CLINICAL TRIALS FOR BREAST CANCER
table of contents | october • november 2015
28 MEDI•CABU•LARY.....................10 Local experts define health related terms
JUST ASK!.......................................12 Healthcare questions answered by local professionals
Clinical Trials for Breast Cancer: Women are the Heroes Breast cancer is an equal opportunity killer. It doesn’t discriminate. Class lines are not important to breast cancer. It has no color distinction; it observes no geographic barriers, no age limits, no income brackets.
NEW & NOTEWORTHY.............14 A listing of new physicians, providers, locations and upcoming events in greater Richmond
HEALTH POINTS.........................18 Interesting facts and tidbits about health
THE ANATOMY CHALLENGE..................................21 How much do you know about Our Anatomy? In this issue, test your knowledge when it comes to the LYMPH SYSTEM.
THE ANATOMY ........................... 22 The Lymphatic System: Exploring How the Lymphatic System Keeps Us Healthy
In Memoriam...............................................37 For 15 years, Stephanie Rochon was a familiar face to area TV viewers. She was known as a news anchor on Richmond’s CBS affiliate, WTVR, and for her Buddy Check 6 news reports, which focused on breast health and encouraged breast self-exams and regular mammograms.
Clinical Trials:..............................................38 Help Others. Help Yourself.
6
OurHealth | The Resource for Healthy Living in Greater Richmond
The Resource for Healthy Living in Greater Richmond
FIT BITS!........................................................................... 39 Brave the Barre! This one-of-a-kind workout is a continual, fat-burning series of exercises that tone the entire body in an effective yet safe way.
hello, HEALTH!................................................................. 40 Capturing the spirit of those working in healthcare and of people leading healthy lives through photos
48
Growing Emotionally Healthy Children
42
We will explore tips and techniques to help parents, grandparents and educators nurture the development of emotionally healthy and resilient children.
New Procedure can Eliminate Lymphedema’s Debilitating Symptoms Lymph node transfer surgery is a relatively new procedure in the U.S. that is helping breast cancer survivors improve their quality of life. NUTRITION..................................................................... 46 HEALTHY EATS: Shop Seasonally for Better Flavorand Extra Value: Try your hand at yummy Quinoa Crepes and Peach Pumpkin Oatmeal!
CLOSER LOOK................................................................. 58 Images reflecting the landscape of healthcare in Richmond *
A chance to win prizes!
PLUS *
THE THIRD ANNUAL
BEST B E D S I D E MANNE R AWARDS
WINNERS ANNOUNCED IN THE NEXT ISSUE! DECEMBER 2015! www.OurHealthRichmond.com
7
The Resource for Healthy Living in Greater Richmond
october • november 2015 OURHEALTH’S EXCLUSIVE MEDIA PARTNER
PUBLISHER PRESIDENT/EDITOR-AT-LARGE VICE PRESIDENT OF PRODUCTION PROJECT COORDINATOR AND FITNESS EXPERT ACCOUNTING MANAGER CHIEF DESIGNER COPY EDITOR ORIGINAL COVER ART WORK ORIGINAL PHOTOGRAPHY WEBSITE & DIGITAL MEDIA SPECIALIST SOCIAL MEDIA INTERN
McClintic Media, Inc. Steve McClintic, Jr. | steve@ourhealthvirginia.com Jennifer Fields Hungate Deidre Wilkes Laura Bower Karrie Pridemore Bobbi Hoffman Joseph Palotas Tyler Darden/www.tylerdardenphotography.com Dalton Holody Jourdan Markey
CONTRIBUTING RICHMOND MEDICAL EXPERTS Jason Hull, MD Giao Phan, MD, FACS Bimaljit Sandhu, MD Tovia Smith, MD Nathan Zasler, MD CONTRIBUTING PROFESSIONAL Susan Dubuque EXPERTS & WRITERS Rich Ellis Tricia Foley, RD Charles Nance Rick Piester Suzanne Ramsey Edwin Schwartz Deidre Wilkes ADVERTISING AND MARKETING Richard Berkowitz Senior Vice President, Business Development P: 804.539.4320 F: 540.387.6483 rick@ourhealthvirginia.com SUBSCRIPTIONS To receive OurHealth Richmond via U.S. Mail, please contact Deidre Wilkes via email at deidre@ourhealthvirginia.com or at 540.387.6482
@ourhealthmag
COMMENTS/FEEDBACK/QUESTIONS We welcome your feedback. Please send all comments and/or questions to the following: U.S. Mail: McClintic Media, Inc., ATTN: Steve McClintic, Jr., President/ Publisher/Editor: 303 S. Colorado Street • Salem, VA 24153. | Email: steve@ourhealthvirginia.com | Phone: 540.387.6482 Ext. 1 Information in all print editions of OurHealth and on all OurHealth websites (websites listed below) and social media updates and emails is for informational purposes only. The information is not intended to replace medical or health advice of an individual’s physician or healthcare provider as it relates to individual situations. DO NOT UNDER ANY CIRCUMSTANCES ALTER ANY MEDICAL TREATMENT WITHOUT THE CONSENT OF YOUR DOCTOR. All matters concerning physical and mental health should be supervised by a health practitioner knowledgeable in treating that particular condition. The publisher does not directly or indirectly dispense medical advice and does not assume any responsibility for those who choose to treat themselves. The publisher has taken reasonable precaution in preparing this publication, however, the publisher does not assume any responsibility for errors or omissions. Copyright © 2015 by McClintic Media, Inc. Reproduction in whole or part without written permission is prohibited. OurHealth Lynchburg/Southside is published bi-monthly • Special editions are also published • McClintic Media, Inc. • 303 S. Colorado Street, Salem, VA 24153, P: 540.387.6482 F: 540.387.6483. MAIN: ourhealthvirginia.com | ourhealthswva.com | ourhealthlbss.com | ourhealthrichmond.com | ourhealthcville.com | Advertising rates upon request.
LOCAL EXPERTS D E F I N E H E A LT H R E L AT E D T E R M S
What is an advance medical directive?
What is Barrett’s esophagus?
Virginia’s advance medical directive is an important legal document for anyone 18 years of age and older. A medical directive consists of:
Barrett’s esophagus (BE) is a condition in which tissue that is similar to the lining of the intestine replaces the tissue lining the esophagus. BE is a precancerous condition that may progress to esophageal cancer.
• a power of attorney for healthcare that authorizes an individual’s choice of personal representative to make medical decisions when he or she is unable to express them; • a living will which informs doctors of end-of-life medical care wishes of the individual. Before a spouse or loved one can discuss a person’s health condition, obtain medical records or seek a second opinion, they need a written document executed by the individual, with very specific language required by federal HIPAA privacy laws. Charles Nance
The Nance Law Firm, PLC Richmond | 804.213.3007 www.nancelawfirm.net
Gastroesophageal reflux disease (GERD) increases chances of developing BE. GERD is a more serious, chronic form of acid reflux, a condition in which stomach contents flow back up into the esophagus. Refluxed stomach acid that touches the lining of the esophagus can cause heartburn and damage the cells in the esophagus. Between five and 10 percent of people with GERD develop BE. Other risk factors include obesity, smoking and white race. Treatment options for BE include medical therapy with stomach acid reducers called proton pump inhibitors (PPI). These medicines can prevent further damage to the esophagus and, in some cases, heal existing damage. Treatment of BE is based upon the general condition of the patient. Bimaljit Sandhu, MD
Richmond Gastroenterology Associates Richmond | 804.673.2806 www.RichmondGastro.com
10
OurHealth | The Resource for Healthy Living in Greater Richmond
What is immunotherapy? Immunotherapy is using the body’s immune system to treat disease. Cancer immunotherapy uses the patient’s own immune cells to kill cancer, similar to how the immune cells kill foreign invaders like bacteria. Immunotherapy uses agents that either stimulate the anti-cancer immune cells or remove the brakes that suppress the immune cells. It can also involve infusing the body with active anticancer cells. Immunotherapy offers enormous potential for personalized medicine. Most importantly, it offers a chance for durable remission since the immune cells are potentially active everyday even if the patient is not receiving therapy. Every day, new and promising immunotherapies for a variety of cancers are being developed and tested in clinical trials at cancer research centers. Giao Phan, MD, FACS
VCU Massey Cancer Center Richmond | 804.828.5116 www.massey.vcu.edu
H E A LT H C A R E QUESTIONS ANSWERED BY LOCAL PROFESSIONALS
What are some treatment options for women suffering from urinary incontinence (leaking urine)? Too often, women are told that incontinence is part of aging, and there is very little that can be done to correct it. To make matters worse, many who have considered seeking treatment have chosen not to for fear of surgical treatment being their only option. The first step in treating leakage is to determine the type of incontinence. Stress incontinence is leakage with coughing, sneezing or exercising. Urge incontinence, or overactive bladder, is a combination of frequency and urgency, resulting in leakage due to not getting to a bathroom in time. There are several non-invasive treatments that women experiencing stress incontinence should try first. If these options are not enough, then a urethral sling may be recommended. Both mesh and non-mesh slings can be used in these procedures; both options are FDA approved and are considered safe and effective. For women suffering from overactive bladder, treatments include exercises, diet and lifestyle modifications, medications, in-office procedures and BOTOX® injections. Speaking with a specialist can help to determine the best treatment. Tovia Smith, MD
Urogynecologist Virginia Women’s Center Richmond | 804.288.4084 www.virginiawomenscenter.com
12
OurHealth | The Resource for Healthy Living in Greater Richmond
What are some things to consider when deciding to have joint replacement surgery? The decision to move forward with hip or knee replacement surgery is deeply personal, and the “right” time to have surgery is different for every patient. Central to this decision is pain and its impact on simple everyday lifestyle activities, personal hobbies, leisure activities, and even sleep. Arthritis pain not relieved with conservative treatment measures, such as physical therapy and exercise, weight loss, activity modification, anti-inflammatory medications, injections or pain medications, can profoundly affect one’s quality of life. Every patient perceives pain and its impact on function and quality of life in a different manner, and therefore the point at which the benefit of joint replacement surgery outweighs risk is different for every patient. After a detailed individualized discussion with an orthopaedic surgeon, patients can make an educated decision whether it’s the right time for them to proceed with joint replacement surgery. Jason Hull, MD
Tuckahoe Orthopaedics Richmond | 804.285.2300 www.tuckahoeortho.com
What are some causes of post-traumatic headache (PTHA) after a concussion? Of the post-concussion symptoms that occur after a traumatic brain injury, headaches are among the most common early features. A physician can determine the underlying cause for a post-traumatic headache (PTHA) with appropriate time taken to acquire an adequate history, as well as conduct a careful physical evaluation (including all relevant head, neck and upper back structures) and as indicated, order appropriate diagnostic testing. Treatment should be started as soon as possible with the goal of prescribing treatment that can be optimally complied with, as well as educating the patient and family regarding the condition and its treatment and prognosis, all in order to avoid the negative effects of more chronic pain. PTHA may be caused by direct head trauma, neck, jaw and head disorders, various severe types of headaches, and rarely problems such as blood clotting in and around the brain. The most common cause of PTHA is neck disorder related to headache after concussion and/or whiplash injury. Nathan Zasler, MD
Concussion Care Centre of Virginia, Ltd. Richmond | 804.270.5484 www.concussioncarecentre.com
THE THIRD ANNUAL
COMING December 2015
w w w. o u r h e a l t h r i c h m o n d . c o m
NEW
NOTEWORTHY
NEW PHYSICIANS, P R O V I D E R S , L O C AT I O N S AND UPCOMING EVENTS
Shedding New Light on Depression Researchers from the Department of Psychiatry at Virginia Commonwealth University in Richmond, working in collaboration with scientists from the University of Oxford and throughout China, have identified genetic clues to the underlying causes of clinical depression.
VCU’s Virginia Institute for Psychiatric and Behavioral Genetics was a key participant in the research that successfully isolated specific changes in DNA that increase risk for major depression. This study was published online in the journal Nature in July of this year.
Kenneth S. Kendler, MD, professor of psychiatry and human and molecular genetics at VCU School of Medicine—part of a team that is uncovering the genetic links to clinical depression.
“This type of genetic study is the first step in uncovering specific biological pathways to the illness. The findings could potentially lead to new ways to predict hereditary risk for depression and more effective treatments for the disease,” says Kenneth S. Kendler, MD, joint-senior author and professor of psychiatry and human and molecular genetics at VCU School of Medicine. Depression is no small problem. It affects approximately 19 million Americans and 350 million people worldwide.
Studies show that rates of depression for Americans have risen dramatically in the past 50 years. In fact, the World Health Organization has classified depression as a worldwide epidemic. But thanks to this type of innovative research conducted by Dr. Kendler and his associates, one day we may even uncover the secret to preventing this devastating disease. To learn more, watch this video on the breakthrough research at www.VCUDepressionDiscovery.com.
Dr. Matthew Brengman Successfully Implants First FDA-Approved
Intragastric Balloon Weight Loss Device in Mid-Atlantic Region Matthew Brengman, MD, FACS, a bariatric surgeon with Advanced Surgical Partners of Virginia and medical director for the Weight Loss Program at Parham Doctors’ Hospital, successfully completed the first FDA-approved ORBERA™ Intragastric Balloon weight-loss procedure in the mid-Atlantic region. According to Brengman, the ORBERA™ Intragastric Balloon device is a spaceoccupying balloon in the stomach that helps patients feel full and eat less. During an endoscopic procedure using a mild sedative, the deflated balloon is placed into the stomach through the mouth, and then filled with saline until reaching approximately the size of a grapefruit. It remains in place for a period of six months, aiding patients with portion control and achieving sustainable weight loss at a rate of 3.1 times those who engaged in diet and exercise alone. The ORBERA™ Intragastric Balloon is ideal for patients with a body mass index (BMI) between 30 and 40, who are between 30-100 pounds overweight. 60 million people in the United States currently fall into this category. “Patients on average lose about 35 pounds,” said Brengman. “Our comprehensive program supports patients through all stages of the procedure – from initial consultation, placement, and therapy, through a six-month follow-up period after device removal, during which our team helps patients sustain their weight loss through healthy nutritional and lifestyle habits.” This non-surgical and non-incisional procedure fills the treatment gap that previously existed for patients who aren’t considering invasive surgery, but for whom diet and exercise, or pharmaceutical interventions, have not worked.
to perform ORBERA™ placements, and combined with his partners, Michael Barker, MD and Gregory Schroder, MD, Advanced Surgical Partners of Virginia is one of only a few practices in the mid-Atlantic currently offering the groundbreaking procedure.
Brengman is one of an elite group of bariatric surgeons nationwide trained
For more information, visit www.advancedsurgicalpartnersofva.com.
14
OurHealth | The Resource for Healthy Living in Greater Richmond
Virginia Women’s Center welcomes the newest breakthrough in Women’s
Health Treatment
Virginia Women’s Center is adding a leading edge treatment to its practice to resolve vaginal health issues often caused by menopause. The MonaLisa is an in-office procedure that is virtually painless and requires no anesthesia. It received FDA clearance in 2014. Virginia Women’s Center is one of the first practices in Virginia to offer the special fractional CO2 laser specifically designed to help postmenopausal women as well as breast cancer survivors. Performed in an office environment without the need for anesthesia and without pain or side effects, the MonaLisa delivers CO2 laser energy to the vaginal wall to promote vaginal mucosal revitalization and restore vaginal health. Patients undergo three treatments spaced six weeks apart, with each treatment lasting less than five minutes. “MonaLisa is a real breakthrough for feminine health,” says Peter Wilbanks, MD, a gynecologist with Virginia Women’s Center. “It offers a quick and painless remedy for a medical condition with a large unmet need for an effective treatment option. Traditional treatments do not always prove effective, so I am grateful to offer my patients an alternative,” says Dr. Wilbanks. MonaLisa allows for a functional restoration of the vagina, which helps attenuating symptoms related to vaginal atrophy, a common problem for women. Thanks to its action on factors that determine dryness, fragility and loss of mucosal elasticity, this treatment can eliminate troublesome itching, irritation and pain, which become particularly acute during intercourse. The interaction with laser is, in fact, the ideal method to stimulate the collagen contained in the vaginal walls for the rehydration and functional tissue restoration. Its beneficial action can contribute to improved self-confidence and restore intimacy. For more information, visit www.virginiawomenscenter.com.
Virginia Family Dentistry relocates and will host open house October 16th. Virginia Family Dentistry’s Chester office has relocated to a state-of-the-art facility. The new 2,000 sq. ft. office is across from John Tyler Community College and adjacent to the Lowes on Route 10. General dentists Marc Gamache, DDS, Jeffrey Cash, DDS and Rocio Lopez, DDS will be joined by orthodontist Melanie Spears, DDS in this free standing location. Virginia Family Dentistry Open House 2601 Swiftrun Road Friday, October 16th 4:30 p.m. – 6:30 p.m. For more information on Virginia Family Dentistry, visit www.vadentist.com.
NEW
NOTEWORTHY
NEW PHYSICIANS, P R O V I D E R S , L O C AT I O N S AND UPCOMING EVENTS
Bon Secours’ Patient FIRST in Central Virginia to receive New Life-Saving Care Innovative cardiac center is one of 60 in U.S. to evaluate HeartMate 3 LVAD Implant As part of its ongoing commitment to provide exceptional care for patients with heart disease, Marc R. Katz, MD, MPH, cardiac surgeon and chief medical officer of the Bon Secours Heart & Vascular Institute implanted the first HeartMate 3 Left Ventricular Assist Device (LVAD) in August of this year. The patient was selected as part of the prestigious MOMENTUM 3™ clinical trial. Bon Secours is one of 60 elite centers in the United States—and the first in central Virginia—chosen to evaluate the Thoratec® HeartMate 3™ LVAD, a new advancement in mechanical circulatory support (MCS) for people with advanced heart failure. The HeartMate 3 LVAD is an implantable mechanical device that helps circulate blood throughout the body. Sometimes called a “heart pump” or “LVAD,” it is designed to supplement the pumping function of the heart for patients whose hearts are too weak to pump blood adequately on their own. The new fully magnetically levitated (Full MagLev™) flow technology is designed to lower adverse event rates. The HeartMate 3 is smaller in size than its predecessor, HeartMate II®, which enhances ease of surgical placement and allows for patients of a smaller size to benefit from the technology. The MOMENTUM 3 trial, which is expected to enroll more than 1,000 patients nationwide, is designed to evaluate the performance and safety of the HeartMate 3 at six months of LVAD support in patients with advanced heart failure.
Marc R. Katz, MD, MPH, cardiac surgeon and chief medical officer of the Bon Secours Heart & Vascular Institute
For more information visit www.richmond.bonsecours.com.
Scott Thomas Armistead, MD
John Baillie, MD
Keith Eldridge, DDS
Brian Fishero, MD
Rachel Love, MD
Christina McWhorter, MD
Beth Martin, Certified Orthotist, ABC
Robert Parkinson, PhD, LCP
VCU Health Family Medicine Southside Richmond 804.230.7777 www.vcuhealth.org
Louis Formica, DDS
Virginia Family Dentistry Prince George 804.526.4822 www.vadentist.com
16
William Allen Hogge, MD
VCU Health Maternal-Fetal Medicine Downtown Richmond 804.828.4409 www.vcuhealth.org
Virginia Women’s Center Mechanicsville 804.288.4084 virginiawomenscenter.com
OurHealth | The Resource for Healthy Living in Greater Richmond
VCU Health Gastroenterology, Hepatology and Nutrition Downtown Richmond 804.828.4060 www.vcuhealth.org
Virginia Women’s Center Mechanicsville 804.288.4084 virginiawomenscenter.com
Virginia Family Dentistry Richmond | 804.743.8166 www.vadentist.com
Powell Orthotics & Prosthetics Richmond | 804.649.9043 www.powelloandp.com
Commonwealth Ear, Nose and Throat Specialists, PC Richmond | 804.525.4231 commonwealthentpc.com
VCU Health Parkinson’s and Movement Disorders Center West End Richmond 804.662.9185 parkinsons.vcu.edu
www.OurHealthRichmond.com
17
TI P S , T I D B I T S A ND MO R E TO IN F O R M A ND ENT ERTA I N YO U
OCTOBER IS
BREAST CANCER AWARENESS MONTH — GET THE FACTS!
hh Breast cancer is the most common cancer diagnosed in women in the United States, other than skin cancer. It is the second leading cause of cancer death in women, after lung cancer.
Binge eating disorder often results in many of the same health risks associated with clinical obesity, including:
hh The chance of a woman having invasive breast cancer some time during her life is about 1 in 8. The chance of dying from breast cancer is about 1 in 37.
hh High blood pressure
hh High cholesterol levels
hh Be self-aware in your breast health. Know your risk. Get screened. Know what is normal for you. Make healthy lifestyle choices. For more information visit www.cancer.org. For answers to all your breast health questions, schedule an appointment with your local physician.
National is October 24th
DID YOU KNOW?
hh Heart disease as a result of elevated triglyceride levels hh Type II diabetes mellitus hh Gallbladder disease
5th annual
Dunkin’ Donuts Munchkins Run
to benefit ASK Childhood Cancer Foundation
National Food Day is observed to remind us to make changes in our own diets and to take action to solve food-related problems at the local, state, and national level. The theme is Toward a Greener Diet. For more information about National Food Day and ways you can participate, visit www.foodday.org.
Date: Saturday, November 21st Time: 9 a.m. Location: 711 St. Christopher’s Road, Richmond, VA Navigate a 5k course, surrounded by thousands of yummy Dunkin’ Donuts Munchkins and goodies! Enjoy an AWESOME Dunkin’ Donuts post-race breakfast featuring Dunkin’ Donuts Munchkins, donuts, coffee, bagels and hot chocolate, as well as traditional post-race bananas and granola. Lots of other cool stuff! Come out and help support this great cause! For more information about this event, visit www.rrrc.org/events/dunkin-donuts-munchkin-5k-run
18
OurHealth | The Resource for Healthy Living in Greater Richmond
Fun Run and Festival
Tempting Treats! Scared of Halloween candy? Don’t be! These Halloween treats are so low in calories you’ll think you’re being tricked. In addition to calories, be mindful of both fat and sugar grams when selecting your special treat. calories
grams of fat
grams of sugar
10 Whoppers
100
4
14
2 Mini Size Snickers Bars
90
4
12
1 Tootsie Roll Pop
60
0
10
2 Mini Size Reese’s Cups
80
5
10
1 Fun Size 3 Musketeers Bar
70
2
11
11 pieces of candy corn
70
0
14
1 Fun Size Package of M&M’s
100
4.5
13
1 Fun Size Almond Joy Bar
100
5
19
Date: Time: Location:
Saturday, October 17th 10 a.m. – 2 p.m. Broad Street between Belvidere Street and Hermitage Road
The VCU Broad Street Mile combines a street festival with a 5K Run and series of one-mile fun runs on the city’s major thoroughfare, Broad Street. In addition to providing a fun, festive event, the VCU Broad Street Mile provides a turnkey fundraising opportunity for local community organizations. This year’s event promises to be bigger and better with a 5K route through the VCU Campus and performances from local community organizations in the festival area. The FREE festival will feature live music, food trucks, local vendors, kids activities and more. People are encouraged to come enjoy the festival even if you are not participating in one of the run/walks.
Source: www.sparkpeople.com
For more information, visit www.vcubroadstreetmile.com
November is American Diabetes Month Diabetes can strike anyone, from any walk of life. And it does, in increasing numbers every year. Raising awareness of this evergrowing disease is one of the main efforts behind the mission of the American Diabetes Association (ADA). November is American Diabetes Month. This month and every month, encourage people to make healthy changes. Eat healthy, don’t smoke, increase physical activity and have regular check-ups with your local physician. »» Of the nearly 30 million people in the US with diabetes, 9095 percent are type 2 diabetics. »» Another 86 million Americans have prediabetes and are at risk for developing type 2 diabetes. »» The ADA estimates that the total national cost of all diagnosed diabetes in the U.S. is $245 billion.
»» There is hope. People who are at high risk for type 2 diabetes can lower their risk by more than half by making healthy changes. »» Are you at risk? Visit www.diabetes.org to take the ‘Ryan’s Challenge’ type 2 diabetes risk test or visit your local healthcare provider and ask about your risk for type 2 diabetes and heart disease.
29.1 MILLION people in the United States have diabetes. About
9.3%
of the population.
Source: www.diabetes.org www.OurHealthRichmond.com
19
the
Anatomy
CHALLENGE How much do you know about the
__________________ __________________ __________________
Lymphatic
System? First, complete the word search below. Next, match up the correct word with the part of the body in the illustration.
__________________ __________________
[ the Lymphatic System ]
WORD SEARCH appendix
spleen
axillary lymph nodes
subclavian vein
cervical lymph nodes
thoracic duct
inguinal lymph nodes
tonsil
popliteal lymph nodes
thymus gland
red bone marrow
__________________ __________________ __________________
__________________ For answers, visit OurHealth
Richmond's Facebook page at
__________________ __________________
www.OurHealthRichmond.com
21
Exploring how the
LYMPHATIC SYSTEM keeps
words | EDWIN SCHWARTZ
usHealthy
The lymphatic system plays a vital part in the body’s ability to fight disease. Its role is two-fold — refuse collector and police force. To learn more about how the lymphatic system protects us from the spread of infection and cancer, OurHealth consulted the experts at Virginia Cancer Institute, VCU Medical Center and HCA Virginia.
Defining the lymphatic system As part of the body’s defense network, the lymphatic system collects fluid, waste material and organisms (such as bacterial viruses) in the body’s tissues and rids them of damaged cells. The system is mostly composed of lymph vessels and lymph nodes. Lymph vessels are similar to the veins that carry blood throughout the body, but instead of transporting blood, lymph vessels carry a fluid called lymph. Lymph nodes are located throughout the lymphatic system and filter the lymph fluid of foreign substances such as bacteria, viruses or cancer cells. These organisms are then destroyed by special white blood cells called lymphocytes.
The purpose of the lymphatic system According to James Khatcheressian, MD, a medical oncologist at Virginia Cancer Institute and a member of the Breast Cancer Expert Panel for the American Society of Clinical Oncology, the lymphatic system serves two purposes.
www.OurHealthRichmond.com
23
What is Lymph? Lymph is a clear, watery fluid that circulates in the lymphatic system. In addition to carrying lymphocytes, it also contains cellular debris gathered from either dead cells within the body or bacteria from within the lymphatic system.
James Khatcheressian, MD is a medical oncologist at Virginia Cancer Institute. He is certified by the American Board of Internal Medicine with a subspecialty in Medical Oncology.
First, in its role as refuse collector, the lymphatic system drains about 15 percent of the plasma (the liquid part of blood) that accumulates in the tissue between blood cells — called interstitial tissue — back into the circulatory system. The circulatory system moves blood throughout the body; it comprises the heart, arteries, capillaries and veins. Second, the lymphatic system functions as the primary defense network of the immune system. The lymphatic vessels are connected by hundreds of lymph nodes that contain the lymphocytes, which help fight infection and cancer cells. In this policing function, the lymphatic system can really be seen as a network that scans the blood plasma for enemies, both foreign (infection) and domestic (cancer). “Imagine the main blood vessels in the body as large highways that carry the blood throughout the body,” says Dr. Khatcheressian. “The smaller blood vessels are like accessory roads leading to that highway. The lymphatic system is like a broad, farreaching system of country roads that extends all over the body, leading to the main highways and eventually back to the center of the system.”
Other parts of the body that work with the lymphatic system The network of lymph vessels reaches the entire body. The vessels become larger as they meet at the center of the body and drain into two ducts near the heart. “In between this vast network, the lymph nodes are interspersed like police check points scanning for abnormalities,” says Dr. Khatcheressian. All the lymph fluid that drains from the body circulates through the lymph nodes several times before returning to the general blood circulation of the heart. Huan Vu, MD is an associate professor in the Division of Surgical Oncology, Surgery at the VCU School of Medicine. Dr. Vu is certified by the American Board of Surgery.
The spleen (in the left upper abdomen) and the thymus (in the upper chest) are connected to the lymphatic system. They regulate the white blood cells that combat disease and infection.
Diseases and conditions that affect the lymphatic system Swelling of the lymph nodes can result from any disease that involves infection, injury or cancer. This occurs as the lymph nodes try to filter abnormal cells that have entered the system. 24
OurHealth | The Resource for Healthy Living in Greater Richmond
According to Huan N. Vu, MD, associate professor in the Division of Surgical Oncology, Surgery at the VCU School of Medicine, some lymphatic diseases result from the blocking of lymph drainage. “When the lymph channels are blocked or cut, the lymph fluid can’t flow out of the tissue,” says Dr. Vu. “Subsequently, the tissue swells with this fluid, causing a condition called lymphedema.” In the U.S., the primary disease that affects the lymphatic system is cancer. This can originate in the lymphatic system in the form of lymphoma, which is caused by cancerous lymph nodes or cancer lymphocytes that reside in those nodes. According to Karen Roesser, RN, director of oncology practice at HCA Virginia’s Thomas Johns Cancer Hospital at Johnston-Willis Hospital, cancer can enter the lymph nodes in two ways — it can originate there, or it can start somewhere else and spread to the lymph nodes. “If the cancer moves from its primary site — such as the colon, breast or lung — it can travel to other parts of the body via the bloodstream or the lymph system,” says Roesser. “This is one mechanism of how cancer can metastasize to a new area of the body.”
Karen Roesser, RN is the director of oncology practices at HCA Virginia’s Thomas Johns Cancer Hospital at Johnston-Willis Hospital.
Cancer in the lymph nodes has a dual significance, says Dr. Vu. First, it means the body’s immune system has failed to contain or destroy the cancer. And it indicates that the cancer cells are able to live away from their primary site. For example, breast cancer cells were originally normal cells that were only able to live in the breast. Once cancer cells are able to live away from “home,” the ability to destroy them becomes more difficult.
Treatment options for lymphatic system diseases If the lymph nodes are swollen due to an infectious condition, antibiotics may be used for treatment. If cancer has invaded the lymph nodes, treatment is based on the stage of the cancer. —‘Lymphatic System’ continued on page 26
What are Lymph Nodes? Lymph nodes are small, bean-shaped organs that filter harmful substances within the lymphatic system. They are located throughout the lymphatic network and may form junctions where damaged cells, infectious organisms (e.g., bacteria or viruses) and cancer cells are filtered and destroyed. If multiple infectious organisms or cancer cells are present, the lymph nodes typically become swollen.
www.OurHealthRichmond.com
25
—‘Lymphatic System’ continued from page 25
Little known facts about the lymphatic system Did you know the human body has approximately 500 lymph nodes? Typically they can’t be felt until they become swollen. In addition to the lymphatic vessels and lymph nodes, the lymphatic system includes the spleen, thymus, tonsils and adenoids. These organs also protect our bodies from invading pathogens that can cause disease.
“Treatment for lymph node involvement may include surgery, chemotherapy, biological therapy and/or radiation therapy, depending on the given situation,” says Roesser. In cases of lymphedema (insufficient drainage of lymph fluid), treatment usually involves increasing the pressure on the tissue to push the lymph fluid out and back into circulation. This can usually be accomplished with a compressive extremity garment and physical therapy. Due to the fact lymphedema is irreversible and effective therapy is limited, cancer surgery now focuses on removing as few lymph nodes as possible. This is because when cancerous lymph nodes are removed, lymph channels are cut. If the ends of the channels can’t heal with each other, lymphedema can result.
How can we care for our lymphatic system? Since there is no specific screening tool for cancers that begin in the lymph nodes (as with lymphoma), the best way to prevent cancer in the lymphatic system is to practice good health maintenance and screening. Prevention should include colonoscopies and annual mammograms, especially for people with a family history of cancer.
Expert contributers • James Khatcheressian, MD with Virginia Cancer Institute • Karen Roesser, RN with HCA Virginia’s Thomas Johns Cancer Hospital • Huan Vu, MD with VCU School of Medicine
ON THE WEB
More at ourhealthrichmond.com
26
OurHealth | The Resource for Healthy Living in Greater Richmond
Reprints To order reprints of the original artwork featured on this issue’s cover, contact Deidre Wilkes at 540.387.6482 or via email at deidre@ourhealthvirginia.com. To view additional work by our artist, Joe Palotas, visit www.salemartcenter.com
28
OurHealth | The Resource for Healthy Living in Greater Richmond
CLINICAL TRIALS FOR BREAST CANCER
Women are the heroes
Breast cancer is an equal opportunity killer.
words | RICK PIESTER
It doesn’t discriminate. Class lines are not important to breast cancer. It has no color distinction; it observes no geographic barriers, no age limits, no income brackets.
photography | TYLER DARDEN
original art | JOE PALOTAS
Breast cancer doesn’t even observe gender differences. Although women are more than 100 times more likely than men to be diagnosed with breast cancer, more than 2,000 men in the U.S. will be diagnosed with the disease by the end of this year. An estimated U.S. 440 men will die from breast cancer by the end of 2015. According to the American Cancer Society, more than 231,000 women in the U. S. will be diagnosed with breast cancer in 2015, and more than 40,000 will die from the disease. —‘Heroes’ continued on page 31 www.OurHealthRichmond.com
29
30
OurHealth | The Resource for Healthy Living in Greater Richmond
Know the breast cancer danger signals The most common sign of breast cancer is a new lump or mass. A painless, hard mass that has irregular edges is more likely to be cancerous, but breast cancers can also be soft or rounded. They can even be painful. For this reason, it is important to have any new mass or lump or breast change checked by a health care professional experienced in diagnosing breast diseases.
Other possible signs and symptoms of breast cancer include
Kathryn Baskerville
NORTH CHESTERFIELD , VA
—‘Heroes’ continued from page 29
Kathryn Baskerville, of North Chesterfield, never thought she would get a breast cancer diagnosis. Healthy all of her life, Baskerville followed a health regimen that included annual checkups, regular breast self-exams, and annual mammograms to look for breast lumps before they can be felt. There was never a problem. She was so confident that she almost skipped her regular mammogram in 2012, but she gave in to the urgings of her husband, Ralth. “I was going to skip it for a year,” Baskerville recalls. “It had always been negative, and I figured, ‘Why bother?’ But Ralth told me that either I would make the appointment or he would. So I went ahead.” Just before Thanksgiving in 2012, she learned that health care professionals had found stage 3 cancer in her left breast. Cancer starts when something goes wrong in the tiny and violent world of the body’s cellular system. Cells begin to grow out of control, pushing aside or killing normal cells. Like evil armies, they form into groups of similar cells — tumors — that invade surrounding tissue or spread to distant areas of the body. Baskerville, age 61 at the time, was relatively lucky. Her tumor was about 2 inches across, in an area that could not have been felt by self-exam. The cancer had not spread, or metastasized, to other areas within her body. “I was in a daze at first,” Baskerville says. “I could not believe it was happening to me. I kept wondering, ‘Where did this come from?’ I’ve always been healthy, never any health problems.
• Swelling of all or part of a breast (even if no distinct lump is felt). • Skin irritation or dimpling. • Breast or nipple pain. • Nipple retraction (turning inward). • Redness, scaliness or thickening of the nipple or breast skin. • Nipple discharge (other than breast milk). Sometimes breast cancer can spread to lymph nodes under the arm or around the collarbone and cause a lump or swelling there, even before the original tumor in the breast tissue is large enough to be felt. Swollen lymph nodes should also be reported to a medical professional. Although these signs and symptoms can have causes besides breast cancer, they should be reported to a health care professional who can investigate their cause. Source: American Cancer Society
www.OurHealthRichmond.com
31
Kathryn
WITH HER HUSBAND, RALTH, AND GRANDCHILDREN
“I got on the Internet, and I did research on cancer statistics. Then I realized, ‘Why not me?’” The risk of breast cancer is higher among women whose close blood relatives have had cancer. Although Baskerville’s father, uncle and aunt had cancer, none had had breast cancer. She learned that her treatment would start with chemotherapy, followed by radiation therapy, Baskerville and her husband were ready. “The main thing that Ralth said is, ‘You and I are gonna take care of this. We’re in it together,’” Baskerville says, tearing up as she remembers how much of an inspiration and help her husband proved to be. “We got over the initial shock and surprise,” she says, “and we moved on to what we needed to do to take care of this. I had too much living yet to do!” William Irvin, MD is a physician with Bon Secours Cancer Institute Medical Oncology at St. Francis. Dr. Irvin is certified by the American Board of Internal Medicine with subspecialties in both Hematology and Medical Oncology.
Ralth Baskerville retired early so he would be available to help during his wife’s treatment, which took place at the Secours Cancer Institute at St. Francis Medical Center in Richmond. She started chemotherapy treatments in early 2013. In chemotherapy, cancer-killing drugs are injected into a vein or given by mouth. The drugs travel through the bloodstream to target cancer cells in most parts of the body. Chemo is given in cycles, with each period of treatment followed by a recovery period. Baskerville was scheduled for a total of eight treatments, with two weeks between each. “I researched chemo on the Internet,” she says, “and the only thing that scared me was the side effects.”
32
OurHealth | The Resource for Healthy Living in Greater Richmond
Drugs used in chemotherapy have to be powerful to kill rapidly growing cancer cells, but in the course of their work, the drugs can harm perfectly healthy cells, causing side effects throughout the body. Some people manage to go though chemotherapy with hardly a trace of difficulty. Others, including Baskerville, are not so lucky. “My first treatment was really hard,” she says. “It took me maybe a week to recover from it. As time went on, I was so weak that I stopped going to church and to choir practice,” but she endured and had a break of about six weeks before starting radiation therapy. With radiation therapy, high-energy rays are precisely targeted on tumor areas to destroy cancer cells. Her radiation therapy took place between July and early September 2013. When Baskerville’s hair started falling out — a common side effect of the treatment — her husband suggested that she have all of her hair cut off to save her the torment of watching it fall out a little each day. She took him up on his suggestion, and Ralth Baskerville had his head shaved in support. During the treatment, the Baskervilles had to cancel a long-planned 40th anniversary trip to Niagara Falls. Instead, they celebrated their anniversary at home, watching a video of iconic Niagara Falls scenes. As her radiation therapy ended, Baskerville had trouble using her hands. The joints in her hands were achy, preventing her from doing many activities, including working in her garden. Her oncologist at Bon Secours, Ryan S. Raddin, MD, knew of a clinical trial involving the drug Cymbalta, which is prescribed for a variety of ailments but was being studied at the time for its effectiveness with joint pain. Clinical trials are conducted to determine what works and what doesn’t work when it comes to new medical approaches or products. Each trial is aimed at answering two questions — does the product work and is it safe? All prescription drugs and devices sold in America go through a rigorous, long, and expensive schedule of testing and retesting before they get to a pharmacy. Most nonprescription, over-the-counter products also go through clinical trials. People who participate in a clinical trial use new products such as medications or medical devices under carefully controlled conditions before they are available in stores. The variations are unlimited: In some trials (also called “studies”), separate groups of participants may use differing dosages of a medication; in others, some participants use the actual product while others use a placebo that has no active ingredients. “To me, women who participate in clinical trials for breast cancer are some of the real heroes of medicine,” says William J. Irvin, MD, a medical oncologist who heads up clinical research at the Bon Secours Cancer Institute at St. Francis Medical Center in Richmond. “Many women, who can be acutely ill at the time, agree to take part in a clinical trial not knowing whether they will benefit at all. It’s a selfless act.” Baskerville’s participation in the study was successful. She is still on Cymbalta although the trial has ended, and she takes one additional drug to stave off a reoccurrence of her cancer. In April she received the report she had been waiting for — she is cancer-free.
Baskerville was able to return to her beloved garden this year, and with help from her grandson, she says her yard is as beautiful as ever. “I’m almost back to my normal self,” she says. “All I have to do now is take my medications for another three years, and I’m good to go. “I am so thankful that I didn’t wait to have that mammogram,” she says. “I would say to any woman who sees this article, ‘Don’t skip that mammogram.’”
Find us on social media. Follow us on Facebook, Twitter, LinkedIn and You Tube.
There is no lack of breast cancer information online. Following is a list of some of the more popular sites. For most women, the single best source of information on breast cancer is their physician.
Sources • American Cancer Society – www.cancer.org • Breast Cancer.org – www.breastcancer.org • Susan G. Komen – ww5.komen.org • Mayo Clinic – www.mayoclinic.org • Web MD – www.webmd.com/breast-cancer
ON THE WEB
More at ourhealthrichmond.com
34
OurHealth | The Resource for Healthy Living in Greater Richmond
www.OurHealthRichmond.com
35
In Memoriam:
words | SUZANNE RAMSEY
Stephanie Rochon
For 15 years, Stephanie Rochon was a familiar face to area TV viewers. She was known as a news anchor on Richmond’s CBS affiliate, WTVR, and for her Buddy Check 6 news reports, which focused on breast health and encouraged breast self-exams and regular mammograms. According to Stephanie’s best friend and co-worker, Reba Hollingsworth, Rochon considered the Emmy-nominated series the proudest moment of her broadcasting career. Rochon’s dedication to breast cancer awareness went well beyond the TV studio. She served on the board of directors for the Ellen Shaw de Paredes Breast Cancer Foundation and emceed and attended events for various groups, including the Sisters Network, an organization that brings attention to the impact breast cancer has on African-American women. Hollingsworth describes her friend as smart and personable and says Rochon “was well-respected at the station and in the community. She was very involved in the community. She spent a lot of her time, especially on the weekends, emceeing or participating in events.” Rochon was diagnosed with bile duct cancer in September 2014. She died in June 2015, at age 50. Following her death, Hollingsworth took over the Buddy Check 6 report. “I’m continuing the reports that focus on the latest breast cancer news, new drugs and personal stories from the survivors,” Hollingsworth says. “The mission of informing and spreading awareness remains the same. I’m honored to continue her legacy.”
As other evidence of that legacy, the WTVR newsroom was recently renamed the Stephanie Rochon Memorial Newsroom. At the ceremony, news director Sheryl Barnhouse said, “Stephanie inspired those around her to be better journalists and impacted many lives through her anchoring and Buddy Check 6 reports. Stephanie’s spirit, bright smile and infectious laugh will live on in the hearts of many.” Adds Hollingsworth, “While the hole in our hearts remains enormous, Stephanie’s legacy as a mother, wife, daughter, sister, colleague, fighter and friend in Central Virginia is secure. Stephanie was all those things to the people who watched her, knew her and loved her. Her passion, her spirit and her laugh will live on.”
ON THE WEB
More at ourhealthrichmond.com
www.OurHealthRichmond.com
37
CLINICAL TRIALS:
help yourself. HELP OTHERS.
words | RICK PIESTER
As threatening as breast cancer and all cancers can be, medicine has seen a dramatic reduction in the number of breast cancer fatalities over the past 40 years. There are multiple factors behind that good news. Chief among them are vast improvements in screening and diagnostic tests, treatment options, and medications — the results of clinical trials conducted with the help of breast cancer patients in treatment centers across America. The Richmond area is brimming with opportunities for women and men with breast cancer to help improve care for themselves and for future patients.
The VCU Massey Cancer Center, for example, is currently conducting more than 20 clinical trials. They range from cutting-edge research on drugs that show promise for treating patients with an aggressive, triple negative variety of breast cancer — such as that diagnosed in actress Angelina Jolie — to more symptom-related studies, such as helping to find a safe way to reduce hot flashes in women who have been treated for postmenopausal breast cancer. With seven facilities in the Richmond area, HCA Virginia says its system can help patients get access to more clinical trials than any other cancer center in the state. Clinical trials at HCA Virginia also provide options from the Radiation Therapy Oncology Group, the Gynecologic Oncology Group, the National Surgical Adjuvant Breast and Bowel Project and numerous surgical companies. Bon Secours Health System in the Richmond area also offers wide-ranging clinical trials. Researchers there are conducting studies to determine whether a simple blood test may one day detect the presence of cancer. This would be comparable to looking at blood for the telltale signs of Lyme disease or diabetes 38
OurHealth | The Resource for Healthy Living in Greater Richmond
and would, in many cases, eliminate the need for biopsy or exploratory surgery. “It’s going to happen in our lifetimes,” says William J. Irvin, MD, who heads up clinical research at the Bon Secours Cancer Institute at St. Francis Medical Center in Richmond. Other clinical trials there run the gamut from extending the length and quality of life for women with advanced breast cancer, to studies like the one that benefitted Kathryn Baskerville and others that ease the symptoms of cancer and its treatment.
The hard reality of many clinical trials is that they are randomized; some patients in the study receive the promising new drug, while others receive standard therapy or — depending on the nature of the trial — a placebo, an inactive, nonmedicinal substance. In double-blind studies, neither the patient nor the care team knows what the patient is receiving, so the patient may be getting a breakthrough drug or a placebo, like saltwater. But right now, randomized trials are the best way for medicine to determine whether one treatment is really better than another. If you are interested in participating in a clinical trial for any health condition, your healthcare team should be able to get information on any study you might be eligible for. You can also research clinical trials online at www.clinicaltrials.gov, then talk with your healthcare team to see if you might be eligible. If you are chosen for a clinical trial, the risks and rewards will be explained fully, and you might have a chance to help improve the medical options for yourself and others.
ON THE WEB
More at ourhealthrichmond.com
FITBITS
H EA LT H A ND F I T NES S O N THE GO
words | DIEDRE WILKES
Have your friends been talking about going to ‘barre’, and you’re wondering what new hotspot you’re missing out on? When you finally realize they’re not drinking cocktails, but rather working their tails, you’re even more intrigued. So, what’s the barre craze all about? Barre training is designed to use the body’s own mass and very light weights as resistance. This one-of-a-kind workout is a continual, fat-burning series of exercises that tone the entire body in an effective yet safe way. Most barre-based classes use a combination of postures inspired by ballet and other disciplines like yoga and pilates, which also provide a mind-body connection. The barre is used as a prop to balance while doing exercises that focus on isometric strength training (holding the body still while contracting a specific set of muscles) combined with high reps of small range-of-motion movements. Utilizing the barre while contracting the abdominals provides the low back and spine with the stability needed to complete safe movements. It also allows smaller muscle groups to be isolated and sculpted while major muscle groups are simultaneously worked. This technique provides an intense, yet low-impact workout that garners quick, dramatic, and lasting results.
Find a Class:
Workout Stats:
Corner Barre
• Richmond | 804.937.3203 www.cornerbarre.com
Richmond Balance
• Richmond | 804.225.7130 www.richmondbalance.com
Pure Barre
• Richmond - Short Pump 804.918.2568 www.purebarre.com/va-richmond • Near West End | 804.477.6036 www.purebarre.com/vanearwestend
Intensity:
moderate Deidre Wilkes, AFAA, ACSM, Certified Personal Trainer
Deidre is a certified personal trainer with more than 15 years experience in the health and fitness industry. She is the resident fitness specialist for OurHealth Greater Richmond
strength flexibility toning mind/body www.OurHealthRichmond.com
39
AdvanceItUp! - ‘All Kids Deserve the Right to Play’ AdvanceItUp! (AIU!) is a community initiative powered by Advanced Orthopaedics and Ortho On-Call designed to increase recreation options and active living at home and school. By collecting donated, gently used sports gear and distributing to kids who don’t have access to usable sports equipment, AIU! helps get children up and active through programs of Greater Richmond Fit4Kids. Through AIU!, Advanced Orthopaedics and Ortho On-Call annually encourage the public to gather up and donate the sports equipment that they no longer use and that is still in good condition. The physicians and staff from Advanced Orthopaedics and Ortho On-Call, along with volunteers from Fit4Kids, help organize, and clean the collected equipment before distribution.
40
OurHealth | The Resource for Healthy Living in Greater Richmond
During the third annual AIU! drive, Advanced Orthopaedics and Ortho On-Call collected approximately 986 pieces of sports equipment with donations from the public, as well as their staff and community partners. The items from this year’s collection were presented to Greater Richmond Fit4Kids just in time for the fall sports season. Fit4Kids distributes the equipment for use by deserving children through their community partnerships and programs. Additional details about the AdvanceItUp! program are available at www.advancedortho.me/AdvanceItUp. To learn more about the Greater Richmond Fit4Kids, visit www.grfit4kids.com.
Photos courtesy of Etre Communications
ON THE WEB
More at ourhealthrichmond.com
www.OurHealthRichmond.com
41
New
PROCEDURE
can eliminate Lymphedema’s debilitating words | RICH ELLIS
symptoms
Lymph node transfer surgery replaces nodes removed during breast cancer treatment. Lymph node transfer surgery is a relatively new procedure in the U.S. that is helping breast cancer survivors improve their quality of life by alleviating the painful, debilitating symptoms associated with lymphedema. According to Matthew G. Stanwix, MD, with Richmond Plastic Surgeons, lymphedema is a swelling of the extremities — primarily the arm in the case of breast cancer — that results after lymph nodes are removed for cancer surveillance or because of the presence of cancer-causing agents. Lymph nodes process and move lymphatic fluid through lymphatic channels. When those nodes are removed and the channels are damaged from scarring, the fluid can’t be processed well enough to move it through the arm, leading to swelling of the limb.
Lymphedema’s painful symptoms Symptoms associated with lymphedema can be wide ranging and vary in their severity. “There could be a size issue where one arm is bigger than the other arm, heavier or with a larger circumference,” Dr. Stanwix explains. “It could be painful because of the swelling or the fluid itself settling and causing Lymphedema presents an increased risk of infection because the swelling in the arm can lead to breaks in the skin and because the lymph nodes that help fight infection were removed, Dr. Stanwix says. The swelling can also lead to the skin breaking down and taking on a leathery or woody appearance and feel. “It can be quite debilitating, and some patients have to go to therapy three or four times a week for the rest of their lives,” says Dr. Stanwix. “So it’s a quality of life issue both from the symptoms and from the amount of time spent managing it.”
Christina Wood knows all too well about breast cancer and lymphedema. The 46-year-old North Chesterfield resident was diagnosed with breast cancer in March of 2011, had a bilateral mastectomy in April 2011, and developed lymphedema in the fall of 2012. “It began as a mild swelling in my left arm,” says Wood. “I had read about it when going through treatment. When they performed the mastectomy, they removed the sentinel lymph node on my left side. That and the radiation treatment made me very likely to have lymphedema.”
Temporary lymphedema treatment options Matthew Stanwix, MD is a plastic surgeon with Richmond Plastic Surgeons. He is certified by the American Board of Plastic Surgery.
Treating lymphedema through nonsurgical options focuses on helping to move the lymphatic fluid from the arm, Dr. Stanwix explains. These measures, which provide temporary relief but are not a permanent cure, include wearing a compression sleeve to prevent fluid from settling in the arm, having a physical therapist massage the arm to manually move the fluid, and using pump mechanisms that squeeze periodically to push lymphatic fluid from the arm. Wood’s therapist massaged her arm and wrapped it with bandages that she wore all day for weeks at a time to help push fluid out of the arm. Once her arm reached the desired size, she got a compressive sleeve that she wore all day, switching to a different sleeve at night. “I also used a Flexitouch machine,” Wood says. “Every morning I’d lie on my bed for 90 minutes while the machine pumped air through the suit I was wearing.” The Flexitouch System is a pneumatic compression device that simulates the lymphatic system. Wood’s system consisted of a sleeve extending from palm to armpit, a vest covering one side of her body, and a third piece wrapped around her midsection. Hoses hooked to the machine help move lymphatic fluid, reducing swelling.
Lymph node transfer surgery as a permanent solution These treatment options, however, don’t solve the underlying problem that leads to lymphedema. For that, Dr. Stanwix and eligible patients turn to lymph node transfer surgery. “The surgery has been in existence for a decade or so, but it didn’t begin in the U.S. as we’re more cautious when it comes to newer medical technology and advancements,” Dr. Stanwix says. “It’s grown in the U.S. over the last three years. The risks are very low and the advantages are very high because lymphedema is a huge quality of life issue.” The goal of lymph node transfer surgery is to restore the movement of lymphatic fluid by replacing the lymph nodes removed during cancer treatment with healthy lymph nodes from another part of the body. “The good thing about this surgery is that it’s not very invasive,” Dr. Stanwix explains. “Surgery lasts for four to five hours with patients spending one night in the hospital. Pain is minimal with a few 4-inch incisions, and there aren’t too many restrictions on patients afterwards, so they can return to their normal lives in a couple of weeks.” During the surgery, Dr. Stanwix first removes any scarring in the lymphatic channels that resulted from the lymph nodes 44
OurHealth | The Resource for Healthy Living in Greater Richmond
being removed previously and establishes a healthy tissue base. He then removes four to 10 nodes from the groin and transfers them to the armpit area, using microscopic surgery to reconnect the nodes with a blood supply. There’s no need to connect or establish new lymphatic channels; they will develop on their own later. While lymph nodes are also present in the neck, Dr. Stanwix says it’s more common to take them from the leg. “The way you get around drainage problems in the leg is that you don’t remove all the lymph nodes, and you only take the nodes that aren’t draining the leg,” Dr. Stanwix says.
Healing and recovery After the surgery, it takes months for the new lymphatic channels to develop, and during this time period patients must be aggressive in continuing to perform physical therapy in the same manner as before the node transfer surgery. The transfer surgery is still in its infancy, and success is often determined by a reduction in or elimination of a patient’s symptoms and the physical therapy they had undergone to manage the lymphedema. “Not everyone can have the surgery,” Dr. Stanwix says. “We really screen patients, and they must have exhausted their conservative management options over a course of months.” Patients exhibiting the leathery skin symptoms and those experiencing skin infections caused by lymphedema are not candidates for the surgery. Wood said her recovery from the surgery was uneventful and progressing well, and she is looking forward to her lymph node transfer surgery being life-changing so she won’t have to continue with the intensive treatment needed to manage the disease. While she was cautioned that it could take 12 to 18 months for everything to heal and to see results from the surgery, she has since learned that her cancer has returned. She believes it’s interfering with the lymph node transfer surgery’s expected results and success. Those who battle lymphedema may also have to battle insurance companies that don’t always want to approve payment for the lymph node transfer surgery. “The insurance companies are saying, ‘this isn’t lifesaving. It’s a quality of life issue, so why should we pay for it?’” says Dr. Stanwix. “My view is just the opposite.” Unfortunately, lymphedema is somewhat common, and the risk of developing it increases proportionally with the number of lymph nodes removed during cancer treatment. At the same time, lymph node transfer surgery is such a new procedure that many patients and even the physicians involved in cancer treatment aren’t aware it exists. That should change as the surgery becomes better established in the U.S. and awareness grows about its potentially life-changing results.
ON THE WEB
More at ourhealthrichmond.com www.OurHealthRichmond.com
45
HealthyEats Local Apples from:
Quinoa Crepes
Carter Mountain Orchard
(Makes 6 servings)
1435 Carters Mountain Trail Charlottesville | 434.977.1833 www.cartermountainorchard.com
11/2 cups Quinoa flour
About: Perfect fall picks include apples, pumpkins and gourds. Carter Mountain Orchard also houses the Bold Rock Cellar where Bold Rock hard cider is available to sample and purchase. Visit Carter Mountain Orchard daily, 9 a.m. to 5 p.m. thru the end of November.
Ingredients: 1/2 cup wheat flour 1 teaspoon baking soda 1 teaspoon cinnamon 2 cups carbonated or soda water 3 tablespoons olive oil 3 apples, sliced
Directions: 1. In a medium bowl, mix together Quinoa flour, whole wheat flour, baking soda, and cinnamon. 2. Add carbonated water and oil and whisk until well combined. Preheat a large nonstick skillet over medium heat. 3. Add a few drops of olive oil. 4. For first crepe, pour about 1/3 cup of batter into skillet, rotating skillet quickly until bottom is evenly coated. 5. Cook crepe on medium high heat until bottom is light brown. Flip over and briefly cook other side. 6. Repeat previous step until batter is gone. 7. Serve with sliced apples.
Tricia Foley’s Cancer Fighting
QUINOA CREPES
Tricia Foley is OurHealth Magazine’s resident nutritionist, as well as the registered dietitian at the Weigh Station in Richmond.
Growing Emotionally Healthy Children words | SUSAN DUBUQUE
What more could a parent ask for than a happy, well-adjusted child? Today, health and family magazines abound with valuable information on children’s mental health issues — from attention deficit hyperactivity disorder and autism spectrum disorder to bipolar disorder and youth suicide. But let’s approach the subject from a different perspective. We will explore tips and techniques to help parents, grandparents and educators nurture the development of emotionally healthy and resilient children.
“At the foundation of emotional health you will find the combined effects of our genes and environment — nature and nurture,” says Martin Buxton, MD, chief of psychiatry at Chippenham and Johnston-Willis hospitals. “We can’t control our genetic makeup, but there are many ways we can influence a child’s state of emotional well-being through our behaviors, interactions, communications and the environment we create at home, at school and in our communities.”
Look in the mirror Children tend to reflect the emotional status of their parents, and it goes beyond the hereditary implications. “Make an honest assessment of your own emotional status. Are you generally happy, stable and able to cope with the trials and tribulations of everyday life? Or are you depressed, anxious, angry or struggling with some other form of mental distress? In any case, you serve as an emotional role model for your child,” says Dr. Buxton. When you gaze into the emotional looking glass, if you don’t like what you see, get help. If you had diabetes, cancer or the flu, you wouldn’t hesitate to seek medical attention so you could be there for your family. Only if you are mentally healthy can you truly be available to your child. And your child will learn an important lesson too — that it is OK to ask for help when life becomes emotionally overwhelming.
Focus on the whole child “A child’s physical and emotional health are intertwined. In fact, they are really one in the same,” says Aradhana “Bela” Sood, MD, a pediatric psychiatrist with the VCU Medical Center’s Virginia Treatment Center for Children. So let’s start with the basics — the things your grandmother would have endorsed.
Nutrition The relationship between a balanced diet and emotional well-being has been recognized for a number of years. The literature is filled with articles on the consequences of inadequate nutrition, including social withdrawal, decreased concentration, sleep disturbances, irritability, apathy and depression. According to national nutritional expert and registered dietitian Eileen Meyers, “Perhaps the best rules to follow regarding your child’s nutrition are driven by common sense.” • Provide three well-balanced meals a day. That may sound too fundamental to even bother mentioning, but it’s essential to make this point in light of the busy schedules that many families maintain. • Allow some sugar and fats, but not in excess or in place of a wholesome diet. Eileen Myers, MPH, RDN is Vice President, Affiliations and Patient Centered Strategies with The Little Clinic. The Little Clinic is a retail health clinic company operating inside select Kroger stores in the Greater Richmond area.
• Watch out for caffeine, sodium and chemical additives, which are abundant in kids’ favorite snack foods. But don’t be a fanatic — an occasional Twinkie is really all right. • Serve as a role model for good eating habits. • Stock your refrigerator and cupboards with healthy, fun treats like fresh fruit, yogurt, carrot sticks and fruit juice. • Don’t use food as a means of nurturing your child. Rather than rewarding your child with a cookie, give him a hug. Instead of a piece of cake, take a walk together. • Most importantly, don’t allow food to become a source of stress in your child’s life. Mealtime should be relaxed and enjoyable. This is a time for sharing the day’s events, not fighting over uneaten Brussels sprouts.
Forty winks Inadequate and poor sleep can lead to mood swings and behavioral problems, as well as difficulty concentrating and poor performance at school. But how much sleep is enough? While every child is different, the National Sleep Foundation offers the following guidelines: • Newborns (0-3 months) Up to 18 hours around the clock on an irregular schedule • Infants (4-11 months) 9-12 hours at night and 30 minute to two-hour naps, one to four times a day, fewer as the child reaches age 1 • Toddlers (1-2 years) 11-14 hours of sleep in a 24-hour period; when the child reaches about 18 months of age, naps will decrease to once a day, lasting about one hour • Preschoolers (3-5 years) 11-13 hours per night; most children do not nap after 5 years of age • School-aged children (6-13 years) 9-11 hours per night • Teens (14-17 years) 8-10 hours per night 50
OurHealth | The Resource for Healthy Living in Greater Richmond
Tips for avoiding the bedtime drama include: • Encourage your baby to fall asleep independently and to become a “selfsoother.” • Allow toddlers and young children to use a security object such as a blanket or stuffed toy. • Develop regular daytime and bedtime schedules. • Create a consistent and enjoyable bedtime routine, such as reading a book or sharing a story. • Establish a sleep-friendly environment — cool, quiet and dark. • Keep TVs and computers out of the bedroom. • Avoid caffeine.
Just do it Provide your child with plenty of opportunities for exercise. Physical exertion releases natural endorphins that have an emotionally uplifting effect. And there are lots of other benefits from specific activities, so find one that meets your child’s needs. • Martial arts can help children gain confidence as well as self-control and discipline. • Soccer, softball and baseball are great sports that children of any age, size and physique can play. There are plenty of youth leagues that emphasize skill development, fitness, teamwork and sportsmanship. • Weightlifting can help teens who aren’t particularly competitive build self-esteem while they build muscles. • Running and walking are activities that can be done pretty much anywhere, anytime. • When your child is feeling stressed or anxious, suggest a five-minute “power break.” Jumping rope, running around the block or bouncing a ball 100 times can provide a needed bit of relief, especially during a demanding homework session. “Without mental health, there is no health,” says Dr. Sood. Perhaps this should be our new mantra.
Express yourself Help your child develop a “feeling vocabulary” so she can express what’s really going on inside. Otherwise she is may resort to throwing a temper tantrum, acting out, sulking or just holding it all inside and feeling miserable. Feelings are neither good nor bad, they just are. Acknowledge and accept your child’s feelings even when she is sad, angry, hurt, jealous, insecure, lonely, afraid — whatever. “Build a safe place where your child is free to openly express her full range of emotions,” says Evelyn Frazier, MD, developmental behavioral pediatrician with Bon Secours Richmond Health System.
Bela Sood, MD, FAACAP is a psychiatrist with Virginia Treatment Center for Children in Richmond. She is certified by the American Board of Psychiatry with a subspeciality in Child and Adolescent Psychiatry.
While all feelings are OK, the behaviors that follow may or may not be. “Let your child know that while she is entitled to be angry when her little brother breaks her favorite toy, it is not OK to retaliate by hitting him or breaking his toys,” says Dr. Frazier. www.OurHealthRichmond.com
51
As a parent, you are entitled to your feelings too. If you are sad, it is fine to share that with your child. In fact, it gives you the perfect opportunity to demonstrate the best way to deal with negative feelings. For example you could share, “I am very disappointed that we didn’t get to go to the beach today because it rained. But let’s see what else we can do that’s fun. Why don’t we bake some cookies or make a dress for your doll.” Show your child how to look for plan B — a great tool to build resiliency.
Evelyn Frazier, MD is a pediatrician with Bon Secours Developmental and Special Needs Pediatrics in Richmond. Dr. Frazier is certified by the American Board of Pediatrics with a subspecialty in Developmental/Behavioral Pediatrics.
While it is important for your child to understand and express his own feelings, it is equally important that he learn to interpret other people’s feelings. In the aftermath of a dispute between your child and a sibling or friend, take a moment for a little lesson in empathy. Ask your child, “How do you think that made Billy feel when you called him a fatty pants? How does it make you feel when someone calls you a name?” There are excellent books, posters, games and even flashcards devoted to decoding other’s feelings. Children will adopt the family’s attitudes toward other people. “Be aware of disparaging comments — even when made in jest — regarding others. Show respect for people who may be different than your family, and your child will acquire a sense of acceptance and openness,” says Dr. Buxton.
Be an active listener “Busy parents are often half-hearted listeners. Take a few minutes to really connect with your child,” says Dr. Sood. Here are the components of active listening: • Eye contact. Look at your child, not the TV, your phone or the morning newspaper. • Attentive body language. Lean toward your child. Sit close. Nod your head to let him know you’re listening. • Be quiet. Resist the temptation to offer an immediate solution. Ask your child if she would like a suggestion or if she just wants you to be a sounding board. • Verbal following. Make little “I’m listening” sounds, like “oh,” “really?” or “hmm.” Or restate what you heard your child say, like, “It made you feel really sad when Becca didn’t invite you to her party.” Simply paraphrase, rather than getting into deep interpretations. This lets your child know you are really hearing her and allows her to clear up any miscommunications. • Make sharing time a priority. Set aside time to talk with your child on a regular basis — not just when something’s wrong. It may only be 15 minutes every Saturday morning over a cup of hot chocolate, but make sure that time is sacred. Even if you child isn’t in the mood to talk, let her know that time is reserved just for her.
Look for the positives How will your child know what good behavior looks like if you only tell him when he is being bad? “Make it a point to catch your child in the act of being good,” says Dr. Frazier. “Reinforce the behaviors you would like to see with praise. Thank your child for not interrupting you while you were on the phone or remark how nice it was to see him share with a friend.” When your child does slip, as all kids will, provide opportunities to turn things around. Give him a chance to succeed. Help your child find activities or talents where she can succeed and shine. If your daughter has two left feet, don’t insist that she continue with the ballet classes that she dreads. Instead, find something that will help her build her sense of accomplishment and self-confidence.
52
OurHealth | The Resource for Healthy Living in Greater Richmond
Instead of praising your child for his accomplishments and achievement, you can also emphasize: • Intrinsic goodness. Your child’s goodness comes from within and is not attached to any external measure of success. Reinforce positive attributes like kindness, patience, gentleness and humor. Give love unconditionally. Like Mr. Rogers used to say, “I like you just the way you are.” • Effort. Praise your child for trying something new or sticking with a tough assignment, regardless of the outcome. • Intentions. Your daughter drops and breaks a dozen eggs along with your favorite serving dish. OK, so you want to scream. Before sending her to her room, take a deep breath and ask what she was doing. Her answer: She wanted to make breakfast for Mrs. Smith next door who is sick in bed. There isn’t a plate in the world worth more than that act of kindness. Give her a hug and work together to clean up the mess and make Mrs. Smith’s breakfast.
A routine matter Children find comfort in knowing what to expect, and they can thrive when they understand the boundaries. Establish clear and consistent rules and routines with preset consequences, such as bedtime, and then stick to them. “But this doesn’t mean you should be rigid or dictatorial,” notes Dr. Frazier. “You want your home to feel like a fair place. And as your child grows, you will want him to assume more responsibility and control over his destiny.” Author’s note: When I was a teenager, my parents did not give me a set curfew. Instead they told me to “be home at a reasonable hour.” When I asked what that hour was, they would reply, “We trust you to use good judgement.” I came home an hour before any of my friends. Of course, I had to earn their trust, but that lesson stuck with me all these years.
Establish family traditions “Children enjoy a sense of belonging when they experience family traditions,” says Dr. Frazier. “It doesn’t have to be anything elaborate, just something that is unique to your family.” Perhaps you each tell a joke at dinnertime, or every Saturday morning you visit the farmers market and stop for an ice cream cone on the way home. Invite your children to help determine what your traditions should be. These small moments make your family special and help create warm memories for your child.
All together now “Children are not born with a work ethic; it must be taught,” says Dr. Buxton. “They can contribute to the household in an age-appropriate way, from picking up their toys when they are toddlers to mowing the grass as teens. Even very young children can learn to complete their “work” before playtime.” www.OurHealthRichmond.com
53
“As children get a little older, they can also be encouraged to contribute to their community,” adds Dr. Frazier. “A child can recycle, donate money to a charity or volunteer to work for a worthy cause. These are wonderful ways to foster giving, build empathy and help children to be less self-centered.”
Natural consequences
Martin Buxton, MD is a psychiatrist with HCA Chippenham and Johnston-Willis Hospitals. He is certified by the American Board of Psychiatry and Neurology with a subspecialty in Child Psychiatry.
Your child is late for dinner for the fifth night in a row, and you’re tired of being treated like a short-order cook. First, you lecture him for 15 minutes about being inconsiderate. Next, you take away a privilege or ground him after school. Then you cook dinner — all while continuing the verbal assault. Finally, you swear this will be the last time you will ever prepare a second meal if he is late. Sound familiar? Next time this happens, allow natural consequences to prevail. If your child misses dinner, either he doesn’t eat or he prepares his own meal and cleans up afterward. He made the choice; let him live with the consequences. It is a far less combative approach. It puts your child in control of the outcome and removes you from being “the enforcer.”
Maybe yes, maybe no “Help your child build a tolerance for hearing ‘no,’” recommends Dr. Buxton. “Allow him to experience small frustrations so his fuse can grow, and he will be able to deal with larger frustrations and disappointment as he gets older.” In her book, “Stop Struggling With Your Child,” Evonne Weinhaus offers a simple suggestion for parents who are tired of arguing with their children over every little thing — just say “yes.” Instead of saying, “No, you can’t have a cookie because we will be eating dinner in 15 minutes,” say, “Yes, you can have a cookie — right after dinner.” At the mere mention of the word “no,” your child is suddenly prepared for battle. But there isn’t a lot to argue with when you say “yes.”
Limit screen time Let’s face it. We’re living in a digital age, surrounded by gadgets. We even refer to our children as “digital natives.” But what are the effects of spending hours each day in front of a computer or television? And how much screen time is too much? Dr. Frazier offers guidance from the American Academy of Pediatrics on this important subject. “Children under age 2 should have no screen time at all. Older children should limit their screen time to less than two hours a day total. This includes computers, video games, phones and, of course, TV.” In a recent study conducted at UCLA, results indicate a relationship between screen time and social skill development in children. When screen time was limited, the children’s ability to read other peoples’ emotions improved. Other studies suggest that screen time can have a variety of negative effects on kids, including childhood obesity, irregular sleep patterns and behavioral problems. As an alternative to screen time, provide opportunities for children spend more time interacting with the family. “There really is value in game night, throwing a ball or just chatting about the day,” says Dr. Frazier. “And when you are watching TV, engage with your child during the activity. Discuss the program with your child and make it a teachable moment.”
54
OurHealth | The Resource for Healthy Living in Greater Richmond
Cut your losses Even a happy, well-adjusted child can face a very real and devastating loss such as the death of a beloved grandparent or family pet. Or it may be less obvious, such as the loss of self-esteem when your daughter does not make the cheering squad. You can help your child through the grieving process by: • Letting her know that losing someone or something special hurts. Give her permission to grieve. • Encouraging your child to talk about her full range of feelings, such as anger, sadness, denial, guilt, jealously and fear. • Holding on to the good feelings. Help your child create a memory box or memory book. Give him photos of his grandfather and memorabilia like a class ring or medals from military service. Help him capture and preserve the warm loving feelings he had for his loved one. • Embrace positive characteristics of a loved one. Let’s say a close friend or relative dies or moves away. Or perhaps your child is feeling the loss of a favorite teacher when it’s time to move to the next grade. Ask your child what he liked or admired most about that person. Then encourage him to adopt that trait. Your child can keep the memory alive by being as nice as grandma, as funny as Jason or as courageous as Mr. Jones. • Letting go. If your daughter is deeply saddened that she didn’t make the basketball team, help her let go of those feelings and move on. Rather than dwelling on the loss, encourage her to focus her energies on a new activity. While it is important to recognize the pain your child is feeling, it is equally important to help her learn coping mechanisms and regain her sense of control.
www.OurHealthRichmond.com
55
Pull together, even when you’re apart When parents separate or divorce, children suffer. “If you and your spouse have made the decision to end your marriage, do not drag your child into the battleground. Allow him to maintain a close and loving relationship with both parents,” advises Dr. Buxton.
Here are some ways to be good co-parents: • Refrain from making disparaging comments about each other • Avoid blaming and finger-pointing • Give your child free access to the other parent • Try to maintain consistency in parenting styles and household rule • Make major decision about your child as a team
A child’s self-image is in large part a reflection of both parents. If you tell a child that Mommy is bad, he will think he is bad. If tell him that Dad is a creep, he will assume he is one too. “Your child is a miracle that you both created,” says Dr. Buxton, “so set aside your differences and put the needs of your child first.” Find us on social media. Follow us on Facebook, Twitter, LinkedIn and YouTube.
The concept of positive co-parenting is not limited to parents who live apart; they also apply to intact families. Even moms and dads who live together can unknowingly pull and tug at their child’s emotions.
Bullying Bullying in any form — physical, verbal, emotional or relational — can be deeply hurtful to a child, leaving her feeling frightened, angry, helpless, embarrassed and even guilty that the bullying is somehow her fault, says Dr. Buxton. “Children who are bullied can also experience depression.”
Encourage a child who is being bullied to: • Understand bullying. Explain that bullies are really unhappy, frustrated and insecure people. They try to make themselves feel better by controlling other people and making them feel lousy. • Walk away. Bullies want to know they have control over your emotions, so don’t react with anger or retaliate with physical force. If you walk away, ignore them or calmly and assertively tell them you’re not interested in what they have to say, you’re demonstrating that they don’t have control. • Find the humor. If you relax and comment on the bullying situation with humor, you’ll likely no longer be an interesting target for a bully. • Control what you can. Many things in life are beyond our control, including the behavior of other people, so focus on the things you can control such as the way you choose to react to bullies. • Report the bullying to a trusted adult. Unless bullies are reported and stopped, they may become even more aggressive. • If your child is not able to resolve the bullying on her own, get involved. Tell the teacher, contact the bully’s parents, and if you have to, call the police. Your child must feel confident that you will step in to protect her. 56
OurHealth | The Resource for Healthy Living in Greater Richmond
“There is no simple recipe for raising an emotionally healthy child,” says Dr. Sood. “The best advice I can offer is to love and accept your child unconditionally. Focus on your child’s strengths and positive attributes. Keep your sense of humor. And, finally, remember: Before you blink, your child will be grown. So enjoy every moment of the toughest job you will ever love.”
Medical experts • Martin Buxton, MD, chief of psychiatry at Chippenham and Johnston-Willis Hospitals and medical director of Tucker Pavilion • Evelyn Frazier, MD, Developmental-Behavioral Pediatrician, Bon Secours Virginia Health System • Eileen Myers, MPH, RD, LDN, FADA, national expert on nutrition and eating disorders • Aradhana “Bela” Sood MD, MSHA, Senior Professor of Child Mental Health Policy, Professor of Psychiatry and Pediatrics, Virginia Treatment Center for Children at VCU Health
Resources • “Stop Struggling with Your Child” by Evonne Weinhaus • “Stop Struggling with Your Teen” by Evonne Weinhaus and Karen Friedman • “The Optimistic Child: A Proven Program to Safeguard Children Against Depression and Build Lifelong Resilience” by Martin Seligman • “Transforming Teen Behavior: Parent -Teen Protocols for Psychosocial Skills Training” by Mary Nord Cook • “SOS: Help for Parents” by Lynn Clark • “1-2-3 Magic: Effective Discipline for Children 2–12” by Thomas Phelan • “Magic Years: Understanding and Handling the Problems of Early Childhood” by Selma Fraiberg
ON THE WEB
More at ourhealthrichmond.com
www.OurHealthRichmond.com
57
take a closer
LOOK
CAN YOU IDENTIFY TO WHICH LOCAL HEALTHCARE FACILITY THE IMAGE BELONGS?
Post the correct answer on our Facebook page by NOVEMBER 10th for a chance to WIN a Free Magazine Subscription!
The winner will be announced on our Facebook page by November 15th so make sure you check it out! ON THE WEB
More at ourhealthrichmond.com