Healthbeat Fall 2014: October 16, 2014: The Daily Dispatch

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A publication of Maria Parham Medical Center and The Daily Dispatch

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Fall, 2014

Better with age? Y

ou have probably heard it said a few dozen times: “I just can’t do what I used to be able to do!” Or perhaps, “This old body takes a bit longer to recover than just a few years ago.” Or even, “It sure is tough getting old!” Were those people just making excuses or were they actually telling the truth? Well, it turns out that they were indeed on to something — a body at 50 is a very different body than one that is in its 60s and 70s. And that body continues to change as we get older. With the advances in modern healthcare, people are living significantly longer. A female born 50 years ago had the average life expectancy of 73.7 years while a female born 5 years ago had a life expectancy of 7 years more at 80.6 years. The life expectancy for men born in 1964 is 70.17 years of age and 78.09 for males born in 2009. But with the increased longevity, does

care and the before mentioned geriatrics. Dr. Subramanian, who practices at Maria Parham Primary Care, took the time to answer a few questions about health concerns that we face as we get older. Q: Is there a magic number (age) that can be associated with as to when a person becomes “old”? Dr. S: There is no magic number to categorize a person as old. Dr. Kavitha Subramanian According to new research studies, respondents under that mean our bodies are 30 years of age said that aging slower? Does the old age begins at 60 and saying “50 is the new 40,” respondents over 65 years have any validity to it? of age said 74. Aging is not Luckily for the people a homogenous process and in our community, we is influenced by various have a physician who factors like genetics, is board certified in environmental exposures geriatrics on staff at Maria and life style changes. Parham Medical Center, a Medicare benefits start Duke LifePoint Hospital. at age 65, which as we all Kavitha Subramanian, know is expected to go up. M.D., is actually triple Q: What are some of board certified in the main health problems internal medicine, facing the geriatric patient? hospice and palliative Dr. S: Aging is

characterized by progressive physiological and pathological changes associated with increased susceptibility to many diseases. Among older adults heart disease, cancer and stroke remain the leading cause of death, and age-specific conditions such as Alzheimer’s dementia are becoming more common. Diseases like pneumonia and influenza become more lethal than among younger individuals. Q: I notice that as a person ages, their skin seems to get thinner and wounds don’t heal as quick. Is this normal, and is there anything I can do to slow this process down? Dr. S: During aging, skin undergoes several changes like decreased contact between outer layer called epidermis and inner layer called dermis resulting in decreased nutrient transfer and increased skin fragility leading to poor wound

healing. Decreased subcutaneous fat deposits causes dry skin and loss of ground substance in inner layer causes wrinkling and atrophy of skin. Topical administration of all-transretinoic acid appears to reverse many of the age-related changes in sun protected skin like inner thigh. In addition, skin is further damaged by sun light. Skin damage by UV rays can be prevented by the use of sunscreen. Q: I have heard people say that the eyes are the first to go. Should I increase my visits to the eye doctor or to any other specialist for that matter? Dr. S: Different organs in the same person age at different paces, so eyes are not necessarily the first organ affected. Aging is frequently associated with refractive errors, macular degeneration, cataract and glaucoma. So an annual see age/page 4

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HealthBeat

The Daily Dispatch

Fall 2014

Are you prepared for flu season?

D

id you know‌ • Each year, approximately 100,000 Americans are hospitalized and thousands die from influenza and its complications. • Influenza, a vaccine-preventable disease, is the sixth leading cause of death among U.S. adults. • The injectable vaccine is made from killed virus, so you cannot get influenza from the influenza shot. • It takes two weeks for your body to develop immunity to influenza after the vaccination. • Approximately 50 percent of infected people have no symptoms but are contagious. • Influenza is highly contagious and is spread by coughing, sneezing, direct physical contact and contact with objects that carry the virus

• People 50 years of age and older • People of any age with certain chronic medical conditions • People who live in nursing homes and other long-term care facilities • People who live with or care for those at high risk for complications from flu, including health care workers, household contacts of persons at high risk for complications from the flu, and household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated)Â

(for example, doorknobs, phones, desktops). • Influenza is a viral infection and cannot be treated with antibiotics. • The vaccine is safe for pregnant women. In fact, a fever caused by influenza or other infections early in pregnancy can lead to birth defects in an unborn child.Â

Who should get vaccinated

According to the Centers for Disease Control and Prevention (CDC), everyone 6 months or older should get a flu vaccine each flu season. It’s especially important that the following groups get vaccinated either because they are at high risk of having serious flu-related complications or because they live with or care for people at high risk for

developing flu-related complications: • Pregnant women • Children younger than 5, but especially children younger than 2 years old

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When to get vaccinated

The CDC recommends that people get their seasonal flu vaccine as soon as vaccine becomes available in their community.

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HealthBeat

The Daily Dispatch

3

Fall 2014

October is Infant and Pregnancy Loss Awareness Month There is no greater joy than welcoming a new baby into the world. While the majority of pregnancies result in a healthy baby boy or girl who thrives into childhood, thousands of families are faced with the trauma of losing a child. Accor ding to the March of Dimes, approximately one in four pregnancies in the U.S. ends in miscarriage. Additionally, each year, more than 19,000 babies die in their first month of life and 39,000 others do not live to see their first birthday. October is Infant and Pregnancy Loss Aware-

ness Month, a time dedicated to women and families who have experienced the grief of losing an infant. There are many reasons for infant and pregnancy loss, including miscarriage, ectopic pregnancy, sudden infant death syndrome and birth defects. Whatever the cause, losing a baby is a very trying event for a woman and her family filled with difficult feelings and tremendous isolation. It can be hard to know what to say to loved ones in this situation, but it is important that we support them and help

them to heal. It is impor tant that those who have experienced the loss of a pregnancy or infant seek support. Such a traumatic loss may leave a woman and her family feeling shocked, cheated, guilty or angry. These feelings are normal. Talking to loved ones or support groups who have experienced similar losses can be helpful. Building a sense of community with others who can relate to their loss can help those grieving stem feelings of loneliness. In addition to connecting with a support net-

work, other recommendations include: • Give yourself time to grieve. Ever yone grieves in their own way. Give your partner time to get a handle on his or her method of grieving. Some women may want to become pregnant soon after the loss of a pregnancy or infant, while others may be scared of ever trying again. Taking time to grieve the loss that has been experienced can help couples think purposefully about the timing of their next try. • Take care of your body. Plenty of rest and proper diet and exercise

can help boost the spirits and revitalize a body that has been depleted both emotionally and physically. • Talk to your doctor. Physicians can give families insight into their losses and clarity in a time that feels unsettling and unexplainable. Medical professionals also can explore alternative options or actions that can help give a couple the best chance at a healthy pregnancy and baby in the future. If you have a friend or loved one who has experienced pregnancy or infant loss, consider

the following: • Be sensitive, yet suppor tive. All people express grief and loss differently. Some cling to family and friends, while others rever t to isolation. Those coping with pregnancy or infant loss often feel like no one can understand their pain, which in many ways is true. Help loved ones grieve in their own ways while offering support in any areas they are willing to accept it. This could be a shoulder to cry on, making a meal or offering to run errands. see loss/page 4

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age

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Always start slow and go slow, use safety equipment like a helmet as necessary, be sure to drink plenty of fluids unless on a fluid restriction From the Front Page diet and stretch your muscles. Question: Should a person eye exam is recommended, more so seek out a geriatric specialist over a frequently if have any eye problem as recommended by your eye doctor. standard primary care physician as they get older, and if yes, why? Q: How much exercise is Dr. S: A geriatrician appropriate for a person Geriatric is a medical doctor as they get older? Are there any types of physicians focus specialized in the treatment and exercises that should be on all aspects of diagnosis, prevention of disease and avoided as the body gets healthcare and disability in older adults. older? Dr. S: Exercise and work as a part of Geriatric physicians on all aspects of physical activity is good the healthcare focus healthcare and work as for everyone. At least team to address a part of the healthcare 30 minutes of activity that makes you breathe issues that affect team to address issues harder is recommended elderly patients that affect elderly patients rather than just treating on most or all days of the the medical illness. week. It is not necessary rather than just Geriatricians are to exercise for 30 minutes treating the highly trained in taking continuously, 10 minutes medical illness. care of health problems at a time is adequate. that frequently affect It is not necessary older adults such as memory loss, to avoid any particular exercise, frequent falls, urinary incontinence, but check with your doctor before beginning exercise if you have chest osteoporosis, polypharmacy and evaluating an individual for their pain, palpitations, recent blood clot or surgery or any new symptom you ability to take care of themselves in have not discussed with your doctor. their day to day activity.

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• Remember their loss. There are many ways to remember a baby including blankets, footprints and memor y boxes. These small mementos can help celebrate a life cut tragically short. Immediately after a loss, many families may be inclined to avoid conversation and mementos of their lost baby, so be sensitive and mindful of overwhelming them too soon. However, as time passes these keepsakes can help transition from grief to healing. There is a special group that was established to help those in our community deal with this topic. The LAC (Loss of a Child) Support Group has been established by the Abria’s Chase Foundation Inc. for parents who have lost children. The group meets

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Fall 2014 Fall 2014

on the second Monday of the month from 6 to 7 p.m. at Maria Parham Medical Center. The LAC Support Group treats grief as a process, provides a listening ear and shares words of encouragement; people who have suffered such loss should embrace each

other in the knowledge that they are not alone. This service is free and open to the public. Anyone interested in participating should contact Ayana Lewis at (252) 767-6696. After a summer hiatus, the group will start meeting again in October.

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5

Protect your health with preventative screenings

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e’ve all heard the saying that an ounce of prevention is worth a pound of cure. While this idea is relevant to many parts of our lives, it is particularly meaningful to our health. There are many important ways we can prevent health-related problems, including eating right and exercising regularly. One of the most effective ways to protect our health is through regular health screenings. Regular health screenings and checkups are vital to a healthy lifestyle. By taking a proactive approach to your health that includes yearly screenings, you and your doctor can identify future health risks such as cancer, heart disease and other underlying issues before they escalate. Screenings also can encourage those who are healthy to continue or improve their habits for better health. Today, all health plans cover a range of important preventative health screenings, and covered individuals can receive many regular screenings at little or no cost. Common recommended screenings for men and women that are covered by all health insurance plans include: • An annual wellness visit: It is important

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sensitivity fecal occult blood testing or a sigmoidoscopy. Each screening tests for precancerous polyps so they can be removed before becoming cancerous. • Screening for depression: Physicians often use a health questionnaire to help patients describe their emotional status, sleep patterns, appetite and concentration to identify depression. Depression screening is important because studies have shown that depression can negatively impact your overall health and is linked to a range of health concerns including chronic pain. Additional screenings recommended for women include: • A pelvic examination: Annual pelvic exams can identify a number of health problems in women, including ovarian cysts, sexually transmitted see health/page 7

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Fall 2014

Take time to focus on men’s health

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omen, on average, live almost six years longer than men. In fact, men die at higher rates than women from the top 10 causes of death, including heart disease, stroke, cancer and suicide, according to the Men’s Health Network. While there are many factors that contribute to these disparities, one important and preventable contributor is awareness. Research shows that men are less aware of their overall health than women. Things men can do to begin a healthier life Get regular check-ups: Many men do not see their physicians for annual check-ups because they do not have any health concerns or troubling symptoms. However,

many medical conditions common in men may not have obvious symptoms, and regular check-ups can help flag any issues before they become a problem. Visiting a physician regularly also ensures that men receive recommended health screenings, including checks of weight, blood pressure, cholesterol and blood glucose levels. Electrocardiogram screens, prostate specific antigen (PSA) and hemoccult tests, and colonoscopies are other tests physicians recommend men regularly receive as they age. Men should talk to their physicians about what tests are right for them. In addition to in-office health screenings, all men 20 years of age and older should perform skin, oral and testicle self-exams

each year. Start an exercise routine: The numerous benefits of exercise include longer life expectancy; lower risk for many common health issues; healthier muscles, bones and joints; better work performance; better mental health; and more energy. A man’s body needs three types of exercise at least three times a week: 1. Resistance training to strengthen and tone muscles 2. Stretching to enhance flexibility, balance and coordination 3. Aerobic exercise to improve heart and lung health. Eat a healthy diet: A balanced diet leads to optimum performance and health. Men should make an effort to eat

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fruits and vegetables as their primary sources of vitamins, minerals and fiber and limit foods and drinks that are high in calories, sugar, salt, fat and alcohol. A hearty, healthy breakfast is a great building block for a day’s nutrition.

Get enough sleep: Sleep deprivation is associated with medical conditions including heart disease, diabetes and depression, and can lead to motor vehicle and workplace accidents. Men typically need between seven and nine hours of

sleep each day. Maintain good work/ life balance: A man’s mental well-being directly affects all aspects of his physical health. Men must strive to create a healthy work/life balance by determining their priorities and effectively managing stress. If you have questions about your health, talk to your doctor. Maria Parham Medical Center, a Duke LifePoint Hospital, has physicians who can help. For help finding a doctor, call (252) 438-MPMC or go to mariaparham.com and click on Physician Finder.

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the age of 65. An additional test recommended for men From Page 5 is a prostate cancer screening. Prostate cancer infections, uterine fibroids screenings may consist of and early stages of cancer. two tests: a digital rectum • Pap tests: A yearly pap exam (DRE) and a prostate test is recommended for specific antigen (PSA) women ages 21 to 65. A pap test. The DRE can indicate test will determine your risk if the size of the prostate for cervical cancer. and abnormalities, and the • Mammography PSA test will measure the screening: Mammograms amount of PSAs in the blood. are x-ray screenings that will Higher levels of PSA and identify developing breast large prostates can indicate changes or cancer. It is prostate cancer. recommended that women If you have questions 50 to 74 should complete a about your health, talk to screening every two years. your doctor. Maria Parham • Bone mass Medical Center, a Duke measurements: Bone mass LifePoint Hospital, has measurements can indicate physicians who can help. For your risk for osteoporosis by help finding a doctor, call measuring your bone mineral (252) 438-MPMC or go to density. It is recommended mariaparham.com and click annually for all women over on Physician Finder.

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Fall 2014

Heart attack risk factors

 The number of hear t attacks has been declining since 1968 and can still go lower. By correcting a few of the risk factors that we have learned about, you can decrease your chances of ever having a heart attack. There are three main factors that contribute to heart attacks, and each of them can be corrected. These three major risks are high blood pressure, high cholesterol and smoking. High blood pressure is easy to diagnose by simply having it checked. When it is elevated, it can be treated with changes in lifestyle, diet and medicines. In a few cases, high blood pressure is caused by a surgically correctable obstruction of the

arteries to the kidneys or other lesions. A high cholesterol level can be diagnosed by a simple blood test. To get the most accurate reading, it should be done in the morning after you have fasted for twelve hours. High levels are treated by a lowcholesterol diet, exercise and medicines. These measures usually lower the cholesterol nicely. Today’s medicines are very effective. The third factor is smoking. Nicotine is a stimulant and irritant for the heart and forces the heart to work harder. Smoking causes the blood to clot and plug the arteries more easily and the lung damage also creates more work for the

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heart. It is extremely important to stop smoking. There are now many aids to help you quit, including stop-smoking classes and various medicines in the form of patches and pills. Together, these are fairly effective. Check your blood pressure and cholesterol once a year, avoid smoking and exercise regularly. Doing these things will give you a healthier heart. If you have question about your heart and how to keep it healthier, consult your physician. For help finding a doctor in our area, call Maria Parham Medical Center at (252) 438MPMC or visit mariaparham. com for a listing of medical providers.

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HealthBeat

The Daily Dispatch

Fall 2014

From ‘Thinking Pink’ to thinking prevention and detection O ctober is National Breast Cancer Awareness Month. “Think Pink” slogans and pink ribbons are highly visible, and the team at Maria Parham Medical Center, a Duke LifePoint Hospital, understands the importance of leveraging that awareness to move people to action to protect themselves and their loved ones against the disease. Education is critical in battling breast cancer, and what’s equally crucial is taking the proper actions to reduce your risk of developing the disease. Creating a personal early detection plan to identify your risk

factors and monitor your health and scheduling annual mammograms are two things that could save your life. It is recommended that every woman consult with her physician to discuss individual risk factors and identify key lifestyle changes that could reduce one’s chance of getting breast cancer. In addition, people can utilize several online resources, such as the National Breast Cancer Foundation’s online risk assessment tool, to create personalized early detection plans. The importance of early detection According to the

National Cancer Institute, when breast cancer is detected early, the five-year survival rate is 98 percent. However, more than 30 percent of women are diagnosed beyond the early detection window. This has lead to higher mortality rates. Currently for women, breast cancer is second only to lung cancer in terms of mortality. In 2011, more than 230,000 new cases of breast cancer were detected among women and more than 2,100 cases among men. Nearly 40,000 of these women (almost 20 percent) and 500 of these men (nearly 25 percent) died.

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disease. These include: • Women with a histor y of breast cancer. Women have a three- to four-times increased risk of developing a new breast cancer, unrelated to the first one, in the other breast or in another part of the same breast if they have previously had breast cancer. • Women with a family histor y of breast cancer. Having a mother, sister or daughter who has or has had breast cancer increases your risk for developing the disease. The risk is even greater if your relative had cancer in both breasts or developed the breast cancer before menopause. • Women over age 50. About 77 percent of women diagnosed with breast cancer each year are over age 50, and almost half are age 65 and older. • Women with a previous breast biopsy result of atypical hyperplasia, or those with a previous abnormal breast biopsy indicating fibroadenomas with complex features, hyperplasia without atypia, sclerosing adenosis and solitar y papilloma. • Carriers of alterations in either of two familial breast cancer genes called BRCA1 or BRCA2. • Caucasian women are at a slightly higher risk of developing

breast cancer than are African-American, Asian, Hispanic and Native American women. • Women who have their first child after age 35 or never have children. • Women who started menstruating before age 12. • Women who begin menopause after age 55. • Over weight women, with excess caloric and fat intake (especially postmenopause). • Women who have two to five alcoholic beverages a day are 1.5 times more likely to develop breast cancer than women who drink no alcohol. • Those exposed to excessive amounts of radiation, especially before age 30. • Women who use Hormone Replacement Therapy (HRT) for an extended period of time. (Risk seems to return to that of the general population after discontinuing use for five years or more.) • Those with other cancer in the family. A family histor y of

cancer of the ovaries, cer vix, uterus or colon increases your risk of developing breast cancer. For people who display one or more of the risk factors, it is important to understand and be able to detect the symptoms. While breast cancer often has no symptoms in its early stages, the following symptoms may be present as a tumor develops: • A lump in the breast or underarm that persists after your menstrual cycle • A marble-like area under the skin • Swelling in the armpit • Persistent breast pain or tenderness • Any change in the size, contour, texture or temperature of the breast • A noticeable flattening or indentation on the breast • A change in the nipple, such as an indrawn or dimpled look, itching or burning sensation, or ulceration • Unusual discharge from the nipple

9

Fall 2014

How to perform a breast exam at home Courtesy: American Cancer Society

Lie down on your back and place your right arm behind your head. The exam is done while lying down because, when lying down, the breast tissue spreads evenly over the chest wall and is as thin as possible, making it much easier to feel all the breast tissue. Use the finger pads of the three middle fingers on your left hand to feel for lumps in the right breast. Use overlapping dime-sized circular motions of the finger pads to feel the breast tissue. Use 3 dif ferent levels of pressure to feel all the breast tissue. Light pressure is needed to feel the tissue closest to the

skin; medium pressure to feel a little deeper; and firm pressure to feel the tissue closest to the chest and ribs. It is normal to feel a firm ridge in the lower cur ve of each breast, but, you should tell your doctor if you feel anything else out of the ordinar y. Use each pressure level to feel the breast tissue before moving on to the next spot. Move around the breast in an up and down pattern starting at an imaginar y line drawn straight down your side from the underarm and moving across the breast to the middle of the chest bone (sternum or breastbone). Be sure to check the entir e br east ar ea

going down until you feel only ribs and up to the neck or collar bone (clavicle). Repeat the exam on your left breast, putting your left arm behind your head and using the finger pads of your right hand to do the exam. While standing in front of a mirror with your hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour or dimpling, or redness or scaliness of the nipple or breast skin. Examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area.

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10

HealthBeat

The Daily Dispatch

Fall 2014

Early detection is key to controlling diabetes November is the start of the holiday season — a time to celebrate fun, family and food. It also is a time to consider a medical condition for which as many as 79 million American adults are at risk of contracting: diabetes. November is American Diabetes Month. If you aren’t living with diabetes yourself, chances are that at least one of the friends or loved ones with whom you will celebrate in the coming weeks has been touched by the disease. Diabetes is a condition that causes blood sugar levels to rise higher than nor mal. Our bodies break down the food we eat into glucose, or sugar, so it can be used for energy. A hormone called insulin helps the glucose to get inside our cells. When our bodies don’t make enough insulin or the insulin we have isn’t being used properly, sugar starts to build up in the blood. Complications from diabetes can include blindness, heart disease, kidney failure, severe ner ve damage leading to limb amputations, and strokes. More than 25 million Americans cur rently have diabetes. This number is on the rise, and more than one in three American adults suffers from pre-diabetes, which occurs when blood glucose levels are higher than normal but not high enough to be

Dr. Kris Reddy

considered diabetes. People with pre-diabetes who do not change their lifestyles usually develop type two diabetes, other wise known

as adult-onset diabetes, within three years. Changing your lifestyle to incorporate regular physical activity, weight loss and a healthy diet with lots of fruits and vegetables can help maintain blood sugar levels. This can help prevent diabetes in those who have pre-diabetes and assist those who have diabetes in better managing their disease. “Uncontrolled diabetes can lead to multiple complications affecting dif ferent organs,” said Dr. Kris Reddy with

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Maria Parham Endocrinology. “W ith the help of healthy lifestyle changes, medication and blood sugar monitoring, we can prevent these from happening. Seeing a r egister ed dietician is also ver y beneficial. We are here to help ever yone learn the signs and symptoms of diabetes, understand their risk factors, and establish a path for optimal health. ” Symptoms of diabetes include: • Urinating often • Weight loss • Feeling very thirsty

or ver y hungr y even when you have just eaten • Extreme fatigue • Blurry vision • Slow-healing cuts and bruises • Tingling or numbness in the hands and feet If this list looks familiar to you, talk to a doctor as soon as possible. Please note that not ever yone experiences some or all of these symptoms. If you can detect your diabetes early, you and your doctor can help control it together.

Pre-diabetes, unfortunately, has almost no symptoms, so people should carefully assess their risk factors for type two diabetes. These include: • Being 45 years of age or older • Being overweight • Hypertension • A family history of type two diabetes • Engaging in physical activity less than three times a week • Having had diabetes while pregnant (gestational diabetes) • Having given birth to a baby who weighed

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HealthBeat

The Daily Dispatch

more than 9 pounds If one or more of these factors describes you, talk to your doctor about your diabetes risks and get your glucose levels checked. To learn more about diabetes and to take a risk factor test, visit the American Diabetes Association at diabetes.org. If you’re concer ned that you or someone you love may be at risk of diabetes, please reach out to their doctor or to diabetes specialist Dr. Reddy and Maria Parham Endocrinology. Their of fice number is (252) 436-6240.  Sources: American Diabetes Association and Centers for Disease Control and Prevention

Coping with colic

H

aving a colicky baby can take much of the fun out of being a new parent. Attempting to soothe a baby that cries for a couple hours after feedings and flails his arms and legs about is a trying experience. Nothing seems to calm the baby for more than a few minutes. Dozens of possible causes have been suggested, but no single cause is well-accepted. Everything from allergies to colon spasms and family tension to faulty feeding techniques has been blamed. It is difficult for new parents, who begin to doubt their ability as parents

and feel like failures. Also, for colic, although many the physical and mental physicians will prescribe exhaustion can be a real antispasmodics or sedatives stress on the to help the family. symptoms. An There is no Fortunately, exam is always colic is self-limited medical cure for important to make and will improve colic, although sure that there with time no not another many physicians is matter what you cause for the will prescribe do. These babies crying, such as are often good antispasmodics hernias, thrush, or feeders who grow or sedatives to infections. well. They are It is useful to try plump and healthy help the feeding the baby symptoms. and there are no more slowly and in long-term effects an upright position or health problems for these with frequent burping. babies. Giving smaller feedings is There is no medical cure often helpful. Breastfeeding

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mothers should eliminate milk products from their diets and formula-fed babies may try a soy formula. If efforts to comfort the baby do not help in 30 minutes, leave the baby alone for 20 to 30 minutes. Remember, the most important treatment is giving the baby time to develop; the colic will eventually go away. You baby’s pediatrician can help you if you have question about colic. For help finding a pediatrician in this area, call Maria Parham Medical Center at (252) 438-MPMC or go to mariaparham.com.

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