Leading Medicine Magazine, Vol. 7, No. 1, 2013 by Houston Methodist

A Publication of The Methodist Hospital System ® Volume 7, Number 1, 2013

LEADING MEDICINE the

SPORTS MEDICINE ISSUE

A Publication of The Methodist Hospital System ® Volume 7, Number 1, 2013

LEADING MEDICINE the

SPORTS MEDICINE ISSUE

A Publication of The Methodist Hospital System ® Volume 7, Number 1, 2013

LEADING MEDICINE the

SPORTS MEDICINE ISSUE

LEADING MEDICINE

Volume 7, Number 1, 2013

The Methodist Hospital System® is proud to be the official health care provider for the Houston Texans, Houston Astros, Houston Dynamo, Rice Athletics, Houston Ballet and Rodeo Houston.

MATT SCHAUB Houston Texans quarterback

ARIAN FOSTER

ROBERTA SCHWARTZ Executive Vice President RAMON “MICK” CANTU, J.D. Executive Vice President, Chief Legal Officer and Strategy and Business Development Officer

CHRIS BROOKS

Houston Texans running back

MARC L. BOOM, M.D. President and CEO

American gymnast, Olympic alternate

BUD NORRIS Houston Astros starting pitcher

H. DIRK SOSTMAN, M.D. Executive Vice President, Executive Vice Dean and Chief Medical Officer SUSAN H. COULTER, J.D. Senior Vice President, Development, Marketing and Public Relations ERIN SKELLEY Director of Marketing Executive Editor SHESHE GIDDENS Managing Editor DENNY ANGELLE Associate Editor DENNY ANGELLE JULIANNA ARNIM MEGHAN BLANTON SHESHE GIDDENS LINDA GILCHRIEST THELMA GROS DONNA HURST GEORGE KOVACIK PATTI MUCK ANDREW NELSON MICHAEL E. NEWMAN Contributing Writers ADCETERA Design FANTICH STUDIO ROBERT SEALE PHOTOGRAPHY SCOTT H. JONES WILLIAM STEWART PRODUCTIONS Photography Leading Medicine magazine is published by The Methodist Hospital System® Marketing Department for patients, physicians, employees and supporters. © 2013 The Methodist Hospital System

ON THE COVER

Arian Foster and Jessica Goswitz discuss how changing their diets helped them bring their A-game. Page 6

Send address corrections and letters to: Leading Medicine The Methodist Hospital System Publications Department 1707 Sunset Blvd. Houston, Texas 77005 Tel.: 713-790-3333 esource@tmhs.org

LAUREN ANDERSON JESSICA GOSWITZ Rice University Owls basketball player

BRAD DAVIS Houston Dynamo midfielder

If you wish to cancel your free subscription to Leading Medicine magazine, contact us at 713-790-3333 or esource@tmhs.org.

Artistic education outreach associate and former principal dancer for the Houston Ballet

LINDSEY BIGGART Elkins High School soccer player

LEADING MEDICINE

Volume 7, Number 1, 2013

The Methodist Hospital System® is proud to be the official health care provider for the Houston Texans, Houston Astros, Houston Dynamo, Rice Athletics, Houston Ballet and Rodeo Houston.

MATT SCHAUB Houston Texans quarterback

ARIAN FOSTER

ROBERTA SCHWARTZ Executive Vice President RAMON “MICK” CANTU, J.D. Executive Vice President, Chief Legal Officer and Strategy and Business Development Officer

CHRIS BROOKS

Houston Texans running back

MARC L. BOOM, M.D. President and CEO

American gymnast, Olympic alternate

BUD NORRIS Houston Astros starting pitcher

ON THE COVER

Arian Foster and Jessica Goswitz discuss how changing their diets helped them bring their A-game. Page 6

Send address corrections and letters to: Leading Medicine The Methodist Hospital System Publications Department 1707 Sunset Blvd. Houston, Texas 77005 Tel.: 713-790-3333 esource@tmhs.org

LAUREN ANDERSON JESSICA GOSWITZ Rice University Owls basketball player

BRAD DAVIS Houston Dynamo midfielder

If you wish to cancel your free subscription to Leading Medicine magazine, contact us at 713-790-3333 or esource@tmhs.org.

Artistic education outreach associate and former principal dancer for the Houston Ballet

LINDSEY BIGGART Elkins High School soccer player

LEADING MEDICINE

Volume 7, Number 1, 2013

The Methodist Hospital System® is proud to be the official health care provider for the Houston Texans, Houston Astros, Houston Dynamo, Rice Athletics, Houston Ballet and Rodeo Houston.

MATT SCHAUB Houston Texans quarterback

ARIAN FOSTER

ROBERTA SCHWARTZ Executive Vice President RAMON “MICK” CANTU, J.D. Executive Vice President, Chief Legal Officer and Strategy and Business Development Officer

CHRIS BROOKS

Houston Texans running back

MARC L. BOOM, M.D. President and CEO

American gymnast, Olympic alternate

BUD NORRIS Houston Astros starting pitcher

ON THE COVER

Arian Foster and Jessica Goswitz discuss how changing their diets helped them bring their A-game. Page 6

Send address corrections and letters to: Leading Medicine The Methodist Hospital System Publications Department 1707 Sunset Blvd. Houston, Texas 77005 Tel.: 713-790-3333 esource@tmhs.org

LAUREN ANDERSON JESSICA GOSWITZ Rice University Owls basketball player

BRAD DAVIS Houston Dynamo midfielder

If you wish to cancel your free subscription to Leading Medicine magazine, contact us at 713-790-3333 or esource@tmhs.org.

Artistic education outreach associate and former principal dancer for the Houston Ballet

LINDSEY BIGGART Elkins High School soccer player

LEADING MEDICINE

Volume 7, Number 1, 2013

The Methodist Hospital System® is proud to be the official health care provider for the Houston Texans, Houston Astros, Houston Dynamo, Rice Athletics, Houston Ballet and Rodeo Houston.

MATT SCHAUB Houston Texans quarterback

ARIAN FOSTER

ROBERTA SCHWARTZ Executive Vice President RAMON “MICK” CANTU, J.D. Executive Vice President, Chief Legal Officer and Strategy and Business Development Officer

CHRIS BROOKS

Houston Texans running back

MARC L. BOOM, M.D. President and CEO

American gymnast, Olympic alternate

BUD NORRIS Houston Astros starting pitcher

ON THE COVER

Arian Foster and Jessica Goswitz discuss how changing their diets helped them bring their A-game. Page 6

Send address corrections and letters to: Leading Medicine The Methodist Hospital System Publications Department 1707 Sunset Blvd. Houston, Texas 77005 Tel.: 713-790-3333 esource@tmhs.org

LAUREN ANDERSON JESSICA GOSWITZ Rice University Owls basketball player

BRAD DAVIS Houston Dynamo midfielder

If you wish to cancel your free subscription to Leading Medicine magazine, contact us at 713-790-3333 or esource@tmhs.org.

Artistic education outreach associate and former principal dancer for the Houston Ballet

LINDSEY BIGGART Elkins High School soccer player

LETTER FROM THE CEO

“Best Hospital in Texas” – U.S.News & World Report

Thank you to the physicians, nurses, staff and volunteers whose dedication to our patients makes Methodist a national leader. Together, we are Leading Medicine. RECOGNIZED IN 13 SPECIALTIES, MORE THAN ANY OTHER HOSPITAL IN THE STATE: CANCER • CARDIOLOGY & HEART SURGERY • DIABETES & ENDOCRINOLOGY • EAR, NOSE & THROAT • GASTROENTEROLOGY GERIATRICS • GYNECOLOGY • NEPHROLOGY • NEUROLOGY & NEUROSURGERY • OPHTHALMOLOGY

Organizations across the country often ask me to speak about the impact of health care reform on hospitals like Methodist and more importantly, on patients like them. This topic is broad and complex and often deserves more discussion than a lunchtime agenda will allow. But there are a few certainties. One of them is that Methodist is well-positioned to adapt to the changing landscape of reform because it has always been and will continue to be dedicated to quality, patient safety and service. These performance measures are central to reform policy and Methodist is a national leader across the board. Just this year, U.S.News & World Report named The Methodist Hospital the No. 1 hospital in Texas. We have built our reputation on delivering an exceptional standard of care and we will continue to raise the bar even higher. Another certainty in the reform discussion is that we as a country must improve our health. The current health care system is ill-equipped to manage the population’s predicted array of chronic health conditions, many of them related to the obesity epidemic. The statistics about the future of our health are staggering, but the good news is we can do something about it. An active and healthy lifestyle is one of the most effective ways to control the ever-rising costs of health care. This issue of Leading Medicine highlights how to stay active, especially after injury. Methodist physicians are helping their patients — many of them professional athletes — push the boundaries of human performance. Our cover story highlights Houston Texan Arian Foster, one of the best running backs in the NFL. His diet and training regimen offer fascinating insight into the capabilities — and limits — of the human body. Foster and many of the athletes featured in this issue reveal that knowing your limits is just as important as pushing your limits. And our medical experts weigh in on how to do both. As the health care providers to Houston’s professional athletes, dancers, singers and other performing artists, Methodist physicians specialize in keeping their patients active, injury-free and healthy. From Olympians to everyday runners, our patients share their stories of recovery and ultimately, success. In keeping with our mission of promoting good health, Methodist works with companies across the city to help their employees get and stay healthy. New Astros owner Jim Crane talks about the importance of these corporate wellness programs. And staff at our own Wellness Center offer tips on how to overcome obstacles to exercise in the Healthy Living section.

ORTHOPEDICS • PULMONOLOGY • UROLOGY

I’m issuing a prescription to make a commitment to improving your own health. You can start here. V I S I T M E T H O D I S T H E A LT H . C O M | C A L L 7 1 3 - 7 9 0 - 3 3 3 3

Best of luck!

Marc L. Boom, M.D.

Leading Medicine • Volume 7, Number 1

LETTER FROM THE CEO

“Best Hospital in Texas” – U.S.News & World Report

ORTHOPEDICS • PULMONOLOGY • UROLOGY

I’m issuing a prescription to make a commitment to improving your own health. You can start here. V I S I T M E T H O D I S T H E A LT H . C O M | C A L L 7 1 3 - 7 9 0 - 3 3 3 3

Best of luck!

Marc L. Boom, M.D.

Leading Medicine • Volume 7, Number 1

The

SPORTING LIFE By Dr. David Lintner

Humans are built for physical activity. Our bones, joints and muscles work together in a sort of physical symphony — letting us run and jump, climb and throw with remarkable dexterity. We are designed to absorb strain and exert force; with practice and repetition, we gain skill and strength — some of us even compete, earning satisfaction in testing ourselves against others. All of this activity, however, can take a toll. Athletes at all levels — from casual walkers to players in the NFL — sometimes need support from their doctors. Overuse and repetitive stress injuries can reduce function in even the weekend athlete, while professional athletes combine unusual physical strain (and significant risk) with the high stakes of a career. The orthopedists and sports medicine specialists throughout The Methodist Hospital System are fortunate to be able to provide care to athletes on Houston’s professional sports teams and serve the area’s universities, secondary schools and even amateur leagues as sideline physicians and consultants. And every day, we work with casual athletes and individuals at every level to help them stay in good physical condition.

Dr. David Lintner is an orthopedic surgeon at The Methodist Hospital and chief of sports medicine. He is also medical director for the Houston Astros as well as a team physician for the Houston Texans.

In this issue of Leading Medicine, we take a look at some of the work that we do to keep our patients — famous and not — healthy and active for life. n Rice Owls basketball player Jessica Goswitz

The

SPORTING LIFE By Dr. David Lintner

In this issue of Leading Medicine, we take a look at some of the work that we do to keep our patients — famous and not — healthy and active for life. n Rice Owls basketball player Jessica Goswitz

COVER STORY

What can athletes, their diets and training teach us about the

POTENTIAL

T HE H U M A N BODY?

by denny angelle

n ancient days, they were the gods who walked the earth, the titans whose feats of strength were immortalized in tales handed down through generations. They have swung swords and baseball bats, thrown spears and footballs.

And they have always run: simple, fast and free, into the future and forever. They are the athletes, the real-life superheroes who seem to defy gravity and transcend mortality with rippling muscles and mythical reflexes. People dream to be like them:

S T RONG , FA S T A N D SE E M I NG LY AG E LE SS. How do these humans evolve into such perfect specimens? Are they born with natural ability, or do they determine at some point they will trade childhood for an obsession that one day will turn them into an elite athletic adult? Experts will assure us, it’s a little bit of both. And yet — there is something more. Yes, there is training and an almost-scary fixation on performance. And yes, it helps to be born with the right combination of talent and physical attributes. One also needs a spark, a desire burning in the heart that leads one to become an athletic competitor. With that drive, athletes can develop superior physical skills and excel on the playing field of their choice. But in recent years, athletes have uncovered other ways to gain an edge — some are illegal, unfair or simply unsportsmanlike. The real edge, people have discovered, is knowledge. Learning about how their bodies work, the fuel that keeps them going and the habits to

Houston Texans running back Arian Foster

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Leading Medicine • Volume 7, Number 1

embrace or avoid is essential to modern athletes and nearly as important as physical training and practice. What they know is what we can learn.

FOOD FOR THOUGHT Perhaps no one embodies the modern, 21st-century athlete more perfectly than Arian Foster, a running back for the Houston Texans. Since signing with the team in 2009, Foster has become one of the National Football League’s premier running backs. He rushed for more than 1,000 yards in his first two full seasons with the Texans and was invited to the Pro Bowl each year. And early in the 2012 football season, Foster set a historic mark: he surpassed 5,000 yards rushing and receiving in his 40th game, becoming the third-fastest player to do so, behind only Edgerrin James (36 games) and Eric Dickerson (39 games). Yet Foster is unconventional among his professional peers. He scoots around the Texans’ Reliant Stadium facilities on a Segway, deftly maneuvering among

giant teammates. He writes poetry and thinks deeply about everything he is asked; after all, he majored in philosophy at the University of Tennessee. Attempts to fit him into the conventional image of a pro football player can exasperate and amuse Foster. He is quick to point out, “That’s one of the clichés everybody uses.” But he is also quick with a laugh and a fresh observation. “People ask: what advice would I give to a young person?” Foster says. “I would say to ask yourself, ‘Why do I want to do this?’ When you are satisfied with the ‘why,’ you never really have to answer to anyone else. Look in the mirror and be satisfied with what you see.” Going into the 2012 football season bedecked with honors and the promise of another trip to the playoffs for the Texans, Foster unwittingly touched off a firestorm this summer when he casually announced on Twitter he was now a vegan. He gave up red meat and dairy in June, working the new diet into his overall discipline.

COVER STORY

What can athletes, their diets and training teach us about the

POTENTIAL

T HE H U M A N BODY?

by denny angelle

Houston Texans running back Arian Foster

methodisthealth.com/leadingmedicine

Leading Medicine • Volume 7, Number 1

embrace or avoid is essential to modern athletes and nearly as important as physical training and practice. What they know is what we can learn.

Midway through the season, Foster elaborated that he enjoys chicken from time to time, although he is still largely vegan. But at the time, the Twitterverse came alive with scoffing, dismissal and second-guessing from football fans. Some critics went so far as to predict Foster’s new diet could actually affect his performance on the field. Yet it was a careful decision on Foster’s part. He says he researched it for years after seeing a documentary in high school that made him think about where his body gets nutrition and energy. “I always told myself when I fi nished my football career I would become a vegetarian, but I needed the protein for my sport,” Foster says. “But in the past year, I started talking to doctors, nutritionists, other players and I realized I could make the switch now.” He consulted with the team’s dietitian and balanced his diet of fruits and vegetables with nuts and seeds and dried fruits to replace the protein one normally gets from meat. While Foster’s switch came with the full support of team officials and health care providers, he didn’t expect it to get so much attention in the media. “If I would have known what it would cause,” he says, “I wouldn’t have said anything about it. That’s another of the stereotypes of football. I guess people are not used to seeing athletes with that kind of diet. It’s not very common, I suppose.” Foster says some people also tried to talk him out of becoming a vegan. “People are always going to have their opinions and viewpoints,” he says. “Usually people with the strongest opinions are the least educated about a subject.”

Foster says some people also tried to talk him out of being a vegan. “People are always going to have their opinions and viewpoints,” he says.

And deep into the current football season, Foster is looking like he will have yet another stellar year.

“Usually people with the strongest opinions are the least educated about a subject.”

methodisthealth.com/leadingmedicine

Leading Medicine • Volume 7, Number 1

LOOKING AHEAD Dr. James Muntz, an internist at The Methodist Hospital, has worked with Houston’s professional sports teams for 30 years. He is a team physician for various professional teams, including the Houston Texans, Houston Astros and Houston Rockets. Muntz has also worked with the Houston Dynamo and now-defunct teams Houston Oilers, Houston Comets and Houston Gamblers. He says he has certainly seen a change in athletes’ attitudes and depth of knowledge about their own health. “No question about it, professional athletes are more studied in the way they approach their physical training and their own health,” says Muntz. “They have picked up information from the Internet, as well as from their own education through their respective schools and teams, and talking to other athletes.” The physician has also seen a growing awareness among professional athletes about their health after their competitive days end. “It’s one thing to be a 300-pound football lineman when you are in your 20s, but it’s a completely different ball game to carry that kind of weight when you are retired and in your 50s,” Muntz explains. And players want to know what effect jumping up and down on a basketball court or pitching hundreds of innings of baseball will have on their joints and muscles in later years. In some cases, Muntz says, ex-players will take up a lower impact physical activity like golf or tennis just to keep in shape. Dr. David Lintner is an orthopedic surgeon at the Methodist Center for Sports Medicine, and is team physician for the Astros as well as medical director for the Texans. He says that athletes’ sophistication in their approach no longer surprises him. “They are always looking for an edge and this often extends to their health,”

he says. “Sometimes they can go toward outlandish diets or supplements. I just try to point out that there’s just a lot of risk in trying unproven diets. And supplements come from an unregulated industry — you just don’t know what is in them. I give them the facts and suggest the right path to take.” The depth of information available about treatments, surgeries and recovery is also helpful in giving an athlete an accurate picture of what to expect after an injury. “With this new level of knowledge, athletes are far more involved in treatments and recovery from injuries,” Lintner says. “It used to be that athletes were almost passive in their treatment, they just did what they were told was best. Today, although the treatments are evolving, what’s changed is the patient’s participation in the decision-making process.” With athletes on a professional team or even a high school athlete and his or her parents, Lintner approaches each patient with a respect for this knowledge. “My job is to give the patient the best scientific information I can — to educate and provide reliable, honest guidance,” he explains. “Then I let the patient decide what steps to take next.” Another physician who sees athletes at all levels is Dr. Patrick McCulloch, an orthopedic surgeon with the Methodist Center for Sports Medicine and a team physician for the Houston Astros, who also works with Rice Athletics and the Houston Ballet. McCulloch says an athlete’s level of fitness and coordination before an injury can help determine the quickness of recovery. “Not just the physical attributes, but an athlete’s mental attitude toward surgery and rehabilitation can also assist with recovery. Athletes are highly motivated patients who are willing to put in time

Foster says some people also tried to talk him out of being a vegan. “People are always going to have their opinions and viewpoints,” he says.

And deep into the current football season, Foster is looking like he will have yet another stellar year.

“Usually people with the strongest opinions are the least educated about a subject.”

methodisthealth.com/leadingmedicine

Leading Medicine • Volume 7, Number 1

“With the kind of schedule a

grass-fed or pasture-raised meats, vegetables, fruit and nuts. It excludes grains, dairy products, refined salt and sugar, and processed foods.

college athlete has, it’s hard just keeping an even balance and maintaining the basics.

“I look for replacements for foods not on the diet,” Goswitz adds. “It’s a great alternative and really, I don’t miss anything and can’t see that I have any less energy than usual.”

But I am quickly learning what kind of food helps me perform at my best and gives me healthier energy levels.”

With her future stretching out before her, Jessica believes she is on the right path for a healthy and active life. Meanwhile, high school teacher R. “Don” Ruggles is on the same path, just a few steps ahead. Ruggles, 68, calls himself an endurance athlete. He says: “I’m not a jogger, I’m not a runner. I’m an endurance athlete!” Ruggles has competed in 83 marathons and ultra-marathons, including one 100-mile race, one 100-kilometer race and numerous 50-mile runs.

Rice Owls basketball player Jessica Goswitz

and effort to get a superior result. Being competitive, they often see injuries as an obstacle that must be overcome (in order) to get back on the field,” he says. “When a doctor tells an athlete how long he or she is likely to be out, the athlete will see that as a challenge and try to beat that mark and prove they can get back faster.” Lintner says that’s a lesson the weekend warrior can learn from the pros. “Rather than looking upon an injury as an inconvenience, make your treatment and recovery a focal point,” he suggests. “Take the time and effort that you would be putting into your sport and invest it in recovery and rehabilitation.” McCulloch agrees: “Elite athletes are very competitive with themselves,

are goal-oriented and results-driven. Applying these same attributes to overcoming your own injury can help you get back on the field faster.”

HIGH-PERFORMANCE ATHLETES Jessica Goswitz spends a lot of time at a great height, looking down upon the campus of Rice University. She’s an Owls basketball player in her senior year, but Jessica isn’t a high-jumping center. She’s a guard whose gritty play earned her the Fighting Owl Award last season. Goswitz’s high-flying pastime involves running up and down the steps of Rice Stadium, with ankle weights, often in the sweltering heat that is Houston most of the year. “I’m a gym rat, no question about it,” she says with a chuckle.

“No matter if it’s basketball season or not, I can’t keep still.” Her major is kinesiology, or exercise science. She recently completed an internship with a dietitian’s practice in Houston, and that opened her eyes to the importance of knowing one’s body, and what to feed it. “With the kind of schedule a college athlete has, it’s hard just keeping an even balance and maintaining the basics,” she says. “But I am quickly learning what kind of food helps me perform at my best and gives me healthier energy levels.” She has adopted a form of the Paleolithic — or “caveman” — diet, based on what hunters/gatherers of ancient times might consume. The common Paleolithic diet consists mainly of fish,

methodisthealth.com/leadingmedicine

He is the Engineering Academy coordinator for Hightower High School in Missouri City, and has been a teacher for 12 years. At age 42, he says he weighed more than 200 pounds and his cholesterol was skyrocketing. “I had lost control of my health,” he says. “So I made the decision to start running.” A voracious reader, Ruggles sought all the information he could about training plans. He settled on a plan that helped him gradually build up his running mileage. In 1991, he ran his first marathon and tried for more than 10 years before he finally qualified to participate in the Boston Marathon. “It took 12 years of failing in my training methods before I got it right,” he says. “It’s all second nature now.” Ruggles runs five days a week, going various distances and speeds, depending on if he is training for a marathon or not. He frequently has a “long run” of about 20 miles on Sundays.

Leading Medicine • Volume 7, Number 1

To those who may consider running in his footsteps, Ruggles suggests starting slowly, and building up to various distances. “Don’t sign up for a marathon your first time out,” he says. “Do a 5K (five kilometer race, about 3.1 miles), a 10K or a half marathon. Spread them out. “And find a running friend — someone you can depend on to show up every time. That’s critical; find somebody who is your speed or a little faster,” he adds. Ruggles says he got into running first for his health (which is much better now), for the competition and for the social interaction with others. “It’s evolved into a total lifestyle for me,” he says. “My essence.” Brian Gilliam didn’t really choose his current lifestyle, but he wouldn’t trade it for anything right now. Born with a heart defect, Gilliam was diagnosed with congestive heart failure when he was in his early 40s. His heart weakened continuously and finally, in 2008, Gilliam received a heart transplant at the Methodist J.C. Walter Jr. Transplant Center. Since then, he has become an active spokesman for transplant and donor awareness. In 2010, he participated in the National Kidney Foundation Transplant Games as a member of the golf team. This summer, Gilliam captained a team of 86 transplant recipients, living donors and donor family members to participate in the Transplant Games of America in Grand Rapids, Michigan. Team Texas (with one member from Louisiana) competed in 17 events, including bicycling, track and field, swimming, and golf. “I competed in golf and did some basketball before I pulled a hamstring,” says Gilliam. “It was an amazing event.” With a transplanted heart beating in his now 50-year-old chest, Gilliam must be aware of everything his body tells him at

all times. “The biggest obstacle for me is not to overdo it,” he explains. “Even golf, which wouldn’t seem to be that strenuous, can get rough when you’re out in the Texas heat.” Nevertheless, Gilliam also enjoys fishing, hunting and other outdoor activities. He also says it’s important to keep working. “I work in construction and it really keeps me moving,” he adds.

WORK HARD, PLAY HARD No matter the source of information, any good advice on activity and athletics will emphasize the importance of rest. Even the ever-running Ruggles takes two days of rest, usually during the week. He says it’s important — the time off gives his body an opportunity to recover. Rice Owl Goswitz builds in downtime so she can complete her studies. They happily take short breaks from their sports because they know they will return to them. Players who are injured have tougher adjustments to make. “It’s really tough to tell an athlete they have to stop,” says Lintner. “They aren’t wired to be inactive, so a kind of depression sets in.” McCulloch explains further, “From a rehabilitation standpoint, it is important for us to recognize this and keep things positive. We mix up workouts to keep them interesting and give (the athlete) concrete goals to work toward in rehab.” Foster, for his part, looks forward to his time off. It’s important to take time to recover, because football is such a physical game. “I just like to relax and take my mind off everything,” he says. Gliding on his Segway helps Foster save his legs for the next game, and he doesn’t really do anything athletic off the football field. “I guess at this level, anything athletic you do, it all goes toward your craft, your profession,” he says. “I’m lucky — I consider my craft to be fun.” n

“With the kind of schedule a

grass-fed or pasture-raised meats, vegetables, fruit and nuts. It excludes grains, dairy products, refined salt and sugar, and processed foods.

college athlete has, it’s hard just keeping an even balance and maintaining the basics.

“I look for replacements for foods not on the diet,” Goswitz adds. “It’s a great alternative and really, I don’t miss anything and can’t see that I have any less energy than usual.”

But I am quickly learning what kind of food helps me perform at my best and gives me healthier energy levels.”

Rice Owls basketball player Jessica Goswitz

are goal-oriented and results-driven. Applying these same attributes to overcoming your own injury can help you get back on the field faster.”

methodisthealth.com/leadingmedicine

Leading Medicine • Volume 7, Number 1

i n

CHANGE YOUR DIET, CHANGE YOUR LIFE

a d d i t i o n

An active lifestyle calls for active eating choices

e didn’t plan it that way, but Houston Texans running back Arian Foster touched off a firestorm in pro football circles this past summer when he announced his decision to pursue a largely vegan diet. It wasn’t a snap decision on his part. Foster says this was an idea that had been gestating since he was in high school. “Back then, I saw a documentary that sort of pushed me toward getting more aware about protein, what your body needs and what it doesn’t need,” Foster says. “I didn’t act on it then, but, as I looked more and more into it, I decided finally that I could make the switch.” Foster has eliminated most of the meat from his diet, although he occasionally includes chicken. He consulted doctors and dietitians, but he also listened to his body: Foster knew how a big meal with meat made him feel. “My body was telling me all the time — when I would eat something that made me feel sluggish,” Foster explains. “I felt in my heart of hearts that food isn’t supposed to do that. It’s supposed to make you feel good.” Foster’s teammate on the Houston Texans, quarterback Matt Schaub, feels the same way. “At the NFL level, our bodies are how we make our living. What you put in is what you get out. And I like to put in food that helps me feel the best and get my best performance,” he says. Schaub says over the years, as he progressed through college and into pro football, he looked around and saw what habits worked for veteran players.

Houston Texans running back Arian Foster

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Leading Medicine • Volume 7, Number 1

by denny angelle

He sketched out his own personal playbook on what foods kept him in peak shape. “For me, it’s a lot of fruit and a lot of vegetables. I keep them as part of every one of my meals,” Schaub says. “I enjoy chicken, seafood and a little steak every once in a while. But I like to keep everything as lean as I can.” That lesson is echoed by Jessica Goswitz, Rice University’s senior basketball guard. A kinesiology major, Jessica recognizes that many people, no matter their exact diet, have a greater general awareness of the beneficial foods versus the foods that aren’t so great for you. She feels a few minor details escape many people, though, when the food is hot and fresh and piled up ready to eat. “Many think that pasta is the best for adding carbs, especially before an athletic event,” she says, “but our bodies aren’t made to break down pasta. They can more efficiently break down vegetables, which may not have as many carbs as pasta, but have more beneficial nutrients.”

long run,” he says. “No fast food — there are some things I eat that always cause severe consequences [while running].” He will eat a small amount of pasta or salmon the night before a long run, then will supplement during the run with easy-todigest sports gels and beans to give him an extra boost of energy. “My favorite pre-race food is a banana, because it’s easy to digest,” Ruggles continues. “Or I might have a power bar or the occasional bagel. You want to be able to focus on the run, and only the run.” Long before he received a heart transplant, golfer Brian Gilliam and his family stopped using salt in cooking. “We became very used to it, and, after a little adjustment, we didn’t even notice it was missing,” he says. “When we eat out, I can immediately taste the salt.” Gilliam developed diabetes as an offshoot of his heart disease, so he’s very careful about his diet. He likes venison — he’s an avid hunter — because it is lean and healthier than other red meats.

Everywhere she goes, Jessica encounters catered meals but she resists the temptation to load her plate with anything but a pile of vegetables before a game. “Don’t get me wrong, I like my meat too much to ever give it up altogether,” she laughs. “But I try to stick with the basics, and they always work for me.”

So our panel of athletes agree: watch your carbs, balance your dietary choices, and know that fruits and vegetables are MVPs for any diet. Stay hydrated and keep those pre-sport meals light and easy to digest. Anything else?

Veteran long-distance runner Don Ruggles has an elaborate routine to help him prepare for a marathon, or an even longer run. His cardinal rule is direct: “I don’t put any garbage in my body for six hours before a

Arian Foster: “Stick with what you know is right for you, no matter what other people tell you,” he says. “People are going to try and convince you their way is the best way, but always stay true to yourself.” n

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An active lifestyle calls for active eating choices

Houston Texans running back Arian Foster

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Leading Medicine • Volume 7, Number 1

by denny angelle

o one expects a healthy, active person’s heart to stop in the middle of a game or race. But it happens every year. Thousands of Americans who are otherwise perfectly healthy suffer from congenital or genetic heart conditions that may produce no symptoms at all — until a crisis occurs.

Maintaining a healthy lifestyle is essential in helping prevent cardiovascular disease, stroke, hypertension and other complications. But we also hear stories of young athletes — high school football players, marathon runners — suffering serious heart stress or even death in the midst of activity. Understanding how these unknown vulnerabilities can be discovered before it’s too late can help people at all activity levels learn the red flags associated with potential heart problems and how they can be treated or prevented.

HEART BASICS

VIM, VIGOR & HEART SCREENING ACTIVE INDIVIDUALS for HEART DISEASE By Julianna Arnim

Your heart is a complex muscle: think of it as a power station that powers the circulatory system throughout the body. Just like any building, the heart needs functional plumbing and electrical systems to stay in top shape. The heart’s plumbing system, a network of arteries and veins, brings vital nutrients to the heart, which is constantly contracting. The electrical impulses that work as this natural pacemaker stem from conduction tissue, a system of microscopic “cables” that carry signals to keep the heart pumping. They work in tandem with the circulatory system to keep the heart beating 70-to-80 beats per minute, every minute of every day. When something goes wrong with these basic heart systems, even the healthiest and fittest individuals can be affected. If the flow of blood through the coronary arteries is impaired, the heart will work harder to compensate; if an electrical impulse is flawed, it could lead to tachycardia (a heart rate that is higher than its normal range) or even heart attack. Many of these causes are congenital, or present from birth, but can easily go undetected, especially in young, healthy people. Even so, there are ways to be proactive about risk and screening.

RISK FACTORS & SYMPTOMS “Be aware of your blood pressure, cholesterol and blood sugar numbers,” says Dr. Keith Ellis, an interventional cardiologist at Methodist Sugar Land Hospital. “Hypertension, high

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Leading Medicine • Volume 7, Number 1

cholesterol and diabetes are all conditions that should lead to an evaluation by a cardiologist, but genetics also play an enormous role in screening for cardiac disease.” This sentiment is echoed by other heart specialists, who say that knowing your family history is often the most important information to have when you visit your doctor. If a close male relative died from a heart attack or heart-related illness at age 45 or younger, or a female relative at 55 or younger, you are at a much higher risk — sometimes as much as 50 percent higher than average — for developing heart problems yourself. Factors such as genetic abnormalities, a diabetic mother or even belonging to a particular ethnic group can predispose individuals to congenital heart defects they may not be aware of. Heart conditions such as cardiomyopathy or Marfan syndrome cannot be overcome with diet and exercise alone, but must be treated medically. Certain blood tests, stress tests and imaging can help diagnose existing or potential heart conditions in people who fall into a risk pool. Though many of these defects or conditions cause no symptoms, there are some warning signs to be aware of: • Chest discomfort or shortness of breath during exertion • Heart palpitations or irregular heartbeat while at rest • Passing out or losing consciousness when active • More fatigue than peers when active • Seizure activity or involuntary muscle movement If you are healthy and active and experience any of these symptoms, “stop training and get checked,” says Dr. Miguel Quiñones, chair of the Department of Cardiology at The Methodist Hospital and professor of medicine at Weill Cornell Medical College. “There are three ways to tell if further testing is needed: symptoms, family history or an abnormality.” There are numerous tests that can inform doctors and patients of heart disease risk.

HEART BASICS

VIM, VIGOR & HEART SCREENING ACTIVE INDIVIDUALS for HEART DISEASE By Julianna Arnim

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£ Chest discomfort or shortness of breath during exertion £ Heart palpitations or irregular heartbeat while at rest £ Passing out or losing consciousness when active £ More fatigue than peers when active £ Seizure activity or involuntary muscle movement Dr. Miguel Quiñones

ASSESSING YOUR RISK WITH CAROTID ULTRASOUND

SCREENINGS AND TESTS

PREVENTION

Echocardiogram. This noninvasive test uses sound waves to produce an image of the heart. In some countries outside the United States, it is used to screen all adolescents before they participate in sports to rule out congenital abnormalities that could result in harm during exertion.

While congenital defects cannot be prevented, there are steps everyone can take to reduce their risk of heart disease. Dr. Christie Ballantyne, a cardiologist at the Methodist DeBakey Heart & Vascular Center, recommends the “ABCs” of prevention: aspirin, blood pressure, cholesterol, diet and exercise. (Daily aspirin regimens are not recommended for all adults, so you should always consult your physician before starting a new aspirin or exercise regimen.) Knowing your numbers, staying fit and maintaining a balanced, nutritious diet are all key to preventing heart disease, especially if you are not genetically predisposed.

Stress test. For people with lower risk factors or who are looking to become fit after being inactive, a cardiac stress test can be an effective indicator of potential heart disease risk. A combination of treadmill exercise and echocardiogram, a stress test is best at revealing major blockages — 70 percent or more — and people who “pass” the test could still have significant blockages and suffer a heart attack. So if your risk is higher, a more detailed test may be appropriate. CT angiography. This test uses a powerful chest X-ray that scans the heart for any plaque buildup in the system. It can reveal blockages as minimal as 10–20 percent, and does not involve an invasive catheter like a traditional angiogram, but it does use radiation and may not be advised for everyone. Carotid ultrasound. Another noninvasive test that uses sound waves to produce images of the carotid arteries in the neck. It helps identify blockages and assess risk of heart disease or stroke. Methodist also puts on a low-cost screening event every year for student athletes in the community. It involves a physical exam, detailed family history, and cardiologists and imaging experts on site to consult or perform and interpret an echocardiogram for those at risk for heart disease.

STIMULANTS AND SUPPLEMENTS Some athletes and active people use stimulants or supplements, such as anabolic steroids or growth hormones, to enhance muscle building and athletic performance. But the price they pay for superhuman strength comes with lots of potential damage: thickening of the heart muscle, elevated blood pressure, abnormal cholesterol, psychiatric problems, liver effects, weight gain, kidney failure, and the list goes on. Over-the-counter stimulants, some of which are equivalent to 20 cups of coffee at once, can cause dangerous levels of stress on the heart, as well as rhythm disturbances. “Exercise training by itself is all you need,” says Quiñones. “Supplements aren’t going to do a thing.” Still not convinced? Ballantyne’s advice is also direct: “The bottom line is, don’t use them.” These supplements and stimulants simply carry too much risk — much of it long term — to be worth the temporary effects.

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“There are three ways to tell if further testing is needed: symptoms, family history or an abnormality.”

HOW CAN YOU PREPARE? Active, healthy people are not immune to heart disease. Even in the midst of great technological strides in medicine, knowing your family history may be the most important diagnostic tool available. And knowing when to push yourself and when to see the doctor is as important as improving your best times or putting on your best game.

Heart and Vascular Screenings The Methodist Hospital System offers heart and vascular screening packages that can help you better understand your risk factors for heart disease. These scans are quick, noninvasive and could save your life. The screenings are conveniently offered at Methodist locations throughout Houston. n To learn more or to schedule a screening, visit methodisthealth.com/heartscans or call 713-790-3333.

Leading Medicine • Volume 7, Number 1

“We take an oath in medicine, primum non nocere,” says Dr. Christie Ballantyne, a cardiologist at The Methodist Hospital and an authority on heart screening. “It means ‘first do no harm.’ There is no harm in this test.” The test he’s referring to is the carotid IMT, a new, noninvasive screening that uses ultrasound to help determine risk of heart disease or stroke. “The question isn’t the presence of disease, but of blockages limiting blood flow to the heart muscle,” says Ballantyne, “and ultrasound is just sound waves — there’s no radiation, and we can measure the carotid artery and scan for plaque.” The carotid arteries carry oxygenated blood from the heart to the head, and being able to see and measure them can give doctors clearer insight into a patient’s risk for a cardiac event. It also determines vascular age, similar to a “real age” test that helps determine an individual’s risk level. It’s painless, easy, radiation-free and has no side effects. It does carry a cost of around $200, but some insurance plans will cover it. It’s still vital to know your family history and stay attuned to potential symptoms, like pronounced fatigue during activity, severe lightheadedness while exercising, or a racing or erratic heart rhythm. “If something has markedly changed during exercise, you should go to your doctor to investigate potential heart problems,” says Ballantyne. “You could be running marathons or triathlons and doing vigorous activity and can still have significant coronary disease.” For active men over 40 or women over 50, Ballantyne recommends the carotid IMT for its convenience and accuracy — it’s not only a preventive measure against heart attack or stroke for those predisposed to cardiovascular disease, but also a boon for early detection in otherwise healthy individuals. n

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ASSESSING YOUR RISK WITH CAROTID ULTRASOUND

SCREENINGS AND TESTS

PREVENTION

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“There are three ways to tell if further testing is needed: symptoms, family history or an abnormality.”

Leading Medicine • Volume 7, Number 1

High school basketball center Adam Ward, pictured with physical therapist Jennifer Fedee, is using the arm bike to warm up his arm, chest and upper back muscles.

the sidelines,” says Lintner, who is also the head physician for the Houston Astros and a team physician for the Houston Texans. “It gives them peace of mind to know that if their child is hurt that they are going to receive top-notch medical care immediately.” After the Friday night lights go dim, Methodist opens its clinic doors on Saturday morning in Baytown, Willowbrook, Sugar Land and West Houston, to give players an opportunity to have their injury evaluated by a specialist without having to wait until Monday. Orthopedic surgeon Dr. David Lintner examines a student at Methodist’s annual preparticipation student physicals event at Reliant Stadium.

GOING THE EXTRA MILE METHODIST WORKS OVERTIME to ENSURE THE SAFETY of HIGH SCHOOL ATHLETES By George Kovacik

t’s Saturday morning and hundreds of high school kids and their coaches are piling onto school buses. This time, their destination is Reliant Stadium. No, they will not be playing in the state finals or working out with the Houston Texans, they will be doing something much more important. They will be getting a preparticipation physical.

For the past five years, The Methodist Hospital System has sponsored a “one-stop shop” for youth extracurricular preparticipation physicals. Every May, doctors in internal medicine; pediatrics; ear, nose and throat; cardiology; neurology; and orthopedic surgery; as well as nurses, fellows, physical therapists and athletic trainers; give their time to make sure more than a thousand kids are healthy enough to participate in school activities.

“In 2009, Texas led the nation in the number of uninsured children. For many, this event serves as the only time they will see a doctor,” explains Dr. David Lintner, an orthopedic surgeon with the Methodist Center for Sports Medicine at The Methodist Hospital and the medical director of the event. “This gives us the chance to fi nd problems that have gone undetected in the past and prevent a possible catastrophic health issue.”

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Doctors and nurses line the concourse around Reliant, checking height, weight, blood pressure, vision, joints, etc., as well as the heart and the brain. What sets this event apart from others is that if a serious heart problem or a history of head trauma or concussion is detected, the athlete will see a specialist from the Methodist DeBakey Heart & Vascular Center or the Methodist Concussion Center on site. “We recently detected a previously unrecognized heart condition in a young girl that placed her at risk for sudden death on the playing field,” says Dr. Patrick McCulloch, an orthopedic surgeon with the Methodist Center for Sports Medicine at The Methodist Hospital. “She was treated and is doing well. Needless to say, she and her parents are grateful.” COVERING THE AREA The Methodist Center for Sports Medicine consults with nearly 175 high schools throughout Houston and the surrounding communities, and works closely with 50. “This means an athletic trainer goes out for weekly visits to evaluate injuries, expedites the specialty care that is needed within 24 hours, and educates players and coaches about things like concussions and safe play,” says Bobby Kinsley, manager of athletic training services with the

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Methodist Center for Sports Medicine. “Physicians will also spend weekend nights during the football season on the sidelines of many high school games.” The Methodist Hospital began its mass community physicals for high school students in 2010, and over the past few years, they have proven so successful that the practice has spread to other Methodist hospitals around the area. Methodist Willowbrook Hospital hosted its first series of screenings this summer, one day each in May, June and August, and saw approximately 300 student athletes. In Fort Bend County, Methodist Sugar Land Hospital also hosted its first community-wide screening for students last August at the new Constellation Field. “I enjoy being on the sidelines for high school games because high school athletics is the purest form of amateur sports, and I can just practice sports medicine,” says Dr. Timothy Sitter, an orthopedic surgeon with the Methodist Center for Sports Medicine in Sugar Land. “I think it’s important to have a physician and an athletic trainer on the sidelines because it provides an extra level of expertise in assessing an injury.”

“An athlete can get an MRI and CT scan or concussion test if necessary. We have the ability to read them on site and can quickly formulate a plan to get them back on the field as soon as possible,” Kinsley emphasizes. “Parents don’t have to miss work and the kids don’t have to miss school.” LEADERS IN THE FIELD Doctors at the Methodist Center for Sports Medicine are all board-certified in sports medicine and take care of the Houston Texans, Houston Astros and Houston Dynamo, as well as Rice Athletics, University of Houston, Houston Ballet and Rodeo Houston. The center is also partnering with CES Performance and the Houston Dynamo on a new training facility at Houston Amateur Sports Park that will feature state-of-the-art therapeutic technology to better treat and train an athlete during the different levels of care. “Taking care of professional athletes is rewarding, but it is really great that we have the type of institution that goes the extra mile for student athletes as well,” McCulloch says. “It’s great for us to be able to give back to a community that has always supported us.” n To learn more or to schedule an appointment with a specialist, visit methodistorthopedics.com.

“Parents I have spoken with like the fact that doctors and athletic trainers are on

High school basketball center Adam Ward, pictured with physical therapist Jennifer Fedee, is using the arm bike to warm up his arm, chest and upper back muscles.

GOING THE EXTRA MILE METHODIST WORKS OVERTIME to ENSURE THE SAFETY of HIGH SCHOOL ATHLETES By George Kovacik

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“Parents I have spoken with like the fact that doctors and athletic trainers are on

FEATURE STORY

NEW

s the quarterback throws the ball, two young football players eager to impress a college scout go for it, colliding helmet-to-helmet with a thud felt by every parent and fan in the stands. One of the receivers is slow to rise and is helped to the sideline; he doesn’t return to the game. It’s a scenario played out every week on ﬁelds across the country, and it underscores the toll concussion takes on young athletes.

APPROACHES

Concussion was once considered a relatively minor risk of playing sports. Today, however, doctors, parents, coaches and players are developing a new understanding of the long-term risks of concussion and other forms of brain injury — including the chronic traumatic encephalopathy (CTE) seen in some retired professional athletes — and are working together to identify and properly treat it when it occurs. The Methodist Concussion Center is playing a leading role — not only in providing care to patients who have suffered concussion, but also in working to help parents, coaches and players understand concussion, diagnose it and treat it appropriately.

HAVING AN IMPACT ON

CONCUSSION

This effort is aided by new understanding of the nature and risk of concussion. In years past, a football player with concussion might sit out a play or two, or a soccer coach might make a temporary substitution, but then the player would typically return to the field. Neuropsychologist Dr. Kenneth Podell, co-director of the Methodist Concussion Center, has been studying concussion for more than 20 years, and he remembers this situation well.

by andrew nelson

A CULTURAL CHALLENGE “When we fi rst started beating the drum about this, nobody would listen,” says Podell. “These were pros and college athletes that could care less, because it wasn’t in their mindset. They were never taught about concussion being an injury — they were taught the exact opposite: It’s nothing, it’s a dinger, you go back in and continue playing.” These decisions — by players, coaches and even sideline physicians — were partly rooted in the culture of sports. Players are conditioned to make light of injury, playing through pain and not letting teammates down. Houston Texans quarterback Matt Schaub — himself a high-profi le concussion victim and an ambassador for the Methodist Concussion Center — understands that feeling.

Houston Texans quarterback Matt Schaub

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Leading Medicine • Volume 7, Number 1

FEATURE STORY

NEW

APPROACHES

HAVING AN IMPACT ON

CONCUSSION

by andrew nelson

Houston Texans quarterback Matt Schaub

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Leading Medicine • Volume 7, Number 1

These decisions — by players, coaches and even sideline physicians — were partly rooted in the culture of sports. Players are conditioned to make light of injury, playing through pain and not letting teammates down. Schaub suffered a concussion in a 2007 game against the San Diego Chargers. Initially, says Schaub, he contested the decision to remove him from the game. “I wanted to be back out there with my team and play through it. But the doctors and coaches felt it wasn’t a smart decision, given my symptoms and the tests that they did.” Ultimately, Schaub would sit out the following week’s game, returning to play only when cleared to do so by the team’s doctors. “We had to be smart to make sure that all of the symptoms were clear before going out there,” explains Schaub. “I wanted to be out there, but ultimately it was the smart decision.” UNDERSTANDING CONCUSSION Concussion is often described as a “mild traumatic brain injury,” or MTBI. Dr. Howard Derman, a neurologist and co-director of the Methodist Concussion Center and associate professor of neurology at Weill Cornell Medical College, uses a simple analogy — a rubber ball in a cardboard box — to describe the basic mechanism of an impact concussion. “The brain sits in a vault of bone, covered by bone on all sides,” explains Derman, a team neurologist for Rodeo Houston. “[The brain] would be a rubber ball, and the cardboard box is like the skull. When the brain suffers a concussion, different parts of the brain hit up against the skull — just like different parts of the rubber ball hit up against the box.” Concussion can be caused by direct impact to the head, by an impact to or sudden movement of the body — as in an automobile accident, when the brain’s contact with the skull is actually the result of the body’s violent motion — or even through an abrupt rotation of the head.

“If you twist the brain fast enough and in a certain number of degrees,” explains Podell, “that causes a significant strain on certain parts of the brain — and that itself can induce a concussion.” The symptoms of concussion can vary a great deal, depending on the mechanism and severity of the initial injury. In general, however, concussion produces symptoms categorized into four basic groups. Physiological symptoms can include headache, sensitivity to light (photophobia), sensitivity to sound, dizziness and balance problems. Concussion can also cause emotional symptoms, such as feeling irritable, sad, depressed or anxious. Sleep can be disrupted, with some concussion sufferers sleeping too much, and others sleeping too little. Unusual fatigue is another symptom. And cognitive difficulties are another hallmark of the injury, with concussed individuals often feeling “slow” or having difficulty concentrating or remembering. The exact way in which concussion causes these symptoms isn’t completely

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OF CONC USSIONS G O U N R E CO G N I Z E D.

understood, though the nature of the impact is thought to play a role. “Different parts of the brain do different things,” explains Derman. “The back of the brain is responsible for vision, the front of the brain is responsible for memory, the sides of the brain are responsible for balance. So depending on which parts of the brain suffer the biggest insult would sort of dictate what symptoms the patient has.” CONCUSSION TREATMENT Schaub’s week off the playing field after his 2007 concussion is a good example of the accepted treatment for concussion injury. “‘Rest is best’ is still the motto,” says Podell, a team neuropsychologist for Rodeo Houston. Dr. Scott Rand, a primary care sports medicine specialist at Methodist Willowbrook Hospital and a physician for numerous high school and college programs in the Houston area, succinctly describes the importance of postconcussion rest. “The phrase I use for the parents and the athletes is that things that push more blood to the brain — like exercise — or things that require more blood in the brain — like homework, texting, video games, Batman movies, and arguing with your girlfriend — all cause your brain to require more blood and can make you symptomatic longer,” he says. Waiting until concussion symptoms have completely resolved before resuming activity is of primary importance. “The biggest concern with concussion today is truly not necessarily with the concussion that we’re dealing with, but with sure indication that the patient recovers completely before he or she could have a second concussion,” explains Derman. “We feel that if we can let the brain recover completely, the likelihood of their having longterm [complications] is much less.”

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A SURGE IN PUBLIC AWARENESS OF THE RISKS OF CONCUSSION ON AND OFF THE PLAYING FIELD HAS BEEN AN IMPORTANT PART OF CHANGING THE CONVERSATION AROUND CONCUSSION.

Methodist Concussion Center co-directors, Dr. Kenneth Podell (left) and Dr. Howard Derman (right), work with Houston Texans quarterback and concussion center ambassador Matt Schaub (center) to support the center’s mission to help parents, coaches and players understand, diagnose and treat concussion. GROWING PUBLIC AWARENESS A surge in public awareness of the risks of concussion on and off the playing field has been an important part of changing the conversation around this minor traumatic brain injury. New medical recommendations require a player who has suffered a concussion to cease play for the day; laws such as “Natasha’s Law” in Texas make concussion awareness training mandatory for public school coaches; and parents are taking a more active role in ensuring that their children’s athletic activity doesn’t put them at increased risk of complications later in life. “I’ve seen a phenomenal swing of the pendulum,” says Podell. “What I’ve started to see is that young kids over the years have been told that concussion is an injury, it’s serious, you’ve got to be careful about it. And they’re used to getting baseline testing for concussion, they’re used to being pulled from competition when they were kids. And if you’ve had that mindset since you were playing Pop Warner football or high school football, it stays with you.” In the greater Houston area, the Methodist Concussion Center is the epicenter of an ongoing outreach and educational program to teach coaches, parents, youth and adult athletes, and even the general public, to understand and recognize the

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symptoms and risks of concussion, and accept the importance of treating it not as just a “ding,” but rather as a serious injury requiring careful medical care. Methodist physicians are actively involved in conducting awareness training for school and league coaches. The Methodist Concussion Center provides, at nominal cost, preseason ImPACT (Immediate Postconcussion Assessment and Cognitive Testing) tests for athletes — providing a baseline assessment that can be used for reference if a concussion should occur. And the concussion center hosts and sponsors public and media events aimed at raising general awareness of concussion, its treatment and its risks. As the official spokesman for the Methodist Concussion Center, Schaub has seen the work firsthand, through The Methodist Hospital System’s role as official health care provider for the Houston Texans. But he feels its benefit extends well beyond the professional playing field. “It helps the general public and the community [to] offer a place where they can go and they can get the knowledge and the resources to help them,” he explains. “So many [concussions] are being had, through automobile accidents, through youth sports and through normal kids playing out in the backyard. But they’re

often overlooked because parents, teachers and coaches don’t know how to properly diagnose them. “Ultimately, with the kids, you have to protect them and watch over them,” Schaub says. “As parents or high school or youth league coaches — being able to recognize these things can help a lot of these kids out.” Schaub’s participation has been an important part of outreach efforts at the Methodist Concussion Center, and for good reason: young athletes look up to their idols in the professional ranks. Fortunately, public awareness seems to be closely tracking increased understanding at the professional level. Podell, who has worked as a consultant to numerous professional sports teams, has seen it firsthand. “I’ve seen some pros in the last year or two who are telling me, ‘I still don’t feel quite right; I’m close, but I don’t want to risk it — I’ve got my little girl to worry about,’” he says. “The mind shift is there.” n To learn more or to find a specialist, visit methodistneuroinstitute.com or call 713-790-3333.

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A SURGE IN PUBLIC AWARENESS OF THE RISKS OF CONCUSSION ON AND OFF THE PLAYING FIELD HAS BEEN AN IMPORTANT PART OF CHANGING THE CONVERSATION AROUND CONCUSSION.

Leading Medicine • Volume 7, Number 1

When Injury Means

A NEW BEGINNING BY PAT T I M UC K

Patti Muck, long-distance runner

bright and bold sun glinted off the Atlantic Ocean as hundreds of barelegged, cold runners lined up for the Kiawah Island Marathon on Saturday, December 12, 2009. With temperatures in the upper 30s, cold and dry, it was a perfect day to run 26.2 miles. This would be my 61st marathon, and South Carolina would be the 16th state in my bid to run marathons in all 50 states.

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Leading Medicine • Volume 7, Number 1

When Injury Means

A NEW BEGINNING BY PAT T I M UC K

Patti Muck, long-distance runner

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Leading Medicine • Volume 7, Number 1

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“The rehab center itself was a place of inspiration, where I watched others of all ages and abilities work hard and improve. Holland encouraged me to work on my own in a swimming pool, where treading water — sometimes for hours at a time — helped me regain mobility.”

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Dr. Kevin Varner During the marathon, the deal-breaker came at mile 10. Like an old-style telephone cord being stretched taut then released, I felt something in my right inside ankle snap and go all loose and wobbly. Intense pain followed every movement for the next 16.2 miles. I finished the marathon, but I was in big trouble.

seen in overweight women over 50. The transfer surgery is complex, and more people live with the problem than choose surgery. While the condition can be treated with medication, orthotics and physical therapy, a dysfunctional tendon would not allow long-distance running and certainly not marathons.

RUNNING IS MY LIFE

“Have you ever performed this surgery on a runner who was able to return to marathon running?” I asked. “No,” Varner responded, looking me straight in the eye and saying nothing more.

For more than 12 years, running defined my life. It gave me structure, discipline and purpose. Waking up at 4 a.m. on a Sunday was not unusual if I wanted to get in a 20-miler before it got too hot outside. Recording the miles, the marathons, the shorter races — it was all part of the routine to keep me healthy, on balance and in tune with myself. I wasn’t happy if I didn’t get my run in for the day.

He always likes to leave a bit of hope for the patient, no matter what Varner believes the outcome may be. With work and perseverance, a patient could conceivably work back to the place they were before the injury.

My family came with me as we traveled to races around Texas. They cheered me along the route of the Houston Marathon every year. As my kids got older, they stopped asking if I won. And, as I got older, I slowed down a lot. Since I was never that fast to begin with, it didn’t matter. Running always provided new challenges and goals.

So his one-word answer was the best thing I’d heard in weeks. In that ‘no,’ I heard possibility. Varner then explained the 10-month recovery period and the intense physical therapy that would follow surgery. By doing so, Varner gave control back to me. This was something I could tackle with discipline and training.

Now, here I was in Kiawah Island using my 80-year-old aunt’s cane and crawling up the stairs butt first.

Varner would do his part and use a toe tendon to replace my broken tendon; then he would realign the heel to provide the support needed to walk and run normally. He would start me out with the physical therapy team as soon as the cast came off. The rest was going to be up to me. Varner provided the hope I needed to schedule the FDL (flexor digitorum longus) transfer surgery.

THE DIAGNOSIS Back in Texas, a quick X-ray showed nothing was broken, but the results of a follow-up MRI brought devastating news: I had a posterior tibialis tendon near-rupture, and surgery was the only solution. The first doctor told me, “Forget about running the Houston Marathon in two weeks, and your Florida marathon in February is a no-go as well.” By the time of my appointment with orthopedic surgeon Dr. Kevin Varner at The Methodist Hospital, I was fighting depression, gaining weight and feeling pretty sure I wasn’t going to get good news. A ruptured tendon never heals on its own, and without drastic action I would never run again. REGAINING CONTROL One look at the MRI and Varner said the entire tendon was degenerative. He recommended a tendon transfer and accompanying heel realignment. It was not a running injury, he told me, but an ongoing degenerative process most commonly

LEARNING TO RUN AGAIN Nearly four months after my Kiawah Island disaster, I was in the operating room. Varner made a two- to three-inch incision on the inside of my right ankle. He took the shorter FDL — the tendon that moves the four smallest toes — and grafted it to the diseased tendon. An osteotomy was done to help relieve the load of this new tendon. Frankly, this part of the surgery was scarier than the tendon transfer. The heel was cut, moved and then two screws were inserted to hold the bones in place. Without this critical bone work, the tendon transfer alone probably would not have been enough to allow a return to distance running. I went back to work two days after surgery, using a wheelchair and then crutches. My family cooked meals, carted me around,

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and generally encouraged me to think ahead. “You will run again,” my daughter texted from college. My longtime running friends sent cards and promised to see me on the trails soon. The encouragement got me through six long weeks in a cast. The minute it came off, Varner referred me to Matt Holland, manager of physical therapy and occupational therapy at the Methodist Center for Sports Medicine. “The physical therapy part is as important as the surgery,” Varner told me. Holland and his crew were not sickened by the purplish blob that was now my ankle. They massaged it and worked it; they taught me exercises and slowly eased me into a routine I could do on my own. The rehab center itself was a place of inspiration, where I watched others of all ages and abilities work hard and improve. Holland encouraged me to work on my own in a swimming pool, where treading water — sometimes for hours at a time — helped me regain mobility. He urged steady and steadfast repetition with stretch bands to move the ankle, calf, toes and foot. Twice a week, all summer, Holland and his team iced my ankle and patiently watched and encouraged me as I progressed from picking up marbles with my toes to pedaling a stationary bicycle. After 18 rehab sessions, I was discharged to continue recovery on my own. A follow-up with Varner in September showed the heel was mended and the screws were firmly in place and would not bother me. He told me I could start running, a quarter mile at a time, with no more than a 10 percent build-up per week. My training log for the week of September 6–12, 2010, reads “21st Recovery Week — 1st Week Return to Running.” LOVING EVERY STEP On January 15, 2012, I lined up to run my 13th Houston Marathon and my 62nd race of 26.2 miles or more. Four hours, 25 minutes and three seconds later, I crossed the finish line — a little teary-eyed and emotional because it was a long time coming. My ankle felt great. In fact, since the surgery, running has been a lot more fun and virtually pain-free. I enjoy every run. Every step is a victory. In October, my 21-year-old daughter ran her first marathon in Portland, Oregon. And I was on the finish line with her. n To learn more or to schedule an appointment with a specialist, visit methodistorthopedics.com.

Leading Medicine • Volume 7, Number 1

Foot & Ankle Care The ability to stand and move upright on two legs is central to human experience. The complex network of bones, tendons and tissue in the foot and ankle, as well as throughout the lower extremities, supports form and movement. But the stress of that support can also contribute to injury. Methodist specializes in the treatment of conditions and injuries of the foot, ankle and leg, including tibial fractures, sports-related injuries and trauma to the lower extremities. While our physicians treat professional teams and artists like the Houston Dynamo and Houston Ballet, their focus is treating patients of all ages and professions with the finest orthopedic care possible. Common conditions treated include, but are not limited to: • Achilles tendon rupture • Achilles tendon tendonitis • Ankle arthritis • Ankle injury and instability • Bunions • Cavus (high arch) foot • Deformities • Flat feet • Foot drop • Fractures • Hammertoes • Morton’s neuroma • Plantar fasciitis • Post-stroke ankle reconstruction • Rheumatoid arthritis • Tarsal tunnel syndrome To request a referral or to schedule an appointment, call 713-441-BONE (2663). n

i n

a d d i t i o n

RUNNING IS MY LIFE

“Have you ever performed this surgery on a runner who was able to return to marathon running?” I asked. “No,” Varner responded, looking me straight in the eye and saying nothing more.

Now, here I was in Kiawah Island using my 80-year-old aunt’s cane and crawling up the stairs butt first.

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Leading Medicine • Volume 7, Number 1

LONG ROAD HIGH BAR back to the

hris Brooks saw the blood-soaked bandage and thought all his hopes and dreams were gone.

“I looked at my father’s face when they started taking it off and he was pale. When I looked for myself and saw the size of the wound, I couldn’t believe how bad it was,” he says about seeing the wound for the fi rst time after surgery. Brooks’ dream of becoming a gymnast started at age 5. His dad, Larry, saw potential in his son and started teaching him the basics at home. When Chris began taking classes at age 6, he was way ahead of his peers. At age 17, in the spring of his junior year of high school, he was making a name for himself on a national level. He competed in the all-around, floor exercise, pommel horse, still rings, vault, parallel bars and high bar and was gearing up to attend the USA qualifying championships his senior year. “I was getting close to making the jump to the senior ranks on the U.S. National Team,” Brooks says. “I really felt like it was the year I was going to push some of the senior guys for a spot on the team.” During training in March 2004, Brooks was performing a routine release move on the high bar where the gymnast jumps from the bar to catch it again. When Brooks tried to do this, the grip he was wearing got caught and caused his right hand to lock in place while his body kept moving forward. The bones breaking in his right arm sounded like a shotgun going off in his ear. He was taken to the emergency room at Methodist Willowbrook Hospital where they set both bones. Brooks believed he would be in a cast for four to six weeks, after which he’d be good as new. The next day he went to see Methodist orthopedic surgeon and hand and upper extremity specialist Dr. Korsh Jafarnia.

by g eorg e kovac i k

“He had a lot of swelling and we determined pretty quickly that he had developed compartment syndrome,” Jafarnia recalls. “So we took him to the operating room immediately.”

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Leading Medicine • Volume 7, Number 1

LONG ROAD HIGH BAR back to the

hris Brooks saw the blood-soaked bandage and thought all his hopes and dreams were gone.

by g eorg e kovac i k

“He had a lot of swelling and we determined pretty quickly that he had developed compartment syndrome,” Jafarnia recalls. “So we took him to the operating room immediately.”

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Leading Medicine • Volume 7, Number 1

“Chris’ level of commitment was phenomenal and that helped him make great strides very quickly.”

Compartment syndrome results from an increase in pressure in the muscle compartment. If this pressure is not released in a timely manner, it can cut off circulation and cause muscle and nerve damage, and in some cases, require amputation. “Had the Methodist ER not set the fracture, compartment syndrome would have occurred much sooner and been much more devastating and resistant to treatment. But still, this injury was bad, at least 9.9 out of 10. We knew time was of the essence in order to save his arm,” says Jafarnia. “We had to make big incisions in his skin to release the pressure, and we used two plates and 12 screws to fix the fractures.”

pretty aggressive treatment regimen. We allowed him to do more things than the average patient,” Hannahs says. “Chris’ level of commitment was phenomenal and that helped him make great strides very quickly.” Although he was committed, rehabilitation was not easy. Brooks required four more surgeries, including a flap procedure to fix his skin. Once he was strong

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“If a thousand people have this injury, maybe one of them would have the result Chris has had,” explains Jafarnia. “His passion, determination and sheer will to compete fueled our passion as doctors and specialists to help him get to where he wanted to be.”

Dr. Korsh Jafarnia enough, he got back on the high bar. He describes the first time he put on the grips and swung as “frightening.”

Brooks began intensive therapy treatment with Gail Hannahs, supervisor of sports medicine rehabilitation at Methodist Willowbrook. Hannahs says her first job with patients is to get them to believe things will get better — then she works on the physical part of the rehab assignment.

After enduring a two-year recovery process, he entered the University of Oklahoma, experienced his first year of uninterrupted training since his injury and took top honors in high bar at the U.S. Championships.

“Because we knew he wanted to get back to competition, we began a

“I remember standing on the podium thinking to myself, I just won first place in

Leading Medicine • Volume 7, Number 1

Brooks worked through the pain by training and working hard toward his goal of making the U.S. Olympic Men’s Gymnastics team. Early in 2012, he was named an alternate. “When I heard my name called, it was such a relief. I had finally made it all the way back,” Brooks says. “I owe a lot to Dr. Jafarnia, Gail and everyone else who helped in my rehab. They knew what I wanted to do and they jumped through hoops to get me there.”

After the surgery, Jafarnia had the difficult task of telling Chris and his family that his days as a competitive gymnast were probably over. “He came in and broke the news to us, and then gave my dad and me a few minutes,” Brooks says. “My dad basically said there was nothing we could do about the injury and that I could either sit around and cry about it or do something about it. I’m not a quitter, so I decided to go for it.”

the competition that almost destroyed me,” Brooks says. “Winning, after being told I might never compete again, was amazing and I knew my future was bright.”

What would his father think about him being named an alternate on the U.S. Olympic Men’s Gymnastics team? “He would have been pretty pumped,” Brooks replies, “because he always told me I could do it.” n To learn more or to schedule an appointment with a specialist, visit methodistorthopedics.com.

“Chris’ level of commitment was phenomenal and that helped him make great strides very quickly.”

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Dr. Korsh Jafarnia enough, he got back on the high bar. He describes the first time he put on the grips and swung as “frightening.”

“Because we knew he wanted to get back to competition, we began a

“I remember standing on the podium thinking to myself, I just won first place in

Leading Medicine • Volume 7, Number 1

the competition that almost destroyed me,” Brooks says. “Winning, after being told I might never compete again, was amazing and I knew my future was bright.”

MEET THE TEAM of ORTHOPEDIC SURGEONS and SPORTS MEDICINE SPECIALISTS at the METHODIST CENTER for SPORTS MEDICINE.

As the ofﬁcial health care provider for the Houston Texans, Houston Dynamo, Houston Astros, Houston Ballet, Rice Athletics and Rodeo Houston, our team of dedicated specialists leads the nation in outstanding patient care for both professional and amateur athletes. This is our ﬁeld.

FROM LEFT TO RIGHT: Drs. Vijay Jotwani, Scott Rand, Kaare Kolstad, Patrick McCulloch, Bruce Moseley, David Lintner, Timothy Sitter, Winﬁeld Campbell, David Braunreiter, Gregory Seelhoefer, Kenneth Renney, William Bryan, Christian Schupp, Leland Winston and Mark Maffet Texas Medical Center® • Baytown • Clear Lake • Greenway Plaza • HASP • Pearland • Sugar Land • West Houston • Willowbrook For a physician referral or appointment, call 713-790-3333 or visit methodistorthopedics.com.

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Leading Medicine • Volume 7, Number 1

MEET THE TEAM of ORTHOPEDIC SURGEONS and SPORTS MEDICINE SPECIALISTS at the METHODIST CENTER for SPORTS MEDICINE.

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Leading Medicine • Volume 7, Number 1

ACTIVE BODY CARE

FROM HEAD TO TOE

PRIMARY CARE SPORTS MEDICINE BY J U L I A N NA A R N I M

Victoria Korenek, now a freshman at Clear Falls High School, sustained a severe concussion during a club soccer game in March 2012. Dr. David Braunreiter, a sports medicine specialist at Methodist Sugar Land Hospital and team physician for Rodeo Houston, happened to be in attendance at the game that day, and subsequently treated Victoria for her injuries. Healed and healthy, she looks forward to a new season.

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thletes are just like the rest of us; when they get sick, they need a family doctor. They need physical exams, flu shots and treatments for conditions like asthma, diabetes or a heart murmur. But active individuals — from pro athletes to weekend warriors — also require care to treat the aches, pains and injuries associated with sport and robust activity. Dr. David Braunreiter In the past, caring for an active body usually meant having a primary care doctor and an orthopedist, but primary care sports medicine offers both types of care in a single physician. Primary care sports medicine has been an established practice for more than two decades, focused on giving holistic care to active individuals. From physicals and checkups to sinus infections and musculoskeletal injuries, these specialists provide the complete care of family medicine with a focus in sports medicine. Methodist offers a unique fellowship program for physicians seeking this specialization after completing a residency in family medicine, internal medicine, emergency medicine or pediatrics. “Active people need someone to keep them healthy and to fi x them up when they injure themselves,” says Dr. Scott Rand, a primary care sports medicine physician at Methodist Willowbrook Hospital and director of the sports medicine fellowship at Methodist. While musculoskeletal medicine is not always emphasized in family practice, “We are not limited by shoulders, knees or spines,” contends Rand, a team physician for Rodeo Houston. The one-year fellowship focuses on learning to manage musculoskeletal overuse or trauma, and physicians spend 36 weeks with orthopedic surgeons to better understand surgical and nonsurgical treatments and procedures for orthopedic injury. The remaining fellowship rotations are spent working with radiology and imaging specialists, physical therapists and rehabilitation medicine, concussion management, and specialized electives on areas such as

Leading Medicine • Volume 7, Number 1

hand, foot, neurology, spine and other focused treatment areas. Every week also has specific times dedicated to practicing clinical skills in the Denver Harbor clinic and performing research that fellows will present at the annual American Medical Society for Sports Medicine conference. “Active individuals don’t like to seek care just anywhere; primary care sports medicine physicians care for the whole person actively,” says Dr. David Braunreiter, a sports medicine specialist with the Methodist Center for Sports Medicine in Sugar Land. Knowing the ins and outs of fractures, sprains, strains and stress injuries equips these doctors to treat active people and athletes in the office or on the sidelines — for everything from managing asthma to coping with emotional stress. “It’s like getting the whole picture in a single physician,” says Braunreiter. The Methodist fellowship in primary care sports medicine has been established at Methodist Willowbrook Hospital and Methodist Sugar Land Hospital, which work collaboratively to promote total care for active people in Houston and the surrounding communities. There’s a powerful new team in town — you and your doctor. Whether you train for marathons, play in a sports league or simply lead an active lifestyle, your health needs can now be treated by a single specialist. n To learn more or to schedule an appointment with a specialist, visit methodistorthopedics.com.

ACTIVE BODY CARE

FROM HEAD TO TOE

PRIMARY CARE SPORTS MEDICINE BY J U L I A N NA A R N I M

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Leading Medicine • Volume 7, Number 1

GREAT EX PECTATIONS TOTAL JOINT REPLACEMENT in YOUNGER PATIENTS By Andrew Nelson

total joint replacement patient was once an older individual, suffering severe pain from arthritis and in search of solutions that could return them to comfort and a level of moderate function. Opting for this surgery late in life tended to reduce the likelihood of having to perform a repair or a second replacement. But in recent years, the number of younger patients choosing to have total joint replacement has sharply increased. Hip replacement statistics from the American Academy of Orthopedic Surgeons provide a representative example: in 1998, patients aged 45 to 64 made up just 27 percent of the total number of hip replacements performed. But by 2008, this number had risen to 40 percent. Orthopedic surgeons at Methodist have seen this shift fi rsthand. There are several reasons why. DIFFERENT LIFE EXPECTATIONS One factor is that today’s younger joint replacement patients are simply more active than those of years past — and they’re less likely to be satisfied with a lifestyle of significantly reduced physical ability. Faced with significant pain from a damaged or deteriorated joint, many of these younger, active patients are actively investigating joint replacement as an option — seeing it as a way to continue with the physical activities that are an important part of their lifestyles. “I’ll see people, and their entire social network is around tennis,” says Dr. Kenneth B. Mathis, an orthopedic surgeon at The Methodist Hospital and associate professor of clinical orthopedic surgery at Weill Cornell Medical College. “It’s what gives them pleasure in life. [And] if it’s really

Debby Dreyfus leads a spin class after her hip replacement surgery.

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Leading Medicine • Volume 7, Number 1

important to them, isn’t that why we’re doing the joint replacement? Number one is to get rid of pain, but also to improve their quality of life.”

much more active, and high school and college sports have become much more prominent than they were one or two generations ago — especially for women.”

Debby Dreyfus, 53, is a good example of a patient whose experience with joint replacement happened much earlier than expected. X-rays taken after a car accident revealed that her hip was degenerating. For more than a decade after this diagnosis, she continued her highly athletic lifestyle, including specific exercises designed to strengthen supporting muscles around her hip.

Overuse injuries from running and racquet sports; arthritis secondary to past surgical repairs to ligaments in the knee; and complications from incomplete healing of old injuries on the playing field or the ski slopes are all leading relatively young patients to discuss joint replacement options with their surgeons.

It worked for a time. “The symptoms would come and go,” explains Dreyfus. “I was always working out at some level, and changing my workout as my pain increased over time.” Eventually, however, the pain of the deteriorating joint became a significant problem. “I would go to the gym and work out in the morning,” she says. “Then what I could do, over time, was come home and be a couch potato — I was basically not very mobile for the rest of the day. And I’m a very active person. When you basically can’t walk short distances because it becomes too painful, then it’s defi nitely time to make a change.” The change was a total replacement of Dreyfus’s hip joint performed by Mathis, a team physician for Rodeo Houston. MORE WEAR AND TEAR The original damage to Dreyfus’s hip was most likely the result of an injury during childhood. Many other younger patients are presenting with cumulative damage from a lifetime of sports and exercise. “People are wearing out their joints more quickly,” says Dr. Stephen Incavo, professor of clinical orthopedic surgery at Weill Cornell Medical College and section chief of adult reconstructive surgery at the Methodist Center for Orthopedic Surgery. “People are generally

Houston Texans defensive line coach Bill Kollar, now 60, played professional football with the Cincinnati Bengals and the Tampa Bay Buccaneers for eight seasons — until a knee injury ended his playing career. “Back when I was playing, I injured it, tore the ACL (anterior cruciate ligament),” says Kollar. “They didn’t repair the ACL — I was done playing. So they decided to just let it go, try to strengthen it up. And I’d already had cartilage that was taken out,” says Kollar. Injuries like these have lasting effects. “If you injure your ACL, or tear your meniscus or another knee ligament when you’re young, that at some level is the beginning of damage to your knee joint,” says Incavo. “Although it may take many, many years to develop, it really predisposes you to have arthritis of your knee later in life. The same goes if you have a fracture of bones around the joint.” Over time, Kollar’s injured knee began to have a negative impact on his comfort and his physical activities. “My knee just kept getting worse — it was down to bone-on-bone,” Kollar says. “They said, ‘sooner or later you’re going to end up getting a replacement,’ because it was bothering me quite a bit.” After he moved to Houston, Kollar fi nally elected to have the knee replaced.

GREAT EX PECTATIONS TOTAL JOINT REPLACEMENT in YOUNGER PATIENTS By Andrew Nelson

Debby Dreyfus leads a spin class after her hip replacement surgery.

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Leading Medicine • Volume 7, Number 1

important to them, isn’t that why we’re doing the joint replacement? Number one is to get rid of pain, but also to improve their quality of life.”

much more active, and high school and college sports have become much more prominent than they were one or two generations ago — especially for women.”

T H E BIOM EC H A N IC A L GE N DE R G A P

He’s been happy with the results. “I was through jogging 10 years ago. But I still walk, do stairs, use the treadmill, and go out and walk — because I still like to work out. It obviously took a lot of pain away, and I really walk now without a limp.”

SURGICAL IMPROVEMENTS Joint replacement surgery was once a highly invasive process. Improvements in surgical methods and tools, however, have made the surgical process more minimally invasive than conventional surgery.

BETTER APPLIANCES The improving quality of the prosthetic joints themselves is another reason for the increased number of joint replacements in younger patients. Simply put, the joints are less likely to need early repair or replacement — even when the initial surgery is performed on a relatively young patient.

“The surgery has defi nitely become more refi ned; although, the general concepts are still the same,” Incavo points out. “You expose the joint, you take out and repair the damaged areas, then reconstruct it with the replacement parts — we just do it in a much more sophisticated manner; the surgical approach is much less invasive than it used to be.”

A particular advancement has come in the plastics used on the weight-bearing surfaces of prosthetic joints. Today’s standard is a very dense high-molecular-weight crosslinked polyethylene — strengthened during manufacturing through the application of focused doses of radiation. These innovations are the result of close collaboration between surgeons and designers, and Methodist is one of only a few hospitals nationally to encourage and support such endeavors. Methodist surgeons have been instrumental in the development and use of 25 hip and knee replacement procedures, three generations of hip replacement devices and more than 20 hip implant projects. Seventeen percent of all hip and knee replacement and revision surgeries in Houston — and five percent of those in Texas — are performed at Methodist, more than at any other hospital in Texas.

Dreyfus started with walking. “The minute I got back from the hospital, I got up and went up and down my block several times a day,” she says. “I started getting back on the bike at the gym about three weeks after surgery, and I increased my workout every day by five minutes.” RETURNING TO ACTIVITY The trend toward joint replacement in younger patients reflects differing expectations, better appliances and better surgeries. Given demographic and lifestyle trends, the shift shows little sign of tapering off.

“I’ve been here at Methodist 22 years, and there have been dramatic improvements in the materials,” says Mathis. “We have better ability to fi x the implants to the bone, so they don’t come loose. And we have much better materials that have dramatically lowered wear. So we have greater expectations that I can put a hip or a knee in a younger patient, and it lasts longer than if I’d done that 10 or 15 years ago.”

Dr. Kenneth Mathis

ACL INJURIES

and the smaller incisions that we’ve had, have led us to be able to do rehab much quicker,” adds Dr. Carl Hicks, an orthopedic surgeon at Methodist Sugar Land Hospital and chairman of Methodist Orthopedic Specialists of Texas. “People are up and moving and going again more quickly.”

Younger patients like Debby Dreyfus are putting their new joints to active use. In fact, she works several days a week as a personal trainer — leading spin classes and training clients in proper resistance training technique.

Another important development — and one that has helped to make joint replacement surgery more acceptable to many patients — is better pain management. “We’ve had dramatic improvement in pain, just in the last five to seven years,” says Mathis. “[With] the newer (pain) blocks that we’re doing, what’s called multimodal pain management, we’ve eliminated IV narcotics from the orthopedic joint replacement floor. We’ve got people all night, the next day, saying, ‘Hey, I’ve got no pain.’ With something that used to be incredibly painful. So that’s exciting.”

Dreyfus describes the results of her hip replacement surgery in simple terms. “I got my life back,” she says. “I can do, for the most part, anything I want to do. I’m not supposed to do yoga, and I’m not supposed to do anything high-impact. But I can adjust my workout to my personal needs.

These improvements in surgery have translated into speedier recoveries as well. “The pain management we’ve had,

To learn more or to schedule an appointment with a specialist, visit methodistorthopedics.com.

“And having looked at when I did [the hip replacement] versus how many years I let pass, had I known how much better I would have felt — how I feel now, after the surgery — I probably should have done it earlier than I did!” n

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I N F EM A LE AT H LET ES BY J U L I A N NA A R N I M

he evidence is clear: more women injure their anterior cruciate ligaments (ACLs) than men. Elkins High School soccer player Lindsey Biggart can attest to that. This past spring, Lindsey ruptured her ACL during a game. Because of the extent of her injury, Dr. Timothy Sitter, an orthopedic surgeon and sports medicine specialist with the Methodist Center for Sports Medicine in Sugar Land, performed a surgical transplant on Lindsey with an ACL from a donor. “There’s no question that I see more women in my practice than men; it’s two to one,” says Sitter, a team physician for Rodeo Houston; Dulles, Elkins, Dr. Timothy Sitter Kempner and Travis high schools in Fort Bend ISD; Stafford High School in Stafford ISD; and also the designated orthopedic surgeon for the Houston Aeros and Rodeo Houston. More often than not, women enter sports training later in life than men, which gives them different skill sets, and their training is often structured differently as well. “Women’s training programs are less rigorous, but [women are] competing at the same level as men,” says Sitter, who believes training programs for women should be reevaluated. Plyometrics, or “jump training,” can be an effective way for women to train or warm up before a game, refining landing techniques while strengthening muscles and reducing the impact on the joints. In terms of prevention, being physically fit and prepared for the sports you play is obvious. ACL injuries are most common in directional-change

Leading Medicine • Volume 7, Number 1

sports such as volleyball, basketball and soccer, in which players pivot and jump. The ACL is a small ligament — part of a network of tissue that attaches the femur, or upper leg bone, to the tibia, or lower leg bone — that works behind the kneecap to help keep the knee and leg bones from rotating too far. However, in female athletes, it is often vulnerable to tears that require surgical repair and intensive physical therapy; the reasons why are unclear. “Once [the gender gap in ACL injury] was determined, a lot of research and work was put into figuring out why,” says Dr. Winfield Campbell, an orthopedic surgeon at Methodist West Houston Hospital, who is a team physician to Rice Athletics and Rodeo Houston. “The bad news is, we still don’t know, likely because it stemmed from multiple factors.” Studies show that women are anywhere from two to nine times more likely to injure their ACLs as men, and Campbell cites five potential reasons:

Since her ACL transplant surgery, Lindsey has recently been cleared to fully participate in her sport again. “It was a lot of work getting back,” she says, “but it feels amazing.” Her care team also kept her motivated. If she had advice to give others in her situations, she says it would be to “never give up. You have to work hard and trust your therapist, and push yourself to get back where you were.” Her mother, Michelle Biggart, says a crucial turning point in her daughter’s treatment occurred when Lindsey went in for her operation and Dr. Sitter discovered that the donor ACL was not a good fit for her. “The ACL just wasn’t right,” recounts Michelle, “and Dr. Sitter said, ‘I could’ve made it work, but I would not put it in my daughter’s leg, so I’m not going to put it in yours.’” n To learn more or to schedule an appointment with a specialist, visit methodistorthopedics.com.

• General leg alignment. Women have a greater “Q angle” in the kneecap than men, increasing the risk of knee injury. • Anatomical differences. The intercondylar notch, or space inside women’s knees to which the ACL attaches, is physically smaller and narrower than men’s. • Hormonal cycle. Studies have shown an increased risk for ACL tears during ovulation, possibly due to increased tissue laxity. • Biomechanics. Men and women have different landing techniques when they jump. Women tend to land straighter and turn the knee inward, which makes the ACL more vulnerable. • Differences in neuromuscular communication. Specific training can be an effective defense against natural neuromuscular disparities among men and women.

Elkins High School soccer player Lindsey Biggart

T H E BIOM EC H A N IC A L GE N DE R G A P

Dr. Kenneth Mathis

ACL INJURIES

These improvements in surgery have translated into speedier recoveries as well. “The pain management we’ve had,

To learn more or to schedule an appointment with a specialist, visit methodistorthopedics.com.

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I N F EM A LE AT H LET ES BY J U L I A N NA A R N I M

Leading Medicine • Volume 7, Number 1

Elkins High School soccer player Lindsey Biggart

IF YOU BUILD IT… houston ASTROS owner teams with METHODIST to apply lessons learned by de n n y a ng e ll e

A S A ST U DEN T-AT H LE T E I N COLLEGE , J I M C R A N E LE A R N ED SOM E SI M PLE BU T I M PORTA N T LESSONS ON T H E BA SE BALL F I ELD. NOW, 40 Y E A R S L AT ER , T H E SA M E LESSONS RESONAT E E V EN LOU DER I N A N A RENA T H AT H A S GOT T EN M UC H L A RGER .

im Crane just completed his rookie season as owner of the Houston Astros, which he purchased late in 2011 for more than $600 million. The Houston businessman has been successful in the freight and energy industries, but becoming an owner of a professional baseball team was the fulfi llment of a courtship that began on a diamond at what used to be Central Missouri State University. As a sophomore, young Crane pitched a shutout for the Mules in the 1974 NCAA World Series, striking out 11 batters in a row. The right-hander had a stellar season as a junior, but an injury stopped him in his senior year, when Crane fi nished his baseball career with a 21–8 record. “Baseball has had a big impact on me from the time I was little and for the better,” Crane said when he was announced as the Astros’ new owner in 2011. “It has helped me gain confidence and has taught me to work hard. I will use all those lessons moving forward with the Astros.”

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a gymnasium and a spinning area at his corporate headquarters and added healthy menu items to the cafeteria. Assuring employees’ health is certainly a good investment, Crane feels. “It’s always a win when you can help keep your people healthy and give them the time and opportunity to address health issues before they become big deals,” he says.

cessation and weight loss. It also offers a complete package of screenings for cholesterol, blood pressure, bone density and heart health, as well as immunizations for influenza and travel requirements. Methodist Wellness Services has worked with businesses for more than two decades, and many of its programs are successful because they’ve been tested and practiced in-house at Methodist.

“One of my executives didn’t catch his prostate cancer early, and it wound up costing him his life,” Crane continues. “After that, I made it mandatory that all of our executives get a physical every year.”

“Yes, we try everything out on our own workforce,” Hunnicutt says. “Everything we offer businesses has been developed with Methodist’s employees.”

He called upon Methodist to help build a culture of wellness throughout all of the Crane companies. Representatives from Methodist Wellness Services tailored programs to fit specific needs of employees and set health and wellness goals for the companies.

Programs for weight loss, healthy eating, exercise, smoking cessation and health screenings have certainly made a positive impact on Methodist’s employees. In 2010 and 2011, employees managed to reduce their health risks by five percent in consecutive years.

“I learned early on what keeps me healthy and helps me relax,” he explains. “And I continue to sponsor that [healthy mindset] in all the companies I work with.”

Michele Hunnicutt, director of Methodist Wellness Services, says that initial strategy is very important in building an environment that promotes and rewards healthy lifestyles.

“That’s a great selling point — we’ve managed to improve our employees’ health by 10 percent over two years,” says Hunnicutt. “So we turn these programs around and take them out to the market with a real record of success.”

He became acquainted with The Methodist Hospital System through its affi liation with the Houston Astros — Methodist is not only the team’s official health care provider, but also provides wellness services to team employees on and off the baseball field.

“We seek to create a change that makes a positive impact on people, but the biggest challenge is making those new habits stick over a long period of time,” Hunnicutt explains. “That’s why we seek to tailor each of our solutions to the particular company we are working with.”

Jim Crane is certainly sold on Methodist’s record. “We really solidified and expanded our work with Methodist when we bought the Astros,” he says. “We sought to use [Methodist’s] services in our other businesses because we believe in them.” n

Working with Methodist Wellness Services, Crane established a health program for executives and employees at all of his companies. He also built

The Methodist corporate wellness program can provide behavioral and educational programs in areas such as nutrition, fitness, stress management, smoking

To learn more about Methodist Wellness Services and its corporate and executive wellness programs, call 713-441-5978 or visit methodisthealth.com/wellness.

Today, Crane keeps in shape with an exercise regimen that he has tailored to his busy work and travel schedule. Three or four times a week, he goes through a cardio workout for a little less than an hour, then complements that with weightlifting and stretching.

Houston Astros owner Jim Crane

Leading Medicine • Volume 7, Number 1

IF YOU BUILD IT… houston ASTROS owner teams with METHODIST to apply lessons learned by de n n y a ng e ll e

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“Yes, we try everything out on our own workforce,” Hunnicutt says. “Everything we offer businesses has been developed with Methodist’s employees.”

“I learned early on what keeps me healthy and helps me relax,” he explains. “And I continue to sponsor that [healthy mindset] in all the companies I work with.”

Michele Hunnicutt, director of Methodist Wellness Services, says that initial strategy is very important in building an environment that promotes and rewards healthy lifestyles.

Working with Methodist Wellness Services, Crane established a health program for executives and employees at all of his companies. He also built

The Methodist corporate wellness program can provide behavioral and educational programs in areas such as nutrition, fitness, stress management, smoking

To learn more about Methodist Wellness Services and its corporate and executive wellness programs, call 713-441-5978 or visit methodisthealth.com/wellness.

Houston Astros owner Jim Crane

Leading Medicine • Volume 7, Number 1

eep into the 2008 football season, Houston Texans announcer Marc Vandermeer was working a game, broadcasting play by play to more than 30 radio stations across the state. During the game, Vandermeer began to notice something wrong. But not on the ﬁeld.

He felt something in his throat, a scratchy feeling, and with every word, Vandermeer knew he was in trouble. Nobody was warming up off the bench for relief — the live broadcast, like the game, must go on. “I managed to scratch my way through the rest of football season,” Vandermeer recalls. “When the season wound down, I needed to see somebody who could get to the bottom of the problem.” For someone like Marc Vandermeer, a voice problem can be a season-threatening injury. For 11 seasons, Vandermeer has been the “Voice of the Houston Texans,” calling all the games during a season and appearing on dozens of radio programs about the football team. A broadcaster for 20 years, he knew he needed to seek out a professional who would take his voice issues as seriously as he does.

MAKING THE RIGHT CALL ON VOICE PROBLEMS by de n n y a ng e ll e

His fi rst stop was The Methodist Hospital, the Texans’ official health care provider. Vandermeer checked the stats on Dr. C. Richard Stasney, deputy chief of otolaryngology and a clinical professor of otolaryngology at Weill Cornell Medical College. Stasney also has a long history of working with opera singers, newscasters and performing artists on their voice issues. So it didn’t take long for Vandermeer to realize he had found his man. “Dr. Stasney has treated opera singers for 30 years and is a big fan of the opera. So is my dad. He lives in New York, goes

to the Met, he’s a huge opera fan,” says Vandermeer. “In Dr. Stasney’s office, I was looking at the framed, signed photos of opera singers on the wall and texting the names to my dad. I had never heard of any of them, but my dad would reply ‘That’s the world’s top tenor, that’s the world’s best baritone.’ I figured if [Stasney] could help them, he could help me.” In fact, Vandermeer’s condition was one Stasney has encountered many times before — in opera singers. “It’s caused by acid reflux, when contents of the stomach leak back into the voice box (larynx) and cause irritation,” Stasney explains. “For people who use their voice a lot, it can affect their performance.” There are two types of acid reflux: gastroesophageal reflux disease (GERD), where stomach contents leak into the esophagus (the tube from the mouth to the stomach); and laryngopharyngeal reflux (LPR), where these stomach acids reach the throat. LPR is commonly found in as many as half of all patients with voice problems. Patients with GERD may not have LPR, and conversely, patients with LPR may not have GERD. Patients with GERD typically have heartburn as their main complaint, while LPR patients may or may not have heartburn. Stasney is quick to caution that acid reflux is not the cause of all voice problems, but he says it’s a good place to start. “There can be other, overarching issues beyond

Houston Texans announcer Marc Vandermeer

MAKING THE RIGHT CALL ON VOICE PROBLEMS by de n n y a ng e ll e

Houston Texans announcer Marc Vandermeer

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The Methodist Center for Performing Arts Medicine

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MEETING THE SPECIAL NEEDS

OF PERFORMING ARTISTS by t h e lm a g ro s

Much like athletes, performing artists need a special team of physicians and therapists to help keep them in peak condition so that they can both inspire and entertain audiences without missing a beat. From dancers to singers, musicians to acrobats, the Methodist Center for Performing Arts Medicine (CPAM) has more than 100 physicians with specialized knowledge and experience pertaining to the particular medical needs of performing artists.

Dr. C. Richard Stasney is founder of the Methodist Center for Performing Arts Medicine (CPAM), a comprehensive group of medical professionals who are able to provide preventive, diagnostic, specialty and emergency care to performing artists.

simple overuse of the voice or acid reflux,” he says. “The fi rst step is making sure you have the correct diagnosis.” Vandermeer was immediately assured that the correct diagnosis is exactly what he received. “I can’t say enough how important it was for me to get the right diagnosis,” he says. “I had no idea. I never had reflux that I was aware of, never any symptoms. My symptoms wouldn’t have been so noticeable if I didn’t talk so much.” Stasney’s team worked with Vandermeer on breathing techniques that singers use to pace their voices through strenuous performances. “They told me to breathe more like a singer, not to talk with my throat but with my lungs,” Vandermeer says. “When I learned how to do that, it took a lot of pressure off my vocal cords and got me back on the right track.” Anyone with a voice problem can exacerbate the trouble by pushing through the discomfort. And it doesn’t have to be a singer or a radio announcer,

Stasney says, who can suddenly fi nd themselves with little voice left. “It could be a fan screaming at a ball game, a priest or a rabbi during their respective holiday seasons, or even a lawyer who has given a four-hour deposition. Anyone can encounter voice problems,” Stasney notes. A comprehensive analysis of voice problems will include a computer analysis of samples of the speaking and singing voice to obtain an accurate “picture” of the voice. The analysis reveals vocal strength, the pattern and symmetry of vocal cord movement, variations in pitch and breath control, and voice breaks, among other conditions. Patients can be given exercises or medication to relieve symptoms and, in acute cases, surgery may be required to repair a leaky stomach valve or damaged vocal cords.

have to get to the real cause and, in many cases, it’s somewhere besides the throat and the vocal cords. “The worst thing you can do is tell people to stop talking and rest the vocal cords,” he continues. “For many, that’s cruel and unusual punishment.” For Marc Vandermeer, his job depended on the correct diagnosis and treatment. “You can’t exactly address the problem until you get the right guy to look at it, and I know I did that with Dr. Stasney,” he says. “We were able to work through the problem together,” Vandermeer continues, “and that’s a good thing. Because for me, not talking was not gonna happen.” n For more information, visit methodisthealth.com/cpam.

“Treating hoarseness is only treating the symptom,” Stasney says. “You

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hospital to institutionally support a center like CPAM. Like Methodist, the center goes beyond the cure. CPAM takes a coordinated and specialized approach to world-class patient care through integrated arts performances, exhibits and classes as part of the hospital environment and commitment to innovative educational, rehabilitative and therapeutic research.

The center focuses on interventional research, including music’s After being contacted 25 years ago by a unique patient, a concert effect on the mind and how physicians can use that research pianist, Dr. C. Richard Stasney founded the center in 2000 in to help other patients — not necessarily performing artists — response to a need for focused care for Houston’s performing heal. For example, one of CPAM’s current research initiatives artists. The original intention investigates stroke patients, behind CPAM was to emulate their rehabilitation, and the other centers, but, surprisingly, impact that listening intently none existed at that time. and regularly to different As a result, Stasney and his styles of music in different team became pioneers. With ways has on their neurological the inspired vision to cover recovery. The idea behind this everything from voices to initiative is that music, if used ankles, from top to bottom, in a coordinated way with they assembled a consortium of existing therapy, may augment specialists to tackle the tough rehabilitation and help the challenges facing Houston’s brain, in a sense, “rewire” artists. Today, under the itself around the injury, which direction of Jefferson Todd carries major implications Frazier, CPAM is one of only for long-term recovery. Dr. C. Richard Stasney with his key associate at the Texas Voice a few centers of its kind and is Center, Dr. Apurva A. Thekdi, an otolaryngologist who is also a home to nationally recognized In addition to top-quality CPAM physician. specialists in the fields of patient care, the center hosts otolaryngology, voice disorders, orthopedics, ophthalmology, numerous musical events each month, usually free and open kidney disease, neurology, psychiatry and urology. to the public, including events co-sponsored by the Houston Symphony, Houston Grand Opera, Rice University, Texas Music Instead of just treating the problem, CPAM’s physicians believe Festival, Texas Medical Center Orchestra, American Festival for in also working to prevent injury to protect one of Houston’s the Arts and many other professional and amateur ensembles. most valuable assets — its artists. Like the Texans’ sideline doctors, Stasney sees the center’s physicians as “on the sidelines For physicians like Stasney, “It’s fun to marry vocation of the arts. All performing arts are athletic endeavors.” For and avocation,” and when they both involve music, it’s a artists, a cold can mean much more than a minor annoyance. beautiful partnership. n As Stasney says, “When you carry your Stradivarius [violin] in your throat, you can’t just change your E-string.” The Methodist Hospital is the ofﬁcial health care provider for the Houston Ballet, the Houston Grand Opera and the Distinguished from other hospitals by its belief in providing Houston Symphony. For more information about CPAM, holistic care in a spiritual environment, Methodist was the first call 713-394-6088 or visit methodisthealth.com/cpam.

Leading Medicine • Volume 7, Number 1

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a d d i t i o n

MEETING THE SPECIAL NEEDS

OF PERFORMING ARTISTS by t h e lm a g ro s

“Treating hoarseness is only treating the symptom,” Stasney says. “You

methodisthealth.com/leadingmedicine

Leading Medicine • Volume 7, Number 1

CONQUERING the PAIN DEVICE PROVIDES RELIEF for CHRONIC PAIN SUFFERS By Linda Gilchriest

is transformed into a more pleasant tingling sensation “because that gate in the spinal cord has been closed.” The spinal cord stimulator delivers tiny pulses of electricity to the spinal cord through implanted leads in the patient’s back. These leads connect to a small generating device — also implanted — that is in turn controlled through a small wireless remote control. Although the theory behind these stimulators had been around since the 1960s, spinal cord stimulators did not become popular until the 1980s when European physicians used them not only for back pain, but also for treatment of angina. In the United States, the Food and Drug Administration has only approved spinal cord stimulation for chronic pain, although Satija says studies continue to explore its use for heart patients. EFFECTIVE PAIN RELIEF FOR COMPLEX CASES

Yvonne Redman discusses her treatment options with Dr. Richard Simpson.

vonne Redman describes herself as a “tough cookie.” No challenge or pain ever got in her way — until a 2009 accident caused such severe back pain that even standing was too much for her.

“It was excruciating pain,” Redman says. “I went into physical therapy, but that didn’t help.” Redman, 63, had surgery to remove damaged disks and months of therapy after that, but there was no relief. Redman says she was diagnosed with lower failed back syndrome: chronic back and leg pain that occurs after back surgery.

But Redman, being a tough cookie, was not going to suffer without putting up a good fight. In June 2012, she saw Methodist’s Leading Medicine TV special, “Stop Living in Pain,” about chronic back and joint pain and began researching one of the procedures discussed — spinal cord stimulation. This led her to Dr. Pankaj Satija, director of the Pain Management Center at the Methodist Neurological Institute.

To Redman’s relief, she turned out to be a good candidate for a spinal cord stimulator. “A spinal cord stimulator is a device to relieve pain,” Satija explains. “How it works is not completely illuminated yet.” He says the theory behind the device is that pain travels from the body to the brain through a sort of portal, or gate, in the spinal cord. With the stimulator, the sensation of pain

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Spinal cord stimulation has come into use as a way to ease types of pain that have eluded relief from more typical treatments. “What we have learned over the last few years is that there are some very important ways to ease chronic pain which have not responded to multiple surgeries and pain medications,” Satija says. “Most times, patients have had medication, physical therapy and maybe traditional surgery,” says Dr. Richard K. Simpson Jr., a neurosurgeon with the Methodist Neurological Institute. “If one of those things fails,” he continues, “then spinal cord stimulation is something to consider.” There aren’t narrowly defined parameters to identify patients who are suitable for spinal cord stimulation. “Spinal cord stimulation is not for everybody,” Satija says. “It is about choosing the right patients and giving them this option at the right

Leading Medicine • Volume 7, Number 1

time in their treatment plan. It has to be decided on a very individualized basis.” To this end, before Satija approves patients for spinal cord stimulators, he completes a series of tests to decide candidacy. For instance, young patients with classic neuropathic pain, who have had one small surgery and a few problems, may not be candidates. Satija says a typical patient is older, has had surgeries that have not relieved the pain and, in some cases, may no longer be able to tolerate medication. That said, the nature of spinal cord stimulation can be effective for patients with a wide range of conditions. “This is not as invasive as spine surgery; it does not give you the bad side effects of medications, and it does not require the patient to be proactive, such as doing physical therapy,” says Satija. “It is not a treatment restricted by your body type. Big people can have it; small people can have it; young people can have it; old people can have it.” A TRIAL PERIOD — THEN A MINOR PROCEDURE Before implantation surgery, patients have an opportunity to “test drive” the device. In this trial period, doctors place electrical leads over the spinal cord. The leads hang outside the skin, connected to a small battery that the patient carries in a fanny pack or pocket. The patient returns home and wears the temporary device for a week to 15 days to see if it works. “The patients get to decide whether this is something they absolutely love or is life-changing for them,” Satija says. “When I put this instrument in someone I want to know, number one, is their pain significantly better? I tell them, ‘Your pain should be 80 or 90 percent better or this is not the instrument for you.’”

them off pain medication. “Once these criteria are met, I will give them the go-ahead to get the stimulator.” Surgical implantation of a spinal cord stimulator can take as little as an hour to perform, and the procedure is completely reversible. “If the patient decides he doesn’t want it, the mechanism can be removed,” Satija explains. Simpson says he occasionally has removed a stimulator when the patient doesn’t feel it’s needed any longer. “We do have patients that this [stimulator] gets them through a window of pain that lasts for a few years and, down the road, they find they are not using it as much,” he says. “Some patients ask to have it removed, but that isn't common.” HIGH HOPES FOR A TOUGH COOKIE Redman says she cannot wait to get her permanent stimulator. At this writing, she is in her trial period with the new device, and is thrilled with the experience. “Within 30 minutes of getting the device, I didn’t have pain,” she says. “The next day, I went out to the grocery store and could push the cart without being all bent over.” She is also optimistic about a return to the dance floor. “I love dancing. Right now, if I do socialize, I just sit there, wishing I could be out there [on the dance floor]. I always used to be the first to liven up the party, but right now it is just sitting and watching.” Redman is confident that this wallflower phase will be a temporary one. “It’s going to be a good future. I have hope now. Once out of the pain, I am okay.” n To learn more or to ﬁnd a specialist, visit methodistneuroinstitute.com or call 713-790-3333.

Satija says that during this trial period, he wants his patients active and wants

CONQUERING the PAIN DEVICE PROVIDES RELIEF for CHRONIC PAIN SUFFERS By Linda Gilchriest

Yvonne Redman discusses her treatment options with Dr. Richard Simpson.

vonne Redman describes herself as a “tough cookie.” No challenge or pain ever got in her way — until a 2009 accident caused such severe back pain that even standing was too much for her.

methodisthealth.com/leadingmedicine

Leading Medicine • Volume 7, Number 1

Satija says that during this trial period, he wants his patients active and wants

By Michael E. Newman

atty liver disease. Never heard of it? Neither had Kathy Bourquardez, office manager for a Houston oilfield equipment company and a longtime diabetic. For five years straight, the blood work during Bourquardez’s annual physical had shown elevated levels for her liver enzymes. However, the physician she had trusted for three decades never recommended that the abnormality be studied more thoroughly. “He just wanted to keep an eye on it to wait and see if the numbers got better or worse,” Bourquardez says. It wasn’t until Bourquardez was referred by a family member to Dr. Kathleen Wyne, an endocrinologist at The Methodist Hospital, that the seriousness of her condition was suspected. “Dr. Wyne suggested that because of my diabetes, I also might be suffering from fatty liver disease and that might explain the elevated enzymes,” Bourquardez says. “After an ultrasound and a liver biopsy, I learned that not only did I have fatty liver disease, but it had already progressed to cirrhosis (scarring and hardening of the liver) that was starting to destroy my liver.” Ultimately, her diagnosis was of an advanced form of nonalcoholic fatty liver disease (NAFLD) known as nonalcoholic steatohepatitis, or NASH. AN UNFAMILIAR DIAGNOSIS, A COMMON PROBLEM Unfortunately, Bourquardez’s story is not that rare. “NAFLD is currently the most prevalent liver disease in the United States, and the number of patients being diagnosed is growing rapidly in parallel with the

epidemic of obesity,” says Dr. Howard Monsour Jr., chief of hepatology at The Methodist Hospital. “Even more serious is the fact that fatty liver disease is quickly overtaking hepatitis C as the major reason for patients to need a liver transplant.”

“Studies have shown that 5 to 20 percent of patients diagnosed with steatosis will eventually get NASH if the fat deposits in the liver are not treated, and up to 25 percent of those people will die or need a liver transplant,” Monsour says.

NAFLD exists in two states. The first, a simple form known as bland fatty liver or steatosis, is defined as abnormal retention of lipids (fats) within the liver cells. NASH — Bourquardez’s diagnosis — is the second type. This is a more complex, more dangerous form in which the body responds to the fat deposits with inflammation. NASH can, in turn, progress to cirrhosis and hepatocellular carcinoma (liver cancer).

ENDANGERING A CRUCIAL ORGAN The liver is the second-largest organ in the body. It is located under the rib cage and carries out a number of functions critical to survival.

“Texas is number two in the nation for fatty liver disease, a treatable condition that is strongly linked to hepatocellular carcinoma. Liver cancer is the eighth deadliest cancer in the United States, and rising. To answer this challenge, Methodist doctors have developed a sophisticated program focused on improved care for patients with liver disease and cancer,” says Dr. R. Mark Ghobrial, director of Methodist Center for Liver Disease and Transplantation.

30%

O F A L L A M E R I C A N S H AV E N O N A L C O H O L I C FA T T Y L I V E R DI S E A S E According to the National Institute of Diabetes and Digestive and Kidney Diseases

The biggest threats to healthy liver function include heavy alcohol use, drug abuse and hepatitis C. All three can lead to cirrhosis and liver failure and, ultimately, a choice between transplant or death if left untreated. The fourth villain to threaten our livers — fat — is just as dangerous, but much harder to detect. When fat first begins to build up in the liver, most people don’t have any symptoms. When they begin to experience abdominal pain, numerous other possible causes must be ruled out — making a diagnosis of NAFLD what doctors call a “diagnosis of exclusion.” What’s most important about fatty liver disease, according to Monsour, is catching it early so that doctors and their patients can team up to reverse the harm already done, restore normal liver function as much as possible, and avoid having to face the prospect of a liver transplant. In many cases — including Bourquardez’s — the first sign of trouble with fatty liver disease is routine blood work that reveals elevated levels of certain liver enzymes.

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F AT T Y L I V E R D I S E A S E

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GROWING CONCERN

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When these elevated enzymes appear, physicians will look for other conditions that have also been linked to NAFLD, such as central obesity — weight gain around the Dr. Howard Monsour Jr. waist — high cholesterol, high triglycerides, high blood pressure or diabetes to determine if further screening is advised. This further screening may initially include ultrasound, CT or MRI examinations. These imaging studies can reveal if the liver is enlarged, and suggest the presence of fatty liver disease, but the only positive diagnosis is through a liver biopsy, in which a small sample of liver tissue is removed and microscopically evaluated. TREATMENT Once a patient is diagnosed with NAFLD, the next step is developing an effective treatment plan. “At The Methodist Hospital, we have a multidisciplinary team approach to dealing with fatty liver disease,” Monsour explains. “Our patients are served by a group made up of an endocrinologist, a lipidologist, a diabetologist, a dietician, and if necessary, a surgeon, so that all aspects of diagnosis, treatment and lifestyle adjustment are covered.” In addition to patient care, Methodist is actively involved in researching the causes of fatty liver disease. Researchers at The Methodist Hospital are investigating fatty liver disease at the genetic level, searching for underlying causes of the disorder and analyzing population data to define what groups are genetically more predisposed to develop it. HARD WORK AND OPTIMISM For Bourquardez, the care that she’s received at Methodist has put her on the right track to a better quality — and hopefully longer — life.

LOSE WEIGHT According to Dr. Howard Monsour Jr., studies here at Methodist and elsewhere have shown that a program of cardiovascular exercise, three times a week for 30 minutes, and a loss of 12–15 percent of body weight, e.g., a 260-pound man slimming down to 220, will yield significant changes in the fat composition of the liver.

CHANGE YOUR DIE T Patients should consider shopping only the perimeter of the grocery store because that is typically where one fi nds the fresh fruits and vegetables, meats and breads for a healthier, more balanced diet. The aisles are where the processed, often high-sugar and high-fat foods are lurking.

TA K E A N T I O X I D A N T S Studies show that when patients with NAFLD took 400 to 800 units of vitamin E each day, there were considerable reductions in liver fat content, inflammation and fibrosis (scarring).

ASK YOUR PHYSICIAN ABOUT A N T I D I A B E T I C M E D I C AT I O N S Patients who do not respond to other treatments or who have advanced to NASH can benefit from antidiabetic medications such as rosiglitazone and pioglitazone. These patients are often insulin resistant, and these medications increase insulin and fatty acid sensitivity, and in turn, appear to help reduce liver damage that excess amounts of both can cause.

“I wish that I had gone to Methodist four years earlier,” she says. “Once you’re diagnosed with fatty liver disease, you have to consider it a lifelong challenge to control it because the alternatives are too scary. Everyone on my Methodist team works so hard to keep me focused and accountable; I just love going to them!” n

Consult your physician about other options such as statin drugs; gastric sleeve or bypass for morbidly obese patients; or a daily course of fish oil. n

For more information on fatty liver disease, visit methodisthealth.com/FattyLiverDisease.

any new treatment program.

Leading Medicine • Volume 7, Number 1

EXPLORE OTHER OPTIONS

Please consult your physician before starting

By Michael E. Newman

ENDANGERING A CRUCIAL ORGAN The liver is the second-largest organ in the body. It is located under the rib cage and carries out a number of functions critical to survival.

30%

O F A L L A M E R I C A N S H AV E N O N A L C O H O L I C FA T T Y L I V E R DI S E A S E According to the National Institute of Diabetes and Digestive and Kidney Diseases

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F AT T Y L I V E R D I S E A S E

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Consult your physician about other options such as statin drugs; gastric sleeve or bypass for morbidly obese patients; or a daily course of fish oil. n

For more information on fatty liver disease, visit methodisthealth.com/FattyLiverDisease.

any new treatment program.

Leading Medicine • Volume 7, Number 1

EXPLORE OTHER OPTIONS

Please consult your physician before starting

Dr. Vadim Sherman (second from the right) provides instruction in the procedural skills training lab during a fellowship course of the 2011 Society of American Gastrointestinal and Endoscopic Surgeons meeting, hosted at MITIE.

etooling. Every professional needs to retool from time to time to become adept at advancements in his or her field. Pilots in simulators practice the latest methods for handling hazardous conditions, and astronauts train underwater to refi ne their ability to work in microgravity. Even baseball players and golfers employ virtual reality systems to upgrade the swings they’ve been using for years. But what about medical practitioners — surgeons, nurses, internists and anesthesiologists — who have years, maybe even decades, of experience in the operating room under their belts? For them, retooling hasn’t always been easy.

MITIE MAKES RIGHT INNOVATIVE INSTITUTE KEEPS MEDICAL PRACTITIONERS AT THE TOP OF THEIR GAME

by michael e. newman

“We have great medical schools and nursing schools for our future caregivers and great teaching hospitals for when they become residents and trainees, but traditionally, the education infrastructure stopped there — in other words, once you were launched, you were on your own to stay current,” says Dr. Barbara L. Bass, chair of The Methodist Hospital’s Department of Surgery. “What was needed was a comprehensive center in which practicing physicians and other surgical personnel could learn new procedures, get hands-on training, and become certifiably skilled without putting a single patient at risk.” The dream became reality in 2007 when The Methodist Hospital established the Methodist Institute for Technology, Innovation & Education, otherwise known as MITIE. Housed in a 35,000-square-foot education and research facility since 2011, MITIE includes three core components: a virtual hospital for team training in a simulated, high-risk patient environment; a procedural skills laboratory for individual training on state-of-theart models with 15 “mini” operating rooms; and a suite of six operating rooms for image-guided procedure research, robotic surgery and technology development. To best understand how MITIE works, Bass — who serves as the institute’s executive director — offers one example of how the resources of all three components make it possible for professionals to acquire a new skill and then master it. “Laparoscopic colectomy is a minimally invasive procedure where part of the colon is removed using a video camera and surgical equipment inserted through small tubes rather than a traditional operation that requires opening up the patient,” Bass says. “It’s a great technique — less painful for the patient, quicker recovery time and a shorter hospital stay — but many surgeons aren’t comfortable with it. MITIE makes it possible for them to observe, learn, try, make mistakes, practice and fi nally, gain confidence with the procedure without endangering a single human being.”

MITIE MAKES RIGHT INNOVATIVE INSTITUTE KEEPS MEDICAL PRACTITIONERS AT THE TOP OF THEIR GAME

by michael e. newman

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MITIE training for the laparoscopic colectomy, Bass explains, begins with physicians and other surgical team members using the center’s amphitheaterlike MedPresence room to observe the procedure via video as it is performed in one of Methodist’s operating rooms. Each seat in the MedPresence room includes a computerized, interactive learning station, so students not only watch the surgery as it happens, but also can ask questions, manipulate camera angles to personalize views, and access relevant educational materials. Once he or she has become familiar with how to perform the technique, the surgeon moves to one of the stations in the procedural skills laboratory for individual practice using the latest equipment and a virtual model of the abdomen. This is followed by a chance for the entire surgical team to train together in a MITIE suite arranged so that it duplicates the conditions found in a typical laparoscopy operating room. However, in this simulated environment, the “patient” is a full-body mannequin that breathes, talks and responds to medications. Even the evaluation process is high-tech. “Methodist faculty can observe the trainees in action via MITIE’s telepresence network,

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HOUSTON ENDOWMENT

“The great thing about MITIE is that it’s designed to provide comprehensive, procedurally based instruction and education for surgeons and their teams.”

C O M M I T T ED TO M I T IE’S SU C C ES S

which not only includes cameras in the virtual operating room, but also a cameraequipped headgear worn by the surgeon,” Bass says. “This lets the evaluator see what the team sees in real time.”

delivering the training itself,” Dunkin says. “We are studying how our students learn, what stresses they encounter while learning, and in what ways we can measure how well they have learned.”

Dr. Brian J. Dunkin is medical director of MITIE and section head of endoscopic surgery at The Methodist Hospital. He is also a professor of clinical surgery at Weill Cornell Medical College and the John F. Jr. and Carolyn Bookout Chair in Surgical Innovation and Technology. “The great thing about MITIE is that it’s designed to provide comprehensive, procedurally based instruction and education for surgeons and their teams,” Dunkin says. “First, the individuals learn at their own pace and with their own unique ways of processing information, and then the individual abilities are blended through team training into a unit that can do a procedure at the best-of-practice level.”

For example, the MITIE staff uses thermal imagery of a surgeon’s face to record the stress he or she is feeling while trying to master a new technique. “We find that once a surgeon becomes stressed in this situation, hot spots appear across the face and these regions expand and get hotter as the nervousness increases,” he explains. “As the stress level rises, we see a corresponding jump in speed, carelessness and the number of mistakes. So, we look for what factors cause the learning anxiety and suggest ways to reduce or eliminate them in order to increase proficiency and confidence.”

However, it’s not only the students who learn at MITIE. The program, Dunkin says, also provides lessons for the teachers as well. “Along with instituting best practices in the operating room, we are using MITIE as an experimental platform to define, refine and establish the best practices for

MITIE also serves as a testbed for the research and development of technologies that can greatly improve the retooling process for surgical teams. “In one case, we are exploring the use of telepresence and teleproctoring to train and evaluate practitioners in one region while the faculty is in another, perhaps thousands of miles away,” Dunkin notes. “If we can show that such a system works, then we can use it to set up accredited standards

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for testing and certifying surgical teams — anywhere in the world from anywhere in the world — as ready to perform a variety of learned skills on actual patients.” Thanks to MITIE and planned future centers like it, Bass even envisions medical practitioners taking “surgery sabbaticals” where they could “take a break from the OR and upgrade their skills in a safe, effective and manageable fashion.” During the first five years of MITIE, Bass says proudly, the institute has schooled more than 5,000 practicing surgeons and their colleagues across 25 different specialties from nearly every state in the nation and from eight foreign countries. Each successfully trained graduate, she says, proves again and again that MITIE offers something no other system can when it comes to procedural training. “What we do in the operating room is immediate,” Bass says. “There are no doovers. We get one shot at what we do and mistakes cost lives. MITIE gives us the chance to retool, make the most of that one shot and avoid the mistakes. After all, in a virtual learning environment, the only thing that can get hurt is your pride.” n For more information, visit mitietexas.com.

Leading Medicine • Volume 7, Number 1

As part of its program “to support educational institutions that produce and maximize enduring benefits for the people of the greater Houston area,” the Houston Endowment awarded a $1.3 million grant earlier this year to the Methodist Institute for Technology, Innovation & Education (MITIE). “Developing, maintaining and continuously improving the programs at MITIE isn’t an investment we can make alone,” says Dr. Brian J. Dunkin, medical director of MITIE. “Thanks to the support and commitment of groups such as the Houston Endowment, it’s no longer just a dream to have a sustainable education and research institute focused on the needs of practicing health care professionals.” Dunkin says that the Houston Endowment gift has been used so far to fund two projects “to help MITIE teach best practices better than it currently can and make even more significant impacts on health care.” In the first project, in-depth interviews are being conducted with MITIE stakeholders — both the practicing caregivers for whom the procedurally based educational program is designed and members of other groups that would benefit from better trained surgical teams, such as insurance companies, health care systems (Kaiser Permanente, for example) and federal health care agencies. Input from these interviews, as well as from a conference to be held in February 2013, will assess

the program’s strengths and weaknesses and then be used to create a roadmap for growth and improvement. The second funded project, Dunkin says, requires MITIE to prove its value through two pilot demonstrations known as “Train the Trainer.” In one pilot, the staff members will attempt to use a MITIE training program to increase the number of medical practitioners who will learn ultrasound guidance for placing central lines, the intravenous tubes inserted into large vessels for supplying nutrition, delivering chemotherapy and other purposes. “Although this is the state-of-the-art method, surgeons aren’t using it as much as they should,” Dunkin explains. “Our hope is that by making our trainees skilled in the practice, they’ll encourage others to learn and use it.” Another pilot hopes to achieve a similar outcome for another best practice, laparoscopic colectomy (described in the main article about MITIE). “Although data show that laparoscopy gives better results than traditional colon cancer surgery, only about 20 percent of surgeons use the technique,” Dunkin notes. “We want to train surgeons to be proficient in it and then support them when they go back to teach others at their institutions — what we refer to as a halo effect.” Dunkin says that MITIE plans to conduct the first training in both pilots in the first quarter of 2013. n

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HOUSTON ENDOWMENT

“The great thing about MITIE is that it’s designed to provide comprehensive, procedurally based instruction and education for surgeons and their teams.”

C O M M I T T ED TO M I T IE’S SU C C ES S

which not only includes cameras in the virtual operating room, but also a cameraequipped headgear worn by the surgeon,” Bass says. “This lets the evaluator see what the team sees in real time.”

delivering the training itself,” Dunkin says. “We are studying how our students learn, what stresses they encounter while learning, and in what ways we can measure how well they have learned.”

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Leading Medicine • Volume 7, Number 1

LIKE MOTHER, LIKE DAUGHTER

BREAST CANCER SURVIVORS

SHARE COMMON BOND By Donna Hurst

others and daughters often share a special bond. But for Ruby Wilson and her daughter, Lisa Edwards Benford, that bond goes much deeper.

In 2000, only two months after her annual mammogram came back normal, Wilson felt a movable lump in her breast. After further testing, Wilson, a nurse at The Methodist Hospital, was diagnosed with breast cancer. Eight years later, Wilson’s daughter learned she also had breast cancer. Both of them are now survivors and inspiring their friends and family, as well as the rest of the nation. Their stories attracted the attention of the Ford Motor Company, which named Wilson and Benford “Models of Courage” for 2012. They are two of the 11 women and men recognized for their strength and courage in the fight against breast cancer. As a result, Wilson and her daughter flew to Los Angeles to participate in the Models of Courage campaign to make their national debut as inspirational models for Ford Warriors in Pink® gear, benefitting breast cancer research. “When I was diagnosed 12 years ago, I worried about taking care of my family,” Wilson says. “But when my daughter was diagnosed four years ago, I was glad it was me fi rst. I was able to help my daughter because she had seen me go through it.” LAUGHTER IS GOOD MEDICINE Wilson and Benford had their surgeries and treatment at the Methodist Cancer Center, both undergoing mastectomies with surgical removal of the left breast for Wilson and

Lisa Edwards Benford and her mother, Ruby Wilson, are both breast cancer survivors.

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the right for her daughter. The procedures were followed by reconstructive surgery and chemotherapy. Faith and laughter kept the mother and daughter strong. “We always say I’m a ‘lefty’ and Lisa’s a ‘righty,’” Wilson jokes. Benford, who is a biological safety manager for the University of Houston, reviews a lot of clinical research protocols that come across her desk. Benford says she really lights up when she sees the ones for breast cancer and that they further inspire her and her mom to educate the community about the disease. “Mom and I do everything we can to tell people at our workplace, church and community about the importance of early detection,” Benford says. “Everyone needs to know that breast cancer is not a death sentence. Mine was stage 0 and had changed from one year to the next in the mammogram. My mom was doing her self-exam in the shower and found it soon after her annual mammogram. That’s why it’s critical to check yourself and get your mammogram.” “My mother was given to me as an example,” she adds. “If you look at a true Model of Courage, she’s it. We were already close, but when you go through something like this, it’s like wow, if you can get closer, you just did.” n To learn more about Methodist's cancer diagnostic and treatment services or to find a specialist, visit methodisthealth.com/cancer or call 713-790-3333.

LIKE MOTHER, LIKE DAUGHTER

BREAST CANCER SURVIVORS

SHARE COMMON BOND By Donna Hurst

others and daughters often share a special bond. But for Ruby Wilson and her daughter, Lisa Edwards Benford, that bond goes much deeper.

Lisa Edwards Benford and her mother, Ruby Wilson, are both breast cancer survivors.

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NEW REASON SMILE TO

When the removal of a brain tumor left half her face paralyzed, Karen Espitia turned to The Methodist Hospital for help. By Linda Gilchriest

Karen Espitia pictured with her two children at Discovery Green Park.

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Leading Medicine • Volume 7, Number 1

NEW REASON SMILE TO

When the removal of a brain tumor left half her face paralyzed, Karen Espitia turned to The Methodist Hospital for help. By Linda Gilchriest

Karen Espitia pictured with her two children at Discovery Green Park.

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Leading Medicine • Volume 7, Number 1

aren Espitia became accustomed to the unﬁltered comments of her elementary school students. “Hey, Ms. E., what happened to your smile?” one concerned youngster asked. “Baby, Ms. E’s smile is broken,” she replied.

A complex brain surgery had left Espitia with extensive facial paralysis. The story could have ended here had it not been for Dr. Michael Klebuc, director of the Center for Facial Paralysis Surgery and Functional Restoration at The Methodist Hospital and Methodist’s multidisciplinary facial reanimation team.

branches of the facial nerve. “What happens over time is the masseter nerve fibers will grow into the facial nerve and repopulate the facial muscles,” Klebuc explains. “Initially, you will need to clench your teeth together to create a smile. However, with diligent practice, over time, the smile can become reflexive and effortless.”

The 35-year-old single mother of two recalls the constant ringing in her ears that ultimately was evaluated by an MRI. The results showed a brain tumor that needed to be removed immediately.

Nerve selection is crucial. “You want a nerve that, when you divide it, its function is going to be as close to smiling as possible, and that when you cut it, you don’t create a major issue some other place,” Klebuc adds.

“It was a very large tumor, but benign. They told me I was going to lose hearing on my left side, and I did,” Espitia says. “But the tumor was completely wrapped around my facial nerve. So when they took the tumor out, they had to sever my facial nerve to prevent recurrence. “It left me with the entire left side of my face paralyzed. My eye wouldn’t close and my face was hanging. Everything was gone on that side.” The neurosurgeon highly recommended Klebuc because of his work in state-of-the-art facial paralysis surgery. “We can help people restore their facial symmetry and their motion after facial Before paralysis,” Klebuc says. The causes of the paralysis vary. “Sometimes it is Bell’s palsy that doesn’t recover fully, other times it is trauma or tumors that cause the problem. There are also congenital causes of facial paralysis where individuals are born without the ability to move their face.” With advances in medical technology, Klebuc explains that none of these facial damages need be permanent. “We have techniques that can be used for almost anybody, regardless of age or the cause of their facial weakness.” For instance, when the proximal portion of the nerve is not available because it was damaged near the brain stem, as in the case of Espitia, Klebuc and his team perform a surgical technique that was developed at Methodist. The procedure calls for taking a branch of one of the chewing nerves, called the masseter nerve, and connecting it to selected

That is where Dr. David Rosenfield, director of both the EMG and Motor Control Laboratory and the Speech and Language Center at the Methodist Neurological Institute and professor of neurology at Weill Cornell Medical College, and his team of neurological specialists come in. “He [Rosenfield] can provide very important information to me about the health of the facial nerve, the continuity of the nerve. He can also tell me if the nerve is spontaneously trying to regenerate on its own,” Klebuc points out. “So he can provide an immense amount of important information to me. It’s definitely a team approach.” After

This operative diagram illustrates the masseter-to-facial nerve transfer with combined cross-face nerve grafts that Dr. Michael Klebuc performed on Karen Espitia.

“If you use those grafts alone, the motion is always weaker than the normal side. But if you combine the masseter transfer and the cross-face nerve grafts, then there is a marriage of power and spontaneity that can produce a very natural-appearing smile.”

Klebuc also implanted a weight in her upper eyelid to help the eye close. According to Espitia, the weight was removed after one year as the nerve grafts eventually allowed the eye to close in its own. “It wasn’t a surgery I had to have,” the teacher asserts. “The surgery was lengthy and complex, but I tell everyone I would have that surgery again in a heartbeat.” Klebuc contends that this surgical technique, while state-of-the-art, is not for everyone. But he notes there is a treatment available to almost everyone who suffers with some type of facial paralysis. “In long-standing cases of facial paralysis, we often transfer local muscles to restore an active smile or will transplant a segment of inner thigh muscle using microsurgical techniques,” Klebuc says. “If someone is very elderly, and they would not have physical stamina to go through a lengthy surgery, there are still other treatment options.

Rosenfield’s testing showed Espitia to be a good candidate for surgery. Klebuc says he chose a hybrid surgical approach.

“So even simple procedures have the potential to take somebody who is very self-conscious and reclusive and give them the confidence to get back out into the community, doing grocery shopping, Dr. Michael Klebuc meeting with their friends and having a good quality of life. For many patients with facial paralysis, surgical treatment can be a real life-changer,” Klebuc says. n

“We transferred the masseter nerve to the facial nerve, but I also used a series of nerve grafts to bridge the facial nerves from one side of the face to the other,” Klebuc says.

For more information about facial paralysis restoration procedures, visit Methodist Center for Facial Paralysis Surgery and Functional Restoration at methodisthealth.com/facialparalysis-smilerestoration.

“We do very sophisticated electrical studies,” Rosenfield explains. “What the testing tells you is (A) whether the nerves that go to the face are conducting electrical stimulation, and (B) if they are not doing it appropriately, where the problem is in the nerve and what kind of problem it is. “What Dr. Klebuc often wants to know is whether this nerve is healthy, whether this muscle is healthy and what he can move around and what to do. We can give him that information so he can then make an intelligent, clinical decision,” Rosenfield says.

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Leading Medicine • Volume 7, Number 1

THE METHODIST INSTITUTE FOR

Reconstructive Surgery With state-of-the-art equipment and innovative surgical techniques, our dedicated team is committed to restoring lost form and function. WITH CENTERS FOR:

• Reconstructive Microsurgery • Facial Paralysis Surgery and Functional Restoration • Breast Restoration • Lower Extremity Restoration (limb center) • Genito-Urinary and Pelvic Reconstruction • Body Contour Restoration Dr. Pierre M. Chevray

Dr. Michael J. Klebuc

Dr. Tue A. Dinh

Dr. Michael A. Lypka

Dr. Warren A. Ellsworth, IV Dr. Aldona J. Spiegel Dr. Jeffrey D. Friedman

For more information about the Methodist Institute for Reconstructive Surgery please call 713-441-6100. 6560 Fannin Street Houston, Texas 77030

The 35-year-old single mother of two recalls the constant ringing in her ears that ultimately was evaluated by an MRI. The results showed a brain tumor that needed to be removed immediately.

This operative diagram illustrates the masseter-to-facial nerve transfer with combined cross-face nerve grafts that Dr. Michael Klebuc performed on Karen Espitia.

Rosenfield’s testing showed Espitia to be a good candidate for surgery. Klebuc says he chose a hybrid surgical approach.

“We transferred the masseter nerve to the facial nerve, but I also used a series of nerve grafts to bridge the facial nerves from one side of the face to the other,” Klebuc says.

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Leading Medicine • Volume 7, Number 1

THE METHODIST INSTITUTE FOR

Reconstructive Surgery With state-of-the-art equipment and innovative surgical techniques, our dedicated team is committed to restoring lost form and function. WITH CENTERS FOR:

Dr. Michael J. Klebuc

Dr. Tue A. Dinh

Dr. Michael A. Lypka

Dr. Warren A. Ellsworth, IV Dr. Aldona J. Spiegel Dr. Jeffrey D. Friedman

For more information about the Methodist Institute for Reconstructive Surgery please call 713-441-6100. 6560 Fannin Street Houston, Texas 77030

“I preach gradualism,” says Feltovich. “The problem with saying, ‘I’m going to run four miles tomorrow’ is that you get sore, and then you don’t exercise. So all you’ve done is set yourself up to get set back.”

HEALTHY LIVING By Andrew Nelson

hysical activity is crucial to our health and well-being. It provides numerous shortand long-term physical and emotional benefits. But for people who haven’t exercised before — or who haven’t exercised for some time — it can be hard to begin and stick to an exercise plan. Staff and physicians with the Methodist Wellness Center have long experience at working with individuals to develop activity and fitness plans that not only provide lasting health benefits, but also fit into real life. Here, they offer some proven tips to get going and keep moving — whether you’ve never exercised, or you’re starting again after taking a long break. GET A CHECKUP We’ve all heard this instruction: consult your physician before beginning an exercise program. Is it really that

Tips to get moving

important? Yes. Dr. Michael J. Feltovich, an internist with the Methodist Wellness Center and an assistant professor of medicine at Weill Cornell Medical College, explains why. “You’d like to be certain that there’s no medical condition on the musculoskeletal side or on the medical side which would somehow be problematic in terms of the exercise program,” he says. When you talk to your doctor, he or she will talk to you about what exercise you’ve done in the past, and ask you some questions about your current health. “I’ll ask, ‘Do your knees give you problems? Do your ankles give you problems?’” says Feltovich. “And then on the medical side, ‘Do you have any established medical diagnoses? Do you have high blood pressure, do you have known heart trouble, do you have diabetes?’ Because exercise has to be designed to take all of those into consideration.”

Based on your answers to questions like these — as well as the results of a basic physical examination — your doctor may clear you to exercise, or may recommend some additional testing. All of it, though, is designed to make sure that your exercise objective is safe, manageable and appropriate to your current health. GET SOME ADVICE Once you’ve seen your doctor, it’s time to develop an exercise plan. A personal trainer or an exercise physiologist can do a basic fitness assessment and then help you put together a plan that’s suited for your experience and your condition. Determination is as important at this stage as any other, so try to stay positive. “A lot of people are afraid to get started again, thinking, ‘Oh, it’s going to be too hard to get started,’” says Peter Puzon, an exercise physiologist and senior wellness coordinator at The Methodist

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Walking is often the fi rst step — no pun intended. “The most important thing, and the simplest thing for someone who has not worked out in a while, or who has never worked out, is walking,” explains Oliver Batinga, also an exercise physiologist at the Methodist Wellness Center. “It’s the most simple and basic functional thing we do on a daily basis.” A walking plan might start with a very short walk at a gentle pace. But with repetition, you’ll soon be able to increase the distance and the speed — and before long, you’ll be gaining real cardiovascular benefit. DON’T GO IT ALONE Starting something new can be intimidating when you’re flying solo. Having a partner can be a real help — for company and for motivation. “If you have someone waiting for you, like a personal trainer, or if you have a workout buddy, you know someone’s waiting for you, and you know you’re going to be accountable for your time,” says Puzon. “So, people have a tendency to show up.” Batinga agrees. “If you have someone who can motivate you as well as work out with you, that’s one thing that can help get you back on track,” he says. FIND EXERCISE EVERYWHERE Exercise doesn’t just have to be something that you do at the gym or at

Leading Medicine • Volume 7, Number 1

a set time in the day. A good element of a healthy life can be a commitment to increasing your activity throughout the day as a part of your everyday activities. You can make a point of parking at a distance from the grocery store, to add a short walk to your trip. And you can make a point of walking all of the aisles in the store, rather than going straight to the top items on your list. At the office, you can take the stairs, rather than the elevator, for short trips. Even if you use an escalator, you can walk to speed your progress. And if you have a meeting with one other person, you might suggest that the two of you take the meeting on foot — making it a walk, instead of a sit-down meeting. Speaking of sitting down, that suggests another direction. “We do a lot of sitand-stands every day — we sit and stand from our chairs,” says Batinga. “By doing so, you work your large muscle groups. So, if you’re at your desk, you can sit and stand up and down a few times. That will work your leg muscles, which is good for strengthening and balance.” KEEP GOING Starting an exercise program is, by defi nition, a beginning. But it’s a good one, and it can improve your health, your self-esteem and your quality of life. Once you’re under way, the key is to stick with it. “You take the initiative of starting somewhere. Then once you get used to it, then you start feeling good about yourself, and then, bam! You’re in your own workout,” contends Batinga. “But then it’s also a matter of maintaining it and persevering — so that you maintain your goal and then improve your lifestyle even more.” n

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TAKE IT SLOW Most plans will begin not with fullfledged cardiovascular exercise, but with steadily increasing levels of physical exercise — and for good reason.

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Hospital’s Wellness Center. “But you’ve got to start somewhere!”

Dr. Gregory Terry

Making the Right Moves Finding the right exercise for you is just as important as getting started. Dr. Gregory Terry, a family medicine physician at San Jacinto Methodist Hospital, recommends weight-bearing exercises, such as walking, doing tai chi or using an elliptical machine to strengthen bones. “Walking at least 30 minutes, five days a week, is not only good for your bones and joints, it’s aerobic exercise that helps lower your risk of heart disease and high blood pressure,” says Terry. “As you get in better shape, you can tailor and lengthen your walks for maximum enjoyment,” suggests Terry. “Doing some stretching after walking, especially if the walk is going to be long or strenuous, helps to keep the joints flexible.” If you have serious problems or pain while doing any weight-bearing exercise, try going to the local pool. “Water exercise doesn’t help so much with strengthening bones, but it is great for strengthening muscle, and improving balance and range of motion,” says Terry. The buoyancy of water reduces the pressure on bones and joints, so try moving your legs in place while standing in water up to your neck. Stay close to the edge if you need to grab on to maintain balance. While hanging on to the pool’s edge, try some leg kicks or pull your knees up to your chest and stretch them out again. n For more information on services at San Jacinto Methodist Hospital, please call 855-999-7564.

HEALTHY LIVING By Andrew Nelson

Tips to get moving

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Leading Medicine • Volume 7, Number 1

a d d i t i o n

TAKE IT SLOW Most plans will begin not with fullfledged cardiovascular exercise, but with steadily increasing levels of physical exercise — and for good reason.

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Hospital’s Wellness Center. “But you’ve got to start somewhere!”

Dr. Gregory Terry

ACCOLADES The Methodist Neurological Institute’s Eddy Scurlock Stroke Center, the largest stroke unit in Houston’s Texas Medical Center, is the first hospital in the United States to receive a comprehensive stroke center certification by DNV Healthcare Inc. DNV’s Comprehensive Stroke Center certification was recently approved as a nationally recognized program, following the guidelines set forth by the Brain Attack Coalition and American Stroke Association. San Jacinto Methodist Hospital received the American Heart Association/American Stroke Association’s Get With The Guidelines® — Stroke Gold Plus Quality Achievement Award for the second year in a row. The Methodist DeBakey Heart & Vascular Center has entered into a multiyear agreement with Memorial Hospital in Lufkin to support the growth of the cardiovascular program at Memorial. This relationship is made possible by generous support from the TLL Temple Foundation. Memorial is also expanding its clinical offerings for patients in the region by collaborating with Methodist physicians, attending educational programs offered by the DeBakey Institute for Cardiovascular Education & Training, as well as local and regional outreach programs lead by Memorial Hospital. n

JAIME GATENO, M.D., D.D.S. Dr. Gateno, chairman of the Department of Oral and Maxillofacial Surgery at The Methodist Hospital, was one of six surgeons worldwide selected to represent a Craniofacial Expert Group for the AO Foundation, a medically guided nonprofit organization specializing in the treatment of trauma and disorders of the musculoskeletal system. Gateno has an international reputation for his expertise in craniofacial and orthognathic surgery.

JUDY PAUKERT, Ph.D. Dr. Paukert, vice president of The Methodist Hospital Education Institute, was honored with the Parker J. Palmer Courage to Lead Award at the annual meeting of the Accreditation Council for Graduate Medical Education (ACGME) in 2012. Paukert is Methodist’s designated institutional official for the ACGME and for the hospital’s Graduate Medical Education Committee sponsored programs. In just seven years, Paukert has achieved successful accreditation of 25 ACGME programs and transitioned five others from an institution that no longer sponsors ACGME programs. During the same time span, she organized and supported dozens of GMEC sponsored fellowship programs that operate under the same rules and guidelines as the accredited GME programs. The Parker J. Palmer Courage to Lead Award honors designated institutional officials who have demonstrated excellence in overseeing residency programs at their sponsoring institutions.

KENNETH PODELL, Ph.D. For the seventh year in a row, The Methodist Hospital System is ranked among FORTUNE magazine’s 2012 “100 Best Companies to Work For,” remaining the only health care organization ranked in Texas. Methodist is ranked No. 53 and is one of four companies in Houston to receive the prestigious distinction. FORTUNE listed 11 Texas-based companies on its 2012 list. Among the other companies listed, Methodist ranked No. 2 for the hiring of minorities and No. 12 among the country’s large companies. “Our employees and physicians make it possible to be honored as one of the ‘100 Best Companies’ for seven consecutive years,” says Dr. Marc Boom, president and CEO of The Methodist Hospital System. “Methodist is a great place to work because of them and because of their complete and selfless dedication to our patients and to our values.” n

The Methodist Hospital ranked among the country’s top hospitals in 13 specialties in U.S.News & World Report’s 2012 America’s “Best Hospitals” issue, and was named the No. 1 hospital in Texas. The Methodist Hospital also ranked No. 1 in the Houston area in the magazine’s “Best Metro Area Hospitals” list. San Jacinto Methodist Hospital ranked No. 7 in the metro area and No. 12 in the state, and Methodist Willowbrook Hospital ranked No. 10 in the metro area and No. 37 in the state. The Methodist Hospital ranked nationally in the following specialties: cancer (38), cardiology & heart surgery (12), diabetes & endocrinology (21), ear, nose & throat (33), gastroenterology (18), geriatrics (26), gynecology (20), nephrology (23), neurology & neurosurgery (17), ophthalmology (15), orthopedics (21), pulmonology (26), and urology (29). n

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Dr. Podell, a neuropsychologist focused on concussion and head injuries, is now co-director of the Methodist Concussion Center. He is also the team neuropsychologist consultant for the Houston Texans, Houston Astros, Houston Dynamo, Rice Athletics and Rodeo Houston. Podell worked with a team of neuropsychologists in the early 1990s to develop the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) test, the most widely used computerized test for sports concussions, which is used by the NFL, NHL and MLB, and throughout the world for testing players for concussions.

CLARE HAWKINS, M.D. Dr. Hawkins, director of San Jacinto Methodist Family Medicine Residency Program, has been selected to serve as president-elect of the Texas Academy of Family Physicians (TAFP). He was elected during the TAFP annual meeting in Austin in July.

Leading Medicine • Volume 7, Number 1

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Leading Medicine • Volume 7, Number 1

CLINICAL

Notes

Jason Sakamoto, Ph.D., interim co-chair of the Department of Nanomedicine; Michael Thrall, M.D., medical director of digital pathology and assistant professor of pathology and laboratory medicine at Weill Cornell Medical College; Shanda Blackmon, M.D., M.P.H., thoracic surgeon in the Department of Surgery and assistant professor of surgery at Weill Cornell Medical College; Mauro Ferrari, Ph.D., president and CEO of The Methodist Hospital Research Institute, Ernest Cockrell Jr., Distinguished Endowed Chair, and professor of biomedical engineering in medicine at Weill Cornell Medical College; and Min P. Kim, M.D., thoracic surgeon in the Department of Surgery, and assistant professor at Weill Cornell Medical College.

Researchers at The Methodist Hospital and the University of Texas M.D. Anderson Cancer Center have announced the development of a new technique that allows scientists to grow lung cancer cells in three dimensions. The process uses biological matter to form miniature lungs that mimic the structure and function of real lung cancer, after which researchers add human lung cancer cells. This technique could accelerate discoveries for a cancer that has benefited little from scientific research over the last several decades. Principal investigator Dr. Min Kim says new models for lung cancer research are crucial since current models cannot accurately predict what will happen in patients with lung cancer.

Christie Ballantyne, M.D., director of the Center for Cardiovascular Disease Prevention at The Methodist Hospital.

Researchers with The Methodist Hospital and eight other institutions say with a little exercise and dieting, overweight people with type 2 diabetes can still train their fat cells to produce a hormone believed to spur HDL cholesterol production. Ballantyne says of the findings published in the Journal of Lipid Research, that “even overweight people who are physically active and eating a healthy diet are getting benefits from the lifestyle change.” Ballantyne was principal investigator for the study.

Youli Zu, M.D., Ph.D., director of the Cancer Pathology Laboratory at The Methodist Hospital Research Institute; co-director, hematopathology in the Department of Pathology and Genomic Medicine, The Methodist Hospital; associate professor of pathology and laboratory medicine at Weill Cornell Medical College.

Zu has received a $1 million R33 grant from the National Cancer Institute to develop and validate an assay for the detection of circulating tumor cells. According to Zu, this test will be a great advance over the existing test, and will allow for earlier detection and more accurate results. The proposed assay will allow physicians to detect circulating tumor cells in one drop of patient blood and provide results in seconds.

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CLINICAL

Notes

Christie Ballantyne, M.D., director of the Center for Cardiovascular Disease Prevention at The Methodist Hospital.

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