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Adam Weiger Amber Davis, R.N. Anne C. Jewell Ashleigh L. McKenzie Belinda Maples, M.D. Ben Macklin Bobi Jo Creel, MSN, CRNP Brett Davenport, MD Brian Baer Cameron Smith Page Carmen Moyers RD, LD Christen Burns Bridges Cobb Alexander, MD Crystal Barber, MBA Curt Freudenberger, MD D Kishore Yellumahanthi, MD, MPH David B. Engle, MD, MS, FACOG David Kumbroch Donald Aulds, MD Elisa Brooks Elizabeth McCleskey, DO George Faison, MD Greg Brown Heather Mendez Heather Morse, MS, ATC, OTC Jackie Makowski Jarrod Roussel, PA-C Jason Lockette, MD, MBA Jill Windham John Johnson, M.D. Jonathan Ramsey, MD Josh Woods Julie Drzewiecki, MS, RD, CDE Kaki Morrow Kari Kingsley, MSN, CRNP Kelly Reese Kimberly Waldrop, MA Kristin Scroggin LaChara Fletcher Larry Parker, MD Margetta Thomas Marilyn Ligon, MD Mark Beaird, LPC, NCC Matthew Clayton, M.D. Michael Beuoy, PT, Cert. MDT Michael Potter Michael Salter, MD Neeta Kohli-Dang, M.D. Neil Lamb, PhD Nick Thomas Nikki Rohling Nisha Mailapur Noel C. Estopinal, MD Patricia Hartley Patti Hutchison Paul J. Fry, M.D. Paul Vandiver, OD Philip B. Adamson, MD, MSc, FACC Rachel Sullivan, MFTA, CFLE-P Ragan Bailey, MA, ALC Ray Sheppard, Jr., MD Rodney Farmer Salpy Pamboukian, MD Shelly Rich, R.N., LBSW Shivani Malhotra, MD Stephanie Perez, PT, DPT Sydney Taylor Teairah Wilder Tiernan O'Neill Traci McCormick, MD Victor Chin, MD William T. Budd, Ph.D Winston T. Capel, M.D., MBA, FACS, FAANS
Dear Readers-
consumer Guide to HealthCare
If eating an apple a day kept the doctor away, we would invest in an orchard, right? Better, if we understood our human make-up as rare and complex, could we outrun illness all together? At Inside Medicine, it is our desire to compile information that provides educational tools to act as a guide during healthcare challenges. As we face the uncertainty of a global pandemic, we can be encouraged by the revolutionary breakthroughs that are taking place in medicine. And while we cannot outrun the social and economic impacts of COVID, and future unknown healthcare concerns, we can make it easier for people to access educational articles that will satisfy their need for additional medical education. The practice of medicine has certainly evolved over the years. Physicians have now recognized the importance of sub-specialties. Medical facilities are categorized by area of primary focus; cardiology, spine and neuro, vascular, mental health, lifestyle medicine, orthopedics, endocrinology. Many trending specialty centers have popped up around communities to better serve patients and their families. For example, dialysis treatment centers are on the rise across the country. Cancer patients are now given IV chemotherapy among a community of peers, instead of being treated in an isolated environment. These type of changes in medicine allow patients to be encouraged by friends and family, as they walk away with new found hope and faith. In many ways, that is why Inside Medicine exist. As you read articles by our qualified and experienced contributors, many of which are some of the best in the industry, you will be encouraged to keep fighting through the healthcare challenges that all of us will face at some point or another. You will also have access to practical content from how to create nutritious eating habits on a budget, to editorial pieces concerning wellness strategies for every lifestyle. Our editorial is diverse but our focus and overall theme remains the same – God’s goodness and the promise that we have a hope and a future. With faith, we need not worry. It is a blessing to deliver this information!! We invite you to join us and enjoy all that comes from being encouraged that you are not alone. We are all in this together and we are honored to be a part of your journey.
eese Kelly R
by, Jason Lockette, MD, MBA
HEALTHCARE INNOVATION COMES TO HUNTSVILLE
The U.S. spends more per capita on healthcare than any other country in the world yet we do not have outcomes to support those huge expenditures. We all know this, yet healthcare costs continue to outpace inflation. Why is this, and what can we do to be more responsible with our healthcare resources? I believe empowering consumers with information through technology is an important component of any solution. Let me explain.
How it works
Download the app and chat with K whenever you don’t feel right. She’ll show you what to expect based on people like you who felt the same.
EVERYONE NEEDS ACCESS TO INFORMATION
In a system as complex as medicine where only the providers have the information we all need to make informed decisions, it’s hard for patients to know when and where to go for care, which often leads to over-utilization. As professionals, we’re paid for this, and our payment is often increased if we decide to do additional testing or treatment, whether or not it’s needed or has any measurable impact on the patient’s health. Every year we see overcrowding in emergency departments and urgent care centers during flu season. Very few of those patients receive any measurable benefit from their visit. They are diagnosed with influenza and experience a few days of fever, chills, and body aches regardless of whether they take any medication. This over-utilization adds cost and decreases access to healthcare for patients whose outcomes we can actually affect.
REPLACING “DR GOOGLE”
Meanwhile, online health content is overly general and sometimes incredibly misleading. At Integrity Family Care, we partnered with a new AI powered health app, called K, to give our patients access to information that is based on real cases from similar people who had similar symptoms. K is not intended to replace a provider but, rather, to replace “Dr. Google.” K recognizes the difference, for example, in the significance of a particular symptom in someone who is 25 years old versus someone who is 75 years old, so the app provides users with information that’s actually relevant to their age, gender, and symptoms. In addition, our partnership with K allows our patients to share their K report with their provider if they choose.
When we review patients’ K reports, we see detailed information about their symptoms as well as important symptoms they don’t have. We’re able to reassure patients who might not benefit from a visit while expediting the care of those who may have more emergent conditions. K leaves both patient and doctor more informed, which helps us collaborate faster on developing the right care plan for the patient. Our intent is to decrease the number of unnecessary and costly visits while increasing access for patients who really need to be seen. Wouldn’t it be better if we could devote more of our time as providers to helping patients manage dangerous chronic diseases such as diabetes and hypertension? Better control of these conditions results in fewer hospitalizations and a longer, more productive life. Meanwhile the majority of patients with non-emergent acute issues have enjoyed being able to monitor symptoms at home or pick up a prescription without an in person visit. The feedback has been overwhelmingly positive.
EMPOWERING PATIENTS WITH TECHNOLOGY
Wouldn’t it also be nice if you could see how patients just like you with symptoms just like yours were diagnosed and treated? With this information in hand, patients are reassured to see the kind of care they might expect to need, avoiding
unnecessary visits, the total cost of which can be upwards of $500. We have also seen that by having the ability to share your information with your provider, we can arrange for more timely and efficient access for patients whose conditions warrant further evaluation. K works for adults 18-85 and the app is free in the app store and Google Play. Try it out and see what it is like to use a health app that actually provides relevant, reliable health information. Think about what it would be like to read a K report before walking into an appointment. In fact the vast majority of patients who have shared their reports with us so far have been reassured to rest at home or prescribed medication that they can pick up at the pharmacy without a visit. This is just the beginning of how we can begin to provide practical solutions by empowering consumers with information through technology.
HOW INTEGRITY + K CAN HELP:
K can provide you with information from patients just like you who have had the same symptoms. By having this information, you can then make an educated decision as to whether or not you want to visit your provider. If you aren’t sure, and are a patient of Integrity Family Care, you can elect to share the information with us and we will respond. We might reassure you, expedite your visit, electronically send medication, or coordinate additional testing prior to your visit if needed. Jason Lockette MD, MBA, President, Integrity Family Care 1041 Balch Rd #300, Madison, AL 35758 256-325-1540 www.integrityfamilycare.com
EXAMPLES OF OVER-UTILIZATION AND UNNECESSARY CARE ANTIBIOTICS FOR VIRAL INFECTIONS:
It is estimated that only about 2% of viral upper respiratory infections (common colds) progress to bacterial sinusitis. Even if you are unlucky enough to get a bacterial infection, antibiotics will decrease the length of symptoms by only about one day. Yes, that is correct. Patients spend hours in an urgent care center or ER, pay their copay and deductible, buy an antibiotic, deal with the side effects, all for one day less of symptoms. Consider, also, the added risk of potential allergic reactions, Clostridium difficile infection, and antibiotic resistance and you have to wonder why we continue to do this to our patients.
Send us your results.
Share your report with us when you see the prompt. If we get it before 2pm, you’ll hear back same day. After 2pm, we’ll reply by 10am the next morning.
We’ll fast track your care.
You’ll get a message with suggested next steps. We might recommend rest, medication, a test, or a priority appointment.
Inside Medicine | Late Summer Issue 2018
9
Telemedicine
By Sanat Dixit, MD, MBA
& the Blockbuster Video Experience
Movies. Seems like we’ve all been streaming lots of movies recently because of the lockdown. On Demand. Rent and watch now. Download and watch later. Sheltering in place has been good for digital media companies. (We have to stay entertained to not go Covid-crazy.) Now recall what the experience of renting a movie was like, not even twenty years ago. You went to the corner Blockbuster, walked the aisles and sifted through hard plastic DVD boxes or (if you were really old-school) VHS cassette tapes; looking for a copy of Gladiator or that movie where Tom Hanks kept talking to a volleyball. Our movie selection experience centered around driving, parking, sifting, waiting, eyeballing microwave popcorn, paying, driving back and hopefully remembering to return the movie in 48 hours. It was what we expected – it was normal, and quite frankly, it stunk. Blockbuster was a huge, $8.4 billion dollar business but then Reed Hastings started a company to redefine the video rental market in 1997. They had a simple idea – make video rental convenient, and skip the store. They had no idea how much they were about to redefine the new normal. Some people would say this is a great comparison to telemedicine and the “typical” venue of healthcare. This is almost true, but not quite. COVID-19 has starkly reshaped what’s normal in healthcare. Social distancing bred a near complete standstill of most hospital operations. Clinics and physician offices saw a drop in patient visits. (Waiting rooms became less popular than Nick Saban loitering at Toomer’s Corner.) But, in reality, doctors and patients still needed to see each other. In a moment that can be considered monumentally novel, the Centers for Medicare & Medicaid Services slashed the red tape associated with telemedicine visits, enabling access and ensuring reimbursement for services previously not covered. The scope of technology approved to allow virtual visits between providers and patients was also expanded; allowing for Facetime and Skype to be used for video chats, at least temporarily. What is telemedicine, exactly? Simply put, it’s a way of sharing health information and providing care using modern telecommunication devices, when the doctor and patient are not physically together. The most commonly used is video
“
chat, but other examples include use of secure messaging and remote patient monitoring. I think of it as a supplement to the traditional doctor visit, not a replacement. I’ve used virtual visits in some way, shape or form for the better part of 6 years. I quickly learned that most of the sales pitches around telemedicine centered around technology solutions geared to hospitals, like robots that made hospital rounds, and less around allowing physicians to provide better care. I started my first telemedicine company in 2014 with a focus on managing avoidable hospital readmissions from nursing homes and rehab facilities. (One in four nursing home Medicare patients were readmitted to the hospital and those readmissions cost Medicare in excess of $11 billion in 2011 alone.) We discovered the most valuable element wasn’t the technology, it was the ability to keep the onsite nurses and offsite doctors connected. Empowering front line care staff allowed for better patient care. Patients liked being looked inon by their doctors; while their family members found it reassuring. What we also discovered was that even though we were solving a significant healthcare problem, the nursing homes didn’t want to adopt the service because the status quo was good enough. (It wasn’t.) I also used telemedicine as a neurosurgeon to help triage offsite patients at community hospitals where a neurosurgeon wasn’t readily available. This enabled us to provide more appropriate care closer to home for most patients, who most definitely did not need to be airlifted 100 miles from home to have me say they wouldn’t need surgery. The democratization of tele-health came out of necessity; but the services have been available for many years. Many health plans offer tele-health visits through established provider platforms like Teladoc and American Well. Many large health systems offer their own tele-health services for things like front line triage of acute stroke patients. The promise of increased access and improved efficiencies fostered an uptick in telemedicine companies; offering up everything from generic HIPAA compliant video chat platforms, to well funded startup companies offering direct-to-consumer healthcare services. Patient focused telemedicine has also become associated with technology - and that is both a good and bad thing. Many of you may
COVID-19 has starkly reshaped what’s normal in healthcare.
l
0
have already had your first telemedicine encounter, running the gambit from being a great visit to a frustrating placeholder until you could physically be seen in the office. The reality is telemedicine is not about what device, app or gadget you’re using. It’s about allowing patients and doctors more direct access with each other, and about delivering a better healthcare experience. By the time you read this, we will hopefully be well past the peak of the COVID curve. Everyone has been clamoring for a return to normalcy. Hospitals and physician clinics may return to something close to normal, but it will never quite be the same. The pandemic forced the system to adapt and evolve. Another spike in cases may be on the horizon very soon. We discovered there were some unique benefits and efficiencies to telemedicine and it’s not going away. Let me say that again - IT’S NOT GOING AWAY! Before the COVID pandemic, we ran a pilot at SportsMED using telemedicine to interact with post surgical patients. We found patients enjoyed the convenience of a virtual visit, stayed more engaged with their post operative care plans, and described a better experience overall. We’re working on the next phase to minimize wait times and improve access to our providers. (I cannot imagine anything more frustrating than taking time off work and wasting 4 hours of the day, to have a 5 minute check-in with your doctor.) Some people still want the status quo, because it’s familiar and waiting is what they’ve come to expect. I would argue if you’re spending 4 hours in a waiting room to see a doctor, maybe neither one of you is doing it right. Not every telemedicine visit is going to be the same. Some providers will use it more effectively than others. Done poorly, it adds little value - sort of like putting a drive thru window in a video store. Done correctly, it becomes a game changer for healthcare. Then again, some things will never change - some doctors will expect patients to wait to see them, and some patients won’t feel comfortable unless they are seen in a hospital or clinic for every healthcare visit. Things evolve and tastes change, especially when something like Netflix comes along and shows us how much easier and better it can be to accomplish certain things. Blockbuster Video declared bankruptcy in 2010. Netflix grew to an enterprise value of over $201 billion because they delivered what was really important to their customers improved access and offered a better experience. Nowadays, no one should settle for the Blockbuster experience from 20 years ago, even in healthcare - especially in healthcare.
Dr Dixit is a neurosurgeon with SportsMED Orthopedic & Spine Center. He is the founder of two tele-health 1companies. He enjoys movies but always paid a late fee when renting DVD’s at Blockbuster.
Preventing Provider BurnOUT
by Kari Kingsley, MSN, CRNP
Dr. Lowery: Throwing back his third cup of lukewarm 3-hourold coffee as he’s running over an hour behind in clinic, the good doctor rolls his eyes as he picks up the chart to Room 7. It’s involuntary. His body becomes rigid and he struggles to put on his best fake smile as he enters the room. Like a psychic reading Tarot cards, he predicts the seemingly never-ending barrage of questions that await him as soon as he opens the door. His patient doesn’t disappoint. She is holding an entire page and a half of college-ruled hand written questions to go over… in detail… Ethel Flannergan: Nervously moving her eyes from her watch to the back of the door in Room 7 and to the list of questions and symptom log she diligently poured herself into the night before, Ethel waits the hour and sixteen minutes to see Dr. Lowery. She has carefully addressed each symptom she’s had over the last few weeks, months, even years, in an effort to help her doctor sort out the debilitating fatigue she’s been experiencing. She’s been waiting over an hour, first in a waiting room with sick people coughing, and now in a cold and sterile room. She paid a $50 copay, but it’s worth that and more for a chance at regaining her quality of life. These different perspectives are two sides of the same coin. The fictional Dr. Lowery is hands down one of the best in his field. He is an excellent physician but the strain of owning and operating a private practice is taking its toll. The hiring, firing, and staffing issues, along with insurance reimbursement, broken EMR systems, taxes, malpractice insurance, and the ever-present pressure that his patients’ lives are in his hands weighs heavily on his mind. He loses sleep over medical traumas he has seen in his career; he knows that losing a patient can put a permanent mark on a person’s soul. Ms. Flannergan on the other hand is a pleasant person who wants answers (and appropriate treatments) to get her life back on track. Physicians, nurses, medical assistants, scrub techs, nurse practitioners, CRNAs, phlebotomy techs… you name it, provider burnout is real. And it is becoming a real problem. Burnout is the culmination of emotional bankruptcy, disconnection from patients and coworkers, declining career satisfaction, self confidence in your scope of practice, overall exhaustion, and a diminished sense of personal accomplishment. In today’s modern go-go-go society, it is becoming an epidemic. Medical schools and nursing programs train us to strive for excellence. Anything less than superhero status is unacceptable. That can be a lot of pressure. Most of us can’t leap tall buildings in a single bound. We are just human. Oftentimes in medicine, decisions have to be made in the blink of an eye that can save (or cost) someone their life. Medicine, while very rewarding, is a stressful career path. Chances are high you know someone in the medical field that can attest to their rigorous schedules. Increasing workloads, long hours, emotionally and physically challenging patients, high accountability, demanding family members, and a legal environment in which every other interstate billboard is a lawyer offering a big payout, takes its toll. Medical providers are at higher risk to abuse alcohol and drugs, and oftentimes have a higher rate of anxiety, depression, and even suicide. The numbers are shocking. According to the American Foundation for Suicide Prevention (AFSP), 28% of medical residents experience a major depressive episode during training compared to 8% of similarly aged individuals in the general U.S. population. The suicide rate
among male physicians is 1.41 times higher than the general male population and among female physicians, the relative risk is 2.27 times greater than the general female population. In one study, 23 percent of interns had suicidal thoughts. So, what’s the solution? AFSP suggests that physicians and healthcare workers who proactively address their mental health needs are better able to optimally care for patients and sustain their resilience in the face of stress. “Mental health problems are best addressed by combining healthy self-care strategies (which should not include self-medicating) along with effective treatment for mental health conditions.” Regular exercise, a healthy diet with proper nutrition, yoga, meditation, rest, and vacations are just a start. Addressing the emotional needs of the providers is crucial. Perhaps the most important step to addressing provider burnout is talking to someone about their mental health issues. Consider changing work hours, or even positions depending upon the level of stress and anxiety. Nurturing healthy relationships with family, friends, and colleagues is also integral in preventing provider burnout. In a perfect world, Dr. Lowery would be able to take hours to address Ethel’s ailments, but in the real-world providers must manage their time to best serve patients while also preventing their own burnout. Providers aren’t superheroes, but most are compassionate caregivers that entered the medical arena in the hopes of helping others. Providers take a Hippocratic oath to do no harm. They are sworn to uphold specific medical ethics and to put the health of the patient above all else. But they also have a responsibility with that oath to take care of themselves. With a little self-preservation and self-kindness, they will be able to go on treating patients while treating themselves as well. Helpful resources for providers in distress: • Acumen Institute: Specializes in acute distress assessments and education for medical professional. www.acumeninstitute.org • Depression and Bipolar Support Alliance: An advocacy group that provides support, resources and information for people living with depression and bipolar diagnoses. www.dbsalliance.org • National Suicide Prevention Lifeline: Provides confidential support to people in suicidal crisis or emotional distress. 1-800-273-TALK (8255) suicidepreventionlifeline.org • Vanderbilt University Program for Distressed Physicians: Offers a 3-day course that provides help for distressed physicians in a confidential environment. • The American Foundation for Suicide Prevention: Medical provider-specific suicide information, including the documentary Struggling in Silence. www.afsp.org
Kari Kingsley, MSN, CRNP is an otolaryngology nurse practitioner with over 8 years of ENT experience who currently works at Huntsville ENT (256-882-0165). She is a medical writing consultant for Inside Medicine and enjoys writing articles on pertinent material to keep the residents of North Alabama up to date on the forefront of medicine.
WHY WE NEED ETHNIC DIVERSITY IN MEDICAL RESEARCH by, Victor Chin, MD
Imagine you are being treated for cancer with a chemotherapeutic drug. You assume the drug is approved by the U.S. Food and Drug Administration (FDA) to be safe and effective for your particular cancer condition based upon results from medical research trials. Did you know if you are a person of color your cancer drug may have never been tested in your unique ethnic or racial group? In essence, you could be an unwitting participant in an unregistered medical experiment. MINORITIES ARE UNDERREPRESENTED IN RESEARCH STUDIES: Cancer specialist Dr. Jonathan Loree and colleagues in the August 15, 2019 edition of Journal of the American Medical Association Oncology reviewed 230 cancer drug trials conducted from 2008-2018 that involved over 112,293 participants. Only 7.8% of the 230 studies documented participants from the 4 major races in the United States (white, Hispanic, black, Asian). The percentage of trials including participants from different racial groups did not change significantly over the 10 year period. The percentage of Hispanic and black participants in the cancer studies was far lower than the proportion of Hispanic and black patients who would have disease in the general population. The burden of disease among minority groups was not addressed in the makeup of participants in cancer research studies. THE EFFICACY OF A MEDICATION CAN VARY IN DIFFERENT RACIAL GROUPS: Why is it important to study medications in various racial/ethnic populations? A particular medication’s efficacy may vary depending on the patient population. For example, current guidelines from the American Heart Association recommend that for treatment of hypertension in black patients a physician start with a thiazide-type diuretic or a calcium channel blocker. In research studies, these medications have shown relative greater efficacy in blacks for hypertension as opposed to an angiotensin converting enzyme (ACE) inhibitor, which is often used first-line in other patients. THE ARGUMENT FOR SOCIAL JUSTICE IN MEDICAL RESEARCH: Numerous advocates raise the issue of social justice in medicine - the idea that racial group disparities in the delivery of healthcare and outcomes in health should be eliminated. The inclusion of people of color in medical research is crucial to improving health for all people in our society. The FDA has recognized the importance of diversity in medical research and in 2016 issued a non-legally-binding guidance statement encouraging study sponsors to include more racially/ethnically diverse participants in trials:
“FDA expectations are that sponsors enroll participants who reflect the demographics for clinically relevant populations with regard to age, gender, race, and ethnicity.” In June 2019 the FDA released a new draft guidance statement furthering its encouragement of diversity in medical research in which it stated: “Broadening eligibility criteria and adopting more inclusive enrollment practices will open clinical trials to a diverse participant population reflective of the population that will use the drug if the drug is approved.”
Personalized healthcare and medicine have brought this issue front and center. The keyword here is ‘personal’ which for me involves the reality that every male on my biological father’s side of the family died from cancer. The fact that I have sons that may be affected by the lack of racial diversity in medical research hits home. I could no longer be a bystander when witnessing the lack of ethnic diversity in both genomic research and clinical trials. I thought that if government and policymakers will not address this form of health disparity and health inequality, then it is up to me to intervene and make a positive impact. I want to ensure the treatments of the future apply to people of color.” -Delmonize “Del” Smith, founder and CEO of Acclinate Genetics explaining his inspiration to diversify medical research.
I n s i d e M e d i c i n e | Fa l l I s s u e 2 0 1 9
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HudsonAlpha: Impacting by Maureen Mack
HudsonAlpha Institute for Biotechnology
The statistics surrounding Alzheimer disease are staggering and frightening. More than five million Americans have Alzheimer disease. The cost of Alzheimer: $259 billion in 2017 alone. The human cost of Alzheimer and other dementias also continues to grow. According to the Alzheimer Association, the number of deaths from Alzheimer has increased 89% since 2000. At HudsonAlpha Institute for Biotechnology, scientists are on the forefront of leading technology to help us better understand Alzheimer disease and other neurological diseases.
Disease samples to learn more about the genetic causes of Alzheimer disease and related disorders. Identifying New Causes This unique group of patient samples is comprised of a mix of early onset Alzheimer disease patients, typical Alzheimer patients, those suffering from other dementias and “control” cases. The early onset cases are of particular interest to the science team at HudsonAlpha.
“We know there is a significant genetic component to Alzheimer and related dementias,” said Rick Myers, PhD, president and science director of HudsonAlpha. “Now, we can truly begin to explore those root causes and search for new therapies and prevention strategies.”
“Researching early onset cases increases chances of finding new, causative genes at a lower cost and less time. Hopefully with this large group of rare, early onset patient samples, we can more quickly identify new genes associated with Alzheimer disease in a more cost effective manner,” explained Dr. Myers.
HudsonAlpha scientists will apply a number of different methodologies and experimental processes to a large set of patient
Using a collaborative approach, HudsonAlpha will share findings with the entire research community, which will increase the power to
identify new genes with confidence. This will aid in developing new, targeted medicines that benefit patients. “This is a huge opportunity to advance our knowledge of why some people get these diseases and others don’t,” said Dr. Myers. “Our findings could lead to better screening tools, early detection, prevention, improved medicines and possibly cures.”
Using knowledge from their successful program with another neurological disease, they will explore the potential for gene regulation with Alzheimer disease by identifying all the “on/off ” switches for known Alzheimer disease genes. By learning how to turn off the abnormal genes, research may lead to completely new therapeutic approaches that could significantly slow or stop progression of Alzheimer disease.
Early Detection Based on recent research, it is known that the underlying disease process starts decades before symptoms. If the process can be targeted before symptoms that would be a much better option as early detection of Alzheimer disease is known to improve treatment outcomes. HudsonAlpha will apply its expertise in immunogenomics (applying genomic technologies to better understand the immune system) to help identify the earliest onset of Alzheimer disease. By analyzing the immune response found in the blood of Alzheimer patients, HudsonAlpha can generate a picture of health – called the immune repertoire – that may allow clinicians to detect disease long before symptoms appear or are recognized, making early drug therapies more effective. If successful, this new diagnostic test could offer patients alternatives to the current more expensive tests. Discovering New Therapeutic Approaches All genes have an “on/off ”switch. Controlling how genes are turned on and off is an important process called gene regulation. HudsonAlpha scientists are experts in this method and have experienced positive results.
Live cells from human skin cells that have been grown in the lab as neurons. Watching the cells while they are alive provides valuable insight, such as reaction to treatment. Photo credit: Nick Cochran, PhD
“Often what people really want to know is how close we are to effective therapies, which can be almost as good as a cure,” said Nick Cochran, PhD, a postdoctoral fellow in the Myers lab at HudsonAlpha. “The first key idea is that prevention is going to be the name of the game.” To learn more and support HudsonAlpha’s Alzheimer disease research, visit http://hudsonalpha.org/memory-and-mobility-fund.
By the Numbers: (Alzheimer’s Association) More than
5 million
Americans are living with Alzheimer disease today; that number will triple by 2050
Dr. Myers
Every
66 Seconds
someone in the U.S. develops Alzheimer disease
$259 billion cost for people with Alzheimer
and other dementias to the nation
Nick Cochran, PhD
The HudsonAlpha Institute for Biotechnology is a nonprofit research institute, but also has more than 30 for-profit biotech companies on its campus. One company in particular is Serina Therapeutics, a pharmaceutical company that has developed a proprietary, patented polymer technology for drug development. Using this Randall Moreadith, MD, PhD President and CEO of Serina Therapeutics
technology, the company developed a oncea-week injection, called SER-214, which may not only reduce the amount of needed treatments, but it may also become an alternative to levodopa—a common Parkinson’s drug which causes a well-known side effect associated with the disease.
How common is Parkinson disease in the U.S.? As many as one million Americans in the US are presently diagnosed with Parkinson disease, and approximately 60,000 new patients are diagnosed every year. It is one of the most common and debilitating neurological diseases in the US and worldwide, with as many as 10 million patients worldwide.
If a family member has Parkinson disease, what is the likelihood that I will also receive diagnosis? Most patients who are diagnosed with Parkinson disease have the non-familial form of the disease, which means they do not have a genetic predisposition to developing the
disorder. Only about 5 % of Parkinson disease is inherited. That means 95% of the patients who are diagnosed, generally at an age over 50, do not have an identifiable genetic link to developing the disease. There is much work being done to identify genetic links to the disease, and in the future it may be possible to diagnose the disease with a genetic test before one even begins to develop signs or symptoms of the disease.
What types of treatment options are available? There are many treatment options for patients with Parkinson disease, both pharmacological – meaning drugs – to nonpharmacological such as dance and exercise, and finally even surgery. The most commonly prescribed drug for Parkinson disease is levodopa given as an oral formulation
in combination with another drug that inhibits the breakdown of levodopa before it can enter the brain. Once levodopa enters the brain, it is converted to the missing chemical in the brain that leads to the disorder – dopamine. Dopamine is a neurotransmitter that is required for normal coordination … if it is deficient, then one begins to develop the common manifestations of the disorder including tremors, bradykinesia and gait disturbance such as imbalance. There are other drugs that act like dopamine in the brain – we call those dopamine agonists. Commonly employed dopamine agonists include rotigotine – which is available in a transdermal patch, and ropinirole and pramipexole, which are available as oral drugs. All of these drugs can be used to control the symptoms in Parkinson disease, but like many drugs, they have side effects including nausea, somnolence, pathologic gambling, onset of involuntary motor fluctuations known as dyskinesia, and hypersexuality. Other classes of drugs include those that prevent the normal metabolism of dopamine by inhibiting the enzymes that convert dopamine to its metabolic end products in the brain (MAO-B inhibitors), as well as those that inhibit it’s breakdown in the blood (COMT inhibtors). Finally, if the options described above do not provide symptomatic relief, then surgical options are available including an intestinal catheter that delivers levodopa continuously into the small intestive, and an invasive procedure known as deep brain stimulation (DBS). The latter approach involves implantation of electrodes within the brain that provide tiny pulses of electrical stimulation that can provide dramatic improvements in some patients – but there can be complications with the surgical procedure. The intestinal catheter and surgery are generally reserved for patients with significantly advanced disease.
What is SER-214? SER-214 is an injectable candidate drug that can be taken just like you take an insulin shot, except that you would take it once a week. We programmed this pharmacokinetic profile using our polymer drug platform, which allows drugs to be delivered as a single injection. The drug attached to the polymer is rotigotine, which is a known safe and effective drug that can be delivered as a transdermal patch on a daily basis (Neupro). The advantages of SER214 over the patch are significant – you have to shave your body to apply the patch, it often causes significant skin ir-
ritation and itching, and it can fall off if you sweat. There are chemical components in the patch that can also cause an acute allergic reaction. SER-214 goes into the blood directly following the injection – no shaving, no skin irritation, no significant side effects, and it delivers rotigotine continuously over a one-week period. There is no product like this right now, and we are in Phase I development now in Parkinson disease patients.
Have you started clinical trials? We are in the earliest phase of clinical development now known as Phase I. Our Phase I study is being conducted in Parkinson disease patients, and you can read more about this on our website at www.serinatherapeutics.com. On the website, you can pull down a fact sheet as well as the entire description of the trial on ClinicalTrials.gov site.
How far away are we from a cure? That is a great question, and it is the mission of organizations like the Michael J Fox Foundation who want to achieve that. We may be years away from curing the disorder, but in the meantime there are effective treatment options that are available to control the symptoms of the disorder while we work diligently to find a cure for this very common and often debilitating disease.
Alzheimer disease Q&A with Nick Cochran, PhD
A
ll neurological diseases are interconnected. At HudsonAlpha Institute for Biotechnology, scientists are using cutting-edge technology to better understand neurological diseases, such as Alzheimer disease and frontotemporal dementia. While some advances have been made in treating the symptoms of these conditions, it is critical that we learn more about the genetic factors involved in these devastating and debilitating diseases. Above: Live cells from human skin cells that have been grown in the lab as neurons. Watching the cells while they are alive provides valuable insight, such as reaction to treatment.
Photo credit: Nick Cochran, PhD Above right: Nicholas Cochran, PhD, is a postdoctoral fellow in the Myers lab at HudsonAlpha where he investigates the genetic risk factors or causes of neurological diseases.
Finding answers about one neurological disease may lead to answers about many of them. To help speed discovery, HudsonAlpha has established the Memory and Mobility Fund (M&M Fund) to support new projects and continue existing work in a variety of neurological diseases. One project in particular aims to sequence the genomes of more than 1,500 patients with Alzheimer disease and frontotemporal dementia.
How common is Alzheimer disease in the U.S.? More than five million Americans have Alzheimer disease. Every 66 seconds, someone new is diagnosed with the disease. If a family member has Alzheimer disease, what is the likelihood that I will also receive diagnosis? Estimates for this vary widely, and it is likely because the answer depends largely on the age of onset for the family member. For example, if your sibling or parent had Alzheimer disease and was diagnosed between ages 65 and 85, risk of a diagnosis with earlier onset Alzheimer disease is lower for you. However, if family members happen to have onset before age 65 in multiple generations, it’s a good idea to contact a neurologist and/or geneticist, because this is rare and could have a very strong genetic component.
What types of treatment options are available? There are currently two treatments for Alzheimer disease. Neither addresses the underlying cause of the disease. Both can “plateau” progression for about 6 months. Together, they can delay nursing home placement by about two years, so they do have a measureable benefit, but there is a lot of room for improvement.
What advancements have been made so far in Alzheimer disease at HudsonAlpha? At HudsonAlpha, we have been positioning ourselves to analyze whole genomes for Alzheimer disease and other types of dementia. The word “analyze” is important here because there are a few other places that have been sequencing whole genomes for Alzheimer disease and other types of dementia, but the expertise at HudsonAlpha is really top-notch for analyzing the whole genome, and not just the part coding for proteins. The other thing we’ve gotten off the ground recently is cultures of human brain cells – neurons, as well as supporting cells. We’re not doing anything scary to get the human brain cells – we are simply using cells that were re-programmed from an adult’s skin cells. Having this type of culture available allows us to mimic the types of genomic changes we find in patients, which can help provide evidence for or against a given genomic change being associated with disease.
How is studying the genomes of Alzheimer patients going to advance our knowledge of the disease? With science we can never guarantee anything going in, but what we can do is position ourselves for success as well as possible given what’s worked well in the past. So, we’ve done that with Alzheimer disease and related dementias by selecting a group of samples from patients that are highly likely to have one underlying cause of their disease. Specifically, these are earlier onset and/or atypical cases of Alzheimer disease and frontotemporal dementia. Earlier onset cases are more likely to be strongly genetic. We could learn a few different things from these data. One critical thing is that we could find new genes that have variants that cause disease. This is critical because it’s only by knowing what genes have variants that cause disease that we can take any kind of rational approach for therapeutic development. Another key set of observations we could gain from these are identifying biomarkers of disease. We will be making measurements of immune response, which has come into the limelight in the research field recently as being very important.
How far away are we from a cure? Often what people really want to know is how close we are to effective therapies, which can be almost as good as a cure. The first key idea is that prevention is going to be the name of the game. There has been a lot of work lately showing that the most effective therapies in development are performing the best in people who have very mild symptoms. This is probably due to the fact that based on work done recently, we now know that the underlying disease process starts decades before symptoms. So, if we can target that process before symptoms, that would be even better and screening tools are in active development (and some are already approved) with the hope of doing just that. For Alzheimer disease, I would speculate if we could get to two or three effective therapies, targeting underlying disease process, we could make an impact on prevention that is very tangible. Some of these are close to completion, and more and more will read out over the next 5 to 10 years.
What other neurological disease research is happening at HudsonAlpha? We are doing and have done quite a lot of work in different neurologic diseases, from childhood intellectual disability and developmental delay, to major depression and schizophrenia, to other adult-onset neurologic diseases like Huntington disease, Parkinson disease and ALS. I think we gain a lot of synergy by doing this, because while these are distinct diseases, we can often learn things about one disease from another, both from commonalities and differences between them.
For better or worse HOW GENETICS CAN AFFECT RELATIONSHIPS
Marriage requires working as a team, tackling challenges like joint finances, work-life balance and parenthood. Navigating these challenges impacts how satisfied a couple is in their relationship. Successful problem solving is shaped by factors like communication style, level of trust and a couple’s prior history. Now scientists say genetics might also be a player. Social support – feeling that one partner understands the views, opinions and abilities of the other – is an important measure of marital satisfaction. Another is attachment security, the feeling of emotional safety that comes from others being responsive to our needs. Two scientific publications – one in the Journal of Family Psychology and the other in PLOS One – illustrate how variations in a gene previously linked to personality can also be associated with patterns of behavior and emotional response that ease or increase marital pressures. However, before you conclude that genetics predetermines the fate of our relationships, let’s dig a little deeper in the findings. HOW GENETICS CAN AFFECT OUR RELATIONSHIPS The most recent papers build on already-published research into the effect of variations in OXTR, the Oxytocin Receptor gene. The receptors can modify a range of responses to social stimuli, such as stress or anxiety. DNA changes in OXTR have been connected with several personality traits associated with sociability and bonding. For example, a 2009 paper found people with one specific variation in the OXTR gene thought and behaved less empathetically. That same variation also led people to have a stronger stress response, both mentally and physically. As you can imagine, people with less empathy and higher stress relate differently to other folks and the world at
by Neil Lamb, PhD
large. Intuitively, those effects would carry over to marriage. Now researchers can demonstrate that carry-over through careful study. THE ROLE OF GENETICS IN MARRIAGE The team of scientists leading the Journal of Family Psychology study recruited 79 couples and asked each partner to come up with a pressing issue to discuss with the other – a personal problem not linked to their partner or partner’s family. For example, they might discuss a problem with a coworker. The scientists recorded ten minutes of conversation on the subject then analyzed the interaction to see how the partners supported and accepted support from one another. They also surveyed the individual partners to get a broader sense of each spouse’s perceptions about their marriage and obtained saliva samples for genetic testing. Variation along the OXTR gene influenced both the actions and the perception of those actions for men and women. That said, husbands with a specific genetic change (defined as the TT genotype at SNPrs1042778) reported less satisfaction with the recorded interaction with their wives, and lower marital satisfaction overall. The scientists hypothesize that husbands with this variant may have trouble identifying and interpreting the social support signals coming from their partners, and therefore perceive them as being less responsive. The PLOS One study examined 178 midlife and older married couples. Here too, participants provided saliva samples for genetic testing and completed surveys about their feelings of marital security and satisfaction. The study focused on the OXTR variant described above in the 2009 paper (rs53576). When at least one partner had the GG genotype – the opposite of the variation that led to less empathy
and more stress – the couple reported higher satisfaction and security in their marriage than couples without this variant. Individuals with the GG genotype also reported lower levels of anxious attachment, which prior research has shown to be associated with a lower likelihood of jealousy and better relationship quality. Of course, this is still just a small portion of the marriage equation. OUR GENES, OUR BEHAVIORS Genes may have an influence on marriage, but that impact shouldn’t be overstated. The researchers found that the genotypes of both partners combined to account for about 4% of the variance in marital satisfaction. Because both studies analyzed relatively homogeneous populations of caucasian couples, it’s important to replicate these experiments using larger, more diverse populations. However, it’s worth noting that this gene shapes both behaviors and perception of a partner’s behaviors. The authors of the PLOS One study even suggest that the patterns of each partner can rub off on one another over time.
Further research could examine how those same genetic variants shape our interactions with positive and negative relationship experiences. After all, marriage often revolves around understanding and context. The genetics likely do as well. HOW WE LOVE The way we love stems from all kinds of factors, from our upbringing to our genome to the way we respond to the large and small stressors of the moment. Some pieces of our genetic code influence how we process feelings like empathy. So it’s understandable that our DNA recipes play a role in our most important relationships. It’s interesting that we can link genetic variation to how supported a partner feels in a marriage. That certainly seems like a factor that could boost relationship satisfaction. Still, it’s important to realize that the science isn’t saying two people are genetically incompatible because of this one variation — or any other genetic information for that matter. Love, marriage and long-term relationships are complex and we’re just starting to learn more about how genetics play into the way we relate to others.
To see more stories like this, visit www.shareablescience.org
Huntsvil e,
VALVE REPLACEMENT Without Open Heart Surgery b y Alex Vasquez, MD
AORTIC STENOSIS Aortic stenosis is the second most common valvular heart disorder found in clinical practice. The term refers to a gradual narrowing o f the aortic valve that affects the outflow of blood from the heart's left ventricle into the aorta. The main cause for the narrowing is degenerative, as a result of thickening and calcification of the valve components, and as such it increases with age.
More than one in eight persons age 75 and older have moderate or severe aortic stenosis; a rate that will only continue to increase as the age of our population rises. Most patients are diagnosed before symptoms appear, when a loud sound or murmur (generated by blood exiting the heart through the narrowed valve) is heard during a routine physical examination. Once the murmur is discovered, a physician will order an echocardiogram (heart ultrasound) to determine the extent of the valve narrowing. Once the narrowing becomes severe, most patients will develop symptoms, generally manifested as fatigue, chest discomfort, lightheadedness and shortness of breath.
For more information please contact: Christy Cantey, CRNP
Valve Clinic Program Coordinator 1.800.519.TAVR
TREATMENT OPTIONS Given a mortality rate as high as 500Ai only one year after the onset of symptoms, we recommend replacing the valve once the diagnosis of symptomatic aortic stenosis has been made. The traditional way to replace the valve is surgical, through an open-heart procedure known as a surgical aortic valve replacement (SAVR). Most recently, a less invasive, non open-heart, transcatheter aortic valve replacement (TAVR) option is available for patients who are considered to be at intermediate or high risk for surgical aortic valve replacement. In the vast majority ofpatients who qualify for this procedure, a new valve can be safely introduced from the leg and carefully threaded up to the heart and across the diseased valve. Once there, the new valve is expanded, pushing the native valve aside, and rapidly restoring normal function.
HEART VALVE TECHNOLOGY TA VR can be performed under strong sedatives and local anesthesia, eliminating the need for general anesthetics. That allows for a quicker recovery and dramatically shorter hospital stays. The diagnosis, clinical decision-making and treatment of the patients with complex valvular disease requires involvement of a well-structured multidisciplinary valve team. In August 2014, Huntsville Hospital's valve team performed the first TAVR in North Alabama, under the leadership of Dr. Alex Vasquez. Since then, over 525 TAVR procedures have been successfully performed. As technology and our experience have advanced, we have expanded our team as well as the clinical applications to treat other major structural heart problems with less invasive techniques.
An Innovative Approach to
HEART FAILURE MANAGEMENT by, Philip B. Adamson, MD, MSc, FACC
Despite medical advancements, heart failure is a worsening epidemic. 8
I n s i d e M e d i c i n e | Fa l l I s s u e 2 0 1 8
The number of people in the United States with a diagnosis of chronic heart failure is expected to double in the next 15 years–forcing physicians to face the significant challenge of delivering quality health care for a growing population. There are many medications and devices focused on heart failure management that bring great hope for clinical improvement–and the potential for recovery. Even still, there is a significant gap in treatment options. For example, half of the approximately six million people living in the United States with symptomatic heart failure have a normal ejection fraction. While there has historically been limited medical therapies to improve patient outcomes, new innovations are allowing us to identify advanced heart failure patients earlier in their progression, resulting in improved survival and quality of life.
REMOTE HIGH-TECH MONITORING
As a heart failure cardiologist, I can attest to the emotional and physical burden that this disease brings to patients and their caregivers, especially when hospitalization is needed. Heart failure remains the leading cause of hospitalization in Medicare beneficiaries, and accounts for a large percentage of the overall $40 billion cost of expenditures. In fact, clinical evi-
Courtesy of Abbott
dence shows that increased hospitalizations can actually compound challenges for patients and lead to worsening cardiac function and even mortality. This is important since hospitalizations for advanced heart failure patients tend to be recurrent with 25 percent of patients readmitted within 30 days and 50 percent within six months. While Medicare penalties through the Hospitalization Readmission Reduction Program appear effective in lowering 30-day readmissions, recent analyses suggest that increased mortality is associated with the national trend for reduced readmissions. This phenomenon does not appear to be the case with other targeted reasons for hospitalizations, such as myocardial infarction and pneumonia. One major challenge in clinical management of patients with heart failure is that most of the patients’ lives are spent away from their health care provider, leaving physicians to rely on a reactive approach for managing their patients once symptoms present. Many patients also feel very anxious when they are not in the general proximity of their care team, which limits their ability to travel or enjoy visiting loved-ones who do not live nearby. Traditional methods of tracking have not overcome this issue, since relying on changes in physical symptoms simply does not help keep patients from developing acute decompensation. One novel solution to this problem is the, Abbott CardioMEMS HF System™, which consists of a tiny permanently implanted pressure sensor in the pulmonary artery (PA) with the ability to remotely measure PA pressures daily
Courtesy of Abbott
THE STIGMA OF
Mental Illness
by, Rachel Sullivan, MFTA
What if we talked about mental health as openly as physical health? Imagine what our communities would look like if individuals affected by a mental illness were able to gain support from their family and neighbors for their depression, the same as when they are post-op from a heart surgery. There is such a stigma surrounding mental health. A stigma is defined as “a mark of disgrace associated with a particular circumstance, quality, or person.” Layer that over mental health, and specifically mental illness and now the definition reads “a mark of disgrace associated with mental illness.” Ouch. It breaks my heart that mental illness continues to carry a mark of disgrace with it, especially with the high prevalence in our communities.
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Did you know that an estimated 1 in 5 adults struggle with a mental illness? When we include youth and children in this estimate, the percentage rises. With such significant numbers, the fact that mental health is still discussed minimally, if at all, is discouraging. We know that individuals with a mental health diagnosis are at a greater risk for social isolation, have greater difficulty developing fulfilling relationships, and that there is a correlation between untreated mental illness and suicide risk. Despite the known complications, as well as the known benefits of treatment, conversations about mental illness continue to happen below the threshold necessary to encourage change. Wouldn’t it be wonderful if we talked about mental health as openly as physical health? It would be so helpful if individuals affected by a mental illness were able to gain support from their family and neighbors for their struggles, the same as when they are discharged from the hospital after a procedure. Consider what the recovery process for mental illness would look like if when someone disclosed their struggle and their journey to wellness they were accepted and encouraged! Do you think that kind of support would affect whether people with mental illnesses reach out for help? I think so, and I believe this kind of change is possible, with some shifts in how society thinks about mental health. How do we begin to unravel the stigma? I believe the first step is to get educated! Almost without exception, when I have a judgment about a topic, it is due to a lack of information about that subject. Mental health is no different. In my opinion one issue that prevents people from being educated about mental health includes the lack of open discussions regarding the prevalence and impact of mental illness. Due in large part to stigma, many individuals who struggle with mental illness feel unable to talk as openly as someone who is battling cancer – and yet mental illness can be just as detrimental. When we hear personal testimonies about how mental illness affects people, we can connect our hearts with the importance of the cause. As I see it when we become educated, through real people accounts, our understanding and compassion provides the catalyst for reducing the stigma and normalizing mental health care. To begin changing the conversations surrounding mental health I have unpacked some points I believe are important. 1. Understand mental illness is not a choice. Depression, Anxiety, Bi-Polar Disorder, PTSD, Anorexia, Oppositional Defiant Disorder. These diagnoses, like so many others, involve a reaction in the brain that the afflicted individual has difficulty controlling without outside assistance. The behaviors, thoughts, reactions, and effects are not something the person would choose for themselves. Unfortunately, because of a lack of information, society sometimes paints a picture that people who are mentally ill choose to live this way. The truth is that even if they felt comfortable doing so, many people do not know where to turn to for help, or even that something is “wrong”. Mental illness tells lies like “You are the only one that feels this way”, it is from this isolating place that the person struggling keeps their battles tucked away, lest they seem “crazy”.
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2. Mental illness can be treated. The field of psychiatry and therapy has grown tremendously over the past few decades. What we now know about the brain allows clinicians and physicians more opportunities to assist individuals diagnosed with mental illnesses. Previously, a schizophrenia diagnosis would almost certainly mean hospitalization. Fortunately, the advances in medicine and psychiatry have allowed a more comprehensive approach, providing platforms for many individuals with schizophrenia to live full, independent lives. These advances have positively impacted the field of mental health in many ways. Understanding the possibility of treatment can encourage those struggling to get help, which means more people on the road to wellness. 3. People with mental illness are not their diagnosis. Mental illness does NOT define an individual. We do not say “That bi-polar woman”, but rather “the woman with bi-polar disorder”, because the diagnosis does not define the person. It is a struggle they are walking through, not a definition of their being. Can you imagine calling the mom battling breast cancer “the cancer lady”? Absolutely not, and yet society has normalized the labeling of people struggling with mental illness by their diagnosis. In my opinion, this reinforces the stigma, rather than creating space for safe, open conversation about the struggle. Realizing that mental illness is something that affects the individual, rather than who they are, is key in updating how we view mental illness. 4. People with mental health diagnoses are capable. Individuals with a mental health diagnosis are just as capable of living abundant lives, raising families, and working fulfilling jobs as people who do not struggle with mental illness. It is true that some diagnoses will require more intense, or even long-term care for symptom management, but this does not prohibit productivity or decrease the value of the individual. Some of the most resilient people I know have battled mental illness and come out with more grit, tenacity, and compassion for others than individuals who have never dealt with mental health issues. So, what do we do with all of this? The reality is mental illness is not going away, a fact we cannot change. What we can change is the way we perceive mental health as well as the individuals who struggle with mental illness. We can set into motion a snowball effect of acceptance, and thus facilitate dialogue for healing. I believe when we do so the stigma decreases, and the topic of mental health care becomes a more normal conversation. People who are struggling feel more safe reaching out for help, and a shift begins. I am ready to be a part of the change, are you?
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SMART-O GOALS by Rachel Sullivan, MFTA
Ahh. Another new year. I do not know about anyone else, but 2019 flew by. It seemed that as soon as I gained solid footing, it was already time to start writing 2020 on everything. Despite the year passing quickly, I was able to achieve several goals I had set for myself. I prefer to set goals instead of resolutions. Neurologically the words we choose make a noticeable impact on how we respond to them. For example, when we set a New Year’s “resolution” we are making a firm decision to do or not to do something. When we fail to resolve the identified thing, mentally we file that as a fail. Conversely, when we set ourselves a “goal” we identify something as the object of our ambition or effort and determine our desired result. It creates an end point we gradually work towards rather than a pass or fail. Did you mentally register those words differently as you read them? Me too. So, when you are setting goals, where do you start? I am sure you are familiar with the S.M.A.R.T. acronym, Specific, Measurable, Achievable, Relevant, Time-Limited. I use this outline, with a small addition of my own, to establish goals
for myself since it allows me to structure backwards from my desired result. In therapy I use this same concept to help clients work towards their therapeutic goals. Something important to keep in mind when setting goals, they should always be framed in the positive. This helps your brain focus on what you DO want, rather than what you DO NOT. Look at these examples: Eating less junk food and no more lethargy vs. Living a healthier lifestyle with more physical activity and smarter food choices. The first example contains words like “less” and “no more” which are negative phrases the brain picks up on, setting you behind before you begin. The second example tells the brain “more” and “smarter”, helping the brain identify positives that you are aiming for. Positive words create a shift in the brain and help us as we work towards our desired result. Let us look at some examples of how this plays out practically, using an example of “increasing positive selftalk”.
Are you 50 years old or older?
Do you get heartburn weekly or more?
SPECIFIC: When we set a goal for ourselves the item needs to be specific enough that we know exactly how we are directing our efforts. Essentially, we need a target. When I work with clients, we take time during our first sessions to discuss goals. As we talk, we unfold what is important to them, and begin to pull out some specific items that we can use as our target. The bullseye in the middle represents the desired result, with the outer rings representing other areas of life that will benefit from us hitting that center. If we identify “increasing positive self-talk” as our goal, this becomes the specific object of our ambition. MEASURABLE: A goal must be measurable. In other words, you need to be able to see how your ambitions are paying off. While increasing positive self-talk you should see some benefits (the other rings on the bullseye) of your efforts. Perhaps you see your efforts paying off as you feel more confident a few weeks into your new practice. Or, your attitude is more pleasant because you are being kinder to yourself. Identifying some ways to measure your efforts up front will help keep you motivated as you work hard.
ACHIEVABLE: The goal you set needs to be something you can achieve. Determining to grow 8” if you are already full grown is not achievable. Ensuring your goal is realistically achievable helps set you up for success. Our example goal, increasing positive self-talk, is entirely possible to achieve. RELEVANT: Your chosen goal should be something relevant to you. Frequently, I see people who identify goals that someone else would like them to achieve. This is a fast pass to failure. The goal needs to be yours, and it needs to mean something to you. When we set a goal that is relevant to our current season in life, it creates a sense of accomplishment when we obtain it. However, a goal we are working towards that is someone else’s idea will neither motivate us nor fill us with accomplishment. If it is relevant to you, increasing your positive self-talk will be something you are motivated to work towards. More than that, it will feel great when you achieve it. TIME-LIMITED: Goals that are limited by a timeframe help keep us on track. Say we begin our positive self-talk journey March 1st and determine to increase the ways in which we speak positively to ourselves for 90 days. By the end of
those 90 days we have created a new habit, formed new connections in our brain, and made a positive impact on our mental health. Additionally, when we have a finishdate we can work backwards from there to structure our measurement markers so we can see our progress. This continues to signal our brain to identify the growth, and acknowledging the growth keeps us motivated. See the cycle?
OUTSIDE HELP: Here is where my addition shows up. There is no “O” in the original SMART goal acronym. However, many goals I have set for myself included resources outside of my scope of expertise. So, taking inventory at the beginning of goal setting to identify outside help you may need boosts your chances of obtaining your desired result. The truth is none of us have all the tools and skills necessary to obtain every goal we set. Thus, acknowledging the need for, and enlisting help when necessary is smart, and practical. Perhaps for your self-talk goal you will need a book of positive confessions, or an accountability partner. A bigger goal may require professional help in the form of an academic institution, fitness facility, medical professional, or lending agent. As you begin to think about this new year laid out before you, I want to challenge you to consider where you would like to be by December 31st. What looks different in your life? How are you relating to people in a way that is an improvement from right now? If _________ were better, what would that change? 2020 is a blank slate. You have a lot more power over the outcome than you might think. It may require some outside help. Likely it will take some SMART goal setting. Whatever the course, whatever the goal, I hope your year is as amazing as you dream it can be. Happy New Year!
Rachel Sullivan, MFTA Solid Ground Counseling Center 9694 Madison Blvd St A7 Madison, AL 35758 256-503-8586 www.solidgroundmadison.com
NAVIGATING THE
World of Dieting By Tara Vardaman, MS, RDN, LD
As many of you know, trying to diet comes with a lot of confusion and frustration. But it doesn’t have to be that way. Many diets that are heavily promoted today are what dietitians consider “fad diets”. They offer quick results with dietary changes that are almost impossible to maintain long term. These fad diets also often lead to the yoyo effect – weight loss and gain that continues to repeat without any last effect of continuous weight loss. The key to dieting is to actually not “diet” at all. Achieving great health comes down to simply making dietary and lifestyle modifications that you can sustain for life. Consuming a diet that is full of fruits, vegetables, and unrefined grains, as well as lean proteins in moderation will provide your body a large variety of vitamins and minerals that are needed for the body to function properly. Additionally, consuming a highly plant-based diet helps to reduce the risk of developing chronic health conditions, and can even help with the treatment of many health conditions (heart diseases, high blood pressure, diabetes, high cholesterol, etc.). Now I’m sure as you read the words “plant-based diet” I lost some of your attention. The truth is, you do not have to become vegetarian or vegan, but consuming a diet that has a strong foundation of whole, plant-based foods is likely to drastically reduce the intake of refined sugar, total cholesterol, saturated fats, and sodium, all of which have been linked in some way to increasing the risk of developing the health conditions outlined above. In addition to diet modification, lifestyle modification is the other major component to achieving great health. This includes everything from physical activity to where and how you eat your food. Lifestyle modification can be broken down into three categories. The first lifestyle modification category is physical activity. It is recommended to engage in a minimum of 30 minutes of moderateactivity (brisk walking, biking, sports, etc.) 5 days a week, while also participating in resistance exercises (Pilates, weights, yoga, boxing, etc.) at least 2 days a week.
The best way to achieve physical activity modification is to set SMART (Specific, Measurable, Attainable, Relevant, and Time-based) goals or yourself and gradually increase your activity level each time you reach your goal. The second lifestyle modification category is mindful eating. Mindful eating essentially means that you are putting primary focus on your plate while eating. This involves ensuring that you are in a minimally distracting environment while eating. This includes avoiding visual distractions such as screens (TVs, phones, tablets, computers), books, and even eating while driving. Additionally mindful eating also focuses on staying in tune with your body and its hunger level throughout the eating process. Ideally, you want to start eating when you start to become hungry (not when we are starving) and stop eating as soon as your hunger has resolved. The idea behind mindful eating is that it will help prevent over eating. The third lifestyle modification category is eating habits. Eating habits play a huge role in how much we eat at meals. Due to the fast-pace culture that we live in, many of us tend to eat fairly quickly. The reality is, eating quickly often results in overeating due to the delayed signaling from the stomach to the brain to let us know that we are full. To help slow down the eating process, follow three simple steps: Take small bites, chew foods thoroughly, and set down utensils between each bite. As you can see, achieving great health takes work but it doesn’t have to be overly complicated. Consuming a diet that is focused on whole-foods, engaging in physical activity regularly, ensuring that you practice mindful eating, and modifying your eating habits will help you achieve the health you want and deserve. It is also important to remember that results are not going to appear overnight. It takes time, sometimes a lot of time. Be willing to find gratitude in the smallest achievements, as those small achievements are what lead you to your greatest success.
“LET FOOD BE
THY MEDICINE
AND MEDICINE BE THY FOOD”
– HIPPOCRATES
Hernia Mesh Is it Good or Bad? by Ray Sheppard, Jr., MD
If you watch TV, you have seen them-advertisements by lawyers warning you of “dangerous” hernia mesh. Since more than 1,000,000 hernias are surgically repaired each year with mesh, literally millions of Americans are wondering, “Should mesh be used to fix hernias?”
Since the early 1990’s, nearly all hernia repairs have utilized hernia mesh. Mesh based repairs have become the “gold standard” because surgeons observed significant problems with tissue based repairs. The most common hernia is the inguinal or groin hernia. Over 70 different types of nonmesh or tissue based repairs have been reported in the surgical literature. The large number of different repairs is a clue to the fact that a good, reliable repair has been difficult to discover. Hernia recurrence following these tissue based repairs is routinely reported as high as 35%. Techniques to reduce these recurrence rates have incorporated multiple suture lines of permanent suture (which may actually be similar to a mesh) and frequently are associated with prolonged post-operative pain. Alarmingly, even such efforts are associated with unacceptable hernia recurrence rates. The story is even worse when one considers the type of hernia that is seen in an old incision from a patient’s previous abdominal surgery. Hernia recurrence rates with non-mesh repairs for this type of hernia are commonly in the 50% range. With such poor results of tissue based repairs, a desire emerged to find a better way. During the past 25 years, different styles of mesh and different methods for utilization of mesh
have been employed. A drastic reduction in recurrence rates has been observed. In manycases, post-operative pain has been reduced with a faster return to the normal activities of life. If this is the case, then why do we see these “bad mesh� ads? One thing which is important to understand is that risk is associated with every choice that we make. Everyone understands the risks involved with sky-diving. Most decide to never take that risk. On the other hand, we all know that thousands of people are killed in automobile accidents every year, yet we take that risk every day. When it comes to driving our cars, we have judged the risk to be low compared to the benefits. There are some adverse events that can occur after a mesh repair, but these occur only a small percentage of the time. Alternatively, the risks of hernia recurrence are much more frequent and carry life-threatening consequences. Hernia experts have carefully analyzed these outcomes and have judged that the risk of hernia mesh is actually very low compared to the great benefits. Another critical fact is that mesh must be used wisely and with a safe technique. There are actually inappropriate methods of deploying mesh. This has led some patients to experience mesh complications. The main cause for this concern has been in procedures that are not related to abdominal wall hernia surgery. These complications have been primarily found in surgical repairs of the pelvic floor for women suffering from pelvic prolapse. For more information please visit the
FDA website: fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh/default.htm. This highlights why hernia patients are best served by surgeons who are wellversed in the best practices for mesh utilization, as well as in a variety of hernia repair techniques. Although our current results with mesh repairs for abdominal wall hernias are better than has ever been seen in the history of mankind, we are always searching for improvements. Many of us who are most involved in hernia surgery have joined forces in the Americas Hernia Society Quality Collaborative. This is an effort to pool our experiences and identify strategies to obtain better results for our patients. Despite the fact that complication rates from hernia mesh have been occurring at a very low rate, the medical device industry has expended and continues to spend millions of dollars to research even better mesh and bring the complication rate as close to zero as possible. Together, surgeons and researchers are working to make our already outstanding outcomes even better. So, is mesh good or bad? Once you have more of the information, hopefully you can see that hernia mesh is not as bad as TV commercials would have you believe. I’m a hernia surgeon, and I wouldn't have my hernia repaired without it! Ray Sheppard, MD - General Surgery raysheppardsurgery.com
Hormones
TALKING ABOUT
by, Donald Aulds, MD
WHAT ARE HORMONES? Hormones are chemicals produced in certain organs of the body and released into the blood stream to act on other areas of the body. Some hormones may have mainly a single action while other such as estrogen may act on multiple areas of the body and produce multiple actions in the body.
Hormones are probably one of the most misunderstood chemicals in the body. The term hormones can stand for multiple chemicals including those from the thyroid gland, adrenal gland, pancreas and of course the ovaries or testes. I will try to approach this from the standpoint of a question and answer approach.
HOW DO HORMONES WORK? Hormones act on areas of the cell called receptor sites. The receptor site in the presence of the hormone releases some response in the cell to produce the response that is intended to occur. Some of the receptor sites may be blocked by other chemicals to reduce the response to the hormone. Also, synthetic hormones may incompletely act on the receptor site and not produce the expected response. WHY DO I BEGIN TO HAVE SYMPTOMS RELATED TO HORMONE CHANGES? This is a complicated question, but in order to try to simplify the answer, you must understand that each hormone in the body has a time in which maximum production of the hormone is achieved and production will begin to decrease beyond this point. As a good example, testosterone production peaks in a woman in her later 20’s and in a man in the early 30’s. After this point of life, testosterone will drop in production and symptoms of decreased testosterone can begin. Some conditions or diseases will accelerate the loss of certain hormones. WHY DO I FEEL TIRED OR CAN’T SLEEP? These two problems are often two of the most common complaints that I hear from patients. The can be multifactorial and can not be helped often without measuring hormone levels. These studies can include evaluation of sex hormones, thyroid hormones, and stress hormones. IF HORMONES LEVELS ARE NORMAL, WHY DO I STILL HAVE PROBLEM? Reactions to hormones are also affected by other chemicals of the body particularly vitamin D. Vitamin D is con-
sidered a prohormone meaning the it has to be present for the hormone to produce the response that is expected of the hormone. Without adequate levels of vitamins and minerals in the body, the body just does not respond the way it was intended to work. An example, thyroid hormones must have such chemicals as selenium and boron present to work on certain tissues. WHERE DO THESE CHEMICALS COME FROM? Mainly from foods that we consume or by supplements taken as directed by your physician. The World Health Organization recommends a low caloric diet such as the Mediterranean diet and exercise to boost response of healthy function of our bodies. WHEN DO SYMPTOMS OF DECREASED HORMONES TYPICALLY OCCUR? For most women and men, symptoms usually start or become significant in the 40’s to 50’s. Some symptoms may show up earlier in certain individuals, but some may not occur until later in life. WHAT CAN BE DONE FOR THE SYMPTOMS? I always try to select therapies based on a combination of symptoms reported by the patient and the results of lab tests of the hormones. Specific panels of test of hormones are based on the sex of the person. When lab test results are available approaches of therapy can be planned based on the individual’s needs. AREN’T HORMONES BAD FOR ME? Multiple studies done mainly in Europe have shown that bioidentical hormones (naturally derived hormones) are safe compared to synthetic hormones. One result of a French study showed that testosterone in a woman helps protect against breast cancer along with other benefits to the body. These must be discussed with a physician. HOW LONG WILL I HAVE TO BE ON HORMONE THERAPY? As long as you are getting benefits from the therapy. There are no studies on naturally derived hormones that show or suggest a time limit for therapy. I tell patient daily that length of therapy is a personal choice, but whenever hormones are stopped, symptoms may return. It all depends on how well you feel, if the hormones are helping control the symptoms, and whether you desire to do everything you can to maintain your health. Dr. Donald Aulds is an obstetrician-gynecologist in Huntsville, Alabama and is affiliated with Huntsville Hospital for Women and Children. He received his medical degree from Louisiana State University School of Medicine in New Orleans and has been in practice for more than 25 years.
Whitehead
Papule
Blackhead
Cysts
Nodule
acne
Pustule
By D Kishore Yellumahanthi, MD, MPH, FAAFP
Acne, also commonly known as Pimples, is the most common skin condition seen in the United States. It is estimated that at any given time, about 40 to 50 million Americans have acne. The most common age of onset of acne is teenage. However, acne can occur at any age. It can occur in both men and women. Below, is summarized briefly the causes of acne, its clinical presentation, prevention and management.
What actually causes acne? Acne appears when a pore in the skin clogs. This clog begins with dead skin cells. Normally, dead skin cells rise to the surface of the pore, and the body sheds these cells. However, if the body starts to make lots of sebum, oil that keeps the skin from drying out, the dead skin cells can stick together inside the pore. Instead of rising to the surface, the cells become trapped inside the pore. Sometimes a type of bacteria that lives on the skin called Propionobacterium acnes (P acnes), also gets inside the clogged pore. Inside this clogged pore, P acnes, has an ideal environment for multiplying quickly. The clogged pore becomes inflamed when it is filled with loads of bacteria
inside and this leads to its red and bumpy appearance. If the inflammation goes deep into the skin, an acne cyst or nodule appears.
How does acne manifest as? A person who has acne can have any of the following: • Blackheads • Whiteheads • Papules • Pustules (what many people call pimples) • Cysts • Nodules Although face is the most common site for acne, it can appear on the back, chest, neck, shoulders, upper arms and buttocks. Often, the treatment of acne depends on the type of acne lesions that are seen. For example, if one has only blackheads, a topical retinoid is more appropriate than other treatments. Therefore, it is important to know how each of the acne lesions appear. White heads: If a pore in the skin is clogged with bacteria,
dead skin cells and with excess oil, it can close the pore and form a tiny white or flesh colored bump. This is called a whitehead. Blackheads (dark spots): If the pore fills with debris but stays open, a blackhead is noticed. Papules (Early pimples): When excess oil, dead skin cells and bacteria push deeper into the skin and cause inflammation (redness and swelling), small, red bumps are formed. The medical word for these are papules. They feel hard. If the inflammation goes deep into the skin, an acne cyst or nodule develops. There is no universally accepted scale for grading acne severity. Mild acne is classically defined by the presence of clogged skin follicles (either black heads or white heads) limited to the face with occasional papular or pustular lesions. Does mild acne need to be treated? Given the fact that in most cases, acne is supposed to be self limiting once the patient matures through adolescence into adulthood, many patients with acne and their parents, do not seek treatment for it either at all or when the symptoms are mild. However, early and prompt treatment of acne has several advantages. For example, if treatment is sought when acne is mild, one can relatively get faster relief from their acne. It also minimizes the likelihood of having scars and also reduces the need for using stronger medications that have a potential for severe side effects. It is also worthy to remember that treating mild acne promptly could also help in maintaining one’s self esteem. Research shows that acne can take a toll on the psyche. Many patients seemed to have mentioned that their self-esteem suffered after developing acne. Some had reported of having depression and suicidal ideations as well. It is also important to note that the severity of the acne doesn’t seem to matter - Acne can have negative effect on self-esteem whether one has mild or severe acne. Therefore, every effort needs to be made to get acne treated as early as possible regardless of its severity.
care of. The following are some tips for good skin care to help with acne. •
Do NOT try a new acne treatment every week or so. Give an acne treatment time to work. Use a product for 6 to 8 weeks. It takes that long to see some improvement. If no improvement is appreciated by then, at that time, another product can be tried. Complete clearing generally takes 3 to 4 months.
•
Do NOT apply acne medication just only to the acne lesions. To prevent new acne lesions, spread a thin layer of the acne medication evenly over your acne-prone skin.
•
Use makeup, skin care products, and hair care products that are labeled “non-comedogenic” or “won’t clog pores.” These products don’t cause breakouts in most people.
•
Do NOT share makeup, makeup brushes, or makeup applicators. Even if one uses only non-comedogenic products, sharing makeup can lead to new acne formation. Acne isn’t contagious, however, sharing makeup, makeup brushes, or applicators, can result in transfer of the acne-causing bacteria, oil, and dead skin cells. These can clog the pores, leading to breakouts.
•
Do NOT sleep with makeup. Even non-comedogenic makeup can cause acne if you sleep with it. Therefore, please make sure the makeup is removed before going to bed.
•
Wash face twice a day & after finishing any activity that causes sweating but do NOT wash multiple times a day.
•
Do NOT dry out your skin. Skin with acne is oily, so it can be tempting to apply astringent and acne treatments until the face feels dry. However, dry skin is an irritated skin and is more prone for acne. Therefore, use acne treatments only as directed. If it still makes the skin feels dry, applying a moisturizer helps.
•
Do NOT scrub the skin. To get rid of acne, one could be tempted to scrub one’s skin clean. But, scrubbing can irritate the skin, causing acne to flare. Therefore, be gentle when washing the face or other acne prone skin. Usage of a mild, non-comedogenic cleanser is recommended. Apply the cleanser lightly with the fingertips, using a circular motion. Gently rinse it off with warm water, using only the fingers. Then pat the skin dry with a clean towel.
•
Do NOT Pop or squeeze breakouts. When acne is popped or squeezed, there is a possibility of pushing some of what’s inside (e.g., bacteria or pus or dead skin cells) deeper into the skin. When this happens, inflammation increases. This can lead to more-noticeable acne and sometimes scarring and pain.
How to treat whiteheads and blackheads? Topical retinoid is usually recommended to unclog the pores. Adapalene is a type of retinoid available without a prescription. In addition to using a topical retinoid, using a benzoyl peroxide wash can also help. It can help get rid of the excess P. acnes bacteria on the skin. What about treating papules? Try washing face twice daily with an acne face wash that contains benzoyl peroxide or salicylic acid. If lot of papules are present, it may require a consultation with a healthcare provider. Any presence of acne cysts or nodules, in general, would require an appointment with a healthcare provider for their management. For best results of acne, along with using the right medications, general skin care also needs to be taken
3
There are several types of skin cancer. The three common types of skin cancer are:
Skin cancer occurs as a result of uncontrolled growth of abnormal cells. Skin cancer occurs when mutations or errors occur in the DNA of skin cells. Often this is the result of exposure to UV radiation either from sunshine or tanning beds. These mutations in turn cause the cells to rapidly multiply and form malignant tumors. Skin cancer is the most common cancer in the US.
>>>
One in five Americans will develop skin cancer in the course of lifetime.
by D Kishore Yellumahanthi, MD, MPH
Basal cell carcinoma Squamous cell carcinoma Melanoma Basal cell carcinoma (BCC):
Epidermis is the top layer of the skin. The epidermis has four layers. BCCs are abnormal, uncontrolled growths that arise in the skin’s basal cells, which line the deepest layer of the epidermis. It is believed that long-term sun exposure over the lifetime as well as occasional extended, intense exposure (typically leading to sunburn) combine to cause damage that can lead to BCC. The risk factors for the development of BCC include, intermittent intense sun exposure (as identified by prior sunburns), radiation therapy, immunosuppression, a fair complexion, red hair and a positive family history of BCC. The clinical presentation of BCC is variable. For instance, it can present as open sores, red patches, pink growths, shiny bumps or scars. It has the least potential to spread from the primary tumor site. However, that does not mean it should be taken lightly as the treatment in the advanced stage may need a large excision that can be disfiguring at times. Given its variable presentation, it is often not easy for a common man to diagnose them by looking at them. Therefore, any new spot or bump or any other lesion on the body, should be brought to the attention of a physician immediately.
Squamous cell carcinoma (SCC):
SCC in an uncontrolled growth of abnormal cells arising in the squamous cells, which compose most of the skin’s epidermis. It is the second most common skin cancer. It is caused most commonly due to chronic sun exposure. Anyone with a history of substantial sun exposure is at increased risk although people with light hair, fair skin and blue, green, or gray eyes are
at highest risk of developing the disease. Usage of indoor tanning beds is also a risk factor for SCC. The number of women under 40 years diagnosed with SCC is on the rise and it is largely believed due to their greater use of indoor tanning. Unlike BCC, in about 0.5 -5% of cases, it can spread and can become fatal if untreated. Similar to BCC, it can also have varying appearance. One clue to differentiate between the two, although not absolute, is often the skin around an SCC reveals telltale signs of chronic sun damage such as wrinkles, loss of elasticity, age spots, or broken blood vessels.
Melanoma:
This is the most dangerous form of skin cancer. It arises from melanocytes, which are pigment producing cells present in the basal layer of the epidermis. Most melanomas are black or brown in color. However, they can also be skin colored, pink, red, blue or purple. Melanoma also has various morphological/clinical presentations. Melanoma is caused by intense, occasional UV exposure more so in genetically predisposed individuals. Besides genetic predisposition, the strongest risk factors include light complexion, light eyes, blond or red hair, heavy freckling, the occurrence of blistering sunburns in childhood, a tendency to sunburn easily and tan poorly. If melanoma is diagnosed and treated early, it is almost always curable. However, if it is not recognized early, it can spread to the other parts of the body and can lead to death. Therefore, it is very important that it is diagnosed early.
What are ABCDE of melanoma? Melanoma can occur either in an existing mole or can present as a new lesion. It is very important for everybody to know their skin very well and to recognize any changes in the moles. Look for the ABCDE signs of melanoma.
A B C D E
Asymmetry: When symmetrical, if you draw a line through the middle, the two sides match. On the other hand, if you draw a line through a mole, the two halves do not match, it means it is asymmetrical, a warning sign for melanoma. Borders: A benign mole has smooth, even borders, unlike melanomas. The borders of an early melanoma tend to be uneven. Color: Most benign moles are all one color — often a single shade of brown. Having a variety of colors is another warning signal. Diameter: Benign moles usually have a smaller diameter than malignant ones. Melanomas usually are larger in diameter than 6mm, but they may sometimes be smaller when first detected. Evolving: Common, benign moles look the same over time. Be on the alert when a mole starts to evolve or change in any way. Any change — in color, shape, size, elevation, or another trait, or any new symptom such as bleeding or crusting — points to danger. Noticing one or more of the above, would warrant an appointment with a physician.
FEELING FOGGY? A look at how your inner ear can affect the brain and cognitive thinking. by, Kari Kingsley, MSN, CRNP
Several years ago, I developed intermittent bouts of what I would later term brain fog in which I experienced nonlucid moments, similar to waking up after anesthesia. The first and most memorable of these occurred while I was driving on I-565 to work one morning. While not exactly dizzy, I recall feeling so strange that I pulled the car over on the interstate and waited for the spell to pass. After a few minutes, the episode subsided and I went on with my busy day, forgetting about the strange incident. Months later, similar spells began occurring more frequently, heightening my preexisting hypochondriac tendencies that I had developed from years of reading medical books and watching TV programs about the rarest medical conditions in the world.
The spells would come on suddenly, without warning, and felt like a cloud engulfing my consciousness. I had a really hard time explaining the symptoms to my family practitioner at the time. “You know that feeling… where you’re having a dream… and then you start to fall… but then you don’t fall… but the ground is moving… and your thoughts don’t come as crisply or clearly…” Gosh, I sounded crazy even to myself. I further tried to explain that words sometimes did not come easily, decision making became more difficult, and my concentration span seemed shortened. After some routine blood work, I was reassured that my symptoms were likely from fatigue with an added dash of anxiety. But something felt wrong. The foggy spells progressed and I began experiencing pressure in my head, although the entire myriad of symptoms remained very non-specific. Being in my late 20s and a medical provider with just enough medical insight into her own health to be unbiased, I did what any circumspect and logical person would do: I Googled it. After hours of pouring over medical articles, researching medical websites and reading the rantings of a few passionate bloggers, I settled on a very rational explanation for my symptoms…I had a brain eating amoeba. My family practice provider referred me to a neurologist where I was subjected (at my insistent request) to nearly every test known to man…MRI scans, toxicology, blood tests, nerve studies…you name it! The only time he laughed at me was when I asked him (only half-jokingly) if he would do a brain biopsy to make sure the large amounts of sushi I had been consuming hadn’t left an uninvited parasite swimming in my gray matter. The testing came back completely normal. No multiple sclerosis, no brain tumor, no lead poisoning, and certainly, no brain-eating amoeba. I was the picture of health. Now, if you’re like me, there is nothing in the world more frustrating than knowing something is wrong and not having an explanation. What I’ve failed to mention thus far is that at this point in my life, I was working as an Ear, Nose, and Throat nurse practitioner, specializing in dizzy patients. As I continued to see patients day-after-day and listened to the way they described their symptoms, something clicked for me. My patients with inner ear conditions, specifically Meniere’s Disease, complained of dizziness, lightheadedness, vertigo and a feeling of being “foggy headed”. Eureka! But I wouldn’t describe my spells as dizziness exactly, more like a deviation from my normal clear thinking. About this time, I began noticing the pressure in my head was centered over my right ear and that I had developed a faint humming and roaring tone. Feeling a bit silly to have struggled for so long with what was quickly becoming a familiar ENT scenario, I asked our audiologist to check my hearing and run a simple sound test for Meniere’s Disease. It was positive in my right ear. Suddenly the brain eating amoeba had a name!
But I had been treating patients with inner ear conditions for years and was completely oblivious to the fact that I had developed Meniere’s Disease! I laughingly tell my patients how I came to realize I had Meniere’s Disease. They too are generally relieved to have a diagnosis; especially one that is treatable. My best advice as a Meniere’s patient (and as their provider): STAY OFF GOOGLE! Dr. Google is the most dangerous physician in the world because he plays on the fears of uncertainty lurking in the dark parts of our (amoeba eaten) brain. Meniere’s Disease is an inner ear condition usually characterized by dizziness, ear fullness, tinnitus (or noise in the ear), and hearing loss. You can have a combination of symptoms or all of the symptoms which can vary case-by-case. Meniere’s Disease is thought to arise from genetic and environmental factors, although the exact etiology is unknown. Pathophysiology is not fully understood, but thought to be related to a variety of events that lead to elevated pressure in the endolymph fluid causing a condition known as hydrops. Although dizziness can be Pandora’s Box in terms of differential diagnoses, inner-ear should always be a consideration once acute issues such as cardiac, vascular, and neurological conditions have been excluded. The history is critical. Find an ENT team (hint, hint) that will take the time to listen to your symptoms. Standard workup includes a hearing test (or audiogram) along with simple sound tests to measure inner ear pressure. Not to brag (cough, cough) but our practice recently upgraded to stateof-the-art inner ear test equipment that is second to none. As advances in technology continue to grow, we work closely with our audiological team to interpret results so that we can appropriately treat our patients. Upon confirmation of a Meniere’s Disease diagnosis, treatments include initiating a low-salt, low-caffeine diet and medications such as diuretics, steroids, anti-nausea pills and drying agents (anticholinergics) depending upon the individual patient. Trans-tympanic steroid perfusion therapy offers a minimally invasive, in-office procedure that provides significant lasting relief for most patients. Some of the more invasive procedures and surgeries such as endolymphatic sac decompression should be reserved for more severe cases and are generally performed by board-certified neuro-otologists at universities in larger cities such as Birmingham and Nashville. Destructive procedures, such as gentamycin perfusions and labyrinthectomy can cause irreversible effects such as permanent hearing loss and are reserved for dire cases. (These are the Dr. Google recommendations we try very hard to stay away from). Most patients respond well to steroid perfusion therapy and rarely require further action.
Tissue
PASS ME A by, Kari Kingsley, MSN, CRNP
Do you consider yourself to be open-minded or closed-minded? Open-minded people are considered to be more willing to embrace change and generally have a higher level of curiosity. They try new things, live in the present, and often times seem less judgmental. While it is often perceived as a good thing to have an open mind, you don't want to be so open-minded that your brains leak out of your nose! In today's culture, it is possible that our thoughts leak too freely; however, there is a true medical condition in which your mind lubricant literally drips out of your nose… cerebrospinal fluid rhinorrhea or CSF rhinorrhea. It’s important to know when to dive for a tissue and when to call your nearest ENT. Most of us have suffered the embarrassment of talking to a close friend or loved one only for your nose to begin running like a sieve. Perhaps triggered by a blooming Bradford pear tree, the outdated perfume of the sweet elderly lady who sits close to you in church, or even a hot bowl of your favorite chicken noodle soup. We quickly dart our eyes around the room to make sure no one is watching, then hightail it to the nearest box of tissues before our sleeve is saturated. Clear nasal dripping can be one of the most aggravating and embarrassing
issues to deal with. Each year, millions of Americans are seen at walk-in clinics, primary care offices, and by otolaryngologists and allergists for nasal discharge. Common causes of nasal drainage include seasonal or non-seasonal allergies, upper respiratory tract infections such as rhinovirus and cold temperatures. Crying (or trying not to cry) during your favorite Nicholas Sparks book can sometimes cause a drippy nose. Rebound congestion after prolonged use of topical decongestant drugs such as Afrin, chronic sinusitis, nasal polyps and cluster headaches can also be to blame. However, cerebrospinal fluid rhinorrhea is a rare and potentially life-threating condition that also presents with clear nasal discharge. CSF rhinorrhea occurs when the meninges (the membrane barrier that lines the skull and vertebrae to protect the brain and spinal cord) is torn and cerebrospinal fluid drips down the nose. Ascending infection can lead to meningitis and in some cases death. The cause of common rhinorrhea or drippy nose is characterized by overabundance of mucin produced by mucous membranes that line our nasal cavities. With rhinorrhea, mucus is created faster than the body is able to process it, leading to clogging in the nasal cavities. Gravity takes over, causing nasal discharge. Accompanying symptoms generally vary based on the underlying cause, but can include nasal congestion, facial pain, headache, nosebleeds, sneezing, ear pressure, sometimes ear infection and even sinusitis. As excess mucus drips down the back of the throat, excoriation can occur causing sore throat and coughing. Generally, nasal drainage is evaluated by medical providers with a thorough history to elicit the exact cause so that they can treat you accordingly. Many cases are self-limiting, such as the common cold, and do not require treatment. For allergic and non-allergic rhinitis, medications can be helpful including cortisone nasal sprays, antihistamines, vasoconstrictors, and sometimes antibiotics if a bacterial infection is suspected. Many claim that natural treatments like saline sprays and herbal oils can also be helpful. New in-office treatment options are available to alleviate nasal drainage. And then of course there’s honkin’ your schnoz (nose blowing) for which the Kleenex family greatly appreciates your business. Allergy testing and immunotherapy are helpful for some. Evaluation by an Ear, Nose, and Throat provider can be valuable to rule
out underlying co-morbidities such as sinusitis, nasal polyps, and additional upper respiratory disease. Sometimes what you may think is good-old-fashioned snot can actually be something far more deadly. Cerebrospinal fluid rhinorrhea is a rare malady that can occur traumatically or spontaneously. Classic nasal CSF leak presents with unilateral (one-sided) clear nasal drainage that often worsens when bending forward. Sufferers sometimes complain of a metallic or salty taste. Predisposing conditions include obesity causing increased intracranial pressure, severe sleep apnea, congenital skull bone malformations, hyper-pneumatization of the sphenoid sinus, and a condition called empty sella turcica. Accompanying symptoms can include headache, lack of smell, nasal congestion, weakness, dehydration, and night cough. Severely symptomatic patients present with symptoms of meningitis including nuchal rigidity, sudden high fever, altered mental status, photophobia, phonophobia, and even seizures. Traumatic CSF rhinorrhea is a sign of basal skull fracture related to head trauma and can have devastating complications. CSF leak is also a very rare complication of sinus surgery. Evaluation and diagnosis are centered around a thorough history, sampling of collected nasal discharge which is sent for β-2-transferrin assay, nasal endoscopic examination to visually identify the place of leak, and radiological diagnosis with skull CT scans. MRI helps in detecting hernial protrusion of the brain in the skull found in encephalocele. Treatment options include watchful waiting as some CSF leaks will heal spontaneously. Surgical intervention includes a type of bypass surgery in which an overlay lumbo-peritoneal shunt is placed. Moderate failure rate is expected and surgeons then perform transcranial and trans-nasal approach surgery with osteoplastic craniotomy with closing of the defect using the patient’s own donor tissue. Timing is critical. Risk of meningitis in patients with persistent CSF rhinorrhea may be as high as 20%. Meningitis is a life-threatening condition in which the meninges becomes infected leading to fever, headache and neck stiffness. Untreated meningitis is almost always fatal. If you or a loved one suspect you may have CSF rhinorrhea, don’t delay evaluation by an otolaryngologist (ENT). Most of the time, clear nasal drainage is a nuisance rather than a life-threating situation. But it’s important to know the warning signs of CSF rhinorrhea and seek immediate medical help. While I would normally encourage everyone to “keep an open mind”, please don’t keep it so open that your thoughts (or spinal fluid) leak out on to your shirt. “Kari Kingsley, MSN, CRNP is an otolaryngology nurse practitioner with over 8 years of ENT experience who currently works at Huntsville ENT (256-882-0165). She is a medical writing consultant for Inside Medicine and enjoys writing articles on pertinent material to keep the residents of North Alabama up to date on the forefront of medicine.”
Comfort
...in your own home
Death is Coming by Belinda Maples, M.D.
The hospice philosophy focuses on a death with dignity without pain or suffering. There comes a point in time when a treatment is worse than the disease, when medications and procedures do not help and physical and emotional suffering is not relieved. Many people find death is too disturbing to discuss and therefore avoid talking about it. Talking openly about death and dying may be considered disrespectful and some believe that it will lead to despair or even accelerate the process of dying. Some patients fear that entering hospice care represents that they have been given up on, hastens death
or shortens one’s life. This is misconception and studies demonstrate a 100-day survival advantage with end stage heart failure patients. Such attitudes in the general public can cause delayed treatment with palliative care services and increase the amount of suffering. Discussions on death, palliative care, and hospice need to be made early in any terminal disease process between a patient and their health care provider. Hospice care provides medical care and support to patients with a life limiting illness and focuses on quality of life rather
than curing the illness. The hospice philosophy focuses on a death with dignity without pain or suffering. The care and treatment provided are based on the patient’s and family’s goals and values. This holistic approach focuses on symptom management, support, and assistance by way of communication and providing coordination of care. Hospice is appropriate when patients are entering the last months to weeks of life and when decisions are made to stop disease modifying therapies and focus on maximizing comfort and quality of life. The World Health Organization has identified the most common conditions that require palliative care for adults and include dementia, cancer, cardiovascular disease, cirrhosis, COPD, diabetes, HIV/AIDS, kidney failure, multiple sclerosis, ALS, Parkinson’s disease, stroke, lupus, rheumatoid arthritis. and drug resistant tuberculosis. An individual is referred to hospice when the life expectancy is less than 6 months and it is especially important if the goals of care are comfort, being at home, and staying in control. This timeline is difficult to estimate in advanced illness due to effective new therapies, psychological reasons to maintain hope, and the clinician’s overly optimistic desire to cure disease. It becomes easier to predict death when the end is closer and usually less than 3 weeks. These individuals can benefit from hospice care as long as they continue to exhibit a decline consistent with the progression of the disease process. Many symptoms are demonstrated in the last phase of life. These can be disturbing to family members and health care providers alike. A decrease in heart function and blood volume leads to diminished or increased heart rate, low blood pressure, cooling in the extremities, discoloration of the skin, and loss of peripheral pulses. Families cannot rely on vital signs alone to determine impending death. Infections and febrile episodes are among the most common acute complications by terminally ill patients and may represent the end. Neurological changes such as decreasing levels of consciousness leading to coma, delirium with confusion, restlessness, agitation, and day to night reversal may also occur. Moaning, groaning, and grimacing may accompany the delirium, but may be misinterpreted as uncontrolled pain. Some will have hallucinations that involve deceased individuals from the past and make references to “going home” or dying. Breathing may become shallow and labored with periods of absent breathing where family members perceive this pattern as holding her breath or breathlessness. Breathing difficulties may be reduced with oxygen through a nasal cannula or face mask and bedside fan may relieve the sensation of being short of breath. The buildup of saliva and secretions may lead to gurgling, crackling or rattling sounds with each breath, which is sometimes referred to as the death rattle. This can lead to inability to rest, worsening shortness of breath, coughing spells, predispose to infections, and increase distress to family. Proper positioning, cleansing the mouth with sponge sticks, and suctioning to clear secretions are appropriate for short term benefits. As patients near death, they spend more time in bed or a chair and one of the most significant milestones of functional decline is the loss of ability to independently transfer from bed to chair. Assis-
Family is encouraged to stay with patients to improve comfort and safety and one on one sitters may be needed.
Weight
upon my
by Dawson Willford
O
n July 7, 2016 at 12:13 AM my wife was dying. She just had an emergency C-section and went into shock. I stood by her head while she was bleeding out and remembered every fight we ever had and the things I never did for her. I couldn’t let her know how scared I was. I stood in front of my wife saying my final good bye! What do you say to someone knowing it’s going to be the last time you talk to them? I tried so hard to comfort her and tell her everything is okay. I tried to smile and pretend that it’s all part of the operation. They called a code blue and people started rushing into the room. She was shaking so much!!! I kissed her and asked God “please don’t take her home.” I thought about all the times I missed church at Way of Life. I thought about how to tell my new family the bad news. So much was going through my mind that I had no time to enjoy my son. I had to be strong for my family. I had to put the weight upon my shoulders and walk with this load of having my wife pass in the operating room. I didn’t know what to say. I didn’t want to pray because I thought God would shun me for not being a good Christian. I was so sorry and asked God if somehow he could just hear this last request. I was rushed to a different room and waited for about 10 minutes. Jackie finally showed up and my heart was so so so so heavy with grief. I wanted to pick her up and carry her out of the hospital as if everything would be fine. I wanted to leave and have this nightmare be over! I stood with Jackie for about 3 minutes and the worst happened. She lost about 1 litter of blood in a couple seconds. I didn’t say anything, I was so scared. I just looked at my wife and couldn’t utter a word. I wanted to say I love you and tell her it’s okay. I wanted to help her as much as I could. I wanted to stop everything and start all over again. I knew she was dying in front of me. They called another code blue! This time my heart stopped. I thought why didn’t I pray every night! Why didn’t I love her like God has loved me! I died in that room! I truly died! I didn’t know what to do again. I watched helplessly as they tried to save my wife. People were running and pushing me farther away from her. She finally uttered a word and it was like the room went silent. She asked for some water and I knew she was leaving earth. They took me and my newborn son to another room. As we were walking I saw my mom and family. I wanted so hard for someone to hold me. I wanted someone to carry me like a kid and tell me it’s gonna be okay. I didn’t want to be a man anymore. I wanted
shoulders to cry! I wanted to cry out to God and ask him why! I stood by my family for about 2 minutes looking at everyone and holding back all of my emotions. My mother asked me “How is Jackie?” I almost lost it and cried like a baby. I just shrugged my shoulders and said I don’t know yet. I was lying, I knew she was in really bad shape. I wanted to run back in the room and hold her but I had to take care of my son now. He had to be given antibiotics to prevent an infection from starting. After about 5 minutes I asked the nurses if I can go see my wife and they reluctantly said yes. The hallway to where my wife was is about 40 yards. I walked about 5 yards and started crying alone. I couldn’t keep up this persona for much longer. I was scared to walk back and hear the news. I wanted my dad to comfort me! I’m still his little boy! I had around 30 something yards to walk and God spoke to me. Gabriel my son I love you more than you can imagine. I heard you and I was there! I saw the c section. I helped the doctors find the problem. I saw when she hemorrhaged and made sure they caught it really quick. I was waiting for you in this hallway when you wanted your father. It’s okay to call on me. I will always love you. Just as you asked to save your wife. I’ve been asking my father to save yours. I walked with more love in my heart for everything in that moment. My wife and son are doing great and will be discharged Sunday. If you see me at church don’t ask me where I have been. Just say I’m glad to see you’re home!!’
T
A Mother’s
LOVE
by Dr. Sunita Puri
MedCare + 8075 Madison Blvd., Suite 106 Madison, AL 35758
he clock read 3 a.m., and I was finishing a 24-hour shift in a remote rural emergency room when Millie came in with her child wrapped in a blanket. She was reluctant to place him on the bed. I asked her if I could peek under the blanket. When I pulled the blanket away, I saw unseeing eyes and dysmorphic facial features, but Millie smiled and looked at her son, Michael. The boy had mild respiratory distress. I touched his cheeks and said, “Michael, we will take good care of you.” Millie relaxed and allowed him to be examined. He was wheezing and had a respiratory rate of 25 per minute, with mild retractions. Other vital signs were within normal limits. Pulse oximetry was 96% on the room air. Millie sat on the bed, holding Michael’s hand and watching every move I made. Michael was treated with an aerosolized bronchodilator, to which he responded. A chest x-ray revealed right lower lobe pneumonia. When I told Millie that Michael needed to be hospitalized, the color drained from her face. She shook her head and said, “No.” I asked her to tell me more about her son. Now 14 years old, Michael had been diagnosed at age 1 with Hurler syndrome. I had noted the characteristics of this rare syndrome when Millie placed him on the bed. Michael is now three feet long and had profound growth and mental retardation. Originally, Millie was told that he would live only a few years. She refused to entrust his care to an institution. For 14 years, she had loved this child into living and observed the smallest changes in his behavior as indication of how to take care of him. It was obvious that Millie knew more about caring for Michael than anyone else did. I respected her wish to take Michael home, and we agreed to treat Michael with antibiotics as an outpatient. Since then, I have seen Michael twice for similar illnesses; we treated him and released him into his mother’s care. As a seasoned medical professional, who may be unaware of the family dynamics, we often feel our judgment is right, particularly when a child with special needs is involved. This year, Michal will celebrate his 17th birthday. I can only admire this super mom who gives all her time and energy to taking care of this youngster. Had Michael been placed in an institution and deprived of his mother’s care, he might not have lived for 17 years.
Sometimes, only mother knows best.
Carry me Safely Downstream by Andy John King Campus Pastor, Lindsay Lane East
When I was in college, my friends and I traveled to Tennessee for a weekend white water rafting trip. While I do enjoy white water rafting, I’m not much of a risk taker or an adventure seeker. Truth be told, I usually err on the side of caution, so when the river guide gave us the safety speech, I made sure to pay attention. During that speech, the guide told us that if a rapid tossed us over the side and we found ourselves under the raft and in the water to “SWIM ONE WAY”. The reason for this instruction is due to the feeling of panic. Panic would send a swimmer in that situation in all kinds of directions seeking a way out, but it would ultimately delay escape to safety. Wouldn’t you know it, half way down the river, a rapid tossed a few of us out of the raft and into the water; and when my head came to the surface of the water, the raft was on top of me. Quickly I remembered, “Swim One Way”. I began to swim like a gold medalist in a single direction and within seconds the rapids sucked me up from beneath the water and carried me safely downstream to where I shortly joined my group again. I can still remember those few seconds… sheer panic. In that brief moment, I had a choice between feeling or faith. Everything within me wanted to absolutely freak out, fall apart, and
move at random for anything that felt right; but faith said to trust the guide. Not only was the guide a knowledgeable expert, but the guide had our best interest in mind. He knew the ride would have its struggles, unexpected circumstances, and even possible falls, but he also knew how to get us to the end. I didn’t understand all of the guide’s advice and perspective, but he did and when compared to my knowledge and perspective, I chose to trust the guide. Hopefully the point is becoming clear by now. Ours is the choice to trust our feelings or to trust the Guide. In Proverbs 4:23, the Bible instructs man “guard your heart above all else, for it determines the course of your life”. This is warning towards living according to how we feel. Living by feeling is limited and does not keep perspective, leaving one to swim in circles within the here and now. Proverbs 3:5-6 suggests that we trust the Guide: “Trust in the Lord with all your heart; do not depend on your own understanding. Seek His will in all you do and He will show you which path to take.” Though living by faith can be difficult, it is dependable because the object of our faith – Jesus – is our dependable, experienced, knowledgeable, compassionate, all powerful, eternal guide.
Cervical Disc Replacement M6 Javier Reto, MD, was the first surgeon in Alabama to implant the M6 artificial disc replacement for the cervical spine. By Javier Reto, MD
Neck pain occurs in approximately 2 out of every 3 adults throughout their lifetime and chronically in 15% of the population at any one time. As a result, treatments for neck pain have become increasingly utilized. Thankfully, the vast majority of folks that experience neck pains recover uneventfully. For the subset that require further assistance, physical therapy and over the counter anti-inflammatory medicines, e.g. ibuprofen, naproxen may be necessary to aid in recovery. Interventions such as injections and prescription medications typically become next-step options if needed. Finally, we consider surgery for those unfortunate enough to fail all measures. There are a significant number of younger people identified, typically falling into 20-50 age range, that become surgical candidates. In the past, these folks were given the option of living with the pain, repeat injections or neck fusion surgery. Neck fusions, where two adjacent vertebra are fused together with intervening disc entirely removed, have been a time-proven and quite successful option for reducing or eliminating pain. However, these surgeries come at the expense of eliminating motion at the particular level or levels involved. In the long run, the loss of motion increases stresses at adjacent disc levels and can lead to more surgery in 20-30% of patients.
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As a spine surgeon I am invested in finding both innovative and effective options that function best for patients in all age ranges. As such, options like the M6 device which provides accurate reproduction of motion in all planes, including compression, can be a better option than the typical fusion.�
Cervical Disc Replacement surgery is an alternative surgical option for those with little to no arthritis with the added benefit of preserving motion and thus potentially reducing the incidence of disc breakdown at adjacent levels. The last few years have seen several cervical disc replacement options come to market. While they all exhibit motion-preservation technology the manner in which this is accomplished varies and can significantly impact their overall effectiveness. Keep in mind that the ultimate goal of any disc replacement device is to reproduce normal spinal motion or kinetics. But what defines normal, and how is this measured? Luckily for us, spinal kinetics have been well-studied and a few guiding principles have been identified. A well-functioning device should have the ability to mimic normal motion in all normal anatomic parameters. It serves no good purpose for an implant to allow 360 degrees of rotation as humans are not owls! Likewise an implant that allows less than normal motion is restrictive and will result in early wear and likely failure. Normal neck motion is 80-90 degrees of forward bending, 70 degrees of backward bending, 2045 degrees of side to side bending, and up to 90 degrees of side to side rotation, as well as abc vertical distraction/ contraction. Most disc replacement options do a good job
at reproducing the majority of normal neck movements, but do not necessarily cover all the movements well. The Orthofix M6 device has been out in the European market since 2006 and in the US market recently in 2019. I was the first surgeon to implant the M6 last August and chose to use it because of its promising characteristics. Laboratory testing has shown that it does among the best at hitting all ranges of normal motion well, including the up and down distraction/contraction movement. It has a shock-absorbing center (nucleus) and outer wall (annulus) that work together to replicate the controlled range of movement and cushioning effect of the natural disc. As a spine surgeon I am invested in finding both innovative and effective options that function best for patients in all age ranges. As such, options like the M6 device which provides accurate reproduction of motion in all planes, including compression, can be a better option than the typical fusion. Ultimately the goal is to fit the surgical solution to the specific pathology as opposed to one size-fits-all approach. For those that are identified as appropriate candidates, the cervical disc replacement device can be a wonderful option. If you have on-going significant neck or arm pains it would be wise to consult with a spine specialist about the right options for you.
OH MY aching... by Chad Hobbs, PT, DPT, COMT
Aches and pains often seem like a fact of life, but all too often they begin to limit our activities, our ability to perform our household or work tasks, and even impact our mood and happiness. The good news is that help is available. Regardless of what stage in the “ache and pain” process you are in, there are many great options to help you get things back in order. One great option that many of us have heard of, but may not really understand is physical therapy.
Why should I try Physical Therapy? Physical therapists are the movement specialists in the healthcare industry. It is their job to assess your movement and how it affects your pain. Pain can change the way you move. This incorrect movement can increase your pain by producing excess stress on the body, causing it to break down and start hurting. It can become a vicious cycle where pain causes incorrect movement which leads to more pain. The physical therapist’s job is to do a thorough evaluation of your movement and determine what is moving correctly and incorrectly and how that affects or is caused by your pain. The best treatment is one tailored to your weakness and deficiencies. In most cases, correcting improper movement will eliminate your pain, or at the very least, significantly decrease your pain and improve your ability to function. Physical therapy is a great option for many conditions. While we often associate physical therapy with rehabilitation after a surgery, physical therapists have the ability to help with multiple conditions. Physical therapy is a great option for any musculoskeletal issue (i.e. neck pain, shoulder pain, etc.), however; some physical therapists can also treat many other conditions, such as headaches, vertigo, dizziness, TMJ/TMD, balance issues or unsteadiness, weakness, tendonitis and even plantar fasciitis.
Why should I try Physical Therapy again? Many patients have had an unsuccessful bout of physical therapy in the past. This can often be the result if the treatment was not customized to the patient’s specific problems,
or the painful area was treated but their improper movements were not corrected. For example, if every patient with neck pain gets the same ten exercises to treat their neck, then the treatment is not being tailored effectively to get the best result. Or, if a patient has low back pain which was treated previously, but treatment neglected to correct a stiff arthritic hip, the low back pain may not resolve or the pain will likely return. Physical therapy can be highly specialized and customized to your specific condition and it should be. If physical therapy did not work the first time, it is worth trying again with a treatment plan that is personalized to your specific needs.
What is Manual Physical Therapy? With manual physical therapy, the therapist uses a handson assessment to determine your physical dysfunctions, whether it be stiff joints, muscle spasms, or poor muscle recruitment patterns. This assessment then allows the therapist to decide what treatments and exercises will be most beneficial. A specific customized plan involves the use of manual techniques, like joint mobilizations and soft tissue release, to treat limitations, such as muscle and joint stiffness, to correct movement. These treatments typically offer patients some immediate relief and allow them to tolerate specific exercises that help produce and maintain long-term corrections.
What should I expect from Physical Therapy? There are many things that make a great therapy experience, but the following list should be included in your experience. • A thorough evaluation consisting of a history, medical review, and hands on physical exam • An explanation of the findings of the evaluation and the treatment plan moving forward • Hands on techniques performed by the physical therapist • Specific exercise program consisting of exercises with reps, sets and number of times per day along with an explanation of what the exercise is accomplishing • Re-evaluation by the physical therapist each visit which assesses movement, so treatment can be adjusted or modified based on the patient’s response to the last visit. • Detailed discharge plans. Once therapy is over, the patient should know what to do to progress activities and how to respond should the patient experience a flare-up or symptom regression.
Chad Hobbs PT, DPT, COMT is the Director of Operations and partner at the local physical therapy company, Focus Physiotherapy. Chad graduated with his Doctorate of Physical Therapy from Belmont University in Nashville, TN. He currently holds the position as the Federal Affairs Liason on the Alabama Physical Therapy Association and is a current board member on the Alabama Board of Physical Therapy.
Physical Therapy
If you are having any of these aches and pains, you should discuss physical therapy with your physician, as it may be a great option for you. In the state of Alabama, you also have the ability to go straight to a physical therapist for an evaluation. Physcial therapy treatment cannot begin without the approval of a physician, but you can get a full assessment from a therapist and have that to discuss with your physician. Understanding what options are available enables you to make better choices for your body. Physical therapy is a great tool to assist with maintenance and management of your overall wellness. ...............................................................................................
In search of solutions to
Bridge the Gap Physician Extenders to Close the Ranks of Emerging Healthcare Shortages by Kari Kingsley, MSN, CRNP
Legs slightly crossed, with my back posture as stiff as that of a military cadet, I nervously clear my throat as my interview for what I consider to be the cremdelacreme of nurse practitioner positions begins. Sitting across from the impeccably dressed and perspicacious otolaryngologist, I silently pray she won’t notice the bead of sweat forming on my upper lip or the faint quiver in my voice as I try to answer her straightforward questions in the most astute way my nervous 29-year-old brain could formulate. Luckily, she missed my dry heaves in the ornate Viburnum bushes landscaping her charming office parking lot, after the interview concluded. Thinking back on that moment, a smile inches across my face. My nerves got the best of me. At the time, I would have bet the entire Powerball Lottery I wouldn’t be getting the job offer. I’d never been so happy to be wrong. I now con-
sider my collaborative physician to be not only my mentor, but one of my dearest friends and confidants. I jokingly embellish the retelling of my interview story by adding that I made sure to find out Dr. Neeta Kohli-Dang’s dress style and shoe size before we agreed on terms so that I could take full advantage of her flawless taste in clothes and accessories AND her generous heart when it comes to lending me outfits for special occasions. I count my blessings daily for the working relationship I have with my boss. I have nurse practitioner and physician assistant friends at all ends of the spectrum in terms of job satisfaction and fulfillment. They range from highly salaried slave labor positions in which they work grueling hours, rarely seeing their families all the way to those seeing 5 patients a day, begging for more work. I’m happy to fall in the middle. We run a state of the art ENT practice performing cutting-edge in office surgeries using low radiation CT imaging, complete with in office neck and thyroid ultrasounds, a speech pathology department, and audiologic testing. Likewise, Dr. Dang recognizes in me a very hardworking, OCD, type-A nurse practitioner that loves to solve the puzzles human anatomy and physiology can pose. While exemplary patient care is always our top priority, we still find a few minutes here and there to laugh and sip lattes. As our aging population continues to grow and as we continue to make astonishing advancements in medicine, raising the cost of healthcare, the American medical paradigm is shifting into uncharted waters. As our Baby-Boomers retire, the growing demand for healthcare abuts our government’s dwindling reimbursement deterring many young medical school graduates from a career in primary care… or a career in medicine altogether. Reduced reimbursement also lays a heavy burden on specialists requiring heavier patient loads with less time to spend on one-on-one care. Dawn C. Joy, Accredited Practitioner and Nursing Instructor at Gannon University has said, “I feel that the healthcare system is an upside-down pyramid; we have the personnel with the most education and knowledge farthest away from the patient because of administrative and regulatory requirements.”
So, what’s the solution when you need to connect two separate forces and bring the patients at the top of the pyramid to meet physicians at the bottom? To put it simply: You build a bridge. Physician extenders such as nurse practitioners, physician assistants, and nurse midwives are specially trained individuals, licensed to perform certain tasks and procedures that might otherwise be performed by physicians themselves. They work under the direction of a supervising or collaborating physician to bridge the gap. Physician extenders are not meant to replace physicians, simply to extend highly-skilled, quality medical care such as determining differential diagnoses, implementing protocols of care, using critical thinking skills to interpret laboratory tests and medical imaging, and performing patient education regarding various treatment modalities. Physician extenders alone will not solve the tough healthcare reform changes America has to face. But they do provide a valuable solution to an accelerating need by providing competent medical care. Metaphorically (and possibly literally), nurse practitioners and physician assistants will be the bridge on which we will carry our patients from the top of Dawn Joy’s pyramid to the bottom. Bariatric physician extenders are reaching for their back braces as they read this. When I put ink to paper and list the top characteristics my “Dream Job” would entail, my position with Dr. Neeta KohliDang at Huntsville Ear, Nose, and Throat fulfills them all. She and I have formed an enthusiastic working relationship with a strong passion to provide exemplary care to our patients, which enriches both our lives. These strong interpersonal relationships between physician and physician extender are vital to support our efforts to bridge care to patients. And it doesn’t hurt that I get to borrow Dr. Dang’s Jimmy Choo’s. Kari Kingsley is a board certified acute nurse practitioner. She graduated from the University of Alabama in Huntsville with a Master of Science in Nursing. She maintained a 4.0 GPA throughout her training and graduated with honors. Kari is licensed by the Alabama Board of Nursing and certified by the American Nurses Credentialing Center. She currently serves on the Board of the North Alabama Nurse Practitioner Association and is the Huntsville Chair-person for the American Foundation for Suicide Prevention.
Who is Actually Responsible by Tiernan O’Neill
The current state of health care and the business realities of the industry have seen an ever-increasing list of certain policies enacted at many offices in recent years. These policies can often come across as strict, inconvenient or unwelcoming to many patients. These rules and regulations are more readily seen in smaller private office settings. Prior to any individual throwing an absolute fit aimed at the office or more specifically the staff enforcing such policies, it would be best to better understand the background and possible necessity of such rules. The first root of many office policies in fact stem from the unfortunate history and lessons learned from previous patient encounters. Methods by which offices deliver health care in the most efficient and conscientious way possible can often be obstructed by difficult, unreasonable or unruly patients. After such circumstances and upon further review, typically the physician and management of the office will collaborate to develop policies in the future to avoid similar problems of a specific encounter or pattern of encounters. These policies are usually well thought out and tough to adopt, as no office wants to create lists upon lists of restrictions in providing health care. Often it is also unfortunate these general blanket type changes have to be made due to isolated incidents. But they are enacted primarily to avoid repeated, disruptive and threatening events experienced in the past; it really often boils down to a classic example of a few bad apples always ruin it for the bunch. The second cause and genesis of many office policies is the office and physician are being unreasonably expected to meet demands dictated by insurance companies or others in the health care environment. Often mandates or expectations are thrust upon those providing the actual health care which they have never agreed to or have even been included in the decision making process. Typically the expectations cause major disruptions to well es-
For office policies tablished office operations and also excessive burden to its time and resources. As a result, you will see office’s either unwilling to comply to expectations created but never agreed to by third parties, or more so generating additional fees and costs they will transfer on to the patient. Again, no office or physician wants to add a never ending list of additional fees to the delivery of health care as we are all too aware of the increasing cost patients encounter in receiving affordable treatment. There is one additional perceived cause of such policies, which should be adamantly debunked. That is these office policies and subsequent enforcement are generated by and the responsibility of the office staff. It is rarely the case that general staff members are ever responsible for such rules and restrictions. This is an important fact to understand as too often it is these such employees who are left to follow, enforce and receive the ire of patients when they are unhappy with such policies. Unfortunately too often patients or other individuals take out their frustrations on employees who are simply doing their job and have no way in waiving or changing office policies ordered by their employer. Furthermore, many of these hostile encounters can cause strained relationships with patients and for the most part staff who are dedicated and well intentioned in their role in delivering excellent health care. Possible solutions to the above would be the following suggestions. First fully understand where such policies come from. Second, empathize and reason whether these are necessary policies. Third, provide reasonable feedback to appropriate management or physicians. As mentioned before, these policies are typically well thought out and good intentioned. But having said that it is possible they have unintended consequences and may need to be altered or removed entirely. The majority of physicians and management professionals I have come in contact with are always
willing and eager to receive such feedback, cooperation and input from patients. But a caution should be to all there is little entertaining, progress made or ultimate satisfaction ever gained from treating staff not responsible in such decisions as whipping posts for those to take out their frustrations.
RESPECT
is everyone’s responsibility
Patients Visitors Workers Doctors
HMO/
Managed Care Plans Objectives and Requirements
by Tiernan O’Neill
A popular but well bemoaned insurance coverage option for many people has been HMO Managed Care Plans offered by insurance companies. Often these products are offered through private purchase rather than employer benefits, and can almost always be found on the state exchanges in one form or another. They are popular because the premiums tend to be much lower than other options, even including high deductible plans. They are frequently bemoaned because too often patients do not understand the limitations they have now placed on their health care and can subsequently incur greater medical expenses as a result. To understand the reason why these plans exist is best explained by the insurance company’s expectation that their costs generated by patient care will be minimized and contained by the involvement of a physician involved in all health care decisions. They believe this is best served by patients identifying, coordinating and receiving authorization for all of their care by an established and long term Primary Care Physician (PCP). Basically, they expect the involvement of such a physician to be more cost effective than simply allowing patients to coordinate their health care on their own; this is especially relevant in the case of specialists the patients need or want to see.
Here are some of the misunderstood or overlooked guidelines of these plans where most patients encounter their problems:
1 2 3
4 5
The PCP you select must actively accept this role; this is not a one way decision of the patient’s and can’t be determined by the insurance company either. And this relationship needs to be established ahead of the critical times you require them Any and all referrals needed must be initiated and authorized by your PCP; most physicians will require you to see them ahead of your specialist visit in order for them to determine, justify and agree for the need of this appointment. When the term of your initial authorization expires you will need to receive a new referral or extension from your PCP; this should be done well in advance allowing for clinical and administrative timeframes. More importantly, most PCP’s will require you to see them ahead of and in order to receive a new referral. This is because it is within their discretion and responsibility you are receiving effective and appropriate follow-up from these specialists. These three mentioned stipulations need to be satisfied prior to any specialist visit. Most PCP’s will not and actually won’t be allowed by insurance plans to retroactively authorize services for other providers, whether it is an intentional act of the patient or a simple oversight. Lastly and most importantly, all four conditions above and any other not mentioned are the responsibility of the patient. Never allow or assume a third party such as a specialist or insurance company will take care of these for you. Just the same as the financial responsibility of any non-covered services will fall completely on you and you alone if the limitations of this plan are violated.
So really despite the pervasive attitudes that these plans are too difficult to adhere to, they can in fact be a good way for patients to lower their premiums and other health care costs. They do however require your attention to the limitations, expectations and responsibilities. It would be really hard to argue PCP involvement, knowledge and expertise in coordinating your health care needs/services to be a bad idea. It does however require planning and adherence by patients; all of which are reasonable and pretty common expectations for any insurance coverage plan.
Fighting Obesity One Person at a Time by Nisha Mailapur
ALARMING Our state of Alabama ranks 3rd highest in the nation when it comes to rates of adult obesity! Add to this, childhood obesity is on the rise, nearing 35.5% of 10-17 year olds statewide. Not only is obesity unhealthy, it is also expensive. According to STOP Obesity Alliance's "Fast Facts: The Cost of Obesity," the yearly expense for an obese woman and an obese man is $4,879 and $2,646, respectively. Research from McKinsey Global Institute shows that the economic output of obesity and its consequences accounts for 4 to 8 percent of America’s gross domestic product. Obesity is the culprit of many chronic diseases such as diabetes, hypertension, liver cirrhosis, and is responsible for increased risk of some cancers, such as breast cancer. One of the most shocking facts about obesity is that it is entirely preventable and reversible with a change in lifestyle. I was first introduced to the effects of obesity after listening to multiple success and failure stories from some of my father's bariatric patients. As a runner and food lover, I am impacted by their journeys in fighting obesity. Since then, I have felt the need to increase awareness of obesity in my small community of Huntsville. I started with a simple goal: expanding the simple clichés-“be you” or “be comfortable in your own body”-past just words. Yes, we need to be comfortable in our unique body, but it is imperative that we all are aware that obesity comes with a very heavy price on our well being (physically and financially)—leading to chronic diseases that are expensive. So, for me, raising awareness about obesity is not about sculpting a perfect body; rather, it is about cul-
tivating a habit of exercise and healthy eating to maintain our own body and its needs. After ruthless brainstorming, in the summer of 2016, the took form. The goal of the Say No to Obesity 4K is to create an environment where people of any shape, size, or fitness level can come together and pass a simple thought bubble: “Hi, what’s your name? What’s your story?” or “Let’s run/walk/jog/crawl this together!” The vision of this event is to get people to lace up their shoes, put on a t-shirt, and just get outside. The road race came together with the relentless support and guidance from not only my parents and cross-country coach, but also from community leaders from Huntsville Track Club and Fleet Feet, as well as key members of the Huntsville Hospital Foundation. With two Say No to Obesity 4K events behind me, I began to dig deeper into what obesity is and how to fight it. I realized that fighting obesity goes beyond just exercising, walking, or running. Obesity is linked to the consumption of highly processed foods. According to Harvard T.H. Chan's School of Public Health, what you put in your body matters. Buying fresh fruits and vegetables for the week, rather than going to fast food restaurants or stocking up on pre-made meals at the grocery store, can end up being less costly in the long run, fill you up more than processed foods, and is better and healthier for your body. I thought, wow! ...no wonder my mother tells me to
choose the grapes and cheese rather than the hidden stock of cookies in the pantry. Reminded of the healthy eating habits my mother strived to cultivate in my family, I began to venture into the food culture of obesity. In the summer of 2018, I interned with Ms. Steakley, a local dietician/nutritionist at Huntsville Hospital. While I meticulously learned about wholesome meals-proteins, carbohydrates, vegetables, monounsaturated fats-portion control, nutrition facts, reading labels, and recipe building, we looked at a study started by Dr. Amy Custack, professor at Michigan State University and nutrition director at the Michigan State University-Hurley Children’s Hospi-tal Pediatric Public Health Initiative: "Fruit and vegetable intake tracks from childhood to adulthood, making it important for health care professionals to guide children towards healthy eating early on." Similarly, Ms. Steakley had mentioned that her patients do not eat fresh vegetables, mainly because they do not buy them and because they do not know what to do with them. So, in a thirty min-ute interview with Dr. Custack, I was able to learn about how their fresh fruit and vegetable prescription program in Flint, Michigan could be emulated in our community of Huntsville. "We need to consider not only nutrition education but also barriers to access and affordability of fresh fruits and vegetables, particularly in underserved areas. The prescription program is a first step to introducing fresh, high-quality produce to children,” says Dr. Custack. Keeping in mind Dr. Custack’s study, I proposed using the funds raised from the Say No to Obesity 4K Run/Walk to start a fresh produce prescription program to promote the consumption of fresh produce in order to decrease reliance on processed food. The objective is to distribute “veggie vouchers” as prescriptions by our community of physicians to further raise awareness and fight obesity. This pilot program is unfolding as I write this article; my goal is for this prescription program to be fully implemented by next year. In the meantime, in an effort to further sustain this fresh produce prescription program in the long run, I created a GoFundMe: “A Recipe for Prescription.” Will you join our efforts? We live in America, in a democracy. Change starts with the people. Let us battle the politics, FDA subsidies on processed foods, medical bills, and increased weight. We make the choices, not them.