Inside Medicine April-May 2017

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april-may 2017

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features &

CONTENTS

Sharing with Purpose

Inside Medicine | april-may 2017

FEATURES Finding the Silver Lining A beloved Huntsville doctor’s career ended much too soon

My Journey–Sally Barton shares from the heart

How does a provider assess, diagnose, and treat a dizzy patient?

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Human “blueprint” offers a peek into the future

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A mom’s journey of love and loss

Understanding Dizziness

Genetics for the rest of us

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Lateral Fusion For some, this procedure has become a well proven and significantly successful option

Facts and Myths of Long Term Care coverage

C O N T R I B U T ORS

Maureen Mack

CONTENT

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Vol u m e 1 , I s sue 4

Ben Macklin Lisa Layton Jeffrey Hull, M.D. Sally Barton Kari Kingsley, MSN, CRNP Javier Reto, M.D. Michael Dohrenwend, M.D. Karen Fox, CRNP

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Joe Knoch Kaki Morrow Angela L. Hampton, D.P.M. Steve Burcham Morgan Boone

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When preparing for retirement, consider LTC insurance

Join our mission to establish and grow an alliance among 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 kelly@insidemedicine.biz or 256.652.8089 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.

Nemil Shah, M.D. Tiernan O’Neill Fred Gilbert, PT, DPT Belinda Maples, M.D. Jonathan Threadgill, DMD Anne Jewell Jennifer Grady Jeffers D Kishore Yellumahanthi, M.D., MPH Ellery Miller S A L E S & M A R KETING

Kelly Reese, Co-Owner Lisa Layton, VP Sales/Marketing C H I E F E D I T O R I A L WRITER

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

Karen Gauthier P U B L I S H ER

Brandon Reese, President Blake Bentley, Vice President w w w . i n s i d e m e d icine.biz


} FROM THE EDITOR

Dear Readers– As a writer, I have always tried to notice and elaborate on the little details and bring them out to the reader. This way, the reader can easily visualize and “see” what is being communicated via words on

new realities & graceful transitions

a page. You don’t just see a tree in the distance. You should see parts of the tree; bark, leaves, branches, roots, and even animals that live in the tree or around the tree. If we could live our lives seeing the details, as a writer sees the details, picking apart the big picture to identify the interesting aspects, imagine how much more insightful we would be and how much more we would appreciate the beauty around us. In this edition of Inside Medicine, we have seen a special member of our community do just that. Dr. Don Wheeler provides us with some life lessons and “never give in” attitude in his story. He had to adjust his normal to find a new reality and gracefully transitioned to be an excellent example to others. The same can be said for Dr. Jeffrey Hull. Dr. Hull was coasting along in life and then was hit with a diagnosis of Parkinson’s disease. Instead of calling it quits, he has found treatments and therapies to help him on his journey. I only hope he can help you as well. And then there’s Sally Barton’s story about losing her son to addiction and how she has coped with her sadness and is using it to guide others on their similar, difficult journeys. Along with inspirational stories, this edition is packed full of such useful information. We explore mental health/illness, esophageal concerns, technology in healthcare and even the Affordable Care Act, along with many other insightful editorials. We hope you learn something new and maybe find some hope and guidance in our stories. As always, our prayer at Inside Medicine is to display passion for our community and our Savior. Please, if you ever have an idea for a story or want to be included in our magazine, feel free to contact us.

Kimberly Waldrop


}RESEARCH

Genetics for the rest of us Human “blueprint” offers a peek into the future 4 What if the medication you take isn’t working, but you don’t know it? 4 What if you carry potentially devastating diseases you could pass down to your children? 4 What if you, yourself, have an increased risk of cancer? 4 Would you want to know?

Maureen Mack

HudsonAlpha Institute for Biotechnology

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The HudsonAlpha Institute for Biotechnology, a nonprofit genomics research powerhouse located in Huntsville, Ala., debuted a new program called Insight Genome in March. Insight Genome decodes individuals’ blueprint - DNA to look for answers that could help predict future health and help people make decisions about their care. “This is information not found in one comprehensive tool elsewhere,” says Howard Jacob, PhD, HudsonAlpha’s executive vice president for genomic medicine. Genomic medicine is the use of an individual’s genomic sequence-the entire set of DNA that makes you unique-- to deliver personalized and precise medical care. “By using whole genome sequencing-- basically spelling out the entire genetic code for an individual-- we can look at genetic changes that make you unique, and identify specific changes to your DNA that put you at risk,” Jacob explains. The genomic medicine program at HudsonAlpha isn’t new; previously, the institute has focused on rare and undiagnosed diseases. More than 130 children with rare disease have been diagnosed through the institute’s collaborative research and clinical work, and new genes linked to previously unknown conditions have been identified. Insight Genome, however, is the Institute’s first foray into genomics “for the rest of us.” “One question that I am continually asked is when can I sequence my genome?” says Neil Lamb, PhD, HudsonAlpha vice president for educational outreach. “We are now able to explore how whole genome sequencing can become transformative for clinical care, and also engage both physicians and patients.” The Insight Genome process is fairly simple. A small vial of blood is drawn and sequenced. Sequencing involves spelling out all the “letters” (remember A-C-G-T from middle school?) in a patient’s DNA — about six billion of them. While humans are eerily similar scientifically, they do vary at about four to six million spots in their DNA. Many of those changes are just simple variation, such as eye color or height. Other changes to the DNA, or variants, are medically meaningful.

Inside Medicine | april-may 2017


“Those are the ones we’re concerned with,” says David Bick, MD, a clinical geneticist at the Smith Family Clinic for Genomic Medicine in Huntsville. “Of the variants linked to disease, some are well-established as pathogenic. That means we know there is a high likelihood of them causing disease. Think of changes to the wellknown breast cancer gene BRCA1 as an example. Other variants indicate you carry a disease. While you may not have it — like a cystic fibrosis or sickle cell — you have a chance of passing it along to your children. There are also variants of unknown significance. We think they may be harmful, but simply don’t know enough them. Yet. “The more genomes we sequence, the more we are learning about human variation and what DNA changes increase risk. We’ve come so far since the first genome was sequenced less than 20 years ago. Projects like Insight Genome are accelerating our discovery,” Bick continues excitedly. Insight Genome is comprised of two genomic clinical tests and must be ordered by a physician: * A clinical report.This is medical information you and your physician can use. Pathogenic variants and carrier status are included in this report. * Pharmacogenomic report from Kailos Genetics, a HudsonAlpha associate company (pharmacogenomics are how your genes impact your response to medications). The test explores more than 100 different medications and how your body will react to them.

Patients are seen at the Smith Family Clinic for Genomic Medicine,

which is on the HudsonAlpha campus. Dr. Bick and a team of experienced genetic counselors get a medical history and provide pretesting counseling to explain the nuances of genetic testing.

“It’s important to remember that what you learn about your genome isn’t just yours, it impacts your whole family,” Bick reminds patients. “Before undergoing this testing, we encourage open conversation with family members around just what they would and would not want to know about their potential futures.” Delivering that type of information is part of Kelly East’s role. She is a certified genetic counselor who helps patients understand just what they’re getting into. “Not only what their family will want to know, but just what will the patients themselves be comfortable with? Some people don’t want to know about particular disease risk, such as Alzheimer disease. Others want to know absolutely everything. It’s our job to make sure they understand what information they will get, and how it could impact them,” explains East. For example, while federal law protects people from having their health insurance impacted by genetic testing, those same protections don’t extend to life and long-term disability insurance. And while it is protected health information like any other doctor visit or medical test… “In this era of social media, people self-disclose a great deal more information than the generations before them. So while it’s not legal for a potential workplace to surf Facebook and learn about (continued on p. 8)

Understand your health with your own DNA... The HudsonAlpha Institute for Biotechnology introduces Insight Genome: a unique program to truly personalize healthcare through the world’s most high-tech and complete measurement available: the human genome. From the six billion bits of information contained in your DNA, our world-class genetics and genomics physicians and scientists can tell you:

• conditions you are at risk for • specific disease risks you might pass on to your family • medications that could be most effective for your overall care

Learn more today at www.smithfamilyclinic.org/insight-genome

Inside Medicine | april-may 2017

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} HEALTHY LIVING

SAVE Your KNEEs by Ben Macklin

T

he knee is the largest joint in the body. It is also one of the most complex and most vulnerable joints in the body. The knee is comprised of 2 joints, 4 bones, and 14 ligaments. It requires at least 12 muscles and perfect balance between the hip and ankle to function properly. While walking, our knees support 1.5 times our body weight; when climbing stairs it’s about 4 times our body weight; and when squatting it’s about 8 times our body weight. The knee joint doesn’t have much protection from the daily stress we put on them. Dr. Brett Franklin, knee specialist at SportsMED Orthopaedic Surgery and Spine center notes, “Knee pain is one of the most common complaints bringing people to the orthopaedic office. There are multiple causes including traumatic and chronic conditions.” The most common knee injuries are acute injuries, or sudden injuries resulting from a traumatic event, such as a fall, collision, or twisting motion while the foot is planted in the ground. Examples of acute injuries include: fractures and dislocations, sprains and strains, tendon tears, meniscus tears, and ligament tears. Acute injuries happen quickly, and you usually know just how bad the damage is immediately after the injury occurs.

(“Genetics” continued from p. 7)

your genomic testing and that you may be at higher risk for a certain disease and then not hire you because of it, there’s no absolute guarantee that might not happen,” warns Jacob. People who decide to do the Insight Genome also have the opportunity to participate in a unique research study about the impact of genomic sequencing. In the study, researchers at HudsonAlpha hope to learn how the return of genomic sequencing information impacts participants in terms of utility for health, and its perceived utility. Participants in the study will receive a personalized research report from their genome sequence which contains risks variants in their DNA that are linked through studies to common disease risk. Examples include some types of cancer, heart disease, and musculoskeletal conditions. The research report provided to participants also will give information on specific traits, a noted example being whether one is able to smell asparagus in their urine (not a joke). So who is likely to do Insight Genome? Howard Jacob explains. “I’ve had my own genome done. Several other researchers at HudsonAlpha have also been sequenced. Others are discussing it. While I’m lucky and didn’t learn anything catastrophic, I learned very valuable information about medications I take and how one just wasn’t working. That was very useful for me. Adults who want to have children. Who want to empower themselves to engage in better prevention strategies. Who want to do everything they can to be healthy,” Jacob believes. 8

Inside Medicine | april-may 2017

“We have had people of child-bearing age, and people up into their 80’s. This is a very inquisitive, smart city and there is a lot of interest in science. The reasons people decide to do Insight Genome vary, but we are hearing the same feedback regardless of those reasons: they found it useful.” While a physician referral isn’t necessary, Dr. Bick encourages people thinking about genomic testing to have a conversation with their primary care doctor anyway. “This works best in a triad of care: you, your doctor, and your genome. The information you learn, that your physician learns, is best explored and acted upon with sound medical knowledge,” Bick says. While physicians are becoming more comfortable with the integration of genomics in the clinic, some feel they need more training. For that reason, HudsonAlpha held a Genomic Medicine Conference in summer 2016, and plans to hold another in March of 2018. “I truly believe this is a better way to practice medicine. I believe we are saving lives already through diagnostics, and will make lives better through genome sequencing for ‘the rest of us.’” -- Howard Jacob, PhD The cost of Insight Genome, which includes the pre- and posttesting physician visits, genomic counseling and the tests, is approximately $7000. For more information on Insight Genome, visit www. smithfamilyclinic.org/insight-genome. To learn more about the Insight Genome research study, visit hudsonalpha.org/insightgenome.


Symptoms caused by Acute Trauma to the Knee • Significant swelling and stiffness • Pain, tenderness, and warm to the touch • Weakness or instability of the knee joint • Hear a popping or crunching noise at the time of injury • Locking, or inability to straighten the leg Treating for Knee Injuries with the R.I.C.E. Method • Rest: reduce daily activity, or take a few days off from intense activity • Ice: 20 minutes every 4 hours for 2-3 days to help with pain and swelling • Compression: use an elastic bandage or wrap to keep swelling down and add support to the knee joint • Elevation: place a pillow under your heel when you are sitting or lying down to reduce swelling Overuse injuries are another cause of knee pain. Overuse injuries are common among weekend warriors, and can be the result of the sudden changes in activity level. A pickup game of basketball or the start of a new slow-pitch softball season is a distinct change in activity level that can result in overuse injuries. Overuse injuries are easily identifiable and symptoms appear almost immediately. How to Prevent Overuse Injuries: • Warm up properly before and after any activity • Daily exercise and stretching keep muscles strong, flexible, and ready for activity • Gradually increase your activity level • Wear activity specific shoes with good arch support • Give your body time to recover Another common cause for knee pain is chronic repetitive stress. These types of injuries can be a bit of a head scratcher to diagnose, because unlike acute trauma or a sudden change in activity level, there usually isn’t a specific event that caused the issue. Repetitive stress injuries develop slowly over time, and are caused by the gradual buildup of irritation to the tissues in the knee joint. An example would be a painter who works for years with no problems, until one day notices some discomfort in their knee. Knee injuries from repetitive stress can often times be the most difficult for people to overcome. How to Reduce Knee Pain cause by Repetitive Stress • Physical Therapy program designed specifically to your needs • Exercise using low impact activities such as elliptical, bicycles, or swimming pools • Braces can help reduce pain and improve mobility • Anti-inflammatory medications • Joint injections • Surgery Dr. Brett Franklin adds, “Most knee conditions can be managed and evaluated in a conservative manner. Physical therapy, bracing and joint injections can help alleviate pain and improve daily function. If conservative treatments are unsuccessful, it might be time to consider surgical intervention.”

Do these therapy exercises regularly and

Your KNEEs will Thank you Quad Set: Slight Flexion

1. Tense muscles on top of thigh, hold 5 seconds 2. 10 repetitions per set, 1 set per session, 2 times per day

Straight Leg Raise

1. Tighten muscles on front of thigh, then lift leg 8-10” from surface, keeping knee locked 2. 30 repetitions per set, 1 set per session, 2 times per day

Wall Slide

1. Leaning on wall, slowly lower buttocks until thighs are parallel to floor 2. Hold 5 seconds 3. Tighten thigh muscles and return 4. 10-30 repetitions per set, 1 set per session, 2 times per day

Terminal Knee Extension

1. Face anchor with knee slightly bent and tubing just above the knee 2. Gently pull the knee back straight 3. Do not overextend knee 4. 30 repetitions per set, 1 set per session, 2 times per day

Heel Raise: Bilateral (standing) 1. Rise on ball of feet, lower back down 2. 30 repetitions per set, 1 set per session, 2 times per day

Inside Medicine | april-may 2017

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} FEATURE

by Lisa Layton

On a rainy day in March, Kelly Reese and I had the privilege to sit and listen to an inspiring story of a beloved Huntsville doctor whose career ended much too soon when he was forced to become the patient and have his life significantly altered. Once this man began to tell his story, we witnessed truth in the old saying “that every dark cloud has a silver lining”. We felt a gentle reminder to hold onto our faith; that even though we may not see a purpose in God’s plans and timing, it does not mean that He is not hard at work in our lives.

So begins this doctor’s story…

In the 1960’s when many of America’s youth were living out their days of freedom and self-expression, there was a young man who chose a path of discipline and focus to enable himself to live out his dream of going into the medical profession. Don Wheeler was raised in the beautiful, rural town of Pikeville, Tennessee on a dairy farm. He learned a good work ethic at a young age. He went on to receive his undergraduate degree at the University of Tennessee, and later earned his doctorate at UT Medical School. After completing his internship year, Wheeler spent two years serving his country as a flight surgeon in the Air Force. Upon finishing his time in the military, he went on to complete his residency with a specialty in Obstetrics and Gynecology. After some prompting by his medical school friends who had moved to Huntsville before him, he made the decision to follow them and establish his practice in Huntsville as well. Dr. Wheeler, with his wife Kay and their two children, John David and Beth, began their life in the Tennessee Valley. He soon became the fourth partner in the well-known practice, Clinic for Women.


Dr. Wheeler spent many years working hard, building a thriving practice and becoming a popular member of the community. He was active in various organizations, enjoyed his church and became one of four founding members of The Surgery Center of Huntsville. His days and nights were spent doing what he loved most; being a devoted family man, a loyal friend and a gifted surgeon. Through the years, Dr. Wheeler delivered approximately 3,500 babies. He occasionally sees some of these babies he delivered who are now grown men and women with children of their own, and surprisingly, he remembers the mothers of a great many of them. During our conversation, he would light up talking about his days with his patients and reflected on touching stories of the women he cared for. He spoke softly about the times when he would have to deliver devastating news to a young mother and offer comfort to families during some of their darkest moments. This man is not just a doctor, he displays a compassion for those around him and never has taken lightly the God-given responsibility he had to usher his patients through some of their most joyous and devastating times. He truly cherishes the relationships he formed with his patients and never dreamed of being faced with the obstacles that were soon to come his way.

The journey…

In 1995, Dr. Wheeler was enjoying a game of golf when he experienced a severe pain in his right shoulder during a golf swing. This one incident would re-write his future forever. He knew he had injured himself but did not realize until later the full extent of his injury. The onset of his sudden pain and partial paralysis was difficult to diagnose. After consultations with multiple specialists, Dr. Wheeler was referred to a neurosurgeon where a diagnosis of “entrapment of the suprascapular nerve” was made. Surgery was performed, and the prognosis was that full function was to be expected, but that it could take two years. A few months after surgery, Dr. Wheeler was involved in a skiing accident which resulted in a crushing injury to that same shoulder. He underwent months of physical therapy. He confirmed that doctors do not always make the best patients, and unfortunately, he was going to be a patient for quite a long time. This brought on radical changes in the way he was going to manage his busy practice. Dr. Wheeler was up for the challenge if it would enable him to return to his quality of life, both personally and professionally. Throughout this, he was optimistic this would not be a permanent condition. However, after months of physical therapy, he was told by his doctors that he needed to face his new reality. This condition was not going to improve, and decisions about his professional future would need to be made.

The road to recovery and healing…

This was quite the emotional blow to a man who never questioned that he would not be ok. Medicine is such a huge part of who a

physician is that in Dr. Wheeler’s exact words, he “was psychologically, emotionally and physically devastated”. Aside from feeling the loss of his identity, he likened it to losing a spouse. You do not know how you will live with the loss, but you realize that life goes on. However, you never quite get over the devastating disappointment of losing what was and the insecurity of not knowing what will be. You realize that you have to find new and different ways to replace and fulfill what once defined you. During this time of making sense of his situation, a friend encouraged Dr. Wheeler to attend a healing service at the Episcopal Church of the Nativity. This service involves prayer and petition to God to grant healing of the mind, body and spirit. At the time, while he was growing stronger spiritually, his body was remaining the same. He realized he was going to have to walk away from patients and a profession he had loved for 31 years. Facing the fact that a life of retirement was inevitable, he began his process of acceptance and seeking healing in ways he could never have imagined. We all face losses of many kinds, and when we are eventually able to reflect on events in our lives and find peace and joy in the memories, we see that another form of healing has begun to take place. When asked what he misses most, Dr. Wheeler quickly said that he misses the interaction with his patients and the relationships he formed. He misses working with his partners and the office staff because they were and will always remain his family. He told us that they left his name on the door for years; he still has a key and loves to visit often, although initially, these visits were emotionally difficult. When we spoke with one of his partners, he said that Dr. Wheeler’s absence was felt most in the simple day to day presence. Their camaraderie was a brotherhood, and his compassion was unmatched. Not having him readily available to mentor or offer insight and advice was a loss to his partners and medical staff. It was an adjustment for them to go to a work place where such a void was strongly felt. One of the most empowering things Dr. Wheeler said is that throughout his professional career, he has no regrets in how he treated his patients and ran his practice, even after seeing what life was like being in the patients’ shoes. He has had a good life, and he has lived it well. He has had trials and outcomes that he would not have chosen for himself or for anyone else, but he has learned to enjoy rewards that he never knew existed until he was forced to “stop and smell the roses”. God has not stopped writing Dr. Wheeler’s story and those of you who know him, or were fortunate enough to be his patients will always appreciate his warm smile, kind eyes, loving compassion and wicked sense of humor. He is a true gift to all who know him and an inspiration to anyone going through something similar. Inside Medicine | april-may 2017

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Bike share Mobility, health, community. by Ellery Miller

As Downtown Huntsville becomes an increasingly popular hub of activity in the region, Downtown Huntsville Inc.’s CEO and President, Chad Emerson, saw the need for more biking/pedestrian transportation options. When Zagster opened and reported that Huntsville, AL had the second-biggest debut of all of Zagster’s 150 bikeshare programs, we realized Huntsville agreed. Forty people signed up for the Downtown Huntsville BlueBikes within mere hours of it opening. Emerson secured a sponsorship with Blue Cross Blue Shield of Alabama for the high-tech bikeshare program. Zagster, the leading turnkey bikeshare company, agreed to provide Downtown Huntsville with 40 bikes at eight different stations, including full maintenance on the system. The way the Downtown Huntsville BlueBikes presented by Blue Cross Blue Shield of Alabama works is people can download the app Zagster, sign up with their name, address, and payment info, select the plan they’d like ($25 annually is the best deal, with all rides under one hour being completely free), and are ready to ride! When you’re ready to take a bike for a spin, simply enter the bike number located on the back of the bike into your Zagster app and it will send you an unlock combo. They locks are Bluetooth-powered so the combos change regularly. You are then free to bike around Downtown Huntsville and can plug in to any of the stations, from Five Points to Campus 805, the Avenue to 200 Westside Square. If you sign up for a yearly or monthly subscription, all of your rides under one hour are completely free. Rides over one hour are $3/hour up to $24. If you want to rent a bike for the night, for Bikes and Brews, for instance, you’ll only be charged up to $24. If you want to ride a bike from any of one of the eight stations to another, lock it in, end your ride, do whatever you need

to do, check a bike back out, and ride back, you pay $0. There are no limits to how many underone-hour rides a day you can take. Local businesses sponsored each of the stations for the bikes to “plug into.” The eight stations are at Clinton Ave., Twickenham Square, and Five Points sponsored by Toyota Motor Manufacturing Alabama, 200 Westside Square sponsored by Crestwood Medical Center, Von Braun Center (VBC)/Big Spring Park West sponsored by Huntsville-Madison County Convention and Visitors Bureau, Butler Green/Campus No. 805 sponsored by Alabama Colon & Gastro, P.C., Church Street/YMCA sponsored by Huntsville Committee of 100, and The Avenue sponsored by SportsMED Orthopaedic Surgery and Spine Center. All are currently operational except the Avenue and the VBC, which are coming soon. The Downtown Huntsville BlueBikes serve a critical need for transportation and tourism in our city. The hope is that the bikes will be used for traveling to meetings, visiting destinations such as the Clinton Row Shopping District and Campus 805, and to socialize biking in Downtown Huntsville. The user ability is topnotch with Downtown Huntsville being one of the first hightech programs in the country and claiming the first Zagster program in Alabama! The bikes are the newest model and feature a light, durable, and easy-to-maneuver design, let’s not forget about the basket, bell, lights, and gear shifters! If you’re thinking about driving or walking around Downtown Huntsville, try a Downtown Huntsville BlueBike instead and see how the program works for you! We’d love to hear what you think. Email Ellery@downtownhuntsville.org with any questions.


by Jeffrey Hull, M.D.

A

fter practicing pediatric medicine for 35 years, I was looking forward to the approach of retirement. About five months before the date for my retirement, I was experiencing some mild but puzzling symptoms. Thinking back, these symptoms had been very subtle for about 12-18 months or so. I was noticeably weaker and had a mild tremor (shaking) in my hand when holding a fork at meals. I also had a couple of other mild but mystifying experiences, such as loss, years earlier, of my sense of smell. I literally could not smell a dirty diaper that mothers would instantly notice. Another common symptom was writing very small, no matter how hard I tried to write larger. However, it was a sharp eyed nurse, and problems playing pool that motivated me to go to a neurologist. I felt sure that my tremor and other symptoms were simply age related. My wife went with me to see the neurologist and left an hour and a half later. The neurologist diagnosed Parkinson disease, confirming my worst fears. I was numb. Gradually, shock changed to sadness, anxiety, and depression. By about three months after my diagnosis, I was at a low point, physically and emotionally. I was on anti-Parkinson medication, which seemed to help to some degree with the symptoms of mild tremor and weakness, but I felt depressed and alone. It did not help that while I worried about my illness I was very busy with the closing of my medical practice. I thought there must be something to do more than waiting for new tremors.

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Inside Medicine | april-may 2017

Then one day the local newspaper printed a human interest story about the Rock Steady Boxing therapy for Parkinson disease. A group was just forming in Decatur. I called the contact number right away, and I have been in the program for six months. What is Parkinson disease? Parkinson (or Parkinson’s) disease, or Parkinsonism, is a chronic degenerative disease of the brain for which there is so far no cure. It is caused by death of certain types of brain cells which manufacture a substance, dopamine, which is essential for normal function of muscles. Progressive loss of dopamine proceeds over a typical course of 10 to 15 years, although some patients have much slower progression of symptoms. The disease most often affects people 50 years or older, but may appear in younger persons as well. Physical findings in Parkinson disease include a characteristic stooped, shuffling gait; facial weakness (called “mask face” that makes one appear to be angry); eventual trouble swallowing properly; and most characteristic the tremor. This shaking often involves one hand first, and will eventually affect all muscles of the body after a number of years. The Rock Steady program The main method of treatment of Parkinson disease has largely been the use of drugs. Chief among these medicines is L-dopa, a pill that can relieve tremor and other symptoms temporarily, but does not alter


the underlying and ongoing deterioration that remains. Side effects are common, requiring careful monitoring and medication adjustments. Parkinson patients have generally been encouraged to exercise to stay as limber as possible. But in the last few years, research has been found that a program of more strenuous exercise combined with fine motor drills, gait training, and a variety of similar drills targeting significantly extend better well-being. The program is called Rock Steady Boxing. As the name implies, it is centered around non-contact boxing drills, meaning that participants do not hit each other, but spend time practicing flexibility and balance, then fitness and strength, and finally boxing moves and punches on the heavy bags, speed bags, shadow boxing, and a variety of boxing moves that teach the body to restore movement, and reduce tremor. Since beginning the program, Rock Steady Boxing has been a Godsend for me. Rock Steady is a physical

more fluid. Ask us what we are doing, and we say: fighting back! ................................................................

training program to retrain the nervous system to cope with long term effects, but it is a lot more than that. It is a close knit group from diverse backgrounds and different stages in the disease but bound by a common enemy, Parkinson disease. It is about group members helping one another, encouraging, listening - more like a “family” than I ever expected. And most importantly, the program works. Muscle strength increases, balance improves, and joint movements are

Rock Steady Boxing is a nationwide program with programs scattered throughout the country. In our area there are local groups in Decatur and Huntsville. Each leader has been trained at the national headquarters in Indianapolis, Indiana. In Decatur, sessions are from Noon to 1:30pm on Monday, Wednesday, and Friday at Bender’s Gym where they generously provide the use of the gym space at no charge. In Huntsville, sessions are from 9:15 – 10:30am on Monday, Tuesday, and Thursday at a local gym located at 3228 Leeman Ferry Road, Hunstville, AL (Behind Matrix Gym). The phone number for the Decatur location is 256-303-0710, or visit their website at www.decatur@rsbaffiliate.com. For the Hunstville location, the phone number is 256-513-8164, or visit their website at www.rocketcity.rsbaffiliate.com.

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Robert Maynor, M.D.

Michael Salter, M.D.

Jennifer Martin, O.D.

William Mitchell, M.D.

Brian Baxter, O.D.

We are proud to welcome Dr. Michael Salter to our exceptional team of doctors!

Call us today to SEE what you’ve been missing HUNTSVILLE: GUNTERSVILLE: 256.533.0315 256.582.1211 www.maynorandmitchell.com Inside Medicine | april-may 2017

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Inside Medicine | april-may 2017


} FEATURE

by Sally Barton

It’s Saturday morning, February 25, 2017. I wake up at 6:15 a.m. anxious to get to this walk I’m involved in and scream “JAY?” Tears start flowing down my face and I’m having shortness of breath. Another dream, another reminder that I can’t kiss my son, smell my son, hug my son, tell him how much I love him, tell him how proud I am to be his Momma, tell him he has gorgeous blue eyes and Melissa is quite a lucky lady, watch him play with his precious niece Brinkley and little Finn man, watch him play softball, meet him for lunch, find out how his day was, or have him over for our routine Sunday night supper after a round of golf together with his Daddy! We get up, eat breakfast and hurry to the park to meet my friends from NOT ONE MORE ALABAMA and their families. I have a best friend with me from Huntsville, Shawn Bentley and three friends from Atlanta: Deborah, Diane, and Cindy. They are four parts of my rock star friends that are ALWAYS there for me! I see thousands and thousands of people! People with shirts on slamming heroin, signs with pictures of loved ones who are gone or who are in therapy, buttons on shirts with an addict’s picture; like the 13 buttons with Jay’s picture on them from all of the sports he played. TEARS start flowing again. I meet up with my group and love seeing the matching shirts with NOT ONE MORE ALABAMA on them. We get a group shot and here come the tears again. I personally know what all these people feel like. I hate it, but I can relate to the pain. I know what it’s like to feel that knot in your throat, that fear. The fear that death is coming, that you’ve done everything you can think of to help your loved one. You’re broke, you’re tired, you are absolutely longing for a day, just one day when you can feel like that loved one is safe, safe from the devil. To me, fear is this: Feeling Every Addicts Reality! Well, I felt it for over 12 years. The going in and out of recovery, praying that this time he could beat it, going to AL-Anon meetings because I thought I was crazy – are just some of the fears. Jay Barton, my precious son, my only son was born on May 19, 1984. He died on July 5, 2016 at 3:15 a.m. in the morning with a needle in his left arm and his chip in his right hand. That needle was NOT heroin. It was mixed. This Birmingham walk was a blessing to me. Knowing that there are thousands of people out there that you can turn to for help with recovery, addiction, love and support is a very heart-

warming feeling to me. It’s a feeling that I have longed for since July 5, 2016. I’m a Momma who cares, who is not ashamed, who feels a calling to help others get through this fear, this nightmare, this train wreck. Not One More Alabama is a way for us to fight! God set my son free! Free from the devil! God also set me free, Free from FEAR! I do not feel alone anymore. The only way to fight the devil is to LOVE! The Birmingham walk was a whole lot of Love! Not One More Alabama is a whole lot of LOVE! That walk was a day where God made the sky a gorgeous blue color just like my son Jay’s eyes. God is up there smiling at all of us because he knows we care together and together we can fight this evil heroin epidemic with LOVE. A quote from the Bible that always catches my attention is from Romans 5: 2-5: Suffering produces perseverance Perseverance brings character Character brings Hope And Hope does not put us to shame, because God’s love has poured into our hearts through the holy spirit who has been given to us. I will spend the rest of my life helping to fight this disease because I have God on my side. ALL MY LOVE,

Sally Barton Inside Medicine | april-may 2017

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} HEALTH

FEATURE

understanding

dizziness by Kari Kingsley, MSN, CRNP

Define dizzy. It’s not as easy as it sounds. What one person may describe as an intermittent spinning sensation may be described as lightheadedness to the point of almost passing out by another. Others may feel they are experiencing a constant drunk and staggering feeling at all times. Dizziness is a catch-all term for a variety of different sensations caused by many medical problems. Because dizziness is subjective rather than objective, it can be difficult for patients to describe. For those of us on the frontline of medicine, it can be Pandora’s box in terms of evaluation and differential diagnoses. That one simple sentence, “I’m dizzy”, could range from a simple ear infection to a brain tumor. Our job as clinicians is to know the difference.

W

ebster defines dizzy as an adjective that causes “a feeling that you are turning around in circles and are going to fall even though you are standing still”. The term can also mean mentally or emotionally upset. Rising co-payments and deductibles are making me maddeningly dizzy! Dizzy also has a connotation of “feeling silly” or “tending to forget things”. Public misconception and stigma of the word sometimes delay those who want to receive help for fear of scrutiny of hypochondriasis and psychological conditions such as anxiety. Dizziness is a symptom of a medical condition and not a disease by itself. Dizziness can be classified as peripheral and central. Peripheral dizziness is caused by conditions affecting the ears. Central dizziness arises from conditions affecting the brain and central nervous system such as a lesion in the brainstem or cerebellum. So, what qualifies someone to write an article on dizziness? Well, if you remember the 1980’s infomercial: “I’m not only the president of Hair Club for Men, I’m also a customer!”; that pretty much sums up my perceived knowledge-base and repertoire on the subject. I have worked in Otolaryngology as a Nurse Practitioner for the last 7 years. For the last 3 years, I’ve had the privilege of working alongside Dr. Neeta Kohli-Dang at Huntsville Ear, Nose, and Throat. We devote a large portion of our practice to diagnosing and treating dizziness. Having been diagnosed with Meniere’s disease myself 6 years ago, I have developed a passion for treating dizziness and feel like I could write a novel on the subject. I’ll save you the time (and associated papercuts) and give you the Cliff Notes version so that the next time you or a loved one is experiencing dizziness, you’ll have an idea of how to get off the merry-go-round. Patients probably wonder, how does a provider assess, diagnose, and treat a dizzy patient? The secret to delineating a proper dizzy diagnosis begins with obtaining a proper and thorough his18

Inside Medicine | april-may 2017


} HEALTH

tory. You must be able to recognize which key words in a patient’s history that scream abracadabra! You are on the right track! The goal of this article is to provide you with the ammunition to delineate symptomatology of dizziness in more detail so that you will obtain a proper diagnosis quicker and begin treatment sooner. If we pretend that all of the many medical conditions causing or contributing to dizziness are represented by flowers on a dogwood tree, seeking the proper diagnosis seem like finding a needle in a haystack. But if you think of the word dizziness as the trunk of a tree, with certain key phrases (or “abracadabra” words) directing you down varying branches, the job gets much easier. Let’s start with the most common conditions and work our way on to the “zebra’s”, as we in the medical field like to call those rare conditions that news shows love to cover (e.g. Brain eating amoeba causes dizziness in 33-year-old nurse practitioner). For your edification, I’ve notated key “abracadabra” words in bold. Perhaps one of the most common causes of dizziness and least dangerous is Benign Paroxysmal Positional Vertigo. However, if you ask anyone who has ever suffered from BPPV, they will tell you this condition is anything but benign. Positional vertigo is condition arising from the inner ear in which people experience brief, repeatable spells of a spinning sensation when changing position. The condition can be acute and chronic as well as atypical (not responding to common therapy, although this is rare). Tiny calcified otoliths (or “crystals”) that have come loose in the vestibular canals create the sensation of a true vertigo (sensation of spinning) when the head is reoriented relative to gravity. The condition is diagnosed based on the Dix-Hallpike maneuver eliciting nystagmus (specific eye movements). Treatment of BPPV consists of a simple procedure called an Epley maneuver, which moves the otolith crystals out of the balance canals to be reabsorbed by the body. “PLEASE do your Voo-doo maneuver” is a request I frequently get from several patients when symptoms recur. Many of them get a good chuckle at the fact that, yes indeed, their rocks have come loose and they’ve temporarily lost their marbles. Brandt-Daroff exercises can also be helpful. Medications are rarely needed for this condition and in fact, can sometimes hinder progress. One of the next common inner ear conditions is Meniere’s disease, which is probably my favorite condition as a clinician to treat. If I were to “speak” all dizzy languages, then this would be my native tongue. Probably because I have this condition and relate to those with it. Sadly, what I experience is only a fraction of what other patients feel. Picture yourself on a seemingly never ending tilt-a-whirl in which your right ear feels as

FEATURE

if it might explode from pressure as a car horn blares roaring tinnitus in your ear. Just about any medical provider assessing a patient with these classic symptoms would suspect an inner ear issue. Classic Meniere’s patients present with bouts of dizziness that can be described as an “off-balance sensation” all the way to true “spinning-vertigo” usually coming in spells that can last several hours. Generally, there is significant ear pressure and fullness in one or both ears accompanied by ringing or roaring tinnitus. Patients may also have low-frequency hearing impairment. But you can also have atypical forms of Meniere’s, with only some of these symptoms. Diagnosis is based on the patient’s history, audiogram, and vestibular testing. Magnetic resonance imaging (MRI) should be conducted to exclude transient ischemic attack (TIA), stroke, acoustic neuroma, or a tumor of the endolymphatic sac. Treatment of Meniere’s disease generally begins with a step-wise approach. Patients are advised to lower their sodium intake and also eliminate other triggers such as caffeine, tobacco, and alcohol. As a full-time working nurse practitioner student being told to limit my caffeine intake, I literally spewed coffee from my mouth, laughing, as I spilled Mountain Dew in my lap. Mediations such as diuretics, steroids, anti-emetics, and vestibular suppressants can be helpful for some patients. Physical therapy and an exercise regimen are advised for many. Transtympanic dexamethasone perfusion therapy provides a minimally invasive, in-office procedure that provides significant lasting relief for most patients. Invasive procedures such as endolymphatic sac decompression and shunt placement should be reserved for more severe cases. Destructive procedures, such as gentamycin perfusions, labyrinthectomy, and vestibular neurectomy can cause irreversible effects such as permanent hearing loss and are reserved for dire cases. Most patients respond well to steroid perfusion therapy and very rarely require further action. I am grateful to work for an ENT that uses cutting-edge technology and the safest techniques possible to perform these procedures on myself and her patients. And likewise, I think she is grateful NOT to have a staggering and stumbling nurse practitioner wobbling around her office! Infectious processes such as vestibular neuritis result from inflammation in the inner ear thought to be bacterial or viral in origin. Symptoms can be precipitated by a head cold and are generally described as severe vertigo in which the patient is unable to walk without assistance. Labyrithitis is suspected when symptoms are accompanied by unilateral sudden hearing loss. Patients usually experience associated nausea, anxiety, and malaise as the brain receives distorted balance signals from the inner ear. Treatment in Inside Medicine | april-may 2017

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the acute phase consists of vestibular suppressants such as Valium or Meclizine, however, patients are encouraged to wean these as soon as possible to avoid potential addiction. Physical therapy and specific vestibular rehabilitation is crucial for some patients. Physical therapy combines repetitive head, eye, and postural changes with walking exercises in the hopes of achieving permanent compensatory changes in the brain. Patients that complain of lightheadedness should be evaluated for syncope and near syncope. Although sometimes these symptoms can be descriptive of otogenic causes, more often the culprit is vascular. Workup for orthostatic hypotension, poor blood circulation, TIA, cardiomyopathy, heart attack, and heart arrhythmia should be considerations for patients that present with dizziness. Syncope work-up can be extensive but necessary for some. Laboratory considerations should include serum glucose, complete blood count, electrolyte levels, renal function tests, cardiac enzymes, creatine kinase, and urinalysis. Imaging studies are also critical. Again, use your “tree branch” methodology to elicit a proper diagnosis. If a patient is dizzy with fever, leukocytosis, and cough, consider a chest x-ray to rule out pneumonia. Other etiologies that can present with lightheadedness include congestive heart failure and pulmonary masses. CT head, chest, and abdomen are considerations when accompanying symptoms warrant them. Rather than a shot-gun approach to medicine, ask as many questions as possible and try to narrow your target range. MRI and MRA are helpful in delineating brain and neck structures to assess for abnormal vertebrobasilar vasculature. Ventilation-perfusion scanning is appropriate for patients presenting with symptoms of a pulmonary embolism. Echocardiogram is helpful in evaluating mechanical cardiac causes of lightheadedness. EKG, Holter/Event monitoring, and stress testing can be helpful (and sometimes critical) to diagnosing arrhythmias, myocardial infarctions, or myocardial ischemia. Don’t panic! If you are a clinician, know your scope of practice and call in outside resources. Consult otolaryngology, neurology, neurosurgery, cardiology, pulmonology, nephrology, or endocrinology. You are not alone! A multitude of neurological conditions can present with dizziness. Migrainous vertigo or vestibular migraine is a type of migraine causing dizziness associated with severe headaches. Additional neurological conditions causing disequilibrium include multiple sclerosis and Parkinson’s disease. These processes generally cause deconditioning which can lead to progressive loss of balance. Cerebellar ataxia can be caused by a wide variety of infectious, immune mediated, metabolic, toxic, and degenerative etiologies. Discussion of any serious head injuries should always be included in the work-up of a dizzy patient. Brain tumors can also cause dizziness. Again, consult neurology or neurosurgery as needed.


} HEALTH FEATURE

Medications. Here’s a biggie! Run and grab 4 pill bottles from your medicine cabinet. I’ll bet you a dollar to a donut that somewhere on that long list of “possible side effects” you’ll find dizziness. Many medications can cause dizziness. Common culprits are blood pressure medications, antidepressants, sedatives, tranquilizers, and stimulants. However, in clinical trials, the FDA requires manufacturers to list side effects that occurred more often among patients taking the drug than those receiving placebo. Some companies even choose to list symptoms reported in the experimental AND control groups. Thus, common conditions like headaches, nausea, and dizziness will commonly show up on medication side effect profiles. Polypharmacy is another major contributor to dizziness. Polypharmacy is the use of four or more medications and can affect as many as 40% of elderly adults living at home. When assessing dizziness, always take in to consideration a person’s medication list. As I mentioned above, numerous medications can lead to dizziness. Adding medications that cause dizziness to medications that cause dizziness is a recipe for disaster! Many people have multifactorial dizziness or a combination of factors contributing to their symptoms. Balance requires a person’s eyes, ears, sensory nerves, and proprioception to work properly. When one’s equilibrioception has a kink in the chain, the bicycle won’t work properly. All of these components work together to tell a person where they are in space and time. Let’s take a classic diabetic male patient for example. Chronically elevated blood glucose levels have caused permanent damage to the microvascular blood supply in a person’s feet (peripheral neuropathy). Suddenly he no longer has sensory feedback to tell him where he is standing. The same high blood sugar has affected his eyesight causing diabetic retinopathy. Now he can’t see. Lastly, his fluctuating blood glucose levels are sending signals to his brain that “something’s not right” causing disequilibrium and lightheadedness. A break down in one of the critical faculties for balance can cause an issue. A break down in them all can mean big trouble. Ok, now the zebras. These conditions are rare but do exist (remember, I said zebras, not unicorns). Arnold Chiari Malfomation is a neurological condition in which brain tissue extends into the spinal cord. Patients often times present with headaches and dizziness described as a bouncing sensation when walking. Treatment varies based on the severity of prolapse and symptomatology. Mal de Debarquement Syndrome is a rare neuro-vestibular condition that occurs when a person exits a sustained motion event such as a cruise or aircraft flight. A major diagnostic indicator is that patients may feel better while in passive motion such as driving or riding in a car. Medications such as vestibular suppressants and vestibular rehabilitation are the mainstay of therapy. A perilymph fistula or labyrinthine fistula is an abnor-

mal opening in the bony capsule of the inner ear causing perilymph fluid to leak from the semicircular canals into the middle ear. PLF is usually caused by trauma although can be congenital or a complication of some ear surgeries. Middle ear exploration is often required for diagnosis. Treatment usually includes watchful waiting and avoidance of activities that increase intracranial pressure (weightlifting, scuba diving, etc). Again, vestibular rehabilitation may be indicated for some. Superior semicircular canal dehiscence syndrome is a rare thinning or complete absence of part of the temporal bone overlying the superior semicircular canal portion of the vestibular system. Patients often present with dizziness, autophony (hearing one’s own self-generated noises such as speech, eye movements, heartbeats, etc.), and positive Tullio’s phenomenon (sound induced dizziness). Diagnosis is made through coronal CT scan of the temporal bone. Treatment again depends on severity of symptoms but can include middle fossa craniotomy with soft tissue grafting or use of bone cement to surgically resurface the affected bone. Vestibular schwannoma or acoustic neuroma is a benign tumor growing along the vestibulocochlear nerve. Incidence is thought to be 1 to 2 people per 100,000 per year. Symptoms generally include asymmetrical hearing loss with speech discrimination impairment along with tinnitus and dizziness. Any patient presenting with these symptoms should undergo a MRI contrast with specific cuts through the internal auditory canal. Treatment options vary based on symptoms and patient’s age but include watchful waiting, surgical resection, and radiation treatment. Dizziness can be an overwhelming symptom unless you know what key phrases in a person’s history to watch for. Ask questions. Look for the “abracadabras” and Ah-hah! moments! Don’t become overwhelmed. Use your resources. Consult ENT. The goal of treating dizziness is to find the underlying cause and manage the condition effectively. There is nothing more gratifying as a clinician than properly diagnosing a patient, starting the proper treatment regimen, and having your patient come back to me and say, “THANK-YOU, I’M MUCH BETTER”. So… after reading this article, if you weren’t dizzy before… You probably are by now! J And yes, brain eating amoebas probably cause dizziness. I’ll let you know when I see a case. Please call 256-882-0165 to schedule an appointment with Kari at Huntsville Ear, Nose, and Throat. Kari Kingsley is a board certified acute nurse practitioner. She graduated from the University of Alabama in Huntsville with a Master of Science in Nursing. She maintained a 4.0 GPA throughout her training and graduated with honors. Kari is licensed by the Alabama Board of Nursing and certified by the American Nurses Credentialing Center. She currently serves on the Board of the North Alabama Nurse Practitioner Association and is the Huntsville Chair-person for the American Foundation for Suicide Prevention.

Inside Medicine | april-may 2017

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} SURGICAL TECHNOLOGY

Lateral Fusion After what seems an eternity waiting, filled with angst, fear, most certainly a sense of resignation, you walk into the office of the Spine Surgeon. You have dealt with chronic severe low back pains with or without intermittent leg numbness, tingling, and again pains. The long journey that got you here included a laundry list of treatments: including enough medications you could fill a pharmacy, exercises, physical therapy, and very likely multiple epidural injections. Imaging tests, including MRI and X-rays, have identified and localized your pain generator and you resign to the idea of continuing the treatments to date ad nauseum. Like it or not, you have now been identified as a prime candidate for spinal fusion. What now? Every day for thousands of patients across the United States these circumstances are their reality. However, obtaining personally applicable information on the internet, which is easy to understand, is close to impossible. Even more difficult is obtaining information on the various surgical options and understanding the personal ramifications of each of these. This is where you rely on your spine physician. For the sake of appropriate context, it is very important to know that low back pain is nearly universal with over 80% of the population experiencing symptoms that require treatment over their lifetime. Yet just a small fraction of these patients end up requiring surgical fusion. Luckily the great majority of patients with low back pain eventually heal and do not require long-term treatment. Unfortunately, for the remaining number of people, the options become limited and significant pains become a daily reality. So what information should you know about your prospective surgery? First, any discussion of fusion surgery should involve what we as surgeons are attempting to achieve. Fusion involves bridging of a spinal level, adjacent vertebrae and intervening disc, with bone to stabilize and eliminate motion 22

Inside Medicine | april-may 2017

For the Patient

across that level. Achieving successful fusion involves stabilization and removal of motion across that level, which is why we typically add screws and rods. This allows patients to be able to be ambulatory immediately after surgery without allowing gross motion that inhibits successful fusion. An added benefit of this early ambulation and activity involves reducing the incidence of complications, including blood clots and pneumonias. It is extremely common these days to achieve successful fusion not only with insertion of screws and rods, but also by adding additional stability and surface area for fusion with the use of grafts inserted into the disc space after disc excision. Traditionally, these grafts were inserted by entering the lumbar spine from the abdomen, meaning a second incision added to the back incision. As techniques evolved, we then turned to an approach that allowed insertion of a smaller graft through the very same back incision. Grafts were smaller because of limitations of the anatomy, i.e. nerve proximity, imparts to the safe access and visualization of the disc. However, with expert technique, this is a very good option for many. More recently however, the development and refinement of a newer technique marries less invasive, smallincision principles with ability to insert inherently more stable and large grafts. Spinal surgery is an ever-evolving field with the rate of progress amongst the most dynamic in all of medicine. One of the most exciting advancements in the last fifteen or so years is the development and refinement of Lateral-access fusion surgery. This involves accessing the spine and intervertebral disc through a small horizontal incision on the side of the abdomen. The offending disc can be excised and replaced with a relatively large graft, typically made of a synthetic plastic polymer. This graft, combined with screws and rod hardware, allow for the maximal strength possible in stabilization of the spinal level. There is still a requirement for a sepa-

by Javier Reto, MD rate back incision, but these incisions are typically much smaller and associated with less disruption of the lumbar musculature. There are several benefits to be had when using this type of construct. Primarily, it provides the necessary and optimum environment for local bone-forming cells to proliferate and form bone, thus leading to successful fusion. Another significant benefit includes the ability of the lateral graft to improve and often correct scoliotic curvatures and rotational deformities that so commonly occur in elderly patients. This exciting development in surgical technique is a valuable tool all spine surgeons have become aware of and truly accepted. Moreover, most spine surgeons have recently adopted this technique as part of their armamentarium in dealing with pathologies that require fusion surgery. The technique has gone through rigorous scrutiny and proven to be reliable and safe given appropriate training and experience. Where lateral access surgery was once looked at with suspicion and doubt, it has evolved on a level accepted as equal to and many times superior to that of traditional techniques. So you’re at the surgeon’s office and you’re about to discuss fusion surgery. Understand that for you, the correctly identified candidate, it becomes a well proven and significantly successful option. Furthermore, you have a number of techniques that help to achieve goals with success. With appropriate discussion, you should leave the office feeling more confident that the technique chosen is the one right for you.


HUNTSVILLE MADISON ATHENS DECATUR

Orthopaedic Surgery Sports Medicine Joint Replacement Spine Surgery Neurosurgery Physiatry Podiatry Workers’ Comp

256.881.5151

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esophageal

cancer

Dr. Michael Dohrenwend Board Certified, Gastroenterology Center for Digestive Health 256.430.4427

Karen Fox, CRNP

Are you 50 years old or older? Do you get heartburn weekly or more? Consider Esophageal Cancer or Barrett’s Esophagus Screening Please feel free to call our office for an appointment or visit our website cdhhsv.com. We are happy to help with questions, concerns, and screenings. Center for Digestive Health 7738 B Madison Blvd. | Huntsville, AL 35806 256.430.4427 | cdhhsv.com

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Inside Medicine | april-may 2017


Do you have heartburn? Are you at risk for Esophageal Cancer? Awareness…Education….Early Detection through age appropriate screening … is the best defense against illness. “The best defense is a good offense”. A good offense is being proactive instead of taking a passive role in your health. April is Esophageal Cancer Awareness Month. Know the facts so you are aware.

What is heartburn?

Heartburn is the most common symptom of gastroesophageal reflux (GERD). It usually feels like a burning sensation in the lower chest area. The burning sensation is caused by acid regurgitation into the esophagus. GERD is when food and/or liquids from the stomach travel back up into the esophagus. This movement of stomach contents into the esophagus causes irritation to the lining of the esophagus. Acid and other digestive juices from the stomach can cause damage to the lining of the esophagus. Some other or atypical symptoms people may experience from GERD include: regurgitation, sour taste in mouth, cough, difficulty swallowing, chest pain and hoarseness. It is important to note there are often no classic symptoms of GERD and some people have only minor symptoms.

Why is it important to pay attention to heartburn?

The most common symptoms of GERD is heartburn. According to the American Society for Gastrointestinal Endoscopy (ASGE) 20% of Americans experience heartburn. People with GERD are at an increased risk of developing esophageal cancer. According to American College of Gastroenterology (ACG) the diagnosis of GERD is associated with a 10-15% risk of Barrett’s esophagus (BE). Barrett’s esophagus is a condition where the esophageal lining changes to become similar to the tissue that lines the stomach. Barrett’s Esophagus is named after Dr. Norman Barrett, an Australian born British thoracic surgeon. In 1950 he described the term reflux esophagitis and the correlation of reflux to changes in the lining of the esophagus. The risk of cancer progression for Barrett’s Esophagus is based on the degree of dysplasia seen on biopsies and ranges from 0.5% to 7% per year.

Who is at risk for Barrett’s Esophagus?

Esophageal cancer is three times more common in men as opposed to women. The highest rate is found in middle aged Caucasian males with a history of heartburn for many years. The risk factors according to ACG include: male gender, age >50 years, Caucasian race, presence of central obesity, Chronic (>5 years) GERD symptoms, current or past history of tobacco smoking, and a confirmed family history of Barrett’s Esophagus or Esophageal Cancer (in a first-degree relative).

How is Barrett’s Esophagus Diagnosed?

A trained physician will perform an upper endoscopy (EGD)

for diagnosis. The patient is sedated for the procedure. A flexible tube with a light and camera on the end is passed through the mouth, into the esophagus and stomach. The outpatient procedure itself is usually less than 10 minutes. The physician will take multiple biopsies to confirm the diagnosis if it appears to be present.

Can Barrett’s Esophagus be treated?

Barrett’s can be successfully ablated by a specially trained doctor. Endoscopic ablation currently is recommended if Barrett’s Esophagus develops dysplasia. The goal is to ablate the Barrett’s and restore a normal esophageal lining. This procedure has a low complication rate and is done in an outpatient setting. Treatment does reduce one’s risk of the likelihood of progression to esophageal cancer. According to Esophageal Cancer Awareness Network (ECAN) the type of esophageal cancer caused by reflux disease (Adenocarcinoma) is increasing at a faster rate than any other cancer in the USA since the 1970’s. Only 1 in 5 people diagnosed with esophageal cancer will survive 5 years because it is most often discovered in late stages. The key to surviving esophageal cancer is early detection. Know the facts. Early detection saves lives. It is important to talk to your health care provider if you have symptoms of GERD.

What is Esophageal Cancer? There are two types of Esophageal Cancers: 1. Adenocarcinoma is the most common in the Western world and usually results from long standing GERD, persistent heartburn or reflux, and can be from progression of Barrett’s Esophagus. 2. Squamous cell carcinoma risk factors are tobacco use and excessive alcohol intake. Many cases of adenocarcinoma of the esophagus begin with Barrett’s tissue. Esophageal cancer is when cancer cells form in the esophagus. The esophagus is the muscular tube that moves food from the mouth to the stomach. Esophageal cancer starts at the inside lining and spreads outward. Surveillance Epidemiology and End Results (SEER) reports esophageal cancer is one of the most aggressive cancers with only a 17% survival rate of 5 years after diagnosis. Esophageal cancer diagnosed in early stages or even before it becomes cancer, such as Barrett’s Esophagus has a high survival rate.

Are you at risk for Esophageal Cancer?

If you have a history of heartburn greater than once per week, difficulty swallowing or chest pain, you should discuss these symptoms with your health care provider. Awareness…Education….Early Detection … Your best defense is a good offense with risk factor appropriate screening.

Inside Medicine | april-may 2017

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Dr. Michael Dohrenwend Board Certified, Gastroenterology

Karen Fox

MSN, Certified Registered Nurse Practitioner .......................................

Are you 50 years old or older with Heartburn weekly or more? Trouble swallowing, chest pains or upper stomach pain? Consider Esophageal Cancer and Barrett’s Esophagus Screening. We can help with your gastrointestinal concerns.

April is Esophageal Cancer Awareness Month

Dr. Michael Dohrenwend

Board Certified, Gastroenterology

Photo by: Jade Cooper

256.430.4427

7738 B Madison Blvd. • Huntsville, AL 35806

www.cdhhsv.com

ridgeline construction residential / commercial

roofing & exteriors

256-325-1345 26

Inside Medicine | april-may 2017


Improving Indoor

AIR Quality

This month we are asking Joe Knoch a certified ASCS (air systems cleaning specialist—one of only 21 in the state of Alabama ) and also CVI ( certified ventilation inspector)—how would someone know if they need their air ducts cleaned? One of the simplest ways to help determine if you need cleaning is asking yourself a series of questions.

Do you or anyone in your family suffer from the following when indoors? 1. Allergies 2. Asthma 3. Headaches 4. Sore Eyes 5. Sore Throat 6. Flu-Like Symptoms Indoors 7. Constant fatigue

Does your home seem to have the following issues? 8. Dust or dust balls 9. Excess dirt 10. Fur balls 11. Cold/hot spots 12. Discoloration of carpets, drapes or furnishings 13. Musty odors 14. Mice or rodent problems 15. Smokers or previous smokers in the house 16. Pets or previous Pets in the home 17. Previous Fire or Water damage

Have you had any of the following home improvements done? 18. New Home construction 19. Renovations 20. Drywall or painting 21. New carpet or flooring The rule of thumb is if you answered “yes” to more than 5 of these questions, chances are you could very well benefit from a professional air duct cleaning service. If after answering yes to these questions, you still have some questions regarding cleaning, it might be prudent to arrange an inspection of your duct system and HVAC unit with a professional. A word of caution though. Joe explains the term “air

by Joe Knoch

duct cleaning” can be a little misleading as cleaning the air ducts alone in the home is usually not enough. You should look for a service that cleans both the HVAC Unit and the ductwork at the same time. The reason for this is that a lot of mold, dirt and debris sits near or actually can start at or inside the unit and spread right back over or re-contaminate any cleaned ductwork. State law actually requires any company that offers air duct cleaning to carry a certified HVAC license perhaps for this very reason. You can verify if a company is in compliance with state regulations by visiting the AL Board of Heating and Air Conditioning. You should also check out the credentials of a company with NADCA - www.NADCA.com as well as your local BBB. Joe Knoch, President Air Essentials Inc. 256-217-2273 | www.airessentials.com

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A powerful pledge by Kaki Morrow

Development Manager of Distinguished Events, American Cancer Society

March has come and gone, but it doesn’t mean that we should forget about everything that was included in that month. March brought on crazy weather, St. Patrick’s Day, and National Colorectal Cancer Awareness Month. With March came an opportunity to don both summer outfits and winter coats, wear green and attend Huntsville’s St. Patrick’s Day parade, and to bring attention to potentially lifesaving actions people can take. So while March may now be a distant memory, commit to continuing March’s mission and spreading awareness of colorectal cancer. With the American Cancer Society’s and CDC’s collaborative 80x’18 initiative, raising awareness, spreading the news about colorectal cancer and preventing colon cancer is becoming a more attainable goal to reach. The National Colorectal Cancer Roundtable, cofounded by the American Cancer Society and the CDC, is working toward a shared goal of 80% of adults aged 50 and older being regularly screened for colorectal cancer by 2018. According to the American Cancer Society, more than 135,000 people will be diagnosed with colorectal cancer in the United States this year, and over 50,000 will die from the disease. In fact, colorectal cancer is the nation’s third-leading cause of cancer-related deaths for both men and women and secondleading cause of cancer-related deaths when both sexes are combined, accounting for about 8 percent of all cancer deaths. And while a combination of earlier detection, changing patterns in risk factors, and better treatments have yielded a 51% decline in the colorectal cancer death rate over the past 40 years, about 1 in 3 adults in the United States who fall within recommended screening guidelines are still not being tested for colorectal cancer. The good news? Screening can help find and prevent colorectal cancer. It is one of the most successfully treated cancers if diagnosed early. The five-year survival rate is around 90 percent for colorectal cancers caught in their earliest stage. Chip Moore, a 2017 Belles & Beaus Ball Honoree, who is also currently fighting colon cancer shares, “Some people may not want to be screened because of the time and inconvenience. But if you think that’s an inconvenience, it’s really nothing compared to not catching/preventing the disease and having to attend multiple doctors’ office visits, PET scans, and CT scans. Being screened years ago would have drastically altered the course my life has taken. Take control of your life and get screened, or life will take control of you.” Despite that course, Chip has remained energetic,

and cancer hasn’t taken his positive outlook of life away from him. The American Cancer Society recommends that most people begin regular screening at age 50, as about 90 percent of cases are diagnosed in individuals 50 and older. People at higher risk, such as those with a family history of the disease, may need to start screening earlier. Obesity, physical inactivity, smoking, heavy alcohol use, and eating a diet high in red or processed meat also increases your chance of having colorectal cancer. Regular screening is one of the most powerful weapons for preventing colorectal cancer. If polyps are found during colorectal screening, they can often be removed before they have the chance to turn into cancer. Screening can also result in finding cancer early, when it is easier to treat and more likely to be curable. There are a number of myths about colorectal cancer that people use as excuses to avoid getting tested. One myth is that the tests are embarrassing and painful. The fact is there are a number of different tests for colorectal cancer, including simple take home options. Each have benefits and limitations. A discussion with your doctor can help you figure out what may be best for you. So, what can you do about it? So far, over 1,300 organizations have signed the 80 percent by 2018 pledge, committing to help reach this public health goal. Join these organizations and American Cancer Society in spreading the word beyond March and into 2018. If you haven’t been tested, talk to your doctor. If you have been tested, talk to your family and friends. Make sure they know the facts and encourage them to get tested. Together we can help reduce the number of adults who develop and die from colorectal cancer.

Take the pledge (on upper right corner of page)

Follow Chip’s Cancer Journey via Instagram @lewismoore31 ....................................................................................................... For more information on how to get involved in the American Cancer Society’s life-saving mission, contact Kaki via email kaki.morrow@cancer.org

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The Joy in the Sea by Angela L. Hampton, D.P.M.

When I reflect on my early childhood, I mostly have fond memories. I was fortunate to be a member of a military family that traveled to many wonderful places. My exposure to different cultures, religions, and perspectives was vast. I enjoyed our adventures. If you asked my childhood self, “Are you happy?” the answer would be “Yes.” If I equated my early childhood to a large body of water such as the sea, I would say it was very calm and beautiful. But, I think my viewpoint of this sea of my life was what I saw as I stood on the beach at a distance. During my early adolescence, I had a wonderful time making friends, excelling in school, playing sports, and learning many new things. Life was good. Then, in my fourteenth year, my grandmother passed away suddenly. I felt like someone had punched me in the stomach. I believed in God, but I could not understand why he would let this happen. I cried until there were no more tears left. Someone tried to comfort me by saying something about sorrow may endure for the night, but joy will come in the morning. My teenage self said thank you without comprehension of that statement. I thought I would not be happy for a long time. To me, happiness and joy were one in the same. My calm sea of life now experienced its first noticeable ripple. I was no longer viewing my sea at a distance from the beach. I felt like I had stumbled to the water’s edge and disrupted the calm of my sea. The ripple of my sorrow and raw emotion eventually vanished. If I asked my adolescent self, “Are you happy?” the overall answer would be a more slowly answered, “Yes.” Young adulthood was a whirlwind. Many wonderful things such as graduations, travel, and relationships happened. Along with the good also came the bad such as broken relationships, death, stress, and unexpected detours. In my sea of life at this point, I was deep in the water. The ripples were more frequent and larger. At times, I felt like I was sinking. When I reached a point when there were more ripples than calm, I prayed. I needed saving. At this point, I officially accepted Jesus as my savior. If I asked my young adult self “Are you happy?”, the answer would be, “Is happiness really the goal?” As I grew in my faith, I remembered the comment made after my grandmother’s death. “Sorrow endures for the night, but joy comes in the morning.” I had always thought happiness and joy were the same. I was wrong. Happiness does not last. It fluctuates depending on the situation. In my faith, I have learned that true joy does not fluctuate. Joy is a constant sense of peace that God’s grace gives us. It remains in the good and bad times. I now want joy. Four years ago, the sea of my life was in a raging storm. The skies above were dark and waves were monstrous. There was nothing I could do but endure. I was not floating in this sea alone. I now had a boat…God. I survived that storm in my sea. I have yet to obtain pure joy. I still worry and try to handle things on my own sometimes. The difference is now that I have experienced moments of joy and the peace only my savior can give, I will work toward pure joy. My search for joy has now surpassed my desire for happiness.

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Joy or Happiness? The word happiness originated from the word happenstance, meaning coincidence or by chance. Happiness, by definition, is dependent upon circumstance. A rainy day, a loss by your favorite sports team, or getting bad news can all rob you of your happiness. Likewise, a sunny day, a big sports victory, or a promotion at work can bring temporary happiness to your life. Happiness is not a bad thing, but happiness is fragile and inconsistent, and is often dictated by circumstances outside of your control. The Bible doesn’t promise happiness; it promises joy. Joy is an unwavering emotion that is rooted in faith in Jesus. Joy pursues the good in every situation, even the worst of situations. James 1: 2 says, “count it all joy, my brother, when you meet trials of various kinds…” Having trials of various kinds will definitely not lead to happiness. But look what James says in the next two verses, “For you know that the testing of your faith produces steadfastness. And let steadfastness have its full effect, that you may be perfect and complete, lacking in nothing.” Joy is an attitude of the heart that anticipates the spiritual growth that follows times of suffering. Joy is the Christian pursuit of being perfected and complete in Christ. Happiness comes and goes, but joy in Christ is eternal. – Ben Macklin


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FOR A STRONG RECOVERY,

patient attitude is paramount by Steve Burcham, Vice President, Digium & Heart Disease Survivor

Steve, your heart is shot. It’s done. You need a new one. I’m transferring you to the University of Alabama, Birmingham Hospital tonight for treatment. Laying on the operating room table in the catheterization lab at The Heart Center in Huntsville, Alabama, I couldn’t believe the words that just came out of the physician’s mouth. “A heart transplant,” I repeated the doctor’s declaration silently to myself. How could that be true? Yes, I had struggled with heart disease for a few years. Shortness of breath, exercise intolerance and missing heartbeats had already led to implantation of a cardiac pacemaker, but I really thought I was on the mend, not on the road to endstage heart disease. What I didn’t know laying there waiting for the medevac team to air-lift me to the University of Alabama, Birmingham Hospital was that the pressure readings the doctor measured & recorded inside the 4 chambers of my heart were deemed “incompatible with life.” The fact that I was still alive, awake and conversing with the doctors was amazing if not miraculous. Internally though, I wasn’t rattled. Besides having a strong faith, I simply never believed for one minute that my health was that bad nor did I believe that my life was nearly over. Fast forward time to 2017: On Valentine’s Day, I celebrated my 5th anniversary after receiving a full heart transplant in 2012. Since heart transplant surgery, I have: • Played over 50 rounds of golf • Run more 5K foot races than before heart transplant • Traveled to China for business & to Hawaii on vacation • Walked my daughter Anna down the aisle on her wedding day, • Welcomed my new granddaughter into the world, and • Have spent some quality time with Cindy, my wife of over 30 years. 32

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My strong recovery got started by the challenge my medical team gave me which, simply stated: “Set for yourself a post recovery goal.” Knowing that the Cotton Row foot races were scheduled for late May, I figured that I would gain my doctor’s permission & train to run the 5k race on May 27, 2012. My father, sister, brother, nieces & I crossed the finish line, not with record times but with a lot of joy knowing that they were there with me to celebrate my full recovery. So now, I would like to share some of my “lessons learned” with those that are dealing with disease, treatment & recovery. First and foremost is attitude. Consider yourself a member of the medical team (not just a patient). Teams huddle together to plan & execute to win, not to lose. So right up front, put you yourself “in the game” as a team player set on winning the battle of survival! That also means that whining and complaining are not allowed. A good example of participating as a team member was when my life was hanging in the balance with complete heart failure. After the doctors recorded those readings “incompatible with life,” they asked me if I wanted to be sedated for the trip to Birmingham. I said no. I figured that if I continued to be stable, then I wanted to be awake for the arrival so that I could speak to the doctors about what I had been experiencing. Turns out, that was a good idea, because when I arrived in Birmingham, I discussed all the available options to me with the doctors & surgeons, including the immediate implantation


of a Left-Ventricle-Assist-Device (LVAD) to sustain me until I could be qualified for a heart transplant. As a team, we chose less invasive intravenous drug treatments in lieu of the LVAD which allowed me to avoid one trip through the Operating Room and associated recovery time. I was released on life support and returned to Madison to continue working until a donor heart could be found for me. I continued to work at Digium with an IV bag of medication, pump, and batteries by my side 24 hours a day. Rather than walking around with an IV pole, I repurposed a Camelbak backpack (made for athletes to stay hydrated during exercise) by removing the water bladder & refilling it with my medicine, batteries and pump. Most people I encountered during the day had no idea that I was so sick and on 24 hour per day medications to sustain me until heart transplant.

My results were outstanding. I was up and walking around the ICU 48 hours after heart transplant.

It wasn’t long until we got “the call” from the heart transplant coordinator that a donor heart was available to me. Cindy and I behaved much the way a couple does when they are expecting their first child, except it was me that was going to the hospital and my wife running around the house, calling the neighbors making all the final preparations to leave for Birmingham for my heart transplant! When I arrived in the ICU in Birmingham, I remember one nurse talking to me like I was a kid at Christmas time. She said, “How do you feel? Are you excited? Tomorrow you’re going to wake up with a new heart and feel better than you have in years!” She was right, my results were outstanding. I was up and walking around the ICU 48 hours after heart transplant, I walked a mile inside the hospital 3 days after transplant, and was discharged a week later. My team members at Digium “gave me a hard time” because in their view, by answering emails via my laptop, I “worked” the day before & day after my heart transplant – overachieving for sure! (continued on p. 35)

Inside Medicine |

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Inside Medicine | april-may 2017


(continued from p. 33)

It’s been 5 years since receiving that wonderful gift of a new heart. I’ve learned that sustaining my new heart requires daily attention and work. I maintain a running EXCEL spreadsheet that tracks daily readings on my vital signs, plus any reactions to medications, feelings I’m experiencing, issues navigating life, etc. When issues do arise, like an allergy to a particular medicine, the team and I compare notes and come up with solutions rather quickly. For example, due to developed intolerances to some medications, I’m on my second cocktail of antirejection medications and the team and I continue to monitor and tweak the medication doses used to control my blood pressure. Set-backs and challenges go more smoothly and result in better outcomes when you and your medical team can candidly discuss data & facts about your condition. Secondly, staying physically fit is on top of my priority list. I use a Fitbit to track my daily steps, exercise and sleep patterns. I also use website MyMedSchedule.com to help me keep track of my medications and to remind me to take them three times daily. I think it’s a great idea to use technology, in many cases free technology, to help patient’s recovery and to provide valuable data to doctors when needed. Finally, my wife, Cindy is the closest physician I have! She encourages me, helps me keep notes & schedules on treatment plans, results and next steps. For sure, she deserves the caregiver’s gold medal for all her love, support and tenacity. To celebrate the fifth anniversary of my heart transplant, Cindy and I will be joining our friends for a week of snow skiing in Park City, Utah. As the saying goes, Life is Good. If Life is Good, then Life Post-Transplant is Great! I hope that my experience may encourage and lead you or someone you know to an abundant recovery! About the Author: Steve Burcham is VP of Manufacturing & Quality for Digium a Unified Communications company headquartered in Huntsville, Alabama. Living in Madison, Alabama, he and Cindy have three adult daughters and one granddaughter. An engineer by profession, he is an inventor, and contributing author to Old Huntsville Magazine and published his autobiography, Prayer and Grace, My Journey to a New Heart in 2012.

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Technology and Medical Practices by Morgan Boone

Technology is a part of our everyday lives and we use it to complete the simplest tasks in our daily routines. Whether that is ordering our groceries through an app on our smartphones, communicating with friends and family through social media or checking our email; technology is there every minute of every day to assist us in day to day tasks to ultimately make our lives easier. While there appears to be an app for everything these days, how come we aren’t seeing more interaction between technology and our doctors’ offices? Studies show that nearly 68% of adults have smartphones that they use daily on an average of 4.7 hours a day. We utilize the technology we have to quickly find answers to questions and educate ourselves on a variety of topics. Imagine being able to use your phone to manage your healthcare, communicate directly with your provider, and be informed about multiple aspects of your care within minutes. With access to this kind of technology there would be no more calling your doctor’s office for quick questions, playing phone tag for simple refill requests and you would have the ability to schedule appointments at your convenience. This is the direction modern medicine is moving, to enable patients to be an active participant in their health care. Being a millennial myself, and being just as attached to my smartphone as the next person, I have to ask myself, why aren’t there more applications to communicate directly with our healthcare providers? I know that in most situations millennials would prefer to use the non-face to face communication approach that patient portal technology allows for. Working in healthcare I have seen the challenges first hand, and let me tell you it is hard to change the cycle of habits patients have always used. It requires time, dedicated staff and educating the patient base at hand on how to effectively communicate with their office. The family practice I am a part of introduced this technology to our patients a few years ago, and while it has been a process to educate our patients, it has allowed for more effective and efficient patient care. We are able to quickly respond to our patients directly through their portal, share their lab results with them, and even collect updated demographic documents. What

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makes this so highly efficient and effective is the elimination of the paper process and the ability to directly integrate this information in with the patient’s electronic medical record. While patient centered technology such as a patient portal allows for physicians to share information with their patients, it also allows for the patient to share useful information back with their provider. There are a number of fitness trackers and health monitoring devices that have the capability to share collected data through a patient’s portal and then directly integrate back into the patient’s chart. Through this kind of technology, patients can accurately share blood pressure readings, blood glucose readings and much more. This information is beneficial to healthcare providers and patients because it allows for an active partnership in the patient’s care. This in turn allows providers to share with their patients the accountability and the patient education tools they need to reach their goals and overall improve their health. Patients who have access to this type of technology are empowered and given choices in monitoring their care. The positive comments I have heard from patients in our office have proven to me that this type of technology is making a difference in the way patients view healthcare. Physicians and their staff should join together to provide the resources that the millennial generation strives for to create lasting and trusted physician-patient relationships. In a city such as Huntsville where an abundance of knowledge and technology is available, let’s work together to continue to provide patients with the resources they need to create a positive, healthy lifestyle for many years to come.


Simplifying Healthcare Access: by Nemil Shah, M.D. Timeliness in providing access to health care varies widely. Delays in access to health care have multiple consequences, including negative effects on health outcomes, patient satisfaction with care, health care utilization, and organizational reputation. Patients typically face long wait times to both make and get appointments. At the same time, providers cannot easily fill no shows, cancellations, or off-peak appointment times in their clinics. Mismatched supply and demand and a provider-focused approach to scheduling play a large role and barrier to timely health care access. Increasing numbers of patients are also opting for convenient care facilities or clinics for treatment of medical conditions requiring non-emergency or non-urgent care. However, information to enable potential patients to make informed decisions in selecting a particular convenient care facility is also limited. To find useful information (e.g. “in network”, “procedures performed”, “consumer rating”, “hours of operation”, “right provider for right problem”, “finding a convenient care location close to patient’s location”, “wait times”), patients generally have to do some digging, check multiple sites, and waste time waiting. I created ApproXie out of the necessity to bridge the healthcare access and scheduling gap to improve healthcare delivery, reduce wasted time, and to empower both patients and physicians. Not only does improved access to care prevent disease, but it has far-reaching downstream effects. The intangible benefits of optimizing access and scheduling include improvements in quality of care, lower healthcare costs, and improving the utilization of care centers. ApproXie matches underutilized provider supply with patient demand to facilitate same day visits and referrals in two ways: a mobile on-demand app and a web-based telemedicine application. In a society increasingly reliant on smartphones, ApproXie leverages digital technology to raise brand-awareness for care providers, fill vacancies and no shows while making it easy for patients to access information about health care, their options, and save time. Our mobile app also eliminates waiting on the dreaded automated telephony service when booking an appointment. In layman’s terms, if Uber, Task Rabbit, and OpenTable had a beautiful baby, then you would have ApproXie. For added convenience, ApproXie also lets patients utilize a facetime-like system that enables patients and providers to connect over video. Whichever option you choose, ApproXie is ultimately THE solution for efficiency in a health care system that deploys its most valuable resource—highly trained personnel—inefficiently. We hope to transform access by working with you and for you.

www.approxie.com

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Future of healthcare by Tiernan O’Neill

For all of the negative aspects, changes and implications the medical environment has seen since the inception of the Affordable Care Act, and there have been plenty, it could be said it hasn’t received quite the credit it deserved. Namely, the topic and details of health care under the ACA have become common place discussion. The many rules and regulations which seemed to only apply to and be concerned with by health care professionals are now being shared with patients as well. One of the greatest indicators of this fact is the growing interest and knowledge patients have about the cost of their health care. Prior to the ACA, many patients seemed oblivious to the concept of a health care deductible; even despite it being the same concept as the deductible applied to auto or home insurance. Now, not only do patients know they have a deductible and what it means, but they can also identify whether they have a high deductible plan or not. Furthermore, they are far more informed and actively pursue in network health care providers. This is just but one example, and can be easily seen in other facets of health care costs such as health reimbursement accounts, prescription savings and even as far as whether patients select certain procedures to be performed. With the current political landscape and promises of repealing and replacing the ACA, some are taking this as an opportunity to separate parts of the law which worked for people and they would like to keep. This may turn out to be very problematic when one remembers from economics 101, there is no such thing as a “free lunch”. I can speak on this subject at length having escaped the universal health care downfall that occurred in Canada. Keeping things such as pre-existing conditions or children staying on their parent’s health plans, while popular, will prove to be costly and potentially unrealistic if we are to return to a private system. Alternatively, I would say law makThe goal of the ACA, although ers, insurance companies and medical professionals should focus on missed, was to produce afford- a free concept from the ACA which could be used to expand on the able health care for patients. I health services already provided. believe this is still a goal which Customer education is key. During the ACA especially and could possibly ultimately be really throughout the years, the Primary Care Office has been left on reached even in a privatized the front lines of medicine vs finance on their own. We have had the health care system. difficult and unfortunate charge of explaining and enforcing coverage restrictions and charges to patients far before they ever visit a specialist or other health care provider. Some cooperation with this could go a long way. As patients have clearly now shown interest, comprehension and shared responsibility with the understandings of their health coverage, this would be an ideal time for insurance companies and providers subsequently expanding the base of knowledge which we provide patients in regards to their insurance coverage and limitations. The goal of the ACA, although missed, was to produce affordable health care for patients. I believe this is still a goal which could possibly ultimately be reached even in a privatized health care system.

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I’m dizzy again, what do I do?! Ever considered a Physical Therapist? We’re all familiar with the benefits of physical therapy after surgery, when recovering from a sports injury, or when helping you gain the mobility and strength to get down on the floor to play with your grandkids. But have you ever considered seeing your Physical Therapist for your dizziness? Physical Therapists in your area are trained to evaluate, differentially diagnose, and treat many causes of dizziness. Common symptoms evaluated and successfully treated by a Physical Therapist include: ¤ ¤ ¤ ¤ ¤ ¤

Vertigo (sensation that the room is spinning about you) Lightheadedness or a floating sensation Feeling off balance Difficulty keeping words in focus when reading Difficulty walking a straight line Any time my neck hurts, I get dizzy!

A Physical Therapist is a critical and trusted member of your healthcare team that is essential for accurate diagnosis and optimal recovery from a number of diagnoses commonly associated with dizziness. Listed below are just a few of the common diagnoses that your Physical Therapist can help with: ¤ ¤ ¤ ¤ ¤ ¤ ¤

Benign Paroxysmal Positional Vertigo (BPPV) Meniere’s Disease Post-Concussion Dizziness Post-Motor Vehicle Accident Dizziness Vestibular Neuritis Labyrinthitis Cervicogenic Dizziness (related to your neck)

After a thorough hands-on evaluation and consultation with your healthcare team, your Physical Therapist will develop a complete plan of care to help you understand and overcome your dizziness. Treatment techniques utilized by your Physical Therapist may include: ¤ ¤ ¤ ¤ ¤ ¤ ¤ ¤

Corrective Maneuvers for BPPV (i.e. Epley Maneuver, BBQ Roll, Semont Maneuver, etc.) Habituation Exercises Manual Therapy (hands on treatment) Postural Correction Techniques Balance and Gait Training Mobility and Stability Exercises Work and home-related ergonomic recommendations Education to help you understand your dizziness

by Fred Gilbert, PT, DPT

The exercises your Physical Therapist will prescribe will provide a variety of benefits to help with your inner ear or neck-related dizziness. The exercises can help to even out the signal between the two sides of your inner ear, they can help you readjust to the visual blurriness when you turn your head or walk, they can improve your balance and can even help to stabilize your neck to keep certain types of dizziness from coming on! Physical Therapists are one of the many options to help you understand and overcome your dizziness. Often a Physical Therapist will be able to get you in the office the day your symptoms start, making diagnosis and treatment quick and effective. Your Physical Therapist is trained to recognize when the symptoms do not fit within our treatment scope and will always help you navigate to the best and safest practitioner to begin your treatment. You have trusted your Physical Therapist with your neck, shoulder, low back, and hip pain. The next time you experience your dizziness, know that you can trust your Physical Therapist.

Did you know... ä Doctor of Physical Therapy (DPT)...

The entry-level requirement to become a Physical Therapist is a Doctorate of Physical Therapy.

ä Direct Access...

In the state of Alabama you can be evaluated by a Physical Therapist without a referral from your physician. You can learn more at www.apta.org/ DirectAccess

ä What a Physical Therapist can

do for you... The American Physical Therapy Association’s (APTA) position: “Move Forward. Physical Therapy Brings Motion to Life.” For more details visit www.moveforwardPT.com

Dr. Gilbert is a Physical Therapist at Focus Physiotherapy in Huntsville, AL. Dr. Gilbert received his Doctor of Physical Therapy degree from the University of Alabama at Birmingham in December of 2015. In April of 2016 Dr. Gilbert completed his Competency in Vestibular Rehabilitation through Emory University, making him one of two practitioners in north Alabama to complete this rigorous training. Dr. Gilbert is also currently completing his residency in Orthopedic physical therapy with the North American Institute of Orthopedic Manual Therapy (NAIOMT). Inside Medicine | april-may 2017

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Your

Health.

When it comes to your health, it is your choice on where to have outpatient surgery. The Surgery Center of Huntsville offers a state-of-the-art facility designed to promote excellence in patient care and outpatient surgery. Our specialty areas include The Eye Center, The Pain Management Center, The Breast Center and The Endoscopy Center. We are staffed with dedicated professionals, including almost 100 registered nurses and over 70 doctors who choose The Surgery Center of Huntsville as their Surgery Center.

It’s your health, so make The Surgery Center of Huntsville your choice for outpatient surgery.

Your

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Excellence in Outpatient Surgery O

ne of the most well-known facilities to the Huntsville area’s premier healthcare community is The Surgery Center of Huntsville, an outpatient surgery center focused on providing the highest quality of patient care. This pristine facility may replicate a modernized castle. However, it is much more than the brick and mortar of an impressive establishment. In fact, it is “The Surgery Center of Huntsville”, a BRAND that is carried out and delivered by the professionals that work there. With over 100 highly trained clinical staff members, including registered nurses and anesthesiologists, as well as surgical technologists, the center is the ideal working environment for physicians who need to perform a procedure or treatment that does not require a stay greater than 24 hours. More than 100 area physicians practice within The Surgery Center of Huntsville. From the staff to the state-of-the-art operating rooms and recovery areas, The Surgery Center of Huntsville strives to provide “excellence in outpatient surgery” with the comfort and safety of patients in mind. Bill Sammons, CEO of The Surgery Center of Huntsville states, “Surgery is what we do best!”, and the reputation in the community is undeniable when it comes to patient quality and satisfaction. The Surgery Center of Huntsville also offers specialty centers: The Eye Center, The Pain Management Center, The Breast Center, and The Endoscopy Center. Each of these facilities offer the highest quality and services in their fields and provide the perfect location for specialized, outpatient procedures. From the waiting rooms, to pre-op rooms, to the operating rooms and post anesthesia rooms: all the way to the extended care center, The Surgery Center of Huntsville is the place of choice for physicians and patients in our area. www.the-surgerycenter.com

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livelifewell by Belinda Maples, M.D.

May is Mental Health Awareness month. The term “mental health” is commonly used in reference to mental illness, but knowledge in the field has progressed to a level that appropriately differentiates the two conditions. Although mental health and mental illness are related, they represent different psychological states. Mental health is “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” It is estimated that only about 17% of US adults are considered to be in a state of optimal mental health…that leaves 83% of adults with something to strive for. It seems the new “normal” is to have some kind of mental health issue. The indicators of mental health include emotional well-being, psychological well-being and social well-being. It is the perceived life satisfaction, happiness, peacefulness, self-acceptance, optimism, purpose in life, self-direction, social acceptance, beliefs in the potential of people and society as a whole and the personal feeling of self-worth. There is emerging evidence that positive mental health is associated with improved health outcomes.

The stigma and denial surrounding mental illness leads many people to not seek the care they most need.

]


Mental illness is defined as “collectively all diagnosable mental disorders” or “health conditions that are characterized by alterations in thinking, mood, behavior or some combination thereof associated with distress and/or impaired functioning.” This includes depression, anxiety, bipolar disorder, schizophrenia and other psychosis. Depression is the most common form of mental illness, affecting more than 26% of the US adult population. It has been estimated that by the year 2020, depression will be the second leading cause of disability throughout the world, trailing only behind heart diseases. The burden of mental illness is felt worldwide. According to the World Health Organization, depression is the third most important cause of disease burden of the world in 2004. Unipolar depression was in 8th place in low income countries and first in middle and high income countries. Bipolar disorder has been deemed the most expensive behavioral health care diagnosis, costing more than twice as much as depression per affected individual. Mental distress was measured as 14 or more days of poor mental health in the last 30 days. Almost 10% of US adults experienced frequent mental distress in the last 3 months. The Appalachian and Mississippi Valley regions displayed high and increasing prevalence of frequent mental distress, whereas the upper Midwest showed low and decreasing prevalence of mental distress. Does anyone want to move? The former surgeon general notes there are social determinants of mental health as there are social determinants to general health. Adequate housing, safe neighborhoods, equitable jobs and wages, quality educations and equity in access to health care all have some influence on our mental well-being. Alabama cut 36% of its total general fund for the mental health budget from 2009 to 2012. Alabama has fewer psychiatrists, relative to its population size, than almost any other state in the nation. “Hospitals are filled beyond capacity and shortages in acute care hospital and crisis beds have reached critical levels” according to the National Alliance on Mental Illness report. This demonstrates that not enough mental health providers are available to address the needs of the population. Timely access to care is critical! In addition, the stigma and denial surrounding mental illness leads many people to not seek the care they most need. It is common for individuals to deny

they are ill and therefore think that they do not need help or medical treatment. The patients may hide or not fully disclose essential aspects of their symptoms for fear of the consequences of their disclosure. Another layer of complication is that the federal and state laws surrounding involuntary hospitalization of individuals with mental illness, whilst designed to protect patient’s rights, often leave loved ones and medical professionals frustrated that they have no voice, minimal sway or influence over the decisions in court. In the state of Alabama, a person cannot be committed due to a drug or alcohol problem even in light of underlying mental illness. A petition has to be filed with the Probate Court with clear and convincing evidence that the person is mentally ill with a real and present threat of substantial harm to himself or others, unable to make rational decisions regarding their treatment, or continue to experience mental distress and deterioration of their ability to function independently if not treated. I have called on the Probate office many times with intentional overdoses due to severe depression and they have refused help stating that they were depressed because of alcohol or drug issues and should resolve when they quit! Misunderstanding and stigma surrounding the mental ill are widespread. Despite the existence of effective treatment for mental disorders, there is a belief that they are untreatable or that people with mental disorders are difficult, not intelligent, or incapable of making decisions. This stigma can lead to abuse, rejection, and isolation that exclude people from health care and support. 78% of adults with mental health symptoms and 89% of adults without such symptoms agreed that treatment can help persons with mental illness lead normal lives. 7% of adults without mental health symptoms believed that people are caring and sympathetic to persons with mental illness. Only 25% of adults with mental health symptoms believed that people are caring and sympathetic to persons with mental illness. This highlights the need to educate the public about how to support persons with mental illness and the need to reduce barriers for those needing or receiving treatment for mental illness.

Belinda Maples, M.D. Athens Primary Care Associates, LLC 101 Fitness Way, Ste 1200 Athens, AL 35611 | 256.232.0636

Inside Medicine | april-may 2017

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Bisphosphonate and Dental Treatment by Jonathan Threadgill, DMD Watching television, you may have come across an actress promoting Boniva to prevent osteoporosis. It is estimated 54 million Americans have osteoporosis, or a decrease in bone mass. Studies suggest approximately 1 in 2 women and 1 in 4 men over 50 will break a bone due to osteoporosis. Boniva is a Bisphosphonate medication reported to slow the loss of bone density as we age, thus preventing or decreasing the incidence of bone fractures. Unfortunately, these drugs have been shown to have a potential side effect that can cause necrosis of jaw bones, Bisphosphonate Related Necrosis of the Jaw (BRONJ) especially when undergoing dental surgery. Bisphosphonates are a class of drugs that regulate bone metabolism and help to prevent osteoporosis and reduce the incidence of fracture and pain associated with some forms of bone-related cancer. These drugs have a high affinity for hydroxyapatite, the main component to bone mineral. This strong affinity is why they play a role in disease processes that affects bone remodeling. Bisphosphonates can be taken orally or intravenously(IV). The higher potency IV forms slow or modify the progression of malignant cancer bone diseases, i.e. breast, lung and prostate cancers. Oral bisphosphonates are more commonly used to treat osteoporosis, although some injection forms are available.

List of common medications: Oral Bisphosphonates • Fosamax • Boniva • Actonel IV Bisphosphonates • Reclast • Zometa • Aredia Next generation anti-resorptive medications • Prolia • Xgeva

BRONJ can be defined as an area of bone in the jaw that has died (necrotic) and exposed in the mouth for more than 8 weeks in a person taking a bisphosphonate medication without history of radiation to the jaw. Symptoms of BRONJ may include localized jaw pain, swelling, and draining infection. This condition is most commonly seen after dental extractions. Recently the American Association of Oral and Maxillofacial Surgeons (AAOMS) has suggested to rename this process to Medication Related Osteonecrosis of the Jaw (MRONJ), because of other anti-bone restorative medications causing similar type of necrosis. While most patients on a Bisphosphonate will not develop jaw bone necrosis, patients on these drugs with other issues ie. diabetes, smoking and taking corticosteroids appear to have an increased chance of developing this condition. The type of bisphosphonate, amount of drug, and duration are the most important determining factors. Once the necrosis has developed, treatment is based on the severity of the disease.

Clinical stages of Bisphosphonate osteonecrosis of the jaw: • Stage 0: Nonspecific clinical findings and symptoms • Stage 1: No pain with presence of exposed or necrotic bone and no evidence of infection • Stage 2: Presence of exposed necrotic bone, accom panied by infection and redness around the teeth and gums • Stage 3: Presence of all stage 2 characteristics with additional features, such as jaw fracture or draining abscess Treatment may start with discontinuation of the bisphosphonate medication. Your surgeon may recommend additional measures such as antibiotic therapy, use of chlorhexidine-containing mouth rinse and conservative debridement of loose necrotic bone up to major reconstructive surgery. Early detection allows your oral and maxillofacial surgeon to diagnose and treat the condition as quickly as possible. (continued on p. 47)

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Inside Medicine | april-may 2017


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(continued from p. 44)

How can we prevent BRONJ when I need dental work done, and is it safe for dental implants? BRONJ is in most cases manageable and can even be preventable. Frequent preventive dental examinations and maintaining optimal oral hygiene can improve outcomes and reduce the incidence of the disease. Before starting IV bisphosphonate it is recommended to have a thorough examination and all teeth with poor prognosis extracted, then allowed to properly heal. Patients wearing dentures should be examined for any mucosal irritation and make sure they are well fitted. These decisions must be made in conjunction with the treating physician and dentist if the systemic conditions allow the delay of the bisphosphonate. If you are taking oral or IV bisphosphonates, you should have a consultation with your surgeon before any invasive dental surgery. A request may be made to your physician that you take a short discontinuation from therapy before any surgery is performed. This drug “holiday” may decrease your chance of developing jaw necrosis. When taking the IV form of the medication to treat cancer, dental implants might not be possible because of the more potent dose and increased frequency. The AAOMS has established guidelines how to manage patients taking these medications. Oral Bisphosphonates: • Less than 3 years with no clinical risk factors- No delay planned in oral surgery is necessary • Less than 3 years with clinical risk factors- 3-month drug holiday is recommended • More than 3 years with or without risk factors- 3-month drug holiday is recommended • Dental implants may be possible following proper protocol and informed consent Intravenous Bisphosphonate: • Elective dental surgery should be avoided for those being treated for cancer • Emergent dental surgery: Discontinuation of the bisphos phonate in conjunction with the physician and continue with the oral surgery limiting the amount of unnecessary tissue trauma as possible; serial follow up appointments • Dental implants usually not recommended in patients being treated for cancer o Limited studies have shown success with implant placement in patients being treated for osteoporosis with IV infusions Bisphosphonates are medications that slow the progression of osteoporosis and decrease pain associated with certain types of bone cancer. Patients should be aware of the potential side effect of osteonecrosis of the jaw. It is important to discuss concerns with your treating physician and dentist before starting these medications. Inside Medicine |

april-may 2017

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} FEATURE

What if Myths are True? Myths come in many forms. Some are symbolic narratives that attempt to grapple with lofty topics about the origin of the earth, the universe, or even life itself. Other myths are merely beliefs that have emerged as “conventional wisdom” and attempt to explain more specific or even mundane aspects of our lives. When it comes to making decisions about health care, careful consideration to separate myth from fact can be critical. Unquestioning belief in widespread myths surrounding Long Term Care (LTC) can leave individuals and families poorly prepared and with devastating consequences. While you prepare for retirement, it is a must that you review your LTC options and costs and be certain to separate myth from fact. Can you identify common myths regarding Long Term Care?

I do not need to purchase Long Term Care coverage

Many people think they can “self insure” when it comes to long term care. If we had a crystal ball to see into the future, we could be certain that we identify the assets we will need and we could set aside the funds to cover the inevitable costs. Absent that certainty, and with no LTC policy in hand, the ever-growing costs of health care and the increasing demand could easily wipe out your life savings.

Only old people need Long Term Care services

According to the US Department of Health & Human Services (www. longtermcare.gov), more than two-thirds of today’s older adults require some kind of help with the basic activities of daily living, and these needs only increase for the weeks, months, and years as they age.

Long Term Care is only for Nursing Homes

As long as I can remember, people have expressed their expectations and the sequence of events that will occur as they get older, and the scenario almost always includes moving to a nursing home when that time comes. Many years ago, assisted living and home health care did not exist, so nursing homes were the only option. Nowadays you can expect to stay longer in the comfort of your own home thanks to LTC coverage which provides you with caregiver assistance, training, respite care and even hospice care in an end-of-life scenario.

by Anne Jewell President, Cox Associates, Inc.

We don’t need Long Term Care coverage because we have each other

Family members are the most common source of caregiving in the United States today. Husbands and wives, brothers and sisters, and sons and daughters typically step into the caregiver role. I am an example. I took care of my father for nearly 8 years prior to moving him to an assisted living facility. Although many personal sacrifices were made, and extra responsibilities were taken on, our LTC policy provided invaluable assistance in the form of on-site caregivers and medical professionals, and facilitated the quality of care I was able to deliver for him. According to Brian Harrington of Genworth Insurance LTC Division: “Health Insurance covers medical needs such as doctor visits, hospitalization and prescriptions. Life Insurance provides financial security in death. Disability Insurance provides supplemental income when employees can’t work due to illness or injury, and Retirement Plans help people build a nest egg. But none of these types of insurance covers the cost of service and support that people need when they can no longer care for themselves because of an accident, illness or cognitive disorder.” This is precisely where LTC insurance fits in. So, is the following statement a myth or a fact?

“I will become a burden to my family as I get older.” Your planning will determine the answer. Make it a myth. Call your local LTC professional for more information. Anne C. Jewell | 256-533-0001

I’ve got Medicare, so I do not need Long Term Care coverage

Of all the LTC myths, this one is the most onerous. Medicare generally pays for your physician bills and hospital bills, but not for long term disability such as illness, loss of mobility or cognitive impairment. Medicaid will generally pay for long term care skilled care expenses, but it is difficult to qualify for this benefit.

I can’t afford the cost of Long Term Care coverage

Maybe you can’t NOT afford LTC coverage. Think about how improvements in technology and methods of care are extending life expectancy. So, long term care is becoming longer term care. Without protection, this can cost you much more over time, draining your savings and threatening your assets. Today’s LTC products offer many different kinds of plans to fit all pocketbook sizes. Inside Medicine | april-may 2017

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JJeffers@jdrf.org 50

Inside Medicine | april-may 2017


The FUTURE OF TYPE 1 DIABETES JDRF’s Promising Research Progression by Jennifer Grady Jeffers Development Coordinator for JDRF

If you live with type 1diabetes (T1D), you spend a lot of time thinking about your blood-sugar levels now and worrying about the complications that T1D may one day bring. You don’t want anyone else you love to ever know the physical, emotional and financial toll this disease takes. You want a cure. So does JDRF. And we are committed to funding the development of new therapies and treatments to keep people with T1D healthier, longer, until that cure is found. That’s why we invest in multiple therapeutic approaches to cure, prevent and treat T1D. We identify and invest in promising therapies in their early stages, helping researchers pursue innovative ideas and approaches. This investment strategy ensures that the most life-changing breakthroughs can make it through the long research, development and delivery process and get to people living with T1D sooner. Currently, managing T1D is a never-ending, difficult chore because the body often defies even the most vigilant efforts to keep blood sugar normal levels. As a result, even sleep can be anxiety filled for people with T1D, because that’s often when dangerous low blood sugar episodes occur. Simply enjoying a slice of pizza can require significant insulin dose planning in order to avoid high sugar and the resulting risk of serious diabetic complications. JDRF wants to remove the constant worries and burdens placed on T1D’s. Currently, JDRF is involved with over 50 clinical trials worldwide, some of which are already greatly impacting the way a T1D lives. Let me share with you how we are already positively changing the management of the disease, our plan to prevent or reverse its impacts and finally, our path to finding a cure. Our Glucose Control and Artificial Pancreas (AP) programs tackle blood-glucose control head on. Managing insulin alone won’t achieve perfect control. So we’re investigating how managing other hormones or repurposing drugs approved for other uses can work with insulin to improve control. Artificial pancreas technology will improve control by automating blood-glucose sensing and insulin delivery. Tighter control reduces complications and eliminates the need to think about blood-sugar levels, insulin dosing and carbohydrate counting. In addition, the FDA has already approved the first generation of the AP and will be available to patients sometime in April of 2017. This was a huge milestone in our efforts and gives our donors proof their dollars are making a difference. Beta cell encapsulation therapy holds the promise of eliminating the need for daily insulin treatment for up to 24

months through a small implant. The researchers and partners we support through our Beta Cell Replacement Program are testing multiple efforts to perfect cell replacement therapies, including the development of materials to protect the cells and discovery of new replacement cell sources. We think for people with T1D who are on duty all day every day just to stay alive, encapsulation will sure feel like a cure. We refuse to accept the idea that people with T1D must live in fear of life-threatening diabetic complications. Our Complications Program seeks to better understand how diabetic kidney and eye diseases start so we can stop them in their tracks. Of course, the best way to ward off complications is to protect people from the disease entirely. Our Prevention Program’s primary goal is to develop a universal childhood vaccine that prevents the autoimmune attack on insulin-producing cells. As we work toward that goal, we’re also pursuing secondary prevention therapies that will prevent people from becoming dependent on insulin therapy once T1D is diagnosed. Our Restoration Program is attempting to do something that has never been done before—prevent, halt or reverse an autoimmune disease and return normal function of the beta cells. For more than a decade, JDRF has funded studies to unravel the mysteries of T1D and develop therapeutic interventions to bring the body back to normal after the disease strikes. Each one has added to our understanding of what’s necessary to stop the immune system from destroying insulin-producing islets cells, keep these cells healthy and functional, and restore the body’s normal ability to produce insulin. In addition, JDRF offers a match program, Clinical Trial Connection, which helps both T1D’s and T2D’s be paired with specific research. By participating you not only are helping yourself, (continued on p. 53) Inside Medicine | april-may 2017

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sunscreens

And their role in prevention of skin cancer by D Kishore Yellumahanthi, MD, MPH

Skin cancer is the most common form of cancer in the United States. One out of every five Americans will get skin cancer at some point in their life span. The risk of developing skin cancer, about 90% of time, is directly related to the amount and intensity of ultraviolet (UV) light exposure. Fortunately, with regular use of sun protection, UV exposure can easily be minimized. Sunscreen is an important part of this protection. Sunscreens are products that combine several ingredients to help prevent sun’s UV radiation from reaching the skin. Sunscreens can be both chemical and physical substances. Physical sunscreens, such as zinc oxide and titanium dioxide, deflect and scatter the UV rays before they penetrate the skin. Chemical sunscreen ingredients, such as PABA (para-aminobenzoic acid) and cinnamates, absorb UV rays and convert the sun’s radiation into heat energy. Both types of sunscreen can be effective and safe if used properly. UVA and UVB are the two types of UV radiation that damage the skin and can increase the risk of skin cancer. UVA can also cause premature ageing of skin, causing wrinkles and age spots. It can even pass through window glass. On the other hand, UVB rays primarily cause sunburn and are blocked by window glass.

What is SPF?

The strength of the sunscreen is determined by its sun protection factor (SPF). It is a measure of the sunscreen’s ability to prevent UVB from damaging the skin. For example, if it takes 1 hour for unprotected skin to start turning red, using a SPF 30 sunscreen theoretically prevents reddening 30 times longer, which would be about 30 hours.

What is an ideal Sunscreen to use?

Given that both UVA and UVB are harmful, broad spectrum sunscreen that protects against both UVA and UVB needs to be used. The American Academy of Dermatology recommends that everyone use a broad spectrum sunscreen with SPF 30 or higher that is water resistant. The sunscreen with SPF 30 blocks around 97% of the sun’s rays. Higher- number SPFs block slightly more of the sun’s rays. Unfortunately, no sunscreen can block 100% of the sun’s rays. Currently, there is not any scientific evidence that indicates using a sunscreen with an SPF higher than 50 offers any protection better than a sunscreen with an SPF of 50. It is also important to remember that high- number SPFs last the same amount of time as low number SPFs. Therefore, a high-number SPF does not mean that one can spend additional time outdoors without reapplication.

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Inside Medicine | april-may 2017

There are different kinds of sunscreens available – lotions, creams, gels, ointments, sprays and wax sticks. The kind of sunscreen to be used is a matter of personal choice and may vary depending upon the area of the body applied. For instance, gels may be better for hairy areas and creams for dry skin and the face. Regardless of the type of sunscreen used, the key is to use adequate amounts at recommended frequency - to ensure that the full SPF of a sunscreen is accomplished, about 1 oz of sunscreen needs to be applied 15-30 minutes BEFORE sun exposure. Reapplication is as important as putting it on in the first place, so reapply the same amount every two hours. It is often thought that one would not need a sunscreen on a cold or cloudy day. Up to 40% of the sun’s UV radiation reaches the earth on a completely cloudy day. Therefore, sunscreens are needed to be applied on cloudy days as well. Following the same logic, one can also be exposed to sundamaging UV rays when indoors or even in a car. Remember, UVA passes through window glass which means one can acquire skin damage while driving or in any room windows. This is one of the reasons why skin cancer in the US is more common on left side of the face which is the driving side. Therefore, it is recommended that one use sunscreen every day, all year along regardless of whether one is outdoors or indoors. A sunscreen, in addition to offering protection from skin cancer, also offers protection from sun burn and early skin ageing. However, one should not rely on sunscreen alone to protect the skin against UV rays. In addition to using sunscreen, seeking shade when appropriate and wearing protective clothing is also important. Avoiding tanning beds is also vital. A tan, whether it is acquired on the beach or in a bed is not good as it is caused by harmful UV radiation and thus over a period of time can lead to premature skin ageing as well as skin cancer. Included with the plan of taking care of your skin using a comprehensive skin protection program and early diagnosis of skin cancer, self-examination of the skin needs to be done at least annually. If there happens to be any spot on the skin that is changing, bleeding or itching, medical advice needs to be sought immediately to confirm or rule out skin cancer.


(continued from p. 51)

but you are also contributing to the studies being done to curing, preventing and treating the disease. You have the opportunity to not only help save your life, but save the lives of others! There is no charge to participate and some studies offer financial assistance with your diabetic-related expenses. We know it won’t be easy. It will take time and require a significant financial investment. But we want it all: a biological cure for T1D, transformational treatments that improve lives now and prevention so that future generations never know T1D.

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Plantar Fasciitis

Take care of your feet, and they’ll take care of you Like most things in life we take our feet for granted. We often give them little or no thought until we have a problem. Feet are the unsung hero of the human body. They are quite literally the foundation of our body. The average person takes between 6,000 and 10,000 steps per day. Over the course of a lifetime, that adds up to around 100,000 miles. That’s the equivalent of 4 trips around the earth. We use them, abuse them, and ignore them. Then blame them when we have a problem. I hear in my office all the time “I just have bad feet.” The truth is you probably don’t have bad feet. Your feet deserve a medal for all that you put them through. One of the most common problems I encounter in the office is heel pain. Heel pain can be caused by many things, but the most common culprit is Plantar Fasciitis. If your first step in the morning is extremely painful you may have Plantar Fasciitis. It’s an injury that affects the bottom of your foot. Basically it’s inflammation of the tough fibrous band of fascia that connects your heel to your toes. In the extremely active person, plantar fasciitis is typically associated with over use. In the sedentary person, it is often the result of weight gain. There are a number of things that put you at risk for developing plantar fasciitis. Among them are having extremely high or low arches, being overweight, or being female. Wearing bad, worn out, or just the wrong shoes for your biomechanics also increases your risk. People who have jobs that require standing on hard surfaces such as concrete or those who run or walk for exercise are also more likely to experience plantar fasciitis. In most cases your first symptom is a dull soreness similar to a bruise. You will likely feel it after a long period of standing or after exercising. Usually the pain doesn’t occur during exercise, but after. As it progresses, the pain usually becomes sharper in nature and you develop the hallmark symptom of plantar fasciitis “first step pain”. Your first step in the morning or after a long period of sitting will be very painful, but the pain typically lessens after a few minutes of walking. To ease the first step pain it’s usually helpful to sit on the side of the bed for a few minutes and get your feet warmed up before walking on them. You can do some ankle rolls to start gently loosening them up. Draw a circle with your toes then start rotating your foot in one direction and every few seconds change directions. It’s also a good idea to keep a stretching strap and a tennis ball next to the bed. You can loop the strap under your foot just behind the toes and gently pull back to stretch your foot and Achilles tendon. Rolling your foot on the tennis ball is a good way to massage your foot and get blood flowing. Start out with just the weight of your leg, and gradually increase pressure to massage deeper. If you begin treatment early most cases respond to conservative measures. Untreated plantar fasciitis can lead to knee, hip, and back pain.

by Paul A. Dobbs, Jr. C.Ped

This is due to the fact that sometimes you change the way you walk to try to relieve the pain. Conservative treatments include stretching, icing the sore area, anti-inflammatory medications, steroid injections, and arch supports or custom orthotics. Plantar fasciitis, like all foot injuries, require patience. Unlike injuries to other areas of the body, you have to walk on your feet and unfortunately there is no quick fix. Approximately 90% of cases respond to conservative treatment protocols, however the other 10% may require surgery. Surgery involves releasing part or all of the plantar fascia. Recovery time is generally 6-10 weeks before you’re walking comfortably and up to 3 months before you are able to run or do high impact exercises. The best way to treat plantar fasciitis is to prevent plantar fasciitis. Some of the risk factors such as the height of your arch, working a job that requires long periods of standing on hard surfaces, or being female may be beyond your control. You will have to live with those and control the things you can control. If you run or walk for exercise, try to find an unpaved trail. Your feet will thank you. This brings us to shoes. You should avoid going barefoot for long periods of time. Make sure you are wearing the right shoe for your foot and the given activity. Think of shoes as tools. You don’t use a hammer to drive in a screw, you use a screwdriver. I’m asked every day, “What’s the best shoe?” My answer is always the one that fits and functions best for your foot and is right for the activity. If you’re going to church or out to dinner dressy shoes with little or no support may be fine. But if you plan to stand for a long period or walk a long distance you will probably be better off in something more supportive. This is particularly important for shoes that you exercise or work in. It’s also a good idea to keep track of mileage on your shoes. I like to take a sharpie and write the date I begin wearing a pair of shoes under the insole. If you’re a runner it’s easy to track mileage, but for other forms of exercise or work shoes it can be more difficult. The rule of thumb for runners is to replace your shoes every 300-500 miles. If they are work shoes it’s a good idea to replace them once a year or twice a year if you work on your feet for extended periods of time. If you’re not sure what type shoe you need it is a good idea to go to a shoe store with trained staff. They can assess your feet and help guide you to the right shoes. The key to preventing or treating plantar fasciitis is to consistently take good care of your feet. Buy good shoes, maintain a healthy weight, and avoid going barefoot and wearing flip-flops for extended periods of time. Don’t take your feet for granted. Give them the respect they deserve. In short, take care of your feet and they’ll take care of you.


Comfort & Style...You really CAN have it all Each year, more than 120,000 work-related foot injuries are reported, and

about two million sick days are taken because of leg and foot problems.

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important to make an extra effort to take good care of feet and legs. Doing

years of hands-on experience since the store opened! Both are highly edu-

so can go a long way toward staying healthy and happy.

cated in a diverse range of knowledge enabling them to provide a dynamic

The best place to start is with finding the right shoe! Doctors recom-

duo of biology and marketing to better understand the wants, needs, and

mend a good fitting shoe with proper arch support. This effects not only

even anatomical mechanics of each customer. They work daily to make

the feet but can help with knee and back discomfort. Finding that perfect fit

shopping at Valley Sole “all about the experience”.

can be a daunting task. Thankfully, there is a place to go for help!

ing back and work every day to serve the community. In their own words,

At Valley Sole, the trained staff can help determine the best shoe and

Both Julie and her mother have many years of sales experience. When

The store stands on several key ideas. They absolutely believe in giv-

arch support for your feet.

they want to “give back to the world, along with the community”. They’ve

Julie Pierce & Holly McGinness, owners of Valley Sole (formerly Valley

partnered with a local church to build a school in Africa benefiting the Masai

Birkenstock) in Huntsville, Al., understand plantar fasciitis and other foot

Tribe. It was a “perfect fit” because they actually used the Masai Tribe as the

ailments that lead to the importance of good shoes. Both ladies person-

inspiration for the shoes that helped them make the profit.

ally have been living their own lives having to take their hurting feet into

account. They realize the possibilities for help are endless. Valley Sole is a

customer! They strive to give customers that “Aha” moment when they

good start! The mother/daughter owned shoe store is located in the heart

find the perfect pair of shoes and see someone walk out of the store

of the valley and has overcome the many obstacles of being a family-owned

pain-free. Another part of what they love is getting to know the people of

business. Their mission to serve includes an ability to direct their clients in

Huntsville as they shop local. Customers and relationships are what the

the appropriate direction based on the individual lifestyle of each customer.

business is built on and they are excited to help you purchase the perfect

God has surely blessed Holly and Julie, their business, and their clients.

shoes for you to keep happy, healthy feet!

The ladies focus on SHOES & OVERALL SATISFACTION from each

See what it means to.... SHOP LOCAL

with a mother daughter team who can help your hurting feet and promise you won’t have to wear “old lady” shoes!

Thanks for shopping with us, Huntsville.

964 AIRPORT ROAD | HUNTSVILLE, AL 35802 256.881.1067 | VALLEYSOLE.COM

Inside Medicine | april-may 2017

55



A letter from a Reader

Inside Medicine...sharing with purpose

As a retired 60 year old man, I really wasn’t looking forward to an early morning visit to my wife’s oral surgeon and having to wait on her and drive her home after sedation; go ahead, yes, I should be ashamed. While purposely leaving my iPhone in the car (that’s a subject for another day), I started browsing for something to read. They had the usual People, Cosmo, Popular Mechanics magazines, etc. I then noticed this rather thin kind of interesting looking magazine called Inside Medicine. As I got to flipping pages, I was actually surprised that this thing actually had a bunch of interesting articles versus mostly a series of glossy advertising that most local publications of this sort have. The first article that caught my eye was one on the necessity and risks of not having a colonoscopy. Well, I’ve been putting that off knowing that of all people, I needed one. I’ve had them in the past, but at least 10 years has passed since my last one. My sister has Crohn’s Disease, and I inherited the gene that leads to potential intestinal blockages that manifest themselves around age 50. Well, I’ve had about 4, and I thought kidney stones were bad! Needless to say, I immediately called and made an appointment for a colonoscopy spurned on by this article. The article about vitamin D was amazing. It mentions the importance of sunlight and actually going barefoot outside and the possibility of depression and lack of Vitamin D. The article about youth sports and injuries was fantastic. Dr. Andrews was mentioned. It mentioned the normal pitfalls of parents pushing and travel ball, etc. But as a former athlete, coach and 30-year veteran educator, I loved it when the article mentioned things like encouraging your kids to participate in a variety of sports; how that winning is important, but according to kid surveys, children cite other attributes such as enjoying their teammates and enjoying the actual competition over trophies and training for college scholarships. The article talked in depth about how few kids actually play ball in college; what causes youth sports injuries; the value of not concentrating on one sport, etc. By this time, I had read for around 45 minute and was just starting an article on a young lady born with spina bifida when I was called back to my wife. I had earlier noticed that this was a local publication and the name Kelly Reese. Actually for a split second, I thought about quietly slipping the magazine into my wife’s purse, ha! Not really especially since Mrs. Reese gathers her articles with a faith-based perspective, which was very refreshing indeed. I called Kelly requesting a subscription; and to make a long story short, she stated that I made her day upon which I stated the same to her! I plan on and am looking forward to finishing this edition and hopefully many more in the future. Congratulations to Kelly and her team for outstanding work!!

– Keith Schrimsher


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