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Diabetics need special treatment

FACIAL Rejuvenation News

Exercise 'can be as good as pills'

Global Health

Aircraft noise 'link' to stroke and heart disease deaths


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The addition of 3D Mammography (tomosynthesis) to conventional digital mammography results in a 30 percent reduction in the overall recall rate



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Whiplash Associated Disorders – What are the Facts?

The risks of stroke, heart and circulatory disease are higher in areas with a lot of aircraft noise, researchers say.

Jonathan Chung, DC

Diarrhea… When Should I be Concerned?

Diarrhea can be described as a change in the consistency of stools, which will cause them to become loose and often can be quite watery.

Breast Cancer Awareness Month


ational Breast Cancer Awareness Month is a chance to raise awareness about the importance of screening and the early detection of breast cancer. About 1 in 8 women born today in the United States will get breast cancer at some point during her life. After skin cancer, breast cancer is the most common kind of cancer in women. The good news is that many women can survive breast cancer if it’s found and treated early. If you are age 40 to 49, talk with your doctor about when to start getting mammograms and how often to get them.

Women ages 50 to 74 need mammograms every 2 years. You may choose to start getting mammograms earlier or to get them more often. Talk to a doctor about your risk for breast cancer, especially if a close family member has had breast or ovarian cancer. Your doctor can help you decide when and how often to get mammograms.

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October 2013


Aircraft noise 'link' to stroke and heart disease deaths


By Jane Dreaper

health correspondent, BBc News

heir study of 3.6 million residents near Heathrow Airport suggested the risks were 10-20% higher in areas with the highest levels of aircraft noise. The team's findings are published in the British Medical Journal.

They agreed with other experts that noise was not necessarily to blame and more work was needed.

Their work suggests a higher risk for both hospital admissions and deaths from stroke, heart and circulatory disease for the 2% of the study - about 70,000 people who lived where the aircraft noise was loudest. The lead author, Dr Anna Hansell, from Imperial College London, said: "The exact role that noise exposure may play in ill health is not well established. "However, it is plausible that it might be contributing - for example, by raising blood pressure or by disturbing people's sleep."

"There's a 'startle reaction' to loud noise - if you're suddenly exposed to it, the heart rate and blood pressure increase.

"And aircraft noise can be annoying for some people, which can also affect their blood pressure, leading to illness. "The relative importance of daytime and night-time noise from aircraft also needs to be investigated further." The study used data about noise levels in 2001 from the Civil

Aviation Authority, covering 12 London boroughs and nine districts outside of London where aircraft noise exceeds 50 decibels - about the volume of a normal conversation in a quiet room.

The authors say fewer people are now affected by the highest levels of noise (above 63 decibels) - despite more planes being in the skies - because of changes in aircraft design and flight plans. The researchers - from Imperial and also King's College London adjusted their work in an effort to eliminate other factors that might

Noise 'has fallen' The study covered 12 London boroughs in the centre and west of the capital - and nine council districts beyond London, including Windsor and Maidenhead, Slough and Wokingham.

Heathrow Airport's director of sustainability, Matt Gorman, said: "We are already taking significant steps to tackle the issue of noise.

"We are charging airlines more for noisier aircraft, offering insulation and double glazing to local residents and are working with noise campaigners to give people predictable periods of respite from noise.

"Together these measures have meant that the number of people affected by noise has fallen by 90% since the 1970s, despite the number of flights almost doubling."

have a relationship with stroke and heart disease, such as deprivation, South Asian ethnicity and smoking-related illness.

They stressed that the higher risk of illness related to aircraft noise remained much less significant than the risks from lifestyle factors - including smoking, a lack of exercise or poor diet. In an accompanying editorial, Prof Stephen Stansfeld, from Queen Mary University of London, said: "These results imply that the siting of airports and consequent exposure to aircraft noise may have direct effects on the health of the surrounding population.

"Planners need to take this into account when expanding airports in heavily populated areas or planning new airports."

A government spokesman said: "The number of people affected by high levels of noise around Heathrow has been falling for years due to improvements in aviation technology, better planning of flight paths and other factors. We would expect to see this trend continue." A separate study, also published in the BMJ, demonstrates a higher rate of admission to hospital with cardiovascular problems for people living near 89 airports in the US.

Prof Kevin McConway, from the Open University, said: "Both of these studies are thorough and well-conducted. But, even taken together, they don't prove that aircraft noise actually causes heart disease and strokes.

Obamacare boosts generic drug makers


By Brajesh Upadhyay

BBc News, Washington dc

epublican opposition to President Barack Obama's healthcare law is at the heart of the government shutdown in the US. The same law is creating new jobs and business, thousands of miles away in India. As millions of Americans are encouraged to enrol in health insurance plans under the new system, executives in India's generic drug and software industries foresee an upswing in business. Nearly 40% of the generic drugs used in the US now come from India, and industry insiders say sales will grow as the reforms collectively known as Obamacare roll out.

Muralidharan Nair of Ernst and Young says Obamacare envisages savings of $150bn (ÂŁ935m) per year from drug cost reductions. That is also the size of opportunity for people who work in the industry. "Obamacare will be a harbinger of a tectonic change in the way generic consumption is going to

happen in the US, and India stands to gain significantly," says Mr Nair. He forecasts a year-onyear growth of 25-30% in the generic drug industry in India, already branded as "pharmacy to the world".

'Zero' cost

Experts say generic drugs are pivotal to the success of the new healthcare system. That is because nearly 90% of patients in the US have some kind of copayment on their insurance, which encourages them to take lower-priced generics rather than brand-name drugs. "If you move to generic drugs, the out-of-pocket cost drops to zero in many cases," says Kavita Patel, a former advisor to the Obama administration on health reforms and now with the Brookings Institute. "A generic medicine for cholesterol can be as low as $4 a month compared to $300 a month for a branded one."

Doctors in the US are now encouraged to switch to generics where appropriate.

Man's penis amputated after he abuses erection drug

GIGANTE, Colombia — A Colombian man's attempt to impress a new girlfriend with his sexual prowess backfired in an ironically tragic way. According to the La Nacion

newspaper, the 66-year-old had to have his penis amputated after reportedly overdosing on the erectile disfunction medication Viagra. Doctors in southern Colombia

say the man intentionally overdosed on Viagra to impress his new girlfriend. As a result, he experienced a constant state of erection for several days, according to the paper.

After seeking medical attention for the days-long erection, doctors found the man's penis to be inflamed, fractured and showing signs of gangrene. In order to stop the gangrene from

spreading to the rest of his body, doctors say they were forced to amputee the man's penis. Doctors say the man is now recovering and doing well, relatively speaking.

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Global Health Tribune is a newspaper published every month in Palm Beach county and surrounding areas. Copyright 2013, all rights reserved by SEA Publications, Inc. Contents may not be reproduced in any form without the written consent of the publisher. The publisher reserves the right to refuse advertising. The publisher does not accept responsibility for advertisement error beyond the cost of the advertisement itself. All submitted materials are subject to editing.

October 2013

Page 3




Arthur Hansen DPM, M.S.

oot ulcers and amputations are a major cause of morbidity, disability, as well as emotional and physical costs for people with diabetes. It is important to obtain early recognition and management of independent risk factors for ulcers. This can prevent amputations and/or delay the onset of adverse outcomes. Below are recommendations for people who have yet to encounter foot ulcers. Each segment strives to educate an effective way of identifying and managing risk factors for ulceration in hopes of preventing an ulcer. IDENTIFYING RISK

Identifying risks for diabetic ulcerations is the key to preventing them. The chance of developing a diabetic ulcer/amputation begins to increase after ten years of being diagnosed with Diabetes, poor sugar control, if you are male, and also having comorbidities such as renal, retinal and cardiovascular disease. Risk

Diabetics are prone to many problems that affect their feet and legs. Some of which may lead to the amputation of part of the foot or the entire leg. If you are a Diabetic, you need to have your feet checked by a professional regularly.

identification is fundamental in order to be effective in prevention.

Below are symptoms that are associated with an increased risk of amputation:

• Peripheral neuropathy with loss of protective sensation • Altered biomechanics (in the presence of neuropathy) • Evidence of increased pressure (erythema, hemorrhage under a callus) • Bony deformity • Peripheral vascular disease (decreased or absent pedal pulses) • A history of ulcers or amputation • Severe nail pathology


Anyone with diabetes should have an annual foot examination to identify high-risk foot conditions. People with any of the mentioned high-risk foot conditions should be examined more frequently. The exam should include assessment of

Conservative & Surgical Treatments Available Whirlpool with every visit!

protective sensation, vascularization, foot deformities, and skin assessment. Diabetics with known peripheral neuropathy should have their lower extremities inspected during every professional health care visit.


vascular disease complications. An appropriate and timely referral to a foot care specialist is gravely important for prevention. PATIENT EDUCATION

Patients with diabetes and associated risk factors for foot conditions must be educated regarding these risk factors and how to manage them. Diabetics must fully understand the complications associated with the risk factors. They must inspect their feet daily, clean and dry them daily, and be aware of their shoe gear. As many diabetic patients have trouble seeing or reaching their feet, family members should also be educated on the risks and daily examinations. The American Diabetic Association makes the following recommendations:

Equal sensory loss to both feet usually starting at the toes and working up is one of the most important predictors of ulcers and amputation. Neuropathy can be delayed significantly by controlling glucose levels to as near normal as possible. A cessation of smoking should be encouraged to reduce the risk of

• All individuals with diabetes should receive an annual foot examination to identify highrisk foot conditions. This examination should include assessment of protective sensation, foot structure and biomechanics, vascular status, and skin integrity.

• People with neuropathy should have a visual inspection of their feet during every visit with a health care professional.

• Evaluation of neurological status in the low-risk foot should include a quantitative somatosensory threshold test, using the Semmes-Weinstein 5.07 (10-g) monofilament.

• Patients with diabetes and highrisk foot conditions should be educated regarding their risk factors and appropriate management.

• Initial screening for peripheral vascular disease should include a history for claudication and an assessment of the pedal pulses.

For Diabetics, the loss of a foot and/or a leg is a real concern. Identification of those patients most at risk, education, and prevention is the key to saving limbs. If you are a diabetic make your appointment today.

• People with one or more highrisk foot conditions should be evaluated more frequently for the development of additional risk factors.

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October 2013


The addition of 3D Mammography (tomosynthesis) to conventional digital mammography results in a 30 percent reduction in the overall recall rate Another benefit is the improved imaging in women with mammographically dense breasts, because of the elimination of viewing the overlying tissues above and below the areas of interest.

Because of the 3D information included in obtaining the tomosynthesis images, the relative position of a suspicious area in the breast can be more precisely identified in all three planes.


Eric M. Baumel, M.D. American Board of Radiology

By: Eric M. Baumel, MD

reast tomosynthesis, also known as 3D mammography was approved by the FDA on February 11, 2011.


Breast tomosynthesis minimizes the effect of overlapping breast tissue by having the X-ray tube and detector moving in tandem, acquiring the images at different angles. These images are then combined to create a three dimensional picture that can be manipulated by the radiologist when reviewing the mammograms. At the current time, the tomosynthesis images are acquired at the same time as the conventional 2D mammograms. Using conventional mammography, about 10 - 15% of women are called back for additional imaging. Tomosynthesis reduces the need for many of these call backs, because the initial studies with tomosythesis will be free of overlapping structures.

A recent large study of tomosynthesis was published online July 30, 2013 in Radiology by Brian M. Haas, M.D. and colleagues, from the Yale University School of Medicine in New Haven, Connecticut. The addition of tomosynthesis to conventional digital mammography resulted in a 30 percent reduction in the overall recall rate.

"All age groups and breast densities had reduced risk for recall in the tomosynthesis group," Dr. Haas said. "Women with dense breasts and those younger than age 50 particularly benefited from tomosynthesis.� Lower recall rates help reduce patient anxiety and also reduce costs from additional diagnostic examinations, Dr. Haas said.

Tomosynthesis has one significant drawback: a radiation dose approximately double that of digital mammography alone. However, Dr. Haas noted that new technology approved by the U.S. Food and Drug Administration could reduce the dose. Dr. Baumel is the Medical Director at Independent Imaging where 3D Mammography is available.


The Women's Center at Independent Imaging offers women the latest in Digital Mammography, Breast MRI, DEXA Bone Density, and Breast and Obstetric Ultrasound in a comfortable, tranquil setting developed around a woman's diagnostic needs.

October 2013

Page 5


FACIAL Rejuvenation News Sublative skin rejuvenation is the world’s first non-laser resurfacing technology that uses radio-frequency waves to help restore a youthful look to the face.


By Dr. R. Sabates CLS, CME

he word ablative means removal of skin with erosive techniques for resurfacing, for example: CO2 Laser Resurfacing, Erbium, or IPL (Intense Pulsed Light). It can also mean microdermabrasion and deep peels. Sublative, on the other hand, is a less invasive technology that heats the dermis with minimal epidermis disruption. To the patient, the main difference between ablative and sublative is discomfort, cost, and down time. Ablative laser technology often requires only one prolonged treatment.

It is very effective in deep wrinkles, but it can be very painful and requires nerve blocks and anesthetic creams. It can take some time for the skin to heal and is not recommended in darker or tanned skin because of the risk of hyperpigmentation. With sublative technology and using the newest eMatrix equipment, a full face may take only 15 minutes. It’s recommended that the treatment

be repeated three or more times every four to six weeks. There is also minimal down time. Generally, the patient can go to work the very next day and makeup can be applied in just 12 hours. It is safe on all skin types and side-effects, such as hyperpigmentation are rare. The uniqueness of the eMatrix equipment is that the applied energy is FRAXELATED. The disposable applicator delivers radio waves though a grid (Matrix) of 64 spaced electrodes that does not penetrate the skin. This grid effect leaves space for intact tissue this speeds up healing and recovery. 95% of

the energy generated penetrates deep into the dermis leaving only 5% ablation of the epidermis. This unique inverted cone shaped delivery of thermal heating causes high levels of dermal collagen remodeling and skin tightening without disrupting the skin. Through the course of the treatments, wrinkles, sun



damage, and acne scars are attacked from the inside out. It can also treat fine wrinkles and crow’s feet.

Studies show that after treatments using eMatrix, 90% of patients reported brighter skin, improved skin smoothness of fine lines, and wrinkle reduction according to the Journal of Drug & Dermatology.



Probably the most spectacular results have been observed in acne scars. These lesions are very distressing to patients and notoriously hard to treat. Medical studies show statistically significant reduction in scars with a high patient satisfaction rate one to three months after treatment. As stated by Dr. Michael Gold, Tennessee Clinical Research center, “The literature has shown eMatrix radiofrequency to be safe and effective for all skin types with much less risk of hyperpigmentation than all the other alternatives. Patients like the result, tolerability, and short downtime. It doesn’t get any better than that.” If you would like to learn more about eMatrix, or any other procedure that we offer, please give us a call at 561-753-3336. You can also visit our website at

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October 2013

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Exercise 'can be as good as pills' Daily Walk May Cut Your By Michelle Roberts

Health editor, BBC News online

Exercise can be as good a medicine as pills for people with conditions such as heart disease, a study has found. The work in the British Medical Journal (BMJ) looked at hundreds of trials involving nearly 340,000 patients to assess the merits of exercise and drugs in preventing death. Physical activity rivalled some heart drugs and outperformed stroke medicine. The findings suggest exercise should be added to prescriptions, say the researchers. Experts stressed that patients should not ditch their drugs for exercise - rather, they should use both in tandem.

Prescriptions rise

Too few adults currently get enough exercise. Only a third of people in England do the

recommended 2.5 hours or more of moderate-intensity activity, such as cycling or fast walking, every week. In contrast, prescription drug rates continue to rise. There were an average of 17.7 prescriptions for every person in England in 2010, compared with 11.2 in 2000. For the study, scientists based at the London School of Economics, Harvard Pilgrim Health Care Institute at Harvard Medical School and Stanford University School of Medicine trawled medical literature to find any research that compared exercise with pills as a therapy. They identified 305 trials to include in their analysis. These trials looked at managing conditions such as existing heart disease, stroke rehabilitation, heart failure and pre-diabetes. When they studied the data as a whole, they found exercise and drugs were comparable in terms

of death rates. But there were two exceptions. Drugs called diuretics were the clear winner for heart failure patients, while exercise was best for stroke patients in terms of life expectancy. Amy Thompson, senior cardiac nurse at the British Heart Foundation, said that although an active lifestyle brings many health benefits, there is not enough evidence to draw any firm conclusions about the merit of exercise above and beyond drugs. "Medicines are an extremely important part of the treatment of many heart conditions and people on prescribed drugs should keep taking their vital meds. If you have a heart condition or have been told you're at high risk of heart disease, talk to your doctor about the role that exercise can play in your treatment." Dr Peter Coleman of the Stroke Association said exercise alongside drugs had a vital role that merited more research. "We would like to see more research into the long-term benefits of exercise for stroke patients. "By taking important steps, such as regular exercise, eating a balanced diet and stopping smoking, people can significantly reduce their risk of stroke." "Moderate physical activity, for example, can reduce the risk of stroke by up to 27%."

Breast Cancer Risk lder women who walk every day may reduce their risk of developing breast cancer. And those who exercise vigorously may get even more protection, according to new research. The study of more than 73,000 postmenopausal women found that walking at a moderate pace for an hour a day was associated with a 14 percent reduced breast cancer risk, compared to leading a sedentary lifestyle. An hour or more of daily strenuous physical activity was associated with a 25 percent reduced risk, the study found. This is welcome news for women who aren't very athletic. "The nice message here is, you don't have to go out and run a marathon to lower your breast cancer risk," said study researcher Alpa Patel, senior epidemiologist at the American Cancer Society, which funded the study. "Go for a nice, leisurely walk an hour a day to lower risk," Patel advised. Breast cancer is the leading cancer among women. In the United States, about one in eight women will develop the disease in her lifetime. The women who reported moderate exercise walked about three miles an hour, or about a 20-minute mile. The more vigorous exercisers participated in such activities as fast walking

-- about 4.5 miles in an hour, the equivalent of a light jog, Patel said -- moderate cycling or lap swimming. For the study, published online Oct. 4 in Cancer Epidemiology, Biomarkers & Prevention, Patel and her team identified more than 73,000 women past menopause who were enrolled in an American Cancer Society study on cancer incidence. When they enrolled in 1992, the average age was nearly 63. The women completed a questionnaire about medical, environmental and demographic factors at the start and repeated the reports every two years between 1997 and 2009. The study participants also reported on their physical activity and time spent sitting, including watching television and reading, and reported any diagnosis of breast cancer. During the follow-up, which was roughly 14 years, 4,760 women developed breast cancer.

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Page 8

October 2013


Dear Deborah

DEAR DEBORAH: Do you believe in love at first sight? What about lust? Sleeping with someone after a first face to face meeting? Could any of those things lead to a long term relationship? - Quick to Commit?

Dear Quick to Commit: Of course, I believe you can love someone’s appearance when you initially meet. However, I do not believe that you can fall in love with the person until you get to know them. I absolutely believe in lust. Personally, I do not believe in having sex with someone when you first meet them. If you want to have and sustain a long term relationship, get to know the person prior to being sexually intimate. In doing so, you will never question whether or not it would have worked out if you had waited. Take your time as the beauty in a relationship comes from learning about your partner and seeing how well you both are together.

DEAR DEBORAH: I was recently invited to a childhood friend’s wedding reception that will take place next month. We were best friends in our teens and just recently reconnected after 20 years (we’re now 35). When I

received the invitation, it only had my name on it and did not give me an opportunity to “add one.” Since I am single and do not know her family or anyone attending, I would prefer to bring someone. How do I go about asking if I could bring a guest without pushing the issue? - Add One?

Dear Add One: Since you just recently reconnected, I certainly would not ask your old friend if you could bring a guest. There are many reasons for not doing so, one of which is that you do not know her current financial situation and she may have already over-extended herself by adding you to the guest list. There may also be a limit on seating. What I do recommend when you arrive at the reception, take a look around and see if you are interested in anyone in the room and go and talk with them. Many people have met their future partners at a wedding reception and you may be next to walk down that aisle.

DEAR DEBORAH: I have been dating a man for two years now and I still do not know about his financial situation. He knows what I earn because I was foolish enough to use his accountant for my tax return last year. I am 28, never married, have a great career, earn a very nice income, and would like to start a family within the next four years.

He is 35, never married, and a contractor. I have tried over and over again to get him to open up about what he earns, but he changes the subject. When we’re apart, he sends me text messages with photos of cash and checks from his clients. Why does he avoid the conversation when we are together? I want to plan for my future, but unless he opens up, he will not be a part of it. - What is HE Afraid Of?

Dear What is HE Afraid Of: My concern is that he is not willing to discuss this matter in your presence, yet he sends you photos through text messaging. That is definitely a red flag in my opinion. He is obviously hiding something or in his case, he does not earn much and is hiding nothing. If you do earn more than he does, he could be insecure and self-conscious and in fear of losing you if you were to find out the truth. In reality, he is pushing you away by his lack of willingness to disclose this information. You need to be assertive and tell him in no uncertain terms that it does not matter how much he earns, but it does matter that he is trying to avoid a very important topic in your relationship. If he cannot be honest and forthright with this matter, you will always wonder if there are other issues that he is either hiding or not being completely honest about. Get to the bottom of this BEFORE taking your relationship to the next level.

Dear Deborah is a monthly advice column written by Deborah Lynn with a common sense approach to dating. If you have any questions or comments, please forward them to: as we would love to help.

Global study: World not ready for aging population


AP Kristen Gelinau

he world is aging so fast that most countries are not prepared to support their swelling numbers of elderly people, according to a global study being issued by the United Nations and an elder rights group. The report ranks the social and economic well-being of elders in 91 countries, with Sweden coming out on top and Afghanistan at the bottom. It reflects what advocates for the old have been warning, with increasing urgency, for years: Nations are simply not working quickly enough to cope with a population graying faster than ever before. By the year 2050, for the first time in history, seniors older than 60 will outnumber children younger than 15. Truong Tien Thao, who runs a small tea shop on the sidewalk near his home in Hanoi, Vietnam, is 65 and acutely aware that he, like millions of others, is plunging into old age without a safety net. He wishes he could retire, but he and his 61-year-old wife depend on the $50 a month they earn from the shop. And so every day, Thao rises early to open the stall at 6 a.m. and works until 2 p.m., when his wife takes over until closing. "People at my age should have a rest, but I still have to work to make our ends meet," he says, while waiting for customers at the shop, which sells green tea,

cigarettes and chewing gum. "My wife and I have no pension, no health insurance. I'm scared of thinking of being sick — I don't know how I can pay for the medical care." Thao's story reflects a key point in the report, which was released early to The Associated Press: Aging is an issue across the world. Perhaps surprisingly, the report shows that the fastest aging countries are developing ones, such as Jordan, Laos, Mongolia, Nicaragua and Vietnam, where the number of older people will more than triple by 2050. All ranked in the bottom half of the index. The Global AgeWatch Index ( was created by elder advocacy group HelpAge International and the U.N. Population Fund in part to address a lack of international data on the extent and impact of global aging. The index, released on the U.N.'s International Day of Older Persons, compiles data from the U.N., World Health Organization, World Bank and other global agencies, and analyzes income, health, education, employment and age-friendly environment in each country.


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October 2013


Upcoming Medical and Fundraising Events October 13

October 8 – November 8, 2013

19th Annual C.R.O.S. Ministries End Hunger Walk. Registration is at 2:30 p.m. and starts at 3:00pm. The walk starts at Holy Trinity Episcopal Church and proceeds north along Flagler. If you are interested in participating, please contact Gibbie Nauman at for a pledge envelope. For additional information, contact the CROS office at (561) 233-9009.

October 14

Wellington Regional Medical Center. Free Bariatric Information Session. Wellington Surgical Weight Reduction Center, 1397 Medical Park Blvd., Suite 140, Wellington on the hospital grounds. The session begins at 6:00pm. Please call for additional information, 561-798-8587.

October 16

Jupiter Medical Center and the Kristin Hoke Breast Health Program. Key to the Cure 2013 Kick-off Event. Charity Shopping Event at Saks Fifth Avenue, Palm Beach Gardens. The kick-off begins at 5:30pm and the entry fee is $40.00 per person or $75.00 per couple. The shopping event takes place over four days, from October 1720. For additional information, call 561-263-5728 or e-mail

October 19

Wellington Regional Medical Center. Self-Exam and Breast Health Class. The Community Room in the medical center. Guest speaker, Kathleen E. Minnick, MD, will discuss breast health, risks, and screenings. The class takes place between 10:00 – 11:30am. For additional information and to reserve a spot, contact 561-798-9880.

October 20

Gold Coast Down Syndrome Organization. 19th Annual Palm Beach County BUDDY WALK. Cost is $15.00 per person prior to October 6 and $20.00 thereafter. That includes your entry fee for the one-mile Advocacy Walk or 5K Fitness Walk and a t-shirt. There will also be a silent auction as well as food for a small donation. For additional information, contact Anne at 561-752-3383 or

October 25

Big Brother Big Sisters of Palm Beach and Martin Counties. 2nd Annual Casino Night at Seasons 52 in North Palm Beach. Cost is $100.00 per person. Doors open at 6:00pm and the cost is $100.00 per person. There will be cocktails and hors d’oeurves, a live auction, and raffle prizes. Registration is limited, so please call 561-7273450 for additional information.

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October 26

8th Annual Golf for the Cure benefiting Susan G. Komen South Florida. King’s Point Golf, Delray Beach. This will be a shot gun, best ball tournament. This event does not require an RSVP. For information, visit encontact.html.

November 2

Alzheimer’s Association. 2013 Walk to End Alzheimer’s. Meyer Amphitheatre, West Palm Beach. Registration begins at 7:30am. For information, contact Duane Hamilton at 313-318-4505, 800272-3900, or e-mail him at

November 3

Big Brothers Big Sisters of Palm Beach and Martin Counties. South Florida Runs Coconut 5K. Okeeheelee Park, Micanopy Pavilion, 7500 Forest Hill Blvd., West Palm Beach. For additional information, visit

Center for Family Services. Princess and Pirate Ball. International Polo Club, Wellington. All ages welcome. Benefitting the Pat Reeves Village Shelter, which helps families with children who either homeless or at risk for homelessness. Call Stanton Collemer, (561) 616-1257 or e-mail

Page 9


More Black Women in U.S. Diagnosed With Breast Cancer, Report Finds hite women 40 and older have traditionally had the highest rates of breast cancer in the United States, but rising rates among blacks have narrowed the gap in recent years, according to a new American Cancer Society report. "This convergence of rates is being driven by steady rates among white women and a slow increase in recent years among African-American women," said report co-author Carol DeSantis, an epidemiologist in the society's Surveillance and Health Services Research Group. From 2006 through 2010, breast cancer rates increased 0.2 percent among black women but remained stable among whites, researchers found. White women still have more cases of breast cancer, however, with about 127 cases per 100,000 compared with 118 cases per 100,000 black women. But deaths from breast cancer are more common among blacks, according to the report published Oct. 1 in CA: A Cancer Journal for Clinicians. The gap is closing most among women aged 50 to 59 years old, and the reasons why aren't clear, the researchers say. Another expert voiced concern. "Even with all the attention and awareness raised around breast cancer, the incidence of the disease holds steady," said Dr.

Stephanie Bernik, chief of surgical oncology at Lenox Hill Hospital in New York City. "Although the incidence haven't declined, we have made strides in the effort to improve the survival rate," she noted. "Death rates have declined by 34 percent since 1990. However, not all ethnic groups are enjoying this improved survival." The death rate during the study period was 30.8 per 100,000 among black women compared to 22.7 per 100,000 among whites, the reports says. Blacks have a worse prognosis stage for stage, and the incidence of breast cancer in this group in increasing, Bernik said. "The reasons for this increase among African-American women are unclear, but may be linked to socioeconomic status and barriers to treatment," she said. Bernik added that improvement in the survival rate is encouraging, but said more work needs to be done to prevent the disease from starting in the first place.

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Page 10

October 2013


5 Things You Didn't Know About CyberKnife


Kishore K. Dass, MD

Board-Certified Radiation Oncologist

r. Anurag Agarwal, radiation oncologist at South Florida Radiation Oncology, explains CyberKnife, the robotic radiosurgery system used for treating tumors.

No pain to gain

We enter with a scalpel-like cut. We don’t actually go in and cut the tumor, but we deliver appropriately high doses of radiation to areas of interest and minimize radiation to the healthy areas. We have submillimeter accuracy with CyberKnife. There is no open incision, no anesthesia and no ventilator. Patients can even drive themselves home afterward.

Making history

CyberKnife allows us to treat patients for whom,

Anurag Agarwal, MD Board-Certified Radiation Oncologist

historically; this degree of success could not be possible. For example, if a patient has a tumor around the spinal cord, CyberKnife is an ideal technology for the treatment. Some surgeons are reluctant to remove a spinal tumor because it’s in a potentially dangerous position. We can enter and treat a spinal tumor with incredible accuracy.

Careful planning

Each case is incredibly complicated to plan. At South Florida Radiation Oncology, we have physicists involved in planning each case. It takes extensive amounts of time and research to execute the imaging and physics. Since we are employing sub-millimeter accuracy, everything must be perfectly calculated and considered.

See you in an hour

Patients wear normal clothes during the treatment while on the CyberKnife table. Because of the type of radiation emitted, they are alone in the room, but we provide material such as an iPod station to play their music of choice. Sessions may last from 30 minutes to two hours; we inform patients to lie still for the duration of the treatment.

Not for everyone

It’s about using the CyberKnife technology appropriately. There are many steps involved in determining treatment, and CyberKnife may not be a suitable treatment for every case. For example, a simple skin cancer may be treated effectively with a high success rate using another procedure. Your team at SFRO will determine if CyberKnife is right for you.

Anurag Agarwal obtained double board certification in radiation oncology and internal medicine. He also completed fellowship training in the ultraniche specialty of proton beam radiation at Harvard Medical School’s Massachusetts General Hospital. Dr. Agarwal attended George Washington University (GWU) in Washington, D.C., and went to medical school at the GWU School of Medicine and Health Care Sciences. He completed his radiation oncology training at The University of Pittsburgh School of Medicine, one of the leading academic centers for gene therapy and stereotactic radiosurgery (SRS). He treats all types of cancers, with special interest in breast, prostate, lung and CNS (brain) tumors, as well as soft-tissue sarcomas.







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Dr. Agarwal is experienced with a full spectrum of radiation oncology technologies, including protons, CyberKnife SRS, Gamma Knife SRS, high-dose rate and low-dose rate (HDR and LDR) brachytherapy, intraoperative radiation (IORT), intensitymodulated radiation therapy (IMRT) and image-guided radiation therapy (IGRT).

Dr. Agarwal helped establish the first CyberKnife program in Broward County. He has also done research in the exciting field of gene therapy. He has a volunteer clinical faculty appointment at the University of Miami School of Medicine.

Dr. Agarwal currently sees patients at South Florida Radiation Oncology’s Boca Raton and Broward offices.

Now Let the Experts in Breast Cancer Treatment Take Care of You. The American Cancer Institute predicts that, despite a healthy lifestyle, more than 200,000 women in the U.S. will contract breast cancer this year. That’s why at South Florida Radiation Oncology, our team of radiation oncologists renders the most technically advanced treatments in the field, including protocol based, IMRT, TrueBeam™ and partial breast irradiation. Our medical staff — together with you, your specialist and primary care physician — will collaborate and select the best treatment option for your particular diagnosis as well as your personal requirements. At South Florida Radiation Oncology, we recognize that every patient is an individual, with unique treatment needs and a distinctive lifestyle. Call South Florida Radiation Oncology and let us take gentle, compassionate and effective care of you today so you can get back to taking care of yourself tomorrow.

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Page 12

October 2013



with the intent of arriving at a diagnosis.

The way I was trained in Chicago, was to look directly into the patient’s eyes and make as much eye contact as possible, which was fairly simple those days, before the advent of computerized medicine.


l had a lot of good times and fun seeing patients in my early years of practice in Florida. I worked hard in different hospitals; taking emergency room calls, waking up late at night to go to the ER for emergencies, and also being called by the hospital and my private practice multiple times when I was blissfully sound asleep! Considering how I was trained in my residency program in Chicago, the calls I took in the hospitals in Wellington were a piece of cake!

Shekhar V. Sharma, M.D. Board Certified in Internal Medicine

llow me to tell you a story of how my personal perspective of life has changed for the traditional doctor of yesteryear to the doctor of today. Having been trained in a large training and post-graduate institution in Chicago, more than two decades ago, I learned how to practice medicine by examining the patient and taking the appropriate time to do so. This required a complete physical examination, but also entailed the ability to obtain a good history from the patient by asking direct and relating questions. In doing so, this method allowed me to extract as much information as possible within a limited period of time -

While in the emergency room and after thoroughly examining a patient around 2:00am or so, I would discuss the case with the patient’s family at that time when there were no HIPAA laws and no restrictions as we see nowadays. Life was much simpler in treating patients compared to today with modern computerized medicine where a physician stares at a computer screen when interviewing a patient. My eyes are more directed to the computer screen

than ever before. Those days l practiced patient care and nowadays, I am practicing computer care.

The question becomes, is this something that I elected to do or was it something that was mandated by the government? The answer is simple, it’s both the above. I believe in practicing medicine with the help of a computer because it makes things much easier when trying to compile information from both the patient as well as various other physicians the patient had seen for a variety of other medical problems.

Back then, handwriting notes was the normal practice during my younger days. Nowadays, the use of a computer and the gentle tapping at the keyboard has taken over my life. Staring at a bright screen is not something that I had envisioned or predicted when I was in Chicago. I was not trained in how to type long histories quickly and efficiently on a keyboard while transferring my thoughts from a page of a patient’s medical record to a computer screen. Needless to say, this was all quite a transformation, one of which I had never expected.

When l started using an electronic medical record system, I had no choice but to

tap on the keyboard with a couple of fingers tediously and laboriously while trying to keep up with the patient as they recited their medical history and keying in the results from their physical examination, all while the patient and I are in the room together. Talk about time consuming! It’s no wonder why the patient in the next room is wondering why I am a bit behind schedule.

Add to the mix - computerized billing, electronic health records, and as you can clearly see, things have become much more complex and tedious. Let’s not forget about the new set of rules that have been implemented by Medicare and Medicare HMOs, which are called “quality measures” that as a physician, we must report after the patient’s visit to the office.

So, not only do I continue to practice my old medicine, but now l also incorporate something quite new that was not part of my training program. Therefore, I have to cautiously negotiate and navigate through the pot holes and speed bumps brought upon by modern day computerized medicine, compared to those simple, but effective days of yesteryear. Let me give you an example of how a “new normal” patient visit

might go. If the patient is a diabetic, I have to report those quality measures mandated by Medicare to be part of a cost savings and cost sharing program with Medicare. Those include things like Hemoglobin A1c, otherwise called HbA1c, urine for microalbumin levels, LDL cholesterol levels, make sure the patient has seen an ophthalmologist, of which I need to report to Medicare as well as various other things like recording of blood pressure readings, mammograms, and colonoscopy - all which is a time consuming method of checking to be sure these quality measures have been completed on the computer and sending them to Medicare.

So, this is my journey into the new normal practice of medicine. With all the new guidelines and restrictions, I now have to make sure there is no duplication of services, confer with the other consultant doctors that I had sent a patient to, make sure that l have read all of the reports that come back to me, and that is when a visit to my office is now called a complete visit. I have accepted this new journey and decided that l had to move on with the times since… Time and Tide Wait for No Man. Thank you very much for all your patience.

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October 2013

Page 13


Whiplash Associated Disorders – What are the Facts? injury. While they may or may not be correct, the truth is that whiplash is a type of injury with serious implications, and is frequently mismanaged by unscrupulous folks with a big stake in the business of personal injury.

Dr. Jonathan Chung is a Doctor of Chiropractic who focuses on Structural Correction and is primarily concerned with Structural Shifts of the spine. He graduated from the University of Central Florida with a B.S. in Microbiology and Molecular Biology. Dr. Chung then went on and received his doctorate from Life University's College of Chiropractic. Dr. Chung is certified in pediatrics from the International Chiropractic Pediatric Association, and is a Structural Chiropractic Researcher who has been published in scientific peerreviewed journals.


By Jonathan Chung, DC

n my experience, I’ve found that whiplash is a commonly misunderstood diagnosis among the patient population. Many people selfdiagnose the pain in the neck following a bad roller coaster ride or car accident as a whiplash

Whiplash is a common name for a group of neck disorders known as cervical accelerationdeceleration injury or cervical sprain/strain injury. It occurs when the head and neck are placed in motion and suddenly forced to a stop causing a hyperflexion or hyperextension motion. This irregular movement of the neck causes the ligaments of the spine to sprain and the muscles to splint the unstable structure. This type of injury is also known to cause the discs of the spine to bulge and herniate, thus complicating matters even further.

It’s easy to see how whiplash can be a real pain in the neck (pun intended), but most people treat it like a sprained ankle and hope that the pain goes away in a few weeks. However, there can be long term consequences; even for people who don’t have pain symptoms immediately. Research has shown that whiplash associated disorders are related to inflammatory and endocrine problems like those seen in chronic fatigue syndrome or fibromyalgia. Whiplash is also associated with chronic pain by

look at their x-ray and see that the structure of the neck fits the familiar S-shape of a previous rear end collision. Here are your take home messages:

making your brain more sensitive to pain signals, which explains why so many people can suffer without any evidence of physical damage. Additionally, people who report whiplash injuries after a rear-end accident are likely to show complaints of headaches, TMJ, back pain, fatigue, and sleep problems even 7 years later! Whiplash has even been associated with chronic inflammation by making the body’s own immune system overly responsive to normal stimuli.

Though the focus of my practice has never been on auto-accidents cases, the truth is that most drivers will be involved in a collision no matter how good a driver they may be. Most will probably not experience pain immediately after a collision, especially if you’re in your teens or early 20’s. However, the impact of a vehicle traveling at speeds as low as 15 mph can show visible signs of structural damage to the neck. These

include s-shaped curves in the neck, anterior ligament instability, Atlas Displacement, and Anterior Head Syndrome. A recent study has found that this type of trauma to the spine can cause parts of the brain and brain stem to slip further into the neck creating a condition called Chiari Malformation6. While they may not be painful in their early stages, these structural changes can pre-dispose the spine to early degeneration and arthritis if left uncorrected over the course of several years. As a chiropractor focused on structural correction, I see patients everyday with Secondary Conditions like headaches and TMJ related to accidents that took place many years earlier. While some of these patients suffered painful injuries and received treatment following an accident, most people will walk in and say they didn’t have any symptoms until years later. When someone asks why their pain seemed to come out of nowhere, I can usually

• First, problems can grow in the body in the absence of symptoms. Much like cancer and heart disease don’t happen overnight, people with chronic pain usually under go slow physiologic changes in their brain and hormonal systems for years before they have a condition that won’t go away.

• Second, if you have a physical/structural problem, then you must go beyond treating the pain symptoms to help get full resolution of the problem. Whiplash injuries cause distinct structural problems in the spine. While pain relief is important, making the pain go away while leaving the structure in bad shape is like taking the battery out of a smoke detector when a fire is burning in the house. Whiplash associated disorders can be a complicated problem that requires a comprehensive solution. When selecting a team of doctors, make sure that you have someone in your corner that can look at you from a functional standpoint rather than sheer pathology, that addresses the structure of your spine in 3dimensions, and understands the nature of traumatic injuries.


• arm Pain • carpal tunnel (Wrist) • canal stenosis • degenerated Joints • digestive disorders • disc herniation • dizziness (Vertigo) • dowager’s hump • Fatigue •  Fibromyalgia •  headaches •  hearing Issues • Itchiness •  low Back Pain • mid Back Pain • migraine headaches • muscle spasm • muscle tension • Neck Pain • Numbness/tingling • Pinched Nerve • Poor Posture • rotator cuff • shoulder Pain • sinus conditions • spinal decay • strength Issues • thoracic outlet syndrome • tmJ Issues • Upper Back Pain

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October 2013


Select Specialty Hospital Do you have a success story?

Mike Corvaia has been in healthcare administration for over ten years and is currently the director of Business development for select specialty hospital in Palm Beach. he holds a Bachelor’s degree from the University of Florida and is completing his master’s degree this year in Business administration, with an emphasis on healthcare administration.

Please feel free to send any healthcare related questions to

Ventilator Care

Judy Barth was working in her yard when she experienced what she thought was heartburn. The pain increased to the point that she called for help. The last thing she remembers is

scrambling for her insurance cards and passing out. Her next memory is one month later when she woke up at Select Specialty Hospital- North Knoxville. Judy had gone into cardiac arrest and was admitted to the local medical center where she was treated and stabilized. Doctors were concerned that a lack of oxygen might have affected her brain. Judy had spent almost a month unconscious and on a ventilator in the ICU when she was referred to Select Specialty Hospital to get her off the ventilator and functioning again. During her two week stay at Select Specialty Hospital, Judy woke up, got off the ventilator and beat the odds by discharging home. She has since returned to work and walks one to two miles every day.

Wound Care

Eugene Harris and his wife Jerlean were working on his antique truck, trying to get it to start. He was working with the carburetor when it blew up. Eugene was sent to the burn unit in Memphis in critical condition with twenty-four percent of his body burned. His family was told he might not survive. A month and a half later, still

unconscious and having survived several life-threatening infections, Eugene was transferred to Select Specialty Hospital in Memphis. He was on a ventilator with pneumonia and required dialysis. Eugene was with Select for nearly two months, his wife by his side every day. While he was at Select, he weaned from the ventilator and saw his kidney injuries resolved. He no longer needed dialysis. His burns continued to heal and he was discharged to a rehab facility with the goal of returning home as soon as possible. Almost four months after the accident, Eugene returned home. He says now he plans to enjoy the

comforts of home with his wife of 46 years.

Cardiac Care

Thirty eight year old Myrtle Mason had been struggling for breath for about a month. Her body was swollen from fluid retention due to congestive heart failure and she had been sleeping upright in a chair so she could breathe at night. When she could no longer take it, Myrtle sought the help of a physician. She was admitted to the local medical center with acute respiratory failure and was placed on a ventilator. Doctors told her family that getting off the ventilator would be a long shot

and she might not survive. Then, Myrtle was transferred to Select Specialty Hospital- Fort Smith. At Select, the team got her up and moving again. Her congestive heart disease, diabetes and blood pressure were brought under control and she was weaned from the ventilator. Myrtle was originally scheduled to go to rehab, but she surprised everyone by walking out of the hospital on her own and discharging home. It was her son’s 18th birthday. Myrtle feels like she has learned the importance of taking care of herself and is grateful for a second chance. “They gave me my life back. They were there for me.”

October 2013

Page 15


Diarrhea… When Should I be Concerned? Chronic diarrhea

By Ishan Gunawardene, M.D.

What is Diarrhea?

This form of diarrhea lasts longer than two weeks and may also be due to another medical illness. If due to infection, it may be associated with vomiting, cramping, and fever.

Diarrhea can be described as a change in the consistency of stools, which will cause them to become loose and often can be quite watery. It also contributes to the frequency in your bowel movements, which are passed three or more times a day (or more than usual).


Some people may experience cramping, abdominal pain, nausea, an urgency to go to the bathroom, chills, fever, bloody stools and of course dehydration.

People of all ages can experience that uncomfortable feeling, but the good news is that in most cases, it will simply go away on its own within a day or two. However, there are other times when medical intervention becomes necessary.

There are different types of diarrhea – mild, moderate, or severe.

Diarrhea is considered mild if it consists of up to three loose stools.

Diarrhea can be divided into two categories:

Moderate diarrhea is considered

Acute diarrhea

Is generally caused by an infection, such as bacterial, viral, or a parasite. It may last up to two weeks and can be caused by a number of factors. Those factors include emotional stress, food intolerance, inorganic agents, food allergies, sodium nitrate, organic substances (mushrooms and shellfish), antacids (with magnesium), and some medications.

to be about four stools a day with local symptoms that include abdominal cramps and nausea.

Serious diarrhea is when four or more stools a day are generated and include more severe symptoms such as fever, chills, and dehydration. When food poisoning is the culprit, you may experience vomiting, cramps, and fever hours after consumption which can last between 8-16 hours. The organism was therefore present in food and produced a toxin after eating.

Treating dehydration

Acute diarrhea is self-limited and does not need therapy other than fluids. Although drinking water is important, it does not include the electrolytes necessary to

prevent dehydration. You can help prevent dehydration by drinking fruit juices, sports drinks, soft drinks free of caffeine, and even broths contain electrolytes. There are also a number of products that are geared toward replenishing lost electrolytes, those include; Pedialyte, CeraLyte, Naturalyte, and Infalyte. Oral glucose is another treatment used to rehydrate.

When to consult a physician?

If your symptoms exceed three or more days and are not improving, accompanied by fever or over

102 degrees, become dehydrated with excessive thirst, are severely weak or lightheaded, or producing little to no urine, have severe abdominal cramps or rectal pain, or bloody or black tarry stools, it is necessary to isolate the bacteria which may require specific therapy.

In order to properly isolate the cause, your physician may request a stool sample for testing as well as blood work. In doing so, your physician can come to the proper diagnosis in order to treat your illness. They may also prescribe antibiotics specifically tailored to treating your symptoms.

Advanced Medical, P.A. Internal Medicine & Family Practice “If you ever need to be hospitalized, we will be with you from the office to the hospital and at your bedside”.

Heart / Chest Pain

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LLECTURE ECTURE SERIES: SERIES: PPalms a lm s W West est Hospital Hospital - C Classroom lassroom 2 - It’s It ’s time time to to refuel refuel yyour our ppower ower ssource ource - your your health! health! o october c tober



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Tickled Pink nk | 12:30-1:30 Tickled Pi 12:30- 1:30 p.m. p.m.

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Steven Steven PPliskow, liskow, MD, MD, FFACOG, ACOG , w will ill ddiscuss i sc u ss obstetrics, obstetrics, gynecological g ynecological health, health, cancer cancer prevention, prevention, ddetection etection and and treatment. treatment. Lunch Lunch will will be be served. s e r ve d .

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october oc tober

G General eneral Surgeon, Surgeon, James James Goad, Goad, MD, MD, FACS, FACS, aand nd C Colleen olleen Campbell, Campbell, Navigator Navigator of of Women’s Women’s Services Ser vices at The he B Breast Center will at T r ea s t C enter at at PPWH, WH, w ill discuss d i sc u ss diagnostic options, diagnostic bbreast reast sscreenings, creenings, ssurgical urgical op tions, and more and mo re - so so yyou ou sstay tay iinn the the bbest est of of breast breast hhealth. ealth. Lunch Lunch will will be be served. s e r ve d .

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Technology Te chnology & Health Heal ealth th | 12 -1 p.m. p.m. 12-1 SSeth et h H Herbst, erbst, MD, MD, FFACOG ACOG aand nd M Moises oises Virelles, Virelles, MD, MD, FFACOG, ACOG , w will ill discuss discuss tthe he importance impor tance ooff a COEMIG COEMIG designation, designation, ggynecological, ynecological, ppelvic, elvic, bbreast reast aand nd uurologic rologic health health as as well wel l s e r ve d . aass rrobotic obotic ssurgery urger y op options. tions. LLunch unch will will be be served.

Bone B one H Health ealth eal th | 12-1 pp.m. .m. R ajen N Rajen Naidoo, aidoo, M MD, D, FACS, FACS, aand nd David David A Adler, dler, DO, DO, FFACOG, ACOG , will w ill discuss d i sc u ss w women’s omen’s orthopedic or thopedic hhealth, ealth, jjoint oint replacement, replacement, osteopenia, osteopenia, oosteoarthris, steoar thris, osteoporosis, osteoporosis, bio-identical bio-identical hormone hormone ttherapy herapy and and testosterone testosterone ttreatment. reatment. Lunch Lunch will will be be served. s e r ve d .

The The PPink ink FFling ling will be held at our BR AND NEW Breast Center located at 12989 Southern Blvd., Suite 101, Loxahatchee. The T he ffun-packed un-packed eevening vening iincludes: ncludes: • Physician meet and greet • On-site annual screening mammos • Spa treatments

• Makeup pit stops • Accessor y shopping • Delicious bites & sinful desser ts


To reserve your spot at a lecture or to R.S.V.P. for The Pink Fling, call


Palomino Park III • 3347 State Road 7 Suite 206 • Wellington, FL 33449 Phone: 561.434.1935 • Fax: 561.434.3169

I am

living proof.

In 2009, I contracted the H1N1 virus, also known as swine flu. My immune system had been compr omised due to my pregnancy pregnancy and within compromised days, I was on a ventilator and in an induced coma. I don’ remember the next five weeks, don’tt remember but I suf fered a miscarriage and fought really really suffered har d for my life. My lungs collapsed six times and, hard despite other serious complications, the doctors knew exactly what to do to make me better better. After I woke up, I stayed in the hospital for another month. The nurses tr eated me like treated family family.. They held my hand, sang to me, told me inspirational stories and most importantly… they gave me hope. My husband and I agr agree… ee… W e don’ We don’tt think I would have made it if I had gone anywher e else. It’s It’s why we returned returned anywhere here to deliver our son. I am living pr oof here proof that Wellington Wellington Regional saved my life.

Aubr Aubrey ey Opdyke Unbreakable Unbreakable Mom

To T o read read more more of Aubr Aubrey’s ey’s story, story, visit ER / ICU Physicians are are independent practitioners who ar are e not employees or agents of Wellington Wellington Regional Medical Center. Center. treatments provided provided by physicians. The hospital shall not be liable for actions or treatments

2013 october global health tribune  

Health Care Newspaper of Palm Beach County

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