Inside Medicine Volume 3 Issue 16

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Volume 3 Issue 16





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Vol u m e 3 , Is s ue 16 C O N TRI BUTOR S

Crystal Barber, MBA

FEATURES Organization is the Key to Winning Tommy Tuberville shares his story with Inside Medicine

Bringing Back the Disappearing Doctor

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Giving Control Back to the Patients

Beyond the White Coat Your provider is not your enemy...they are your best soldier

CONTENT Smart-O Goals An Outline for Establishing What Your Goals will be this Year

Defeating Drainage A Look at the Newest Options for Combating Your Drippy Nose


Recruit Your Glutes


Elisa Brooks Greg Brown William T. Budd, Ph.D Winston Capel, M.D., MBA, FACS, FAANS Bobi Jo Creel, RN, MSN, CRNP


Kari Kingsley, MSN, CRNP Neeta Kohli-Dang, M.D. Heather Morse, MS, ATC, OTC Larry Parker, M.D.


Check out some of the benefits of strong glutes

Rachel Sullivan, MFTA Adam Weiger Jill Windham D Kishore Yellumahanthi, M.D., MPH

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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. 6

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Dear Readers– I am so excited to help bring you another edition of Inside Medicine. Every time I start reading and looking into content, it gets me excited about sharing with our community and allowing

excited about our topics

our magazine to be a small part of our readers’ lives. This issue is no different and I just know you are going to enjoy it and learn something new or have something to share with others. It seems that we have all settled into 2020. (without any flying cars or true, robotic maids name Rosy.) As the year goes, so go our resolutions we might have started out with. In Rachel Sullivan ‘s article, she offers the suggestion to call those goals what they are, “goals”. I love the outline she provides to help us in laying out what we want to accomplish and how to get it done. I always enjoy the articles contributed by Kari Kingsley. Her latest articles focus on provider burnout and defeating sinus drainage. Although they are two completely different topics, both give so much information to things we just don’t think about every day. In this issue, you can read about things ranging from urinary tract infections to acne to fostering pets to back pain after pregnancy and even maximizing your glute muscles. We were also blessed enough to talk with Senate hopeful, Tommy Tubberville and include a bit of his interview in this edition. He gave us a good idea of where he stands on healthcare issues and what he is willing to offer to the people of Alabama. We work hard to try and give you stories that are uplifting, informative, and even spiritual. In this edition of Inside Medicine, we have two devotion editorials that are sure to give you some awesome insight. Our team at Inside Medicine is passionate about providing you with the best information out there. That passion is also filled with a love for our Savior. We want our publication to reflect our

Kimberly Waldrop

heart. As always, we hope you enjoy our magazine and will share it with others. If you ever have any questions or concerns, ideas for stories, or want to be a contributor, please let us know!

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if Tuberville gets elected to the Senate, he has decided to donate his salary to the veterans in the State of Alabama. Â

“Organization is the Key to Winning” Interviewed by Greg Brown, Co-CEO & CFO of Brown Precision, Inc.

Tommy Tuberville is best known in our area as the former head football coach at Auburn University. He led the tigers from 1999-2008. During his time there, Coach Tuberville and his team were very successful. They had eight consecutive bowl appearances, five SEC Western Division titles, one SEC Championship, and a 13-0 season in 2004 that lead to Coach Tuberville being named AP’s SEC Coach of the Year. Also during that perfect season, Tuberville was named Paul “Bear” Bryant Coach of the Year, Walter Camp Coach of the Year, Sporting News Coach of the Year, and AFCA Coach of the Year, among other awards. Coach Tuberville has received many accolades and has achieved much success on and off the football field. But he feels it is now time to “give back”. Although he served the public through working with students in public education, he believes he has always had a void of desiring to give back to his country. He wasn’t in the military but he has the desire to serve the people of our country through serving in another way. Tuberville said his father instilled the love of the United States into their family. “This country is the greatest country on earth and gives us so much”. His father Charles Tuberville was a decorated World War II Veteran, landing at Normandy at age 18. Charles Tuberville received 5 bronze stars and a purple heart. He passed away in the military at age 53. The admiration for his father is so apparent when Tuberville speaks of him. This is a big part of the reason that if Tuberville gets elected to the Senate, he has decided he will not take a salary but will donate it to the veterans in the State of Alabama. So that’s where Tuberville is today, running for the US Senate. He has quite the platform and a list of “issues” he is focusing on. For the purpose of Inside Medicine, we were interested in what he had to say about healthcare. Obviously, Tommy Tuberville knows how it feels to be successful.

He has a belief that the United States has a “great structure to be successful, we just need to be organized and the Federal Government has to be involved” in the issues surrounding the increasing cost, delivery and evolution of healthcare. He asserts that healthcare and healthcare costs are on everyone’s minds and everyone’s agendas. He believes the system in place is still good, compared to other countries, but it is almost in peril. Tuberville states, “We have a good structure but need to work on the organization”. He adds, “We need answers to the prices of healthcare and drug costs because people are getting to where they can’t afford it.” Obviously, this is a problem he wants to work on. Although he is against Big Government, he definitely thinks the Federal Government should be “all in” when it comes to healthcare and healthcare reform. “America has the money and resources to be at the forefront and that’s exactly where we should be”. Tuberville told us about a recent study at UAB that President Trump is supporting. He is excited to see the initiative and that the President is on the front lines. With the research they are providing (customized medical treatment on a per patient basis), they are hoping to see a decrease in premiums and an even higher success rate for patients and patient providers. When asked what role the federal government should play in supporting Bio-Tech research, Tubberville responded that “Bio-Tech is what the future of healthcare is all about and the United States should be at the forefront.” In his opinion customized medicine and healthcare on an individual basis is the way to lower the cost of healthcare across the board. Tommy Tuberville is hoping to represent the people of Alabama. He wants to be a voice for people and not for special interests. We are thankful for the opportunity and time he gave us in order to hear his opinions. Find out more about Tommy Tuberville’s stance at I n s i d e M e d i c i n e | Vo l u m e 3 I s s u e 1 6


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Bringing Back the Disappearing Doctor: Giving Control Back to the Patients by: Crystal Barber MBA & Heather Morse MS, ATC, OTC

There’s little doubt that the front line of medicine — the traditional family or primary care doctor and the patient relationship— has been under siege for years. Choice is what we all want, as most would say. There is a growing cognizance that patients can and should play an important role in deciding their own care, in defining optimal care, and in improving healthcare delivery. There is much growing evidence that engaging patients in treatment decisions and supporting their efforts at self-care and preventative care, can lead to more beneficial long-term outcomes. Patients who are active participants in a shared decision-making process have a better knowledge of treatment options and more realistic perceptions of treatment effects.

The resulting treatment choices are more likely to concur with their preferences, lifestyles, and attitudes to risk. Actively engaged patients are also more likely to adhere to treatment recommendations, and less likely to select expensive procedures.

The Modern Primary Care Model One would assume all of the above benefits would shape a modern, successful model of healthcare. Yet this is not the model patients are exposed to in this modern era. Higher healthcare costs, skyrocketing drug prices, and lower reimbursements for physicians have created an environment that does not support a patient-centered model of care. Doctors are working under more pressure than ever before. Recent changes in health care – such as ramped-up productivity requirements, increased documentation, and new quality metrics have left physicians scrambling to see more patients on a daily basis to cover rising supply costs, higher malpractice rates, and increased staff costs. Even so, patients deserve their undivided attention. These conditions have many patients feeling dissatisfied by the quality of the office visits with their physicians due to time restraints and longer wait times. While the ballpark office visit time is about 11-15 minutes, patients are not getting as much time as they need to address healthcare concerns. By all accounts, shorter visit times take a toll on the doctor-patient relationship and may represent a missed opportunity for getting patients more actively involved in their own health. There is less of a dialogue between patient and doctor, studies show, increasing the odds patients will leave with a prescription for medication, rather than a behavioral or lifestyle change — like trying to lose a few pounds, going to the gym, or electing alternative for pharmaceutical treatments.

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What We Can Learn From Old School Practices The term “old school” in many facets of life has negative connotations. We live in a modern, technologically advanced and fastpaced world — and there’s no room for things that hold us back.How did we get to the stage where a genuine and caring doctor has become the odd one out? The old school physician pulled up a chair, took the time to sit face-to-face with their patient, maintained eye contact, and asked open-ended questions. They allowed the patient to express genuine healthcare concerns, directing them when necessary towards the questions that need to be asked to benefit them as an individual. It included some good old-fashioned talking and learning about the patient’s lifestyle and choices. At the end of the encounter, they were given a chance to ask any questions, offered education, and given multiple treatments options. In the former healthcare era, herbs and alternative medicine treatments were offered along with education to help the patient understand all the options available. The treatments were then used in conjunction to offer the patient the best outcome possible. The modern era of medicine has lost some of the key components that made medicine successful in the first place. Methods like house calls and alternative forms of medicine offered patients options to get involved with their healthcare, alternatives medicines that would not cause additional addiction and further harm the body, and face to face time to be educated and heard.

"In 1930, about 40% of doctorpatient interactions were performed through house calls, but by 1980, the rate was down to only 1%." Physician House Calls: An Old Model with a Modern-Day Twist The concept of a doctor coming to a patient rather than a patient going to a doctor is hardly a revolutionary concept yet could be the answer the modern era of healthcare is looking for. In 1930, about 40% of doctor-patient interactions were performed through house calls, but by 1980, the rate was down to only 1%. We now live in a time of convenience and speed. We have grown so accustomed to instant information, feedback, entertainment and more, that we’ve grown impatient with waiting. This transition to an easy access and fast pace life has actually helped to bring back the nostalgic house call. 12

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The new era has also brought the ability to reach information quickly about better healthcare choices that are now being offered to patients via concierge medicine. While we want instant access to our doctor, we also want more time with them to discuss all of our health and wellness concerns.

However, TFM does not fall into the trap of all-or-nothing thinking, expecting patients only to see their providers either in the office or remotely. With a little creativity, we can envision mobile health technologies such as telemedicine leading to the restoration of an almost forgotten medical tradition: The House Call. Imagine the connected provider traveling to patients as needed, with a portfolio of cloud-enabled diagnostic, therapeutic, and decision-support tools at their disposal. Blending the importance of conventional medicine, as you know it today, with the proven results of traditional (the old ways) we can truly bring healthcare back to the patient. Simply managing treatments is no longer acceptable for many in our population. Patients want answers, they want options, and they want to know they are being heard when they voice their concerns.

A New Spin on Healthcare for Your Lifestyle

You can learn more about Traditional Family Medical Center on their website:


The young adult population is very tech-savvy. They are accustomed to using apps and quickly scheduling appointments with a few clicks. They are also very busy working and caring for young children, so a model that doesn’t require them to leave their homes when they have a sick child is very appealing. The search for affordable, convenient healthcare has now brought advancements such as tele-med visits and house calls to the forefront. Patients want healthcare options that suit their lifestyle and are of a higher quality of care. Patients are now seeking out practices that offer not only technology based patient interaction for more affordable rates, but also practices that offer a more patient-centered approach. Services such as house calls and same day telemedicine visits from the comfort of their own home are now what patients are seeking the most.


Crystal Barber, MBA, is a co-owner of Traditional Family Medical Center & Heather Morse MS, ATC, OTC owner of Salt on the Rocks and co-owner of Traditional Family Medical Center

Traditional Medicine Concepts Meet New Age Lifestyles in North Alabama Old school traditional medicine concepts work. These concepts help patients feel more at ease with treatments, obtain better long-term outcomes, and cut individual healthcare costs. With this knowledge and experience in mind, the owners of Traditional Family Medical Center will open its first location in Huntsville Alabama, in late March 2020. The vision started with traditional family medicine concepts and has grown to include a long list of services including holistic, integrative medicine. This service puts patients at the forefront of their healthcare again. Traditional Family Medical Center offers patients the choice of conventional pharmaceutical treatment options as well as an avenue where patients can choose to treat illnesses with holistic options. Their goal is to truly get to the root problem and not only manage symptoms but work on a reversal of the problem. One very valuable service that will implemented is telehealth, whereby providers use email, phone, text, or video for consultations, reducing the need for time-consuming inoffice visits. I n s i d e M e d i c i n e | Vo l u m e 3 I s s u e 1 6


SMART-O GOALS by Rachel Sullivan, MFTA

Ahh. Another new year. I do not know about anyone else, but 2019 flew by. It seemed that as soon as I gained solid footing, it was already time to start writing 2020 on everything. Despite the year passing quickly, I was able to achieve several goals I had set for myself. I prefer to set goals instead of resolutions. Neurologically the words we choose make a noticeable impact on how we respond to them. For example, when we set a New Year’s “resolution” we are making a firm decision to do or not to do something. When we fail to resolve the identified thing, mentally we file that as a fail. Conversely, when we set ourselves a “goal” we identify something as the object of our ambition or effort and determine our desired result. It creates an end point we gradually work towards rather than a pass or fail. Did you mentally register those words differently as you read them? Me too. So, when you are setting goals, where do you start? I am sure you are familiar with the S.M.A.R.T. acronym, Specific, Measurable, Achievable, Relevant, Time-Limited. I use this outline, with a small addition of my own, to establish goals

for myself since it allows me to structure backwards from my desired result. In therapy I use this same concept to help clients work towards their therapeutic goals. Something important to keep in mind when setting goals, they should always be framed in the positive. This helps your brain focus on what you DO want, rather than what you DO NOT. Look at these examples: Eating less junk food and no more lethargy vs. Living a healthier lifestyle with more physical activity and smarter food choices. The first example contains words like “less” and “no more” which are negative phrases the brain picks up on, setting you behind before you begin. The second example tells the brain “more” and “smarter”, helping the brain identify positives that you are aiming for. Positive words create a shift in the brain and help us as we work towards our desired result. Let us look at some examples of how this plays out practically, using an example of “increasing positive selftalk”.

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SPECIFIC: When we set a goal for ourselves the item needs to be specific enough that we know exactly how we are directing our efforts. Essentially, we need a target. When I work with clients, we take time during our first sessions to discuss goals. As we talk, we unfold what is important to them, and begin to pull out some specific items that we can use as our target. The bullseye in the middle represents the desired result, with the outer rings representing other areas of life that will benefit from us hitting that center. If we identify “increasing positive self-talk” as our goal, this becomes the specific object of our ambition.

MEASURABLE: A goal must be measurable. In other words, you need to be able to see how your ambitions are paying off. While increasing positive self-talk you should see some benefits (the other rings on the bullseye) of your efforts. Perhaps you see your efforts paying off as you feel more confident a few weeks into your new practice. Or, your attitude is more pleasant because you are being kinder to yourself. Identifying some ways to measure your efforts up front will help keep you motivated as you work hard.

ACHIEVABLE: The goal you set needs to be something you can achieve. Determining to grow 8” if you are already full grown is not achievable. Ensuring your goal is realistically achievable helps set you up for success. Our example goal, increasing positive self-talk, is entirely possible to achieve.

RELEVANT: Your chosen goal should be something relevant to you. Frequently, I see people who identify goals that someone else would like them to achieve. This is a fast pass to failure. The goal needs to be yours, and it needs to mean something to you. When we set a goal that is relevant to our current season in life, it creates a sense of accomplishment when we obtain it. However, a goal we are working towards that is someone else’s idea will neither motivate us nor fill us with accomplishment. If it is relevant to you, increasing your positive self-talk will be something you are motivated to work towards. More than that, it will feel great when you achieve it.

TIME-LIMITED: Goals that are limited by a timeframe help keep us on track. Say we begin our positive self-talk journey March 1st and determine to increase the ways in which we speak positively to ourselves for 90 days. By the end of

those 90 days we have created a new habit, formed new connections in our brain, and made a positive impact on our mental health. Additionally, when we have a finishdate we can work backwards from there to structure our measurement markers so we can see our progress. This continues to signal our brain to identify the growth, and acknowledging the growth keeps us motivated. See the cycle?

OUTSIDE HELP: Here is where my addition shows up. There is no “O” in the original SMART goal acronym. However, many goals I have set for myself included resources outside of my scope of expertise. So, taking inventory at the beginning of goal setting to identify outside help you may need boosts your chances of obtaining your desired result. The truth is none of us have all the tools and skills necessary to obtain every goal we set. Thus, acknowledging the need for, and enlisting help when necessary is smart, and practical. Perhaps for your self-talk goal you will need a book of positive confessions, or an accountability partner. A bigger goal may require professional help in the form of an academic institution, fitness facility, medical professional, or lending agent. As you begin to think about this new year laid out before you, I want to challenge you to consider where you would like to be by December 31st. What looks different in your life? How are you relating to people in a way that is an improvement from right now? If _________ were better, what would that change? 2020 is a blank slate. You have a lot more power over the outcome than you might think. It may require some outside help. Likely it will take some SMART goal setting. Whatever the course, whatever the goal, I hope your year is as amazing as you dream it can be. Happy New Year!

Rachel Sullivan, MFTA Solid Ground Counseling Center 9694 Madison Blvd St A7 Madison, AL 35758 256-503-8586

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TRIGEMINAL NEURALGIA Article content provided by Alliance

Kathy Cooper’s facial pain started when undergoing a dental procedure. She believes the procedure aggravated her trigeminal nerve, which runs along the jaw and is responsible for sensation in the face as well as motor functions like chewing and biting. For the next two years, the left side of Cooper’s face basically ached 24-7. “Talking was one of the biggest triggers,” said Cooper, a certified nurse anesthetist at Decatur Morgan Hospitals. “If we went out to eat and laughed and talked, I’d have to go home and put a heating pad on my jaw. I spent many nights like that.” Cooper consulted with an ear, nose and throat specialist, a neurologist, dentist and an oral surgeon to try to pinpoint the cause of her pain, but it was her family doctor who finally solved the riddle and diagnosed her with trigeminal neuralgia – a chronic pain condition that affects the trigeminal nerve. Most sufferers experience brief, intense pain triggered by facial stimulation. Cooper’s

was more of a continual ache. In addition to a heating pad, Icy Hot cream, Tylenol and ibuprofen provided some relief. “Cold weather on my face made the pain much worse, so winter was a real drag,” she said. In 2018, Cooper’s neurologist referred her to Dr. Jack Gleason at Alliance Cancer Care in Huntsville. Dr. Gleason treats trigeminal neuralgia using stereotactic radiosurgery (SRS) –basically, a high dose of radiation delivered precisely to the patient’s trigeminal nerve to break the pain cycle. SRS typically requires a single outpatient treatment lasting an hour or less. Cooper had read about other trigeminal neuralgia patients getting relief through SRS and was excited to learn that the treatment is now available in Huntsville. “Dr. Gleason told me he expected that my pain would be reduced by about 60 percent after the procedure, and he was right on the money,” Cooper said. “I still have to take Tegretol (a prescription anticonvulsant used to treat nerve pain) twice a day, but no more heating pad.” “I can’t say enough good things about stereotactic radiosurgery and what it’s done for me,” she said.

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By D Kishore Yellumahanthi, MD, MPH, FAAFP

Acne, also commonly known as Pimples, is the most common skin condition seen in the United States. It is estimated that at any given time, about 40 to 50 million Americans have acne. The most common age of onset of acne is teenage. However, acne can occur at any age. It can occur in both men and women. Below, is summarized briefly the causes of acne, its clinical presentation, prevention and management.

What actually causes acne? Acne appears when a pore in the skin clogs. This clog begins with dead skin cells. Normally, dead skin cells rise to the surface of the pore, and the body sheds these cells. However, if the body starts to make lots of sebum, oil that keeps the skin from drying out, the dead skin cells can stick together inside the pore. Instead of rising to the surface, the cells become trapped inside the pore. Sometimes a type of bacteria that lives on the skin called Propionobacterium acnes (P acnes), also gets inside the clogged pore. Inside this clogged pore, P acnes, has an ideal environment for multiplying quickly. The clogged pore becomes inflamed when it is filled with loads of bacteria


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inside and this leads to its red and bumpy appearance. If the inflammation goes deep into the skin, an acne cyst or nodule appears. How does acne manifest as? A person who has acne can have any of the following: • Blackheads • Whiteheads • Papules • Pustules (what many people call pimples) • Cysts • Nodules Although face is the most common site for acne, it can appear on the back, chest, neck, shoulders, upper arms and buttocks. Often, the treatment of acne depends on the type of acne lesions that are seen. For example, if one has only blackheads, a topical retinoid is more appropriate than other treatments. Therefore, it is important to know how each of the acne lesions appear. White heads: If a pore in the skin is clogged with bacteria,

dead skin cells and with excess oil, it can close the pore and form a tiny white or flesh colored bump. This is called a whitehead. Blackheads (dark spots): If the pore fills with debris but stays open, a blackhead is noticed. Papules (Early pimples): When excess oil, dead skin cells and bacteria push deeper into the skin and cause inflammation (redness and swelling), small, red bumps are formed. The medical word for these are papules. They feel hard. If the inflammation goes deep into the skin, an acne cyst or nodule develops. There is no universally accepted scale for grading acne severity. Mild acne is classically defined by the presence of clogged skin follicles (either black heads or white heads) limited to the face with occasional papular or pustular lesions. Does mild acne need to be treated? Given the fact that in most cases, acne is supposed to be self limiting once the patient matures through adolescence into adulthood, many patients with acne and their parents, do not seek treatment for it either at all or when the symptoms are mild. However, early and prompt treatment of acne has several advantages. For example, if treatment is sought when acne is mild, one can relatively get faster relief from their acne. It also minimizes the likelihood of having scars and also reduces the need for using stronger medications that have a potential for severe side effects. It is also worthy to remember that treating mild acne promptly could also help in maintaining one’s self esteem. Research shows that acne can take a toll on the psyche. Many patients seemed to have mentioned that their self-esteem suffered after developing acne. Some had reported of having depression and suicidal ideations as well. It is also important to note that the severity of the acne doesn’t seem to matter - Acne can have negative effect on self-esteem whether one has mild or severe acne. Therefore, every effort needs to be made to get acne treated as early as possible regardless of its severity.

care of. The following are some tips for good skin care to help with acne. •

Do NOT try a new acne treatment every week or so. Give an acne treatment time to work. Use a product for 6 to 8 weeks. It takes that long to see some improvement. If no improvement is appreciated by then, at that time, another product can be tried. Complete clearing generally takes 3 to 4 months.

Do NOT apply acne medication just only to the acne lesions. To prevent new acne lesions, spread a thin layer of the acne medication evenly over your acne-prone skin.

Use makeup, skin care products, and hair care products that are labeled “non-comedogenic” or “won’t clog pores.” These products don’t cause breakouts in most people.

Do NOT share makeup, makeup brushes, or makeup applicators. Even if one uses only non-comedogenic products, sharing makeup can lead to new acne formation. Acne isn’t contagious, however, sharing makeup, makeup brushes, or applicators, can result in transfer of the acne-causing bacteria, oil, and dead skin cells. These can clog the pores, leading to breakouts.

Do NOT sleep with makeup. Even non-comedogenic makeup can cause acne if you sleep with it. Therefore, please make sure the makeup is removed before going to bed.

Wash face twice a day & after finishing any activity that causes sweating but do NOT wash multiple times a day.

Do NOT dry out your skin. Skin with acne is oily, so it can be tempting to apply astringent and acne treatments until the face feels dry. However, dry skin is an irritated skin and is more prone for acne. Therefore, use acne treatments only as directed. If it still makes the skin feels dry, applying a moisturizer helps.

Do NOT scrub the skin. To get rid of acne, one could be tempted to scrub one’s skin clean. But, scrubbing can irritate the skin, causing acne to flare. Therefore, be gentle when washing the face or other acne prone skin. Usage of a mild, non-comedogenic cleanser is recommended. Apply the cleanser lightly with the fingertips, using a circular motion. Gently rinse it off with warm water, using only the fingers. Then pat the skin dry with a clean towel.

Do NOT Pop or squeeze breakouts. When acne is popped or squeezed, there is a possibility of pushing some of what’s inside (e.g., bacteria or pus or dead skin cells) deeper into the skin. When this happens, inflammation increases. This can lead to more-noticeable acne and sometimes scarring and pain. (continued on p. 22)

How to treat whiteheads and blackheads? Topical retinoid is usually recommended to unclog the pores. Adapalene is a type of retinoid available without a prescription. In addition to using a topical retinoid, using a benzoyl peroxide wash can also help. It can help get rid of the excess P. acnes bacteria on the skin. What about treating papules? Try washing face twice daily with an acne face wash that contains benzoyl peroxide or salicylic acid. If lot of papules are present, it may require a consultation with a healthcare provider. Any presence of acne cysts or nodules, in general, would require an appointment with a healthcare provider for their management. For best results of acne, along with using the right medications, general skin care also needs to be taken

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(continued from p. 21)


Role of Diet: Results from small studies suggest that following a low-glycemic diet may reduce the amount of acne. Low-glycemic foods include most fresh vegetables. One mechanism that is thought by which low-glycemic diet may reduce acne is that it eliminates spikes in the blood sugar. When blood sugar spikes, it causes inflammation throughout the body. These spikes also cause the body to make more sebum, an oily substance in the skin. Both inflammation and excess sebum can lead to acne. While some studies showed that following a low-glycemic diet can lead to fewer breakouts, other studies have not found a connection between a high-glycemic diet and acne. Therefore, more research is needed to know for sure. What about Milk? Some studies suggest that drinking milk may be linked to an increase in acne breakouts. In these studies, all types of milk (whole, low-fat, and skim) have been linked to acne. It is not exactly known how milk can worsen acne. One theory is that some of the hormones in milk cause inflammation inside the body. Inflammation can clog the pores, leading to acne. However, more research is needed to know for sure. While milk may increase the risk of developing acne, no studies have found that products made from milk, such as yogurt or cheese, lead to more breakouts. Given this kind of uncertainty surrounding the role of diet, I recommend more of an individually tailored advice to my patients - To avoid any food substances that they know for sure had flared up their acne. In summary, acne is the most common skin disease seen in the US. The health impacts of acne extend beyond the skin as it is known to have caused depression and loss of self esteem in some individuals. We reiterate that acne, regardless of its severity, be treated at the earliest. OTC medications could help in treating mild acne. Reference:

D Kishore Yellumahanthi, MD, MPH, FAAFP, works as Family Physician for Huntsville Hospital in Huntsville, AL and also as a Clinical Assistant Professor at the Department of Family Medicine, University of Alabama at Birmingham (UAB), Huntsville Regional Medical Center, AL. Dr. Yellumahanthi’s educational background is unique in that he has formal training in both Family Medicine and Dermatology.


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we learn from suffering WI NST ON Â T. C APE L, M.D ., MB A , F A C S, FA A N S 22

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As humans we all share common life experiences. Universal to life for all of us are: physical suffering, disease and death. There are no exemptions or immunization from these but there is much variation as to what kind and how severe our suffering and afflictions will be. It is natural to ask why this suffering takes place. I believe the Gospel of Jesus Christ does provide many of the answers to the “why” we suffer. When we view suffering through a spiritual lens our spiritual growth can increase in higher and holier ways. This growth is one of the fundamental purposes of life on earth. We all have an intrinsic spiritual need to see a divine design to life and its experiences. We know from the scriptures that Christ suffered pain, temptation and afflictions of every kind while on earth (see Hebrews 2: 17-18). It is by His own deep and very personal experience suffering “all things in the flesh” that he knows how to “succor” us perfectly. I have observed from my experiences as a neurosurgeon dealing with some of the most catastrophic diseases and injuries known to man that the Lord is involved in the details of our lives. He stands with open arms desiring to bless those who suffer and those who assist him in the care of those that suffer disease and afflictions experienced by all. In my opinion, much is learned by those who suffer and those that care them that suffer. This learning prepares us for life with the Savior for all eternity. Anything that we suffer or experience in this life that better prepares us for life without end with Him is of unfathomable value. In my opinion there are at least 5 things we learn from pain, disease and physical affliction. In the curriculum of this life, designed to prepare us for life with Him, these experiences are not meant to be Torture 101 but Discipleship 600 series. We are all involved in upper level course work in discipleship as we humbly and faithfully submit to these experiences as followers of Christ.

University of Washington’s Institute for Health Metric and Evaluation (IHME) observed: “Despite the fact that people around the world are living longer, they are also expected to spend more time suffering from diseases and other conditions.”

What We Learn from Physical Disease, Affliction and Suffering 1. We cannot cope with nor can these conditions be treated

without His help. This reliance upon Him increases our faith and trust in him in ways that only these experiences can. This increase in Faith has eternal value and consequences. This increased Faith will fortify us for future experiences. Faith is the first principle of the Gospel of Jesus Christ.

2. Our

suffering creates empathy for those who suffer around us. Empathy is earned from experience, like all elements of discipleship it is portable and is to be applied. Our application of these elements is essential as we strive to assist the Lord in the care of His children. Empathy assists us in our striving to have charity which the scriptures define as the “pure love of Christ.” Without the experience of our own personal suffering or the experienced gained when we serve those who suffer it is very difficult to have this Christ like understanding of those who suffer. Those who suffer understand those who suffer like we understand language dialects. There is a dialect of those that suffer. Our challenge is to learn this dialect (the language of suffering) so we can notice, understand and strengthen those whose hands hang low from disease and affliction. (see Hebrews 12:12) 3. Because we suffer we have a greater appreciation of the physical, emotional and spiritual suffering of Christ. Although we suffer microscopically compared to his exponential suffering it is designed to give us a reverential appreciation of His suffering for us. He suffered to redeem us (from physical death through the resurrection and from spiritual death caused by sin making repentance and thus forgiveness possible). A second reason for his suffering is the added experience of learning first hand by his sufferings, how to succor (aid and assist us) even in his perfection. He too learned from the things he experienced while on the earth even while being perfect (see Luke 2:40). He was tutored by the Father in all things (see John 5:19). It is by His grace that he helps us in ways that only he can. 4. We know that all mankind will be resurrected (see 1 Corinthians 15:22). These resurrected bodies will no longer be subject to pain, disease and death. So for the eternities we will enjoy a body without pain, disease and death. What an unimaginable blessing, a gift from God. Our appreciation of this eternal state would be impossible had we not suffered in this life. 5. For those who worry and care for those afflicted with disease there is an invitation from the Lord to be “instruments of grace.” When we are serving our fellowman we are serving Him. (see Matt 25:35-36,40). We draw closer to Him as we do what he would do if he were physically present. His life was spent in the process of healing and comforting the afflicted. Grace is divine help or strength, given through the bounteous mercy and love of Jesus Christ. Through faith in Christ we receive strength to endure and grow in His desired ways through His Grace. Grace is an enabling power to receive strength and assistance in the empathetic service to the afflicted that we otherwise would not be able to do or sustain if left to our own means. This grace also helps us in infinite ways, the majority of the help is unseen and unrecognized. We would be overwhelmed if we could see the help and assistance that comes from the Lord through his grace. It is our privilege and opportunity to assist him by faithfully enduring affliction and serving the afflicted as he did for us. Our greatest expression of our adoration for Him is our emulation of Him.

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Defeating Drainage: A Look at the Newest Options for Combating Your Drippy Nose By Kari Kingsley, MSN, CRNP

Drip. Drip. Sniff. Sniff. Most of us are familiar with the neverending cycle of sinus drainage that is associated with living in the Tennessee Valley. Having worked in the Ear, Nose, and Throat field in Huntsville for the past 11 years, I’ve come across many patients that say Native Americans called our area the “Valley of Death”. While most of us aren’t dying from sinus drainage, we are seriously annoyed. Drainage falls into two categories: allergic and non-allergic rhinitis. Spring is beautiful in the South. Blooming dogwoods, hikes on the Land Trust, and Panoply are just a few of the things that make our area unique. Not so unique, but still a major part of Spring in our area, is the overabundance of pollen. Lots of pollen. Patients call it Sneezing Season. My black car becomes a Horse of a Different Color with streaks of yellow pollen rainbows across the windshield. Summer is warm in the South. Most of us enjoy watermelon, fireworks, and sunny days by the pool. But allergy sufferers don’t enjoy the ever-green and ever-growing grass. I learned long ago that it was worth outsourcing my grass-cutting to a professional. After the boxes of Kleenex, Zyrtec, and Sudafed, I basically break even. Fall in Alabama has a vibe unlike any other. Dazzling foliage, football, and the crisp night air seem like an almost fair trade for newly sprayed cotton fields, ragweed, and leaf mold. While the winter months bring holiday cheer and moderate temperatures, they also bring indoor heat, fireplaces, and damp outside environments to further irritate already cranky noses.


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Nasal nerves help regulate the nasal activity

Out-of-balance nasal nerves may send too many signals, contributing to congestion and runny nose symptoms

Nerve signals are interrupted to reduce congestion and runny nose symptoms

When you Google best places to live for sinus sufferers it is no surprise that saline misted beach towns in Florida and California dominate most lists. Each summer, I have patients tell me that their sinuses did ‘great’ while they vacationed on the beach. Their drippy nose returned once they were home. While the beach is a great place to visit, North Alabama is my home. And I want my home to be as comfortable as possible. Anything to reduce the drip and sniff is well appreciated. The Allergy and Asthma Foundation of America’s 2019 National Spring Rankings list of most challenging places to live with allergies looks at the 100 most populated metropolitan areas. A number is assigned based on the seasonal pollen, allergy medication use, and the number of allergy specialists. Huntsville isn’t included on this list. It’s possible with our size, we didn’t make the cut. Obviously, they haven’t read the latest census that we’re on track to be the largest Alabama city by 2022. Birmingham came in at # 33. Our neighbors in Jackson, Mississippi came in 2nd place and Memphis came in 4th. There is another section of the population that suffers from nonallergic rhinitis or sinus drainage that is not related to allergies. Triggers of nonallergic rhinitis include environmental irritants, foods and beverages, hormone fluctuations, sleep apnea, and reflux. While some think overly fragrant perfumes are attractive and pleasant, there are an equal number of people in the population that would prefer you not take a Chanel Shower. For others, the simple trade-off of a comforting warm bowl of soup on a cold winter day isn’t worth the nasal faucet that ensues. Just as our cars require oil to run properly, mucus is a normal biological lubricant that plays an important role in our health, protecting us from fungi, viruses, and bacteria. We have all heard the expression too much of a good thing... Overproduction of nasal mucus triggered by allergies, upper respiratory infections, as well as dry and cold environments can initiate a myriad of annoying symptoms. Excessive mucus accumulates in the back of the nasal cavity and eventually begins dripping down the back of the throat, causing an

aggravating cough sure to solicit sharp glances from those in closest proximity. In our evolving instant-gratification-society and Amazon delivered it yesterday world, it’s only natural we want a quick and easy fix to one of the most annoying nasal issues. What are our treatment options? Staying hydrated is important. You are, after all, producing about a liter and a half of mucus a day. (Ew; I cringed when I first read those stats). Avoid alcohol, caffeine, and cigarettes as these things tend to exacerbate sinus and allergy issues. Saline irrigations and sprays help lubricate irritated nasal passageways. Over the counter antihistamines, decongestants, steroid-based nasal sprays, as well as prescription anticholinergics and leukotriene modifiers work by blocking mucus production or by drying existing mucus. While these treatments can manage the symptoms of a runny nose and postnasal drip, oftentimes they are not enough and are required daily in most cases. They also have multiple side effects. Avoidance of environmental triggers is also important. As a pet-mom to a horse, a dog, 2 cats, and 6 chickens, that isn’t always feasible. Allergy shots or immunotherapy is an option for some but can be pricey, depending upon insurance coverage. They also include a hefty time commitment. So, what other options are there? One of the newest innovations to sinus health is intranasal cryotherapy. The exact cause of chronic rhinitis is unknown. It is thought to be related to overactive nasal nerves, specifically the parasympathetic posterior nasal nerve. Cryotherapy applied in the nose offers a minimally-invasive approach that interrupts the signals from these nerves to decrease nasal drainage. ClariFix® cryotherapy is the first and only FDA approved medical device used to treat chronic rhinitis in adults. How does it work? Intranasal cryotherapy uses a state-ofthe-art wand that applied nitrous oxide cryogen through a small balloon tip to freeze nerve fibers at the back of the

“Approximately 80% of patients notice a significant reduction in nasal drainage within the first 3 to 6 weeks.”

(continued on p. 28)

...cont’d from page 27 the nose that contribute to excessive mucus production. Downtime is minimal. Side effects are mild and include temporary headache and congestion, usually for a day. Approximately 80% of patients notice a significant reduction in nasal drainage within the first 3 to 6 weeks. Dr. Neeta Kohli-Dang (whom I lovingly call, Boss) has done more cryoablations than any other physician in the Southeast. She says, “We have the procedure down to a fine art.” Topical anesthetics are used in the nose and then a cooling probe is applied which takes less than a minute. Patients enjoy a latte or coffee and then go home. Start to finish, the entire appointment can last less than an hour, most of which is spent numbing the nasal cavity. For some, the option of snorting medications every day may not be the best option. If you are tired of the constant drip and sniff, consider intranasal cryotherapy for a more permanent solution.

Dr. Neeta Kohli-Dang and Kari Kingsley, MSN, CRNP share nearly forty years of ENT experience. Please visit Kari and Dr. Dang at their practice website: or call (256) 882-0165 to schedule an appointment.

Dr. Neeta Kohli Dang performing minimally invasive in-office cryotherapy to improve a patient’s nasal drainage.

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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WHITE COAT by Bobi Jo Creel, RN, MSN, CRNP

Every time another month falls off the calendar, so are we closer to another year, another adventure and, sometimes, another challenge. As a nurse practitioner in a busy internal medicine practice, I learn and am challenged daily by this. Sometimes a diagnosis comes out of left field and it is not something you ever would have predicted. Sometimes you have patients who do not want a challenge and choose not to fight. Sometimes you have one who has all the fight in the world, but God no longer needs them here. All of these have one thing in common—they are outside of my (the medical provider’s) control. These are some things that as a patient, you may never know or see. The line in the sand prevents this. You see your provider as just that—a provider—but, they are much more than that. Providers are there to help you achieve your optimal level of health, but care about more than your physical being. We see YOU. This is an inside look in the heart and mind of the person sitting on the stool. We see you. We feel for you. Some of us pray for you. We are more than doing a job for you.


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There are days that are completely monotonous — Managing chronic, and often complex illnesses Refilling medications Ordering and reviewing labs Ordering screening tests and administering preventative care. Then, there are days that wreck us — When there are not enough hours in the day When there is not a clear answer When there is a looming diagnosis When we are not sure how we are going to have the heartbreaking conversations with those we have come to care for. There are appointments — When everything goes as planned When there are no new problems to discuss When the hot topic is the big game and not anything medical When you get to give the good news. Then, there are appointments — When nothing expected occurs When families with nowhere to turn show up broken in our exam room When minutes and quick recall matter most When life-threatening emergencies lay on our exam tables. There are lessons instilled in us through our training — That tell us this is a provider-client relationship That we are to prevent, diagnose and treat illness That we can treat the physical and mental, but not the spiritual That our empathetic sides have no place in our calling. Then, there are lessons imparted to us through our practice — That challenge our faith with their own That force us to place ourselves in the trenches with them to win the battle That compel us to open-up to them when they need a bigger piece of us That break down our institutional walls to show them they are never alone. There are patients — Who push us Who are do not give away trust easily, if ever Who want a little more of us than we have been taught to give Who do not want to battle a diagnosis we see as a potential victory.

There are moments when — We have had our faith shaken when we could not see the big picture We did not understand why the patient did not see the way out We pondered how to do our job and not care for the people we serve We questioned why a perfect God would gift us with things we cannot use in our calling. Then, there are moments when — We grow in our faith through every rocky day We learn to care about people the way they want to be cared for and take the formality out of the equation We seek to treat patients with our whole hearts We see that God wants our empathy to pour over the ones who trust us to care for them.

You see, the white coat has more to give. They see all sides of you—from the grandmother who dotes on her flock to the single dad who just needs someone to listen. We see the one who is so scared that they lash out at the one they know can take it. We see the one who has only tears and not words. We see beyond the diagnoses you carry to the heart of the one who sits scared on our table. We know that you find our rooms cold, but our hearts are not. We have shared burden where you are concerned. See this. See that we want more for you—even if our goals for you are not something you think are obtainable. We see the big picture. We see your potential. We will fight with you in the battle you choose and sometimes will just be a cheerleader when you need that most. We want you to see that. Look beyond the white coat. The bottom line is that we see you and all of you. Your provider is not an enemy… they are your best soldier.




*The words in this article reflect my personal opinion and do not reflect the opinion of the medical community as a whole. I follow all rules and regulations set forth by the ABN and governing bodies for proper client/provider relationships and roles.

Then, there are patients — Who embrace us Who put all their trust in us—earned or not Who pull parts of us into their lives that we were not prepared to give Who have the will to conquer a mountain and still care for us even when it is not one that can be climbed.

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Back Pain & Pregnancy: The Triple Whammy of Having a Child by Larry M. Parker, MD

1. Pregnancy

We all understand that pregnancy is associated with weight gain (20 to 35 pounds is recommended) with most of the increased weight distributed in the abdomen. This increased abdominal weight creates an increase in lumbar lordosis (the amount of arch in the low back) which can strain the joints of the lumbar spine. Pregnancy is also associated with hormonal changes that relax ligaments and joints to prepare the pelvis for delivery which can further aggravate the lower spine and pelvis.

2. Delivery

You don’t need me to tell you that having a child is a life-altering experience for any young woman. But as an orthopedic spine specialist, I do see a lot of young women in their first year after delivery who were not expecting to deal with low back pain as part of their childbearing experience. In fact, a recent article published in the Journal of American Academy of Orthopaedic Surgeons reports at least a 50 percent incidence of low back pain in first-time pregnancies. So why is low back pain such a common problem for pregnant and postpartum women?

To put it simply, it has to do with what I call the “triple whammy” of having a child: • Pregnancy • Delivery • Childcare

After nine months of changes to a young woman’s body associated with full-term pregnancy the big day arrives—the delivery! Delivery may involve a vaginal delivery or a Cesarean section. A natural vaginal delivery involves a massive expansion of the pelvis to allow passage of the newborn through the birth canal. A C-section requires surgically dividing the muscles of the abdominal wall. In either case, delivery of a full-term baby (or babies in the case of twins, etc.) is very traumatic to a young woman’s body.

3. Childcare

So after nine months of pregnancy and the trauma of delivery, any young lady deserves a vacation but in fact, rarely if ever does that occur, because usually childcare starts immediately. Most new moms have very little time to rest and recover. Eight hours of sleep is uncommon. To make matters worse, childcare usually entails new strain on your back, such as hoisting the car seat with the baby in it into the car, carrying a heavy diaper bag over one shoulder, and more. The “triple whammy” of pregnancy is a reality for most new mothers, and back pain can make the experience of having a child more challenging. So what can you do to tend to your back pain? And what if you have had prior back surgery? Can you reduce the risk of back pain during pregnancy? We will look at those issues next time.

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i am. by Jill Windham


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I’m sitting on my deck on this beautiful Monday morning, two dogs happily playing at my feet. Birds are singing, the air is cool enough for me to wear my cozy gray sweater, and I have THE most perfect cup of coffee next to me. I prayed for my husband. My kids. My friend. Myself. I opened my devotional for the day. The verse was 2 Corinthians 12:8-9. *screeching halt noise* Silence. Paul says he asked the Lord to remove his thorn in the flesh three times (SO wish he had told us what that struggle was, darn it...) and the Lord responded, “My grace is all you need. My power works best in weakness.” Then, Paul said, “So now, I am glad to boast about my weaknesses, so that the power of Christ can work in me... for when I am weak, then I am strong.” Get out of here. (insert all the eyeroll emojis) I boast about alot of things. My kids. My super strong husband. My ability to make THE perfect cup of coffee. My cutest puppy on Earth. But I have never, ever, EVER- not even ONE time boasted about a weakness. In fact, I am side-eyeing a weakness I possess right now. It’s ugly, it wants to rear its head in my heart every day, and it makes me furious that at 40 years old, I still struggle with it. Paul, my dear, you’re my hero and Father in the Faith. But I think you’ve lost your mind on this one, friend. Then, I remembered. A man named Moses once had a mandate from Heaven. God told him to speak to Pharaoh and immediately, Moses went into Jill-mode. Panicking. Excuse making. Groveling. When Moses finally had the nerve to say yes, he asked, “Who will I even say sent me? Pharoah is a tough nut to crack.”

God simply said, “I Am.” Moses: I’m not qualified. God: I Am. Moses: I’m not educated enough. God: I Am. Moses: I’m not a good speaker. God: I Am. Moses: I’m not even known. God: I Am. Oh. Now, it makes sense, Paul. I can delight in my weakness because where I am not, He IS. Where I leave a blank, “I’m not _________,” He fills it. Where my human strength fails, I have a golden opportunity for the superhuman part of me to wake up like springtime. Where I am deflated and defeated, I have paved a road for the Champion to enter the ring. Where I am tapped out, I tap Him in. So, once I realized this simple truth that I should have learned by now (aren’t pastors supposed to know this stuff?), the birds starting singing again. I have a new set of eyes on this weakness thing. I’m going to see it as clearing a path for the Holy Spirit to show up. I’ve got a pretty big spot in this weakness for His power to fill. If I could have fixed it on my own, I would have done it by now. I boast. Not because I HAVE a weakness, but because I have a wide open spot for the grace of God to do its miraculous thing. Switch your binoculars around, friend. Look at the wide open spaces instead of the microscopic places. God is much bigger, much more sufficient than your weakness today!!

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‘Paws’itive Reinforcement

by Kari Kingsley, MSN, CRNP

I love when people ask me how many kids I have. Ten. I have 10 kids. They just happen to have fur and feathers. A horse, a dog, two cats, and six chickens. While not exactly Noah’s ark, I’m getting there. I consider them family (even the fluffy chickens) because they are such an important part of my life. My entire day revolves around when to feed them, when to let them outside, when to ride the horse, when to gather the eggs, and when to take my rambunctious Labrador puppy on a walk to burn off some of that crazy puppy energy… The domestication of animals perhaps started as a symbiotic relationship long ago. Wolves moved into nearby campgrounds of hunter-gatherer communities to scavenge for bones and scraps thrown out by humans. In turn, humans began feeding the wolves as the wolves began providing protection and assisting in the capture of prey. I’ll scratch your back and you scratch mine (literally). From there, the friendship grew. Similarly, cats were attracted to rodents thriving around human settlements. They killed mice that carried disease and became an important part of humans’ lives. The Health Sciences department at the University of California, Los Angeles, published a study in May of 1999 that said that people with AIDS who owned pets were less likely to suffer from depression. Even with the increased risks associated with this immunocompromising disease, the positive outcomes provided by pets many times outweighed the risk. Additional medical research has linked positive physical and psychological research to owning a pet. The Center for Disease Control reports lower blood pressure, lower cholesterol, and an overall reduction in stress and anxiety among those who own pets. Pets give us the opportunity to exercise, socialize, and to manage loneliness. Our pets never judge us and always provide unconditional love. Reductions in cortisol, the stress hormone, which can negatively affect the immune system have been noted. On the other hand, increases of serotonin and dopamine are seen, promoting a calmer and more relaxed state. Newport academy has reported that people with furry friends have increased self-esteem, are less fearful, are more extroverted and generally more conscientious and less preoccupied. The CDC is currently studying the role of animal interactions in kids with autism and conditions like ADHD. Service dogs are frequently trained to assist those with physical and emotional disabilities. 34

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With all the positives that pets provide us, we should be asking what we can do for them. According to the Insurance Information Institute, approximately 67% of U.S. homes have pets. But sadly 6.5 million companion animals enter shelters each year according to the ASPCA. Of those, 3.3 million are dogs and 3.2 million are cats. Approximately 1.5 million shelter animals are euthanized yearly. But that number is on the decline, largely in part to animal rescue efforts. Enter Huntsville’s newest animal rescue: Furget Me Not Animal Rescue Inc. and its founder, director, and CEO, Michelle Underwood. The organization came about as more and more unwanted, abandoned, and abused animals found their way into shelters through no fault of their own. Michelle and her team at Furget Me Not are motivated by the animals that have had humans let them down. “Alabama does not have spay or neuter laws and too many people in Alabama don’t see the need to fix their animals, so, rescues have to become the voice for homeless animals.” Michelle says that the volunteers at Forget Me Not Animal Rescue have long histories with rescue and have collectively saved thousands of animals and will work diligently to save thousands more. “FMN volunteers strive to educate people on the reasons to adopt and not shop. There are lots of great animals in the shelters. Many area shelters are forced to euthanize if the shelter becomes overcrowded. Furget Me Not works daily to see that this doesn’t happen.” Michelle and her team have seen the absolute best and worst in people. “We have seen horrific hoarding cases, animals abandoned in structures with no heat or food, and mom dogs left to have puppies in freezing temperatures. Puppies and kittens are closed up in bags or boxes and thrown into trash bins, fields, or ditches. These animals are starving animals and sometimes have no hair because of mites or severe allergies. Some animals come in with life threatening infections that cause them to have organs and limbs removed. Dogs and cats are bred over and over again, never receiving medical care, baths, brushing, nail care, or even love. We see so many animals that are terrified from abuse or having never been socialized.” Michelle says that rescue is not without its rewards. “The happy side of rescue is watching the volunteers that work tirelessly to save animals. One of the happiest moments in rescue is when a terrified dog or cat who bites out of fear lets

you pet them. It’s the best feeling to be the human they trust for the first time. It takes a great amount of patience and can take days, weeks, or sometimes months but it worth every minute to watch their transformation. It’s even better when they become part of a great family.” Furget Me Not needs your help. Michelle says “We are a brand-new animal rescue and we need help getting the word out about us. We are 100% volunteer based which means 100% of all donations go toward vet bills for the animals. All the animals we pull are placed in foster homes so we have no overhead, no utilities, no salaries, etc., so people can feel better knowing every penny goes to save animals. We are looking for people that would like to become donors or sponsors to support our cause. Without donations for vet bills, we can’t

exist and help animals. FMN takes in seniors, injured, sick, and heartworm positive animals that require surgery in addition to healthy animals. The adoption fees don’t cover the vet bills so we have to rely on donations.” Furget Me Not also needs dog and cat fosters. An animal can only be pulled from a shelter with a foster commitment. Pets are our family. Without them, hard days would be harder. Our pets provide companionship, friendship, and studies suggest the benefits of pet ownership have positive effects on health and wellness. They bring joy and abundant love to our lives and we owe it to them to do more. Please visit Furget Me Not at their website at www.fmnanimalrescue. org, like them on Facebook at Forget Me Not Animal Rescue Huntsville, and follow them on Instagram at fmnanimalrescue.

furget me n t A N I M A L R E S CU E

why we exist With all the positives that pets provide us, we should be asking what we can do for them. According to the Insurance Information Institute, approximately 67% of U.S. homes have pets. But sadly 6.5 million companion animals enter shelters each year according to the ASPCA. Of those, 3.3 million are dogs and 3.2 million are cats. Approximately 1.5 million shelter animals are euthanized yearly. But that number is on the decline, largely in part to animal rescue efforts. organization or cause and which is distributed to members of the media for promotional use, and designed to be sent to a newspaper or magazine as part.

why we need





All the animals we pull are placed in foster homes so we have no overhead, no utilities, no salaries, etc., so people can feel better knowing every penny goes to save animals. We are looking for people that would like to become donors or sponsors to support our cause. Without donations for vet bills, we can’t exist Michelle Underwood, Founder, Director, and CEO of Furget Me Not Animal Rescue Inc. and help animals. FMN takes in seniors, injured, sick, and heartworm positive animals that require surgery in addition to healthy animals. The adoption fees don’t our request cover the vet bills so we have to rely on donations.” Furget Me Not also needs dog and cat fosters. An Furget Me Not needs your help. Michelle says “We are a brand-new animal animal can only be pulled from a shelter with a foster rescue and we need help getting the word out about us. We are 100% volunteer based which means 100% of all donations go toward vet bills for the animals. commitment.





Please visit Furget Me Not We at their website at, like them on Facebook at Forget Me Not Animal Rescue Huntsville, and follow them on Instagram at fmnanimalrescue.

Real Estate: Good Offense, Better Defense Whether your favorite sport is football, foosball or fútbol, you can’t win the game unless you have both a good offense and good defense. Bear Bryant echoed this by saying “Offense sells tickets, but defense wins championships.” The same can be said about winning in business and personal finance. In the classic personal-finance book, “The Millionaire Next Door,” Thomas Stanley and William Danko liken offense to income and defense to how you spend (or do not spend) that income. Their premise is that to win at personal finance and become wealthy, you must be excellent at producing income (offense) and even better at retaining it (defense). Clearly, it takes money to make money and some expenses are unavoidable. However, it is important to focus your attention on saving money the right way and looking at big ticket items. That focus can have a huge impact on your personal finance and financial well-being of your healthcare practice. We recently had two clients who were excellent practitioners; able to produce high revenue for their practice and create significant take-home income. They were great at offense, bringing in income; however, upon reviewing their leases, we found their defense to be lacking.


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Client #1

Our client was leasing space in a multi-tenant building. Her lease was set to expire in just over twelve months, so she was considering relocating her practice or purchasing her existing leased space. After reviewing her lease, we noticed she was paying rent on the entire building (nearly 6,000 square feet), rather than her 4,000 square foot space she was practicing in. She was paying for 2,000 square feet that her practice was not occupying, while the landlord was collecting double rent on the adjoining 2,000 square foot leased space. Consider the ramifications of this. For the sake of round numbers, let’s use a fifteen-dollar per square foot lease rate over a ten-year term. $15 x 6,000 sf = $90,000 (annual rent) x 10 years = $900,000 total rent vs. $15 x 4,000 sf = $60,000 (annual rent) x 10 years = $600,000 total rent The difference in this scenario is $300,000 over a ten-year lease term. It turns out, there was no malicious conduct or deceptive intent on the part of the landlord (just an honest mistake), but this lease was reviewed by a practice broker, an attorney, two or more doctors and others before it was signed. The space was a part of a practice purchase, so the lease unfortunately was an afterthought. How long would it take to make up for a mistake like this by cutting back on supplies? The reality is, no matter how many pennies you pinch on cotton rolls or materials, it’s unlikely you could make up for this type of an oversight. Simply assuming that the math on a lease will work out fairly or believing that it is not worth the time or money to have a professional review the terms of a deal may end up being the costliest mistake of your professional career. This is an example of poor defense: not having someone there to protect your bottom line. (continued on p.38)

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...cont’d from page 36

Client #2

The other client was nearing the expiration of his lease, so we reviewed the negotiable terms; namely tenant improvement allowance, free rent, lease rate, operating costs and escalations. The one that stood out the most was the tenant improvement allowance. On the past lease, the landlord’s terms were at least ten dollars lower than what the client should have achieved. Doing the math here ($10 per SF x 3,500 SF = $35,000). Another example of poor defense. One negotiable term that seems minor or even “fair” could cost you tens of thousands of dollars. The hard part about these transactions is that you want to believe you are being treated fairly. The reality is, your definition of fair is most likely very different than that of an opposing party. You must realize you have competing interests with the landlord, broker or investor that is a professional negotiator with full knowledge of their trade. You could say, a landlord’s offense is better than an unrepresented tenant’s defense. Real estate is the second highest expense for most practices. With this much at stake, it’s not something you want to take a risk on. The good news is that buyers and tenants have every opportunity to create a good defense by seeking professional help. Often times healthcare professionals will have an attorney review the legal ramifications and consequences of a lease, but the legal side of a lease and the fair-market-value side of a lease are completely different. Very few attorneys know the going rate for tenant improvement allowance, free rent, escalations or lease rates in a healthcare-real-estate transaction. Another common mistake is hiring the wrong real estate professional. Be sure to hire a broker or agent with healthcare real estate experience. Failing to understand the electrical, mechanical and plumbing needs of a healthcare practice on the front end can be extremely costly. Additionally, there are many other business deal


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points that are vastly different in healthcare real estate vs. general commercial real estate. In summary, a successful practice focuses on production to increase revenue while investing in resources that drive business without neglecting to protect what has been earned or could be lost. Professional representation protects your interests and the valuable revenue you work so hard to attain. You don’t have to choose between having a good offense or better defense; you can have both.

CARR Inc. is the nation’s leading provider of commercial real estate services for healthcare tenants and buyers. Every year, thousands of healthcare practices trust CARR to achieve the most favorable terms on their lease and purchase negotiations. CARR’s team of experts assist with start-ups, lease renewals, expansions, relocations, additional offices, purchases, and practice transitions. Healthcare practices choose CARR to save them a substantial amount of time and money; while ensuring their interests are always first. Visit CARR.US to learn more and find an expert agent representing healthcare practices in your area.

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CHECK OUT SOME OF THE BENEFITS OF STRONG GLUTES: Reduce Back Pain Reduced back pain: your glute muscles help stabilize and control your pelvis, hips, torso, and trunk. Keeping them strong helps provide strength through your pelvis and helps prevent over-rounding through your lumbar spine. It simply helps support your lower back!

Prevents Knee Pain Prevents Knee Pain: that stabilization mentioned above through your hips affects your legs. If there is imbalance in the hips, your knees may start talking to you and you won’t like what they have to say!

RECRUIT YOUR GLUTES by Elisa Brooks, ACE Certified Personal Trainer & ACE Certified Sports and Fitness Nutrition Specialist

Injury Prevention Injury Prevention: when a muscle group in the body is not strong and doing what it is supposed to be doing, other muscles will jump in to help out. But it is typically at a cost. They may, in turn, become stressed because they’re doing functions they aren’t designed to do! Pain in the lower back, knees, groin, and hamstrings may indicate stress in those areas due to weak glutes. Training strong glutes helps to prevent those injuries.

It’s pretty trendy right now in the world of fitness and in the world of beauty to flaunt a well-rounded backside. You don’t even have to be someone that follows fitness bloggers or Instagramers to know that female celebrities like to show off glutes that are in good shape. The truth is, a well-exercised and trained posterior chain can mean a great looking tush. However, there are several reasons why everyone, not just celebrities, should be training strong glutes - and looks aren’t one of them. First off, there are three different glute muscles: gluteus maximus; gluteus medius; and the gluteus minimus. The gluteus maximus is the largest of the three and helps to shape your booty. The medius and the minimus are smaller muscles that partner to help movement. The three muscles work together for hip extension, along with rotation and abduction of the hip. Giving these muscles some attention and learning to train them can help you move more efficiently and live pain free. (continued on p. 40)

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(continued from p. 39)

Functional Movement Functional movement: in everyday life we might squat down to get at eye level with a child, or to pick something up off the kitchen floor. We help a friend or spouse move a piece of furniture. Many of us walk up and down stairs in our homes or places of work. Strengthening your glutes can help you to do daily activities with confidence and without straining other muscles in your body.

Athletic Power Athletic Power: these power muscles literally are just that … power muscles. When glutes are strong, you can jump higher, accelerate faster, deccelerate quickly, and lift heavier.

Whether or not you are an athlete, avid exerciser, young, old, or somewhere in between all those, your overall health can benefit from building stronger glute muscles. Many exercises can be done at home or at the gym and can be progressed from beginning to advanced. Examples of great movements to strengthen this group of important muscles include:

Lunges Deadlifts Single-Leg Deadlifts Hip Bridges Single-Leg Hip Bridges Weighted Hip Thrusters Clamshells Step Ups Quadraped Hip Extensions

All of these exercises (and MANY more!) can easily be found online. You’ll find videos, how-to’s, and methods of working a movement from beginner level up to advanced exercises. Due to many Americans living a fairly sedentary lifestyle, or working hours at desks, your backside most likely could use some attention. And not just so it looks great in your jeans, but in order to make you stronger and give you a better quality of life. Time to get working!

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Single-Leg Deadlifts

Hip Bridges

Single-Leg Hip Bridges

Weighted Hip Thrusters


Step Ups

Quadraped Hip Extensions

All of these exercises (and MANY more!) can easily be found online. You’ll find videos, how-to’s, and methods of working a movement from beginner level up to advanced exercises. Due to many Americans living a fairly sedentary lifestyle, or working hours at desks, your backside most likely could use some attention. And not just so it looks great in your jeans, but in order to make you stronger and give you a better quality of life. Time to get working!

Whether or not you are an athlete, avid exerciser, young, old, or somewhere in between all those, your overall health can benefit from building stronger glute muscles. Many exercises can be done at home or at the gym and can be progressed from beginning to advanced. Examples of great movements to strengthen this group of important muscles include:


Preventing Provider BurnOUT

by Kari Kingsley, MSN, CRNP


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Dr. Lowery: Throwing back his third cup of lukewarm 3-hourold coffee as he’s running over an hour behind in clinic, the good doctor rolls his eyes as he picks up the chart to Room 7. It’s involuntary. His body becomes rigid and he struggles to put on his best fake smile as he enters the room. Like a psychic reading Tarot cards, he predicts the seemingly never-ending barrage of questions that await him as soon as he opens the door. His patient doesn’t disappoint. She is holding an entire page and a half of college-ruled hand written questions to go over… in detail… Ethel Flannergan: Nervously moving her eyes from her watch to the back of the door in Room 7 and to the list of questions and symptom log she diligently poured herself into the night before, Ethel waits the hour and sixteen minutes to see Dr. Lowery. She has carefully addressed each symptom she’s had over the last few weeks, months, even years, in an effort to help her doctor sort out the debilitating fatigue she’s been experiencing. She’s been waiting over an hour, first in a waiting room with sick people coughing, and now in a cold and sterile room. She paid a $50 copay, but it’s worth that and more for a chance at regaining her quality of life. These different perspectives are two sides of the same coin. The fictional Dr. Lowery is hands down one of the best in his field. He is an excellent physician but the strain of owning and operating a private practice is taking its toll. The hiring, firing, and staffing issues, along with insurance reimbursement, broken EMR systems, taxes, malpractice insurance, and the ever-present pressure that his patients’ lives are in his hands weighs heavily on his mind. He loses sleep over medical traumas he has seen in his career; he knows that losing a patient can put a permanent mark on a person’s soul. Ms. Flannergan on the other hand is a pleasant person who wants answers (and appropriate treatments) to get her life back on track. Physicians, nurses, medical assistants, scrub techs, nurse practitioners, CRNAs, phlebotomy techs… you name it, provider burnout is real. And it is becoming a real problem. Burnout is the culmination of emotional bankruptcy, disconnection from patients and coworkers, declining career satisfaction, self confidence in your scope of practice, overall exhaustion, and a diminished sense of personal accomplishment. In today’s modern go-go-go society, it is becoming an epidemic. Medical schools and nursing programs train us to strive for excellence. Anything less than superhero status is unacceptable. That can be a lot of pressure. Most of us can’t leap tall buildings in a single bound. We are just human. Oftentimes in medicine, decisions have to be made in the blink of an eye that can save (or cost) someone their life. Medicine, while very rewarding, is a stressful career path. Chances are high you know someone in the medical field that can attest to their rigorous schedules. Increasing workloads, long hours, emotionally and physically challenging patients, high accountability, demanding family members, and a legal environment in which every other interstate billboard is a lawyer offering a big payout, takes its toll. Medical providers are at higher risk to abuse alcohol and drugs, and oftentimes have a higher rate of anxiety, depression, and even suicide. The numbers are shocking. According to the American Foundation for Suicide Prevention (AFSP), 28% of medical residents experience a major depressive episode during training compared to 8% of similarly aged individuals in the general U.S. population. The suicide rate

among male physicians is 1.41 times higher than the general male population and among female physicians, the relative risk is 2.27 times greater than the general female population. In one study, 23 percent of interns had suicidal thoughts. So, what’s the solution? AFSP suggests that physicians and healthcare workers who proactively address their mental health needs are better able to optimally care for patients and sustain their resilience in the face of stress. “Mental health problems are best addressed by combining healthy self-care strategies (which should not include self-medicating) along with effective treatment for mental health conditions.” Regular exercise, a healthy diet with proper nutrition, yoga, meditation, rest, and vacations are just a start. Addressing the emotional needs of the providers is crucial. Perhaps the most important step to addressing provider burnout is talking to someone about their mental health issues. Consider changing work hours, or even positions depending upon the level of stress and anxiety. Nurturing healthy relationships with family, friends, and colleagues is also integral in preventing provider burnout. In a perfect world, Dr. Lowery would be able to take hours to address Ethel’s ailments, but in the real-world providers must manage their time to best serve patients while also preventing their own burnout. Providers aren’t superheroes, but most are compassionate caregivers that entered the medical arena in the hopes of helping others. Providers take a Hippocratic oath to do no harm. They are sworn to uphold specific medical ethics and to put the health of the patient above all else. But they also have a responsibility with that oath to take care of themselves. With a little self-preservation and self-kindness, they will be able to go on treating patients while treating themselves as well. Helpful resources for providers in distress: • Acumen Institute: Specializes in acute distress assessments and education for medical professional. • Depression and Bipolar Support Alliance: An advocacy group that provides support, resources and information for people living with depression and bipolar diagnoses. • National Suicide Prevention Lifeline: Provides confidential support to people in suicidal crisis or emotional distress. 1-800-273-TALK (8255) • Vanderbilt University Program for Distressed Physicians: Offers a 3-day course that provides help for distressed physicians in a confidential environment. • The American Foundation for Suicide Prevention: Medical provider-specific suicide information, including the documentary Struggling in Silence.

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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UTI by William T. Budd; Ph.D

Acute urinary tract infections (UTI) are one of the most commonly diagnosed bacterial infections in the US accounting for over 10 million physician visits annually. Over the last decade, the economic burden associated with these infections has increased due to the high rate of recurrence and increased frequency of antimicrobial resistance. The standard diagnostic test to identify organisms causing infection is the standard urine culture. However, recent studies have revealed that less than 5% of bacteria can be cultured under normal laboratory conditions. This is referred to as culture bias. Additionally, there exists a large variability in the physical collection of culture material that affects downstream analysis. For these reasons, traditional culture techniques often fail to identify the individual components that make up these infections. It is also well understood that culture results are incorrect/ incomplete approximately 25% of the time. Elderly and persons that have undergone a urinary tract procedure are at a high risk for complicated infections that contain several bacteria. It is estimated that 33% of urine cultures derived from samples collected from the elderly are poly-microbial and fall within this category. It not uncommon for clinicians to receive a report describing the sample as a mixed flora with unknown constituents as the current diagnostic standard is to not report bacteria from samples containing three or more bacterial species. In properly collected samples, the assumption that urine containing more than three organisms is contaminated is false. The inability to work up these samples and provide clinicians with an appropriate therapeutic regimen increases the likelihood of the use of an empirically prescribed broad-spectrum antibiotic contributing to increased microbial resistance of the organisms. Armed with knowledge of the offending bacteria, physicians can tailor a specific therapeutic regimen to eradicate each organism decreasing the likelihood of infection recurrence. 44

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In addition to the inability to report constituents of polymicrobial infections, urine cultures have a significant by Belinda Maples, false negative rate. Studies show that manyM.D. symptomatic women (25-30%) will have a negative urine culture. These patients have been traditionally classified as having urethral syndrome (symptomatic abacteriuria). The presence of urethral syndrome has been a point of contention for several decades with many physicians dismissing the syndrome in its entirety. Because of this debate, physicians will often initiate antibiotic therapy despite a negative urine culture. Recent studies proved that women presenting with symptoms of a UTI that were culture negative frequently had E.coli and/or Staphylococcus saprophyticus (>90%) that were detectable by polymerase chain reaction (PCR). PCR is highly accurate and able to detect bacteria at lower levels than traditional urine culture. Therefore, this technology can ensure that providers are not making clinical decisions with limited information. Urinary tract infections are a common menace to clinicians. Complicated UTIs can progress to sepsis and ultimately lead to death. This is especially true in the elderly and immunocompromised patient populations. Providers face opposing forces when deciding to treat a UTI. On one hand, the awareness of the deadly potential of a UTI suggests providers should aggressively treat an infection but the increased virulence and resistance associated with overtreatment necessitates accurate diagnosis. Culture and sensitivity have been the gold standard employed for nearly 100 years. The inability to accurately diagnose poly-microbial infections along with the high rate of falsely negative results has created the need for a more accurate diagnostic method. The use of highly specific, multiplexed PCR assays may offer clinicians a better alternative for identification of uropathogens. The panel described in this manuscript is based on empirical results from our community with a high degree of clinical sensitivity and specificity.

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warning signs and urge everyone you know to do the same.

In some cases, a procedure to remove the clot causing the stroke is also recommended. Nintey-one percent of stroke patients who were treated with a stent retriever within 150 minutes of first symptoms recovered with little or no disability. The thing to remember is that stroke is largely treatable. It’s a matter of getting the right treatment, right away.


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©2019 American Heart Association 3/19DS14553

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Colorectal Cancer is...

PREVENTable. TREATable. BEATable.

Colorectal cancer is the third most common cancer and the second leading cause of cancer deaths in men and women in the United States.* Colorectal cancer screening saves lives. If everyone who is 45 years of age and up were screened regularly, as many as 60% of deaths from this cancer could be avoided. Schedule your screening today! It could save your life. To schedule a screening at Crestwood, North Alabama’s only ASGE certified Endoscopy Center, call 256-429-4986.

*American Cancer Society I n s i d e M e d i c i n e | Vo l u m e


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