Medical Insider Blog

Joint Preservation: Avoiding Total Knee Replacement

  • Posted Apr 15, 2014
  • Francis McCormick, MD

Knee replacements typically last 10-15 years, which means in younger patients, they could face several more surgeries. There are new alternatives available for young active patients with which we are seeing great results.

Cartilage TransplantationCartilage and meniscal transplantation
Athletes in their 20s and 30s who suffer knee injuries (torn ACL or meniscus) can be treated with great success. However, problems may occur five to ten years down the road that are a result of those injuries, and they are at increased risk for early osteoarthritis. These problems get in the way of the patient's active lifestyle. Cartilage or meniscal transplantations may be done to return these patients to their active lifestyles quicker and with less risk of complications, compared to total knee replacements using metal or plastic components. The procedure is done through tiny incisions, which facilitate recovery and involve less pain.

A piece of the patient's tissue - the size of a tic tac - is taken from his or her knee and that tissue is sent to a lab in Massachusetts where the cells are grown and expanded. A few weeks later once the cells have grown, we transplant the expanded patient's cells back in the knee. After a few months, the cells grow within the patient's knee with properties similar to those of the original cartilage, repairing the injury and avoiding total knee replacement. The body is really great at healing itself, we just need to help guide it along.

Donated Cartilage
Some patients donate their cartilage when they pass away. This is a source of natural tissue with which young, active damaged knees may be replaced.

Platelet Rich Plasma
Platelet Rich Plasma (PRPs) and stem cells are also potential sources for cartilage transplantation, to reduce inflammation, enhance tissue regeneration and curb tissue degeneration.

Partial Knee Replacement
When there is significant wear on one aspect of the knee, an overnight procedure may be done called a Partial (Uni-compartmental) Knee Replacement, which involves limited pain and rapid recovery compared to a total knee replacement.

From the Patient's Perspective

One of my patients came to me because he felt he was too young for major knee surgery. Here's his story:

Click to watch WSVN 7 segment with our patient Blake McCormack

Learn more about Dr. McCormick from his physician profile: Francis McCormick, MD.
For information on Holy Cross's Sports Medicine program, visit HolyCrossOrthopedics.com.


Thyroid Problems – Are They Serious?

  • Posted Mar 28, 2014
  • Matthew Shlapack, MD

Different types of thyroid problems
Thyroidal illness is a broad medical category that includes both structural problems such as thyroid nodules and hormonal illnesses such as hypothyroidism and hyperthyroidism.

Is it serious?
Thyroid nodules, commonly called “goiters,” are very common but can contain thyroid cancer and should be worked up. Thyroid nodules can be seen as a generalized enlargement of the lower front of the neck or as a mass in this area, but nodules are not always visible to the eye. Thyroid cancer is not usually aggressive but if present and untreated it can be progressive, placing an individual at serious risk. Fortunately, the workup and treatment is straightforward, and in the hands of a good care team, it can be dealt with and usually cured.

How do I know if I have a disorder of thyroid function?
Abnormalities of thyroid function can cause a wide range of symptoms ranging from fatigue and weight gain in the case of hypothyroidism, to heat intolerance, anxiety, and palpitations with hyperthyroidism.

Normalization of thyroid hormone levels with treatment is important for preservation of good health, avoidance of complications and resolution of these symptoms. Talk to your doctor if you are concerned about your thyroid.

Dr. Matthew Shlapack is an endocrinologist (a physician specialist who treats diseases and illnesses involving the endocrine system – thyroid, hormones, metabolism, diabetes, etc.).


Proposed Changes to the Nutrition Facts Label

  • Posted Mar 17, 2014
  • Jessica Weissman, MS, RD, LDN

Since 1993, the only major change to the Nutrition Facts label has been the requirement to declare trans fat, effective in 2006. Since the Nutrition Facts label is such an important tool to help people make better food choices, the United States Food and Drug Administration (FDA) is proposing to update the label in order to more closely reflect how much American’s actually eat. These changes are intended to have a major impact on food choices and American public health, especially in individuals with chronic diseases such as cardiovascular disease and diabetes. The proposal includes changes to the label’s design to highlight key parts such as total calories and serving sizes.

On average, Americans get 16 percent of their total calories from added sugars in products such as soda, energy drinks, and dairy-based desserts and candy, and health experts recommend that Americans should reduce their intake of calories from added sugar. The new label would require more information about “added sugars” so that consumers who want to limit their added sugar intake can compare brands carrying similar products.

Nutrition Facts Labels Serving Size Changes

Additionally, because the amount of consumption of foods has changed over the past 20 years, the new labels would include serving sizes which reflect the amounts people actually eat (see image). In fact, by law, the serving size information must be based on what people actually eat, not on what they “should” be eating. For example, a 20-ounce bottle of soda would be labeled as one serving rather than as more than one serving. Other proposed changes to the Nutrition Facts label include requiring the declaration of potassium and vitamin D, changing the layout to emphasize certain parts such as percent daily value, and increasing the daily value for sodium intake. The proposed changes would affect all packaged foods except those regulated by the U.S. Department of Agriculture’s Food Safety and Inspection Service, including certain meat, poultry, and processed egg products. The proposed rules are available for public comment for 90 days. For more information, please visit the FDA website.


Rehab, Relax and Restore

  • Posted Feb 17, 2014
  • Rafael Gutierrez DPT COMT

Orthopedic manual physical therapy is a hands-on approach to treating musculoskeletal and neuromuscular dysfunction. Physical therapists trained in manual therapy use specific techniques, such as joint mobilizations, manipulations, soft tissue techniques and therapeutic exercises for improving mobility and function throughout the body.

Conditions Treated

Manual therapy is effective for a wide range of ages and can be used to treat many conditions, including:

• Orthopedic and sports injuries
• Cervicogenic headaches
• Neck and back pain
• Radiculopathy
• Sacroiliac dysfunction
• Postural dysfunction
• Postsurgical issues
• Osteoarthritis
• Ligament sprains
• Muscle strains
• Tendinopathies

How it Works

Manual therapy is effective because it helps restore normal mobility to affected joints and muscles. Joint mobilizations and manipulations help reduce stiffness, increase circulation, decrease pain, and restore mobility in joints to improve biomechanical motion. Soft tissue techniques also increase circulation and relax muscles so they can move through the normal range of motion without restrictions.

Therapeutic Exercise

Therapists who have undergone advanced training in orthopedic manual therapy have also received training in therapeutic exercise geared specifically toward rehabilitation. These exercises may differ from your typical exercise routine because they are dosed and targeted specifically toward the problem areas. Therapists will also address other areas in the body that may be adding to the problematic site during the therapy sessions. Through manual therapy and therapeutic exercise, physical therapists can help patients reduce pain and restore normal function to help patients return to their daily activities.

Rafael Gutierrez, DPT, COMT, is a staff Physical Therapist at Holy Cross Hospital’s outpatient physical therapy clinic in Boca Raton. He may be reached at 561-483-6924. Meet our other therapists and learn how we can help you get moving again at www.HolyCrossOrthoRehab.com.


Holy Cross Hospital Receives UnitedHealth Premium® Cardiac Services Specialty Center Designation

  • Posted Apr 08, 2013
  • By Holy Cross Administrator

Holy Cross Hospital in Fort Lauderdale has received the UnitedHealth Premium® specialty center designation in recognition of quality care.

UnitedHealthcare® developed the UnitedHealth Premium specialty center program to give its members information and access to hospitals meeting rigorous quality criteria. Designed to help members make informed decisions should they need cardiac services care, the designation is based on detailed information about specialized training, practice capabilities, outcomes and cost efficiency of care.

To receive this designation, the non-profit hospital met extensive quality and outcomes criteria based on nationally recognized medical standards and expert advice. The criteria incorporate measurements of breadth and depth of care, staff experience, emergency care, quality and outcomes reporting.

“We are proud to be one of the leaders in cardiac care,” said Patrick A. Taylor, M.D., President and CEO of Holy Cross Hospital. “Our focus on clinical excellence, leading edge technology and state-of-the-art procedures continues to be recognized nationally.”

Holy Cross Hospital offers comprehensive cardiac services through the Jim Moran Heart and Vascular Center and progressive research at the Jim Moran Heart and Vascular Research Institute.

About Holy Cross Hospital
A member of Catholic Health East, Holy Cross Hospital in Fort Lauderdale, Fla. is a full-service, non-profit Catholic hospital, sponsored by the Sisters of Mercy. Since opening its doors in 1955, the 559-bed hospital has offered progressive services and programs to meet the evolving healthcare needs of Broward County. Today, Holy Cross has more than 600 physicians on staff representing more than 40 specialties and more than 3,000 employees. To learn more about Holy, visit holy-cross.com, “like” Holy Cross Hospital, Fort Lauderdale on Facebook, or follow @holycrossfl on Twitter.

Holy Cross Hospital  is a participating hospital in the UnitedHealthcare network but is not owned or otherwise affiliated in any way with UnitedHealthcare: a UnitedHealth Group company.

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Really? Fat is better?

  • Posted Jan 08, 2013
  • Alan Niederman, MD, FACC, FACP
Photo from obesityinamerica.org 
 

 It didn't take long for this year's first article to give me an example to show why I write this blog.  And to top it off, this one is a real beaut.

It was funded by The National Cancer Institute and by the Centers for Disease Control and Prevention.  This article was published in JAMA 2013: 309:71-82 and is titled "Association of all cause mortality with overweight and obesity using standard body mass index categories:  A systematic review and meta-analysis."  What the study said was that if you are overweight, you live longer.WHAT!  I kid you not.  This is why people and patients are all confused.  Coffee is good, coffee is bad.  Chocolate will save your life, chocolate will kill you.  Don't eat eggs, eat eggs.  Next week it will be smoking makes you live forever.  Seven out of 10 adults in this country are felt to be overweight.  In 2010, the CDC (the same people who paid for this foolishness) stated that 74% of men and 65% of women were overweight or obese.

How does this foolishness start?  It starts with using the BMI.  Now, close readers of my blog know that I dealt with the BMI foolishness back on 11/08/11 and 11/10/11 in blog posts titled "The tyranny of a number."  I explained how the BMI came into being and that, in general, it is a flawed number that yields silly results.

So why would anyone use it to do a study?  Further, why would we use tax dollars to pay for it?  Don't we have better things to do with our money?  Wait until the Republicans find out.

The study used a total of 97 studies and then discarded 44 of them because of methodical problems.  That left a total of 2.88 million subjects and 270,000 deaths.  The authors claim that severe obesity was associated with an increased risk of death from all causes.  At least they got that part correct.  "Normal" BMI is 18.5 -25 kg/m2.  It is known that a BMI of 18.5-22 has a higher mortality than a BMI of 22-25.  A BMI of 30-35 was associated with the same risk as the BMI of 22-25.  If you were overweight, you had a 6% decrease in mortality.  If you had Grade 1 obesity, it was a 5% decrease in the risk of death.  Kate Moss is doomed.

To have a better understanding of this true insanity, go to the BMI tables and check your number and see where you fall.  Are you happy now?

If you were really interested in this concept you would find 100,000 40 year olds and measure them.  You would then follow them for umpteen years and find out what their weight was when they died.  However, you really need to find out what their weight was when they became sick as patients are often quite emaciated after long illnesses.

This study was an "all cause mortality" study.  This means that it includes all death not just that from illness. The articles came pouring forth.  Weight Watchers stock took a nose dive.  Commentators went on to say that the likely reason for this finding was that if you were overweight, you were already in your doctor's office being treated for all the problems that might kill you. Realistically, as an article in the New York Times on January 3rd written by Paul Campos pointed out, "there is no reason to believe that the trivial variations in mortality risk observed across an enormous weight range actually have anything to do with weight or that intentional weight gain or loss would affect that risk in a predictable way."

Common sense and the fact that we can't fit into our clothes tell us that we are too heavy.  Just look around you and see for yourselves what we look like as a society.  For a real eye opener, go to any other country and look around.  Articles like this and the reporting that they receive don't do us any good.  We can all stand to lose a few pounds.  We all need to eat less and exercise more.  We all need to grow up and take some responsibility for ourselves.

Don't believe everything you read.


Can’t get enough of a good thing

  • Posted Jan 03, 2013
  • Alan Niederman, MD, FACC, FACP

More news about renal nerve denervation has been released.  I have blogged about this topic in the past beginning on 11/30/10 and 12/02/10.  Further blogs advancing the indications for the device can be found on 03/06/12 and 03/08/12.  We now have one year data that was released in print.

Published in Circulation 2012; 126:2976-2982 and entitled "Renal sympathetic denervation for the treatment of drug resistant hypertension: One year results from the Symplicity HTN-2 randomized control trial."  In a nutshell, at one year the patients who have uncontrollable hypertension in spite of being at maximally tolerated doses of three different medications who undergo this procedure have between a 10-20 mm drop in their blood pressure. This is truly astounding and seems to occur both quickly and/or over time.  Moreover, it still seems to be without consequences. The readers of my blogs know that I am a firm believer in "not fooling with Mother Nature." In general she always wins, and sometimes it is not pretty. This treatment is now well into its 5th year of follow-up, and there still doesn't seem to be a downside.  In general, medication doesn't achieve this type of control.  The side effects of taking three medications that still don't adequately work are significant.

So what's wrong with this picture? Well...let's start with the fact that this treatment is not yet available in the United States.  It is being done in this country under the auspices of the pivotal trial for approval for the FDA but only at investigational sites.  One of these sites is here locally at Baptist Hospital in Miami. This is another example of the delay that it takes for what is obviously important therapy to enter the American arena.  The earliest this procedure will be widely available here is in late 2014.  Everyone is trying to get into the initial rollout of this device and procedure much like the feeding frenzy that occurred with the rollout of TAVR.

It should be mentioned that the individuals in this study did not in general have their blood pressure problem solved.  Their blood pressure became easier to treat, and they were able to stop some medication and decrease their medication burden. However, and this is were it got interesting, the lay press went off and began to herald this procedure as a cure for mild blood pressure problems.  Why did they do this?  It seems that the American Heart Association had a press release that speculated that this technique might be able to be used in mild hypertension and that it might "cure it."

That concept is purely speculative and completely unsupported.  In time that study might be done.  A study might enroll patients who have mild hypertension and see whether it could be "solved" with this procedure.  The patients would then need to be followed for a considerable amount of time to see whether a "clinical benefit" occurred by having the procedure instead of taking medication.  This will be difficult to accomplish.  I can guarantee that when this procedure does hit the street, it will be paid for only when certain criteria are met.  It will not be "all comers."

All of us who treat hypertension have patients who need this procedure.  When it is available, it will be an important advance in the management of this illness, which when left untreated in this population, leads to kidney, heart, and brain damage. It is truly the next big thing.

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This years last word on the use of the new anticoagulants

  • Posted Dec 31, 2012
  • Alan Niederman, MD, FACC, FACP

On July 27th I blogged about the 3rd musketeer apixaban, or as it will be known, Eliquis.  This is the last of the new oral anticoagulants to be approved (full disclosure: the Holy Cross Jim Moran Heart and Vascular Research Institute participated in this study, and I was a sub-investigator).  Why approval took so long is not clear.  It was the only drug of the three that had a mortality difference (i.e. if you took it versus taking warfarin, you had less chance of death).

Like the other two drugs, Xarelto and Pradaxa, this drug does not have a specific antidote in the case of active significant bleeding.  Eliquis will need to be taken twice a day like Pradaxa.  I personally believe that the once a day Xarelto is a better option for patients. Eliquis maybe a better option than Pradaxa.  It was superior to warfarin in preventing strokes 1.27% vs 1.60%.  It had significantly less bleeding episodes than warfarin  2.13% vs. 3.09%.  Any death 3.52% vs 3.94% and death from cardiovascular cause 1.80% vs. 2.02%.

To put these numbers in a more rational way, for every 1,000 patients treated with Eliquis instead of warfarin, six strokes would be avoided, major bleeding would be avoided in 15 patients, and death would be avoided in eight.  Small numbers but this is how we make changes.  The question of how much this costs society is not certain.  I am sure that analysis is being done to add up all the costs, but I have not yet seen it.

How your doctor will decide which one of the musketeers is for you, if any, is not clear.  None of these agents have been or will be subjected to the needed test of which agent is more effective "head to head." This is where the dreaded "drug detail" dance starts.  People will come to see me to convince me of the value of their drug versus the other drugs.  Lucky for me, none of them get to see me since I take no samples, and I will sign for nothing.  My choices are based on evidence.   The same that I present in my blogs.

One last piece of news: as I have blogged about before, there was an attempt to use these drugs in patients who have mechanical heart valves.  Nope.  The FDA has now formally declared to cease and desist, and the study (RE-ALIGN) has been permanently halted.  This is unfortunate as it would have been nice to use these drugs.  I do not believe that the dosing was correct.  We use higher doses of warfarin in this setting and so I believe we needed higher doses of the newer drugs.  It is unlikely that this will be accomplished.

As 2012 comes to a close, I would like to thank you my readers for giving me some time in your busy lives to read my blogs.  I hope that they have provided you a better understanding of the issues that I have presented.  As we head over the fiscal cliff, Medicare providers face an almost 30% cut in fees across the board.  With or without the cliff, angioplasty procedural fees and electrophysiology procedural fees have been reduced by 20% for 2013.  I would like to think that when I perform angioplasty on a patient with an MI, that it is worth something.  I guess it is just 20% less than last year.  Is this any way to run medicine?

Happy New Year.  I wish all my readers and patients happiness and good health in the years ahead.


A hard way to learn an important fact

  • Posted Dec 27, 2012
  • Alan Niederman, MD, FACC, FACP

militaryandflagOur servicemen and women have been asked to provide a great deal over the past years.  Perhaps the last war fought that  truly needed to be fought was WWII.  Many people would agree that since then our battles have not accomplished all the goals that had been set out.  This lack of national focus, however, does not prevent the death and suffering that is the legacy of these events.  These events serve as a valuable insight into one aspect of our society.

Since WWII, autopsy results of some of the young men, and now women, who died during the war underwent analysis of their heart arteries during autopsy.  This data was found to be quite unsettling when it was first presented.  In 1953, 77% of the personnel killed during the Korean War that were analyzed had evidence of atherosclerotic changes in their heart arteries.  This atherosclerosis varied from advanced to minimal.  In most cases it was minimal, but the fact that it was present at all was a shock to medicine.

How can an illness like this take hold so early in life?  Are we all doomed to have it?  Can it be prevented? In our country's never-ending attempt to provide fresh data, the servicemen from Vietnam were subjected to the same analysis and were found to have a lower incidence of atherosclerotic changes.  45% of servicemen had evidence of disease.  How the prevalence diminished was not - and is not to this day - understood.

Once again we have had the opportunity to perform this analysis on the servicemen from Afghanistan and Iraq.  As reported in JAMA 2012;308(24):2577-2583, we now have the data from this cohort, and this data set is more complete as we have other information that allow some conclusions to be made. The average age of the group was 26 years old.  3,832 service members were included.  The coronary lesions were divided into minimal which is a fatty streak, moderate (10-49% of the lumen of the artery) and severe (>50% obstruction of the lumen of the artery).  Any atherosclerotic lesion was found in 12.1% - a significant decrease from the 45% of the Vietnam era.  Minimal disease was found in 1.5%, moderate disease was found in 4.7% and severe disease in 2.3%.  Not surprisingly age was the strongest predictor of disease.  Those individuals 4o years old or older had a prevalence of atherosclerosis of 45.9% compared to 24 year olds at 6.6%.

If the subject had high cholesterol, the prevalence was 50.0% vs 11.1%,  hypertension 43.6% vs. 11.1%, obesity 22.3% vs.11.1%.

It is not at all clear as to how the decrease in the amount of atherosclerosis has occurred over a short period of time.  We as a nation have certainly not changed our habits to account for this.  One difference in this group is that they were volunteers, and the other servicemen were predominantly drafted into the service.  How that affects the numbers is not clear.

No matter how you analyze the facts, the difference is striking.  Further, the risk factors of high cholesterol, hypertension and obesity hold up.  It is a clarion call for "prevention." We may have a chance to "prevent" some of this if we as a nation start early enough. I would like to think that this is the last time we will see data that was derived in this way but I'm not that naive.  I wish there was another way.


Throw away your niacin (Part II)

  • Posted Dec 25, 2012
  • Alan Niederman, MD, FACC, FACP

This part of the story surprises even me.  The HPS-2 THRIVE study was stopped by Merck this past week.  This was a huge study run by Oxford University in England.  It utilized 14,741 patients from the United Kingdom and Scandinavia and 10,932 patients from China.  Hold up!  What does this say about China?  Have they finally succumbed to the diseases of the West?  Does any research get done in the United States anymore? After four years of follow-up, this study showed no benefit in adding niacin to a statin in reducing cardiovascular events.  Further, there was a statistically significant increase in some types (not specified) of non-fatal serious side effects.  The story here is even more bizarre than AIM-HIGH.

First, the background: The compound being tested was a combination drug.  The two drugs in the pill were extended release niacin, known as Niaspan, and a new drug laropiprant. The drug laropiprant is a DP1 blocker and works on vascular cells to prevent flushing.  The concept was that the laropiprant would block the side effect of the flushing in the niacin so that people would take the medicine.  This drug has been tested before and was used for a period of time in the United States in 2008.  The FDA issued a "non-approvable" letter to Merck after their first United States study, and they were forced to do further work on the compound.  The  compound known as Tredaptive or Cordaptive is being sold and used in Europe, but now the European regulatory bodies will look into the compound based on this study.

Still not satisfied with the answer, the naysayers (like the NRA) blame everyone and everything except the obvious.  Maybe niacin just doesn't work?  Among the reasons that this study did not prove their point was because this study was all-comers.  This meant that the baseline HDL was 50 mg/dl.  Raising the HDL by 20% in that case would mean a HDL of 60 mg/dl.  I see two points here.  The first is that it says something when a group of patients who have cardiac disease have a mean HDL of 50 mg/dl.  That is felt to be rather high.  The risk is felt to be the greatest in low HDL like 30 mg/dl.   Maybe the whole idea of HDL and raising it to prevent cardiovascular outcomes is not correct.  Maybe Earth is not the  center of the universe.  Why didn't Merck only enroll those that had the lowest numbers?  The second - and perhaps more profound - reason that this study failed is because no one really knows what laropiprant does or what deleterious effects it might have. What if it counters the effect of Niaspan on the artery?  The study should have included more tiers, one of which would have been laropiprant alone.  Why did it not?  As I have mentioned before, the cost of all this is astronomical and getting higher all the time.  We are approaching a point where drug development may come to a grinding halt because the cost of development does not allow a company to obtain a profit.

Where do we go from here?  Eat sensibly, lose weight, stop smoking and take as much statin as you can.  The rest seems to be a waste of time and money.  We as a society will have to wait for the next big idea.  We are out of them for the time being.  I only hope that when the idea comes, we will have the ability and will to test it and bring it to market. I wish all of you a Happy Holiday season.


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About Holy Cross Hospital

Holy Cross Hospital is a nonprofit, Catholic hospital in Fort Lauderdale, Florida, dedicated to innovative, high quality and compassionate care. For nearly six decades, Holy Cross has continuously expanded its services to provide leading-edge care for their patients in Florida and for those from elsewhere in the United States. Holy Cross also offers an International Services program to ensure that patients from outside the U.S. receive the care they need.

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