Friday, June 27, 2014

What is Alzheimer’s Disease?

By: Janice Adams, LPN, Executive Director of Choice Home Care

Alzheimer’s, the most common form of Dementia, is a progressive, degenerative disorder of the brain caused by the death or permanent dysfunction of brain cells (neurons). The disease robs individuals of memory and, eventually, overall mental and physical function.

The causes of Alzheimer’s disease are unknown, and there are no specific treatments that prevent the death of brain cells or cure the disease. Several medications are available that may help slow the progression of symptoms.

Those who are experiencing warning signs of dementia, whose family and friends have noticed changes in their behavior, or those who are at risk due to a family history of Alzheimer’s disease should have a memory screening. It is normal to become more forgetful as you age. The difference between “normal” and dementia or Alzheimer’s is not just that a person is forgetting things, but also the fact that their behavior may have changed.

There are no medical tests for Alzheimer’s but there are some warning signs. Memory loss of recent events, family member’s names, placement of objects, confusion about time or place, or easily getting lost driving to a familiar place. Also, does the person struggle to complete basic daily living activities like bathing, grooming and dressing? If you suspect Alzheimer’s, take the person to someone who is qualified to perform a mental exam. The exam only takes a short amount of time to perform and is confidential. Choice Home Care offers these exams free of charge.

There are some things you can do to promote clarity in the midst of a very confusing time for your loved one. You can put financial affairs in order, and seek power of attorney. 

Thursday, June 26, 2014

Non-Surgical Solutions for Anorectal Disorders

By: Rajat N. Parikh, MD with Birmingham Gastroenterology Associates

Anorectal disorders consist of a vast array of diagnoses and are common; however, patients affected remain undiagnosed and undertreated. Most common in these group of disorders are rectal bleeding from internal hemorrhoids, anal pain and constipation from anal fissures, and fecal incontinence.

Internal hemorrhoid banding for rectal bleeding is a highly effective (99.1%), minimally invasive procedure that is performed in our office in less than a minute. We make recommendations to reduce the chance of recurrence later (currently 5% in 2 years). If there are multiple hemorrhoids, we treat them one at a time in separate visits. During the brief and painless procedure, the physician places a small rubber band around the tissue just above the internal hemorrhoid where there are few pain-sensitive nerve endings. The procedure works by cutting off the blood supply to the hemorrhoid. This causes the hemorrhoid to shrink and fall off- typically within a day or so. Patients probably won’t even notice when this happens or be able to spot the rubber band in the toilet. Once the hemorrhoid is gone, the wound usually heals within one to five days. The procedure is extremely well-tolerated but few patients may experience a feeling of fullness or a dull ache in the rectum during the first 24 hours. This can typically be relieved with an over-the-counter pain medication.

The loss of bowel control, also called accidental bowel leakage or fecal incontinence, is a common problem many of our patients face. Unfortunately, many are not getting diagnosed and treated as they might feel embarrassed to talk about it – the leakage, staining, and odors. Sometimes it is a lack of information on available therapies. There is a non-surgical approach to treat this condition that we offer our patients. Solesta is a quick, in-office injection therapy that can give improved control over accidental bowel leakage by bulking up the tissue in the anal canal. There is no lengthy recuperation and patients can resume their daily activities very quickly. Our experience at BGA has been positive thus far with minimal risk of side effects such as mild pain or bleeding. Patients are evaluated thoroughly before Solesta injection therapy is performed with rectal endoscopic ultrasound and anal manometry, if indicated, to make sure they are a good candidate.

Anal pain is almost always passed off as due to external hemorrhoids, and patients will try all forms of over the counter remedies without benefit. If pain is usually sharp or razor-like with bowel movements and the patient has feelings of anal spasm, it is almost certainly due to an anal fissure. There are various compounded ointments with smooth muscle relaxers or nitroglycerin preparations which can be used to allow the anal sphincters to relax and allow improved blood flow to the area of the fissure to allow for better healing. In addition, once or twice daily sitz baths are also helpful in the healing process. Commonly, patients have relief but symptoms can recur if it is due to a chronic scarred anal fissure. If this is the case, we can inject BOTOX bilaterally into the anal sphincters to allow for more efficacious healing and long-term benefit with minimal side effects. Chronic fissures are sometimes seen in Crohns disease and should be ruled out. Surgery is effective but is a last resort due to difficulty with recovery and possible complications with incontinence.

In summary, there are effective therapies available to patients suffering from anorectal disorders whether it is bleeding, pain or fecal incontinence.

Tuesday, June 24, 2014

A team approach creates successful rehab outcomes and reduces the need for surgical intervention

By:  Christopher Davis, MD, ENT, Carleen Ozley, MS, CCC-SLP, and Daniel Valentine, PhD, CCC-SLP

"Collaboration, communication and comprehensiveness" best defines the unique experience of our patients with vocal dysfunction when seen for assessment, diagnosis and intervention in the Voice Lab at Excel ENT of Alabama, Birmingham, Ala. We provide visualization and interpretation of a patient's larynx to assess vocal fold appearance and function. Unique in this practice, however, is the implementation of interprofessional education and practice (IPE). Recent articles in the ASHA Leader have argued that IPE is a responsive framework to provide best practice to our patients, as well as sharing information with colleagues and with the education students.

The Voice Lab at Excel ENT provides comprehensive examinations using state of the art technology for visual inspection and acoustical analysis (Kay Pentax distal chip flexible endoscopy and/or rigid endoscopy), and interpretations and recommendations are made in collaboration with both the speech language pathologist and the otolaryngologist. The patient also participates in establishing his personal voice plan of care, and personal patient goals are established based on his daily voice use. The team approach, however, does not begin and end at the assessment phase, but is extended when providing treatment to patients with voice disorders. An interdisciplinary approach has long been the accepted model when providing services to patients with cleft palate and craniofacial anomalies,3 and a team approach with patients with vocal dysfunction is becoming the standard.

The Excel ENT Voice Referral Team consists of an otolaryngologist, a speech language pathologist with specialization in voice, a psychologist, a yoga instructor, a vocal coach, an audiologist and a massage therapist. Based on the patient's plan of care, we will work together to help the patient meet his goals. Because of the voice team care approach, patients at Excel ENT have experienced successful rehabilitation outcomes, which has reduced need for surgical intervention.

EXCEL Voice and Swallowing Institute In her recent article, Patty Prelock, PhD, CCC-SLP, challenged our profession to integrate IPE in the communication sciences and disorders curricula and it is with this vision that we have recently established the EXCEL Voice and Swallowing Institute. The mission of the institute is three-fold:

1) provide education to undergraduate and graduate students in speech pathology,
2) offer clinical internships in the areas of assessment and treatment of voice disorders, and
3) provide a comprehensive training program for endoscopy.

This advanced program consists of three levels of clinical experience for speech language pathologists who are interested in furthering their skills for endoscopy, interpretation and vocal rehabilitation. SLPs' use of endoscopy to diagnose swallowing disorders in hospitals and long-term care facilities is becoming more common, as is observing vocal fold function with patients with vocal dysfunction. ASHA's Scope of Practice6 includes the use of endoscopy by speech language pathologists and the Special Interest Divisions 3 and 13 have provided a thorough document on the skills and knowledge for SLPs practicing endoscopy.

However, very few graduate programs offer training in endoscopy and policies regulating this practice often vary from state to state. A goal of this program is to provide a comprehensive and transparent protocol to train SLPs to be competent endoscopists. Excel ENT has partnered with the University of Montevallo Speech and Hearing Clinic, Montevallo, Ala., and in collaboration with faculty members Dan Valentine, PhD, and Chris Gaskil, PhD, will provide observation hours for graduate students in the areas of voice and swallowing.

Spreading the Word We are passionate in sharing their experience, interests, and current clinical setting so that a greater number of patients with vocal disorders can be better served. They are actively engaged in sharing their expertise in various mediums. Recently they have been contributors to the Birmingham Medical News and have addressed allergists and asthma physicians in the diagnosis and treatment of Paradoxical Vocal Cord Disorder (PVCD).

One of the patients summarized Davis' successful practice approach best when he stated, "This is the best experience I have had at any doctor's visit." For further information and most current happenings at Excel ENT of Alabama please visit our website.

Christopher Davis completed his medical degree at the University of Alabama and his residency at The Ohio State University. He has been in private practice for 9 years and specializes in the care of sinus and voice disorders.

Carleen Ozley has been a part of the Voice Care Team since 2012 after completing 36 years at the Birmingham VA Medical Center.

Daniel Valentine is an assistant professor at the University of Montevallo and conducts research and teaches classes in the areas of stuttering, voice and motor speech.

References: 1. Prelock P. The magic of interprofessional teamwork. The ASHA Leader 2013;18(6): 5-6. 2. Pickering J. et al. So long, silos. The ASHA Leader 2013;18(6): 38-43. 3. Austin AA, et al. Interdisciplinary craniofacial teams compared with individual providers: Is orofacial cleft care more comprehensive and do parents perceive better outcomes? Cleft Palate-Craniofacial Journal 2010;47(1): 1-8. 4. Farely E. et al. An interdisciplinary approach to voice disorders. UNWOMJ 2011;80(2): 24-26. 5. Stadelman-Cohen T et al. Team management of voice disorders in singers. The ASHA Leader 2009. 6. American Speech-Language-Hearing Association (2007). Scope of Practice in Speech-Language Pathology. doi:10.1044/policy.SP2007-00283. 7. American Speech-Language-Hearing Association. Knowledge and Skills for Speech-Language Pathologists With Respect to Vocal Tract Visualization and Imaging 2004. Doi: 10.1044/policy.KS2004-00071. 8. American Speech-Language-Hearing Association. Role of the Speech-Language Pathologist in the Performance and Interpretation of Endoscopic Evaluation of Swallowing: Guidelines 2004. doi:10.1044/policy.GL2004-00059.

Monday, June 23, 2014

National Infertility Awareness Week celebrated it’s 25th Anniversary!

By: The ART Fertility Program of Alabama

The National Infertility Association founded a movement 25 years ago, called RESOLVE, in hopes of creating a wider awareness of infertility and making sure those with infertility are able to get the information and/or treatment that they need.

But what does the organization hope to gain by increasing awareness? According to RESOLVE, they have three missions:

1. Ensure that people trying to conceive know the guidelines for seeing a specialist when they are trying to conceive.

The truth is that most couples don’t know when it’s time to see a specialist. In the past, it was traditional that after 12 months of a couple regularly having sexual intercourse with no protection from a condom or birth control without getting pregnant established infertility.

However, for couples under the age of 35 with no prior pregnancy should see a specialist after 5-6 months. For couples who have a prior pregnancy, that drops to 3-4 months.

Based on this information, the notion to wait one full year before seeking fertility services may markedly delay and impair success. Additionally, ovarian age is a fundamental factor in evaluating fertility treatment strategies and determining prognosis. So, infertile couples where the female partner is greater than age 35 should seek help even sooner.

2. Enhance public understanding that infertility is a disease that needs and deserves attention.

There’s no doubt that the public has little understanding that infertility is a disease that affects one in eight couples. In fact, there’s very little understanding of infertility in general. Many still believe that it’s something only women struggle with when in fact it affects both men and women equally. Age is also not the only factor that impacts fertility, as many think, and these are just a couple of the all too common misconceptions that people have.

With millions of Americans struggling with infertility, it’s time for the public to have an understanding of this disease and the emotional and physical tolls that it can take.

3. Educate legislators about the disease of infertility and how it impacts people in their state.

Advocates of RESOLVE have been urging for health care coverage for infertility, medical research, adoption benefits and access to all family building options for those with infertility. In fact, RESOLVE is a major supporter of the Family Act of 2013. This bill would create a tax credit for the out-of-pocket expenses associated with IVF and fertility preservation. If passed, the bill would greatly help thousands of people. People who weren’t able to seek help due to lack of insurance coverage would be able to gain access to the medical treatment they need.

Thanks to RESOLVE, National Infertility Awareness Week became a federally recognized health observance. We encourage you to visit RESOLVE’s website for more ways to get involved and show your support.

The ART Fertility Program of Alabama is located in Birmingham, Alabama with additional locations in Huntsville, Montgomery and Tuscaloosa. The program is led by Dr. Kathryn Honea, Dr. Virginia Houserman, Dr. Cecil Long and Dr. Chris Allemand who are Board Certified specialists in Reproductive Endocrinology and Infertility. All are skilled in comprehensive infertility care and offer a complete range of infertility services.

Wednesday, June 18, 2014

Breast is Best, but….

By: Dr. Kelli Tapley with Birmingham Pediatrics Associates

While William Shakespeare wrote “that which we call a rose, by any other name would smell as sweet,” that is not usually the consensus among parents and some physicians when it comes to infant formulas.

Make no doubt about it raising a child is expensive. According to the USDA, approximately $1500 is spent on simply feeding them during their first year of life. While many mothers chose to breast feed, and we as pediatricians whole-heartedly support their decision, some cannot or chose not to do so while others add supplemental formulas to their breast milk. Then the choice of “best” formula becomes paramount.

It is challenging to address the psychosocial issues each family brings with them to their child’s appointment in twenty minutes or less. We focus on growth and nutrition, meeting developmental milestones and then try to answer any lingering concerns or questions our parents may have. All while trying to assess if the sleep-deprived parents are bonding well with their newborn. Often our nurses are the ones who get the calls regarding infant formulas. More recently, I have begun to encounter them also. Particularly when it comes to the cost of formula.

In a recent publication from the American Academy of Pediatrics, the authors concluded, “store brand infant formulas meet the same criteria as name brand formulas for about half the cost.” Regardless, many parents are resistant to the idea of using a “generic formula.” Some parents choose to dilute the formula, which has potential health and developmental risks.

While there is no perfect formula and mother’s milk is always best, the reality is that more women supplement or exclusively use formula than exclusively breastfeed. The 2013 Breastfeeding Report Card issued from the CDC showed that in Alabama only 23% of mom’s are exclusively breastfeeding at 3 months and only 12% are exclusively breastfeeding at 6 months. It’s important for us, as providers, to be aware that other cost saving options are available to mothers who do not qualify for WIC and take the time to address parents’ concerns regarding formula choice while providing them with unbiased options available to them.

Monday, June 16, 2014

Wider Waistline – A Strong Predictor of Decreased Life Expectancy

By: Aniqa Baqauddin, MD _ Family Medicine at Trinity Medical Center

We have all heard about weight watchers, but now we are beginning to realize the importance of becoming a “WAIST WATCHER.”

Supporting data published in the Archives of Internal Medicine, recommends waist watching. Internal belly fat is like no other fat. Although we need some of this fat for normal bodily functions, too much is harmful to our lives.

Incidence of coronary heart disease, high blood pressure, stroke, high cholesterol, Type 2 Diabetes and different types of cancers all increase with the amount of excessive fat inside our bellies.

Recently, an interesting fact was published on WebMD - the average waistline has increased by one inch for every decade since the 1960s. Studies have found that people who have four extra inches around their waist had a 15%-25% increased risk of dying, irrespective of the Body Mass Index (BMI), meaning that even so called normal weight individuals are also not out of the woods unless their waistline is under control.

Researchers have concluded that men and women with large waist size/ wider abdominal girth had 52% and 80% higher risk of dying respectively, when compared to those who had a waistline of less than 40 inches for men and less than 35 inches for women. The estimated decrease in life expectancy translates to approximately 3 years for men and 5 years for women. While the bulging belly dilemma is found across all ages, the biggest risk is for men and women over the age of 40.

Waist circumference is a very simple measurement that says a lot about your potential life expectancy. There is a quick screening that can be done at home; all you need is a measuring tape. There is a simple diagram from the National Heart, Lung & Blood Institute showing how to correctly measure the waist circumference:

Measuring Tape Position for Waist (Abdominal) Circumference

So if you are not already a “Waist Watcher,” now is the time to become one. Simply:

1. Measure your waist circumference as explained above. Irrespective of your weight and BMI, if it is more than 40 inches for men and more than 35 inches for women, you need to work on reducing the size.

2. Healthy lifestyle is the key - be physically active, eat well and discuss health risks and goals with your medical provider.

3. Be a true “Waist Watcher.”

Sources: 1.
2. Mayo Clinic Proceedings
3. Archives of Internal Medicine
4. Medline plus
5. Web MD
6. Vanderbilt University Medical Center
7. Uptodate®
8. Obesity

Thursday, June 12, 2014

Teach your Young Children to Share through Early Lessons in Cooperation

By: Margaret O'Bryant, Franchise Owner at Primrose School at Liberty Park (Dr. Gloria Julius, vice president of education for Primrose Schools, in photo)

Cooperation is a basic life skill that allows us to make friends, work successfully in groups and get along well with others. Babies are not born knowing how to cooperate or share. This ability is learned through interactions and experiences with parents and other significant care givers. Around age 3, children begin to practice real cooperation through their play by sharing and taking turns.

“Cooperation and sharing are key character traits that teach children how to get along with others,” said Dr. Gloria Julius, vice president of education for Primrose Schools. “Parents and teachers encourage and model these traits because they are critical for children to understand. They help children to form friendships and to have harmonious and respectful interactions with others. Sharing is a necessary daily activity that builds a foundation for positive character development and is a common thread that runs through caring, cooperation, generosity and citizenship.”

Dr. Julius offers parents a few tips to teach children cooperation skills at home:

Model Cooperative Behavior: You are your child’s first teacher, and your behavior greatly influences the way your child acts and feels. Modeling cooperative behavior and talking to your child about lending a helping hand sets the expectation that these are important values. For example, you could say “If we work together to clean up the kitchen after dinner, “we’ll all be able to listen to the new book you borrowed from the library.”

Family Projects: Plan a family project that includes a task for each family member, such as starting a vegetable or flower garden, mapping out the family vacation or playing a game. Help them see the fun in working together to accomplish a goal.

Cooperation Soup: Cooking is a perfect time to learn about cooperation because children can actively help by gathering ingredients, measuring, mixing and then serving and eating. Read the story of Stone Soup by Marcia Brown and discuss how the soldiers tricked everyone in the village into contributing to a wonderful pot of soup that everyone could enjoy.

Book Club: Introduce the concept of cooperation by reading books about characters who share, such as The Little Red Hen. Discuss what happens at the end of the story. Ask your child to tell you how she would respond if someone asked her to cooperate on a project.

Making Music: The way children respond to music is magical. Listen to a short piece of music and discuss how the members of the chorus, band or orchestra worked together to make a beautiful sound. It’s easy to gather a simple set of rhythm instruments that children can use to keep time with the music or just sing along with a song on a CD. If you record their production, they will love hearing it over and over knowing that they accomplished it together.

To learn more about Primrose School at Liberty Park, visit , or call 969-8202  

Tuesday, June 3, 2014

Gastrointestinal Cancers: Prevention and Early Detection Is the Best Cure

By: Brian A. Brunson, M.D., Gastroenterology Associates of North-Central Alabama, P.C.

Over the last couple of decades, the field of gastroenterology has been transformed. Much has been learned about natural history and precursors of gastrointestinal cancers, particularly those of the esophagus, pancreas and colorectum. In that same time period, endoscopic technology has advanced at a rapid pace, and now a majority of upper endoscopy or colonoscopy procedures performed in this country utilize ultra-flexible instruments with high definition video capability. This has allowed gastroenterologists to detect even the smallest of polyps in the colon or short segments of intestinal metaplasia in the esophagus, otherwise known as Barrett’s Esophagus. Both of these are well known to be precursors to cancer. Additionally, a procedure known as endoscopic ultrasound, or EUS, has been developed and now allows significantly better imaging and evaluation of the pancreas and bile duct, including detection and evaluation of cysts in the pancreas which also can be precursors to cancer.

With this knowledge and technology, though, comes greater responsibility. We as gastroenterologists must be prudent following guidelines for screening and surveillance based on scientific data and expert recommendations. Otherwise the cost of screening and surveillance may outweigh the benefits of cancer prevention in the population as a whole. This is especially important in the modern era of medicine with the cost of healthcare continuing to rise at a rapid pace. In some cases, though, the scientific data remains inconclusive, particularly in the case of Barrett’s Esophagus and pancreatic cysts, so these decisions are often not straightforward.

Barrett’s Esophagus, or a change in the lining of the esophagus which can lead to esophageal cancer, can be detected in up to 5-10% of patients with chronic acid reflux symptoms (such as heartburn or regurgitation), but also can be detected in some patients with no significant history of acid reflux. The first issue that we face is who to screen for Barrett’s? Multiple studies have suggested that the risk is highest in males over the age of 55 who are overweight or obese, so all those patients with reflux symptoms probably should be screened. It is not clear, though, if we should screen patients with acid reflux who don’t meet those criteria, although this is still routinely done. Once Barrett’s Esophagus is confirmed by a pathologist, the gastroenterologist is then faced with the decision on how often to repeat the endoscopy to assess for progression towards cancer, known as dysplasia. We know that patients with confirmed dysplasia are at risk for cancer, and need either frequent surveillance or specialized treatment to eradicate the Barrett’s. In Barrett’s without dysplasia, though, it is still not clear if repeat endoscopy every 2-3 years truly allows us to prevent cancer or detect it at an early enough stage to improve survival. This is particularly true of segments of Barrett’s that measure less than 3 centimeters in length. At this time, it is likely most cost-effective to screen those patients with acid reflux symptoms who meet one or more of the high risk criteria (males, over age 55, overweight or obese), and then determine intervals for repeat endoscopy based upon the presence or absence of dysplasia on biopsies and length of the segment of Barrett’s. We await more solid scientific data which will hopefully clarify these guidelines.

Similar issues exist for pancreatic cysts, which are detected more frequently in this era due to the high utilization of CT scans. The cysts are oftentimes an “incidental” finding, but we know that some cysts can lead to pancreatic cancer. Endoscopic ultrasound can often detect findings in the cyst which would identify them as higher risk, so it is quite often utilized for this purpose. EUS also allows the use of a thin biopsy needle to aspirate cyst fluid, which can be sent for tumor markers and molecular studies to further aid in identifying which cysts are higher risk for transforming to cancer. Unfortunately, the markers are oftentimes not consistently reliable. Additionally, the recommendations for timing of follow-up exams are typically based upon “expert recommendations” and not scientifically based in cases of low to moderate risk cysts. Hopefully the science in this field will continue to advance, with development of better markers to help determine exactly which patients are at highest risk and therefore need the closest surveillance.

Prevention of colorectal cancer by detection and removal of colon polyps during colonoscopy, on the other hand, is a modern day public health success story, and is now based on solid scientific data as noted in recent studies published in the New England Journal of Medicine. For colonoscopy to remain as a cost-effective tool in cancer prevention, though, it must be utilized properly by following guidelines guided by scientific data. This includes screening all people at age 50 or at age 40 or earlier if there is a family history of colon cancer. This also includes adhering to guidelines for repeat screening exams only every 10 years in patients without polyps, or sooner if pre-cancerous polyps are found and removed. Additionally, the exam must be “high-quality,” as determined by excellent cleansing of the colon prior to the procedure and adequate time spent looking for polyps.

As a practicing gastroenterologist, I am excited to be in a field with such a strong focus on cancer prevention and early detection. I also know that in the modern era of medicine, with rapidly rising costs, we must be diligent in following expert guidelines based on the best scientific data available. Otherwise we risk overutilization of procedures, which could further contribute to the risings costs of healthcare and economic burden in our country, and lead to less cost-effective screening and prevention.