Inside Medicine Holiday Issue by Inside Medicine

Inside Medicine | Holiday Issue 2017

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Inside Medicine | Holiday Issue 2017

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Inside Medicine | Holiday Issue 2017

features &

CONTENTS

Sharing with Purpose

VOL 2

ISSUE 7

Inside Medicine | Holiday Issue 2017

FEATURES TAVR 12 heart valve replacement

without open heart surgery

CONTENT Infertility

Q&A with local specialist

CO N T R I B U TORS

Traci McCormick, MD Tiernan Oâ&#x20AC;&#x2122;Neill Larry Parker, MD Brett Davenport, MD Brian Scholl, MD

Robotic Spine Surgery with the MAZOR

Breast Cancer screening for answers

Sanat Dixit, MD Paul J. Fry, MD D. Kishore Yellumahanthi, MD Kaki Marrow

Eczema

how to know the signs

Women & Long Term Care

Longevity & Caregiving

Jackie Makowski David A. Long, DC Eddie Ayers Heather Mendez S A LE S & M A RK ETIN G

Kelly Reese, Co-Owner

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

the way healthcare information has been and will be distributed

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

at kellyreese.im@gmail.com or

Making a Difference

and grow an alliance among

256.652.8089

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

Kimberly Waldrop, MA G R A P H I C DESIGN

Leigha Parker Karen Gauthier P U B LI S HERS

Blake Bentley, VP 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.

Inside Medicine | Holiday Issue 2017

www. in s ide me dic in emagaz ine.com

} FROM THE EDITOR

Dear Readers -

Fall

in love with Inside Medicine

Information on random and pertinent health issues is our goal in this edition of Inside Medicine. From the keto diet to mammograms to infertility discussions and dealing with anger and its source, this issue is packed full of useful information. Did you know that revolutionized medicine has allowed heart valves to be replaced without having open heart surgery? Do you have neck pain or irritating hand pains? We have two articles that focus on carpal tunnel syndrome and the new “text neck” that may be what you are looking for. One of our pastor friends, Eddie Ayers, has provided us with a thought provoking devotional piece about being committed to finish things even when the going gets rough. It’s hard to always remember to live our lives this way, but he lays it out in a Biblical perspective for us. As always, our prayer with Inside Medicine is to help our community and show a love for our Heavenly Father. We are always looking for new content and features. Please contact us if you ever have an idea for a story or want to be included in our magazine. We love hearing from you and appreciate your support!

Kimberly Waldrop Inside Medicine | Holiday Issue 2017

Inside Medicine | Holiday Issue 2017

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256.265.PAIN (7246) Inside Medicine | Holiday Issue 2017

HEALTHCARE COSTS by Sanat Dixit MD, FACS

It’s a perplexing time to be a patient in the United States. Technologic innovations abound, yet we are reminded on a daily, if not hourly, basis about the travails afflicting our healthcare system and how something must be done to fix it. Most of the conversations focus on coverage and cost – and understandably so, as US healthcare expenditures grew 5.8% in 2015, and another 6% in 2016, reaching $3.2 trillion. Healthcare expenditures account for almost 18% of our entire economic output. The rising cost of healthcare expenditures has been shifted onto the employers and the patients, with the average premium for an employer-sponsored plan topping $17,500 annually; with workers paying almost $5000 towards the cost of coverage. In spite of the skyrocketing costs, we don’t seem to be getting healthier. The question has to be asked – what are you paying for and what are you getting?

because they didn’t deliver good juice. (Can’t say they did or didn’t as I never tried it.) They failed because they didn’t deliver something of tangible value. In essence they created a solution looking for a problem, and expected us to pay $700 to use it. What does this have to do with healthcare? Well, the system is in kind of a “Juicero” mindset, throwing buckets of money at over-engineered solutions designed to fix problems that may or may not exist; enacting an arms race of sorts. Hospitals are spending tens of millions of dollars investing in wonderful technologies looking to one-up their competition in the hopes of attracting more patients. What’s getting lost in the mix is asking what the patients actually want and making tangible investments in those things. Most patients don’t complain about their doctors not having access to the best technology – they complain about not having the attention of their doctors.

A Medical Arms Race – Healthcare’s “Juicero” Problem*

Connection is a Currency

Have you ever heard of Juicero? It was a company on a mission to make sure everyone had access to the very best cold pressed juices whenever they wanted. The company offered a state of the art juicer with internet connectivity. This $700 juicer (you read that right) cold pressed $7 juice packs (also not a typo) and could tell you if the pack had expired (because reading the packet expiration date was too simple). The idea was so ludicrous, so far fetched and so out of bounds that the company managed to raise $120 million from investors (including Google, no less). Earlier this year, someone managed to figure out that you could squeeze the juice out of your $7 juice pack with your bare hands, saving yourself $400 (did I mention they dropped the price to make it more “accessible?”). Needless to say, the company went belly-up, not *Hat tip to Kim Bellard at Tincture.io for this juicy analogy.

juice machines and patient engagement

Inside Medicine | Holiday Issue 2017

I became a neurosurgeon because I was enamored by the diversity and complexity of the nervous system, but also because I was intrigued by new technology. I discovered something remarkable in the early part of my 17-year career – that while patients were interested in having cutting edge therapy, they were just as interested in having a connection with their doctor. There was a clear correlation between patient satisfaction and how well I communicated with my patients, which was significant given that my practice at the time centered on vascular neurosurgery – a high risk subspecialty dealing with brain aneurysms and hemorrhagic stroke. As medical students, we start our careers with a simple exercise – learning to listen to our patients. As our knowledge base expands, most physicians listen less and talk

more. I had to re-learn the simple truth that listening was just as important as providing information. Enhancing communication enhanced my connectivity and made me a better physician. Connection is a currency in healthcare. Patient engagement is about cashing in on that currency to deliver real benefits. As patients become more empowered healthcare consumers, enhanced engagement is becoming even more of a necessity. Efforts to improve patient engagement have borne fruit in managing chronic diseases like diabetes, congestive heart failure and COPD; but have also demonstrated improvements in surgical outcomes and recovery for surgical patients with joint replacements. (I’ve seen the tangible benefits in my own practice managing brain and spine patients.) The push to enhance connectivity and communication is evident with the rollout of value based care models by the Centers for Medicare and Medicaid (CMS). These models are morphing towards outcome and merit based measures for

compensation – in essence rewarding docs for doing a good job, not just doing more procedures. Part of the equation boils down to how well a patient was looked after. This is where connectivity comes in through improved communication, streamlined care coordination and a dose of good old-fashioned empathy.

Digital Empathy The most underutilized resource in achieving better outcomes are the patients themselves. We are seeing a variety of digital tools being used to augment connections between patients and their care providers. Numerous studies demonstrate the benefits of being proactive with patient engagements using digital (eHealth) products. While the world doesn’t need yet another app or convoluted patient portal, the fact that these products have come to market indicates there is a pressing need to find better ways to connect patients and providers. Incorporating a digital

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Inside Medicine | Holiday Issue 2017

...cont’d from page 9

platform for my surgical patients to interface with me has been an invaluable addition to my practice. “Digital empathy” sounds like a buzzword, but its an apt description of what we strive to deliver, addressing the biggest complaints patients have about the healthcare system outside of cost – bad experiences and poor customer service. By proactively engaging with my patient’s pre and post operatively, I found I was able to provide more effective and efficient care; resulting in fewer hospital readmissions, unanticipated ER visits, better surgical outcomes, as well as delivering a very unique patient experience. No $700 juice machine required.

Barello S, Triberti S, Graffigna G, et al. eHealth for Patient Engagement: A Systematic Review. Frontiers in Psychology. 2015;6:2013. 2 Coorey, Genevieve M et al. “Implementation of a Consumer-Focused eHealth Intervention for People with Moderate-to-High Cardiovascular Disease Risk: Protocol for a Mixed-Methods Process Evaluation.” BMJ Open 7.1 (2017): e014353. PMC. Web. 20 Sept. 2017. 3 “Patients’ top complaint? It isn’t doctors or nurses, study finds.” https://www.advisory.com/daily-briefing/2016/04/28/top-patient-complaints 1

Dr. Sanat Dixit is a board certified neurosurgeon with SportsMED Orthopedic and Spine Center. No juice packets were harmed in the creation of this document.

Inside Medicine | Holiday Issue 2017

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Inside Medicine | Holiday Issue 2017

} SURGICAL TECHNOLOGY

Inside Medicine | Holiday Issue 2017

TAVR with the SAPIEN 3 Valve

Life Is Waiting

“ I can share special moments with my grandkids again.”

“ I have much more energy to cook with my daughter.”

Learn more at SAPIEN3.com

CAUTION: Federal (United States) law restricts these devices to sale by or on the order of a physician. Please see the Important Risk Information on the accompanying page. Edwards, Edwards Lifesciences, the stylized E logo, Edwards SAPIEN, Edwards SAPIEN 3, SAPIEN, and SAPIEN 3 are trademarks of Edwards Lifesciences Corporation. © 2017 Edwards Lifesciences Corporation. All rights reserved. PP--US-2469 v1.0 Edwards Lifesciences • One Edwards Way, Irvine CA 92614 USA • edwards.com

SAPIEN 3 Transcatheter Heart Valve Important Risk Information

Indications: The Edwards SAPIEN 3 transcatheter heart valve, model 9600TFX, and accessories are indicated for relief of aortic stenosis in patients with symptomatic heart disease due to severe native calcific aortic stenosis who are judged by a Heart Team, including a cardiac surgeon, to be at intermediate or greater risk for open surgical therapy (i.e., predicted risk of surgical mortality ≥ 3% at 30 days, based on the Society of Thoracic Surgeons (STS) risk score and other clinical co-morbidities unmeasured by the STS risk calculator). The Edwards SAPIEN 3 transcatheter heart valve, model 9600TFX, and accessories are indicated for patients with symptomatic heart disease due to failure (stenosed, insufficient, or combined) of a surgical bioprosthetic aortic or mitral valve who are judged by a heart team, including a cardiac surgeon, to be at high or greater risk for open surgical therapy (i.e., predicted risk of surgical mortality ≥ 8% at 30 days, based on the STS risk score and other clinical co-morbidities unmeasured by the STS risk calculator). Contraindications (Who should not use): The Edwards SAPIEN 3 transcatheter heart valve and delivery system should not be used in patients who: • Cannot tolerate medications that thin the blood or prevent blood clots from forming. • Have an active infection in the heart or elsewhere. Warnings: • There may be an increased risk of stroke in transcatheter aortic valve replacement procedures, compared to other standard treatments for aortic stenosis in the high or greater risk population. • If an incorrect valve size for your anatomy is used, it may lead to heart injury, valve leakage, movement, or dislodgement. • Patients should talk to their doctor if they have significant heart disease, a mitral valve device or are allergic to chromium, nickel, molybdenum, manganese, copper, silicon, and/or polymeric materials. • The SAPIEN 3 valve may not last as long in patients whose bodies do not process calcium normally. • During the procedure, your doctors should monitor the dye used in the body; if used in excess it could lead to kidney damage. X-ray guidance used during the procedure may cause injury to the skin, which may be painful, damaging, and long-lasting. • Transcatheter aortic heart valve patients should take medications that thin the blood or prevent blood clots from forming, except when likely to have an adverse reaction, as determined by their physician. The Edwards SAPIEN 3 transcatheter heart valve has not been tested for use without medications that thin the blood or prevent blood clots from forming. Precautions: The long-term durability of the Edwards SAPIEN 3 transcatheter heart valve is not known at this time. Regular medical follow-up is recommended to evaluate how well a patient’s heart valve is performing. Safety, performance, and durability of the SAPIEN 3 valve has not been established for placement inside a previously implanted transcatheter valve. The safety and effectiveness of the transcatheter heart valve is also not known for patients who have:

• An aortic heart valve that is not calcified, contains only one or two leaflets, has leaflets with large pieces of calcium that may block the vessels that supply blood to the heart or in which the main problem is that the valve leaks. • Previous prosthetic ring in any position. • Previous atrial septal occlude. • A heart that does not pump well, has thickening of the heart muscle, with or without blockage, unusual ultrasound images of the heart that could represent irregularities such as a blood clot, a diseased mitral valve that is calcified or leaking, or Gorlin syndrome, a condition that affects many areas of the body and increases the risk of developing various cancers and tumors. • Low white, red or platelet blood cell counts, or history of bleeding because the blood does not clot properly. • Diseased, abnormal or irregularly shaped vessels leading to the heart. Vessels which are heavily diseased or too small for associated delivery devices, or a large amount of calcification at the point of entry. • Allergies to blood-thinning medications or dye injected during the procedure. •

For a valve in valve procedure, there is a risk of leakage if the previously implanted tissue valve is not securely in place or if it is damaged. There is also the possibility that a partially detached valve leaflet from the previously implanted valve could block a blood vessel.

• Additional pre-procedure imaging will be completed to evaluate proper sizing. Potential risks associated with the procedure include: • Death, stroke, paralysis (loss of muscle function), permanent disability, or severe bleeding. •

Risks to the heart, including heart attack or heart failure, a heart that does not pump well, irregular heartbeat that may result in a need for a permanent pacemaker, chest pain, heart murmur, false aneurysm, recurring aortic stenosis(narrowing), too much fluid around the heart, injury to the structure of the heart.

• Risks to your lungs or breathing, including difficulty breathing, fainting, buildup of fluid in or around the lungs, weakness or inability to exercise. •

Risks involving bleeding or your blood supply, including formation of a blood clot, high or low blood pressure, limited blood supply, a decrease in red blood cells, or abnormal lab values, bleeding in the abdominal cavity, collection of blood under the skin.

•

Additional risks, including life-threatening infection, dislodgement of calcified material, air embolism (air bubbles in the blood vessels), poor kidney function or failure, nerve injury, fever, allergic reaction to anesthesia or dye, reoperation, pain, infection or bleeding at incision sites, or swelling.

Additional potential risks specifically associated with the use of the heart valve include: • Valve movement after deployment, blockage or disruption of blood flow through the heart, need for additional heart surgery and possible removal of the SAPIEN 3 valve, a blood clot that requires treatment, damage to the valve (e.g., wear, breakage, recurring aortic stenosis), nonstructural valve dysfunction (e.g., leakage, inappropriate sizing or positioning, blockage, excess tissue in growth, blood cell damage, etc.) or mechanical failure of the delivery system and/or accessories.

CAUTION: Federal (United States) law restricts these devices to sale by or on the order of a physician. Edwards, Edwards Lifesciences, the stylized E logo, Edwards SAPIEN, Edwards SAPIEN 3, SAPIEN, and SAPIEN 3 are trademarks of Edwards Lifesciences Corporation. All other trademarks are the property of their respective owners. © 2017 Edwards Lifesciences Corporation. All rights reserved. PP--US-2469 v1.0 Edwards Lifesciences • One Edwards Way, Irvine CA 92614 USA • edwards.com

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Inside Medicine | Holiday Issue 2017

} RESEARCH

Inside Medicine | Holiday Issue 2017

Inside Medicine interviewed Dr. Brett Davenport, a reproductive endocrinology and fertility specialist in Huntsville. We asked the most common patient questions about infertility and conception.

AM I INFERTILE? The definition changes slightly, based on the woman’s age. Women less than 35 years old are considered infertile if they have not conceived a pregnancy after 1 year of trying to conceive with regular intercourse in the absence of contraception. However, for women 35 years or older, infertility is the absence of pregnancy after only 6 months of regular intercourse with no contraception. Infertility can be the result of either male or female disorders, and oftentimes both. It can also occur due to a simple lack of understanding regarding the most optimal timing of a woman’s menstrual cycle. WHAT ARE MY CHANCES OF CONCEPTION EACH MONTH? Pregnancy oftentimes will not happen “on demand.” The average healthy couple has only a 15-20% chance of conceiving each month. This means that patience may be necessary. However, if a man or woman has a known cause or high suspicion for infertility (see below), it is very prudent to seek help from a specialist (OB/GYN or Reproductive Endocrinologist). OVULATING OR NOT? Although there are many causes of infertility, a woman must be ovulating for spontaneous conception to occur. Therefore, this is the first question that a woman should ask herself when she is ready to conceive. A woman is likely ovulating if she has regular predictable menses. There are also other simple but less reliable ways to determine if ovulation is occurring (e.g. basal body temperature testing and ovulation prediction testing). Sometimes, even with the above, it is not clear whether or not ovulation is occurring. This should prompt a consultation with a reproductive specialist to help her determine her ovulatory status. HEALTHY EGGS? There are many factors that can cause a woman’s eggs to be unhealthy and more unlikely to fertilize. Common causes of poor egg quality that can often be modified/prevented are obesity, smoking, excess alcohol, narcotics, and poor diet. Other common causes that usually cannot be avoided are medical conditions such as polycystic ovary syndrome, endometriosis, prior radiation/chemotherapy, and age alone.

WHAT ABOUT THE SPERM? Men must be aware that the health, numbers, and function of their sperm are just as important as their female partner’s egg count and function. Many of the same modifiable factors that cause poor egg health also cause a decrease in quantity and quality of sperm, including excess alcohol, smoking, narcotics, and obesity. Additionally, a common cause of low/no sperm is the use of steroids. Like women’s eggs, men’s sperm can be adversely affected by radiation/ chemotherapy. Several unavoidable causes of low/no sperm can be present from

Inside Medicine | Holiday Issue 2017

birth and/or acquired throughout life. It is important for men to be open to lifestyle changes that will optimize their sperm health. AM I TOO OLD TO HAVE A CHILD USING MY OWN EGGS? In general, couples in the U.S. are waiting longer and longer to have children. It is important that a couple does not lose sight of the fact that a woman’s chances of conceiving with her own eggs begins to decrease around age 34-35. Women also have a higher risk of chromosomal abnormalities as they age above 35, which may increase miscarriage and birth defect chances as well. However, don’t lose hope! This does not mean women above 35 cannot have a healthy child. Statistics indicate the decline is gradual, averaging a 6-7% decline in fertility rate per year when compared to the year before. This simply means that if you are over 35, time is not on your side. You should speak with a reproductive specialist in order to help expedite the pregnancy process if conception has not occurred within 6 months of attempts. Further, the higher above age 35 that you climb, the more urgently you should seek assistance if you wish to conceive using your own eggs. For example, your chances of conception and delivery of a child with your own eggs has declined to <10% by age 42, even with the most aggressive therapies available. Age matters for male fertility also. Miscarriage rates are twice as high for male partners over age 45 when compared to male partners under 25. Older males also have been found to be at greater risk of having offspring with learning and mental difficulties. WE ARE NOT READY TO CONCEIVE NOW. HOW DO I KNOW IF WE WILL HAVE A FERTILITY ISSUE AND/OR WILL HAVE DIFFICULTY LATER ON? It is true that the best way to know you are infertile is to try to conceive, and that many times you cannot predict this until failed attempts have been made. However, there are clues that may indicate potential fertility problems for you or your partner. Is the female partner menstruating irregularly and unpredictably without the use of hormonal contraceptives? Does she have super painful periods, or pain in her pelvis when she is not having a period? Are her periods super heavy? Does she have any pain with intercourse? For men and women, are either of you grossly overweight or underweight (body mass index >30 mg/kg2 or <20 mg/kg2)? Are you a smoker? Do you consume alcohol in excess (>1 drink per day)? Have you had any sexually transmitted diseases in the past? Do you work closely with chemicals? Is there an immediate family history of genetic defects or birth defects? Have you ever had to receive chemotherapy or radiation? Have you had to have surgery at your genitals, pelvis, or inguinal

} MEDICAL ADVANCEMENT

regions in the past (below your belly button, above your legs)? This is not an exhaustive list of red flags, but if the answer to any of these is yes, you should consider appropriate lifestyle/preventative measures and/or a consultation with a specialist sooner rather than later when you are ready to conceive. WHAT IF I AM GETTING OLDER, BUT WOULD STILL LIKE TO CONCEIVE IN THE FUTURE? A few different options exist. Techniques to freeze reproductive tissue (called vitrification) are very advanced. A woman can freeze her eggs at any age, allowing the aging process of the egg to “freeze in time.” This is a good option for a single woman who does not have an intimate partner. A couple can also undergo IVF even prior to their desire to have a child with the ability to freeze their embryos in time. These options can help take the stress of aging off of a couple. WHAT IF I AM ALREADY AT AN ADVANCED REPRODUCTIVE AGE WITH A LOW CHANCE OF FERTILITY? It is also possible for a couple to use eggs that are donated from a younger female. This process requires in vitro fertilization, but is an excellent option for women who would like to carry a pregnancy but are unable to conceive using their own eggs. Also, please don’t forget about the option for adoption! Your reproductive specialist can help you sort through the facts and costs of this decision.

conception, and rather makes couples grow tired of the process more quickly. 3) After intercourse, nothing else is necessary. A woman standing on her head, placing a pillow under her back, or lying down for an extended period of time has not been shown to assist with successful conception. 4) If a woman decides to time her ovulation, she can find the approximate cycle day on which she ovulates by performing daily urine ovulation predictor tests until she receives a positive. However, once a regularly-menstruating woman knows the proper timing, she should let it go and time intercourse according to her initial findings during future cycles. By removing the hassle and stress of daily testing, this will help to make the process more enjoyable.

532 MADISON STREET HUNTSVILLE, AL 35801 (256) 217-9613 FERTILITYALABAMA.COM

WHAT SHOULD I EXPECT FROM A SPECIALIST? If you meet the criteria for an infertility diagnosis and have confirmed ovulation, a reproductive specialist will go on to look for a myriad of other causes through history, examination, and testing. Some of the recommended interventions may include stimulation of the woman’s ovaries with medicine and/or medicine to help induce ovulation. Intrauterine inseminations (placing the sperm into the back of the uterus with a catheter at the time of ovulation), and/or in vitro fertilization are other common interventions. Couples with some diagnoses can expect to gradually move sequentially from more conservative to more aggressive therapies as needed, while couples with other diagnoses might need to move quickly toward more aggressive therapies such as in vitro fertilization. Indications that would call for a couple to move more quickly toward in vitro fertilization are tubal blockages/diseases, severe sperm deficiencies, severe endometriosis, very advanced reproductive age, or desire/need to perform pregenetic testing. HOW CAN I MAKE IT SIMPLE AND KEEP IT FUN? If you are a couple that has not met the definition of infertility above and do not have a high suspicion or risk for infertility, try to keep your conception attempts simple and fun. A few things to remember: 1) Many lubricants can hurt conception chances by hindering sperm movement. The best lubricant (short of natural lubrication) when a couple is trying to conceive is mineral oil (yes, from the grocery store isle). Saliva can also hinder sperm function. 2) A couple must have intercourse regularly around the time of ovulation, but even daily intercourse is not necessary. If you know when you are ovulating, 1-2 attempts around that time should suffice, given that the timing and sperm health are adequate. Intercourse multiple times daily does not increase chances of

Inside Medicine | Holiday Issue 2017

What’s better than early detection?

Earlier detection.

Schedule Your Annual Screening Mammogram Today! 256.429.4888 At Crestwood, we’re giving area women an even stronger weapon in the fight against breast cancer- 3D Mammography. This innovative technology provides exams with greater detail, resulting in improved accuracy and a better chance at early detection, especially for women with dense breast tissue or with an increased risk of being diagnosed with the disease. Screening Mammograms are available at our Huntsville and Madison locations!

MEDICAL CENTER Madison • Crestwood Madison Outpatient Center 20 Hughes Road Huntsville • Crestwood Women’s Center 185 Chateau Drive CrestwoodWomensCenter.com *For a list of risk factors and American Cancer Society recommendations, visit www.Cancer.org. Appointments are on a first-come, first-served basis. An order from a physician or qualified healthcare provider is not required, but the patient must provide a physician/provider name when an appointment is made. If the patient does not have a physician/provider, a list will be provided for selection. All mammogram reports will be sent to the physician/ provider, and the patient is responsible for follow-up. Check with your insurance provider to confirm coverage for a screening mammogram.

Inside Medicine | Holiday Issue 2017

ROBOT I C SURGERY

by Brian Scholl, MD

Dr. Scholl is a member of The Orthopaedic Center Spine Team. He is Board Certified by the American Board of Orthopaedic Surgery. He received his training at Emory University, UAB, and Campbell Clinic. He is a published author and has written two textbook chapters regarding spine surgery. Inside Medicine sat with Dr. Scholl to discuss some recent developments as it comes to spine care. He is excited about the future of robotic technology in his field, especially the Mazor X System. Dr. Scholl shared with us that over the past 20 years, there have been just a few major advancements in spine surgery: pedicle screw instrumentation, kyphoplasty, bone morphogenic protein (BMP) and artificial disk replacement. Robotic surgery isn’t new. Intuitive Surgical’s robot “da Vinci", which revolutionized gynecology, general surgery and urology, has been around for a decade. Recently experts have been developing robotic navigation systems to assist in spine surgery, and the latest iteration of the robotic movement is the Mazor X. Right now, Dr. Scholl is the only spine surgeon in the area to provide this alternate treatment, and he is enthusiastic about it. “It’s a really slick system, and it is the only new surgical technique I have been excited about in the last 15 years,” says Dr. Scholl. There are not that many robotic systems available in the United States and most are affiliated with larger university programs, so Huntsville is lucky to have the option. He does believe that once the technology is proven to be effective and viable, other surgeons will follow his lead. The “R2D2” base unit and robotic arm of the Mazor X helps the spine surgeon know exactly where to place pedicle screws. Dr. Scholl describes the actual equipment as a

Inside Medicine | Holiday Issue 2017

2’x3’ self-contained, box with a monitor and special eyes. The base unit is opened up, and the robotic arm is pulled out and hooked to the bottom of a standard OR table, outside the field of the surgeon. The robotic arm is then draped and the system scans the operative field of view to ensure the arm will not collide with any instrument tables or lights. The robotic arm (about the length of a human arm) then points to the exact spot where each screw needs to go. Then, the pointer zig-zags side-to-side all the way up and down the spine, and the surgeon inserts each screw. The genius behind the system is in the software, which was written by the author of the original software for CT scanners. The software combines a low-dose radiation pre-operative CT scan with standard fluoroscopy that is taken in the operating room. This allows the robot to know the exact location of each vertebra of the spine during the operation. The system does not replace the

surgeon; however, as it requires surgeon input pre-operatively and surgeon confirmation of screw placement. However, it is so accurate that if the surgeon tries to label a spine vertebra incorrectly, the robot will not allow it. Dr. Scholl believes this is the initial stage of robotic spine surgery. It is a step forward, but advancements in the future will continue to help perform surgeries. The Mazor X System is mostly used to insert pedicle screws from the cervical spine down to the pelvis. Although the new tool is not for everyone, it does help substantially with a subset of spine surgeries. With robotic precision, multiple pedicle screws can be put into place quickly, typically in about half the time of a regular scoliosis operation. Since there is no need for intraoperative CT scanning or multiple fluoroscopy images, it requires less radiation and less anesthesia making it is a safer alternative for patients. It allows more accurate positioning of implants in a patient with distorted anatomy like a patient with complex scoliosis or a revision of a previous spine surgery where a large number of screws need to be inserted. In these cases, the spine can be twisted, the patient has already possibly had a couple of surgeries, or the anatomic landmarks aren’t visible and sometimes it is a struggle to get the screws in the correct spot. This system quickly allows screws to be inserted without any anatomy being visible to the surgeon. The technology is also perfect for the patient who need minimally invasive procedures. Dr. Scholl explains that not all patients will benefit from robotic surgery. Most spine surgeries can be easily and accurately completed through a standard open incision. With routine procedures in between, he says he is still quicker and better without it. He goes on to explain a surgeon would not do an artificial disk replacement or XLIF with it. An older patient in need of a procedure such as a 2-level laminectomy and fusion would not benefit from the system. The Mazor X system can help post operatively as well. Especially in a minimally invasive procedure, it can shorten the patient’s hospital stay by a full day. For scoliosis type surgeries where there will be less time under anesthesia, it can shorten the case from 5 hours to 4 hours. The precision and guess work is completed by the technology. It’s easier to wake up from and easier to recover from. It also minimizes any complications that could be due to hardware. In short, it’s a great new technology that speeds up spine surgery, makes it more accurate, and allows the surgeon to make a smaller incision. This kind of advancement makes certain spine procedures safer. One of the best things about the Mazor X is that it is patient–centric. It is not designed to simply make more money for the doctor or hospital, it is designed to make surgery safer and more reliable for the patient.

} SURGICAL TECHNOLOGY

figure 2

In figure 2, a patient with spondylolisthesis. The computer digests the CT scan and automatically segments the spine into its constituent vertebral bodies. The system allows the surgeon to adjust the mid-line and drag-n-drop the screw positions in the software. It allows the surgeon to choose the length, diameter and custom trajectory – which is customized to each individual patient. The system also allows the spine to be rotated and viewed in 3 dimensions. This technology also allows the procedure to be demonstrated to the patient before the actual surgery.

If you are interested in finding out more about Mazor X, please contact Dr. Scholl’s office at 256-539-2728.

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} FEATURE

Screenings the

importance of

This is a tale of good news and bad news. The bad news: most women can quote the statistics, 1 in 8 women will develop breast cancer. Let us look a little closer at these statistics to find some good news. It is true that 1 in 8 women will develop breast cancer, but that is in the span of a lifetime. By age 20, the risk is 1 in 1,760, by age 30 it rises to 1 in 229, and by age 40 it goes up to 1 in 69. Though not zero risk, these are not statistics one should be overly concerned about. It does start to rise to 1 out of 42 at age 50, 1 out of 29 at age 60, and 1 out of 27 by age 70. The lifetime risk is 1 out of 8. Clearly, breast cancer risk rises with age. The significant rise begins between the ages of 40-50. More bad news: the main risk factor for developing breast cancer is one’s sex followed by one’s age. These are both things women have no control over. Other factors include early menarche, late menopause, and increasing times of unopposed estrogen from fewer children and then choosing not to nurse. These are factors in which today’s women still have little control over. There have been studies linking obesity, alcohol, tobacco, and lack of exercise to breast cancer. Though not statistically relevant, living a healthy lifestyle is always helpful. There is some good news that has been found over the last decade, 10% of breast cancer is genetic in origin. The BRC-1 and BRC-2 genes can be tested for and if present, can lead to lifestyle choices and further strategies to detect and treat. Breast cancer is the second most common cancer in women just behind skin cancer. Breast cancer accounts for 1 out of every 4 cancers detected in women. It is no longer a death sentence diagnosis. Cancer survival is statistically monitored by what is called 5 year survival by which one colloquially can call a ‘cure”. Depending on the staging of breast cancer, the difference in survival is primarily a factor of the size of the tumor. Ductal carcinoma-in-situ, kind of like a pre-cancer, has a 100% 5 year survival with proper surgical treatment. Remarkably a tumor up to 2 cm or

Inside Medicine | Holiday Issue 2017

by Paul Fry, MD

a Stage 1 Cancer also has a 100% 5 year survival. A tumor up to 5 cm, about the size one would start to palpate a “lump”, the 5 year survival is near as high, 97%. Stage 3 Cancer, usually a tumor larger than 5 cm or with lymph node involvement, the 5 year survival is still good, 72%. Sadly, once metastatic, the 5 year survival falls to 22%. These statistics are indeed a tale of good and bad news. Compared to other cancers, the survival rate is much better. For instance, Lung Cancer 5 year survival is only 10-15%. Colon Cancer is at 40-50% but falls to only 5% if metastatic. Pancreatic Cancer has only a 5% 5 year survival. Clearly the earlier and ultimately smaller the tumor is detected, the better the survival. The key is early detection. The goal is to detect a tumor before it could be detected by self-exam or physician exam. Screening mammography is the main tool for this early detection. Screening mammography began to be implemented in the late 1980s to the 1990s. Since 1990 there has been a 38% decline in mortality from carcinoma. Though beyond the scope of this article there have been studies directly linking the decrease in mortality to the increasing utilization of screening mammography. Though one of the most common cancers, we are fortunate in that breast cancer is one of the slowest growing cancers. This has allowed us to implement a screening program with a frequency calculated to detect new cancers or changes in size of a cancer between screening tests. The average breast cancer “doubling rate”, the time to double the number of cancer cells, is 282 days, this is just under one year. This is the amount of time one should be able to see interval changes in breast densities or to first detect new lesions. Ideally, with yearly mammograms, a new or growing tumor would be detected in this interval. Mammography is a low dose X-Ray of the breasts. Mammograms are only performed at special facilities that meet both government regulatory and professional society accreditation. A radiologist who is specially

certified in mammography interprets these images. If there is a suspicious finding on the screening mammogram, this can happen up to 10% of the time, the patient returns for further imaging. This does not in and of itself mean one has breast cancer, this is important as it is a common misunderstanding not only of patients but of other medical personnel. It does mean that further imaging is needed. This may mean further compression or magnification views or the utilization of ultrasound and even MRI. The large majority of patients that return for further imaging are shown to not have suspicious abnormality. They are shown to be benign findings or simply artifacts usually from “overlapping” glandular tissues. If there is a finding on the mammogram that cannot be proven as benign, a biopsy may be needed. All mammograms are placed into a category called the BIRADS (Breast Imaging Recording and Data System). If BIRADS 4, “possibly” cancer, the chance of cancer is 30%; If BIRADS 5, “probably” cancer, the risk is 95%. Most suspicious findings are in the BIRADS 4 classification so a minimally invasive biopsy can be performed to detect cancer without resorting to more invasive surgical excision biopsies. If a cancer is indeed detected by mammography, it is usually early and therefore small enough to receive near complete cure rate treatment. The advancements in surgery, chemotherapy, hormonal therapy and breast reconstruction, have made it so even advanced breast tumors or even metastatic tumors have better 5 year survival rates than most other cancers. Clearly, this is good news when faced with the bad news of breast cancer in general. Many, if not most, women given a diagnosis of breast cancer can now expect to live. The American College of Radiology is tasked with certifying facilities and those radiologists that interpret screening mammograms. What follows is the latest Position Statement by The ACR concerning Screening Mammography: “The American College of Radiology recommends

annual screening mammography for women starting at age 40. This affords the maximum benefits of reduced breast cancer deaths, less extensive treatments for cancers that are found, decreased chance of advanced disease at diagnosis, and discovery and treatment of high risk lesions. Breast cancer incidence increases substantially around age 40 and even earlier for high risk women and women of color. All health insurers, including the Centers for Medicare and Medicaid Services, should cover women ages 40 and older for annual mammograms as a preventative service, without additional cost sharing or co-payments. Extensive scientific research shows a 40 % reduction of breast cancer deaths with regular screening mammography screening. The greatest mortality reduction, the most lives saved and the most life years gained occur with yearly mammograms starting at age 40. There is no established age for women to stop screening as long as they are healthy and desire to remain so. Therefore, health care coverage for screening should not have an upper limit.” The Good news of mammography is indeed remarkable. The bad news is in the State of Alabama, the utilization of mammography is still not ideal. From age 40-49 only 63% of women have had a mammogram. From age 50-64, only 72% of women have had a mammogram over the last two years. This falls to only 64% after 65. If you have not had a mammogram, please do. If you know someone who has not had a mammogram, please encourage them. Let us turn bad news into good news.

Paul J Fry, MD is Board Certified in Diagnostic Radiology and is a full partner with Radiology of Huntsville. He presently serves as Medical Director of the Department of Radiology at Athens-Limestone Hospital.

Inside Medicine | Holiday Issue 2017

}MISSIONS

Inside Medicine | Holiday Issue 2017

reversed curve

“TEXT NECK” by David A. Lang, D.C. Something that is becoming a rising issue these days is the altering appearance and shape of the cervical spine in the younger population. When viewed from the side, a spine should have a smooth transition of front to back curves. This allows for shock absorption, center of balance, leverage for proper posture, and flexibility. With our society becoming a digital world, this means we spend most of the day with our heads in a forward or looking down position. This isn’t good for our spinal health. It puts added strain on the cervical joints on the front of the neck, strains the posterior cervical muscles and stresses the delicate tissues of the spinal cord. An ideal neck curve should be between 35-45 degrees, basically the shape of a banana, with the convexity of the curve facing the front. I have seen an increased population of reversed curves in children as young as 6-7 years old. We believe this is due to extended periods of looking down at a tablet, phone or other handheld electronic gaming system. For example, just go in a restaurant and look around. You will see many families looking down at their phones and not talking. For every inch the head goes forward, there is 10 lbs. of pressure exerted on the back of the neck. A standard forward head posture (FHP) in the moderate range is near 5-6 cm. The total range being from 0-6. Ideally, a person should have a FHP measurement of 0-1.5 at the most. This means that a patient with a forward head posture of 6 cm, could have over 35 lbs. of pressure constantly pulling on the back of the head, just to keep the head upright. This can cause pain, stiffness, fatigue, headaches, and many more symptoms. It is caused by the condition of reversed curve or forward head posture (FHP).

Inside Medicine | Holiday Issue 2017

...contâ&#x20AC;&#x2122;d from page 35

At our office we address this by first doing a detailed history and consultation followed by a complete physical exam. In this exam, we will determine and test posture, tenderness in the muscles, active and passive range of motion, strength and stability of joints, functional movement screens, and ortho/neuro exams. If warranted, we will take digital x-rays and measure the degree of loss of curve and or forward head posture (FHP). After careful review of the findings, we will design a specific treatment plan for the patient to address these issues. We use 2 different spinal correction techniques, Pettibon System of Spine Correction, and C.L.E.A.R. Institute of Spine and Scoliosis correction. One technique is geared toward the general condition of postural restoration and the other is geared to address those with postural deficiencies due to idiopathic or structural scoliosis. Both are very effective and safe to do on most people. Careful screening for the proper candidate is always a priority for us. The treatments themselves will be a combination of active and passive range of motion techniques, specific gentle spinal adjusting, repetitive standing cervical traction, and head weighting to initiate and stimulate the involuntary postural reflexes. The patient will also have home isometrics and stretching exercises to do between treatments. We find a strong correlation between patients that do their homework vs. patients that do not. Working on the exercises is important and it most definitely helps determine the ideal outcome.

Inside Medicine | Holiday Issue 2017

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A Message to Those Choosing a Career within Health Care as Support Staff? by Tiernan O’Neill In many communities there is a large population of young adults that start or who wish to start a career in the medical field. They become support staff in various medical offices in either administrative or clinical departments. With limited education they often fall within the roles of receptionists or medical assistants. These roles could be short term or could even expand to a lifetime. I have spent many previous articles defending these staff members and better explaining their job functions to the lay person. Basically, I have done this as I would in my own office, to provide cover and support for staff as they are on the brutal frontlines of the complicated and sometimes volatile environment of healthcare. But it would be shameful not to fully explain the expectations and responsibilities these staff members must assume as well. In most all interviews I have held, I would ask the prospective employee the same question; “By pursuing a job within the medical field, whom have you chosen to serve?” I can anticipate that nearly every candidate, whether they honestly mean it or not, is just trying to give the answer they think I am looking for and will answer “the patient.” In my opinion this would be the wrong answer each and every time. The answer I look for and believe is correct is “the physician.” I elaborate to explain to them that it is the physician who holds the necessary information, education, degree, license and ultimate liability to best serve the needs of the patient. And subsequently it is our role within the support staff that can assist them in making sure all of the patients’ needs and care are met. Having said that, it is important to expand on the things we can do as support staff to best assist the physician. First and foremost, we can take our position in the process as extremely important. As I said before, many of the entry level positions are being filled with young and inexperienced people, but despite that, it would be beneficial for all if these support staff members viewed their jobs as so much more than a means to earning pay. On par with the physician, we expect them to see themselves as vital professionals and dedicate themselves to a long term career in this field….as best as they can. Secondly, they should of course still hold compassion and empathy for patients who are seeing us at their most vulnerable stages in life. Thirdly however, never forgetting the whole time they must continue to serve and not circumvent their physician’s best intentions or plan of care. Most importantly, whether these medical professionals are “directly” involved in the chain of care or are providing support as “simple” as answering phones or copying paper, we need to expect and demand they take their role seriously. It can often be overlooked that each and every action they perform, on a daily basis, holds with it a potential consequence to the care of patients. As such they need to be reminded and perform these duties with the best of intentions and highest regard. Their actions and work product will certainly affect the physician’s best efforts to provide comprehensive care to the patient. Simply put, all staff should see themselves as playing vital roles within the care of patients no matter what their position, and the consequences and gravity of their actions should be fully appreciated. In short, whether they are 18, 65, full time or part time they need and are expected to behave as consummate professionals performing essential tasks that can have life or death consequences to all of those they diligently attempt to serve. 40

Inside Medicine | Holiday Issue 2017

} PERSONAL INTEREST

Inside Medicine | Holiday Issue 2017

by Anne Jewell

Why is Long Term Care important to Women? Could it be that women live longer than men? Do women become disabled more often? Do women end up with more chronic illnesses? Could women become impoverished as they age as widows? It has a lot to do with: "Longevity and Caregiving". Statistically, women outlive men. Therefore, they are far more likely to need care when they get older. Women are natural and lifelong caregivers. They take care of their spouses, kids, grandparents, grandchildren, and even the family pets. Informal unpaid caregiving falls on women heavily. This includes the stress when taking care of sick children and later in life, most commonly, taking care of their elderly parents. Women are masters at multitasking and they keep everyone on their toes and moving like a straight arrow. Mothers, sisters, wives, daughters and friends care for others, indefinitely. They put aside their own needs and allow their health to fail. The burden they often carry, financially, emotionally, physically and spiritually, can break a woman's soul and pocketbook. If you think about all the people in your life who are â&#x20AC;&#x153;made to lastâ&#x20AC;? I believe the obvious answer would include the women in your life. 44

Inside Medicine | Holiday Issue 2017

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} FEATURE

ATOPIC DERMATITIS by D. Kishore Yellumahanthi, MD, MPH

Atopic Dermatitis is the most common type of eczema. Eczema is a clinical and histological pattern of inflammation of the skin seen in a variety of dermatoses with widely diverse causes. Depending on whether the cause of the eczema is from within the body or outside the body, eczema can be classified as endogenous and exogenous eczema respectively. AD is a type of endogenous eczema. Therefore, although AD in colloquial language is often called as eczema, in reality it is only ONE type of eczema. AD affects 15-20% of the children and 1-3% of adults worldwide. It is a chronic skin condition that is characterized by red, itchy, dry and inflamed skin. It manifests during the first year of life in about 60% of patients and usually in 90% will present by 5 years of age. AD is the first manifestation of the atopic triad - AD, asthma, and hay fever. About 50% of the people with severe AD will get asthma and about two-thirds (66%) will get hay fever. AD imposes an enormous burden on the social, personal, emotional, and financial resources of patients and their families. It is a major cause of morbidity in children in the Western world. The annual costs are similar or higher than other chronic diseases, including diabetes, asthma, emphysema and arthritis.

What causes Atopic dermatitis? The exact cause of AD is not known yet. It could be multifactorial. So far the research shows that it is not contagious and that it runs in families. People who get AD usually have family members who have AD, asthma, or hay fever. This means that genes do play a role in causing AD. Children are more likely to develop AD if one or both parents have AD, asthma, or hay fever.

What does Atopic dermatitis look like? The appearance of AD depends on age of the patient. There are three distinct clinical age-related stages of atopic dermatitis: infantile, childhood, and adulthood. During each of these stages both the appearance and site of the lesions change, although the stages often overlap. The infantile phase usually lasts until 2–3 years of age, the childhood phase from 2 years until puberty, and the adult phase from puberty onward. The rash in infancy characteristically begins on the cheeks and scalp and evolves over time to involve the front and outer sides of the legs and arms (figure 1). The trunk may be involved. The rash is generally symmetric, scaly with red patches within which crusting is common. During late infancy to the childhood phase, the flexural surfaces of the extremities become the most commonly involved sites, particularly the front of elbows and back of knees (figure 2). Other frequently involved sites include the neck, front of wrist and back of ankles, and the creases between the thighs and buttocks. In the adult phase, the distribution is generally less characteristic, and Inside Medicine | Holiday Issue 2017

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Inside Medicine | Holiday Issue 2017

...cont’d from page 49

predominantly present as localized dermatitis, like hand dermatitis, nipple, or eyelid eczema.

Management of Atopic Dermatitis Given the chronicity of AD, having a child with moderate to severe AD could have a profound impact on the social, emotional, and financial perspectives of families. Effective treatment not only improves the quality of the child’s life but also helps the entire family as a whole. Education, excellent skin care, avoidance of irritants and allergens, and treating inflammation are the key components of the management.

Education:

Education has a pivotal role to play in its management. It is important for parents to get educated on the nature of the disease and the goals of therapy. Understanding the chronic, relapsing nature of AD is important, as is counseling on the prognosis and natural history. If possible, parents should try to clarify all their questions with their healthcare provider’s office than try to find solutions to their questions and concerns through other resources such as internet as they may not always be reliable.

Skin care:

Emolients: The gist of basic skin care is to make sure skin is well hydrated. Numerous emollients are available that are suitable for use on atopic dry skin. In general, ointments and creams are more effective than lotions. Lactic acid and Urea based creams are beneficial for dry skin but could cause stinging, when applied to areas of eczema. Some children may be more prone to the sensation of stinging and, in such a situation, petroleum jelly or petrolatum-based ointment could be beneficial.

Applying emollients needs to be a fun act: Also it is important to keep in mind that, children, being children, would let the adults apply the moisturizer if the application of emollients is an enjoyable act for them. Therefore, in infants, it could be applied as a gentle massage at the time of changing the nappy. In older children, making pictures or dotting on the cream could be fun. As they grow up it is important that children are involved in their own treatment and encourage them to apply the emollients themselves. Bathing - yes or no: Regarding bathing of AD children, over the years there has been conflicting advice. This is because detergents and ordinary soaps can irritate and aggravate eczema. Current recommendation is to encourage carers to bathe children with eczema daily. Indeed, bathing in lukewarm water for no more than 15 minutes has the potential to rehydrate the outer layer of the skin. Also, bathing once or twice daily is soothing during a flare up of eczema, aids in decreasing bacterial counts, and helps in penetration of topical steroids applied after the bath. A mild, unscented, moisturizing soap or soap substitute or emollient can be used if needed. Excessive exposure to soap, detergents and shampoo aggravate dryness and should be discouraged.

Avoidance of Irritants and Allergens:

In the AD patients, the list of allergens and skin irritants can be quite exhaustive. It is imperative that they avoid them to prevent any flare ups. Stress, heat, sweating, and external irritants like hand and dish soap, laundry detergent, shampoo are some of the irritants. Seasonal pollen, dust mites, pet dander and mold are examples of some of the common allergens. Addressing these triggers may improve the AD.

Anti-inflammatory agents:

Topical steroids are usually the first drugs of choice prescribed by physicians to reduce the inflammation/eczema. Concerns regarding the side effects of topical steroid use is common; in one study 24% of families reported non-compliance with topical steroids due to safety concerns. The actual magnitude of the underuse of topical steroids could be much higher. Another small study revealed that only onethird of patients had proper compliance with topical steroid use. The word ‘sparingly’ often used on prescriptions of topical steroids can also be misinterpreted and lead to under-usage. At this juncture, it is worth to remember that the word ‘sparingly’ in prescription is often meant not to scare the parents about its usage but it is to let them know that it only needs to be applied in sufficient quantity only to the affected area. Topical steroids are being used for more than 50 years and studies clearly show that if used appropriately under supervision, ill effects are rare, and they are an effective treatment for eczema. Therefore, they need to be used as directed when needed to avoid any risks of under treatment such as chronically inflamed skin and diminished sleep quality with the associated detrimental effects on growth and development.

Inside Medicine | Holiday Issue 2017

...cont’d from page 51

Topical calcineurin inhibitors and newer phosphodiesterase 4 inhibitor creams are the other topical medications that can help reduce inflammation.

Role of Allergy testing and food restriction:

Often the general misconception is AD is caused by some allergy to foods or allergens in the environment. While it could be true that some of the allergens can irritate the skin and cause flare ups of AD, they are not responsible for causing it in the first place. Therefore, allergy testing and dietary restriction is not routinely needed in all atopic dermatitis patients.

Anti-microbial therapy & Bleach baths:

Routine antibiotic therapy is not warranted in all AD patients. As presence of infection can cause flare ups of AD, treatment with topical or systemic antibiotics may be appropriate, if there are any signs of infection. However, rather than treating once an infection occurs, it appears that the key in AD is to decrease nasal staphylococcal carriage pre-emptively and to keep the skin decolonized from Staphylococcus. From this aspect, bleach bathes have rapidly become a mainstay in AD patients. Physician, if thinks bleach baths are appropriate for any patient, will discuss with parents as to how they need to be carried out.

Prognosis

AD often becomes milder with age. About 50% of the children who get AD may have it as an adult. Some of the risk factors for disease to progress to adult stage include the degree of severity of AD, its persistence into adolescence, presence of other atopic diseases such as asthma and hay fever, a family history of AD in parents or siblings and early age of onset.

Reference: 1. Textbook of Neonatal dermatology Lawrence Eichenfield, Ilona Frieden, Nancy Esterly 2. Textbook of Pediatric Dermatology Edited by Lawrence Schachner, Ronald Hansen 3. Harper’s Textbook of Pediatric Dermatology edited by Alan Irvine, Peter Hoeger, Albert Yan 4. Textbook of Andrew’s disease of the skin 5. aad.org 6. https://nationaleczema.org/eczema/types-of-eczema/atopic-dermatitis/ 7. Rook’s textbook of dermatology

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The Importance of Screenings