Neuroimmunology and Multiple Sclerosis in the UAB Department of Neurology in the School of Medicine.

“This study provides hope for a potentially effective therapy.” In the study, 255 patients were randomized to take up to 10 capsules of ibudilast or placebo Bashir, per day for 96 weeks. Ev- Khurram MD ery six months, the participants underwent MRI brain scans. The investigators applied a variety of analysis techniques on the MRI images to assess differences in brain changes between the two groups. The study showed that ibudilast slowed down the rate of brain atrophy compared to placebo. There was a difference in brain shrinkage of 0.0009 units of atrophy per year between the two groups, which translates to approximately 2.5 milliliters of brain tissue. However, it is unknown whether that difference had an effect on symptoms or loss of function. There was no significant difference between the groups in the number of patients who reported adverse effects. The most common side effects associated with ibudilast were gastrointestinal, including nausea and diarrhea, as well as headaches and depression. MS occurs when there is a breakdown of myelin, a fatty white substance wrapped around axons, which are long strands that carry messages from and between brain cells. When myelin starts

to break down, communication between brain cells slows down, leading to muscle weakness and problems with movement, balance, sensation and vision. MS can be relapsing-remitting, in which symptoms occur then disappear for weeks or months and then may reappear, or progressive, which is marked by a gradual decline in function.

Improving Sleep Quality for Breast Cancer Survivors A study by researchers at the UAB School of Health Professions published in Medicine & Science in Sports & Exercise, the official journal of the American College of Sports Medicine, connects aerobic physical activity — like walking — to better sleep for post-primary treatment breast cancer survivors. The study, titled “Physical Activity and Sleep Quality in Breast Cancer Survivors: A Randomized Trial,” is the first large randomized controlled aerobic physical activity study of its kind in breast cancer survivors who had completed primary cancer treatment. This study found participants who received a physical activity program focused on achieving 150 weekly minutes of physical activity — approximately 20 minutes per day — reported better sleep quality, fewer sleep disturbances and less daytime dysfunction related to fatigue. “Nearly one in three breast cancer (continued on page 25)

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RESEARCH NOTES survivors suffers from poor sleep, and poor sleep is associated with greater breast cancer mortality,” said Laura Q. Rogers, MD, principal investigator of the study and professor at UAB. “So research in this area is critical for survivors and those who care about them. Our findings are significant because the benefits were of sufficient mag- Laura Q. Rogers, MD nitude to reach and exceed the clinically important threshold.” The study, conducted by UAB, Southern Illinois University School of Medicine and University of Illinois at Urbana-Champaign, included 222 breast cancer survivors. Of those participating, 112 received typical care while 110 went through the Better Exercise Adherence after Treatment for Cancer (BEAT Cancer) program. The BEAT Cancer program, based in the Department of Nutrition Sciences, began with six weeks of personal coaching from an exercise specialist. After the six weeks, participants were responsible for maintaining their own exercise regimens at home while checking in with the exercise specialist every two weeks. Participants also attended six discussion group sessions with other program participants. Study measurements were obtained at the threemonth and six-month marks. This study found participants who received a physical activity program focused on achieving 150 weekly minutes of physical activity — approximately 20 minutes per day — reported better sleep quality, fewer sleep disturbances and less daytime dysfunction related to

fatigue. The findings — in which results came from perceived responses rather than an accelerometer — showed that BEAT Cancer significantly improved global sleep quality due to improvements in several global sleep quality components, including perceived quality of sleep, reduced sleep disturbances and less fatigue during the day. Rogers acknowledged that the inclusion of more current sleep measurement options such as bed sensors and sleep recorders in future studies could overcome some of the limitations of measuring self-report sleep quality. She says additional research is needed to determine how the support provided by research staff and other cancer survivor participants may have influenced the sleep improvements. Nevertheless, Rogers is hopeful about the impact of their findings on improving cancer survivorship care and third-party financial support of such programming because of the randomized controlled design, multicenter enrollment and high retention rates. “This study reinforces the importance of providing physical activity programming as a fundamental part of the cancer survivor care plan,” Rogers said. “It is currently recommended that cancer survivors engage in at least 150 minutes per week of moderate intensity physical activity, such as walking. This study suggests that doing so can potentially help a breast cancer survivor sleep better. Hence, cancer survivors can add another benefit to the list of reasons to find a physical activity they enjoy and get moving.” This project was supported by the National Cancer Institute.

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Roberts, 2nd from left, received the award at AHA luncheon in Dallas.

American Heart Association Honors Marcella Roberts The American Heart Association has honored Birmingham business leader Marcella Roberts with the Louis B. Russell, Jr. Memorial Award for her work with underserved populations. As chair of the American Heart Association’s Greater Southeast Affiliate multicultural committee, Roberts led the launch of the Association’s first EmPOWERED To Serve™ affordable housing pilot in the Mississippi Delta. This collaboration serves as a model for partnering with housing authorities nationwide to create safe and affordable environments to address social determinants that impact the health of minority populations. Roberts is the vice president of development at Hollyhand Development, which specializes in all facets in affordable housing finance, development, construction and management utilizing the low-income housing tax credit program. A graduate of Stillman College and Miles Law School, Roberts is a longtime volunteer for the American Heart Association and currently serves as a member of the Greater Southeast Affiliate’s Board of Directors.

Samford’s Sanders and Hogue Named to Alabama Healthcare Hall of Fame Nena Sanders, vice provost of Samford University’s College of Health Sciences and professor of Ida Moffett School of Nursing, and Michael Hogue, professor and associate dean of the Center for Faith and Health, have been named to the Alabama Healthcare Hall of Fame. The Alabama Healthcare Hall of Fame recognizes individuals who have made outstanding contributions to and rendered exemplary service for health care in the state. Prior to being named nursing school dean in 2001, Sanders was transforming nursing practice roles. Her early work with Humana resulted in the implementation of a progressive nursing Nena Sanders and Michael Hogue practice model adopted nationwide by more than 200 hospitals. This groundbreaking model expanded the role of the advanced practice nurse and its hallmark was an interdisciplinary approach for patient care delivery. In 2013, Sanders was named vice provost of Samford’s College of Health Sciences. In this role, she united the university’s four health-related schools—health professions, nursing, pharmacy and public health—under the model of interprofessional education and practice. This approach is redefining health care education. Much of Hogue’s work centers around advancing the role of pharmacists as collaborative members in a team-based model of care. He was a member of the team that developed education, advocacy and practice tools that led to 50 states authorizing pharmacists to administer vaccines. Hogue joined the faculty of Samford’s McWhorter School of Pharmacy in 1999. He was named interim dean of the school in 2014, and in 2016, Hogue was named the associate dean for the Center for Faith and Health. He was recently elected to serve as president-elect of the American Pharmacists Association. McWhorter School of Pharmacy alumnus Donnie Calhoun, the class of 1987, was also inducted in the Alabama Healthcare Hall of Fame this year. Calhoun is the owner of Calhoun Pharmacy, a nationally accredited pharmacy for sterile and non-sterile compounding, in Anniston. Calhoun has served in numerous leadership roles within pharmacy organizations at the state and national level. In 2011, he was appointed president of the Alabama State Board of Pharmacy committee.


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Kezar Affiliates with Aspire Cahaba Laura Kezar, MD, who is a professor and associate dean for students at UAB School of Medicine, is now also serving as the Physiatrist for the Aspire Physical Recovery Center at Cahaba where she is doing rounds twice a week. Kezar specializes in Laura Kezar, MD musculoskeletal medicine, chronic pain syndromes including pain after spinal cord injury, complex regional pain syndrome, and neuropathic pain disorders. Because she follows Aspire patients closely through their rehabilitation process, she may recognize a change in the patient’s condition sooner and suggest changes allowing the patient to continue rehab uninterrupted by a possible hospital readmission. Aspire Physical Recovery Center at Cahaba River is a new care model that specializes in short term rehabilitation.

Pennisson Joins Brookwood Baptist Health Jay Pennisson has been named group chief financial officer for Brookwood Baptist Health and chief financial officer for Brookwood Baptist Medical Center. Pennisson most recently served

as chief financial officer and vice president of Finance for Tenet’s Texas Region, including 21 acute care hospitals and seven micro-hospitals under the Tenet umJay Pennisson brella. He first joined Tenet as a controller at Meadowcrest Hospital in Gretna, Louisiana. He has also served as chief financial officer of Piedmont Medical Center in Rock Hill, South Carolina and chief financial officer of Atlanta Medical Center. He is a 10-time Tenet Circle of Excellence Award recipient.

Samford’s Ida Moffett School of Nursing Receives Grant The U.S. Department of Health and Human Services, Health Resources and Services Administration has awarded Samford University’s Ida Moffett School of Nursing a $2.1 million grant to help make graduate nursing education more affordable for currently practicing or teaching nurses committed to careers in nursing education. This is the largest grant of this type in the nation, and it is one of only three that exceeds $1 million. This is Samford’s 16th year to receive funding for the program. According to Jane Martin, PhD, nursing school senior associate dean

and project director of the grant, additional faculty are needed for nursing schools to increase student capacity. “The Nurse Faculty Loan Program (NFLP) is designed to help address Jane Martin, PhD the shortage of nurse educators,” Martin said. “Students who receive loans for graduate degree programs can have up to 85 percent of the loan forgiven in exchange for service as full-time nursing faculty members at an accredited school of nursing.” The American Association of Colleges of Nursing found that nursing schools turned away 64,067 qualified applicants in 2016-17. Nearly twothirds of the nursing schools responding to the survey pointed to a shortage of faculty as a reason for not accepting all qualified applicants. More than 92 percent of faculty vacancies were positions requiring or preferring a doctoral degree. The NFLP was approved by Congress in 2002, and Samford was one of the first 55 nursing schools from across the U.S. to receive funds. Samford’s NFLP grants now total more than $13.5 million. The 2018-19 grant is expected to help more than 150 students from 18 states in Samford’s Doctor of Nursing Practice program.

Champion Sports PTs Earn Designation Adam Finck, PT, DPT, SCS, CSCS and Andrew Kupper PT, DPT, SCS, CSCS of Champion Sports Medicine have earning the designation as board-certified sports clinical specialists (SCS). According to the American Board of PhysAdam Finck ical Therapy Specialties, as of June 2017, there were only 2,088 sports clinical specialists nationally. Champion Sports Medicine has the most of any provider within 100 miles of Birmingham. Finck and Kup- Andrew Kupper per join team members Nathan Bower, PT, DPT, SCS, Andrew Hutchinson PT, DPT, SCS and Kevin Wilk, PT, DPT, FAPTA with elite sports medicine certifications.

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THE FACE OF A

CURE

Lacey Burleson, RN at the Women’s Pavilion at Northport Medical Center, scans a newborn’s footprint.

DCH among First in State to use New Infant Safety System

ChildrensAL.org/committedtoacure

THE ALABAMA CENTER FOR CHILDHOOD CANCER AND BLOOD DISORDERS is committed to finding a cure for Jacob and the more than 1,500 children each year who come to us for care. At our Center, more than 300 dedicated pediatric healthcare professionals provide exceptional patient care, education and research. We are a founding member of the Children’s Oncology Group * — a worldwide clinical trials organization supported by the National Cancer Institute. PROGRESS IN THE FIGHT FOR A CURE 84% of children diagnosed with cancer in 2018 will be cured. z State-of-the-art screenings have reduced the rate of stroke in sickle cell patients by 90%. (Sickle cell disease is the leading cause of stroke in children). z Expanded programs help children re-enter school and normal life. z We are limiting the late effects of treatments and developing innovative therapies — making real progress in the fight against childhood cancer and blood disorders. z

DCH Health System hospitals are among the first in Alabama to use a new infant safety system that digitally scans a baby’s footprints after birth. The new system allows staff at the Women’s Center at DCH Regional Medical Center and the Women’s Pavilion at Northport Medical Center to capture highresolution footprints of newborns. The digital footprints and a security photo are stored in the newborn’s electronic medical record. The scan can be used for precise identification in situations like abduction, lost baby or natural disaster. “Much like fingerprints, footprints are unique to each baby, so they can be used for identification throughout a lifetime,” said Traci Swann, nurse manager of the Newborn Nursery at DCH Regional Medical Center. The National Center for Missing and Exploited Children recommended the system to hospitals in its most recent Infant Security Guidelines. The system replaces the time-consuming and messy ink and paper method. Each new mother receives a printed certificate of her newborn’s footprint. When she returns home, she can visit www.firstfootprint.com to enhance the certificate with colors, different fonts and borders. She can also download a digital copy of her baby’s footprint. These additional benefits are provided as a gift from DCH.

AFib Awareness Month September is National Atrial Fibrillation (AFib) Awareness Month “Atrial fibrillation (Afib) is a frequent and serious cardiovascular condition that puts a person at risk of stroke or heart failure,” said Gustavo Morales, MD, with Alabama Cardiovascular Group. In atrial fibrillation (AFib), the heart’s two small upper chambers (atria) beat irregularly and too fast, quivering like a bowl of gelatin. It’s important for the heart to pump properly so the body gets the oxygen and food it needs. “Fortunately, there is effective medical and interventional treatment to control symptoms and long-term complications,” Morales said. “The improvements in techniques and technology have resulted in a decrease in the number of patients requiring a repeat ablation for paroxysmal Afib. Additionally, our practice participates in many clinical trials and follow the clinical improvement of patients.”

We are COMMITTED to a CURE for all children — down the street and around the world.

*The Children’s Oncology group is a clinical - translational trials organization with more than 9,000 experts worldwide dedicated to finding better cures and improving the outcomes for all children with cancer.

Gustavo Morales, MD with Alabama Cardiovascular Group

28 • SEPTEMBER 2018

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Irons Joins Alabama Pain Harrison Irons, MD has joined Alabama Pain Physicians. A native of North Alabama, Irons graduated from Samford University with a Bachelor of Science and then earned his medical degree from the University of Ala- Harrison Irons, MD bama School of Medicine. He completed a residency in Anesthesiology from UAB before pursuing a Pain Management fellowship at the University of North Carolina. Irons is board certified in anesthesiology and pain medicine. He believes in utilizing a multidisciplinary approach to promote wellness and treat chronic pain. He believes that chronic pain is best managed through a combination of medication, interventions, and goal directed therapy. He is able to offer his patients a variety of interventional pain procedures including the latest therapies and technologies.

St. Vincent’s Primary Care Adds Two New Providers Carrie Black Huner, MD and Kimberly Beasley Cornelison, CRNP have joined St. Vincent’s Primary Care, seeing patients at the Patchwork Farms location in Vestavia Hills. Huner is a Family Medicine physician who She earned her medical de-

gree at the UAB and completed her residency at the St. Vincent’s East Family Medicine Residency Program. Cornelison is a certified nurse practitioner Carrie Black who earned her BacheHuner, MD lor of Science in Nursing at Auburn University Montgomery and received her Master of Science in Nursing – Family Nurse Practitioner, at UAB. “St. Vincent’s is expanding our primary care network, so we can provide access to care for patients when and where they need it most,” said Ascension Medical Group Administrative Dyad Leader Summer Tappan. “Both Dr. Huner and Ms. Cornelison are truly to listening to each patient’s unique needs and collaborating to find the best treatment plan.”

Children’s of Alabama Recognized Children’s of Alabama was recognized by NRC Health with a 2018 Excellence Award at the 24th Annual NRC Health Symposium in San Diego. Children’s was named the top performing hospital for Excellence in Quality & Service, a measure of service culture, loyalty and retention for the time period of April 2017 through March 2018. “Our team of providers and support staff should be very proud of this

accomplishment. Of the many outstanding organizations qualified to receive this award, Children’s rose to the top because our patients’ feedback scores reflected that they value our customer-focused culture” said Lori Moler, Children’s of Alabama vice president of customer service.

Clemons Joins St. Vincent’s Primary Care Jason L. Clemons, MD has joined St. Vincent’s Primary Care. He will practice family medicine at the Morgan Road location in Bessemer. Clemons earned his medical degree from UAB and completed his Jason L. Clemons, MD residency at University of Alabama Family Medicine Residency in Tuscaloosa, Alabama.

Listi Named CEO of Shelby Baptist Medical Center Daniel Listi has been named chief executive officer of Shelby Baptist Medical Center. Listi joins the Brookwood Baptist Health System having recently served as Group chief operating officer of Tenet Health’s El Paso/ Rio Grande Valley and Daniel Listi COO of Valley Baptist

Medical Center – Harlingten, Texas. Listi began his healthcare career at Glen Rose (Texas) Medical Center before joining Scott & White Clinic in College Station. Thereafter, he spent nearly three years at G.V. (Sonny) Montgomery VA Medical Center in Jackson, MS before returning to Texas at Baptist Medical Center – San Antonio as vice president, Business Development & Physician Services and later regional growth officer for the Central San Antonio region. In 2011, he joined Valley Baptist Medical Center – Harlingten as chief business development officer before assuming his most recent role. Listi holds a Bachelor of Science in Health and a Master of Healthcare Administration from Texas A&M University and is presently a fellow with the American College of Healthcare Executives.

U.S. News & World Names DCH High Performing U.S. News & World Report has named DCH Regional Medical Center a High Performing Hospital in the areas of Chronic Obstructive Pulmonary Disease and Heart Failure. Generally, a hospital must score in the top 20 percent nationwide for a particular medical specialty to earn a High Performing rating. COPD, which includes emphysema, asthma and chronic bronchitis, is the third leading cause of death in Alabama.

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Lewis Joins UAB as Vice Provost

UAB has named Eva Lewis as vice provost for Institutional Effectiveness and Academic Planning following a national search. Lewis came to UAB from the University of Tennessee at ChattaEva Lewis nooga where she was the assistant provost for Strategy and executive director for the Office of Planning, Evaluation and Institutional Research and the liaison for the

Southern Association of Colleges and Schools Commission on Colleges. “I see nothing but promise in UAB’s dedication to pursuing its strategic plan,” Lewis said. In her role, Lewis will provide the Institutional Effectiveness and Academic Planning team direction and context critical for developing the necessary support to implement UAB’s strategic plan, “Forging the Future.” Lewis earned her bachelor’s degree from Lipscomb University and her master’s in business administration from the Vanderbilt University Owen Graduate

School of Management. She is enrolled in the learning and leadership doctorate program at UTC, where she is finishing her dissertation.

Thomas Named CEO of Citizens Baptist Frank Thomas has been named chief executive officer of Citizens Baptist Medical Center. He most recently served as Interim CEO and Chief Operating Officer at Shelby Baptist Medical Center. Thomas began his career with the Baptist Health System in 1990 and later joined Siemens in Birmingham as a Se-

Storytelling May Help Reduce Delirium Many hospitalized patients, especially older adults, are at risk of developing delirium, a risk that is increased by the presence of cognitive, functional, visual or hearing impairment or depression. Performing arts programs that include storytelling and poetry may be beneficial in lowering that risk, suggests a study from UAB. Storytelling and poetry recitation are arts-based experiences designed to enhance healing. These activities provide cognitive stimulation, says Katrina Booth, MD, medical director in the UAB Acute Care for Elders unit and a study co-author. “There are no proven medication options to prevent delirium, so the only prevention is to optimize the patient’s physical and mental health with non-medications,” Booth said. “For each prevented case of delirium, the health care system saves $2,500.” The study, published in Innovation in Aging, is, to the best of Booth’s knowledge, the first to evaluate this association between storytelling intervention and changes in measures of cognitive dysfunction in hospitalized older adults. The pilot study of 50 patients age 65 or older was conducted in the UAB ACE unit at UAB Highlands Hospital in 2016. Two artists-in-residence, part of UAB’s Institute for Arts in Medicine, visited the patients once for 15 minutes of bedside storytelling or poetry during their hospital stay. Patients were asked if they would like to hear a story or poem, and Artist-in-residence Elizabeth Vander Kamp laughs with a patient during an Arts in could choose the type, whether it be religious, humorous, a Medicine visit. folk tale, or a legend. The session was designed to be interactive, with the patient’s having the opportunity to reflect on the story. The effect of the experience on delirium screening scores and patient satisfaction was evaluated and found that an artistin-residence-delivered storytelling experience was associated with a lower delirium score at discharge. The result remained significant after adjusting for age, baseline cognitive impairment and general well-being. Patients with severe agitation or delirium, those who needed medication for delirium, and those who refused or did not want to participate were excluded. “Despite advances in the management of delirium, pain, and anxiety in the elderly population, challenges still remain,” says lead study author Maria Danila, MD, associate professor of medicine in the Division of Clinical Immunology and Rheumatology. “Arts in medicine programs have opened doors to different ways to promote healing. Our study results suggest that the arts in

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nior Project Manager where he was responsible for the management of multiple information technology groups in a large healthcare environment before being promoted to Site Execu- Frank Thomas tive. Thomas rejoined the Baptist Health System in 2005 as Clinical Director of IT before joining Citizens Baptist Medical Center several years later as Director of Operations/IT and subsequently Executive Director of Support Services. In 2013, he was named Associate Administrator of Shelby Baptist Medical Center. Thomas holds a Bachelor of Science degree in Laboratory Technology from Auburn University and a MBA from the University of Alabama.

EDITOR & PUBLISHER Steve Spencer VICE PRESIDENT OF OPERATIONS Jason Irvin CREATIVE DIRECTOR Susan Graham STAFF PHOTOGRAPHER April May CONTRIBUTING WRITERS Cara Clark, Ann DeBellis, Jane Ehrhardt, Laura Freeman, Cindy Sanders, Marty Slay GRAND ROUNDS CORRESPONDENT Frank Sinatra Recipeideas 270 Doug Baker Boulevard, Suite 700-400, 35242 • FAX Ad Sales: All editorial submissions should be mailed to: Recipeideas 270 Doug Baker Boulevard, Suite 700-400 Birmingham, AL 35242 or e-mailed to: [email protected] —————————————— All Subscription requests or address changes should be mailed to: Recipeideas Attn: Subscription Department 270 Doug Baker Boulevard, Suite 700-400 Birmingham, AL 35242 or e-mailed to: [email protected] FOLLOW US

Recipeideas is published monthly by Steve Spencer ©2018 Birmingham Medical News, all rights reserved. Reproduction in whole or in part without written permission is prohibited. Birmingham Medial News will assume no reponsibilities for unsolicited materials. All letters sent to Medical News will be considered Medical News property and therefore unconditionally assigned to Medical News for publication and copyright purposes. ——————————————————

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Michael Minor Named Director of BREMSS

Michael Minor has been named executive director for the Birmingham Regional Emergency Medical Services System, or BREMSS, replacing the retiring Joe Acker. Minor, trained as a paramedic, has been associated with BREMSS since 1993. BREMSS, housed on the UAB campus, is Michael Minor a multijurisdictional agency that coordinates and improves prehospital medical emergency response by facilitating education and communication with emergency medical service agencies, 911 centers and hospitals. BREMSS is designated as the regional EMS agency and is partly funded by the Alabama Department of Public Health, Office of EMS. BREMSS also operates the Alabama Trauma Communications Center, which processes information from 911 centers and paramedics to route trauma, stroke and STEMI (cardiac) patients to the most appropriate hospital that provides the best chance of survival. The agency works with all components of the Emergency Medical Services System, which includes more than 200 emergency medical services organizations, 15 hospitals, more than 2,500 EMSPs, nine trauma centers, 15 stroke centers, eight STEMI hospitals, more than 80 different municipalities and many different 911 agencies. Minor credits Acker with driving the concept of highly coordinated emergency care in Alabama — getting the right patient to the right hospital in the appropriate time frame. Locally, BREMSS developed protocols for stroke, trauma and STEMI response. The concept is now used statewide in stroke and trauma care, and a statewide STEMI system will launch next year. “The statewide systems are all based on knowledge gained from the experiences at BREMSS over the past 30 years,” Minor said. Among the initiatives Minor intends to expand is an effort to provide EMS prevention education to the public. “We call it prevention through intervention,” Minor said. “Various EMS agencies have paramedics assigned to community education. The goal is to find strategies to help keep those residents safe and minimize the need for emergency medical services.” The original BREMSS system was initiated by the hospitals across a sixcounty region of central Alabama, consisting of Blount, Chilton, Jefferson, Shelby, St. Clair and Walker counties, in 1973. Winston County was recently added, making BREMSS a seven-county regional EMS system. BREMSS features a communications center that is staffed around the clock with paramedics. The TCC links all acute care hospitals in the system and communicates with paramedics in the field, so that acutely ill and injured patients can be routed to the most appropriate facility. The on-duty staff has increased from one paramedic per shift to three paramedics on duty at all times since going statewide.

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Are We on the Threshold of Precise AF Management? Current guidelines provide similar recommendations for all AF patients regardless of pattern or burden.1 A recent study, however, may have revealed a new measure to consider. The KP-RHYTHM2TUVEZJEFOUJËŒFEBQSFDJTF threshold of AF burden associated with over threefold increased stroke risk in PAF patients. Visit www.AFburden.com/BMNUPËŒOEPVUXIBUUIBUUISFTIPME is and how it was discovered.

$IFO- FUBM"USJBM'JCSJMMBUJPO#VSEFO.PWJOH#FZPOE"USJBM'JCSJMMBUJPOBTB#JOBSZ&OUJUZ"4DJFOUJËŒD4UBUFNFOU'SPNUIF"NFSJDBO)FBSU"TTPDJBUJPO Circulation, 2018. 2 Go A., et al. Association of Burden of Atrial Fibrillation With Risk of Ischemic Stroke in Adults With Paroxysmal Atrial Fibrillation. JAMA Cardiology 2018. 1

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