Inside Medicine Magazine Summer 2018

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Inside Medicine | Late Summer Issue 2018

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EMERGENCY CARE WITH

LESS WAITING

E.R. In a medical emergency, every minute matters. So, at Crestwood Medical Center, you’ll find faster care in the emergency room. We work diligently to have you initially seen by a medical professional with the shortest wait time possible.* And, as a full service community hospital, we can provide a lot more care if you need it.

For less waiting and faster care, count on the E.R. at Crestwood Medical Center.

One Hospital Drive • Huntsville 256-429-4000 • CrestwoodMedCenter.com *E.R. wait time, which is defined as the time it takes from check-in at the E.R. desk until a patient is initially seen by a provider, can change quickly. This time is dependent on the severity of the illness and other patients also in the E.R.

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Inside Medicine | Late Summer Issue 2018


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Inside Medicine | Late Summer Issue 2018

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HUNTSVILLE

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Inside Medicine | Late Summer Issue 2018

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TREATMENT

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(256) 533-1600 | spineandneuro.com Inside Medicine | Late Summer Issue 2018

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features &

CONTENTS

Sharing with Purpose

Inside Medicine | Late Summer Issue 2018

VOL 2

ISSUE 10

CO N T R I B U T ORS

Kimberly Waldrop, MA Jason Lockette, MD, MBA

FEATURES Healthcare Innovation better health information and faster care

Shingles & Post-herpetic Neuralgia

CONTENT

08

Is My Hernia Dangerous?

Recognizing the symptoms

18

Pediatric Myopia

nearsightedness in children

how to know the signs

Financial Responsibilities how to lessen the burdens and debt increase when receiving medcial services

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30

Natural Approach to Hormonal Therapy

Noel C. Estopinal, MD Larry Parker, MD Jarrod Roussel, PA-C D Kishore Yellumahanthi, MD, MPH Ray Sheppard, Jr., MD Heather L. Morse MS, ATC, OTC

40

Anne C. Jewell Ragan Bailey, MA, ALC Tiernan O’Neill Margetta Thomas

54

plant derived hormones and their use

Ben Macklin Heather Mendez Paul Vandiver, OD Michael Salter, MD Elizabeth McCleskey, DO Donald Aulds, MD Kari Kingsley, MSN, CRNP Ashleigh L. McKenzie

MD

Join our mission to establish our community and healthcare providers. Together, we can change

the way healthcare information has been and will be distributed

for years to come. To reach our readers, whether through editorial contribution or advertising, please contact Kelly Reese

at kellyreese.im@gmail.com or

Making a Difference

and grow an alliance among

256.652.8089

Julie Drzewiecki, MS, RD, CDE S A LE S & M A R K ETIN G

Kelly Reese, Founder Lisa Layton, VP Sales/Marketing Heather Mendez Will Steward CH I E F E D I T O R I A L W RITER

Kimberly Waldrop, MA G R A P H I C D ESIGN

Leigha Parker The information and opinions contained in this publication constitute general medical information only and should not be construed as medical advice. Before making important medical decisions, readers should consult with a physician or trained medical provider of their choice and have their needs and concerns assessed in a clinical setting appropriate for their problem.

Karen Gauthier P U B LI S H E RS

Blake Bentley, President 6

Inside Medicine | Late Summer Issue 2018

www. in s ide me dic in e magaz ine.com


} FROM THE EDITOR

Dive In with

Inside Medicine

Dear Readers It seems the theme of this edition of Inside Medicine centers around taking care of yourself and having time and knowledge to keep yourself healthy, happy, and content. We are blessed to live in a society that is full of entertainment, work, and just plain busyness. But, at the same time, it can become overwhelming trying to juggle it all and create that perfect balance of life. In two of our feature stories, “6th Sense” and “Barbara: A Beacon of Hope”, we find two special ladies that were led by others, and led by their desires, to follow their hearts and serve others in their professions. One tells her story with a firm confidence that she just feels she is doing what she is supposed to do and feels that contentment in her journey. The other one, looks back on her career and how it has evolved over the years. Through it all, she continues to marvel at what she has been lucky to be involved in. In both cases, it is reassuring that others could feel the same way. “Getting Rid of the Blues” and “Mindfulness” are two stories in this edition. They both tell us a way to help ourselves feel better and how to try and help us get better sleep. Both articles remind us of ways we can control things that seem uncontrollable. Along with these awesome stories, we’ve got lots of information packed in this edition. You can read about things from disc herniation to elderberry to financial issues and long term care. I think you are going to find something, or many things, which peek your interest and make you want to read more. At Inside Medicine, it is always our prayer to be here to help our community and show a love for our Savior. There are so many stories out there and we want to share them with you! We are always looking for new content and features. Please contact us if you ever have an idea, comment, or suggestion, or just want to be included in our magazine. We love hearing from you and appreciate your support!

iK mberly Waldrop

Inside Medicine | Late Summer Issue 2018

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} COVER FEATURE

by, Jason Lockette, MD, MBA

HEALTHCARE INNOVATION COMES TO HUNTSVILLE

The U.S. spends more per capita on healthcare than any other country in the world yet we do not have outcomes to support those huge expenditures. We all know this, yet healthcare costs continue to outpace inflation. Why is this, and what can we do to be more responsible with our healthcare resources? I believe empowering consumers with information through technology is an important component of any solution. Let me explain.

How it works

Download the app and chat with K whenever you don’t feel right. She’ll show you what to expect based on people like you who felt the same.

EVERYONE NEEDS ACCESS TO INFORMATION

In a system as complex as medicine where only the providers have the information we all need to make informed decisions, it’s hard for patients to know when and where to go for care, which often leads to over-utilization. As professionals, we’re paid for this, and our payment is often increased if we decide to do additional testing or treatment, whether or not it’s needed or has any measurable impact on the patient’s health. Every year we see overcrowding in emergency departments and urgent care centers during flu season. Very few of those patients receive any measurable benefit from their visit. They are diagnosed with influenza and experience a few days of fever, chills, and body aches regardless of whether they take any medication. This over-utilization adds cost and decreases access to healthcare for patients whose outcomes we can actually affect.

REPLACING “DR GOOGLE”

Meanwhile, online health content is overly general and sometimes incredibly misleading. At Integrity Family Care, we partnered with a new AI powered health app, called K, to give our patients access to information that is based on real cases from similar people who had similar symptoms. K is not intended to replace a provider but, rather, to replace “Dr. Google.” K recognizes the difference, for example, in the significance of a particular symptom in someone who is 25 years old versus someone who is 75 years old, so the app provides users with information that’s actually relevant to their age, gender, and symptoms. In addition, our partnership with K allows our patients to share their K report with their provider if they choose. 8

Inside Medicine | Late Summer Issue 2018

When we review patients’ K reports, we see detailed information about their symptoms as well as important symptoms they don’t have. We’re able to reassure patients who might not benefit from a visit while expediting the care of those who may have more emergent conditions. K leaves both patient and doctor more informed, which helps us collaborate faster on developing the right care plan for the patient. Our intent is to decrease the number of unnecessary and costly visits while increasing access for patients who really need to be seen. Wouldn’t it be better if we could devote more of our time as providers to helping patients manage dangerous chronic diseases such as diabetes and hypertension? Better control of these conditions results in fewer hospitalizations and a longer, more productive life. Meanwhile the majority of patients with non-emergent acute issues have enjoyed being able to monitor symptoms at home or pick up a prescription without an in person visit. The feedback has been overwhelmingly positive.

EMPOWERING PATIENTS WITH TECHNOLOGY

Wouldn’t it also be nice if you could see how patients just like you with symptoms just like yours were diagnosed and treated? With this information in hand, patients are reassured to see the kind of care they might expect to need, avoiding


unnecessary visits, the total cost of which can be upwards of $500. We have also seen that by having the ability to share your information with your provider, we can arrange for more timely and efficient access for patients whose conditions warrant further evaluation. K works for adults 18-85 and the app is free in the app store and Google Play. Try it out and see what it is like to use a health app that actually provides relevant, reliable health information. Think about what it would be like to read a K report before walking into an appointment. In fact the vast majority of patients who have shared their reports with us so far have been reassured to rest at home or prescribed medication that they can pick up at the pharmacy without a visit. This is just the beginning of how we can begin to provide practical solutions by empowering consumers with information through technology.

HOW INTEGRITY + K CAN HELP:

K can provide you with information from patients just like you who have had the same symptoms. By having this information, you can then make an educated decision as to whether or not you want to visit your provider. If you aren’t sure, and are a patient of Integrity Family Care, you can elect to share the information with us and we will respond. We might reassure you, expedite your visit, electronically send medication, or coordinate additional testing prior to your visit if needed. Jason Lockette MD, MBA, President, Integrity Family Care 1041 Balch Rd #300, Madison, AL 35758 256-325-1540 www.integrityfamilycare.com

EXAMPLES OF OVER-UTILIZATION AND UNNECESSARY CARE ANTIBIOTICS FOR VIRAL INFECTIONS:

It is estimated that only about 2% of viral upper respiratory infections (common colds) progress to bacterial sinusitis. Even if you are unlucky enough to get a bacterial infection, antibiotics will decrease the length of symptoms by only about one day. Yes, that is correct. Patients spend hours in an urgent care center or ER, pay their copay and deductible, buy an antibiotic, deal with the side effects, all for one day less of symptoms. Consider, also, the added risk of potential allergic reactions, Clostridium difficile infection, and antibiotic resistance and you have to wonder why we continue to do this to our patients.

Send us your results.

Share your report with us when you see the prompt. If we get it before 2pm, you’ll hear back same day. After 2pm, we’ll reply by 10am the next morning.

We’ll fast track your care.

You’ll get a message with suggested next steps. We might recommend rest, medication, a test, or a priority appointment.

Inside Medicine | Late Summer Issue 2018

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Head

&

Neck Cancer by, Noel C. Estopinal, MD

A sore throat is usually a sign of a relatively minor problem like spring allergies or the common cold. But if you have a sore throat that lasts for more than two weeks, you should make an appointment to go see your family physician. 10

Inside Medicine | Late Summer Issue 2018


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Inside Medicine | Late Summer Issue 2018

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...cont’d from page 10

That’s because persistent sore throat can also be a sign of head and neck cancer, according to Dr. Noel C. Estopinal, a radiation oncologist with Alliance Cancer Care in Huntsville. Head and neck cancer, which includes cancers of the mouth, throat (pharynx), voicebox (larynx), sinuses, nasal cavity and salivary glands, accounts for about 5-7 percent of cancer cases nationally. But Dr. Estopinal said it’s more common in states with the highest rates of smoking, smokeless tobacco and alcohol use – including Alabama. “It weighs more heavily in the South than in other parts of the country,” he said. Tobacco smoke contains more than 70 chemicals that have been shown to cause or promote cancer. Meanwhile, alcohol irritates the mucous-covered surfaces of the mouth and throat, making them more vulnerable to those carcinogens. Not all head and neck cancers are linked to cigarette and alcohol use. Dr. Estopinal said human papillomavirus (HPV ) is now a leading cause of oropharyngeal cancer affecting the base of the tongue, soft palate, tonsils and side and back walls of the throat. HPV can be spread through sexual contact, including oral sex. In addition to persistent sore throat, head and neck cancer warning signs include persistent difficulty swallowing, a growing lump in the neck, chronic hoarseness, sores in the mouth that won’t heal, changes in how your voice sounds, and unexplained weight loss. Early detection is the key to successful treatment of head and neck cancers, so get to your doctor if you have any of the above symptoms that last for more than a couple of weeks. “When the disease is caught in the earliest stages, we can often achieve excellent long-term control with less aggressive therapy,” said Dr. Estopinal. “For patients with very small lesions on the vocal cords, a short course of radiation alone can result in a cure rate of better than 90 percent. Other patients may only need to have the tumor surgically removed with no further treatment. If your doctor suspects you have head and neck cancer, the first step is usually a tissue biopsy of the affected area. Once the diagnosis is confirmed, the radiation oncologists at Alliance Cancer Care can develop a customized treatment plan. In addition to Dr. Estopinal, the Alliance physician team includes Drs. Harry James McCarty III, Elizabeth Falkenberg, Hoyt A. “Tres”

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Inside Medicine | Late Summer Issue 2018

Childs III, John F. “Jack” Gleason Jr., Traci McCormick and Stanley Clarke. Depending on the stage and location of the disease, the treatment plan for head and neck cancer may include surgical removal of the tumor by an ear, nose and throat specialist, targeted radiation therapy at one of Alliance’s six locations across North Alabama, and chemotherapy overseen by a medical oncologist.

“Head and neck cancer is one of the most intensive multi-disciplinary cancers that we treat,” said Dr. Estopinal. “We’re fortunate in Huntsville to be staffed with many experienced surgeons, radiation and medical oncologists who have successfully treated head and neck cancer.” If radiation is recommended, Alliance Cancer Care uses Intensity Modulated Radiation Therapy (IMRT) and Image Guided Radiation Therapy (IGRT) to deliver the treatment. A CT scan of the patient is taken before and during treatment to make sure the radiation beam hits only the tumor and not the surrounding healthy tissue. The standard regimen for head and neck cancer is 25-35 radiation therapy treatments over a period of five to seven weeks. Side effects may include fatigue, dry mouth, skin irritation in the treated area, pain or difficulty swallowing, and loss of appetite due to changes in the way food tastes. “With IMRT and IGRT, we’re able to steer the radiation dose around the salivary glands, jaw bone, spinal cord and other sensitive organs while targeting the tumor,” said Dr. Estopinal. “That helps to minimize any side effects from treatment and improves the opportunity for cure.”


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Inside Medicine | Late Summer Issue 2018

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Lumbar Disc Herniation 101 by, Larry M. Parker, MD

The most common spine problem that leads a patient to seek medical attention involves the lumbar disc. Diagnostic problems involving the lumbar disc are complex in presentation and therefore each patient’s symptoms are somewhat unique. Some patients have back pain and some have pain in one leg or perhaps in both legs. The pain can be severe or subtle and can come on quickly or slowly. It can appear as numbness, weakness, back spasms, leg pain with no back pain. Every patient is different and a good history is fundamental in figuring out the specific disc problem and how to treat it. Patients can be really confused and certainly anxious because disc problems can cause some serious pain and dysfunction. Rest assured, if you are having some of the symptoms listed above, an experienced Spine Specialist can usually figure out the problem by just listening to you and examining you. “Is my disc ruptured or slipped”? “Do I have a herniated or a bulged disc”? “My Mom had sciatica, and got better with some emu oil”. Most patients have already received some free advice from a relative or friend before they seek a professional opinion. So let’s talk about the subtleties of the lumbar disc…. As I said before, it is all about the history. Lumbar disc problems rarely are the result of trauma, like a fall or a car wreck. Those types of injuries are more likely associated with a fracture, if severe, or perhaps a muscle strain if less severe. Most disc problems are the result of wear and tear and genetics. Most patients just kind of notice a little stiffness for a few days and then suddenly they wake up in severe pain looking for some help. The most distinguishing feature that your Spine Specialist will look for is leg pain known as radiculitis or radiculopathy and commonly known as sciatica. If that is the case, you are more likely to have a herniated or ruptured disc pinching a nerve rootlet in your back and causing the leg pain. Numbness, weakness, difficulty standing and walking, and even difficulty with your bowel and bladder can be present. In these instances, a more urgent approach may be recommended. X-rays and an MRI of your lumbar spine are important and surgery may be necessary if the symptoms are severe and associated with nerve dysfunction. Other options like an epidural injection, or physical therapy and oral medications may be the initial recommendation and can often settle things down without surgery.

If a patient presents with symptoms limited to back pain without leg pain, then a simple back strain may be the cause and the treatment is more cautious. Often times, the problem may not be a back problem at all. Diagnostic studies can be delayed to see if the symptoms will settle down over a week or two. If symptoms persist or worsen, then more aggressive options may be necessary. A degenerative disc or bulged disc that is not putting pressure on a nerve may be the diagnosis. Even these conditions can lead to surgery if they persist for many months and don’t improve with non-surgical treatment. Lumbar disc problems can truly be painful and getting some expert advice and understanding the problem helps out tremendously. Your Spine Specialist will look for the simplest and least invasive way to get you better. Just remember, it all starts with a good history and examination from an experienced professional.

Inside Medicine | Late Summer Issue 2018

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Get Rid of the Blues for a

Good Night’s Sleep by Jarrod Roussel, PA-C

Seems like these days that we would be lost without our computers and smart devices; checking email, watching YouTube, scanning the latest on Facebook, and the list goes on. Add to that larger TV screen sizes with brighter image contrast, and we spend hours a day from morning to night in front of a screen that shines more light than ever before directly into our eyes. It seems innocent enough, but could all this screen time be negatively impacting your health?

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I want to introduce you to the hormone melatonin. Likely, you have heard of it, but you may not be familiar with exactly what it does. Melatonin is released by a small gland in the brain called the pineal gland. This gland sits at the base of our brain and has multiple functions, one of which is controlling our normal daily sleep/wake cycles. The signal for releasing melatonin is actually controlled by the light that enters our eyes. There are special sensors in our eyes that detect blue light and send a signal to the pineal gland telling it that it is “daytime”, thus preventing the release of melatonin. Until recently, the only blue light that we saw was in sunlight. As the sun approaches sundown, the blue light is filtered out by the atmosphere leaving the remaining light with a predominantly reddish hue. Even after sundown, lamps, candles, and fires are reddish in color, plus the brightness is significantly lower than sunlight. This change in the light would stimulate the pineal gland to release melatonin which signals the brain that it is time for sleep. Incidentally, there are other health benefits attributed to melatonin besides regulating sleep. With bright large screen TVs, computer screens, smartphones, etc., we are exposed to an excessive amount of blue light, sometimes well into the wee hours of the morning. This causes a delayed release of melatonin, which then confuses our brain. We “know” that we should be asleep, but we can’t seem to fall asleep. To put it another way, when you have that moment at 2am that you want desperately to be asleep, but try as hard as you might, it just doesn’t happen. And, your body just doesn’t even feel ready for sleep. This is caused by the delayed melatonin release. Ultimately, this can have a domino effect causing even more sleep issues.

Okay, you just had your umpteenth night of tossing and turning. So, what can you do about it? The obvious first step is to reduce or even eliminate the amount of blue light entering our eyes. In an ideal world, you could simply do away with the need for all screened devices after sundown. While this would give the best outcome, it isn’t always practical since many of us rely on our smart devices and computers as tools for work and study. I recommend trying to reduce the total amount of screen time as much as possible to only necessary activities. Restrict computer gaming, television watching, etc. to early evening hours. When you must use a screened device, turn down the brightness level. Some computers and smartphones will even do this automatically depending on the ambient lighting in the room.

Reducing the brightness of the lights in your environment can also be extremely beneficial, especially for young children. You can simply turn off unused lights or switch from overhead lighting to smaller lamps. An effective strategy I have used is installing dimmer switches in your main living spaces so that you can progressively decrease the light levels as bedtime approaches. Use light bulbs that have a warmer tone in the 2000-3000 Kelvin rating, especially in bedrooms and living spaces. This will help reduce the blue light in your home. The Kelvin rating is usually found in a label on the side of the box. Lights that are in the 5000-6000K range are considered more crisp and “invigorating” so are better for work spaces such as garages, laundry rooms, etc. More recently, computers and smart devices have an added feature that shift the colors on the screen to more reddish tones, which is achieved by decreasing the amount of blue used in the screen image. This allows us to still use our devices but still avoid some of the blue light influence. Even with this feature, it is best to limit usage as much as possible.

The issue with blue light exposure is a more recent modern problem, and it is ultimately something we can control. I do want to mention, however, that sleep is a complex process. There are numerous factors that can contribute to poor sleep. If you find that you continue to have significant sleep issues that last for more than a few days, please see your healthcare provider for a more thorough evaluation and work-up. Effective treatments are available for a wide range of sleep conditions. Jarrod Roussel, PA-C Co-founder, The Crunchy Couple, LLC For more information on feeling better and living longer, be sure to check out thecrunchycouple.com or go over to the Facebook page at: facebook.com/TheCrunchyCouple

Inside Medicine | Late Summer Issue 2018

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Shingles

by D. Kishore Yellumahanthi, MD, MPH

& Post-herpetic Neuralgia

Herpes Zoster or Shingles is caused by the same virus that causes chicken pox – Varicella Zoster Virus. After a person gets chicken pox, the rash resolves after few weeks but the virus remains inside the body for the rest of the life. At a later point, this virus, could get activated and manifest as shingles.

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} FEATURE

It is not clearly known what actually causes this activation. It could be spontaneous or associated with factors like stress, immunosuppression or radiation therapy and so on. Although Shingles can occur at any age, the risk increases sharply after 50 years of age. The incidence for herpes zoster is approximately 4 cases per 1,000 U.S. population annually, age-adjusted to the 2000 U.S. population. The incidence among people 60 years of age and older is about 10 cases per 1,000 U.S. population annually. HOW DOES THE RASH OF SHINGLES LOOKS LIKE? • Rash looks like groups of blisters arranged in a ribbon like shape. • Burning pain usually precedes the rash by few days. • The rash can occur anywhere – Lower extremity or Upper extremity or Trunk or Belly or Face. • The rash characteristically occurs on only one side of the body. • Never crosses the midline.

ARE ANY VACCINES AVAILABLE TO PREVENT SHINGLES? Currently there are two vaccines available that can prevent shingles. They are Zostavax and Shingrix. Both vaccines can be administered after 50 years old. Zostavax has been in the market since 2006. It is administered as a single shot (Intramuscular injection). No second dose is required. It reduces the risk of developing shingles by about 51% and PHN by about 67%. On the other hand, Shingrix which has been introduced in October 2017, is administered as two doses, 2 to 6 months apart. Two doses of Shingrix is supposed to be about more than 90% effective at preventing Shingles. The efficacy of two doses of Shingrix for prevention of PHN was about 91% for adults 50years and older and 88.8% in adults age 70 years and older.

WHO ARE SUSCEPTIBLE TO SHINGLES? All those who had chicken pox disease and also chicken pox vaccine are susceptible to shingles. It is to be noted that, people who had chicken pox vaccine are also prone to shingles just as people who had chicken pox disease, although the chances are less. For most part, shingles occurs only one time in lifetime. Second and subsequent attacks are rare. WHAT IS POST-HERPETIC NEURALGIA? The dreaded complication of shingles is ‘Post - herpetic Neuralgia’ or PHN. Unfortunately, it is the most common complication of shingles. Generally, if pain in the area of shingles persists beyond 3 months, it is categorized as PHN. This complication, which occurs in approximately 20% of patients who had shingles, can severely affect the quality of life of that individual, as it can cause severe pain and can last for several years. It would not be an exaggeration to state that, PHN can diminish quality of life to the same extent as that of congestive heart failure, heart attack, type II diabetes and major depression. It is worthy to note that 80% of PHN cases occur in patients 50 years or older. TREATMENT OF SHINGLES: Anti viral drugs like Acyclovir or Famciclovir or Valacyclovir, if taken within 72hrs of onset of shingles, can help in faster healing. It is not exactly clear if these drugs have any role in reducing the chances of PHN or not.

WHAT DOES FUTURE HOLD FOR SHINGLES AND PHN? Given that vaccine is the only way to prevent shingles and the subsequent PHN, it is certainly very exciting to know that there is a vaccine available in the market, that is more than 90% effective in preventing shingles. Since shingles is more common in people above 50 years, effective vaccination is going to significantly reduce the number of new cases of shingles, which in turn is going to reduce the number of PHN cases. Also, the severe long lasting PHN is more common in patients who are affected with shingles after 50 years. Keeping this in view, I believe that with effective vaccination, we can not only drastically reduce the incidence of shingles and PHN but also make the severe debilitating type of PHN, a rare case scenario. In the words of a patient of mine who is suffering with severe PHN, the pain of PHN is a very agonizing pain that she does not want to wish even her deadliest foes to suffer with. Would it not be a great

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...cont’d from page 19

accomplishment, if we can make such an entity a rare one? Therefore, if you are 50 years and above, please contact your healthcare provider to discuss about shingles vaccine. SUMMARY Please keep your eyes open for shingles in any painful rash and seek medical advice as soon as possible - Remember, antivirals, if taken within 72hrs after the onset of the rash, can help in faster healing. Given shingles can cause PHN, a dreaded complication that can cause significant long lasting pain, every effort needs to be made to prevent shingles occurring in the first place through vaccination. Vaccine, Zostavax, reduces the risk of developing shingles by about 51% and PHN by about 67%. Another vaccine, Shingrix, introduced in October 2017, is supposed to be about more than 90% effective in preventing Shingles. It prevents PHN by about 91% for adults 50years and older and 88.8% in adults age 70 years and older. Both vaccines can be administered for all adults 50 years and above unless contraindicated. If you are 50 years and above, please contact your healthcare provider to discuss about shingles vaccine. Reference: CDC.gov Saquil A, Kane S, Mercado M, Lauters R Herpes Zoster and Postherpetic-Neuralgia: Prevention and Management. Am Fam Physician. 2017 Nov 15;96(10):656-663. www.nfid.org/publications/factsheets/varicellaadult.pdf

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} SURGICAL TECHNOLOGY

IS MY HERNIA

Dangerous? by Ray Sheppard, Jr., MD

There are two short answers to that question. The first is: “Maybe”. The second is: “It is complex and needs to be answered in consultation with a hernia surgeon”.

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Inside Medicine | Late Summer Issue 2018

Now for a longer answer. It depends on what type of hernia as well as other factors. In fact, hernia surgery has become a science all of its own. Even the definition of a hernia can be confusing. It actually means something slightly different depending on the region of the body that one is discussing. For this particular discussion, we will only concern ourselves with hernias of the abdominal cavity. Even at that, our discussion can only be very limited (see the second short answer above). The most common hernias that arise are hiatal hernias, umbilical hernias, inguinal hernias, incisional hernias, and ventral hernias. Hiatal Hernia - These are quite common and occur in more than one variety. The most frequently encountered is known as the sliding hiatal hernia, and it is rarely more than an annoyance. The less common paraesophageal hiatal hernia is actually a cause for concern. In this type of hiatal hernia, all or part of the stomach =passes through a defect in the muscular diaphragm which separates the abdominal cavity from the chest or thoracic cavity. The stomach can become twisted upon itself and subsequently rupture or develop gangrene. This is a lifethreatening condition. Symptoms include chest pain and can mimic the pain of a heart attack. Other symptoms include inability to eat more than small amounts of food, anemia, or shortness of breath. Generally this type of hiatal hernia should be surgically repaired, depending on the overall health of the patient. Umbilical Hernia - This hernia is located at your bellybutton or umbilicus. These are very common especially in babies. As the abdominal wall forms, the muscles of the abdomen close around the umbilical cord. A hernia is present when these muscles fail to close completely. This is noticeable as bulging umbilicus or an “outie bellybutton”. Fortunately, most babies that


are born with umbilical hernias will continue to develop so that the hernia closes on its own by the age of 4. Adults may develop a hernia later in life due to heavy lifting, obesity, excessive coughing, or pregnancy. Initially, your body will plug this defect with fatty tissue. This may be noticeable as a bulge in part of your umbilicus. You may actually feel this tissue push in and out through the hernia defect. Over time, these hernias will generally enlarge and intestine can begin to pass through the hernia defect creating a bigger bulge at the umbilicus. This can lead to an emergency with obstruction of the intestine or gangrene of the intestine. Surgery is usually recommended to repair these hernias. In select situations, observation without surgery may be an option. Inguinal Hernia - These hernias are created by muscular defects in the groin or inguinal region. They are very common in men but not common in women. There are two types of inguinal hernias. They are known as direct and indirect inguinal hernias. The two different types occur in different locations of the groin and are caused by slightly different factors. The earliest symptom is groin pain. Some people may not notice anything abnormal until a lump develops. Eventually, the defect in the muscular wall enlarges and allows intestine to protrude out of the abdominal cavity. Often the intestine will then become obstructed or even develop gangrene. This is an emergency situation. Incisional Hernia - As the name implies, these hernias occur at the site of previous surgical incisions which have passed through all of the layers of the abdominal wall. Similar to the other types of hernias, these defects in the muscular wall generally increase in size

over time. The same emergencies of bowel obstruction or gangrene can occur. A bulge or pain in a previous incision site warrants evaluation to search for this type of hernia. Since these hernias form in a portion of the abdominal wall that did not heal optimally after the initial surgical procedure, they are subject to higher recurrence rates after surgical repair than other types of abdominal wall hernias. For that reason, these often-challenging hernias need to be approached with diligence and special attention to every detail. This includes both the surgeon and the patient. Ventral Hernia - This term refers to a hernia of the abdominal wall that is not in the site of a previous incision and is separate from the umbilicus and groin. These are not common but may occur in the midline between the sternum and umbilicus. Rarely, they occur toward the lateral portions of the abdominal wall. Often ventral hernias produce discomfort before a bulge is noticeable. As with other types of hernias, emergencies of bowel obstruction or gangrene can develop. A final word of caution is in order: I have, on occasion, seen small hernias allow intestines through the abdominal wall and lead to emergencies. So if you are wondering if your hernia is dangerous, I would tell you, “Maybe. That question needs to be answered in consultation with a hernia surgeon.� Ray Sheppard, MD - General Surgery raysheppardsurgery.com

Inside Medicine | Late Summer Issue 2018

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THE COMEBACK OF ELDERBERRY IN FIGHTING THE FLU by, Heather L. Morse MS, ATC, OTC

After this last flu season, it seems everyone has heard of people flocking to find their fix of Elderberry Syrup. Most people have likely read some interesting articles or snippets on social media as well. What is elderberry? Where did it come from and why is it making a comeback? Interestingly enough, it was once a staple long before conventional, allopathic medicine. Elderberry (Sambucus Nigra) can be traced back to Hippocrates, although there is also some evidence of recipes as far back as Ancient Egypt. Hippocrates touted elderberry as the plant of his “medicine chest” for treating many aliments. In modern times, it has been used to treat colds, flus, fever, burns, sinus pain, cuts, allergies and more than 80 other ailments. What exactly is elderberry? In short, it is a berry that grows in clusters and can usually be found along streambanks, moist woody areas and power line cuts. Elderberry is challenging to forage on your own as the berries are loved by birds. It is likely that you have some elderberry growing in your yard or neighborhood (assuming you have some spots that are not manicured). I would also bet that your grandmother made elderberry jam that you have eaten – or maybe she made wine! Elderberry has many health benefits including reducing symptoms and duration of the flu when employed within 48 hours of the onset of symptoms. Sound familiar? Luckily there is no evidence of anyone jumping off buildings or in front of cars with the use of elderberry, unlike some conventional medicines, especially in children. In our house, we have long used elderberry syrup to ward off flu symptoms, even when the boys were young. In fact, in 1995 the Panamanian government used Elderberry to fight off the epidemic ( Journal of Alternative and Complementary Medicine Vol. 1, #4, 1995). Interestingly enough, there have been several studies done on the effectiveness of elderberry in fighting the flu. In a study published in the Journal of International Medical Research in 2004, it was concluded that elderberry is effective at reducing symptoms and duration of both A and B strains of the flu and unlike some antiviral drugs it can be administered to the whole population (Zakay24

Inside Medicine | Late Summer Issue 2018

Rones. Et.al 2004). It is considered one of the top antiviral herbs on the planet. How does it work? Simply speaking, it boosts your immune function to fight better. The most common threat to our immune system is from viruses. Your body is exposed to many types of viruses, creates antibodies to fight those viruses and remembers them for next time. However, during the actual “fight” your immune system is busy creating soldiers to fight against the latest virus that is gets worn down and susceptible to other culprits. Think about how many people you know who had the flu and did fine, but then a few days later had something else, pneumonia, strep, or bronchitis? This is where elderberry can help. The contents are rich in powerful antioxidants, much higher than any other berry and almost 5 times the amount found in blueberries. This helps attack the viruses and defend the immune system. Now understand, this is a very, very simple explanation of how the immune system works and how elderberry can help influence. Other benefits of elderberry include anti-inflammatory properties. One example of reducing inflammation, it helps slow the body’s histamine response, therefore reducing symptoms of allergies. This alone is a benefit for the Tennessee Valley that any allergy sufferer can appreciate. How exactly do you use elderberry? We use it in many different forms. This includes tea, syrup, tincture, wine (yes, wine), jellies, capsules, juices and more. My favorite is to make elderberry syrup. I use local honey and local elderberries (when I can get them harvested locally). It has long been understood by south-


ern folk, medicine teachers, and herbalists alike that using plants from your geographical region will have better benefit on your outcome. It is advised to only take elderberry up to five days and not use it long term. If you have any autoimmune diseases that may be related to over active immune function you should discuss the use of elderberry with our medical professional. Because elderberry can also be used as a laxative in higher doses it is advised to be mindful of how much you take. Elderberries should never be consumed raw as they contain a cyanide-inducing chemical which can cause diarrhea and vomiting. You can find locally made elderberry syrup and tinctures at Salt on the Rocks. These preparations are made from high quality organic elderberries and local honey. The staff is happy to help explain further how to use Elderberry safe and effectively.

Heather Morse is the owner of Salt on the Rocks, a new destination experience with Salt Therapy. The Remedy Room inside Salt on the Rocks offers a variety of natural remedies for the beginner, including herbs, oils, teas and tinctures. You can find them at the corner of Bob Wallace and Whitesburg Drive. Visit SaltontheRocksHuntsville.com for more information.

Randomized Study of the Efficacy and Saftey of Oral Elderberry Extract in the Treatment of Influenza A &B Virus Infections. Zakay-Rones, E Thom, T Wollan and J Wadstein, 2004; Journal of International Medical Research Inhibition of Several Strains of Influenza Virus in Vitro and Reduction of Symptoms by an Elderberry Extract (Sambucus Nigra) during an Outbreak of Influenza B Panama. Z Zakay-Rones, N Varsan, M Zlotnik, O Manor, L Regev, M Schlesinger and M Mumcuoglu 1995; Journal of Alternative and Complementary Medicine

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Inside Medicine | Late Summer Issue 2018

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Long Term Care benefits may vary from carrier to carrier but there are two criteria you must meet for benefits to be received: the Benefits Trigger and the Elimination Period. The benefit triggers are used to determine if you are eligible for long term care benefits. Typically, not being able to perform 2 of 6 activities of daily living or a cognitive impairment, such as Dementia or Alzheimer’s, will qualify an individual. The “activities of daily living” (ADL’S) include eating, bathing, dressing, toileting, transferring (getting form a chair to the bed), and continence. A board certified physician has to document that the patient is not able to perform these basic daily functions. Once you are deemed eligible, the insurance company will approve a Plan of Care, on your behalf, that outlines the benefits for which your plan will provide. The elimination period is the amount of time that must pass after a benefit trigger occurs. This is typically 30-90 days from the time care is needed. During the elimination period, the insured is required to pay the cost of all services received. The longer the elimination period, the lower the premium, although this longer period requires more out of pocket costs. There are many features in a Long Term Care contract. This includes daily benefit, length of elimination periCall your local Long Termbenefits Carefor inflation, od, duration of benefits, indexing waiver of premium, non-forfeiture, renewability and professional for more information. shared care, just to name a few. All of these features will Anne C. Jewell, 256-533-0001 play a role in the policy premium. When considering the purchase of a Long Term Care contract you will need to review all the features. I urge you to call for a no cost consultation as an opportunity to learn more about the potential risks, costs, and options available.

Care for yourself the same way you care for others.

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Women today have a greater risk of needing Long Term Care services. It's very important for women to develop a Long Term Care strategy to help preserve their family, career, lifestyle, health and total financial future. Long Term Care protection can save a by Anne C. Jewell woman from the high costs of care. It also People have become and independence more aware of the need for provides them withmore choice, Long Term Care. It is imprtant to understand the and most importantly, to not befora you burden on benefits andBy features that the policies provide. loved ones. arranging Long Term CareLong Term care policies cover the insured for home care services, nursprotection for others, women can stay on ing home services, assisted living, adult daycare, alternate track protect savings theirHome care care,to hospice andtheir respite care forand thekeep caregiver. career. services can be skilled or non-skilled nursing care, physical Chances are that youaides. have experienced therapy, and home health These services must be provided for by state licensed certified health agencaring a loved one and/or at some point home in your cies. In a state licensed nursing home, the care life, so you know how demanding it can be. provided may love be skilled, intermediate, custodial Your for others is whyand/or you should docare. Alternative Care is most often for home modifications. Respite something bold and begin planning for care is temporary care for the insured to provide relief for Long Term Care now. their usual caregivers.

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Finding Mindfulness

by Ragan Bailey, MA, ALC

So many of us run our lives in an autopilot mode and actually become detached from the world and people around us. Mindfulness is an excellent therapeutic technique that is used in the counseling field. Practicing Mindfulness helps an individual become more conscious or aware of the present moment all the while calmly acknowledging and accepting the person’s thoughts, feelings, and sensations. You can find Mindfulness apps on your smart phone or tablet to practice with, but I have also constructed a daily approach. Take the time to slow down and enjoy your life, even the un-enjoyable moments can be used as learning opportunities. Take note how hard implementing this routine is, because the harder it seems, the more disconnected you may actually feel.

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Mindfulness Approaches to Your Day

MORNINGS: Open your eyes and lie in the quietness of your room. Let your mind relax and push all of the day’s needs and happenings from your thoughts. Notice the feel of your room: temperature, lights, and what your body is saying. Take 5 deep breaths. Before breakfast, drink a full glass of water with fresh squeezed lemon to detox. While you fix your coffee or breakfast, pay attention to each task as you prepare it- don’t think about other things, just focus on your task at hand. While you sit to drink your coffee or eat breakfast, don’t look at your phone or read the newspaper- just be. Be present with yourself and what you are doing at the moment. As you leave for the day and step outside, feel the temperature- how your body reacts to it: the sun on your face or the raindrop in your hand. Take in the sounds and the smells of nature around you. If it is a summer day and you can walk barefoot in the grass then do so! These things ground us and connect us with the earth LUNCH: Don’t skip lunch, everyone needs a break in the day. Multi-tasking during lunch causes burnout. Take the time for yourself before finishing the day’s tasks. Even if it is only 15 minutes. Before diving back into the work, take a moment to realign your body, sit with good posture and concentrate on your breathing- when your mind drifts away, re-center it back to breathing. This allows for a calm refocus on what needs to be done. It helps us to feel less anxious and rushed to complete tasks, and it gives clarity of mind to focus on the rest of the day’s tasks EVENING: As you come home in the evening and start shedding the day’s armor (coat, purse, briefcase, shoes) imagine also that you are shedding cares and worries from your day at the same time. For every physical item you remove, remove an emotional one as well. As you prepare or eat dinner take in the smells and tastes from the food. With each bite be mindful of chewing, swallowing, and tasting. At least one hour before bed, put away all electronics and turn off the televisions and radios. This allows your mind to be quiet and helps relaxation and sleep. Leave the noise of the day behind and reflect on all your progress. Take time to be grateful for blessings and protection Ragan Bailey, MA, ALC Foundations Counseling Center, Inc. 725 Market Street Athens, AL 35611 (256) 497-3147

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} FEATURE

THE THREE SOURCES OF VERIFYING FINANCIAL RESPONSIBILITY by Tiernan O’Neill

Now more than ever, patients are seeing their financial responsibilities, burdens and debts increase when receiving medical services. It is probably one of the largest complaints and frustrations of patients; especially considering the everchanging insurance guidelines and rising premiums. However, there are sources at their disposal that individuals can use to verify and possibly even lessen the money they see leaving their pockets for services received. 30

Inside Medicine | Late Summer Issue 2018


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...cont’d from page 30

The first source is the insurance company itself. I always recommend patients know the limitations and benefits of their plan. While the clinics or facilities you use are aware of many guidelines, the insurance companies fail to provide a comprehensive guide; and ultimately the financial responsibility will be yours. Knowledge of your plan comes from two main sources. First, do not throw out that benefit booklet (like so many of us do) that you receive when you first enroll in your plan or anytime the group policies change. It is a fairly comprehensive and invaluable tool to understanding your benefits and limitations. But most importantly, it is sound advice to call your insurance company prior to receiving big ticket procedures. Many times, your clinic can provide you with information to include diagnosis and service codes to assist in these conversations. By calling your insurance company you can get a better sense of what your expenses may be to financially prepare for or possibly weigh the risk/benefit of having the procedure at all. But most importantly, be sure to time-date the call and know who you are talking with. I say this because regardless of your plan guidelines, and any disclaimers they make regarding a promise of benefits, insurance companies for the most part will be held responsible for any expenses which are in contradiction. I have seen many times where insurance companies, when instructed to pull the call log, will cover services a representative erroneously stated would be covered. The second source is the clinic or facility where you receive the services. While these places are knowledgeable to insurance billing, that is not to say mistakes don’t happen. What you are trying to do is simply verify whether they have processed the claim and your expenses properly. I would always recommend meeting with the person in charge of billing directly. Receptionists rarely have the full scope of what they see when it comes to viewing/understanding your insurance determinations. Also, general staff will never have the power or authority to make corrections. I strongly suggest you set a face to face meeting with the designated biller. I say this because you don’t just want to pop in and ambush them. Aside from the “confrontation” or wait, a scheduled meeting will usually allow the staff involved to have all of the pertinent information at hand and more importantly reviewed for any potential internal mistakes. In the case where they find a mistake ahead of time, this may save you a trip to discuss the problem. The third source may be the physician’s office which referred you to the external facility or clinic in the first place. Now tread lightly here because many times the referring physician’s office may have little knowledge or authority to

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assist; and you most certainly don’t want to expect them to take over your responsibilities or burdens. But sometimes they may be a good resource to verify using their professional knowledge and experience if bills or other things sound correct. Also, considering they are the originating source of referrals that tends to mean they have established relationships with those external facilities and may have better contacts or credits built with those places which can help you in the process. Having said all of the above, keep this one most important thing in mind as you navigate the process and sources. It is easier to attract bees with honey, coming into any situation or approaching any other person in a confrontational or disrespectful manner will likely not produce any desired or positive results. These sources are your best contacts, and they tend to hold enormous abilities they may use at their own discretion. Also, establishing professional and mature relationships with these sources is typically not an isolated event. Your reliance, cooperation, and understanding with these individuals should always be respectful and genuine regardless of the outcome. Remember, they rarely, if ever, advised you in signing up for one plan rather than another with better coverage. Lastly, if at the end of the day you are faced with a correct bill that may be too burdensome to pay off due to any circumstance you are personally going through, communicate that with the facility promptly. Many offices will be more than happy to create payment plans, possible discounts, or direct you towards assistance programs in order to make sure all liabilities are met for services rendered. This is something that should be done promptly, as billing departments and offices are less likely to assist individuals who evade and neglect their financial responsibilities, and also have burned up the resource of the office to track them done. Ultimately, I wish all patients the best of luck as even I know this can be a difficult and confusing process. Even for those with personal/professional experience and knowledge.


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} RESEARCH

HudsonAlpha receives $150,000 Alabama Power Foundation grant for bioinformatics program

by Margetta Thomas

HudsonAlpha Institute for Biotechnology has been awarded a $150,000 grant from the Alabama Power Foundation to introduce bioinformatics to students across the state. Through a new program, Characterizing Our DNA Exceptions (CODE), HudsonAlpha will engage small groups of college students with authentic genomic research. Students will work to computationally analyze DNA variants – a practice known as bioinformatics – from real-world, anonymous clinical samples. Current sequencing technologies make it possible to obtain the entire genetic code of an individual in a matter of days. Often, the process detects DNA variants, or genetic changes, that are not well understood because they have not been studied. These changes are known as variants of uncertain significance, or a VUS. “A VUS undergoes extensive analysis and testing to determine whether it has a role in the development of a trait or disease, a process that is very time consuming,” said Michele Morris, workforce development lead at HudsonAlpha. “Because of this, VUS interpretation has historically been conducted in larger universities. Through CODE, we want to lower those access barriers.” In doing so, HudsonAlpha is collaborating with five Alabama colleges and universities across a broader scope of academia. Schools range from nonprofit, to large community colleges, historically black colleges and universities (HBCUs), and liberal arts:

Each school will select a faculty member to serve as program adviser who will then select five to ten students to participate in CODE. HudsonAlpha researchers and educators are hosting a two-day workshop for advisers May 14-15. “It has always been the mission of the Alabama Power Foundation to support advances in our state. As technology continues to evolve and innovation is more vital than ever, it is important that we continue to expose Alabama’s students to cutting-edge initiatives to ensure their success,” said Myla Calhoun, president of the Alabama Power Foundation. “Programs like this one can be real game changers for these students, and we are proud to provide support.” Pilot schools will participate in CODE for the 2018-2019 academic year. Students will present their work at a pilot group symposium in March 2019. Following the initial experience, pilot schools will be eligible to continue participation for a second year and this fall, HudsonAlpha will begin recruiting 25 more schools. “Enormous amounts of genomic data are being generated on a daily basis, so CODE participants will have access to that data and work to characterize newly identified DNA variants,” said Neil Lamb, PhD, vice president for Educational Outreach at HudsonAlpha. “We hope this experience will inspire more Alabama students to pursue a career in the STEM fields such as genomics and bioinformatics.”

• Alabama College of Osteopathic Medicine • Alabama State University • Birmingham Southern College • Lawson State Community College • Wallace State Community College Inside Medicine | Late Summer Issue 2018

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} MISSIONS

Live Like Christ by Ben Macklin

If you pay attention to the national news, use social media, or follow politics in any capacity, one can’t help but notice the polarization of ideas that are driving people apart. The social framework of our culture is changing. Society wants to define who you are based on race, wealth, beliefs, or how you vote. God’s Word no longer defines who we are, what we’re worth, what’s right or wrong; society does. Society tells us who we can and cannot hang out with, society tells us that happiness comes from materialism and self-righteousness, and society can be aggressive and violent in pursuing its deceptions. This isn’t unique to us in 2018. It has always been this way and it will always be this way. It’s one of the great lies of Satan that plagues humanity. There are times when I think about how much better life would be if we had Jesus walking with us today. I think to myself, “He would know what to do…Jesus would fix all of our problems.” But the truth is that’s not the picture of Jesus we see throughout the Gospels. Jesus was, without a doubt, one of the most socially frustrating people to ever walk the face of the earth. That’s why I love Jesus, because there is no one like Him. Jesus spent three and a half years breaking down social barriers in His pursuit of bringing salvation to a fallen creation. Think about it… Devout Jewish men of God were minding their own business, trying to do all the things God had commanded them to do, until one day a carpenter for Nazareth walked into a synagogue, read from the Book of Isaiah, and declared that He was the Messiah. Jesus, that’s blasphemy! You cannot say things like that. Who do you think you are? Jesus walked into the temple during the Passover celebration, and sent the place into chaos. He scattered the coins of the money-changers, He flipped over tables, and He drove every man out with a whip. He even drove out the sheep and oxen. Jesus, what are you doing? You cannot act like that in the temple. And what was all that talk about, “Destroy this temple, and I will raise it up in three days?” People are going to think you’re crazy. Jesus constantly called out the religious leaders for being hypocrites, He performed miracles on the Sabbath, and He challenged the hundreds of man-made rules the Jews had devised for interpreting God’s Law. Jesus, you can’t keep challenging our religious leaders. If you don’t stop, they will kill you. Jesus hung out with the poor, the sick, the lame, the blind, the oppressed…

Jesus, why are you always hanging around with outcasts? They aren’t worthy of your time or energy. And in case you didn’t know, people don’t touch lepers, and they certainly don’t rub spit in someone’s eyes…that’s gross. Jesus surrounded Himself with sinners, He fellowshipped with a despised tax collector, and He had a life-changing conversation with a desperate housewife at a well. Even His closest friends were uneducated fisherman with bad attitudes and cowardly tendencies. Jesus, religious teachers don’t associate with these kinds of people, and they certainly don’t speak to women in public. Jesus knows what it’s like to live in a polarized political environment. He experienced it Himself, so did the Disciples. He faced the criticism and violence, He endured the lies and false accusations, and He suffered the hatred and punishment from the world around Him. But through it all, Jesus remained obedient to the will of His heavenly Father. With the power of the Holy Spirit, Jesus broke through the social structures and division within society with love, compassion, and grace. Jesus didn’t condemn sinners, He set them free. He stepped into the lives of people to show them that His love was more powerful than their mess. Jesus used parables to show us just how much we are loved and how precious we are to God. He used His gifts and abilities to serve and bless others. He brought heaven to earth and restored the relationship between God and man. But most importantly, Jesus went to the cross on our behalf and endured the punishment that we deserve, so that we can be forgiven for our sins and receive the free gift of eternal life. The only thing Jesus asked for in return was that we believe Him. Let your life be a reflection and extension of the love, mercy, and grace you received through Jesus.

God shows his love for us in that while we were still sinners, Christ dies for us - ROMANS 5:8 Beltline Church of Christ 2159 Beltline Rd SW, Decatur, AL 35601 256-353-1876 www.beltlinechurchofchrist.org Inside Medicine | Late Summer Issue 2018

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Cold-Pressed Juice

+Kombucha by Heather Mendez

Cold-pressed juice is all the rage. Kombucha is also becoming popular. But, what exactly are these? Cold-pressed juice uses a juicing process that crushes fruits and vegetables using a hydraulic press and 2000 pounds of pressure with no oxidation. The end result is healthier, longer lasting juice. Because the cold-pressed method uses no heat, the vitamins and live enzymes stay intact, and you get a better tasting and longer lasting juice compared to a centrifugal juicer. Cold-pressed juicing is the only way to maintain the integrity of the produce, ensuring your body absorbs the nutrients in their purest form. The vitamins and minerals in the juice get absorbed into your bloodstream immediately! Kombucha is a bubbly probiotic tea praised for its many health benefits. It starts with organic tea, sugar, and a kombucha culture. It is then fermented for an average of 7-21 days. The culture metabolizes the sugar and caffeine leaving the end result tangy, fizzy, and full of essential probiotics, B vitamins, organic acids, and live enzymes. What does cold-pressed juice and kombucha have in common? We believe they contain the purest, highest quality ingredients available. At The Juicery Press in Madison, AL, we craft our own kombucha and then flavor it with cold-pressed juice and then it is carefully fermented again. Every bottle of kombucha has all the benefits of the cold-pressed juice, but with 1/3 of the sugar compared to drinking pure juice. There are many reasons to drink our “cold-pressed kombucha�. First, it tastes amazing! Also, kombucha can help detox the body, protect and improve liver function, improve digestion, promote weightloss, alkaline the body, boost immunity, and increase energy levels.

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Come purchase your own, locally brewed, Tribal Kombucha at The Juicery Press in Madison, AL. Inside Medicine | Late Summer Issue 2018


Healthy legs in time for summer The Madison Hospital Vein Center is pleased to welcome Dr. Jennifer Kiessling, who is accepting new patients struggling with spider veins, restless leg, varicose veins, leg pain and swelling. Dr. Kiessling is available to treat your legs just in time for summer. Call (256) 265-8346 to schedule your appointment. Office hours are Monday through Friday from 7:30 a.m. to 4:30 p.m.

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Inside Medicine | Late Summer Issue 2018

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} FEATURE

Pediatric Myopia: an Epidemic? by Paul F. Vandiver, OD

Things have changed since I was a kid. We played outside till dark, explored in the woods, got dirty, built forts, watched the occasional “after school specials” and who could forget the cartoon Saturdays. Today kids have visual stimulating gadgets everywhere. Of course, we had the Atari, Nintendo and its Game Boy in the 90s, paving the way to the XBOX, Playstation and others. But its a different world today for sure – driven by handheld devices that are constantly drawing attention from most every kid, whether in restaurants or a big box store keeping Johnny hypnotized while mommy or daddy gets the shopping done. Is the “technogadget, information at your fingertips world” we live in today effecting our youngsters eyes? I would say absolutely, and the evidence is in the research. 40

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According to the journal Ophthalmology (2016), “Half of the worlds population (nearly 5 billion) will be myopic by 2050, with up to one-fifth of them (1 billion) at a significantly increased risk of blindness if current trends continue.”1 Nearsightedness, or myopia, is a condition of the eye where light focuses in front of instead of on the retina. This causes distance objects to become blurry while close objects remain clear. Eyestrain as a result of squinting improves the clarity of distance objects, and over time the focusing system of the eye becomes weak from exhausting this mechanism. The decrease in distance vision over time and headaches are a result. Eyestrain is also a result of excessive near work — reading for hours a day or using computers or phones excessively (where the definition of “excessive” is debatable). The fact that distance vision becomes worse over time is just part of the problem with this eyestrain epidemic. The eye’s ability to focus like a camera is also degraded. We’ve all heard the phrase “my arms aren’t long enough” or “the print keeps getting smaller” etc. due to inability to focus on objects nearby after forty or so birthdays. This complaint is now being heard or revealed in a comprehensive eye examination by much younger patients. I believe in part to the over-stimulation and constant use without breaks. This near demand on our eyes today is worsening compared to ten years ago. To be realistic, there seems to be no way around the world of electronic communication and the social network phenomenon – desired or not. It is widely accepted and frankly not debatable that myopic progression is a high priority. Seeing that the tech world is only becoming the rule and not the exception, we should be aware of its effects on our eyes. Often I am asked “What restrictions should I place on my child’s screen time?” or “How can we prevent his/her eyes from worsening?” These are good questions and with the evidence produced from collective myopic control studies we now have at our fingertips optimum guidelines and treatment interventions to slow down the progression of these myopic changes. To date there is no actual cure for myopia. There are ways to improve myopic vision degradation up to the time it is corrected, but vision can and most likely will change over time. The human eye will stop growing at or around puberty, but very little change in the length of the eye can cause significant change in myopia. This is why refractive surgeries like LASIK can only be considered when the length of the eye is less likely to change. So therefore contact lenses, spectacles, or the various refractive surgeries may not be the only Inside Medicine | Late Summer Issue 2018

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}MISSIONS ...cont’d from page 41

treatment needed throughout ones life, but with the myopic “epidemic” we are seeing today, combinations of the above treatments are needed. This is where MYOPIC CONTROL comes on the scene. We have desperately needed an intervention plan for decreasing the PROGRESSION of vision loss from myopia in children so that they will not be at a higher risk for myopia induced ocular disease, let alone the poor vision and the lifestyle changes it accompanies. What Are Some Causes of Myopic Progression? There isn’t necessarily one cause of myopic progression but rather a combination of factors. Parents that are nearsighted are more likely to have myopic offspring, but not always. It’s certainly a predestination NOT a destiny. It may be that parents who preferred to read a lot have kids that prefer the same activity. We do know that there are factors that contribute but how they vary from one child to another is difficult to gage. Factors like excessive reading (2-3 hours at a time), long term computer use, and some evidence that diet may be a variable. For the purpose of this article we will discuss some interventions. Independent of the causes, the facts are that myopia and its progression over shorter time intervals are worsening. Just like you don’t have to understand the physics of how a bike works to actually ride one, we’ll focus on how to decrease this problem at hand. Why is Myopic Control Important? There are considerable health risk with significant myopic changes, especially if at a high rate. As mentioned, the axial length — or length from front to the back of the eye — is the most influential variable in myopia besides the curvature of the cornea. When the axial length of the retina becomes elongated, there are areas that become stretched and ultimately too thin. Imagine blowing up a balloon. The more air that is blown in, the longer and thinner the balloon becomes. Like all organs the retina’s growth is reg lated by homeostatic control mechanisms and unlike other organs the eye relies on vision as a principal input to guide growth. This thinning of the retina tissue causes significant fall out. The retina is in a way the circuit board encompassing a complex network of nerve fibers and cells that together make up an enormous grid for delicate chemical reactions that produce vision as we know it. Vision Threatening Ocular Disease and Disorders Associated with Myopia Degenerative Myopia – When the elongation of the axial length reaches a certain level or lengthens at a high rate it can become pathological. The risk for retinal detachment is higher due to thinning retina at a rate the eye cannot repair or control its repair mechanism quickly enough. Degenerative myopia can be detected with a dilated exam and there are particular changes the eye care 42

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specialist will detect. This includes macular edema (fluid build up in the center of the retina), “stretch marks” or lattice, holes within the outer segments of the retina, pigment changes called “lacquer cracks” and large optic nerve disc which appear to be tilted with loss of tissue around the nerves. Retinal tears and retinal detachments – This is a painless separation of the retina, particularly the layer responsible for converting light to image. A retinal detachment can be repaired in most cases if medical attention is achieved in a timely manner. Symptoms of retinal tear and /or detachment are flashes of light that are sudden and profound, subsequent floaters, distorted images that do not return to normal within seconds, and most dire the “veil” or “curtain” affect producing dark visual field loss that increases with time. Cataracts – Filmy vision over time that worsens in magnitude is most common symptom of a cataract. A longer eye causes entering light to scatter and in turn causes the lens in the eye to become more dense. This increased density scatters light and ultimately allows UV light to change the lens by distorting polymer chains. Additionally, the elongation of the retina deprives the posterior lens of nutrients and therefore clouding the back surface. Glaucoma – This is an ocular disease which causes one to lose peripheral vision. There are a few ways this can occur. The common finding in each mechanism is the thinning or loss of retinal nerve fiber and retinal ganglion cell complex (GCC). There have been several studies that relate risk of myopia and glaucoma. The most agreed is that the GCC is altered, again from being stretched. The GCC is synonymous with a complex wiring system that connects the all important optic nerve with the macula. If this layer is stressed the macular framework will be unable to remain stable. The exact pathology of how the ganglion complex is altered by stretching of retinal layers is not known but the risk of glaucoma increases as the


...cont’d from page 36

axial length increases. Many studies have established that relationship most notably The Beaver Dam Eye Study. Methods for Myopic Control Research in this area of myopic control has become a global urgency. As more information and facts are determined, professionals on the clinical level are implementing and monitoring the results. As we stand today there are currently five general clinical techniques that are universally accepted as “control methods”. At Schaeffer Eye Center (a MyEyeDr affiliate) our very own Dr. Nicholas Onken, pediatric specialist, has experience with the latest methods. 1. Getting outdoors more. This one seems almost like its not a real treatment but actually does make sense. A little vitamin D and getting dirty with some tree climbing and fort building never hurt a kid (too bad). This kind of activity relieves the eye from over focusing. There is truth to “avoiding the stressor” just like a newly discovered allergy or the co-worker that causes a blood pressure spike. 2. Bifocal or progressive glasses. This idea is centered around the theory that assisting the child’s accommodation mechanism by doing a little of the “work” up close will eliminate some of the stress, and also to cause a “peripheral retinal blur” which prevents the stimulus for the retina to grow or stretch. Executive design lenses (bifocals measured at the center of the pupil) have shown more reduction in myopic progression than progressive lenses – 33% reduction in one study2. Each case will have its unique story as we are all very different and research is not biased concerning a personality or a child’s likes and dislikes. Results from a study may say “x” but compliance with a line vs no-line progressive lens may become a real concern for one individual and not another. Convincing a twelve year old to start wearing a bifocal may be a hard sell and all the years of being the cool doctor are on the line. This can be combated by the fact that an executive lens is actually easier to use since there is no image jump and the child can operate the design almost immediately.3 Dr. Onken points out “many adults are hesitant to use multifocal glasses because they’ve heard that it’s hard to adjust to them. This has never been a problem with kids – they just roll with it!” 3. Multifocal Soft Contact Lenses. This is my personal favorite. For those kids who show a mature character – the overachievers – this seems to be a great option. It’s also very effective as the latest results published to date is a 48% reduction in myopia vs the control group of the same age4. The contacts used in this method are multifocal with a specific design for distance and near separated within the lens. This design can be alternating concentric rings, distance in the middle and near on outside, or translating as near in the bottom and distance on top. This is an example of how the myopic control studies have

changed the paradigm and more options are available than once thought. This premise is consistent with the spectacles as well. The design discourages axial length growth by blurring the outer retina. In the clinic I reside, all cases have shown an obvious decrease in myopia progression compared to those in their age group, even in the more myopic youngsters. A couple mind boggling case studies where we fit multifocal contacts, one age 6 and one 7, come to mind. When these patients reached their three year visit, the resulting myopic magnitude was half that of kids at the same age and refractive error with no treatment. Once a child masters the daily insertion and removal routine and maintains appropriate hygiene, they are usually bought in. Dr. Onken’s experience with fitting kids confirms this. “With contact lens wearers, children are the lowest risk population for eye infections related to contact lens wear. My youngest contact lens wearer is 3 years old, because contact lenses work better than glasses for many visual problems, including the control of myopia”. 4. Ortho-K, Kerotology. This is a rigid gas permeable lens that is specifically designed to reshape the outer portion of the eye (cornea) while one sleeps. The patient then removes the lens and the vision has been corrected secondary to flattening. The cornea is spongelike and will revert back to its original shape over time if the lens is not worn. This is a more advanced method for myopia control as it requires a certification and many patient encounters to reach expert level. This is becoming a more accepted control both professionally and from the patients perspective. The peripheral retina blur is constant throughout waking hours and the corneal epithelium is the only layer of cornea “changed” – making this method low risk for any permanent damage to the cornea if lens is ill-fitting or not ideal. After seven days the corneal epithelium is completely turned over. One downside to ortho-k is the difficulty for some to adapt to the initial fitting, especially with a younger child. The lens material is more difficult to adjust to initially but if educated thoroughly and properly, motivation and dedication will drive the patient to success. This method does yield a healthy 45% reduction in myopic control, similar to multifocal contact lenses5. 5. Atropine. This is a pharmacological method that involves the use of a drop with cycloplegia effects. Cycloplegia is the paralyzing of the ciliary muscle in the eye resulting in the loss of focusing ability. This method of myopic control is using a pharmacological intervention – one drop in each of the eye daily. The temporary paralyzation of the lens prevents accommodation and in doing so decreasing the stimulus to elongate. Statistically this method is the most rewarding but carries a few concerns8. A couple drawbacks are most people and especially children wouldn’t line up for drops that cause a little blur and the drop is off label – requiring very careful attention to pharmacological interactions to medicines since this Inside Medicine | Late Summer Issue 2018

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is a longterm regiment. There are possible central nervous system and cardiovascular implications to be aware of although many atropine supporters suggest very little concern. As a pro argument the most effective concentration was determined to be 0.01%, diluted significantly from the 0.5 - 1% atropine used in optometric exams to treat some injuries with inflammation. The appropriate concentration of 0.01% when used 1 drop a day, can effectively decrease progression of myopia by 68% over a 5 year span.5 Additionally, this method must be adhered to and constant positive reinforcement is necessary. Dr. Onken agrees that “the hardest part is remembering to do them consistently — and a way to keep consistency is putting the drops in when the child is asleep, as it often reduces the stress of the event”. Conclusion There is no doubt that myopia progression rates are on the rise globally. We must be aware of the risk these rates cause on our eyes – specifically our children. We need to ensure that our children are receiving comprehensive eye examinations and creating a dialogue with parents about the risk of myopic progression and intervention possibilities. Optometrist must not only realize the severity of this nearsighted world but get on board with treatment options. Dr. Onken, and many others, are making efforts to improve this concern. Dr. Onken expressed his passion stating, “As a pediatric specialist, one of my biggest concerns is the rapid progression of myopia in today’s kids. Both genetics and our modern day lifestyle contribute to this alarming trend. Fortunately we have tools available to us that did not exist 10 years ago, that give us a fighting chance against myopia”. Being that I am a myopic optometrist and father of 7 year old twins with genetic predisposition – I am in.

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1. Brien Holden, Timothy R. Frickie, David A. Wilson, Monica Jong, Kevin S Naidoo, Padmaja SanKaridurg, Tren Y. Wong Cited Ophthalmology, 2016; DOI: 10,1016 j.ophtha a.2016.01.006 Thomas J. Naduvilath, Serge Resnikoff 2. Myopa Control: A Review Walline JJ Eye Contact Lens, 2016 3. Effect of bifocal and prismatic bifocals on progression of myopia in chidren: three-year results of a randomized clinical trial Cheng D, Woo GC, Drobe B, Schmid KL JAMA Ophthamol.,2014 4. Controlling Myopia progression in children and adolescents Smith MJ, Walline JJ Adolesc. Health Med. There., 2015 5. Current approaches to myopia control Leo SW Curr. Opin. Ophthalmol., 2017 6. Five-year clinical trial on atropine for the treatment of myopia 2 Myopia Control with Atropine 0.01% Eyedrops Audrey Chia, FRANZCO, PhD, Qing-Shu Lu, PhD. Donald Tan, FRCOphth Published Online: August 11, 2015 PlumX Metrics


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The 6th Sense of Clinical Practice: Medical Intuition by Kari Kingsley, MSN,CRNP Merriam Webster defines intuition as, “quick and ready insight; immediate apprehension or cognition; or the power or faculty of attaining to direct knowledge or cognition without rational thought and inference.”That’s fancy wording, but what does that really tell us about medical intuition? As a patient, would we prefer care from the newly graduated straight-A summa cum laude med student….or the seasoned physician with years of experience under his or her belt, but whose medical books harbor millimeters of dust? How does a greenhorn medical provider make split second judgment calls with limited experience to back it up? What makes someone a good provider? Does it all boil down to book smarts, experience, or a combination of both? Some would say medicine should be considered a foreign language. Every drug calculation, medical abbreviation, and short hand symbol for what felt like every adjective, adverb, and preposition in the English language was thrown at us in the first few weeks of school. Almost as if the powers that be were using scare-tactics to weed out the weak! Deciphering physicians’ handwriting felt comparable to reading hieroglyphics. Oh, and pimping! (Mom, it’s not what you think!) Pimping is a word used in the medical community describing a teaching tool used in clinical rounds in which the student is asked a question on the spot. A really hard question. In front of their peers. Like, “Which Biblical character was most likely to have a pituitary adenoma and why?” It can be mortifying in front of your instructor and cohorts to miss the answer. Although, take it from my personal experience (and chaffed backside from the tongue lashing I received), that you’ll never forget why Mrs. Smith in room 217 needed lactated ringers instead of normal saline. In nursing school, I remember silently chanting to myself, “C” equals R.N. Just get through this test, this clinical hour, this procedural check-off. That’s something no patient wants to hear from their nurse. But the truth is, nursing school is tough. It should be! I prefer that the person sticking my Dad with a hypodermic needle full of medicine knows their stuff! And while I ultimately graduated with a B+ average in undergraduate studies, I still remember thinking I would be the first person in my class to flunk out after bombing a pathophysiology test. As a graduate level provider, I had to up the ante. Mediocre grades and blasé mindset wouldn’t cut the mustard. One medication error or temporary lapse in judgement could end in a deleterious event, forever changing (or ending) the life of my patient, not to mention my own. Even after pouring myself into my studies and graduating nurse practitioner school with a 4.0, I felt like I knew NOTHING. (Yes, I am bragging about my 4.0… especially after spilling my “C = RN” mantra). Forever being my own worst critic, I reluctantly joined the work force, con46

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stantly second-guessing myself and running to my collaborating physician for guidance. But with each passing year, something exciting began to happen. I was slowly loosening the reigns on my self-depreciating tendencies and becoming more confident and comfortable with the clinical decisions I was making. Foreign and aloof medical conditions gave way to familiar and recognizable human ailments. Just like Pinocchio shouting, I’m a real boy!!, I started to feel like I could yell to the world that I knew what the heck I was doing! Every profession has a margin of error. It just so happens that in medicine, this margin is very small. Humans make mistakes. That’s a fundamental part of what makes us human rather than divine. Medicine is a career path similar to space flight where one tiny miscalculation can get a person killed. Plenty of other professions carry this weight. I envy the professions that seem to have a larger margin for error. Having spent a large portion of my life with a computer programmer, I’ll pick on them. I can recall hearing that after spending a day typing lines of code only to find a program won’t run, programmers have the opportunity to go back over their work and “de-bug” the problem. Something as simple as changing a misplaced colon for a comma has the whole operation running seamlessly. In medicine, we don’t get these do-overs. We are asked to make high-pressure, critical decisions, sometimes in the blink of an eye, using only our toolbox of clinical expertise and experience. If you’re lucky, no one gets hurt. My pilot father says, “any landing you can walk away from is a good landing” even if you crumpled your plane like a Coke can. But good landings in medicine aren’t enough. Our margin for error is paper thin. Multiple advanced practice journals have published critical reviews and professional papers studying the role of medical intuition in practice. My layman synopsis is that medical intuition is a combination of using evidence-based medicine with what you’ve seen in your own experience. Of course, each of these journal entries are open to interpretation but I see it as “Monkey see, Monkey do, but then Monkey, don’t forget to think for yourself!” Intelligent people are able to extrapolate and implement wisdom over intelligence in their daily actions. I like to think intuition is when your brain, your heart, and your gut are urging you in a similar direction. Apparently, Goliath likely had a pituitary adenoma causing acromegaly and bitemporal hemianopia (fancy talk for a giant with poor vision) as he was described in the Bible. Mercifully, no physician ever pimped me this question. And thank goodness for Google or else you fine folks would still be wondering.


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} SURGICAL TECHNOLOGY

GLAUCOMA AND THE IMPROVEMENT OF SURGICAL INTERVENTION by Michael Salter, MD

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Until recently we have been relying on the same surgical techniques to manage glaucoma that were created over 50 years ago. What if we continued cataract surgery the same way for the past 50 years? Many complications existed then like large incisions, higher complications of edema and retinal detachment, and long recovery times. Surgical techniques are starting to “get with the times.” There are only 4 current targets in glaucoma treatment. 1. Create an alternate way for aqueous to get out of the eye (artificial drain) 2. Decrease the production of aqueous humor at ciliary body.

3. Better facilitate flow through the trabecular meshwork and into Schlemms Canal. 4. Better facilitate flow through the eveoscleral pathway.

A timeline and synopsis glaucoma surgeries

Conventional Penetrating Glaucoma Surgery

1960’s to present This form of surgery bypasses the eye’s natural drainage pathways and is considered the “gold standard” today. The older surgery model involved a tube. High risk of erosion and exposure led to infection with tubes and this led to trabeculectomy or “trab”, “filter” or “express shunt”. “Trabs” can get eye pressure very low and may be option for end stage glaucoma cases, but downside is longer recovery, high incidence of of bleb leaks, shallow anterior chamber, hypotony, and choroidal detachments.

Laser Surgery

Argon Laser Trabeculoplasty (ALT) 1974 Selective Laser Trabuloplasty (SLT) 1998 SLT is considered a first line surgical option. It works well, and arguably safer than using drops. It has been compared to prostaglandin drop treatment with similar efficacy. Most glaucoma specialist would prefer to begin treatment with SLT over drop therapy. ALT is not utilized much as it is considered more difficult and requires more precise treatment areas with less room for error.

Laser Iridotomy

This is offered to those patients with a narrow angle (where cornea and iris meet). Asians are at highest risk, followed by whites and African Americans. This procedure should be offered to those with a very narrow angle and without evidence of glaucoma as a preventative. Transscleral Cyclophotocoagulation Pros of this procedure are that it is noninvasive (no risk of infection), it is quick to do (in office), and repeatable. The cons are if too aggressive a robust inflammatory response can occur postoperatively. This surgery must be done under a retrobulbar block (injection of anesthesia behind the globe of the eye). Micropulse CPC This is a new CPC using the Micro Pulse G6 Laser System. It has been shown to cause very little tissue damage with no incision and a safe procedure for mild moderate and severe cases of glaucoma.

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...cont’d from page 51

Microinvasive Glaucoma Surgery (MIGS)

2004 to present MIGS is a no stitch glaucoma surgery that can be pe formed through a small clear cornea cataract incision and is commonly done in combination with cataract extraction. Trabectome – a cauterizing tool that targets and removes the trabecular meshwork. Kahook Duel Blade – a sharp device that “shaves” the trabecular meshwork. iStent by Glaukos – the smallest device to be implanted in the human body and FDA approved for mid and moderate stage open angle glaucoma in 2012. Only FDA approved if implanted with cataract surgery. Studies have shown no increase in complications compared to cataract surgery alone. There is some risk with IOP spike and hyphema.

Second Generation iStent Inject

This could be approved by the end of 2018 and is considered to be easier to place than the original iStent. It also allows for 2 stents instead of 1. Cypass Stent – only approved with cataract surgery and creates a “cleft”. Risk are myopic shift, hyphema, hypotony and IOP spikes. iStent Supra – a suprachoroidal stent FDA approval by 2018-2019. Hydrus Stent – larger than iStent it bypasses the trabe ular network. Not yet approved by FDA.

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Lifestyle Medicine

by Elizabeth McCleskey, DO

The old expression – ”there is nothing new under the sun” – may indeed be true. But, old ideas sometimes can be explained in a new way.

Many people are already aware that their habits can affect their health. The news is full of “don’t eat this,” or a new study on exercise. And, yet, we as a nation appear to be getting sicker. It is difficult for doctors to discuss health given our current illness-based insurance model. With genuinely caring physicians having such limited time with each patient, the recommendation for a one-size-fits-all diet and exercise approach is often the norm. Fortunately, out of established research a new branch of medicine has emerged with the focus on helping people improve their health and prevent chronic diseases. Based on improving six areas of health, Lifestyle Medicine uses many non-drug modalities to treat, improve, and sometimes even reverse chronic health conditions. Medication, while still used, becomes the supplement to these lifestyle changes. These six areas are: 1. Nutrition – getting vitamins, minerals, protein, fiber, phytonutrients, etc., from a predominately whole-food, plant-based diet 2. Movement – consistent daily movement that works all the muscles, including the heart 3. Sleep – improving the quality of rest 4. Substance use – eliminating the use of tobacco and other potentially harmful substances 5. Relationships – establishing and nurturing supportive social connections 6. Stress management – leading to improved health and productivity

Why focus on so many things? In addition to the fact that individually each of these areas can produce health issues (e.g., tobacco and cancer), they also can affect each other. Improved sleep may assist in weight loss. Moving may reduce stress. And, if you don’t fuel your body with a good quality diet, it’s little wonder you don’t feel like getting off the couch. Would you like to feel better about your health? The process starts by deciding what your goal is and perhaps even writing it down. Maybe you would like to run a 5K or simply be able to play on the floor with your grandchildren. Next is to identify areas you are willing to change. Maybe the coffee creamer will not be eliminated, but you will eat an extra serving of a green vegetable each day. An earlier bedtime is not feasible, but you are willing to encourage deeper sleep by turning off your phone and leaving it in the kitchen overnight. Successes are celebrated and failures are put to good use as you learn to analyze, re-adjust, and overcome. So, while the message is not new–your mother may have told you to eat your vegetables and get plenty of sleep–life has a way of intervening and sending us down another path. Now is the time to learn how to manage that stress, get some quality rest, develop a strong emotional support system, avoid substance use, and become active while being mindful of your food choices. It may just be exactly what the doctor ordered! Elizabeth McCleskey, DO Board Certified Family Medicine Physician Member, American College of Lifestyle Medicine HealthStylesDr.com

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NATURAL APPROACH TO HORMONAL THERAPY by Donald Aulds, MD

Hormones have been used in medicine dating back thousands of years. These hormones were plant derived not manufactured in a laboratory and a manufacturing facility. 54

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} HEALTH FEATURE

A Chinese book dating back over twenty-five hundred years describes using soy for control of bleeding and menstrual problems. The drawings on the Mayan temples and teaching by tribal medicine practitioners of Native Americans describe the use of the Mexican yam root as a source to help women after childbirth and control of menstration. The plants were steeped as teas and drank by the women. Throughout the ages, man has sought the fountain of youth, while it exists in our own bodies. As we age, the hair may get thinner, our waist gets larger, more wrinkles appear and our energy decreases. Our bodies are complicated instruments with all 37 trillion cells for this function. As aging advances, the hormones in the body decrease and diseases will begin. As a women begins to get into the forties, there is a transition toward permanent infertility and sex hormone decrease called menopause. Men undergo a similar event called andropause in which he may have muscle loss, decrease ability to perform sexually and loss of interest in family and spouse. Synthetic hormones produce an inflammatory response which is due to the chemical being different from our bodies own hormones. Any time inflammation is present, there can be development of diseases especially autoimmune disorders. Bioidentical hormones (BHRT or naturally derived hormones) have the same chemical structure to our hormones and do not increase inflammation thereby in many cases may be protective to developing diseases. Menopause and perimenopause is the time in a woman’s life when the hormones decrease leading to the final stoppage of periods. Estrogen, progesterone and testosterone decrease in concentration in the body and the signs of the decrease can be identified ten to fifteen years before the last period occurs. The women may have changes in the frequency and severity of flow of her periods. As estrogen decreases, she may experience hot flashes, vaginal dryness and sleep disturbance. As testosterone levels go donw, the common symptoms include anxiety, depression, muscle aches, weight gain, decreased sexual response and drive, memory loss, night sweats and fatigue. Progesterone decrease can produce joint pain, loss of bone mass, insomnia, depression and anxiety and increased cholesterol levels.

Men undergo a form of menopause referred to by many as andropause with a decline especially in testtosterone and DHEA. These can lead to a decrease in libido and sexual performance, muscle and strength loss, fatigue, sleep disturbance, weight gain and decreased immune system function. Another problem that can occur is now referred to as thyropause with a decline in thyroid production and can occur at any age sometimes as early as late teens or twenties. This can be a problem leading to fatigue, sleep disturbances, difficulty in temperature regulation, thinning or loss of hair, weight gain, fatigue, and loss of cognition, memory and changes in mood. So these problems can each lead to a decreased sense of well-being, and disease. BHRT can be used in the right combination, the right dosage and with the right method of administration to improve quality of life, reverse symptoms and prevent diseases. Testosterone is protective for brain, heart, bones, and breast. Testosterone production in women declines beginning in the twenties and in men in their thirties. The deficiencies can be reversed with administration of testosterone and decrease the risk of heart disease, Alzheimer’s disease, osteoporosis, diabetes, and breast cancer in women and prostate cancer in men. Estrogen protects the skin, heart, bone and metabolism. Progesterone is fairly inactive in men but in women, it helps protect bone, uterus, breast and brain. Thyroid hormone helps with metabolism, brain function, heart, skin and muscle. It has been estimated that approximately 40% of all Americans have low thyroid function. These hormones can all be replaced with bioidentical approaches given the person the best form of therapy. These must be discussed with a physician trained in using the bioidentical approach in the best forms for the individual. Donald Aulds, MD OBGYN drauldsobgyn.com 256.533.1244 401 Lowell Drive SE #9 Huntsville, AL 35801

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The Voice of the Valley by Kari Kingsley, MSN, CRNP

Many of us know him as the quick-witted baritone voice hosting WZYP’s morning show, bringing us real time updates on news, traffic, and weather, with a healthy and colorful splash of today’s current events. He mixes things up with audience call-ins and hilarious recurring segments such as Dear Naked Morning Guy (because he has nothing to hide), Making Headlines, and Random Facts. But what most don’t know is the Man behind the voice has a heart the size of Texas and a passion for philanthropy. Although he would never outright admit it, Mo “Mojo” Jones has done more for the Tennessee Valley by volunteering, advocating, and raising awareness for important issues than most anyone else. I am honored to write about my friend Mojo. But like any novice writer, also a little intimidated. This guy is sharp. He’s adept at cultivating and constructing conversation both on and off the air. Words are his career. And to top it off, he’s a great writer. (I feel like there’s probably an emoji that captures my insecure face perfectly…) In my early attempts to name Mojo’s article, I stuck to my love of alliteration and came up with The Valley’s Voice for Volunteerism, Veterans, and Various Vocations. Okay… que the circus music. That was a bit cheesy, even for me. Even though all of these things are true. As I sounded out the original title, all I could picture was the circus ringleader making introductions as a guy cracked a whip and a tiger jumped onto a ball. Well, I assure you, Mo Jones is anything but a circus act. I met Mojo in 2016 at a charity event called 22 Won’t Do. He emceed this event to raise awareness of the 22 U. S.military veterans a day that take their own lives. Twenty-two pushups in 2 minutes at 10:22 on October 22. Slightly star struck, and shy in general, I worked up the nerve to approach Mr. Jones to ask him if he would be willing to emcee the American Foundation for Suicide Prevention’s Out of Darkness Walk. I had recently signed on to chair the event for the North Alabama Chapter and was more than a little overwhelmed. Fully expecting him to graciously bow out, he accepted my request 56

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Although he would never outright admit it, Mo “Mojo” Jones has done more for the Tennessee Valley by volunteering, advocating, and raising awareness for important issues than most anyone else.


} TESTIMONIAL

with open arms. I never told him that the day I asked him to do this was my late brother’s birthday who we had lost to suicide. With his help, we have managed to grow our walk each year to over 500 participants and we raised $25,000 for suicide prevention in 2017 alone. When I contacted Mojo to tell him these amazing numbers, and how ecstatic I was, he was excited. But he said, “It’s not enough. Next year we’re going for $50,000.” Like many of us, there are times when Mojo questions his career path and asks himself whether he’s made the right decisions. In those moments, he reaches into a small cedar box and pulls out a letter he received from a young girl early in his career… Years ago, while doing his show at Kiss FM in Boise, Idaho, Mojo received a call from a man who told him that his daughter, Chelsi, had a terminal illness and didn’t have long to live. The father explained that the family had spent all of their savings on medical expenses for their daughter and that they had nothing left. Chelsi had heard Mojo announce on his show that Nelly was coming to town. Chelsi wanted to go so badly but she knew her family couldn’t afford tickets. She wouldn’t burden her dad any further other than telling him how amazing this experience would be before she passed. Her dad called to see if Mojo could help. Mojo said he would see what he could do. After hanging up with the man, Mojo and his producer went to work. They set aside tickets for her and called a limo company to arrange for Chelsi and her closest friends to arrive in style. They called Nelly’s record label. When Nelly found out Chelsi’s story, he sent a pair of his Air Force One tennis shoes complete with his autograph and instructed Mojo to bring Chelsi backstage the night of the show. Mojo called her dad back and told him the good news and made plans for Chelsi and her friends to be surprised when they were picked up for the show.

About a week after the show Chelsi’s father called Mojo to thank him for what he had done for his little girl and to break the news that she had passed away. A few days later, Mojo received a letter in the mail. It was from Chelsi… the last letter she ever wrote. As Mojo read that letter, tears flowed down his face as he realized, if not for his job, he would not have been in a position to put together this experience for this wonderful young lady. To this day, if Mojo ever questions his path in life, he pulls out that letter, reads it again, and thanks God for blessing him with this career. Mojo has utilized the opportunities his vocation has provided throughout his life. In 2004, after recently moving to the Tennessee Valley, he pitched the idea to WZYP to build an entire house (floors to roof ) in 24 hours for a family in need. They told him it couldn’t be done. But Mojo’s mentality was: challenge accepted. He helped construct a team of subcontractors who worked through the wee-hours like perfectly choreographed dancers. Drywallers, electricians, carpenters, painters, and roofers moved seamlessly, each knowing their exact time frame and role. At 10 A.M. sharp the next morning (former) Mayor Loretta Spencer turned the key and the new house was presented to the grateful family. Mojo and his team were again brainstorming ideas for how to help their community. A team member proposed raising 104 bicycles in 104 hours so that children in need would wake up on Christmas morning to a brand-new bike. Mojo said, “Why stop at 104 bikes? Let’s use the entire 104 hours and try for 500 bikes.” No one (other than Mojo) thought this was possible. So, for 5 days and 4 nights, Mojo climbed onto a scissor lift 40 feet in the air in November with only a cot, a sleeping bag, and a port-a-potty. With only his voice and dedication to this cause, he encouraged WZYP followers to bring out bikes. Mojo’s Marine Core Reserve experience served him well and he completed the hours. He blew the top of his numbers the first year with over 600 donated bikes. He laughs that he eats better during that week than any other time because of the generous meals brought to him by local businesses. Since the start of Bikes or Bust fifteen years ago they have raised over 27,000 bikes. Monetarily that is $1,350,000. Mojo has made multiple cross-country trips to help those in need. During the Flint Water Crisis in 2014, Mojo was able to partner with Toni Terrell from WZYP’s sister-station WHRP and organize a semi-truck of water to be delivered to those in need. Being a Detroit native, this cause became near and dear to his heart. He followed behind with his team in an RV to help unload. When tornados devastated Moore, Oklahoma in 2013 he and his team went on the airwaves and were able to have 5 trucks donated from a local dealership which, with the help of our listening area, were loaded down with supplies and then convoyed out to help those affected by the tornados. Mojo toured the site of a school demolished by the tornados. Seven crosses stood in memory of the seven children that lost their lives. A baseball helmet hung Inside Medicine | Late Summer Issue 2018

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on a fence post along with letters, stuffed animals, and memorabilia. When Mojo was a coach for his son’s baseball team, he had a habit of walking up to each player in the batter’s box and placing a hand on top of their helmet. He would kneel down, eye-to-eye with the player, and give them words of encouragement. Mojo instinctively placed his hand on top of the helmet hanging on the fence post and cried. His son was nearly the age of the boy who had passed. Recently, Mojo was contacted by a 5th Grade student from Monte Sano Elementary. She and her classmates wanted to find a way to transport the school supplies they had collected to be delivered to Houston after Hurricane Harvey had demolished parts of the city. The students were only seeking donations for shipping. Mojo said, “I can do better than that, we’ll drive the supplies there.” With his cohost Ricky Fernandez, they made the 765 mile trek to Houston. I visibly cringed when I thought about Mojo reading the circus comment. Mojo is one of the most non-judgmental people I know, yet the thought of summing up his accomplishments and doing justice to his advocacy work seemed a staggering task. Full disclosure: I had honestly thought about handing him a pen and paper and asking him to write his own article. The problem with that? He’s too modest. He would leave out important details like the emotional toll performing difficult charity work can take on your soul. Mojo takes it in stride. He is quick to tell you he wouldn’t be able to do any of it without the local support of our amazing community. Reflecting on his own mortality, Mojo said, “I’ve lost several friends and relatives over the past several years. I watch as people share their own memories of each one on social media and think to myself ‘I wonder if they knew they had this kind of impact on others before they passed?’ When I do go, I’d like to think that I’ve made a difference. But I question myself, as well as others....” While I am appreciative of the ab work-out I get from 58

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laughing as I listen to Mojo each morning with his perfectly-timed voice inflections and anecdotal references as he chats with his hilarious co-hosts Ricky Fernandez and DeeDee Morgan, I am much more appreciative of the advocacy my friend does for the Tennessee Valley. Any one of his kind acts would be enough to call him a hero. But Mojo doesn’t stop at one. Or ten. Or even twenty. He keeps giving. And something tells me that will never change. I’ll leave you with my favorite Mojo quote…… “Robin Williams once said ‘I used to think the worst thing in life was to end up all alone, it’s not. The worst thing in life is to end up with people that make you feel all alone’. This is one of the most profound statements I may have ever heard. Each of us, more than likely, have people in our lives who are feeling all alone... We may not know why, we may not understand how, but if you love someone, don’t let them feel all alone... Listen… without judgement. Pray with them that God would heal their inner pain. Spend time with them in person, not over text or social media. Today’s society has made it easy to disconnect from real feelings and emotions and has made it easy to think that if we just hit the ‘like’ button that person will know ‘I’m here for them’... Humans were built to love and be loved..... It’s time we love each other a little more.

Kari Kingsley and Mo Jones in 2017 at the Out of Darkness Walk for Suicide Prevention at Ditto Landing

“Kari Kingsley, MSN, CRNP is an otolaryngology nurse practitioner with over 8 years of ENT experience who currently works at Huntsville ENT (256-882-0165). She is a medical writing consultant for Inside Medicine and enjoys writing articles on pertinent material to keep the residents of North Alabama up to date on the forefront of medicine.”


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BARBARA

A Beacon of Hope by Ashleigh L. McKenzie

One might say the landscape of the medical field has evolved tremendously over the years. It’s always interesting to listen to those who have watched, and been a part of, these changes–such as my mother, Barbara Ledbetter.

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As a 17-year-old student, she walked into the Mobile Infirmary in 1962 to work and remained there as a continuous employee for more than 50 years. Today, she passionately speaks of her service in the medical industry and her love of her profession. I can tell you that her constructive skills bleed over from her career to our family. The values she holds have greatly impacted our own values, traditions, and beliefs.

It is very encouraging to have an influencer who inherently shares her work experiences and passion in a way that positively contributes to her daughter’s career choice. I’ve always felt unrestricted and able to have my own independent thoughts, and as such, I have created my own way. But, my mother has absolutely been a true mentor in my personal and professional life. Entrepreneurs are often challenged with obstacles, and the foundation of their success hinges on the values they bring to their company. My mother’s persistent attitude, determination, and work ethic have been a shining example and saving grace to many, especially me. We’ve all heard how some people have “a childlike love for something.” Without fail, I relate this analogy to many of my childhood experiences. A little one’s eyes eagerly await the evidence that there is hope in the world and that good deeds come out of their work. My mother seems to speak of her career in the same manner. In 1962, she entered into the radiology program at Mobile Infirmary. At the time, it was the second largest hospital in Alabama. She proudly began to grow her role, carrying many responsibilities. She recounts her feelings of pride when she would don the white nurse uniform that came with such distinction. Her uniform was a symbol of having loyalty, being ready to face challenge after challenge, and displaying a love and care for others in a time when helping others was so purposeful. During this era, war was prevalent and periods of deficit affected the economy, but the world of medicine and patient care was a worldInside Medicine | Late Summer Issue 2018

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class phenomenon. The white coats and uniforms were signs of hope and reminders that the ones who wore them had the best interest of the patients they served. It was meaningful! If we look at a timeline over many decades, it is quite amazing to see the evolution of any subject, including medicine. Barbara recalls many events from her career that have changed and improved over time, such as going from allowing smoking in the waiting rooms to being a smoke-free campus, and dark rooms where films were developed have been replaced with imaging rooms that pop up instantaneously. Time-saving streamlined processes, technology, and patient care have all seen vast improvements over the last fifty years, but each generation has developed its own landscape built on the previous notions from a past generation. Even the white uniforms of old have been replaced with scrubs. Decades of research and innovation have brought advancements spanning from medical imaging to pharmaceuticals and surgical procedures. The medical industry is an ever-changing market space. My mother would tell you it continues to impress her as she still carries out her calling in the profession she chose long ago. She now works with new orders that come with oncology improvements and marvels at the success rates of the patients who benefit from the never-ending medical revolution. Barbara Ledbetter has dedicated a life to service and continues to be deliberate in her care of others. This has carried over in value as it influences me and has changed the direction of my heart to love and serve others. As a child looking up to her mother and equipped with optimism, I was ready to take in all life could offer. I have been deeply influenced by my mother and have always looked up to her knowing God had called her to hold patients’ hands as they received a diagnostic report. She continues to do so even though the paper charting reports have since been replaced with computer-generated data that is so advanced it is accessible electronically. Medical professionals, clinical staff members, and technology companies around the world strive to improve the lives of patients everywhere. I feel blessed to have a mother who has used her love for her career to be a beacon of direction and hope for me, as well as all the people she has come into contact with throughout the years. Ashleigh McKenzie is president of MDreferralPRO. MDreferralPRO.com

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DOES DIET PLAY A ROLE IN A HEALTHY GUT MICROBIOME AND THE PREVENTION OF TYPE 2 DIABETES? by Julie Drzewiecki, MS, RD, CDE

The definition of the “gut microbiome� is all the microorganisms, like bacteria, protozoa, and fungi, found in the digestive tract. The gut microbiome affects our health through the fermentation of indigestible foods, immune system regulation, prevention of harmful bacteria growth, and stimulation of hunger and satiety hormones. Gut microbes are necessary. However, greater numbers of deleterious microbes, versus the beneficial ones, can promote an altered gut microbiome. This, in turn, can lead to an increased risk of metabolic disorders, such as diabetes. This article will focus on the latest research about key microbes and associated metabolites that influence metabolic pathways related to Type 2 Diabetes. Menu planning tips for a healthy gut microbiome will also be provided.

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} HEALTH PREVENTION

Lipopolysaccharides And Inflammation

Lipopolysaccharides (LPS) are large molecules that promote inflammation and are thought to be a possible “culprit” in the development of obesity and Type 2 Diabetes. LPS are located in the cell wall of gram negative bacteria. When one consumes a high fat diet, it can lead to the development of “metabolic endotoxemia.” Metabolic endotoxemia is when the gut becomes permeable to LPS. This leads to a sequence of changes leading to insulin resistance and associated hunger cravings, elevated blood sugars, and fat deposition that occur with Type 2 Diabetes. Although LPS does not exclusively cause the progression to diabetes, it is important to recognize its significance as a possible target for prevention.

Short Chain Fatty Acids and the Gut Microbiota

Fermentation of dietary fiber in the intestine by the gut microbiota is a major source of Short Chain Fatty Acids (SCFA). They are considered key messengers by which the gut microbes communicate with other organs and regulate metabolism. There is good evidence that inadequate intake of fiber decreases the production of SCFA. Another role of the SCFA is to maintain gut health and prevent the metabolic endotoxemia from the LPS, which can lead to an inflammatory response. Type 2 Diabetes and insulin resistance are characterized by a low-grade inflammation. This highlights the importance of the role of the gut microbiota and SCFA production for reducing the risk of Type 2 Diabetes.

The Role of the Gut Microbiota in Appetite Regulation

SCFA can modify the levels of gut peptides involved in glucose metabolism, gut barrier protection and energy balance. SCFA may improve blood glucose and suppress appetite by binding to G protein-coupled receptors (GPR) 43 and 41. This increases blood levels of Glucagon-Like Peptide -1 (GLP-1) and Glucagon-Like Peptide - 2 (GLP-2), and Peptide YY (PYY). GLP-1 enhances the secretion of insulin and improves the action of insulin throughout the body. GLP-2 works to provide a tighter mucosal barrier in the intestine, which may help to avert metabolic endotoxemia. PYY can slow emptying of the stomach, increase the efficiency of nutrient absorption of glucose after a meal and suppress appetite. The research on gut-derived SCFA and its role in appetite regulation and the metabolic changes associated with the development of Type 2 Diabetes and obesity is only beginning and more research is needed.

Diet and a Healthy Gut Microbiome

Recent research has studied the effect of probiotics and prebiotics on changes in the gut microbiome. Prebiotics can be defined as “non-digestible food ingredients that are

beneficial because of their selective stimulation of specific bacteria in the colon.” Probiotics can be described as live, beneficial bacteria, such as different strains of Lactobacilli. This strain of bacteria has been shown to improve the efficiency of insulin in the body and decrease the risk of Type 2 Diabetes in those individuals who have impaired glucose tolerance or who are “pre-diabetic.” Emerging research has shown another microbe, Akkermansia muciniphila (A. muciniphila), administered to mice with Type 2 Diabetes showed a reversal of metabolic endotoxemia, inflammation, and insulin resistance. However, human studies are needed to see if A. muciniphila and other species of bacteria can be used as a probiotic for those with Type 2 Diabetes. Scientists at Wake Forest Baptist Medical Center found that feeding non-human primates (Macaques) a Mediterranean-type diet improved the good bacteria living in the gut by up to 7% as compared to only 0.5% for those fed a more meat-centric Western diet. Before the study began, the animals were randomized to either Western or Mediterranean diet groups and studied for 30 months. The Western Diet consisted of lard, beef tallow, butter, eggs, cholesterol, high fructose corn syrup, and sucrose. The Mediterranean Diet consisted of fish oil, olive oil, fish meal, butter, eggs, black and garbanzo bean flour, wheat flour, fruit puree, and sucrose. Each diet plan had the same number of calories. At the end of 30 months, Harom Yadav, Ph.D. – the lead scientist, analyzed the good and bad bacteria that live in the digestive tract of both diet groups through fecal samples. Yadov noted, “Our study showed that the good bacteria, primarily Lactobacillus, most of which are probiotic, were significantly increased in the Mediterranean diet group.” More research on the gut microbiome and its relationship to Type 2 Diabetes is critically needed. In the meantime, Registered Dietitians will continue to promote a fiber-rich, plant-based diet. Congratulations, dear reader! You have just been introduced to the complex, yet exciting research on the relationship between diet and a healthy gut microbiome. The next portion of this article will focus on how you can plan a healthy Mediterranean Diet to possibly increase the beneficial bacteria in your gut. References: Alessandra Sarcona, EdD, RDN, “The Interrelationship of Diet, Gut Microbiome, and Type 2 Diabetes.” On The Cutting Edge newsletter. Volume 38: Number 6. February 2018. Pages 13-17. Harion Yadov et al. “Gut Microbiome Composition in Non-Human Primates Consuming a Western or Mediterranean Diet.” Frontiers in Nutrition. April 25, 2018 Further information on Nutrition and Diabetes can be found on the website of the Diabetes Care and Education Dietetic Practice Group of the Academy of Nutrition and Dietetics, www.dce.org. Inside Medicine | Late Summer Issue 2018

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The Mediterranean Diet is rich in legumes, fruits, vegetables (especially leafy greens), nuts, yogurt, kefir, fish, and olive oil. Here is a week’s work of Mediterranean Diet supper menus for your convenience: “Meatless Monday”: Hummus, Whole Wheat Crackers, Green Salad with Olive Oil and Vinegar Dressing “Taco Tuesday”: Bean Tacos with Fresh Mango Salsa (Recipe included with this article.) “Go Green Wednesday”: Maple Baked Salmon, Kale Citrus Salad with Olive Oil and Vinegar Dressing “Try New Food Thursday”: Black Bean Veggie Burgers, Whole Wheat Buns, Roasted Vegetables, Kefir Milkshake “Fish Friday”: Broiled Lemon Tilapia, Herb-Roasted Potatoes, Broccoli Salad with Raisins and Sunflower Seeds “Super Souper Saturday”: Cheese Sandwiches, Vegetable Barley Soup “Sunday Best Dinner”: Roast Herb Chicken, Greek Salad, Fruit/Nut Yogurt Parfaits (Menu Planning Tip: Some folks find menu planning easier when they have a meme like “Meatless Monday”. You don’t have to stick to the ones listed in the above menu. What about “Slow Cooker Saturday” or “Mexican Monday”? Have fun with your family coming up with your own memes!)

Bon Appetit!

Recipe Courtesy of the Diabetes Care and Education Dietetic Practice Group BEAN TACOS WITH FRESH MANGO SALSA Ingredients: 1 -15 oz. can beans (pinto, black, kidney, cannellini, almost anything will work). Drain and rinse beans well to reduce the sodium. ½ cup fresh cilantro, chopped 3 scallions, chopped Juice of 2 limes

½ teaspoon cumin

Dash of garlic powder

Dash of chili powder and/or paprika

Corn or Whole wheat tortillas cut into quarters (or cut in half if they are small) 1 pint grape tomatoes

½ mango, peeled and chopped into small cubes ¼ cup cilantro

Salt and pepper to taste

Hot sauce or jalapeno (optional) Directions: Bean Tacos 1. Combine beans, ¼ cup of the cilantro, 1 scallion, juice of 1 lime, cumin garlic powder, and chili powder in a medium-sized bowl. 2. Warm the tortillas in the oven or in a dry skillet on medium heat. 3. Fill the tortilla pieces with the bean mixture and serve with salsa found below. Optional, add Greek yogurt on top. Fresh Mango Salsa 1. Pulse the grape tomatoes in your blender about three times or until they are all finely chopped, but not yet liquid. 2. Add the tomatoes and the remaining ingredients in a bowl and stir to combine. Recipe by Marina Bedrossian, RDN, CDN, CLT Nutrition Facts: Servings: Approximately 4 Calories: 198 Protein: 10 g Carbohydrate: 38 g Sodium: 170 g

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