Inside Medicine Magazine Fall 2018 by Inside Medicine

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10/11/2018 1:47:39 PM

features &

CONTENTS

Sharing with Purpose

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VOL 2

ISSUE 11

CO N T R I B U T O R S

FEATURES Heart Failure Management

CONTENT

Robotic Spine Surgery

an innovative approach

Life Really Does Matter

in the days of genetic testing

Tailgating with a Healthy Diet

Shushing the Stigma one physician's story of living with diabetes

Sydney Taylor Larry Parker, MD Cameron Smith Page

William T. Budd, PhD Teairah Wilder Brett Davenport, MD

how to stay healthy during football season

Philip B. Adamson, MD, MSc, FACC

Bobi Jo Creel, RN, MSN, CRNP

robotic technology in the operating room

a story of one family's heartache

Ovarian Cancer

Kimberly Waldrop, MA

David B. Engle, MD, MS, FACOG

Kari Kingsley, MSN, CRNP Nisha Mailapur Carmen Moyers RD, LD Elisa Brooks Heather Morse, MS, ATC, OTC

Join our mission to establish and grow an alliance among our community and healthcare providers. Together, we can change the way healthcare information has been and will be distributed for years to come.

To reach our readers, whether through editorial contribution or advertising, please contact Kelly Reese at kellyreese. im@gmail.com or 256.652.8089

Making a Difference

Jonathan Ramsey, MD Kelly Reese S A LE S & M A R K E T IN G

Kelly Reese, Founder Lisa Layton, VP Sales/Marketing Heather Mendez Will Steward CH I E F E D I T O R I A L WRITER

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

Leigha Parker Karen Gauthier The information and opinions contained in this publication constitute general medical information only and should not be construed as medical advice. Before making important medical decisions, readers should consult with a physician or trained medical provider of their choice and have their needs and concerns assessed in a clinical setting appropriate for their problem.

P U B LI S H E R S

Blake Bentley, President www. in s ide me dic in e ma g az ine.com

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} FROM THE EDITOR

Happy Fall

I can finally feel a little crispness in the air and I can actually see signs of the changing of the season. In Alabama, it seems we are always waiting for the weather to change! With fall comes football, holidays, and typically extra family time. I just love this time of year!! In this issue of Inside Medicine, we have an article from Carmen Mayers giving us good health tips and ideas to keep ourselves mindful of what we eat with all the busyness of fall. There is also a new weight loss clinic in the area, The Lighter Weigh, which can help us stay on track or lose weight during this time of the year. Obesity is already a problem in our state, with the holidays and family get togethers on the horizon, it’s a great time to become aware of these things. At Inside Medicine, we are loving this edition! There are so many good articles we just could not get the magazine printed fast enough! I can’t wait for you to read our heartfelt stories of infant loss and details of the NICU. We never know what someone is going through or what they have already endured. These stories are good reminders. In the feature story, “Life Really Does Matter”, read about one family’s heartache. And in another feature story, “Preemie Strong”, find out how one family endured the NICU and successfully conquered it. Elisa Brooks reminds us in “Finding Grace” how to say no when we are overbooked and learn to give yourself grace, give other people grace, and how to find grace from God. It is a breath of fresh air to realize there is such a thing as grace! How we treat people affects them as well as ourselves. In “A Night to Remember”, Bobbi Jo Creel illustrates this point. We can really just be at the right place at the right time. Along with these awesome stories, we’ve got lots of information packed in this edition. You can read about things from robotic spines to hormone balance to astigmatism. I think you are going to find something, or many things, which give you great knowledge you may even want to share with others. At Inside Medicine, it is always our prayer to be here to help our community and show a love for our Savior. There are so many stories out there and we want to share them with you! We are always looking for new content and features. Please contact us if you ever have an idea, comment, or suggestion, or just want to be included in our magazine. We love hearing from you and appreciate your support!

p o r d l a W y l r e b m Ki

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} COVER FEATURE

An Innovative Approach to

HEART FAILURE MANAGEMENT by, Philip B. Adamson, MD, MSc, FACC

Despite medical advancements, heart failure is a worsening epidemic. 8

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The number of people in the United States with a diagnosis of chronic heart failure is expected to double in the next 15 years–forcing physicians to face the significant challenge of delivering quality health care for a growing population. There are many medications and devices focused on heart failure management that bring great hope for clinical improvement–and the potential for recovery. Even still, there is a significant gap in treatment options. For example, half of the approximately six million people living in the United States with symptomatic heart failure have a normal ejection fraction. While there has historically been limited medical therapies to improve patient outcomes, new innovations are allowing us to identify advanced heart failure patients earlier in their progression, resulting in improved survival and quality of life.

REMOTE HIGH-TECH MONITORING

As a heart failure cardiologist, I can attest to the emotional and physical burden that this disease brings to patients and their caregivers, especially when hospitalization is needed. Heart failure remains the leading cause of hospitalization in Medicare beneficiaries, and accounts for a large percentage of the overall $40 billion cost of expenditures. In fact, clinical evi-

Courtesy of Abbott

dence shows that increased hospitalizations can actually compound challenges for patients and lead to worsening cardiac function and even mortality. This is important since hospitalizations for advanced heart failure patients tend to be recurrent with 25 percent of patients readmitted within 30 days and 50 percent within six months. While Medicare penalties through the Hospitalization Readmission Reduction Program appear effective in lowering 30-day readmissions, recent analyses suggest that increased mortality is associated with the national trend for reduced readmissions. This phenomenon does not appear to be the case with other targeted reasons for hospitalizations, such as myocardial infarction and pneumonia. One major challenge in clinical management of patients with heart failure is that most of the patients’ lives are spent away from their health care provider, leaving physicians to rely on a reactive approach for managing their patients once symptoms present. Many patients also feel very anxious when they are not in the general proximity of their care team, which limits their ability to travel or enjoy visiting loved-ones who do not live nearby. Traditional methods of tracking have not overcome this issue, since relying on changes in physical symptoms simply does not help keep patients from developing acute decompensation. One novel solution to this problem is the, Abbott CardioMEMS HF System™, which consists of a tiny permanently implanted pressure sensor in the pulmonary artery (PA) with the ability to remotely measure PA pressures daily

Courtesy of Abbott I n s i d e M e d i c i n e | Fa l l I s s u e 2 0 1 8

...cont’d from page 9

from the patient’s home. This continuous monitoring alerts the patient’s care team when PA pressures are rising. This is critical as PA pressures increase long before patients develop worsening symptoms or changes in weight. The automatic notification process, coupled with the ability for providers to routinely review patients’ PA pressures, has revolutionized the heart failure disease management paradigm by providing an early warning system for physicians to more proactively manage the care of their patients. The CardioMEMS HF System™ also allows patients to know that, no matter where they are, they can be monitored with clinically actionable information. In fact, the information provided by PA pressure monitoring takes the guess-work out of managing symptoms, weight changes and even estimation of disease progression by physical examination. Instead of a gross approximation of PA pressure–this technology provides the actual number to inform personalized remote management.

FDA APPROVED, ON THE MARKET AND BACKED BY CLINICAL DATA

The CardioMEMS HF System™ is the first and only FDA-approved heart failure monitoring device of its kind to significantly reduce hospital admissions for NYHA class III heart failure patients who have been hospitalized in the previous 12 months. The technology has been proven to reduce hospital admissions by 37 percent when used by physicians to manage patients with previously hospitalized and persistently symptomatic heart failure after 15 months of follow-up. Approximately 10,000 patients have been implanted with the device as of September 2018. While this marks a major milestone, we know the potential for greater adoption is high. The GUIDE-HF trial, the largest heart failure medical device trial in history, is now underway and builds on previous clinical trials to study whether the CardioMEMS HF System™ can improve survival and quality of life while reducing heart failure hospitalizations for people living with NYHA class II-IV heart failure. The five-year investigational study launched in March 2018 and is open to hospitals and eligible to patients nationwide.

REDEFINING HEART FAILURE MANAGEMENT

Managing the oppressive morbidity and mortality associated with heart failure is a daunting challenge for patients and health care providers. Innovative sensor technologies, such as remote PA pressure monitoring, represent a tangible tool to help manage the pandemic of heart failure. This technology is available and ready for integration into routine clinical practice for patients living with advanced heart failure. Philip B. Adamson, MD, MSc, FACC is a Heart Failure Cardiologist and Medical Director at Abbott. Prior to his work at Abbott he served as director of the Heart Failure Treatment Programs at the University of Oklahoma Health Sciences Center and The Oklahoma Heart Hospital in Oklahoma City. 10

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Empowering the

TRANSFORMATION OF HEART FAILURE Innovating with product solutions that set new standards of care across the heart failure continuum

Abbott One St. Jude Medical Dr., St. Paul, MN 55117 USA Tel: 1 651 756 2000 SJM.com/Beat-As-One St. Jude Medical is now Abbott. Rx Only Brief Summary: Prior to using these devices, please review the Instructions for Use for a complete listing of indications, contraindications, warnings, precautions, potential adverse events and directions for use. ™ Indicates a trademark of the Abbott group of companies. © 2018 Abbott. All Rights Reserved. 29521-SJM-HGEN-0918-0060 Item approved for global use.

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3D Printing

TrueFit Dentures

by Sydney Taylor

Dentures have always been a tedious prosthetic to manufacture. From sticky impressions, to laborious fabricating, to sometimes endless perfecting, thereâ&#x20AC;&#x2122;s never a simple moment in creating this product. In addition, once this product is complete, thereâ&#x20AC;&#x2122;s always the possibility of damage, misplacement, and even total destruction, regrettably resulting in a complete do-over from step one. 3D printing, however, removes the hassle of traditional denture manufacturing and brings technology to the forefront of this task to print, yes print, a prosthetic that Oral Arts is proud to present: TrueFit, an all-new revolutionary denture. 12

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There are no messy models, no wasted materials, and every patient’s design is stored for quick and simple reprints for any case of damage, loss or total destruction. Dentures have always been a tedious prosthetic to manufacture. From sticky impressions, to laborious fabricating, to sometimes endless perfecting, there’s never a simple moment in creating this product. In addition, once this product is complete, there’s always the possibility of damage, misplacement, and even total destruction, regrettably resulting in a complete doover from step one. 3D printing, however, removes the hassle of traditional denture manufacturing and brings technology to the forefront of this task to print, yes print, a prosthetic that Oral Arts is proud to present: TrueFit, an all-new revolutionary denture. 3D Printing is the key to the future of fabrication. Over the years, 3D printing technology has evolved into a refined and complex innovation capable of delivering products that are durable, strong, and, crazily enough, printed from computer files. Enterprises throughout the globe have fabricated their work from this invaluable technology. From printing bicycles, to generating helicopter blades, to even replicating rocket engines for NASA, 3D printing is quickly becoming the top manufacturing method for products everywhere in every field of study. In the dental field, Oral Arts Dental Laboratories have researched the success of 3D printing, and have implemented this futuristic technology into their own dental prosthetic fabrication. As a leader of the dental industry, Oral Arts researches constantly for progressive development to apply in their laboratory while performing in-house beta tests to remain abreast of all industry growth. Needless to say, 3D printing proved to be the next step of advancement for the lab. After partnering with the cutting-edge technology of Carbon, Inc. 3D Printers, Oral Arts has reinvented the fabrication process for a popular dental treatment: the denture. This digital phenomenon is not just revolutionary in its sheer fabrication. TrueFit, the new, radical 3D printed denture, illustrates a genuine way to bring patients a smile with results that far outweigh the traditional archaic denture design. TrueFit stems from being completely CAD/CAM scanned and modified, digitally achieving the perfect fit for a patient before

the product design zips to the printer. And, as a finishing touch, there’s no change required in the dental professional’s methods of attaining an impression to have these ground-breaking dentures fabricated. All chairside impression work remains up to the doctor’s preference, and once an impression is ready, Oral Arts does the rest. Additionally, by pairing elite CAD/CAM designs with the state-of-the-art engineering of the Carbon Inc. 3D Printer, TrueFit dentures are designed not just for accuracy, but for beauty and durability that lasts. Like Oral Arts, Carbon Inc. is also an industry leader whose 3D Printers are engineered with the highest resolution on the market, illustrating remarkable miI n s i d e M e d i c i n e | Fa l l I s s u e 2 0 1 8

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...contâ&#x20AC;&#x2122;d from page 13

croscopic details in the final product. A TrueFit denture constructed from a Carbon Printer is anatomically stunning, chiseled flawlessly to exhibit a natural smile full of dynamic detail and esthetics. In addition to exquisite attraction, these dentures are also 3D Printed in the same machine as auto parts, skateboards, and even soles of Adidas running shoes, making TrueFit conditioned to withstand tough elements, embrace harsh impacts, and provide a durable, lasting smile. The future has climactically arrived at Oral Arts Dental Laboratories. With impeccable design bound to cutting-edge technology, TrueFit Dentures have redefined denture prosthetic fabrication with precision, speed, and final results that genuinely fit true. This restoration advancement has opened a plethora of possibilities not just for Oral Arts, but for the dental field as a whole. Printable dentures could be just the start of an entire dental field revolution.

Who knows what the next monumental dental innovation will be? Rest assured, Oral Arts Dental Laboratories will be on the front lines of the dental innovation movement, paving the way to bigger and better prosthetics and dental treatment for years to come. Oral Arts Dental Laboratories 2700 South Memorial Parkway, Huntsville, AL 35801 256-533-6670 www.oralartsdental.com

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} SURGICAL TECHNOLOGY

Robotic spine surgery

by Larry Parker, MD

So you want a robot to do your surgery?

You can now sign up...well at least for robot assisted surgery! Huntsville Hospital has recently purchased the Mazor Robot for spine surgery and it is ready for action. I am sorry to disappoint you or perhaps I am happy to reassure you that a robot is not going to roll into the operating room, scrub in and replace your humanoid spine surgeon at the OR table. So exactly how does a robot help in spine Surgery? Letâ&#x20AC;&#x2122;s describe Mazorâ&#x20AC;&#x2122;s role as a very sophisticated assistant. Spine surgery involves two fundamental tasks: Decompression and Stabilization. Decompression involves the delicate process of relieving abnormal and painful pressure on compressed neural structures namely the spinal cord or spinal nerves. This abnormal pressure can be the result of a disc herniation or arthritic bone spurs that result in spinal stenosis. Even tumors, infection, or trauma can cause painful pressure on neural structures. Pain, weakness or even paralysis can occur from compression on neural structures. Well the robot is not ready to replace the experienced hands of your spine surgeon to perform decompression techniques at least not yet! Stabilization involves strengthening weak areas in the spine. In addition to causing abnormal pressure on nerves, degenerative

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disease, fractures, tumors, and infection can destabilize the spine. Stabilizing a weak area of the spinal column involves fusing the weak area to relieve pain and prevent further danger to the spinal cord and spinal nerves. Fusing a weak, degenerative, or unstable segment of the spinal column can also allow the spine to support the body for ambulation. Modern spinal fusion techniques utilize spinal instrumentation. Instrumenting two or more vertebrae together is accomplished by using screws and rods. Screws placed in the spine are typically placed in a narrow tubular structure called the pedicle. This is where the Mazor robot assists the surgeon. Using preoperative imaging from a CT scan the Mazor robot can map out the exact trajectory to safely place the pedicle screw in the best location even with a very small incision. In some cases this allows the surgeon to become more efficient and use smaller incisions to instrument the spine. Patients can mobilize quicker and sometimes go home from the hospital sooner. I expect robotic techniques will continue to evolve and assist the spine surgeon in the operating room. But I assure you that a robot is no where close to replacing your spine surgeon. So if you need a spine surgery go with the advice of your surgeon. He or she may want to leave the robot in the hallway!

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} TESTIMONIAL

When Your Hands are Enough by, Bobi Jo Creel, RN, MSN, CRNP

Have you ever had a moment in which you thought, "Man, I wish I could have done more?" Or, perhaps, a moment in which you were present at the right place at precisely the right time and afterwards could not stop thinking "what if?" I have had many of these moments in my professional life--moments where I held someone's life in my hands with every resource within my reach. However, I had not had a situation quite like a recent experience. Whether it be a near-miss or nothing short of perfect, divine timing for an intervention, there was never a night that convinced me to write this to implore you more than a hot, humid Saturday night here in our Rocket City. Once I was home, relaxed and had all the grit from a gas station parking lot washed off me, I felt convicted to share this. No matter if you are a stay at home parent, retired, a student or employee, please make it a point to at least have taken a non-medical, bystander CPR class. You never know where or when you may be of use. You don't have to know it all or even close, but knowing enough to be someone's lifeline can really make all the difference. That night, for some reason, after keeping my son out far too late at his favorite Saturday night event (Huntsville Speedway), he and I were engaged in a conversation when my brother, his wife, and my husband noticed a person being pulled out of a car at a convenience store we were quickly passing. We all paused for a second to try and register what was happening when my sister-inlaw thought they may be in distress, so we doubled back. I never saw them. When we pulled up under the bright lights, it was clear there was a life-threatening emergency. A gentleman had helped to pull a young, unconscious man from the backseat of a car. As his friends surrounded him crying and panicking a bystander crouched down over the young man and, with shaking hands, nervously started CPR. As I practically jumped over my family to get out of the back seat of the truck, I identified myself and immediately assessed the situation to be of assistance. After a quick head-to-toe assessment of the young man, while the bystander performed high-quality CPR, I was able to assist with his airway and breathing while speaking to the 911 operator on a bystander's phone that a very nervous, distraught young lady held out to me. 20

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By this time, it was clear it would be a few minutes until EMS arrived and it also became clear to me at that moment that we were resuscitating an apparent overdose victim. Before I became a Nurse Practitioner, I cut my teeth in Critical Care, so I guess you could say that "running codes” is in my blood, but I’ve never ran one under lights, with my bare knees on gravel-covered asphalt at a gas station. This was not "my place," but it is amazing what can happen when a solution meets a need. The young man most likely had no idea at after 9pm that night, he would be under our sets of hands as we prayed and worked with no resources available to us. Pulse established, and rescue breaths delivered, thankfully, rapid response volunteers arrived. I have never been so thankful for an Ambu-Bag in all my career. The volunteers appeared to have had a long night, but they had that, a Narcan and were willing to help. After administering it, we supported him and got his breathing better established, but he did not come around in a timely manner. So, I asked them to prepare another dose. The female responder looked at her partner and I knew we were about to hear something that was not reassuring. The rapid response only had one Narcan and, once used, we were back on our own.This was the 4th or 5th OD that week for them and that was all they were granted. The new shipment was set for the next morning. I, being used to hospital resuscitation, longed to be able to get this young man an airway to aide him and ensure that we had him...but I didn’t. EMS was still on their way, but here we were, again. We were on our own. I asked if they had a stethoscope and they did! And they had an oximeter. With those, we continued CPR and support to the point his oxygen levels improved to normal range. He still required almost full assistance at that time, but we were giving him his best chance. With no more resources, we had our hands, our skill sets and God was there with us. That was more than enough. That young man may not know it, but Jesus loves him and didn’t want him to

suffer. He put that bystander and our truck (out too late and out of our normal routine) in that parking lot for a reason and showed us He was there. I witnessed strangers come together. I saw calm come over a storm. I felt peace and clarity as I helped get blue lips back to pink. As we put him in the ambulance that finally arrived, he moved for the first time in far too many countless minutes and all we could do is thank God for helping us, as well as pray that at some point the young man realizes what a gift he has been granted. When his panic-stricken, brown eyes fluttered open and locked with mine, I had peace that I had done what I had been called to do and it really had nothing to do with being a medical professional. That is why this needed to be shared. If that non-medical person who saw a need and, despite being very frightened, had not jumped in, put his hands on that man and do his best to meet a need, this story might not have ended this way. I may have been two minutes too late. If no one would Bobi Jo Creel, RN, MSN, CRNP Cullman Internal Medicine, P.C. 1890 Alabama Highway 157 Suite 300, Cullman, AL 35058 256-737-8000 www.cullmaninternalmedicine.com

have been equipped with the basic knowledge of CPR, I would not be able to share that I later found out he survived the whole ordeal. I didn’t save him. God did. He put the right people there at the right time. Please don’t judge that young man. Pray for him. God can use that mess of a night in his life for Him. He doesn’t give up and none of us did either. Friends, things happen. It’s not always self-inflicted. This is not a commentary on drug abuse and the pitfalls of addiction. It could be a cardiac event, a person choking or a near-drowning. Your preparation could help save a friend, a family member, a child at the park, a person in a restaurant or a stranger at the beach. You never know where you will be or what you will come across in this world. I simply ask one thing of you and that is to equip yourselves. First with the One who knew how my (and my family’s) night would end before we even woke up that day, and, second, with the tools you need to help save a life-your hands, a little knowledge and a whole lot of faith. "How Do I Learn More About Becoming CPR Certified" Contact local hospitals, community centers and fire departments in your area to see what class options are available for you or visit The American Heart Association's website at www.heart.org/en/cpr to find online options and class listings in your area.

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Life } COVER FEATURE

really does matter

by, Cameron Smith Page

Our son was going to be born and there was nothing our doctor could do to stop it and at twenty-one weeks and two days my son was too young to survive. All year long we see people raising awareness for different causes. They sport ribbons, change their social media avatars, participate in marches, and just about every month has a particular cause tied to it. While I have supported efforts for various issues and illnesses until recently I have never been intimately tied to any cause. I have been blessed with health and happiness, but unfortunately life doesn’t always go as planned, so here I sit writing this story…my story. My story began in late January of this year when my husband and I found out we were expecting. We were early in our marriage and eager to grow our family, which already included my husband’s five-year-old son. We could not have been happier. Everything was going well. We learned at thirteen weeks we would be welcoming a little boy. We wanted to give him a name that had meaning so we chose to name him Robert Craig after the important men in his life. Robert is my husband and father-in-law’s name and Craig is my dad and brother’s name. Now that we knew who our little baby was going to be we kept trucking along and preparing for this season of our lives.

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Everything continued to go well for us until I went in for my twenty-week appointment. It was during that appointment that I was told my cervix had shortened. This was my first pregnancy, so I did not really know anything about potential risks and my doctor did not seem too concerned. He prescribed me daily progesterone and recommended that I reduce my activity. I trusted him, so I left eager to follow his orders and continue moving forward. I was scheduled to see him back in three weeks. Unfortunately I never made it in for that appointment. Instead everything changed a little over a week later on June 3rd. That morning I woke up really early with intense lower back pain. I decided to get up to go to the restroom and walk around for a minute to see if it would stop. That is when I realized I was bleeding. I immediately woke my husband who then rushed me to the hospital where I was sent to labor and delivery triage. At first the nurse did not seem too concerned, but when she decided to check my cervix her expression quickly changed. I knew it was bad. She informed me that my cervix was almost fully dilated and that my membranes were bulging. I was in labor. Just about this time my doctor who happened to be on call walked in. He proceeded to check my cervix for himself and confirmed what the nurse had told us. He then delivered the news my husband and I were not prepared for. Our son was going to be born and there was nothing he could do to stop it and at twenty-one weeks and two days my son was too young to survive. I was told it was hospital policy not to intervene and take a baby to the neonatal intensive care unit until twenty-three weeks. In that moment my world stopped. Thinking back on that moment it is a blur. All I remember is my husband and I holding each other and crying. He kept telling me, “I’m so sorry. I’m so sorry I can’t fix this.” I am not sure how long we sat there crying, but at some point I managed to text my parents who showed up not long after along with more of my family. After my parents, brother, and sister-in-law arrived we all decided it was in the best interest to transfer to a hospital with high-risk specialists. So I was taken by ambulance to another hospital in town. The ambulance ride felt like an eternity. They would not let my husband ride with me, so I rode alone. I was so incredibly scared, but I tried to be brave for my family. When I got settled into the new hospital and finally met with the specialist he confirmed what my doctor had told me, but he did not want to give up on us. He agreed to attempt a procedure called a heroic cerclage in which he would push the bulging sac back in and stitch my cervix closed. He informed us that this would be the most controversial one that he had ever attempted and that it would likely end with him breaking my water or the stitch rupturing, but if we were on board he would try. My husband and I gave it no thought and told him to go for it. At this point we knew the outcome was certain if we did nothing, so we felt like we had nothing to lose and

everything to gain. The doctor informed us that he would put us on the OR schedule for noon the next day and proceed with the procedure as long as my amniocentesis came back good. We made it through that night and the next morning I had the amnio done. By this point I was in horrible pain and I cried and moaned as I gripped my husband’s hand with every contraction awaiting the results of the amnio. When the nurse came in and informed me that they were about to come take me to the OR I felt hopeful, but then the doctor came in with the bad news face. He did not like my amnio results and was calling the procedure off. He told us he was not comfortable risking my health because the results indicated an infection. Just like at the other hospital the doctor told us that they would not intervene with our son and even if they tried and he managed to survive he would have a terrible quality of life. So that was it. My son was going to die and there was nothing I could do. The doctor made the decision to send me upstairs to labor and delivery, order an epidural for me, and let me wait for my son’s arrival. I was wheeled upstairs to a room marked by a leaf on the door letting everyone who worked there know that this was a sad room. A room where hearts break and people’s lives change forever. In that room we waited. No one could tell us how long it would be before my water broke. Family took turns visiting and keeping us occupied. Somehow we managed to make it through another day. The evening of the 5th I listened to my son’s heartbeat on the monitor one last time and went to sleep with the hope that the doctors were wrong and we could hang in there just a little longer so he had a chance. That did not happen. I awoke around 5:00am on June 6th as my water broke. My room was quiet and my husband was asleep on the couch. I woke him up and we paged the nurse. As nurses and

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During our time with him we dressed him in his first outfit, we had him baptized, we prayed over him, rocked him, I told him how beautiful he was, and we loved him fiercely. doctors entered our room for the delivery I just remember thinking I am not ready for this, but it was happening and I could not stop it. After four pushes my son entered this world at 5:40am weighing one pound and one point eight ounces. He was twelve and one-fourth inches long. There was not a dry eye in the room and in that moment a flood of all the different emotions I was feeling flowed out and I cried out like I have never cried in my life as they placed him on my chest. My heart was so overjoyed and in love with this beautiful little boy that my husband and I had created, but at the same time my heart shattered because I knew he was not going to stay. As I held him tight against

Image credit: PACN Community Pregnancy Assistance Center North www.pacncommunity.org

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my heart he moved his little legs and opened his mouth trying to breath on his own. He mad noises and his heartbeat was strong. He was very much alive. During our time with him we dressed him in his first outfit, we had him baptized, we prayed over him, rocked him, I told him how beautiful he was, and we loved him fiercely. Around 9:00am his little heart stopped. When it was time for him to go I looked my son over once more committing every little detail I could to memory. I held his little hand, which by now had gone cold then I gave him one last kiss on the forehead. After that I did the hardest thing I have ever done. I handed my son and a piece of my heart over to the nurses, so he could be taken to the funeral home were I would get to see him one more time to help dress him for his funeral five days later. As I reflect back on my story there are just no words to accurately describe what it is like as a mother to watch your child’s life begin and end in your arms. I had to let go of every hope and dream I had for my son…all the birthdays, holidays, first days of school. There is not a minute that goes by where I am not aware of his absence. I miss him more than I ever thought it was possible to miss someone. In the three short hours I had with him he changed my life in the most incredible way and I am so glad I got the opportunity to meet him. I will always strive to live my life in a way that he would have been proud of. My hope in sharing my story with you all in honor of Pregnancy and Infant Loss Awareness Month is that some of the silence and stigma around pregnancy and infant loss will be broken. It is real and it can happen to anyone and it does happen. According to statistics one out of every four pregnancies will result in miscarriage, stillbirth, or neonatal death. What us loss parents need is not silence. We need conversation. We need support. We need advancements in medicine. We need people to ask about our babies. We need our children’s lives to matter no matter how short. Robert Craig matters, as do all the other babies that left this world too soon.

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Crystal Ditto needed a recipe for relief. Thanks to back surgery and the expertise of neurosurgeons from the Spine and Neuro Center at Huntsville Hospital, her smile is back and she can get back to dishing out the friendly customer service that had become a hallmark at her restaurant. Watch the rest of Crystal’s story at

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BALANCE IN HEALTH by William T. Budd, PhD

What does it mean to have balance in terms of health? In biology and healthcare, the term homeostasis is used to describe the equilibrium maintained by our bodyâ&#x20AC;&#x2122;s systems. 26

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An important component of our body’s ability to maintain this stable state are the bacteria that live in us and on us. Typically, we only think of bacteria when they make us ill. However, the majority of bacteria are not capable of making a healthy person sick. In fact, there are many species of bacteria that are fundamental for healthy living. In 2008, the National Institute of Health launched the Human Microbiome Project (HMP) to understand the role of bacteria in health and disease. Studies show that humans are composed of 10 bacteria for every human cell and that composition/ function of your microbiome is essential for your health.As an example,bacteria in the gut have been linked to a number of diseases such as diabetes and inflammatory bowel disease.

VAGINAL BALANCE

Of particular concern to women is vaginal health. Bacterial vaginosis (BV) is one of the most common gynecological diagnoses and is a disorder caused by an imbalance in the bacteria of the reproductive tract. One in three women currently have bacterial vaginosis and in fact, almost every woman will suffer from at least one incidence of this condition during her lifetime. The diagnosis was once thought to be a mere inconvenience but is now known to be a major health concern that can lead to preterm child birth, pelvic inflammatory disease and an increase in the incidence of sexually transmitted infections. Symptoms of bacterial vaginosis include; abnormal vaginal discharge (white/ gray), itching, painful intercourse, and odor (fishy smell) that worsens after intercourse. Traditional therapy for BV is administration of an antibiotic, most commonly Metronidazole. The exact cause of bacterial vaginosis is not understood. There are a number of factors that increase one’s likelihood of contracting the disorder; such as, increased number of sexual partners, unprotected sex and cigarette smoking.The clinical treatment of BV is difficult as the recurrence rate is extremely high (~60% within a month) despite the use of oral and intravaginal antibiotics. Failure to eradicate BV is frustrating to clinicians and patients. Women suffering from this disorder often describe a lack of sexual interest, low self-esteem and depression. Under normal conditions, vaginal flora is a relatively stable environment dominated by a single Lactobacilli species. One milliliter of vaginal fluid contains over 100 million bacteria, over 99% are Lactobacillus crispatus and are responsible for keeping other organisms at bay by maintaining an acidic pH. During the development of bacterial vaginosis, Lactobacillus crispatus organisms begin to die off setting off a chemical cascade (inflammatory response) that changes the environment allowing other organisms to take hold. The inflammatory response associated with BV is increased during pregnancy and exacerbates the risks of the disorder. Unprotected sex, oral sex with a partner with poor oral health, or use of an antibiotic can cause the initial loss of protective organisms. Loss of the protective bacteria allow other organisms to establish residence. The complexity of the microbial community evolves. It shifts from a homogenous environment dominated by a single organism to a heterogeneous community creating a tough physical structure similar to dental plaque.The structure protects the bacteria allowing them to escape immune system response and antibiotic

therapy. For these reasons, BV is difficult to eradicate and will often recur. In fact, current literature shows once a woman has BV her flora is permanently altered, and the healthy Lactobacillus species is replaced by a non-protective member of the family knows as Lactobacillus iners. The permanent loss of this organism creates a situation in which a woman can swing into and out of BV frequently with some women reporting up to ten occurrences per year.

DIAGNOSIS

There is not a consensus approach on the diagnosis of BV. BV is often a diagnosis of exclusion. Clinical examination for the presence of vaginal discharge and microscopic examination for “clue cells” are often used to diagnose BV. However, studies show these methods are not always accurate. The human microbiome project has created a set of tools that can be used clinically to evaluate the flora of the vagina and provide physicians with a more accurate depiction of the vaginal flora. Using molecular signatures, clinicians can, for the first time, evaluate the balance of the vaginal flora and accurately diagnose the presence of bacterial vaginosis. Accurate diagnosis is essential as studies show that presumptive treatment leads to more problems.

TREATMENT

For some women, the symptoms of BV may resolve on their own but for most treatment by a clinician is required. Antibiotic therapy (Metronidazole) is often required to kill off the non-resident organisms that have taken hold. Studies show that alternative natural therapies may be more effective than antibiotics. Garlic produces a strong antibacterial compound known as allicin. Clinical trials conclude the use of a garlic tablet during a BV episode is more effective than Metronidazole and results in a faster reduction in symptoms. Boric acid suppositories can be purchased over the counter and are also as effective as Metronidazole. It is important to consult a clinician prior to initiating therapy as there is an overlap in symptoms between BV and other infectious syndromes. Accurate clinical diagnosis is important as there is risk in elimination of the healthy flora. The greatest challenge in permanently eliminating BV is replacement of the protective organism. The use of a probiotic composed of Lactobacillus can restore bacterial balance and reduce the rate of recurrence. The overall treatment goal is to reduce the number of non-resident organisms and increase the number of healthy Lactobacilli.

CONCLUSION

Bacteria are a key component of a healthy lifestyle. However, there exists a delicate balance in the numbers and types of organisms. Prevention and treatment are necessary to help maintain the correct balance. Please contact your physician if you ever have questions concerning your balance. William T. Budd, PhD Chief Scientific Officer of Madison Core Laboratories www.madisoncorelabs.com I n s i d e M e d i c i n e | Fa l l I s s u e 2 0 1 8

} FEATURE

Preemie Strong The NICU Family You Never Knew by, Teairah Wilder

Pregnancy is an amazing blessing and each baby is a little miracle. When you get pregnant there is rarely a thought of the Neo-Intensive Care Unit (NICU). The NICU is a place that no one wants their baby to be, but for some of us, that is exactly where they end up. No one can ever prepare themselves for the NICU, nor should anyone have to. The NICU can be a very terrifying place. There are machines and tubes. Some babies have open cribs while others are in enclosed looking machines. There are people everywhere; with nurses and doctors filling your ears with terms that don’t even make sense. All you know is that your baby is in the NICU and not in your arms. The fear, the unknown, the guilt, the everything sets in…But know that YOU are NOT ALONE! There are millions of people out there who have gone through what you are going through. You will hear alarms from everything. Alarms for your baby’s heartbeat, their breathing, their oxygen level, their feedings, their IV, their blood pressure, and their breathing machines. You will sit by your baby’s bed just staring at them or reading their monitor and hoping and praying for everything to be ok. There are times where you may hear that you cannot hold nor touch your baby. “Your baby can not handle the stimulation,” the doctor may say. I am a mom of not one, not two, but three preemie babies. My first son was born at 36 weeks and spent 7 days in the NICU. I started preterm labor at 28 weeks and as a result was in and out of the hospital until they kept me for four weeks on Magnesium. I was sent home at 32 weeks even though I continued to have contractions. The doctor felt the baby and I would be ok to be home at this point. At 36 weeks my contractions became very painful and I knew this was it. Three hours after arriving to the hospital my water broke and the nurse nor I knew it because I had 28

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been leaking fluid. We found this out by my baby’s heartrate dropping into the 40’s and it was discovered I had a prolapse cord. I was rushed to an emergency c-section and Rowan was born at 5 pounds 14 ounces. The twins were a much longer and harder road. I started preterm labor at 23 weeks and was in and out of the hospital for 4 weeks. At 27 weeks Jonas was born at 2 pounds 1 ounce (910 grams) and Rosalie at 2 pounds 2 ounces (935 grams). Both were put on the ventilator within a couple of hours of being born. We knew we had a long road ahead of us but had no idea what was in store. With Jonas, we went through 2 pulmonary bleeds which meant multiple intubations throughout the shifts and the doctors and nurses not thinking that he would make it. Once we got past the pulmonary bleeds we found out on day 10 that he had grade 3 bilateral brain bleed. (Bleeds are on a scale of 1-4, 4 being the worst) I broke down

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yet again on this day after being told that he had a 70% chance of having major deficits. After a long day of crying, my husband and I told ourselves that God has them and whatever happens, happens. We turned our faith over to God, the nurses, and doctors. It was 14 long days before we were able to hold Jonas. With Rosalie, we seemingly had it a little easier. She was only on the ventilator for 5 days and we got to hold her on day 10. On day 10 we also found out that she suffered from a grade 4 brain bleed and was told that she had a 70% chance of having cerebral palsy due to where her bleed was in her brain. Needless to say, I lost it! I do not believe that God makes bad things happen to us, but I do believe that God uses what does happen to us in a way to not only teach us but help and teach others as well. God had a plan for us when we ended up in the NICU, I have no doubt about this. I guess you could say the NICU to us was a blessing in disguise. Don't get me wrong, I would have loved not to have been in the NICU but it has made my family the people we are today. The NICU blessed us with a family that we never knew about. This family will forever be there for us and understands every struggle and every success. God took a bad situation for us and turned it into a gift. We have the ability to help other families that are going through what we went through and be able to speak the word of God. I want to thank everyone at Huntsville Hospital who helped keep my babies alive and treated them like their own babies. They all showed love and care towards my babies. They cared for my micro-preemies when I couldn't be there! They are all our Heroes. About 6 months after the twins were born I knew that I needed to write a book to help others through this journey. It took a little over 2 years to do it but I’m glad I did. There were so many times that I didn’t know anyone who went through what we were going through and wished that I had someone who understood. Our families did not really grasp what we were going through. They got to take their baby home, they did not have to leave them at the hospital. They did not have to watch their baby fight for their life.

I decided to write “Preemie Strong,” to help others going through the NICU hopefully not feel so lost. Also, to help those who know someone that is going through the NICU and to understand what they are going through. I hope and pray that this book can bring some comfort and/or understanding to others. $1 of book purchases goes to give back to the current NICU families. 30

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REVIEWS ON AMAZON: Standfield wrote: “I purchased this book to help me understand what some friends had been through. It opened my eyes to a world that no parent ever wants to experience. I'd guess the book will never fully put you in the understanding of what it would be like to be a NICU parent, but it definitely would prepare you or help you to empathize with your loved ones. I'm glad this book was written, and I appreciate the intimate, vulnerable moments that were shared in it.” Arlene Key wrote: “I loved this book for its raw and personal touch. It’s an honest look at the world of NICU with the ups and downs, fears, tears and joys that come with an unplanned, early delivery.” Michelle Solari wrote: “This book is absolutely amazing. If you or any of your family members or friends have had a NICU journey or are going through one now, READ THIS BOOK! So inspiring and encouraging!”

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} MEDICAL ADVANCEMENT

Cancer and Cryopreservation

with Brett Davenport, MD

“I’ve been diagnosed with cancer and will have to start chemotherapy and radiation within a month. I still want to have children, but my oncologist says that the chemotherapy and radiation may permanently damage my eggs. What should I do?” A devastating dilemma surrounded by so many unknowns. Yet far too few females with cancer ever have this conversation. The answer: consider freezing your eggs or embryos prior to undergoing radiation and chemotherapy. FREEZING IS AN OPTION? Although temporary freezing, also called cryopreservation, of eggs and embryos has been around for over 30 years, it has not been until the last decade that these options could be relied upon with much confidence. It was at this time that vitrification, an almost instantaneous method of freezing, became widely available. Even until very recently, only embryos rather than eggs had a good enough rate of survival through a freeze/thaw process to offer the process as a viable option. WHY SHOULD CRYOPRESERVATION BE CONSIDERED? Cryopreservation of eggs and embryos is a way to prevent eggs and embryos from further aging by dehydrating them and storing them in liquid nitrogen. This allows a woman’s reproductive potential to be preserved at the age in which her eggs or embryos are frozen. It also allows a group of a woman's eggs to remain unaffected by future cancer treatments and by further aging. Eggs and embryos can then be thawed and fertilized at a later time when the woman is ready. WHO ARE CANDIDATES FOR EMBRYO STORAGE? Embryo cryopreservation began as a means of storing left over embryos that were formed but not transferred during an IVF cycle. This has allowed a couple to draw from these embryos for future attempts if an IVF cycle is unsuccessful, and for subsequent children even when IVF is successful. Additionally, the ability to preserve embryos has been a blessing to many women who are already with their life partner at the time of cancer diagnosis. It has also been a good option for the stable couple who wishes to electively prolong childbearing. 32

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BUT WHAT IF I DON'T HAVE A PARTNER AT THE TIME THAT I'M DIAGNOSED WITH CANCER. Even 5 years ago the woman with cancer and no partner was left with limited viable options to have a biological child. They would be forced to use a donor's eggs or adopt if their ovaries became damaged by their cancer treatment. However, as techniques have greatly improved egg survival rates after a freeze/thaw cycle, egg cryopreservation is now a viable option that can be offered with much greater confidence. As such, not only cancer patients without a partner, but also other patients in their 20's and 30's are opting to electively cryopreserve their eggs as an insurance against running out of eggs before their desired childbearing is complete. SO HOW DOES IT WORK? Let’s start with some background: A woman is born with every egg that she will ever have, with an average of 300,000 eggs remaining when she starts puberty. Each day of her reproductive life, a small number of a woman’s eggs die. In fact, it is only a very small percentage of a woman’s eggs that will be stimulated and grow during her reproductive life, and even a fewer number that will ovulate and have a chance at being fertilized. In order to cryopreserve one’s eggs, the group of eggs at that given time, most of which would otherwise die, are stimulated with medications that allow them to grow to the necessary size. The woman is then given another medication that matures the stimulated eggs, making them capable of being fertilized. The eggs are retrieved from the ovaries at this time through a vaginal needle with a vacuum.

The process up until this point is identical to in vitro fertilization. However, during IVF the eggs that have successfully matured would be fertilized by sperm and the resulting embryos cultured and grown in a very controlled environment, all of which must be completed before the embryos can be cryopreserved. Contrast this to egg cryopreservation, where the mature eggs that are retrieved can be immediately frozen. Egg cryopreservation not only eliminates the need for sperm availability in order to be able to freeze a woman’s reproductive potential in time, but it also temporarily eliminates the costs of egg fertilization and embryo culturing, allowing this option to become a viable option to so many more individuals. ARE THESE OPTIONS AFFORDABLE? In vitro fertilization costs $9,000-$12,000 with an additional cost of medication being $3000-$6,000. Cost is the biggest limiting factor to most couples. Consider that this factor is even more magnified for the cancer patient who is simultaneously learning about her necessary cancer treatments, which can tally tens of thousands of dollars. Contrast these IVF costs to egg cryopreservation, which allows the procedure, and thereby costs, to truncate once the eggs have been obtained and frozen. Because of this egg cryopreservation costs $5,000 to $7,000 less than IVF. Although the costs of fertilization, embryo culturing and growth, and eventually embryo transfer eventually be necessary, the patient with an immediate need to preserve her eggs and limited means will appreciate the reduced immediate costs. WHAT IS THE TIMELINE FOR CRYOPRESERVATION? It’s important to have an understanding of the timeline that can be expected for egg and/or embryo freezing. It should be noted that each plan can be specially crafted to meet the limited time constraints of a cancer patient awaiting radiation or chemotherapy. From onset of stimulation, medication until retrieval of eggs takes anywhere from 10 to 16 days. The egg stimulation process will only require 4-6 brief visits to your fertility doctor to monitor the growth of your eggs, followed by a visit for the actual retrieval of the eggs. Sometimes, if time allows, the patient may benefit from an individually-crafted priming protocol prior to stimulation that might help to increase her overall egg yield during the retrieval. However this priming period usually is not essential if time does not permit. SO WHAT DETERMINES IF A NEWLY-DIAGNOSED CANCER PATIENT IS A CANDIDATE FOR EMBRYO OR EGG CRYOPRESERVATION? It is essential that the patient and her fertility specialist coordinate with her oncologist to determine if egg cryo-

preservation is recommended and right for her, and how quickly it must be performed in light of the specific cancer diagnosis and individualized situation. These answers will be determined by the specific type and aggression of cancer along with the necessary treatment modality, intensity, and location that is recommended by the oncologist. For example radiation is only a threat if the radiation is focused at a region of the body that is near the ovaries. Conversely, chemotherapy will reach every region of the body since it works through the bloodstream. Chemotherapy’s threat to the ovaries is solely dependent on the type of chemotherapy, with certain types being detrimental to egg survival while other types having relatively little effect on egg health. These concepts undermine the importance of excellent communication between the patient and her multi-specialty team as soon as possible after a cancer diagnosis. ARE THERE OTHER FACTORS TO CONSIDER PRIOR TO EGG/EMBRYO CRYOPRESERVATION? Many cancer patients might be concerned about the additional stress of egg cryopreservation amidst the many other worries that have been cast upon them by this life-altering diagnosis. Will it hurt? Will it alter my energy levels? Will it affect my ability to respond to my cancer treatment? When communicating with your team of doctors, your doctors will outline the risks that must be weighed against the benefits of preserving your reproductive potential. However, usually these risks are minimal. Modern protocols have almost eliminated the risks associated with stimulation. Aside from occasional emotional lability for the 1-2 weeks of stimulation, most patients tolerate the stimulation medications well. During the egg retrieval the patient is heavily sedated so that they do not feel or remember the procedure. Usually the ovaries return to normal size within 1-2 weeks. There has been no evidence that stimulating the ovaries prior to cancer treatment affects the cancer prognosis in any way. CONCLUSION Knowledge is power. Knowledge of the ability to preserve one's reproductive potential against aging and imminent damage translates into the power to preserve one's ability for childbearing, or to electively delay childbearing where appropriate. Sharing this information with your friends and colleagues is a way to help ensure that no healthy woman misses the sacred opportunity to conceive children due to aging or a cancer. It allows more women to have the right conversation at the appropriate time before it is too late. Brett Davenport, M.D., Practice Director Fertility Institute of North Alabama 532 Madison Street, Huntsville, AL 35801 Phone: 256-217-9613 Fax: 256-217-9618

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} COVER FEATURE

Ovarian Cancer

in the Days of Genetic Testing by David B. Engle, MD, MS, FACOG In 2018 it is estimated that there’ll be over 22,000 new cases of ovarian cancer in the United States. Additionally, there will be over 14,000 deaths from the disease. A women’s lifetime risk of developing ovarian cancer is between 1.5-2%. While it is not the most common gynecologic malignancy it is the most fatal. This high fatality rate is due to the fact that most cases of the disease are found in later stages. In fact, approximately 75% of all cases are found in stage III and IV.

SIGNS AND SYMPTOMS Ovarian cancer was once considered the silent killer. Now, it is referred to as “the cancer that whispers.” This is due to the fact that many of the symptoms of ovarian cancer are nonspecific. They often mimic symptoms associated with either the urinary or gastrointestinal tract. The most common symptoms are: Bloating, pelvic/abdominal pain, urinary frequency or urgency, filling full quickly with eating. Other symptoms can include: nausea, constipation, and fatigue.

SYMPTOMS OF OVARIAN CANCER • Bloating • Pelvic or abdominal pain • Difficulty eating or feeling full quickly • Urinary symptoms (urgency or frequency) The symptoms often start very gradually, and often are not reported as severe in intensity. It is very common for patients with ovarian cancer to report they have been treated for common GI conditions such as GERD or constipation or even received more than 1 course of an antibiotic for a suspected bladder infection. Eventually, as the symptoms do not abate, additional testing will reveal the real culprit. CAUSES/ GENETICS The majority of ovarian cancer cases are sporadic. However, approximately 25% of all cases have a genetic predisposition. This is one of the highest, if not the highest, genetic associated malignancy. Compare this to breast cancer where 10% of all cases are associated with a genetic link. The most common genetic cause of ovarian cancer is the BRCA mutation (Hereditary Breast and Ovarian Can34

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cer Syndrome). The BRCA mutations actually account for deleterious mutations in a group of two genes called BRCA-1 and BRCA-2. These genes, when working properly, are associated with repairing DNA damage. Unfortunately, when these genes are not working properly, they allow DNA damage to accumulate in the cell and increase the risk of developing certain malignancy. BRCA is most commonly associated with Breast and Ovarian cancer. However, it can also be associated with other cancers such as pancreatic, prostate and even melanoma. Approximately 40% of patients with a BRCA-1 mutation and 20% of patients with a BRCA-2 mutation will develop ovarian cancer. While the BRCA mutation is the most common genetic mutation for ovarian cancer, it is not the only one. The second most common germline mutation associated with ovarian cancer is Lynch Syndrome. While Lynch Syndrome is more often associated with colon and uterine cancer, it is also associated with ovarian cancer. Lynch Syndrome is responsible for approximately 10% of hereditary ovarian cancer. Numerous other genetic mutations have been associated with ovarian cancer, to varying degrees. As genetic research continues, our knowledge of which genes are associated with cancer will continue to increase. We are very fortunate to have a research facility right here in Huntsville doing groundbreaking genetic research. Researchers at the HudsonAlpha Institute for Biotechnology will continue to expand our understanding of the genetic code. This knowledge will lead to new treatments and improved patient outcomes. Visit www.information-is-power.org to learn more about HudsonAlpha's Information is Power initiative. PREVENTION Women who have a known family history of a malignant mutation, or a strong family history that has never been tested should be evaluated by a clinic comfortable with genetic testing. In the last decade the cost of genetic testing has decreased to 5 – 10% of the original cost or less. Additionally, most patients are now undergoing a more comprehensive testing panel, as we continue to expand our knowledge of genes associated with certain cancers. For those patients that test positive for a deleterious (harmful) mutation there are often different treatment or screening strate-

gies. The strategies are designed to reduce the risk of cancer, or possible detect them in the earliest most curable stages. Included in these recommendations can be risk-reducing surgery, to remove certain organs before they become involved with malignancy. Other strategies focus on more intense or frequent screening of certain organ systems. For example, women with a BRCA mutation can be offered risk-reducing bilateral salpingoophorectomy (removal of both ovaries and fallopian tubes) surgery after the age of 35, or when childbearing is complete. Risk reducing surgery may decrease the chance of ovarian malignancy by as much as 95%. TREATMENT Several factors must weigh in on the treatment of ovarian cancer. Age, future fertility desires, medical co-morbidities, etcâ&#x20AC;Ś With the exception of very early stage I disease, the mainstay of ovarian cancer treatment is a combination of surgery and chemotherapy. Studies have shown, the best patient outcomes for ovarian cancer is when a Gynecologic Oncologist directs care. A Gynecologic Oncologist is a sub-specialist who is trained in the diagnosis and treatment, both with surgery and chemotherapy, of cancers arising from the female reproductive tract. Currently in Alabama only Huntsville, Mobile, and Birmingham have Gynecologic Oncology Practices. CLOSING A significant percentage of ovarian cancers are from an inherited mutation. Luckily, we now have the tools to screen high risk patients for known mutations. Those found to have an increased risk of ovarian cancer can be offered increased screening or risk reducing surgery. For those patients found or suspected to have ovarian cancer, they should first be evaluated by a Gynecologic Oncologist to direct their treatment plan.

David B. Engle, MD, MS, FACOG Gynecologic Oncologist Tennessee Valley Gynecologic Oncology 256-265-4600 office I n s i d e M e d i c i n e | Fa l l I s s u e 2 0 1 8

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Tissue

PASS ME A by, Kari Kingsley, MSN, CRNP

Do you consider yourself to be open-minded or closed-minded? Open-minded people are considered to be more willing to embrace change and generally have a higher level of curiosity. They try new things, live in the present, and often times seem less judgmental. While it is often perceived as a good thing to have an open mind, you don't want to be so open-minded that your brains leak out of your nose! In today's culture, it is possible that our thoughts leak too freely; however, there is a true medical condition in which your mind lubricant literally drips out of your nose… cerebrospinal fluid rhinorrhea or CSF rhinorrhea. It’s important to know when to dive for a tissue and when to call your nearest ENT. Most of us have suffered the embarrassment of talking to a close friend or loved one only for your nose to begin running like a sieve. Perhaps triggered by a blooming Bradford pear tree, the outdated perfume of the sweet elderly lady who sits close to you in church, or even a hot bowl of your favorite chicken noodle soup. We quickly dart our eyes around the room to make sure no one is watching, then hightail it to the nearest box of tissues before our sleeve is saturated. Clear nasal dripping can be one of the most aggravating and embarrassing 38

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issues to deal with. Each year, millions of Americans are seen at walk-in clinics, primary care offices, and by otolaryngologists and allergists for nasal discharge. Common causes of nasal drainage include seasonal or non-seasonal allergies, upper respiratory tract infections such as rhinovirus and cold temperatures. Crying (or trying not to cry) during your favorite Nicholas Sparks book can sometimes cause a drippy nose. Rebound congestion after prolonged use of topical decongestant drugs such as Afrin, chronic sinusitis, nasal polyps and cluster headaches can also be to blame. However, cerebrospinal fluid rhinorrhea is a rare and potentially life-threating condition that also presents with clear nasal discharge. CSF rhinorrhea occurs when the meninges (the membrane barrier that lines the skull and vertebrae to protect the brain and spinal cord) is torn and cerebrospinal fluid drips down the nose. Ascending infection can lead to meningitis and in some cases death. The cause of common rhinorrhea or drippy nose is characterized by overabundance of mucin produced by mucous membranes that line our nasal cavities. With rhinorrhea, mucus is created faster than the body is able to process it, leading to clogging in the nasal cavities. Gravity takes over, causing nasal discharge. Accompanying symptoms generally vary based on the underlying cause, but can include nasal congestion, facial pain, headache, nosebleeds, sneezing, ear pressure, sometimes ear infection and even sinusitis. As excess mucus drips down the back of the throat, excoriation can occur causing sore throat and coughing. Generally, nasal drainage is evaluated by medical providers with a thorough history to elicit the exact cause so that they can treat you accordingly. Many cases are self-limiting, such as the common cold, and do not require treatment. For allergic and non-allergic rhinitis, medications can be helpful including cortisone nasal sprays, antihistamines, vasoconstrictors, and sometimes antibiotics if a bacterial infection is suspected. Many claim that natural treatments like saline sprays and herbal oils can also be helpful. New in-office treatment options are available to alleviate nasal drainage. And then of course there’s honkin’ your schnoz (nose blowing) for which the Kleenex family greatly appreciates your business. Allergy testing and immunotherapy are helpful for some. Evaluation by an Ear, Nose, and Throat provider can be valuable to rule

out underlying co-morbidities such as sinusitis, nasal polyps, and additional upper respiratory disease. Sometimes what you may think is good-old-fashioned snot can actually be something far more deadly. Cerebrospinal fluid rhinorrhea is a rare malady that can occur traumatically or spontaneously. Classic nasal CSF leak presents with unilateral (one-sided) clear nasal drainage that often worsens when bending forward. Sufferers sometimes complain of a metallic or salty taste. Predisposing conditions include obesity causing increased intracranial pressure, severe sleep apnea, congenital skull bone malformations, hyper-pneumatization of the sphenoid sinus, and a condition called empty sella turcica. Accompanying symptoms can include headache, lack of smell, nasal congestion, weakness, dehydration, and night cough. Severely symptomatic patients present with symptoms of meningitis including nuchal rigidity, sudden high fever, altered mental status, photophobia, phonophobia, and even seizures. Traumatic CSF rhinorrhea is a sign of basal skull fracture related to head trauma and can have devastating complications. CSF leak is also a very rare complication of sinus surgery. Evaluation and diagnosis are centered around a thorough history, sampling of collected nasal discharge which is sent for β-2-transferrin assay, nasal endoscopic examination to visually identify the place of leak, and radiological diagnosis with skull CT scans. MRI helps in detecting hernial protrusion of the brain in the skull found in encephalocele. Treatment options include watchful waiting as some CSF leaks will heal spontaneously. Surgical intervention includes a type of bypass surgery in which an overlay lumbo-peritoneal shunt is placed. Moderate failure rate is expected and surgeons then perform transcranial and trans-nasal approach surgery with osteoplastic craniotomy with closing of the defect using the patient’s own donor tissue. Timing is critical. Risk of meningitis in patients with persistent CSF rhinorrhea may be as high as 20%. Meningitis is a life-threatening condition in which the meninges becomes infected leading to fever, headache and neck stiffness. Untreated meningitis is almost always fatal. If you or a loved one suspect you may have CSF rhinorrhea, don’t delay evaluation by an otolaryngologist (ENT). Most of the time, clear nasal drainage is a nuisance rather than a life-threating situation. But it’s important to know the warning signs of CSF rhinorrhea and seek immediate medical help. While I would normally encourage everyone to “keep an open mind”, please don’t keep it so open that your thoughts (or spinal fluid) leak out on to your shirt. “Kari Kingsley, MSN, CRNP is an otolaryngology nurse practitioner with over 8 years of ENT experience who currently works at Huntsville ENT (256-882-0165). She is a medical writing consultant for Inside Medicine and enjoys writing articles on pertinent material to keep the residents of North Alabama up to date on the forefront of medicine.”

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GENOMICS 101 ON CAPITOL HILL by HudsonAlpha Institute for Biotechnology

We were honored for the opportunity to have a collaborative discussion about how genomics is improving human health and solving key challenges in agriculture. - Neil Lamb, PhD, Vice President for Educational Outreach

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} RESEARCH

Leaders from the HudsonAlpha Institute for Biotechnology, a nonprofit research institute in Huntsville, Ala., were invited to present, “Genomics 101: Exploring the Basics,” on Capitol Hill in June. The educational session was held at the Capitol Visitors Center, SVC 203-2. “It is more important than ever to enhance our understanding of genetics and genomics and the important role they can play as legislation is offered and debated in Congress,” said Sen. Doug Jones, who coordinated the Congressional briefing Legislators and Congressional staffers heard Dr. Neil Lamb, vice president for Educational Outreach, discuss how genetic and genomic information is being utilized in medicine and agriculture to improve human health and secure food supplies. “HudsonAlpha hosts a number of educational seminars for students, teachers, researchers, medical professionals and the public,” said Lamb, “and it was exciting to bring that outreach to legislators on a national stage.” With new discoveries being made every day, “Genomics 101” is an opportunity to give an update on the latest advances and challenges in these fields.

“HudsonAlpha’s mission of Educational Outreach impacts students, educators and decision-makers across the country,” said Richard M. Myers, PhD, president and science director at HudsonAlpha.

We are truly grateful to Senator Richard Shelby and Senator Doug Jones for their interest and support for HudsonAlpha’s work in creating a more genomically-aware public.

Sen. Richard Shelby is chairman of the Senate Appropriations Committee, which has jurisdiction over genetics, genomics, agriculture and other topics discussed today at “Genomics 101”. Sen. Doug Jones is an emerging leader on the Health, Education, Labor and Pensions Committee. HudsonAlpha Institute for Biotechnology 601 Genome Way, Huntsville, AL 35806 www.hudsonalpha.org

Check out the “Genomics 101” session live streamed on the HudsonAlpha Facebook page: www.facebook.com/HudsonAlpha/.

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Fighting Obesity One Person at a Time by Nisha Mailapur

ALARMING Our state of Alabama ranks 3rd highest in the nation when it comes to rates of adult obesity! Add to this, childhood obesity is on the rise, nearing 35.5% of 10-17 year olds statewide. Not only is obesity unhealthy, it is also expensive. According to STOP Obesity Alliance's "Fast Facts: The Cost of Obesity," the yearly expense for an obese woman and an obese man is $4,879 and $2,646, respectively. Research from McKinsey Global Institute shows that the economic output of obesity and its consequences accounts for 4 to 8 percent of America’s gross domestic product. Obesity is the culprit of many chronic diseases such as diabetes, hypertension, liver cirrhosis, and is responsible for increased risk of some cancers, such as breast cancer. One of the most shocking facts about obesity is that it is entirely preventable and reversible with a change in lifestyle. I was first introduced to the effects of obesity after listening to multiple success and failure stories from some of my father's bariatric patients. As a runner and food lover, I am impacted by their journeys in fighting obesity. Since then, I have felt the need to increase awareness of obesity in my small community of Huntsville. I started with a simple goal: expanding the simple clichés-“be you” or “be comfortable in your own body”-past just words. Yes, we need to be comfortable in our unique body, but it is imperative that we all are aware that obesity comes with a very heavy price on our well being (physically and financially)—leading to chronic diseases that are expensive. So, for me, raising awareness about obesity is not about sculpting a perfect body; rather, it is about cul-

tivating a habit of exercise and healthy eating to maintain our own body and its needs. After ruthless brainstorming, in the summer of 2016, the took form. The goal of the Say No to Obesity 4K is to create an environment where people of any shape, size, or fitness level can come together and pass a simple thought bubble: “Hi, what’s your name? What’s your story?” or “Let’s run/walk/jog/crawl this together!” The vision of this event is to get people to lace up their shoes, put on a t-shirt, and just get outside. The road race came together with the relentless support and guidance from not only my parents and cross-country coach, but also from community leaders from Huntsville Track Club and Fleet Feet, as well as key members of the Huntsville Hospital Foundation. With two Say No to Obesity 4K events behind me, I began to dig deeper into what obesity is and how to fight it. I realized that fighting obesity goes beyond just exercising, walking, or running. Obesity is linked to the consumption of highly processed foods. According to Harvard T.H. Chan's School of Public Health, what you put in your body matters. Buying fresh fruits and vegetables for the week, rather than going to fast food restaurants or stocking up on pre-made meals at the grocery store, can end up being less costly in the long run, fill you up more than processed foods, and is better and healthier for your body. I thought, wow! ...no wonder my mother tells me to I n s i d e M e d i c i n e | Fa l l I s s u e 2 0 1 8

} HEALTH

TAILGATING

with a healthy diet

by Carmen Moyers RD, LD

Welcome Fall!

Everyone is hitting the ballpark, hanging out with friends, watching football, gearing up for the holidays, all while trying to keep a healthy diet. Snacks are part of a healthy eating pattern but it’s easy to fall prey to good marketing and healthy sounding foods. For any meal or snack, reading the ingredient label will help you decide if it is a healthy snack. Snacks with fiber, health fats, and proteins can help you stay full between meals or be a healthy appetizer to curb hunger before a tempting autumn get together or buffet. Fiber is found in whole grains, fruits, and vegetables. Focus on whole grains by making sure the first ingredient is whole wheat, not enriched flour. Whole grain carbohydrates will leave you feeling full. Reducing unnecessary sugars will keep you away from a quick pick me up follow by a crash, leaving you hungrier than before. Look for ingredients including sugar, sucrose, glucose, dextrose, high fructose corn syrup, syrup, honey, and nectar. While there are others, these are the most common. It’s okay to have a little added sugar, just shy away from those with sugar in the first few ingredients or multiple forms of sugar. Don’t fear fats. But, remember, not all fats are created equal. Reach for foods with unsaturated fats like nuts, avocados, and oils. Nuts and nut butters can be easy to pack and quick to eat while providing protein, vitamins, minerals, and healthy fats. Salt comes along with many snacks and shelf stable foods. While tailgating, hanging outside and playing means sweating, most people get plenty of sodium and don’t need to add salt to their snacks. Try and find low sodium versions of your favorite options like unsalted nuts and limit high sodium foods like beef jerky.

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HERE ARE A FEW IDEAS ON CHOOSING ON-THE-GO FALL SNACKS. • Yogurt high in protein and probiotics are a bonus, just be cautious on sugar content • Trail Mix aim for whole grains and unsalted nuts. • Granola read your labels carefully. Most granola products have a great deal of added sugar. • Fruit choose whole fruit, not snacks or juice as you miss out on many vitamins, minerals, and fiber. • Vegetable dip Dipping veggies can be a great way to make them fun. Hummus is high in healthy fats and includes fiber and protein. Tzatziki dip is a greek yogurt dip with a lot of flavor added with some spices. Bean dip is a great way to enjoy veggies, especially peppers, for a high fiber high protein snack.

...cont’d from page 43 37

choose the grapes and cheese rather than the hidden stock of cookies in the pantry. Reminded of the healthy eating habits my mother strived to cultivate in my family, I began to venture into the food culture of obesity. In the summer of 2018, I interned with Ms. Steakley, a local dietician/nutritionist at Huntsville Hospital. While I meticulously learned about wholesome meals-proteins, carbohydrates, vegetables, monounsaturated fats-portion control, nutrition facts, reading labels, and recipe building, we looked at a study started by Dr. Amy Custack, professor at Michigan State University and nutrition director at the Michigan State University-Hurley Children’s Hospital Pediatric Public Health Initiative: "Fruit and vegetable intake tracks from childhood to adulthood, making it important for health care professionals to guide children towards healthy eating early on." Similarly, Ms. Steakley had mentioned that her patients do not eat fresh vegetables, mainly because they do not buy them and because they do not know what to do with them. So, in a thirty minute interview with Dr. Custack, I was able to learn about how their fresh fruit and vegetable prescription program in Flint, Michigan could be emulated in our community of Huntsville. "We need to consider not only nutrition education but also barriers to access and affordability of fresh fruits and vegetables, particularly in underserved areas. The prescription program is a first step to introducing fresh, high-quality produce to children,” says Dr. Custack. Keeping in mind Dr. Custack’s study, I proposed using the funds raised from the Say No to Obesity 4K Run/Walk to start a fresh produce prescription program to promote the consumption of fresh produce in order to decrease reliance on processed food. The objective is to distribute “veggie vouchers” as prescriptions by our community of physicians to further raise awareness and fight obesity. This pilot program is unfolding as I write this article; my goal is for this prescription program to be fully implemented by next year. In the meantime, in an effort to further sustain this fresh produce prescription program in the long run, I created a GoFundMe: “A Recipe for Prescription.” Will you join our efforts? We live in America, in a democracy. Change starts with the people. Let us battle the politics, FDA subsidies on processed foods, medical bills, and increased weight. We make the choices, not them.

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} MISSIONS

Finding Grace

by Elisa Brooks

It is no news that we live in a driven society. In all facets of life, the culture around us typically asks some more of every single one of us...more time, more exercise, more money, more success, and the list could go on and on. In reality, we only have a finite amount to give. At some point, all of these things have a limit! When we are tugged and pulled on, asked of, and pressed to do, give, say, BE more…we often over commit and end up exhausted. Or, we could even say “no” and still feel so frustrated and guilty for not doing something when we are asked. Today, I want to remind you about GRACE. It is time for you to remember to extend it to yourself. Create the space for you. What is grace? It is undeserved favor, kindness. Give yourself permission to say no, to sit with your cup of coffee for an extra five minutes, and take some deep breaths. Look at your calendar and keep an evening free from “stuff ”. Extend this grace to yourself and you’ll find it easier to extend it to others. In fact, you will find immeasurable grace when you take the time to get to know the Source of true grace. “We have seen his ( Jesus’) glory, the glory of the One and Only, who came from the Father, full of grace and truth.” John 1:14. What Jesus has, He readily offers to us. Even during the times when we least deserve grace, God extends it to us. Day by day, hour by hour, minute by minute, HE gives us grace. Soak that up for a bit and you’ll find you are able to be more kind to yourself and be willing to offer grace to others. So, instead of allowing the pressure of all that is asked of you to sit on your shoulders, take it back! You are only human and all you can do is all you can do. Revel in it. Be who you are and who God asks you to be. Say no to the things that are not necessary and find the things that truly belong. Let others do the same. Find grace in everyday and in the Giver of Grace and you will be well on your way to finding true JOY.

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} TESTIMONIAL

' ' the S word

by, Kari Kingsley, MSN, CRNP

As an adult, I’ve tragically happened upon another ‘s’ word that many seem reluctant to say. Suicide affected my family in 2012 when we shockingly lost my younger brother, Ben.

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Riding on the school bus as a middle school kid, I clearly remember hearing my first curse word. Actually, I clearly remember saying my first curse word (sorry Mom). Adolescents routinely push boundaries and limits as they grow into adulthood. As an adult, I’ve tragically happened upon another ‘s’ word that many seem reluctant to say. Suicide affected my family in 2012 when we shockingly lost my younger brother, Ben. For months, my small remaining nuclear family survived on the kindness and love of others. The outpouring of support was astonishing. When the fog cleared, it became very apparent that losing a loved one to suicide was very different than other deaths. While many people became the crutch that held us up, others shied away. A few noticeable occasions stood out. Suicide was described to me as a cowardly thing to do. Concerns were raised of where my brother would spend his afterlife. People in the grocery store wouldn’t know what to say and situations became uncomfortable. Suicide carries with it a stigma seemingly insurmountable to change. Stigma is defined by Webster’s dictionary as “a mark of disgrace or infamy; a stain or reproach to one’s reputation.” Perhaps I was part of the stigma before July 24, 2012. I could sympathize for those who had lost loved ones to suicide, but not empathize with someone who was in such a hopeless place that they would take their own life. A good friend who had lost her mother to suicide came to visit me not long after my brother’s death. She changed the way I would look at suicide and mental health forever. She told me that Ben had the equivalence of cancer in his brain. Depression, anxiety, schizophrenia, bipolar mood disorders, personality disorders, trauma-related mental illnesses and eating disorders are all very real diseases. The problem is, you’ll never detect them on a CAT scan or MRI. Because they are not “real” tangible diseases that can be treated with chemotherapy, radiation, or surgery, many in our society do not recognize them as “real”. Buck up, Pull yourself together, Snap out of it, Get it together, Turn that frown upside down… How many times have we heard these sayings? These phrases are perfect for many situations. But for someone dealing with debilitating depression, this is equivocal to throwing a penny in a well and hoping your

cancer will go away. If you broke your arm, you wouldn’t hesitate to go to a hospital. You wouldn’t care about what others would think. After your discharge from the hospital, you wouldn’t hide from your friends and family and refuse loved one’s phone calls wishing you a speedy recovery. Why is a mental health diagnosis so different? The stigma of suicide prevents many people from voicing their symptoms and asking for help. For many, it becomes too late. What’s our solution? Talk about suicide. Say the ‘s’ word. And remember these conditions are just as “real” and serious as cancer. Examine your own views of these topics and try to remove insensitivities regarding these conditions from your mind. Suicide is now the 10th leading cause of death in the United States. Top Ten. It takes a minute for that to sink in. The first time I heard this statistic I was dumbfounded. I could talk statistics and numbers for hours. But until you have lived the nightmare of losing a loved one to suicide, it will never fully sink in. Suicide touches so many of our friends and family members and if we are able to change ONE life as a result of our actions, it will be worth it. I was humbled to have been approached in 2016 by the American Society for Suicide Prevention to Chair their annual "Out of the Darkness" Community Walk in Huntsville, Alabama to raise awareness and support for suicide prevention. This year’s event took place October 21, 2018 (the day before Ben's birthday) from 2-4 pm at Ditto Landing Marina in Huntsville, AL. The American Foundation for Suicide Prevention (AFSP) is the leading national non-profit organization exclusively dedicated to understanding and preventing suicide through research, education, and advocacy. They are also actively reaching out to people with mental disorders and those impacted by suicide.

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

Our therapists provide highly specialized treatments based on a thorough hands-on manual techniques and exercises to facilitate quick and complete recovery.

Call Today 256.883.063 6

www.focus-physio.com 1140 Eagletree Lane SE • Huntsville, AL 35801

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CBD }MISSIONS

What is it really?

There is a ton of buzz about CBD since the legalization of industrial hemp on the federal level. However, for many this doesn’t explain the true nature of the plant, its benefits and how it can help thousands of people. Many people are very confused about CBD, THC and all the other acronyms being tossed around. Breaking it down into very simple terms is important to understand the good behind this plant. Think of this as a beginner’s guide. Marijuana verses hemp. They are different species of the same plant, Cannabis. The basics of the plant are the same, but the resulting outcomes are very different when they are produced (or grown) differently. Their function, cultivation and production are different. The plants themselves, even look different. One produces a higher content of THC (tetrahydrocannabinol) which is what can produce the psychoactive properties or “high”, this is Marijuana. It can contain anywhere from 5-25% THC. Hemp on the other hand contains typically less than 0.3%. Don’t get me wrong, there is some valid use for the psychoactive nature of this plant as well. It is suggested it can help stabilize those with PTSD and several other psychiatric related issues. We won’t dive too deep into this arena here though as it is more detailed than a beginner’s guide. Hemp on the other hand, while it does contain trace amount of THC, not enough to produce any type of psychoactive behavior, is used in more industrial settings. Think of lotions, food supplements and yes even medical uses. It has more than 28,000 uses. Paper, clothing and construction supplies are examples of other applications. It has also been found to have analgesic, anti-inflammatory and anti-anxiety properties*. It really is so much more and to fully understand this, you must know some basic definitions. CANNABINOID any of a group of closely related compounds that include cannabinol and the active constituents of cannabis. CANNABIDIOL (CBD) a major Phyto cannabinoid (naturally occurring cannabinoid) that accounts for 80% of the plant’s extract CANNABIGEROL (CBG) is a parent molecule from which many other CBD’s are made CANNABIDIVARIN (CBDV) homolog of CBD that has reports of anti-convulsive effects*

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by Heather Morse, MS, ATC, OTC CANNABINOL (CBN) non-psychoactive cannabinoid with analgesic properties that aids in sleep and appetite regulation* TETRAHYDROCANNABIVARIN (THCV) non-psychoactive precursor and regulator of various key Phyto cannabinoids CANNABICHROMENE (CBC) contributes an overall analgesic, anti-inflammatory and anti-fungal effect* ENDOCANNABINOID SYSTEM (ECS) you have heard of the Digestive System, the Endocrine System, the Neuromuscular system, but you have more than likely never heard of this system. This newly discovered system is found in every animal and regulates a broad range of biological functions. In simple terms it’s a biochemical control system of neruomodulatory lipids and other receptors that can accept certain cannabinoids. Think of this as a specific key needed to open a specific lock. There are special receptors throughout the body. When a specific cannabinoid or combination thereof binds to these receptors the cell is triggered to change its activity. These receptors are so named Cannabinoid type 1 (CB1-R) and Cannabinoid type 2 (CB2-R), located all over the body. For example, the brain has CB1 and our immune system has CB2 receptors. There are three different types of cannabinoids that can unlock these receptors and contribute to promote homeostasis in overall health and wellness. THE BODY'S ENDOCANNABINOID SYSTEM

ENDOCANNABINOIDS endogenous-fatty-acid cannabinoids produced naturally in the body PHYTO CANNABINOIDS concentrated in the oily resin of the buds and leaves of plants such as cannabis (remember Cannabis is a plant, marijuana and hemp are species). SYNTHETIC CANNABINOIDS manufacture by artificial means in a laboratory (this type has been prescribed to patients needing appetite stimulation) It is important to note that the cannabis plant contains over 113 different cannabinoids, but the main two are CBD and THC. Now that you have a basic chemistry and definitions lesson under your belt, letâ&#x20AC;&#x2122;s talk about the differences between CBD and THC. Both interact with the endocannabinoid system (ECS). THC is the main psychoactive ingredient in marijuana. This compound works by imitating the effects of anandamide, a neurotransmitter produced naturally by the body to help modulate sleeping and eating habits, as well as the perception of pain. It binds to the CB1-R and CB2-R receptors in the body. For this reason, it has been used successfully to help with discomforts associated with chemotherapy, multiple sclerosis, glaucoma, AIDS, spinal injuries and more.* The amount of THC produced by the plant can also dictate the psychoactive effects. Low doses can trigger the appetite, while large doses can trigger paranoia. CBD has the same chemical formula as THC, but the atoms are arranged differently, thus giving it non-psychoactive effects. CBD does not bind with CB1 or CB2 receptors, it signals the bodyâ&#x20AC;&#x2122;s naturally occurring cannabinoids to do what they naturally do. This too has proved to help with discomforts associated with anxiety, depression, muscle spasms, pain, inflammatory conditions and more.* CBD can counter act the effects of THC. It is worth noting that isolate CBD versus full spectrum will give differing results. Most CBD is made from industrial hemp, thus having minimal THC and has been processed at high temperature eliminating the spectrum of other cannabinoids. CBD oils made from marijuana would have to have the THC processed out, thus becoming an isolate. This process degrades the quality and effectiveness of the CBD itself. But when CBD is made from industrial hemp (continuing less than 0.3% THC) the need to isolate it out is not necessary, unless you live in a state that it is all illegal. Federally CBD made from industrial hemp is legal in all 50 states. CBD made from marijuana EVEN when the THC is processed out is only legal in states that medical or recreational marijuana is currently legal. There are challenges in each state as the confusion over the plant

itself, its medicinal uses and frankly its impact on the pharmaceutical, cotton, paper and other industries come into concern. Salt on the Rocks offers ECN (Enhanced Clinical Nutrition) products for many reasons; mainly because of the pain managements physicians we work with trust this product for their chronic pain patients. ECN uses a proprietary extraction technology that allows for high levels of Phyto cannabinoids, while eliminating unwanted amounts of THC. This process leaves the full spectrum profile of non-psychoactive Phyto cannabinoids and synergistic compounds like CBG, CBN, CBC and over 40 terpenes intact. ECN 3rd party tests their product to ensure there are no traces of THC and only full, rich oil with no solvents, heavy metals or pesticides remains. Each batch we sell has its own lab reports that we are happy to provide to anyone. You can find ECN products at Salt on the Rocks. ECN products are not a MLM product line and are only available in our store.

Heather Morse is the owner of Salt on the Rocks, a new destination experience with Salt Therapy. The Remedy Room inside Salt on the Rocks offers a variety of natural remedies for the beginner, including herbs, oils, teas and tinctures. You can find them at the corner of Bob Wallace and Whitesburg Drive. Visit SaltontheRocksHuntsville.com for more information.

Salt on the Rocks also offers educational classes in CBD. Visit their website at www.saltontherockshuntsville.com to learn more about upcoming classes and events. *These statements have not been evaluated by the FDA. This product or claims are not intended to diagnose, treat, prevent or cure any disease. Content source: MedicalJane.com and Enhanced Clinical Nutrition LLC, 820 W Danforth Rd #A-52, Edmond, OK 73025 I n s i d e M e d i c i n e | Fa l l I s s u e 2 0 1 8

Some of the more common symptoms seen in patients at The Smith Family Clinic for Genomic Medicine include, but aren’t limited to:

The Smith Family Clinic uses the power of genomic medicine to diagnose diseases impossible to diagnose through other means. From your DNA, we derive answers that can guide care and make therapeutic decisions.

• Epilepsy • Cognitive or developmental delay • Adult-onset neurological disease (neuropathies, dystrophies, myopathies) • Primary immune disorders • Congenital heart defects, cardiomyopathies, or arrhythmias • Other unexplained or unusual disease processes

The Smith Family Clinic could help. Talk to your doctor or contact the clinic today.

256.327.9640

701 McMillian Way NW, Ste.A., Huntsville, AL 35806 on the campus of HudsonAlpha Institute for Biotechnology

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} HEALTH FEATURE

Shushing The Stigma

by Kelly Reese

Some people often say it's not the reality that creates one’s story but more the perception of what someone sees. After sitting down and talking with one of the most remarkable physicians I know, I can now attest to this thought. Dr. Dwain Woode of Diabetes and Endocrine Wellness Center in Huntsville, AL shared many stories of his life as an endocrinologist with me. There was one in particular that changed his life forever. After listening to him, my life was also changed. He admits that he was not eager to share this story. For a long time, he felt shame when he replayed this particular conversation in his head. It was shortly after he completed his endocrinology fellowship. He, along with his wife Dr. Charmaine Blake Woode, and son, moved to Huntsville and opened Diabetes and Endocrine Wellness Center. He recounts: A young patient was struggling with his diabetes. I offered him words of encouragement. In frustration, the patient said, “You don’t know what it is like to have diabetes”. Perhaps she sensed that I did know what it was like, and his mother asked: “Dr. Woode, do you have diabetes?” I wanted to keep our relationship strictly professional. I did not want to share anything personal with my patients and their families. I did not want to be known as the diabetes doctor with diabetes. So, I responded, “No.” The problem was, that was not the truth. When the patient came back for his next visit, I decided to ‘fess up. The young patient turned to his mother and said: “See, even the doctor is ashamed to have diabetes.” I can’t tell you how much that conversation impacted me and how it has stayed with me. What has been redeeming about that interaction is that I now freely share the fact that I have diabetes with my patients. They know that I understand personally what it is like to struggle with diabetes, how it feels to have to check my blood glucose levels even when I’m busy or I don’t want to. I understand what it is like to pass on certain foods when I would like nothing better than to indulge in my favorite dessert.

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Dr. Dwain Woode Photo by Jourdan Ways

For many diabetic patients, treating their diabetes involves taking insulin. Unfortunately, insulin causes weight gain. Dr. Woode has experienced this himself. He embarked on his own weight loss journey and was able to discontinue his insulin. A significant portion of his patients struggle with weight, not just the patients who have diabetes. Over the past year, he has taken a closer look at the problem of weight management in his patients. He understands the stigma associated with being overweight. He asked himself these questions: "Is there an answer to this epidemic?” “What can I do to assist my patients who also struggle in this area?” The answer to the second question comes in the form of a new business focused on weight management. Dr. Woode has been helping patients with their weight and has seen many success stories. For many of his patients, success is seeing a number on the scale they have not seen in years. More importantly, for others, it means reducing the amount of medication they are taking for their diabetes, hypertension, or hyperlipidemia. With the birth of The Lighter Weigh, LLC, Dr. Woode and his team hope to

impact the Huntsville community by offering a medically supervised weight management program. This program utilizes a comprehensive approach to weight management that does not just focus on nutrition and exercise, but includes total lifestyle transformation. The program will employ a wellness coach to come along side each client and help them be successful. The program will incorporate what we know about how our emotional health, stress and fatigue impact our food choices and ultimately, our weight. Support is critical whenever we attempt to make lasting changes in our lives. Along with having a wellness coach, each client will be part of a community that supports each other on the weight management journey.

I think they appreciate that I can truly empathize with them in their struggle. I also, like many of my patients struggle with maintaining a weight that is healthy. After having a conversation with Dr. Woode and hearing his story and learning about The Lighter Weigh, it has forever changed how I want to approach living a healthier life. He emphasizes that the right tools are needed to be successful. These tools are content, coaching, and community. We can learn better ways to approach our diseases and reach out and engage with others who are there to share our victories and our setbacks. He also taught me that no matter what "disease" we might be facing...whether it is PCOS, diabetes, or obesity... "We need to control the disease, the disease does not need to control us." Diabetes and Endocrine Wellness 1 Hospital Drive Southwest Huntsville, AL 35801 256-881-2700

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SURGICAL MANAGEMENT OF

ASTIGMATISM

by Jonathan Ramsey, MD

Many people are familiar with myopia (nearsightedness) and hyperopia (farsightedness), but fewer recognize the term astigmatism. Astigmatism refers to an irregular shape of the cornea (the clear front cover of the eye), a lower order aberration. Rather than the cornea being round – like the side of a basketball – it is steeper in one direction – like the side of a football. This causes light to be bent irregularly, so that it focuses to multiple focal points, rather than focusing to a single crisp point on the retina. Astigmatism of 1.00 D is relatively common in adults over age 40, with an incidence of 31%1. There are many options available for astigmatism management, both surgical and non-surgical. A primary eye care provider will typically start a patient in glasses or astigmatism-correcting contact lenses called toric lenses. This is a good treatment with low risk. However, glasses and contacts don’t fit into every patient’s lifestyle. There 58

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are surgical options available for those who desire independence from glasses or contacts. Surgical options for astigmatism management include corneal-based and lens-based procedures. LASIK and PRK are procedures that can treat low to moderate amounts of astigmatism by reshaping the cornea. Modern all-laser LASIK uses a femtosecond laser to create a flap in the surface of the cornea, then an excimer laser is used to reshape the corneal tissue and the flap is replaced. Traditional LASIK could manage small amounts of astigmatism, but may create higher-order aberrations, which limit the quality of vision. Custom wavefront-guided LASIK uses wavefront analysis to create a map of the optical system of the eye. A treatment based on this map can reduce higher order aberrations and improve the quality of vision,

including improved quality of vision under dim lighting conditions compared to traditional LASIK. Not everyone is a good candidate for LASIK and it carries a small risk of complications, such as increased dry eye. Astigmatism can also be treated at the time of cataract surgery. For patients who have cataracts limiting their ability to read small print or see to drive, cataract surgery can improve the vision. Research has shown that patients are 34 times more likely to need glasses for every diopter of astigmatism in the better seeing eye2.

An astigmatism-correcting lens, or toric intraocular lens (IOL), can be placed in the eye at the time of cataract surgery to minimize or eliminate the need for distance glasses after surgery. New technology, such as the ORA, uses real-time wavefront analysis to allow the cataract surgeon to align the toric IOL with greater precision. The newest IOLs allow treatment of both astigmatism and presbyopia at the time of cataract surgery, to significantly reduce the need for glasses both at distance and near. Although astigmatism affects many people, there are many good options for treatment. Technology continues to improve and allow greater options for surgical management. Those interested in treatment of astigmatism can discuss which option is best for them with their primary eye care provider.

1. Vitale S, Ellwein L, Cotch MF, Ferris FL 3rd, Sperduto R. Prevalence of refractive error in the United States, 1999-2004. Arch Ophthalmol. 2008 Aug;126(8):1111-9. 2. Wilkins MR, Allan B, Rubin G; Moorfields IOL Study Group. Spectacle use after routine cataract surgery. Br J Ophthalmol. 2009 Oct;93(10):1307-12.

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} TESTIMONIAL

When two become one

PATIENT

Our culture and society have allowed us to become complacent with our daily activities; job, family life, friends and even our religion. Often times, we don't realize the importance of maintaining our health as it results a major impact on these categories. "Health" that has a tremendous role in our dayto-day livelihood. That is unless you become injured and for this, a couple, conquering life at its fullest was a daily and long-term goal that became quickly disrupted by a result of painful symptoms that followed in surgical intervention. Not for one but for both. Staying active and passionate about their endeavors as they encountered an interruption neither had anticipated, began with a desire for answers. Having had the opportunity to sit down with Mr. and Mrs. Dieringer of Huntsville, AL and discover their journey as they walked me through an unfavorable circumstance yet a rivaling recovery had me stunned at their positive recollection of the experience they both endured and triumphed through.

Married for decades and both still working full-time, they always treated life as if they were retired living life to the fullest staying active and holding onto their dreams.

However being accompanied by discomfort and lack of mobility, they had to rigorously train themselves to accomplish simple day-to-day activities. One painful memory for Mr. Dieringer to explain was his discomfort even driving to work. It was once a passion to drive his Harley motorcycle across the U.S. landscape, and now it was a self-medicated way for transportation to and

by Kelly Reese

from work. The wind that once flew past him at ample speed now became distant sound. It was now a relief that he could get as an alternative to driving in a vehicle with less appropriate lumbar support. Why had this couple's lives been turned from merely perfect in the American mind to now a complacency like the majority of us experience? "Getting by." This was a couple who divulged in their travels and loved life for all the versatility, yet they were troubled by unbearable pain. It was time to do something about it. Luckily like we most desire, the two shared common goals and common outcome from their decisions. One decision Mrs. Dieringer had made only weeks before her very own impromptu surgical procedure. She led into the details of her preliminary trials, difficulty completing normal daily duties she had long since been performing for decades. Something had to be done, and she was sure something was wrong. She promptly took her healthcare into her own hands and discovered a possible resolution. It started with her and the medical advice regarding what she thought to be a shoulder issue. "After my consult with our shoulder specialist, an MRI was ordered, which led me straight to the orthopaedic spine specialist, where I discovered only days later I was going to have surgery. My symptoms were a result of a pinched spinal cord; the concerns were too great." If she didn't have surgery, other possible consequences could be ahead involving possible but not probable paralyzation. I had no idea that my symptoms were so serious. At this point, all I could say was how much I loved this physician's bedside manner. He was truly wonderful. Wonderful! He made me feel like a person. I wasn't treated like a number." "When I went for surgery, he marked my site with a peace sign (I am a Hippie, she gladly proclaimed)." "Waking up was another story. Wait... I don't need a neck brace? My quality of life was drastically changed by my post-operative outcome. Immediately, I came out of anesthesia and jumped, startled to think, 'Oh no, I just had cervical surgery, and it should have hurt.' However, it did not. I had no idea how quickly I would recover. I started cleaning house and was right back to work."

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waterbed for minimal comfort.

I was taking medication and multiple epidurals a year for pain. I was told that there was nothing else I could do... until Dr. Freudenberger.

Care for yourself the same way you care for others. Fast forward years later, and I can proudly acclaim that my degenerative disc has been surgically corrected by a synthetic disc replacement. This is with no pain and no need for medicine for intervention. In fact, I must add that I carried my walker proudly through the Call local Long hallsyour of the hospital the nightTerm after the Care surgery when I was asked to move around. It was going to lead me, professional for more information. I held it. The memory of 17 years of canes, pain pills, Anne C.relaxers, Jewell, and muscle and256-533-0001 I now needed nothing! Dependent only on my now recovery." To further acknowledge how successful the surgery was for Mr. Dieringer, he participated in the Iron Butt 62

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Women a greater risk of needing When Itoday askedhave her the simple question that I so ofLong Term Care services. It's important ten hear about do you wish youvery would have done it forsooner, women to develop Long Term My Care her response was a"Oh absolutely! quality of life was drastically changed my post-operative strategy to help preserve theirbyfamily, career, outcome. My quality of life before had been lifestyle, health and total financial future. diminished. I had gotten to aprotection point wherecan I was calling Long Term Care save a in extra help at work just to perform the duties that I woman from the high costs of care. It also was able to easily execute prior to my injury. Living provides them disc withdid choice, independence with a cadaver not keep me from skydiving and importantly, to not be a burden on or most hang-gliding!" loved By arranging Long Hey, ones. this couple is a description of Term what a Care bucket list should be. Now, for Mr.women Dieringer,can How would protection for others, stay on you relate your story to your experience. The same? track to protect their savings and keep their "During my wife's initial visit with Dr. Freudenbergcareer. er, I discussed with him how I was a disabled veteran Chances are that you have experienced with multiple back issues. Instead of dismissing these caring for and a loved at some point concerns only one focusing on my wife in (hisyour patient), life, you know it cantobe. he so addressed themhow and demanding spent time talking me. As Your love fortoothers is whyI was youquickly shouldscheduled do a follow-up my concerns, for an MRI bold and my ownbegin appointment with him. something and planning for My quality of life for years was awful. I had to sleep on a Long Term Care now.

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...contâ&#x20AC;&#x2122;d from page 61

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Wow, what an incredible testimony by this couple. Mrs. Dieringer was overcome with joy when she shared the days after her recovery. I should probably just leave out that it was merely hours that she recalled having full mobility as if she had not undergone a cervical disc replacement, but why not share her good news. Especially when only weeks later her husband had spinal surgery by the same specialist to adamantly decline a walker. I was floored! How amazing was their testimony? Would it not be great if we all could restore our normal lives by treatment and intervention as long as we seek the appropriate medical advice? I encourage anyone after hearing this story to stop living in pain and do something about it! This sweet couple has since visited Alaska and gone biking for long periods of time. Did I mention enjoyable rides, played with their dogs, and discovered that they can conquer the daily task as well as their dreams together? I'm glad to live in a community with such amazing healthcare providers and couples that serve our community as advocates of a healthy and prosperous life! Most people dream of a lifetime spent with a spouse who can engage on all levels of interest with little that they don't find compelling to the other having common goals and interests. This is highly sought after and important to the average person. Don't let pain keep you from enjoying a healthy lifestyle.

Ride about a year and a half ago. The goal was to complete 1,000 miles by motorcycle within a 24 hour period. He and his friend completed 1,079 miles in 15.5 hours! This is a feat that would have been impossible prior to his surgery. "Would I recommend Dr. Freudenberger? H.... YES, Dr. Freudenberger comes in and sits down and talks to you just like you're talking to me now. I've since recommended multiple people to this spine specialist. Not only did he explain thoroughly what was going on, he took the time to make sure we understood. And since we both have gone back later for other concerns, it was nice knowing that he would recommend the conservative approach of injections and other non-surgical options before going straight to surgery when possible. When a surgeon actually recommends no surgery for the best possible outcome, then you know you can rest assured that you're receiving optimal care." Seeing an orthopaedic spine specialist who treats your diagnosis daily is very comforting. He commits to putting people like us back on the road again where feeling the wind as we drive into the sunset...possible. We are here to tell you that we are doing just that! Originally, I had just hoped for a good quality outcome where I could just have a range of motion to do my job. I honestly didn't expect it to be as rewarding as it was." I n s i d e M e d i c i n e | Fa l l I s s u e 2 0 1 8

Business women, facing the world with Huntsville

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passion and power.

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Inside Medicine Magazine Fall 2018

Articles inside

3D Printing & TrueFit Dentures

An Innovative Approach to Heart Failure Management