Insidemedicine winter issue 2018 web

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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.

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www.the-surgerycenter.com Inside Medicine | W inter Issue 2018

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The Road to Pain Relief Starts Here. Precise Pain Relief for: Back & Neck Pain Nerve Pain and Sciatica Knee and Hip Pain Shoulder Pain Discogenic and Radicular Pain Shingles Pain Cancer Pain

Non-Surgical Solutions to Restore your Active LIfestyle.

Team of Double-Board Certified Anesthesiology & Pain Management Physicians Ronald Collins, M.D. Morris Scherlis, M.D. Roddie Gantt, M.D. John Roberts, M.D. Thomas Kraus, D.O.

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256.265.PAIN (7246)


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features &

CONTENTS

Sharing with Purpose

VOL 2

ISSUE 8

Inside Medicine | Holiday Issue 2018

FEATURES Advancements in Surgery 08

CONTENT Giving Back 28

imaging matters

Q&A with local philanthropist

CO N T R I B U TORS

Heather Moorse, MS, ATC, OTC Ben Macklin Kari Kingsley, MSN, CRNP Jarrod Roussel, PA-C Larry Parker, MD

Surgical Optimization decrease the risk of surgery

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Specialty Pharmacy

learning the basics

31

Matt Myer Matthew Clayton, MD Tracy A. Lowery, MD Paul Vandiver, OD

Salt Therapy

a new concept in health & wellness

36

50 is the new 40

discovering aesthetics treatments

56

Kimberly Waldrop, MA Ashley Smith, RN, MSN Margetta Thomas Nemil Shah, MD Tiernan O’Neill

MD

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

the way healthcare information has been and will be distributed

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

at kellyreese.im@gmail.com or

Making a Difference

and grow an alliance among

256.652.8089

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.

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S A LE S & M A R K ETIN G

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

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

Leigha Parker Karen Gauthier P U B LI S H E RS

Blake Bentley, President www. in s ide me dic in e m agaz ine.com


} FROM THE EDITOR

Dear Readers We hope you enjoy this edition of Inside Medicine. From the bottom of our hearts, we hope the articles found in our magazine help you or touch you in some way. Advice, information, and feel good stories fill the pages and we want nothing more than for you to enjoy them as much as we enjoy putting it all together for you! There is a higher reason we go about our lives and endure the journey that God has put out for us. In “Don’t Despise the Journey”, we find a story of success and survival when it was least expected. The article can teach us not to question where we are and where we are led, but to go with joy and enjoy the journey. Along that journey, we will probably experience pain and growing. Having back pain? You may need to see a spine specialist and we have a great article to help explain when to visit your local doctor. Having trouble concentrating or needing to relax? We have found an incredible resource that is new to our area. “Salt on the Rocks” may be just what you need. Articles about surgeries, coughing, cancer prevention, eye exams, and sports safety make this a very well-rounded edition. There is plenty to learn and plenty of information to share with others! As always, our prayer with Inside Medicine is to help our community and show a love for our Savior. 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!

iK mberly Waldrop

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ADVANCEMENTS IN SURGERY by Ben Macklin

imaging matters

John D. Johnson, Jr., MD and Sanat Dixit, MD Neurosurgeons

Crestwood Medical Center and the physicians at SportsMED Orthopaedic Surgery and Spine Center continue to lead the way in changing the surgery landscape in North Alabama. From smartphones and mobile devices to social media and streaming platforms, technology has become an essential part of our daily routine. As technology continues to move us into the future, innovations in digital and information technologies are transforming healthcare capabilities, while saving countless lives in the process. The integration of technology and information into the operating room is revolutionizing the way neurosurgeons diagnose and perform complex surgical procedures of the brain and spine. The evolution of computer-assisted, intraoperative navigation tools are helping to improve surgical efficiencies, create safer and less invasive procedures, reduce costs, and improve the lives of patients.

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} SURGICAL TECHNOLOGY

One highly advanced imaging system surgeons use to navigate the complex structures of the spine is the O-Arm Surgical Imaging System. The O-Arm is a mobile x-ray machine that provides surgeons with a full 360-degree scan of the patient’s changing anatomy during surgery. The O-Arm is best understood as a portable CT Scanner which encircles the operating table to acquire 2D and 3D intraoperative images of the brain and spine. This new technology gives surgeons a number of advantages in the operating room. Hundreds of brain and/or spine images can be taken, processed, and displayed on viewing monitors in a matter of minutes. The portability O-Arm allows us to bring the latest technology to the patient and the operating room avoiding trips to the radiology department. The advanced imaging capabilities of the O-Arm are revolutionizing the way surgeons perform complex spine surgeries. In addition to giving surgeons a detailed anatomical view of the neck and spine during surgery, the O-Arm includes navigational components, similar to a GPS system, which allow surgeons to track and guide instruments more precisely. This gives surgeons immediate confirmation that the hardware or implant has been

positioned in the optimal location. These enhanced imaging features allow surgeons to perform less invasive procedures with greater accuracy and quicker recovery times, while improving patient outcomes. Perhaps the most valuable application for advanced imaging technology is in the treatment of brain cancer. Intraoperative navigation systems are transforming the way neurosurgeons perform complex brain procedures, such as removing brain tumors or performing biopsies. The StealthStation Surgical Navigation System is a precision guided imaging system that provides high resolution, 3-dimensional images of the brain in real time, and allows surgeons to accurately locate and treat patients with brain tumors. Neurosurgeons now have the ability to create tumor models, identify white matter tracts and cortical structures, and visualize blood vessel locations before and during surgery. Using 3-dimensional images to map the brain gives neurosurgeons confirmation that all of the diseased tissue has been identified. Surgeons are also able to track any intraoperative changes during a procedure, which provides critical information and support in making decisions to adjust for brain shifts during surgery. The Stealth Inside Medicine | W inter Issue 2018

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...cont’d from page 9

neuroimaging system allows surgeons to navigate the brain precisely, perform less-invasive procedures, minimize risks, and help improve patient outcomes. Neurosurgeon Dr. Sanat Dixit describes the advances in intraoperative localization as “Moving from driving with intermittent road signs and an old folded up map to pinpoint 3D GPS at our fingertips.” Dr. Johnson stated, “using the latest operating room technology in combination with an experienced and neurosurgery specific dedicated teams of anesthetists, neurophysiologist, operating room nurses, scrub technicians and numerous other team members from pre-op, recovery, ICU and our fourth floor Neuro nursing team enable us the focus on optimizing the complete patient experience.” When performing delicate surgeries involving the brain and spine, neurosurgeons rely on intraoperative imaging to enhance their skills. Advanced imaging technologies give surgeons better anatomical views and more accurate information during surgery. This allows highly skilled surgeons to do what they do best; improve the lives of their patients. As innovation continues to mold and shape the future of healthcare, surgeons will be able to perform more complex and less invasive surgeries, in a safer environment with less risk than ever before.

The dedication and experience of our neurosurgery operating room team coupled with the latest in operating room technology contribute to an outstanding patient experience. - John D. Johnson, Jr., MD

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TreaTmenT

that stands up a strong back is essential to doing all the things you enjoy. Being active again can come from a balanced treatment approach designed by our rehab specialists, physicians and nurses. With a custom treatment plan you are one step closer to getting back to your life.

(256) 533-1600 | spineandneuro.com

Precision to the X degree.

Your spine is complex and delicate. So precision matters. Huntsville Hospital is the only Alabama hospital with Mazor X, the most precise robotic technology for spine surgery. With powerful 3D visualization and superior guidance ability, the Mazor X allows surgeons to create a custom surgery based on your anatomy. Unrivaled technology and precision. It’s precisely what your back needs.

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} RESEARCH

HudsonAlpha to expand Information is Power initiative in 2018 Free genetic cancer risk testing now available for 28 to 32-year-olds

by Margetta Thomas HudsonAlpha Institute for Biotechnology announced the continuation and expansion of the Information is Power initiative to a crowd of 1,300 at the ninth annual Tie the Ribbons luncheon on November 8. Information is Power, a collaboration between HudsonAlpha and Kailos Genetics, offers free and reduced cost genetic cancer risk testing for men and women in North Alabama. Redstone Federal Credit Union (RFCU) will generously sponsor the initiative for another year. Through November 7, 2018, free testing will be available to women and men 28 to 32 years of age who reside in Madison, Jackson, Limestone, Marshall or Morgan County. If you do not fall within that age range, the test is available at a discounted price for individuals 19 and older living in those counties. The test screens for mutations in the well-known BRCA1 and BRCA2 genes, as well as additional genes linked to other diseases including colorectal and prostate cancer. “Since its launch in 2015, Information is Power has provided answers to more than 2,500 women and men, some of which reported little to no family history of cancer,” said Neil Lamb, PhD, vice president for Educational Outreach at HudsonAlpha. “We appreciate Redstone’s continued support of this initiative and recognizing that information truly is power.” Joseph Newberry, President and CEO of RFCU, said sponsoring the initiative is a way to help build healthy and strong communities. “Taking this test could be a very important milestone in caring for yourself,’’ Newberry said. “Redstone is proud to help support HudsonAlpha with Information is Power and know this past year has made a positive impact throughout our communities.” Tie the Ribbons supports the Breakthrough Breast and Ovarian Cancer Research Team, a group of scientists committed to the goal of using genomic science and HudsonAlpha’s state-of-the-art technology to make new discoveries in breast and ovarian cancers.

sponsored by our generous friends at

To learn more about Information is Power or to order a test, visit hudsonalpha.org/information-is-power. Inside Medicine | W inter Issue 2018

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Oh

my aching back... by Larry Parker, MD

when should I seek medical attention from a spine specialist? Acute back pain affects 85% of adults and at some point, it becomes severe enough for them to seek medical attention. Fortunately, in most cases, the pain subsides in a few days to a week without requiring major treatment. Typically, activity modification, a nonsteroidal anti-inflammatory drug, and pain medication will have most people back on their feet quickly.

If the pain persists for more than a week, a thorough evaluation with a spine specialist is recommended. If your acute back pain is initially debilitating and/or includes radiating pain in one or both legs, you should seek immediate attention from a spine specialist. In these circumstances, be aware that you may also experience associated weakness or numbness. In rare cases, loss of bowel or bladder function may occur with severe back pain. This could indicate a surgical emergency and an MRI should be performed ASAP. If you experience unresolved or recurrent episodes of back pain, you should seek medical attention. Remember, in many cases the result of an evaluation with a spine specialist ends with reassurance that no major problems exist and the emphasis is placed on avoiding the recurrence of symptoms.

Inside Medicine has advocated Dr. Larry Parker, an Orthopaedic Surgeon at The Spine Center TOC. We have confidence in his patient care. He specializes in looking at each patient and not treating anyone in a “one size fits all” manner. He can take that “pain in your back” and help decide what treatment is necessary. Surgery is not always the end case and addressing the symptoms is his number one goal. Management and care of symptoms may be the best medicine.

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}MISSIONS

The Cough Conundrum A Review of Laryngeal Sensory Neuropathy by Kari Kingsley, MSN, CRNP

It starts with an annoying tickle in the back of your throat at the most inopportune time (cue Jaws music). Halfway through the Sunday church service, just as Father Mitchell leads his closing prayer (dunn. dunnn), seconds away from a minister asking a wanton groom to kiss his blushing bride (duunnn dunnndunnn dunnn), or when you are asked to give a lecture on your favorite subject to a group of friends and colleagues (DUN DUN DUN DUN DUN. insert shrill tuba noises!!). A tiny bead of perspiration accumulates on your temple. You fidget briefly in your seat in a vain attempt to stop the physically irritating and emotionally embarrassing event about to unfold. The tickle gives way to what feels like uncontrollable chest convulsions producing a dry hacking cough arising from the upper throat. Suddenly, eyeballs everywhere focus in on you like laser pointers. Some are sympathetic but most are accusatory, asking, “Are you seriously SICK out in public?”, “Who does that??”

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For many Americans, inflammation involving tiny nerve fibers within the laryngeal nerves signal the brain to produce a maddening, non-acquiescing cough. Most of us have probably experienced a post-infectious cough that seemed to overstay its welcome following a particularly uninvited upper respiratory tract infection. But for thousands of people, laryngeal sensory neuropathy (LSN) or sensory neuropathic cough can be a momentarily incapacitating condition affecting not only their health, but also their quality of life. Work-up of a typical cough patient includes a thorough medical history to assess for keywords to clue providers in as to which diagnostic procedures to order. Common culprits for chronic cough include asthma, postnasal drip, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), postnasal drainage, eosinophilic bronchitis, infections (the flu, common cold, acute bronchitis, pertussis, tuberculosis), blood pressure medications such as angiotensin-converting enzyme (ACE) inhibitors, bronchiectasis, sarcoidosis, lung cancer, cystic fibrosis, aspiration, and sometimes even heart disease. Picture each question asked by a provider about a particular symptom as a fork in the road. Did your cough start after a recent upper respiratory tract infection? If yes, the path points towards an acute (likely self-limiting) issue that may resolve with medications (e.g. antibiotics, steroids, and cough suppressants). Do you experience heartburn? If yes, providers would take the direction of trying anti-reflux therapy to manage cough and associated symptomatology. Are you a smoker? (FLASHING RED SIGN); consider performing a chest X-ray to assess for sinister pathology. Patients with chronic cough (over 8 weeks) require a closer look. Physical examination and auscultation is critical. Adventitious breath sounds should be addressed and chest radiography considered. Evaluation for chronic cough includes a battery of tests addressing each individual underlying disorder that contributes to cough. Pulmonology evaluation includes chest x-ray, CT scans, sputum cultures, bronchoscopy, and pulmonary function tests. Otolaryngologists perform flexible laryngoscopy, sinus scans, and sometimes allergy testing to delineate underlying issues contributing to cough. Gastroenterology work-up includes esophagogastroduodenoscopy (say that three times fast) otherwise known as EGD. Treatment is usually causality driven and can include antibiotics, cough suppressants, anti-reflux therapy, asthma medication, antihistamines, steroids, and decongestants depending upon the underlying diagnosis. Symptomatic relief is also recommended as in rest, fluids, smoking cessation, and humidified air. But what do you do when you’ve exhausted appropriate therapy recommendations for common cough culprits? It’s time to think outside the box and explore the possibility of LSN. Laryngeal sensory neuropathy is a neural disorder specific to the larynx thought to arise from irritation within the laryngeal nerves leaving them overly sensitive to the slightest stimulus. A droplet of mucus… a whiff of perfume…. a breath of air… any number of things can innervate an LSN patient causing a seemingly unbreakable coughing spell. Accompanying symptoms can include globus (or lump sensation), frequent throat clearing, and sometimes swallowing issues. Consider evaluation for LSN when treatment for common chronic cough culprits such as asthma, allergies, and reflux have been evaluated and managed. Inside Medicine | W inter Issue 2018

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Diagnosis is usually through the process of exclusion. An extensive work-up is required to exclude all other causes for cough. New diagnostic tests are currently on the horizon. The SELSAP or Surface Evoke Laryngeal Sensory Action Potential is a sensory nerve function test that provides non-invasive examination of the laryngeal nerve by placing external electrodes to the side of the voice box and under the chin. A mild stimulus is elicited behind the ear and waveforms are measured to detect abnormalities involving the nerves. A high index of suspicious symptoms coupled with adequate treatment for additional underlying conditions contributing to multifactorial cough may be an indicator that treatment for LSN is appropriate. Medications used to treat LSN include those aimed at “calming” the laryngeal nerves. Amitriptyline (Elavil), tramadol (Ultram), desipramine (Norpramin), gabapentin (Neuronitin), and pregabalin (Lyrica) are used to treat other types of neuropathy and can be helpful to those suffering from LSN. Medications are usually taken for 3-6 months and then slowly phased off based on clinical course and patient preference. Severe refractory cases may be candidates for Botox injections into the thyroarytenoid muscle involving the larynx. Cough is a symptom and not a medical condition. Its prolonged presence warrants the need for further evaluation. A thorough medical history, physical examination, diagnostic testing, and endoscopy play an integral part in evaluating the cough patient. After all common cough culprits have been properly treated or excluded, providers should consider evaluation for laryngeal sensory neuropathy. Consider evaluation for chronic cough before the Jaws soundtrack precipitating an LSN coughing bout swallows you whole.

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

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Surgical

Optimization by Matthew Clayton, MD

When I discuss joint replacement surgery with patients, I will often describe their recovery as being like a marathon, not a sprint. I think this is a good analogy in a number of ways. First, these major surgeries take time to recover from and therefore may require some patience and persistence. Also, like an athlete, a patient must be properly prepared for the challenge that they are about to face. No athlete would attempt to run a marathon unprepared, and it is my hope that none of my patients undergo surgery without being prepared appropriately. In this article, I will briefly discuss a few of the steps that I take to increase my patients’ chance of finishing and winning their race. One of the most important things that a surgeon can do for their patients is decrease the risks of their surgery. Risk reduction does not only occur in the operating room with sterile technique and meticulous surgical technique. In fact, it starts long before the patient arrives at the hospital for their procedure. There are a number of “modifiable risk factors” that can be investigated prior to surgery. Simple blood tests provide information about a patient’s blood count, protein level, and blood sugar control. All of these factors, if abnormal, can affect the patient’s risk of complications. Another very important risk category to consider before undergoing major surgery is a patient’s medical risk. In order to minimize this risk, I require that patients be thoroughly evaluated by their primary care physician. The patient’s PCP will either clear them for surgery or ask for further evaluation by a specialist, such as a cardiologist or pulmonologist, based on the patient’s medical issues. I also require that patients obtain dental clearance prior to joint replacement surgery. This decreases risk of post-operative infection by ensuring that there is no active infection within the mouth or a major dental procedure required quickly after surgery. In addition to minimizing risk, surgeons can also improve the likelihood of surgical success by making sure their patients are prepared both physically and mentally. Patients undergoing joint replacement have often become weak in the muscles around the joint for which they are receiving treatment. This occurs because as pain worsens, the patient naturally uses the joint less, therefore the muscles become weak due to disuse. In an effort to address this weakness, I often send patients to “pre-hab,” which is simply 20

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pre-operative physical therapy. During these therapy visits, patients work to address the weakness of the muscles around the joint and improve their motion. I also think of these visits as a test for the physical therapy facility they will be using for their recovery. As I tell my patients, if you don’t like a facility before surgery, you won’t like them afterwards. It is important that patients feel confident in their therapists, as they will be their coach during the recovery from joint replacement surgery. While physical preparation is important, I would argue that the most pivotal thing for a patient’s success is mental preparation. When patients are informed and understand the recovery process, they are more likely to be satisfied as they recover from these major surgeries. Crestwood Hospital provides an excellent educational opportunity for joint replacement patients through its Joint Journey Program. This program offers pre-operative classes, which help patients understand what they will experience during their hospital stay. In addition to requiring that my patients attend this class, my staff and I spend a large amount of time explaining the preand post-operative processes to my patients. Through this in-office education, we are often able to address questions and common post-operative predicaments before they arise. This process also empowers the patient and allows them to ask well-informed questions. While these steps do require time and effort on the part of the patient, I would like to encourage you to consider this approach if you are thinking about undergoing a major joint replacement. I truly believe through this thorough approach of risk reduction and pre-operative optimization, a patient can maximize the likelihood of an excellent surgical outcome. Matthew Clayton, MD Orthopaedic Surgeon at SportsMED 4715 Whitesburg Drive Huntsville, AL 35802 256.881.5151 sportsmedalabama.com

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Venous Insufficiency and

Varicose Veins

by Tracy A. Lowery, MD

Venous Insufficiency (poorly functioning veins) and varicose veins of the lower extremities are some of the most common medical conditions experienced by people in this country. Over 40 million Americans have some degree of venous problems making it the most common chronic medical condition in North America. Each of us has many veins in our legs with these veins varying in size and location. Regardless of size and location, each of these veins provides the same function. Blood that is pumped to the legs is collected by these veins and returned to the heart. If the veins are not functioning correctly, the legs may develop symptoms or become varicose. Varicose Veins can be seen as dilated twisted blood vessels just below the skin surface that appear bluish and may bulge when sitting or standing. Spider Veins are red or blue veins on top of the skin surface. For many years, physicians have considered most problems with abnormal veins to be cosmetic and not symptomatic. We now know that poorly functioning veins not only affect the appearance of the legs, but also have a tremendous affect on how the legs feel. Symptoms of varicose veins and venous insufficiency include pain, aching, heaviness, fatigue, swelling, and restlessness at night. These symptoms may be present with or without any veins being visible to the naked eye. These symptoms may involve one or both legs. Anyone can develop vein problems, but the risk is increased if there is a family history of vein problems. The risk is also increased as we age, as over half of us over the age of 50, will have some degree of vein problems. Often patients will overlook subtle symptoms thinking that as they age their legs are supposed to be tired and swollen. Women have a higher incidence of vein problems than men, most likely secondary to pregnancy. Other conditions that may increase one’s risk of developing vein problems are obesity, sedentary lifestyle, standing for long periods of time on hard surfaces, and jobs that require prolonged sitting or standing.

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The evaluation of vein function can be determined in a few minutes by a painless, outpatient ultrasound performed in a specialty vein center. If vein function is abnormal, treatment options include both conservative treatment and more aggressive intervention. Conservative treatment of venous insufficiency and varicose veins include increased walking, elevation of the legs and the wearing of graded compression stockings. Stockings can be below the knee, thigh high or panty hose. Stockings do a good job of minimizing leg swelling which tends to improve symptoms of varicose veins. If conservative therapy does not noticeably improve a patient’s symptoms, then more definitive treatment is available. This treatment of abnormal veins is performed in an outpatient setting, requires no sedation, only local anesthesia, and is covered by most insurance carriers. This treatment, radiofrequency ablation, is used to not only improve the appearance of the legs but also improve the symptoms of venous insufficiency.

If you have veins visible on your legs or symptoms similar to those described above, please call Crestwood Vein Center at 256-429-5346 to schedule your evaluation. Tracy A. Lowery, MD Board Certified Vascular Surgeon Varicose Vein Specialist Crestwood Vein Center 185 Whitesport Drive, Suite 2 Huntsville, Alabama 35801


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185 Whitesport Drive, Ste 2 • Huntsville 256-429-5346 2506 Danville Rd, Ste 204A • Decatur 256-429-5346 CrestwoodVeinCenter.com

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Don’t Despise the Journey by Jarrod Roussel, PA-C

We all have those times in our lives when things don’t go quite like we expect or plan. It can be as simple as running five minutes late because you lose your car keys in your pocket or your youngest child spills liquid on their shirt requiring a rushed wardrobe change. In the moment, we become frustrated with the delay as we focus on that one goal. These detours in our journeys can affect minutes or they may even span a protracted time involving weeks or months with a complete change in the plans that we had for our lives.

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Without a doubt, this is upsetting. It is our modern nature to have goals with a plan on how to achieve them. We see the most direct path between point A and point B as being straight, and any distraction to that plan is unacceptable. The distraction is a negative thing and has no value as it deters us from our primary objective. Or does it? I look back upon my life, and I am no different. I, too, have lost my keys in my pocket only to get so frustrated. I have had goals and ideas for my life with a plan that I felt was suitable for reaching that end goal go completely awry. Usually, I was left with a sense of “why”. In my mind, these were good plans with generally noble outcomes. Was there a greater plan at play? Was there a lesson to be learned in all of this? My experience taught me the answer was “yes”. I have seen in my life and the lives of those around me where these circumstances can act as lighthouses, lighthouses on a dark and potentially treacherous sea. We may have a course navigated to go straight to our intended destination, but circumstances can direct us in other directions much like a lighthouse will guide a ship in the night. The ship may not see what lies deep within the dark waters, so instead of staying on the original course, the ship will follow the guiding beam of light. As it approaches the lighthouse, the light may fade as another beacon becomes brighter guiding the ship into another direction altogether. The ship changes its course to follow the new direction even though this new heading seems to back track somewhat. This happens a number of times, all the while, the ship becomes increasingly agitated until it reaches its final destination by the time the sun rises. Once there, it can be seen that the path taken was not straight like previously planned, but the lighthouses navigated it around many dangerous rocks and obstacles that it did not see nor were shown on the ship’s map. It is easy to become angered or confused when we are met with detours in our lives. If we are being honest, sometimes they aren’t detours; they are complete changes of plans. Like in the lighthouse analogy, we should learn to not get frustrated, because the Lord has a different itinerary that may save us from harm or heartache that lay on our original journey. Also, this isn’t just about us as there may be someone we are supposed to meet so that we may bless in some way. I had a recent experience a few months back that left my family living in a house temporarily. Last summer, we placed our house on the market, and it sold within a few days. The buyers wanted to close within a few weeks. In an effort to move quickly, we found a place to rent for several weeks while we made further plans. The amazing part about this rental is it was a vacant, furnished home that was not advertised, nor was it even for rent. My realtor found this place for us, and the owner, after some hesitation, agreed to let us rent it. It wasn’t our original plan for this to happen. But, the Lord had other plans.

During the course of staying there, a young man was electrocuted in the front yard while utility work was being done. I had to administer CPR on the man, who had for all intents and purposes died. Miraculously, he was revived, and after a few months, he made a full recovery. Lord willing, his wife will grow old with him, and he will live to see his young son grow up. Although I performed the CPR, life is not mine to give so that credit belongs only to the Father. My point in sharing this example is to highlight that I would not have ordinarily chosen the inconvenience of having to store my stuff while renting a house temporarily to house my family. It was certainly a detour, but I am 100% convinced that the Lord planned that detour so that He could use me in concert with other people to make a difference in that young man’s life. Next time you are delayed five minutes in leaving your house, realize you may have been saved from a disaster that a momentary shift in timing averted. Unexpectedly losing that job promotion you were assured, may positively alter the spouses your children marry. We can never know all the ramifications of the different paths we could take, but the Lord knows so we must lean on His understanding. We must go where He leads so that He can use us in ways far better than we could ever hope on our own. Just trust Him and don’t despise the journey.

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WHO IS

YOUR

PT?

At TherapySouth, we build relationships with our patients that last a lifetime. We believe that just as you have your doctor and your dentist, you should have YOUR physical therapist. That’s where we come in. TherapySouth is an outpatient physical therapy practice with a fun, family-oriented environment. Our experienced physical therapists know our patients by name and strive to help them achieve their physical goals. We know you have a choice for your healthcare, and we’d love for one of our great people to be your physical therapist! Visit our clinic in Huntsville or call us for more information.

Huntsville | 6485-C University Drive 256.513.8280 | www.therapysouth.com

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This credit union is federally insured by the National Credit Union Administration.

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I n s i d e M e d i c i n e | W i n t e r I s s u e 2 0 118 Inside.Medicine.7.1875x4.7917_BreastCancerAwareness.indd

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} FEATURE

The Basics About

by Ashley Smith, RN, MSN

Specialty Pharmacy

Chances are, everyone has needed prescription medication at some point in their life. This medication, likely an antibiotic or medication for pain or high blood pressure, could have probably been picked up at any drug store in town. There are, however, drugs that can’t be picked up at any drug store in town. These drugs are called specialty medications and must be obtained from a specialty pharmacy. Specialty medications are generally very costly and require intensive patient management by the pharmacy that provides the medication (National Association of Specialty Pharmacy, 2016). Specialty medications cover complex diseases or disorders such as hemophilia, hepatitis C, rheumatoid arthritis, cancer, multiple sclerosis, immune deficiencies, among many others. Specialty medications include those that are taken orally, administered by an injection, or administered by infusion. In other words, these medications could be a pill, a shot, or given through an IV. Sometimes, the medication must be given at the doctor’s office or hospital (National Association of Specialty Pharmacy, 2016). If it can be taken at home, the pharmacy who dispenses the medication will provide the training. Specialty medications require dispensing from specialty pharmacies. The question, then, what is a specialty pharmacy? A specialty pharmacy is one that specializes specific drugs, the administration of these drugs, as well as patient education and coordination of care (BHM Healthcare Solutions, 2013). Specialty pharmacies are closely connected with their patients and care is more comprehensive (BHM Healthcare Solutions, 2013). A specialty pharmacy can be large or small. While larger pharmacies may have multiple locations to offer convenience of pick-up, most specialty pharmacies are also mail-order pharmacies. This means being able to drive to the nearest location is not necessary and medications can be delivered to the home very quickly. Unlike larger pharmacies, smaller pharmacies may have the edge in customer service. Smaller pharmacies have a lower patient population and can offer personalized care to their patients. The specialty pharmacy market has grown significantly since the mid-2000’s (Lapointe, Allen, & Rice, 2016). Likewise, there is no shortage of specialty pharmacies in the United States. When choosing a specialty pharmacy, look for one that is accredited. Accreditation by a third-party ensures that the pharmacy is doing what they say they are doing; it validates their promise for quality care. The ACA requires health plans to have URAC health plan accreditation (Steiber, D., 2016). Likewise, the health plans are requiring specialty pharmacies to acquire accreditation to be an in-network provider. Some of the most prestigious accrediting bodies include URAC, Accreditation Commission for Health Care (ACHC), and The Joint Commission (Steiber, D., 2016). The URAC accredited pharmacies should provide 24/7 pharmacy support as part of the standards in which they operate. Some health plans do not offer much of a choice for in-network specialty pharmacies, but always ask about options. Before making a choice, ensure the specialty pharmacy knows about the specific disease state needed for your therapy and the pharmacist can answer all questions about the drug that is being dispensed. If your medication requires home health nursing or infusion nursing, make sure your pharmacy either employs a nurse to assist in care or coordinates with a nurse or nursing agency that is knowledgeable about the disease state or medication.

References: BHM Healthcare Solutions, (2013). What is a Specialty Pharmacy? Retrieved from bhmpc.com/2013/06/ what-is-a-specialty-pharmacy/ Lapointe, S., Allen, C., Rice, G., (2016). What Defines and Independent Specialty Pharmacy? Retreived from www.specialtypharmacytimes.com/publications/specialty-pharmacy-times/2016/april-2016/ what-defines-an-independent-specialty-pharmacy National Association of Specialty Pharmacy, (2016). NASP Definitions of Specialty Pharmacy and Specialty Medications. Retrieved from naspnet.org/wp-content/ uploads/2017/02/NASP-Defintions-final-2.16.pdf Steiber, D., (2016). Accreditation in Specialty Pharmacy: No Longer Optional. Retrieved fromwww.specialtypharmacytimes.com/publications/specialty-pharmacy-times/2016/april-2016/accreditation-in-specialty-pharmacy-no-longer-optional

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} PERSONAL INTEREST

In the hands of by Kari Kingsley, MSN, CRNP

Kari Kingsley, MSN, CRNP is an otolaryngology nurse practitioner with over 8 years of ENT experience who currently works at Huntsville ENT (256-882-0165). She is a medical writing consultant for Inside Medicine and enjoys writing articles on pertinent material to keep the residents of North Alabama up to date on the forefront of medicine. 32

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God


Lots of little girls dream of one day owning a horse. At the age of 34, I decided to indulge my lifelong reverie and started the process of fencing in a parcel of our 22-acre property in Elgin, Alabama. My dad, a retired contractor and builder, happened to have an injured shoulder at the time. He contacted a man named Chuck Turner to discuss a quote for our project. Mr. Turner is the owner of CCC & Associates in Moulton, Alabama. He specializes in fencing and building. When he arrived at our farm, it was apparent Mr. Turner was different from your ordinary contractor. Mr. Turner is a bilateral trans-radial amputee who lost both his arms in 1969. Probably accustomed to people not knowing quite how to react, he jokingly said to my Dad, “Grab some metal!” as he went to shake his hand. He immediately put everyone at ease and the process of fencing in our family acreage began. Once the fencing job was completed, we asked Mr. Turner for a quote on building a barn for the horses. It’s more than fair to say I am a complete novice when it comes to horses.The largest pet I’ve ever owned is an eightypound Labrador retriever named Kodi. Luckily for me (and my horse), Mr. Turner has kept horses most of his life. He became a wealth of information for my new project.“Did you know your barn stalls should be made of strong wood like oak as opposed to pine? And you’ll need kick-plates that begin about a foot off the ground.” he volunteered. Unless you have an equestrian background, these small pearls of knowledge might escape you. On retrospect, these things seem like common sense when housing a 1000 lb. animal. To this novice horse girl, Mr.Turner became an instant blessing. Many other contractors would not have known the ins and outs of horsemanship and the strength of these creatures. Chuck Turner was born March 25, 1943 in Dyess, Arkansas. He has been self-employed much of his life, having worked in farming, heavy equipment operation, and building. He has 4 daughters, 8 grandchildren, and 13 great-grandchildren, many of whom work with him in his fencing and building business that has been in operation for over 38 years. He has many other young people in his life that he and his wife (and co-worker), Gertha, consider family. On July 28, 1969, Mr. Turner was involved in a work-related accident when a punch press crushed both his hands above the wrists. Mr. Turner underwent surgery, was fitted with prosthetics, and was back on the job within 6 weeks. Mr. Turner’s inspiration after the accident was his oldest brother who was severely wounded in World War II while serving in Patton’s 3rd Army. An artillery shell exploded in his tank causing life-threatening injuries. Mr. Turner’s brother was hit with 32 pieces of shrapnel in the chest and was told by hospital physicians that he would never walk again. He proved them wrong. Mr. Turner has never looked at his injury as a disability, only an impairment. He has spent a great deal of time mentoring others in similar circumstances. The University of Michigan has asked him to join them as a motivational speaker but he prefers to speak to amputees

one-on-one and has become a source of inspiration to them for having overcome his injuries. He tells them that he isn’t handicapped, and that it is all mental. A good friend once explained to me what a “God-wink” was. Godwinks are tiny (and sometimes large) events in your life that make you sit up and take notice that something bigger than you exists in the universe. It’s the feeling that you are being smiled upon by a higher power. Perhaps you’re feeling particularly blue and a special song begins playing on the radio. For me, a large hawk lit on a fence and looked me directly in the eyes after I lost a close family member. I love the quote “Remember, coincidence is just God’s way of performing a miracle anonymously”. I consider Mr. Chuck to be a very special God-wink. When I think of how someone builds something, I instantly picture them working with their hands. One might think it ironic that God sent me a builder with no hands. But I think Mr. Turner was put into my life to strengthen my faith. Faith in people. Faith in humanity. Faith in God. Mr. Turner has never let his accident slow him down. He doesn’t sit around and feel sorry for himself. He gets up every day and says a prayer while eating his breakfast that he will impact someone’s life for the better. He likes to tell people, “Don’t worry about yesterday, there’s nothing you can do to change it. And don’t worry about tomorrow, because you don’t know what’s coming. Deal with today and what’s in front of you, because that you can control. Tomorrow will take care of itself.” When I asked Mr. Turner what message he would like to give to readers, he told me, “Never give up”. He put his life in God’s hands when he had his accident and God has taken care of him. Mr. Turner tries to give as many hugs as he can and asks that people pass them along. He feels if he can reach one person and change their life for the better, it’s worth the effort. My journey into the equestrian world continues. I am fortunate to be surrounded by knowledgeable horse-people. I take regular riding lessons with my horseback instructor, Mrs. Kathryn Scott. I swear I can hear her saying, “keep your heals down” in my sleep! My childhood friend, Elizabeth Luckey, drives a horse carriage in downtown Nashville and has 4 beautiful horses on her property. My aunt, Bitsy Kingsley, is a horse aficionado and is teaching me the basics of caring for my newest family member. But I am especially appreciative of Mr. Chuck Turner and his vast knowledge of horses…. and life. Every time I speak to him, he imparts a piece of wisdom and inspiration about the human spirit. I am especially appreciate of my gorgeous well-built barn that I will cherish forever. Mr. Turner’s favorite part of starting a new job is that he and his customers start out as strangers and end up as friends. Chuck Turner pours good out into the world. And like the butterfly effect, every person he touches carries forth a little more kindness, a little more happiness, and a little more grace than they did prior to meeting him. Every person will at some point have to deal with strife. But, just like Mr. Turner, you have to let it go and turn it over into God’s hands.

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} HEALTH

THE HEALING POWER OF

Salt Therapy

by Heather Morse MS, ATC, OTC

A new trend in spa wellness is emerging in the United States. Halotherapy is not a new concept, but has been around since the 18th century in Europe. Halotherapy began in the late 1800’s when it was discovered that salt miners in Europe had few respiratory issues, appeared healthier and had a more youthful appearance. Salt baths emerged to launch the salt therapy industry in 1839 in Poland. Even a hospital was set up for inpatient treatment within the salt mines in the late 1940’s. This underground climate coupled with the dry salt was observed to produce an effective adjunct treatment for asthma. It became evident that there was a need for a simple way to duplicate the micro-climate in which salt miners in Europe and Russia worked. Because it is not easy to get access to an actual salt mine, in 1985 the Institute of Balneology in Russia, developed the first device to produce the correct micro-sized particles of salt in an aerosol. This is known as a Halogenerator and Halotherapy was born. Dr. Daniel T. Layish M.D., F.A.C.P., F.C.C.P. former medical director of Winter Park Memorial Hospital’s Pulmonary Rehabilitation Program (1999-2013) in Orlando, FL states, “As a pulmonologist, I initially became familiar with halotherapy through my care of individuals with Cystic Fibrosis. Cystic Fibrosis is a genetic disorder characterized by the dehydration of the respiratory epithelial surface, resulting in impaired mucociliary clearance. In this disorder, thick tenacious secretions obstruct the lower airway and sinuses and provide an environment for chronic infection. Nebulized hypertonic saline has been shown (in well done randomized clinical trials) to improve pulmonary function and respiratory symptoms as well as reduce pulmonary exacerbation rate in individuals with cystic fibrosis. This may be referred to as “wet” salt therapy as opposed to Halotherapy which is “dry” salt therapy. Nebulized hypertonic saline can sometimes cause bronchospasm, and not all patients can tolerate this therapy even when premedicated with a bronchodilator. In cystic fibrosis, halotherapy has some theoretical advantages over nebulized hypertonic saline. The patient enters a room to receive the halotherapy, typically in a 45-minute session. The prolonged duration of therapy appears to

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be associated with a much lower incidence of bronchospasm than is seen in the setting of nebulized delivered to both the sinuses and the lower respiratory tract. After seeing anecdotal benefit in our patients with cystic fibrosis, we performed a clinical study, which confirmed that this therapy was well tolerated and the patients derived symptomatic benefit in terms of their sinus complaints. Other studies are planned to study this therapy further in individuals with cystic fibrosis.” (FloridaMD Magazine Aug 20, 2015) Dr. Layish also states “there seems to be very little risk to this therapy other than the financial and time involvement and there is a theoretical basis for the possible benefits of halotherapy, given the known anti-inflammatory and anti- infective properties of salt”. According to The Salt Therapy Association, active dry salt therapy is simple to understand. There are three primary characteristics of pure sodium chloride, known as salt: 1. Absorbent (especially when it is completely dry) 2. Anti-bacterial 3. Anti-inflammatory Some people mistakenly compare the air at the beach to be the same as a Halotherapy session. While being at the beach has some benefits, that salt is already saturated and does not produce the same effects as dry salt used in a Halotherapy session. Being Oceanside does provide a wonderful sense of wellbeing from many other factors, but the benefits for your respiratory system will be far greater in a Halotherapy session. Here is how a Halotherapy session works. As the pharmaceutical grade salt travels in the salt room, micro-sized particles are inhaled into the respiratory system. The dry salt naturally starts absorbing allergens, toxins and foreign substances in your lungs and throughout your respiratory tract. Dry salt may help reduce inflammation and open airway passages. The micro-sized crystal structure of pure sodium chloride particles breaks loose and clears out all the “bad stuff ”. This is how dry salt therapy affects people suffering from discomforts associated with conditions like allergies, asthma, bronchitis, cystic fibrosis and other respiratory ailments. (The Salt Therapy Association)


A new concept in health and wellness is coming to Huntsville, AL. Salt on the Rocks is bringing Halotherapy (salt therapy) to the Tennessee Valley with a twist. Salt on the Rocks will offer the Tennessee Valley a wellness experience for all ages to enjoy. The concept follows the remedies of a salt room, remedy room, and tasting room.

Salt on the Rocks will offer the Tennessee Valley a wellness experience for all ages to enjoy. The concept follows the remedies of a salt room, remedy room, and tasting room. A session at Salt on the Rocks Salt Room will provide the best in salt therapy with an experience of being alongside the ocean. Imagine, walking through the doors into the “resort” where you are greeted with options from the Tasting Room that include local craft brews and fine wines. Also available will be signature Sangria or smoothies; whatever suits your palate. You can then meander through the Salt Room doors to a breathtaking scene of the beautiful Caribbean Sea, complete with “sand” under your feet, a lounge chair and surrounding sounds of the ocean just for you. You can also enhance your experience with sessions that offer yoga and sound therapy in the Salt Room. It is widely known that a day at the beach has many benefits. These benefits include soaking up the sunshine (Vitamin D), feeling ocean spray on your face, hearing the crashing sound of the waves on the sand and smelling the salt air. What is not widely known are the many benefits of salt therapy. Salt therapy is becoming more popular in the United States as more people seek natural alternatives to support their health and wellness. Salt rooms provide this therapeutic alternative. In the Salt Room at Salt on the Rocks, you are surrounded by the finest Himalayan salt; on the floor, on the walls and in the boulders throughout. While these purify the air by emitting negative ions, the real benefit comes from the dry aerosol salt that is circulating throughout the room.

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Winter/Spring 2018

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The Salt Room will provide a Caribbean immersion experience with Halotherapy. Halotherapy is the use of pharmaceutical grade sodium chloride pulverized into micro-sized particles and dispersed throughout the room. These micro-sized particles of dry salt are inhaled and begin the process of “scrubbing” your respiratory system, including sinuses and lungs. It is a gentle, relaxing, non-invasive, medicine-free way to support your respiratory system and get relief from the discomforts associated with allergies, asthma, bronchitis and more. It has superb benefits for skin-related issues as well, including acne and eczema. While the main Salt Room is for adults only, Salt on the Rocks also knows how important and helpful this therapy is for children of all ages. In fact, children have a much quicker response to salt therapy than adults. Salt on the Rocks offers a special Salt Room just for kids under age 13 and their parents. It is a perfect space for play or to finish homework. Do you need some more personal space? Do you want to expose as much skin as possible? There is a specialty Salt Room just for that. This small space is the perfect place to escape the fast pace of the outside world, enjoy a massage or just enjoy the silence. The private Salt Room offers the same benefits as the Caribbean immersion room. Upon exiting any of the Salt Rooms, you are welcomed to explore the Remedy Room. Salt on the Rocks offers a wide variety of natural options to support your journey to wellness. You may find some locally crafted herbal teas and tinctures, essential oils of the purest quality as well as locally made soaps and scrubs. There is even a “library” of resource books for you to do your own research. Before you end your visit, you will want to relax in the Ocean Garden to slowly bring yourself back to reality. Depending on the weather, you may want to sit for a minute or a few hours and enjoy the rest of your Tasting Room wine. The grand opening of Salt on the Rocks is planned for winter/spring of 2018. Be sure to follow them on social media @saltontherockshuntsville and visit www.saltontherockshuntsville.com to subscribe to updates and exclusive discounts. For more information email info@saltontherocks.org Co-owner Heather Morse (MS, ATC, OTC) has been affiliated with the medical community in Huntsville since 1998. As a Certified Athletic Trainer, Certified Orthopedic Tech, essential oil user/educator and herbalist apprentice, she brings a wealth of experience to Salt on the Rocks. There are plans for educational classes for those who wish to learn more about how to use natural options to support their and wellness. Heather can be reached at info@saltontherocks.org.


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How to Prevent Cancer With Food by Traci McCormick, MD

So many questions...is there a cancer prevention diet, what should I eat, what shouldn’t I eat, does it matter what I eat, should I stop eating sugar, should I eat more of some things... The questions I get about nutrition are endless. And it’s no wonder why. Every time we turn on the news or open our Facebook feed, there is a new headline telling us what we should or should not eat to avoid cancer. It’s absolutely overwhelming. How do we know what to believe? Can we trust what we are reading? Is it just someone’s attempt to sell us something? Is it something truly worthy of our attention? I’m going to help you sort through the hype and tell you exactly what you need to know about how to prevent cancer with food and give you some added benefits! And, there are actually a lot of other benefits. By following these guidelines, you will: Cut your chances of dying from cancer by 30% Decrease your risk of dying from any chronic, debilitating disease by 40% Be 50% less likely to die from cardiovascular disease.

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So let’s get started! 1. Prevent Cancer by Eating a Healthy Diet with an Emphasis on Plant Foods If you eat a plant-based diet, you are more likely to live longer, weigh less, and remain free of cancer, diabetes, and heart disease. It is a fact. A plant based diet encourages whole, plant-based foods such as fruits, vegetables, beans, whole grains, nuts, and seeds. It discourages meats, dairy products, and eggs as well as all refined and processed foods. There is definitely some evidence that vegetarians or vegans live longer and have less disease than people that consume animal products. However, I want to emphasize that eating a plant-based diet is not the same as becoming a vegan, or even a vegetarian. You can eat meat, dairy, eggs and (gasp) even the occasional refined or processed foods. You should, however, consume them as a very small portion of your overall diet. As a general guideline, you should fill at least two-thirds of your plate with plant-based foods at each meal. 2. Prevent Cancer by Choosing Foods and Beverages in Amounts That Will Help Achieve and Maintain a Healthy Weight Obesity is truly the number one health crisis we face in America today. Over 30% of us are obese. Another third of us are overweight. Scarier yet, 14% of our children are obese, and another 17% of our kids are overweight. Excess weight plays a huge role in promoting cancer and other chronic diseases. Being overweight is the second leading cause of cancer death in our country and is directly linked to at least 11 different types of cancer. It is also the primary cause of a multitude of other chronic and debilitating diseases, including heart disease, hypertension, diabetes, and stroke–just to name a few. The foods we choose to eat play a HUGE role in how much we weigh. If we choose foods that are low in calories, but high in nutrition, we control our weight and put cancer-fighting foods in our bodies. If we choose foods that help us maintain our weight, we are less likely to eat refined, processed, sugary foods that are known to increase cancer risk. When it comes to obesity and diet, one is not independent of the other. 3. Prevent Cancer by Eating at Least Two and a Half Cups of a Variety of Vegetables and Fruits Each Day Let me first say there is no single fruit or vegetable that holds the power to cure or prevent cancer all by itself. There is no magic piece of produce that you should be forcing yourself to eat day in and day out.

The fact is that a variety of fruits and vegetables work together to help make your body better at fighting cancer and less susceptible to forming cancer cells in the first place. They do this in a variety of ways: Fruits and vegetables are full of vitamins, minerals, antioxidants and other substances that boost the immune system and help protect against cancer. Individuals that eat more vegetables and fruits have less weight gain and a lower risk of obesity. Fruit and vegetable consumption reduces the risk of other chronic diseases, making the body less susceptible to injury and inflammation that may promote cancer growth. Fruits and vegetables are high in insoluble fiber. Insoluble fiber adds bulk to your stool which causes it to pass through your digestive tract more rapidly. This more rapid transit lessens the time that your gut is exposed to potential carcinogens. The interaction between fiber and the bacteria in your gut may also play a role in inhibiting cancer formation. It is important to get a variety of fruits and vegetables into your diet. This includes veggies from all five vegetable categories–dark-green vegetables, starchy vegetables, red and orange vegetables, beans and peas, and other vegetables.

Supplements are not the answer. I also want to emphasize that when it comes to preventing cancer, it is crucial that you get your nutrients from the food you eat—not from a pill. While supplements are ideal for treating some vitamin or mineral deficiencies, supplements have not been shown to be of benefit in preventing cancer. In fact, supplements can sometimes be detrimental. Several decades ago, people were convinced that beta-carotene (a form of Vitamin A) prevented lung cancer. This belief was based on hoards of evidence that people who ate diets high in beta-carotene were less likely to be diagnosed with the disease. So two large trials were initiated involving close to 50,000 people. The study participants took either a beta-carotene supplement or a placebo for an average of 5 years. In both studies, the participants that took the beta-carotene supplement had an almost 30% INCREASED risk of lung cancer and a nearly 20% INCREASED risk of death compared to those that received the placebo. Not the results they were expecting!

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...cont’d from page 43

In another study, patients were given selenium and vitamin E supplements to prevent prostate cancer. The data had shown very convincing evidence that people who consumed diets high in selenium and vitamin E were less likely to be diagnosed with prostate cancer. Well, guess what? The selenium was of no benefit, and the vitamin E slightly INCREASED the risk of prostate cancer. The lesson here is that the nutrients found in fruits and vegetables likely work synergistically to protect us from cancer and other diseases. Our best bet is to include a variety of fruits and vegetables in our diet each day. And remember–two and a half cups is the minimum amount you should aim for. The more fruits and vegetables you eat, the better it is for your health. 4. Prevent Cancer by Choosing Whole Grains in Preference to Processed (Refined) Grains Whole grains include wheat, barley, rye, rice, oats, and corn. Whole grains still have all three parts of the grain kernel (germ, bran, and endosperm). If the bran and germ are removed, the grain is considered refined. For example, brown rice is a whole grain, while white rice is a refined grain. Gluten is the protein found in wheat, barley, rye, and some oats. For those of you that know me, you probably know that I don’t eat gluten. In my blog, I could write an entire post on this another time, but gluten makes me feel TERRIBLE! In fact, there is also a large community out there that believe that grains, in general, are bad for our health—hello my CrossFit and Paleo friends! While I agree without reservation there are people in the world who do better, feel better and are generally healthier when they don’t eat grains (and in particular gluten), the bulk of the data shows that whole grains are good for most people. Whole grains contain fiber, vitamins, minerals, antioxidants, and other substances known to protects cells from damage that may lead to cancer. Multiple studies show that if you eat a diet rich in whole grains, you will lessen your risk of not only cancer but also obesity, heart disease, and diabetes. Refined grains, on the other hand, have little nutritional value and cause rapid spikes in blood sugar. These rapid spikes in blood sugar cause a hormone called insulin to surge. Insulin is a growth hormone, and excess amounts of insulin play a role in cancer development. The bottom line: if you choose to eat grains, make sure they are whole grains and not processed or refined. 5. Prevent Cancer by Limiting Processed Meat and Red Meat Recently, a group of 22 experts from 10 countries reviewed 800 studies. They found that if you eat 50g (4 strips of bacon or 1 hot dog) or more of processed meat a day, you increase your risk of colon cancer significantly. They also confirmed that if you regularly consume red meat, you increase your risk of colon, pancreatic, and prostate cancer. 44

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Overall, the current evidence suggests that for every 100 grams of red meat or 50 grams of processed meat you eat per day, you increase your risk of cancer (in particular, colorectal cancer) by 20%. Consumption of red or processed meat can contribute to cancer formation in several ways. The primary mechanism seems to be through the formation of compounds called nitrosamines. These compounds form when components found in processed or red meat combine with other substances found naturally in your gut. Nitrosamines are carcinogens that damage the cells that line your bowel and promote cancer formation and growth. Does this mean you have to stop eating processed or red meat? No, but it does mean that you need to limit how much you eat. You should eat no more than 18 ounces of red meat per week, and you should avoid processed meat as much as possible. For reference, a 3-ounce serving of meat is about the size of a deck of cards or bar of soap. As for processed meat, there is disagreement about how much is safe for you to consume. Some authorities say that no amount is safe, while others say that the occasional hot dog, slice of bacon, or deli meat sandwich is ok, as long as it isn’t a regular part of your diet. 6. Prevent Cancer by Limiting Alcohol to One Serving per Day for Women, or Two Servings per Day for Men If you consume alcohol, you increase your risk of some cancers, including cancers of the breast, liver, rectum, throat, mouth, and esophagus. However, studies have also shown that moderate alcohol consumption decreases your risk of cardiovascular disease. So, to drink or not to drink–that is the question. The answer is very complicated and not at all straightforward, but here is the bottom line. You should drink no more than one serving of alcohol per day if you are female. If you are male, you should drink no more than two servings of alcohol per day. If you are young and healthy with no cardiovascular risk factors, there is no need to add alcohol to your diet. However, if you are older, smoke, or have other factors that put you at increased risk for cardiovascular disease, then it’s probably wise to get in your allowed serving or servings of alcohol each day.

There is Still so Much to Talk About There is so much that I haven’t covered, but to cover it all would require a book! There is a huge role played by sugar, artificial sweeteners, food additives and preservatives, and many other dietary factors that may (or may not) affect whether you live the rest of your life cancer and disease free. However, if you follow the guidelines I’ve outlined here, you won’t likely be consuming much of any of these things and you’re well on your way to eating to prevent cancer! For more information visit, www.tracimccormickmd.com


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How an eye exam can

REVEAL OVERALL HEALTH by Paul Vandiver, OD

William Shakespeare once famously quoted “the eyes are the window to the soul”. This deep and philosophical statement has been studied and debated for centuries in various fields of study – psychology, sociology, law, ethics, and theology. The eyes are windows in the literal sense as well. Physiologically, the eyes act as a window – revealing signs of overall health that may not have been noticed before. The eye is a fascinating organ interconnected with multiple systems in the body that provide us with the miraculous gift of vision. It is this connection with multiple systems within the body that makes the eye a “window” of health. The eye reveals these clues and some of the most common diseases are discovered first by ocular manifestation.

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Vision is defined as the ability to see; the act or power of sensing with the eyes; sight. Vision is further divided into three components: acuity, accommodation, and field of vision. Acuity is the resolution or detail (sharpness). Accommodation is focusing like a camera. The field of vision is the peripheral limits of each eye when looking straight ahead in all directions. The ability one has to “see” in all three categories is evaluated, measured, and quantified to monitor for changes over time. There are various means of intervention for the correction of decreased acuity and/or accommodation – spectacles, contact lenses, refractive surgery, CRT (corneal refractive therapy) and tissue replacement surgeries (corneal transplant, cataract extraction, and vitrectomy) are a few of the most common. While vision is a common complaint that gets a patient in the clinic for an evaluation, it is the combination of changing or decreasing vision – AND the physical signs the eyes reveal – that provide the eye care professional with information that may uncover unknown disorders. Over the years it has never ceased to amaze me the plethora of knowledge gained from a comprehensive exam. An important pearl to remember: symptoms are what the patient feels or describes, and signs are what the doctor will SEE. Today’s comprehensive eye examination has improved drastically over decades. By far the most notable is the technological advancements. Electronic medical records (EMR), more user friendly and efficient screeners for glaucoma, and higher resolution images for capturing retina images are a few of these. Arguably the most significant is the OCT (optical coherence tomography). By using coherent light, specific tissue layers of the retina and optic nerve can be evaluated in 3D or 2D. This useful tool can help us better understand ocular pathology as it relates to systemic disease. Ocular Manifestation in Systemic Disease and Disorders On a daily basis patients present with symptoms of vision change and variable levels of ocular pain. Similar to yearly physicals with your family physician, there are “routine” comprehensive exams to continue evaluation of the ocular tissue and monitor for subtle vision change in those patients with family history of ocular disease or if diagnosed with managed hypertension and diabetes for example. For new patients and those with sudden symptoms or changes – a comprehensive exam may point us to a differential diagnosis and ultimately to the appropriate management of an underlying disease. There are many disorders that present clinically with ocular manifestation. The endocrine, auto-immune disorders, and cancer are a few examples. The eyes may be the first sign of these conditions and early detection is paramount in therapeutic management. Endocrine It is well understood that diabetes is on the rise. According to the National Diabetes Statistics Report for 2017, “29.1 million people in the United States have diabetes, but 8.1 million may be undiagnosed and unaware of their condition. More than one in every 10 adults who are over 20 years or older has diabetes.” Many of these patients are unaware of their disease and the damage to the eyes that is accompanied.

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...cont’d from page 47 Similar to toes and fingers, where neuropathy symptoms begin, the eye is a peripheral organ where blood flow is critical for nourishment and function. In diabetes, blood supply to the extremity of the body is reduced from increased viscosity (thickness), blocking oxygen delivery. This results in tissue damage, especially the small vessels at and around the macula. The signs of retina hypoxia and viscosity include swelling of retinal cells, microvascular hemorrhaging, and protein deposits throughout the retina. This protein, or exudate, are deposits from leaky blood vessel walls at the blood-retina barrier. These exudates sometimes form a ring pattern and are yellowish in color. The more exudates that form, the more they coalesce and extend. This coalescence of exudates in the macular region is the highest risk of vision loss in diabetes. Diabetes can also cause cataracts to form. When blood glucose levels are elevated, the lens in the eye will absorb glucose. The lens uses an enzyme that converts the glucose to sorbitol – creating a “foggy” or opaque like film in the lens. According to the American Medical Association, about 75 million American adults (32%) have high blood pressure. Hypertension, like diabetes, is readily seen in the eye due to a “live” look at the vessels. The most common ocular signs are artery narrowing, decreased caliber of artery to vein ratio (less than 2/3), crossing changes (arteries crossing veins creating “crimping” appearance), cotton wool spots or ischemic “cotton ball” spots, flame hemorrhages (feathery shaped due to layer of leakage), and papilledema (optic nerve swelling from increased intracranial pressure). Malignant hypertension is diastolic pressure >110mmHg or systolic pressure >220mmHg. Blood pressure at this level can cause a “macular star” or exudates radiating in a star-like pattern. If untreated, permanent vision loss may result from optic nerve damage from central artery or vein occlusion. Healthy vessels in the retina are smooth and consistent caliber. This photo shows early hypertensive retinopathy. Notice the torturous vessels and the faint macular star (dark spot)on the right.

Blockage of larger caliber veins or arteries will cause a decrease in oxygen for the vessels downstream. This is called a branch retinal vein or artery occlusion (BRVO) This results in visual field loss directly relational to the quadrant of retina affected. Visual field testing may show a field defect and suggest a retinal vascular etiology. This photo shows an old or inactive BRVO. This patient is diabetic and the cause of the bleeding was from uncontrolled blood sugar. The resulted scarring (dark patches) is at the top of the photo.

Auto-Immune Disorders and the Eye There are many AI disorders that may present first through the eye. Connective tissue conditions affecting the joints can cause similar inflammatory cascades in the eye – involving almost every structure of the eye. Keratoconjuctivitis Sicca (KCS) is the most common ocular manifestation in connective tissue disease, occurring in up to 15% of rheumatoid arthritis. KCS is dryness of the conjunctiva (membrane covering of the white of 48

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the eye) and the cornea (clear layer on outside of the eye, front of iris and pupil). There have been numerous studies involving dry eye and its mechanism. Due to its complexity, treatment of the disease depends on tear osmolarity, durability, inflammation level, chronic vs acute symptoms, and coexisting ocular surface disease (ex: blepharitis, conjunctivitis, meibomian gland dysfunction). Uveitis is a common finding with auto immune connective tissue disease. It is the inflammation of the middle layer of the eyeball or uvea. If the front of the eye is involved it is anterior uveitis and if the middle of the eye it is intermediate uveitis. It usually presents as unilateral, red, painful, and sensitive to light. The symptoms range from mild to severe and usually present suddenly and escalade quickly. Treatment usually involves corticosteroids, cycloplegics and NSAIDs for anti-inflammatory and pain management. Common connective tissue disorders that present with chronic KCS, or uveitis, or both are: Sjogrens, Rheumatoid Arthritis, Systemic Lupus Erythematosus, Ankylosing Spondylitis, Reiters Syndrome, Crohn’s Disease, Ulcerative Colitis, and Sarcoidosis. When patients present with recurring episodes of uveitis, it is imperative to refer for autoimmune work up. Specific blood markers, or antibodies, can be requested for specificity of autoimmune disease. ANA, RF (Rheumatoid Factor), and HLA-B27 (AS marker) are often used to diagnose underlying disease. A patient is sometimes HLA-B27 positive and have no correlation with AI disease. The markers however indicate future episodes of uveitis are likely. This photo shows moderate corneal staining from a diagnostic dye. The highlighted spots on the eye are the result of chronic dry eyes. This patient was found to have Sjrogrens Syndrome.

Toxoplasmosis, histoplasmosis, cat scratch disease, herpes simplex, HIV, and cytomegalovirus are several inflammatory diseases that present in the retina. Photo: Retinal inflammatory scarring from histoplasmosis. The dark spots in the center and throughout the retina is scar tissue from activation of spores found in the soil where birds and bats have roosted. Histoplasmosis is common in the south.

Multiple Sclerosis Ocular signs in MS involve anterior and posterior segments of the eye. Often the first sign of MS is the demylenation of the optic nerve resulting in optic neuritis. It is more of a symptom, in that the eye appears normal – the patients symptoms of pain in the eye are more intense than the presentation. Multiple episodes of eye pain with no apparent sign warrants MS investigation. Lesions in the optic tract are confirmed with MRI. Ocular signs and symptoms include asymmetric pupil constriction, pain on ocular movement, reported intermittent double vision, and visual field defects. Often there are more ocular symptoms than ocular signs with MS patients and due to variable and inconsistent findings from one patient to another, referral to a primary care physician, neurologist, or neuro-ophthalmologist along with the exam notes and visual field tests may be necessary. Another AI disease masquerading with similar signs is myasthenia gravis. MG affects muscles in the body especially the eyes. It can


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...cont’d from page 48 occur suddenly and patient presents with sudden lid droop and complains of double vision. Muscle weakness throughout the day is the hallmark for the disease and can be a significant deciphering symptom differentiating MG from MS or the mimicking third nerve palsy. Cranial Nerve III Palsy (CN III) A crucial ocular manifestation that requires urgent attention is CNIII Palsy. Cranial nerve III is responsible for the innervation of ocular motility. It allows inward, up and down, and rotary ocular movement . It also controls constriction of the pupil, the position of the upper eyelid and the focusing of the eye. Palsy of CN III may present in the clinical setting as a complete or partial palsy. Due to the extreme responsibility for ocular alignment, the signs of a palsy are obvious. In both a partial and complete CN III palsy, the affected eye will be directed down and out with lid ptosis. The complete type will involve the pupil entirely and will be fixed, dilated, and unresponsive to direct light. In the partial type, there may be a slight decrease in pupil response to direct light or no difference between either eye (pupil sparing). Ischemic disease like diabetes and hypertension tend to be pupil sparing or partial while traumatic injury to the nerve or aneurysm result in complete. Patients presenting with simultaneous double vision, lid ptosis, and a fixed and dilated pupil are considered an emergency that must be sent to the ER immediately – due to the risk of a posterior communicating artery aneurysm, the most critical and time sensitive etiology. Cancer Ocular malignancy may have no physical symptom and are often discovered on routine eye exams. Ocular tumors may develop anywhere in or around the eye. They may appear on the lids, inside the eye, or behind the eye (orbit). Slit lamp evaluations will assist in lid lesion discovery and a dilated fundus exam for retinal lesions. The most common intra ocular tumor discovered in adults is choroidal melanoma – both primary site tumors or if metastasis. In men metastasis from the lung is most common and in women the breast. Dilation is strongly recommended for men over 50 as this risk is higher. Early detection is critical since there is no way to prevent choroidal melanomas. When the melanoma is confined to the eye, the 5 year relative survival rate is 80%. When ocular melanoma has spread to distant parts of the body, the relative survival rate drops to 15%. The patient in this photo presented with no symptoms and needed reading glasses. A comprehensive evaluation including view of the retina by dilated exam revealed the round greenish sphere (choroidal melanoma) at the bottom right portion of the photo. Prompt medical intervention and treatment of the malignant tumor potentially saved his life.

Paul Vandiver, OD Doctor of Optometry, OD, BS chemistry, AOA, ALOA (American Optometry Association, Alabama OA) 445 Providence Main St, Suite 103 Huntsville, AL 35806 Phone: (256) 722-5425 50

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Exceptional food. Exceptional serivce. Timeliness, presentation and reliability are key in my role. Taco Mama always delivers. – Jackie Makowski, Tennessee Valley Pain Consultants

No matter what your occasion demands, Taco Mama will make sure you have everything you need. From a friendly and personable staff to casual, southern style Mexican food... Taco Mama is hands down the top choice for catering an office event, a party or a big family meal. – Kelly Reese, SportsMED Orthopaedic Surgery & Spine Center

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fix

by NEMIL SHAH, MD

Patients, providers, and payors all have stake in the direction of our current healthcare system. The health insurance marketplace has premiums that are increasing year after year. This even includes the “lower” premium, higher-deductible plans. The average single person who can “afford” health insurance is paying close to $10K in premium and paying out of pocket to meet their deductible before insurance starts covering the costs. We are now forcing a population of people to pay for insurance who couldn’t afford basic treatment in the first place. Health care policy is shifting the cost burden not only to the patients, but also, to its care providers and facilities who foot the bill when patients can’t afford payment. This is a poor and unsustainable model of healthcare. So, is there a healthcare fix? One solution is to provide more oversight or accountability on a personal health level. In the US, there isn’t a large incentive for the prevention of disease or accessible self-monitoring solutions to reduce health care costs. Managing population health

will require education, improved healthcare access, improved access to affordable nutrition, reduced red-tape for healthcare and pharmaceutical innovation, and personal ACCOUNTABILITY. The solution will also require better pricing models for healthcare in general through creating more competitive insurance markets which also include options for catastrophic coverage. At our clinic, ApproXie Urgent Family Care, we are going to try new pricing models ameliorate some of the cost burden for our patients. We will also focus on technology solutions to bring efficiency to healthcare delivery. We have developed one app that takes patients straight from the couch to our clinic room and another app that monitors chronic disease. Currently, we are also discounting our flat rate sick visit fee to $50 and offering other pricing models that are attractive for our patients. Come check out our clinic, tell us your solutions and concerns, and what you need as a patient.

Nemil Shah, MD Approxie Urgent Care/Primary Care 101 lvory PIace Madison, AL 35758 Phone: (256) 325-0236 www.approxie.com Inside Medicine | W inter Issue 2018

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ONLINE REVIEWS:

THE SCURGE OF PRACTICING MEDICINE? by Tiernan O’Neill

In this day and age of the internet and information, online reviews are an inevitable cause for concern to all businesses including medical practices. Whether they be general postings, blogs, community forums or dedicated review sites it is hard to ignore their presence. Due to its inevitability, we have to concern ourselves whether or not they are valuable to recognize or ignore. 54

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The most noticeable feature of all online reviews is the extreme disparity between the reviews. It has been studied and observed that often those being reviewed are rarely graded in the middle by a broad group of individuals. The scores typically are high with raving reviews, or low with damaging comments and typically nothing in the middle ground. While it is nice to see the reviews average somewhere in the middle, it is hard to ignore the presence of negative criticisms. As a result, both patients and practices should take extreme caution in reviewing and crediting the comments made. It is funny how often you will see the same measures which are negatively viewed by one patient, to be the exact same measures which are viewed favorable by another patient. In fact you can embrace the opinion patients have of your practice as hopefully a negative review may dissuade future patients from choosing your practice who might have a similar mindset. Addressing or combating negative reviews is a very delicate matter. They recommend for any business to never get in an online war with reviewers as it rarely solves the problem, it may escalate tensions and ultimately come across as sour grapes by the business owner in the end. The end worth and process is definitely complicated within the healthcare world as many of the truths which could exonerate the medical practice are often restricted for public consumption with the patient/physician relation and various privacy laws which protect patient information. This leads to an unfair advantage for the often anonymous patient who will spread half-truths, misunderstanding and sometimes malicious lies with an agenda at heart. But I would always recommend reviews which are malicious and mean spirited to be addressed. The best way to do so would be to contact the online review site itself and counter claims or draw attention to claims which may be reckless or personal in nature. The review sites often share information with each other, so rarely do you have to convince more than one site to remove malicious or liable statements as they tend to be removed from all sites if for one. Medical practices are not without resources to protect themselves from negative reviews. Such reviews typically hold morsels of truth no matter how far without merit they seem. Rarely will I see a review of my business, even when posted anonymously, which I can’t identify the individual and specific event; nor one that I didn’t see one coming. Often these reviews result from misunderstandings which were never resolved or at least recognized. Medical practices should never ignore these events. Instead get out ahead of the potential problem coming online later. Take all patient complaints seriously by communicating with the patient. Even when complaints aren’t in the forefront, making patient surveys/reviews available at the office or on your website can negate a patient’s need to submit a review to a third party site. Many times, the patient just wants to vent and or have their voice heard. And even

despite no matter how baseless you find the claims and whether you correct them at all in the instance, a responsible practice should always welcome the feedback for consideration and possible future process improvements. Ultimately it seems that reviews are here to stay. Efforts made by some physicians throughout the country to make patients sign contracts by which they lose such rights have proven unsuccessful. It can be difficult and even personally demoralizing for office’s to stomach negative reviews. I am constantly amazed that patients don’t implore or consider a “one size doesn’t fit all” possibility before they take to online forums. As said before, many methods of operation of medical offices may be viewed positively by some while the exact practices will be reviewed negatively by others. As such one wonders why patients can’t just accept a certain practice, and more accurately a business in many cases) might not be the best fit for them and simply go elsewhere without commotion. Despite any themes throughout this article which may be viewed as dissuading the validity or place of online reviews within the business of medicine, it would be false to believe such an opinion. Reviews, especially when positive or at least factual can be extremely helpful to medical practices and cause not only a lift in morale but reinforces the good methods by which they might be operating. Conversely reviews which may be negative, especially if the scales tip overwhelmingly to that side, can be extremely helpful to patients in their choice of health care providers and cause for concern, review and improvement for the internal operations of any medical business.

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discovering aesthetics treatments by Kimberly Waldrop

Aging in today’s world can develop many insecurities for most individuals. Our world is full of out of reach targets created by our “selfie” society; thus, managing beauty appears to be only skin deep. Maintaining a youthful appearance is a personal decision. We can look to others or try all we can ourselves. Some people want help in the aging process while others choose to “age gracefully”. Popular magazines often label stories as the “Now 50 is the New 40.” How do we achieve the less damaged skin or more rejuvenated appearance with less wrinkles? Someone that can look “40 at 50” definitely seeks advice or guidance from someone specializing in the field of dermatology. This behavior, like an athlete who prepares for a competition, shows ambition and stamina. This new, “old is young” is our future and should reflect individual goals. Thanks to the world we live in today, technology provides help in reaching our personal goals. Achievement in this field is a result of a better healthcare system, available fitness programs and the environmental conditions we live in. We can quickly click the computer keys or text buttons to send messages, receive answers, and get assistance. This is even true with getting help with outside beauty and looks. A market that is motivated by immediate gratification has created an allegiance to medicine. This can also serve as quite the disservice if we are relying strictly on the fastest answers from our world wide web. We want to make certain that the information we are getting and the services that are being provided are the best of the best. A fielded expert makes managing the expectations obtainable and should be a key factor of what should be important. You wouldn’t call on a plumber to fix a window, and you wouldn’t ask a dentist to perform foot surgery. Our local medical community is no longer a general specialists world; but given today’s medicine, doctors are 56

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specialized and trained and board certified in their area of excellence. One such area specialist is Dr. Bo Rivera. Dr. Rivera works as a licensed physician and surgeon at Southeastern Skin Cancer and Dermatology. He has provided important information to help with skincare needs. When working on your outward appearance, it is best to reach out to someone highly qualified and trained in that area. It is definite that you would want someone helping you to achieve a more youthful self to be the most knowledgeable. So ask yourself, why would we allow just anyone to repair our structures that are connected to our entirety?


} HEALTH

The first thing you need to do is make an initial appointment for a consultation. Dr. Rivera says this allows the opportunity to identify problem areas. You will answer a series of questions as to provide valid regions of treatment options. Some questions that may be asked include: What bothers you the most? How has your immediate family aged? Do you notice any asymmetrical movements with facial expressions? How much sun exposure do you get? What are your long and short term goals? Patients often ask, “what do I need fixed”? The consultation is about what will make the patient feel better and is not intended to be a judgment time. Once Dr. Rivera gets his answers, he will provide a plan with treatment and goals created especially for the patient. The point is to understand the individual’s anatomy, how the treatment works, what to modify throughout the process, and how to manage any unwanted effects or complications. Anyone can apply cream or medicine through a needle, but this is not the plan. The training specialists like Dr. Rivera have will ultimately be so much more beneficial to the patient’s treatment than someone trained in a weekend class or an online course. There is no substitute for specialized residency. Throughout the treatment process, the patient’s plan is always the goal. Everyone sees themselves differently and Dr. Rivera

wants to discover what concerns patients the most. Treatment options can be as simple as over-the-counter products and as complex as lasers and surgical options. Each person has their own priorities involving price, results, time, etc. A solution can always be developed to meet personal needs. With the training a specialist has, a dermatologist should easily be able to avoid “one size fits all” answers and help make YOU the YOU you want to be. Create your best self, with an ageless beauty, by contacting a local specialist like Dr. Rivera today. Achieve your goals and make your own “old is young” decree.

Albert E. “Bo” Rivera, DO, FAOCD, FAAD, FACMS is a licensed physician and surgeon in Alabama, board-certified diplomat of the American Osteopathic College of Dermatology, a fellowship-trained member of the American College of Mohs Surgeons as well as member of several dermatology and medical specialty organizations such as the American Society for Dermatologic Surgery, American Society for Mohs Surgery, American Academy of Dermatology, Skin Cancer Foundation and the Madison County Medical Society.

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