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Vol.1, Issue 4 $ 4.99
Special thanks to: Sharon Osbourne, Sir Elton John, Dr. Edward Phillips, and Cedars-Sinai Medical Center of Beverly Hills.
PARKINSON'S RESEARCH:
Fertility Advances Bring Help & Hope

Acid Reflux: The Burning Issue
THE MONSTER ISNT UNDER THE BED. ITS IN THE fRIDgE.
People with eating disorders often distort the size of their food, so theyll eat less. They distort the size of their body, so thin looks fat. Which yields a fact that isnt distorted at allwithout treatment, many wont survive. But to read about those who have, go to myneda.org
National Eating Disorders Association
On Call with Dr. Porter

Welcome to the April/May issue of What Doctors Know. April is one of my favorite months because it signals the end of the cold and bitter winter months and the start of the amazing sights, sounds and smells of Spring. This month we have added a number of Medical Centers who are embracing our quest to bring readers current and cutting edge healthcare information. We are especially grateful to Michael J. Fox and his foundation for its participation in our efforts to educate and inform. However, the Michael J. Fox Foundation does more than inform and educate. This is a dedicated group lead by the endless energy of Michael J. Fox passionately committed to finding a cure for Parkinsons. We are thankful for celebrities like Michael J. Fox who do more than loan their name for public awareness. These are celebrities who are genuinely involved because they have been affected personally. Last month, we had Sharon Osborne on our cover for her drive to gain attention to colon cancer prevention and the need for screenings. In addition to bringing attention to Parkinson's disease, in this issue we are offering extensive information on acid reflux. Because it is a difficult subject to cover in one issue, over the months we will be offering a collection of articles on the subject. As you read this issue, you may have ideas, thoughts and suggestions. We are always interested in hearing from our readers. Let us know your thoughts. We appreciate reader feedback about the content of the magazine and will continue to improve with input from readers like you. Send us a note at editor@whatdoctorsknow.com. If you are a physician or medical professional interested in writing for the magazine, dont hesitate to contact us with your ideas and suggestions at submit@whatdoctorsknow.com. Help us, educate and inform. Dont forget, its spring, so take a moment to go outside and smell the flowers. Till next month. Steve
Steve Porter, MD Publisher and Chairman
Special Thanks To:

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WHAT DOCTORS KNOW

And you should, too!
HEADlines
6 8
Hitting Sports Injuries Head On How to Handle My Childs Dental Emergencies
10 Otoplasty for Outstanding Ears 12 Could Hearing Loss

Contribute to Dementia?
14 The Answer is in All of Us
P6
IN THE TRUNK
20 Setting the Record Straight:
Why Mammograms Remain the Gold Standard
29 Flu, Cold or Virus 32 Acid Reflux: The

Burning Issue
22 Heart Disease 24 Dont Let Your Allergies

Bloom This Spring for a New Life
36 When Surgery is
Needed to Correct Acid Reflux
27 Luella Love: New Lungs
38 Reflux in Redux
P27
BELOW THE BELT

45 Grumbling Guts? 46 Boys Get Eating
Disorders, Too to Family Life
51 When Eating Goes to Extremes 53 Through Thick & Thin 56 Fertility Advances
Bring Help & Hope
48 The Emotional Road
P45
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Vol. 1 Issue 4
Contents
TECHNOLOGY & YOUR HEALTH
60 Identifying Parkinsons Disease 62 Partial Hearing Loss & The
Hybrid Cochlear Implant
64 Brain Pacemaker Bringing

Hope to Parkinsons Patients
P72
MIND, BODY, AND SOUL

66 HealthWatchMD: Arthritis 68 The Nutritional Gatekeeper & The 72% Solution 70 New Melanoma Drug 72 Osteoporosis: Get the Facts 76 Steer Children Clear of Lawn Mower Injuries 78 Sunscreen: Looking Beyond the Numbers
P64
In Every Issue
01 On Call With Dr. Porter 04 Meet Our Doctors 66 HealthWatchMD: Arthritis
On the Cover
14 The Answer is in All of Us 32 Acid Reflux: The Burning Issue
Science to Get
Excited About
Vol.1, Issue 4 $ 4.99
Special thanks to: Sharon Osbourne, Sir Elton John, Dr. Edward Phillips, and Cedars-Sinai Medical Center of Beverly Hills.
PARKINSON'S RESEARCH:
56 Fertility Advances Bring Help & Hope

Acid Reflux: The Burning Issue
Fertility Advances Bring Help & Hope
Cover photography by Mark Seliger
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Meet Our Doctors
Steven Porter, MD
Founder and publisher of What Doctors Know, Dr. Porter is recognized as one of the top gastroenterologists in the country. He is the medical director of the endoscopy lab at a leading hospital in Ogden, Utah and has been practicing for more than 25 years. Contact Dr. Porter at (801)387-2550.
Timothy J. Sullivan, MD
Contributing editorial advisory board member of What Doctors Know, Dr. Sullivan spent 25 years in full-time academic medicine at Washington University, University of Texas Southwestern Medical School, and Emory University. He currently has a full-time allergy and immunology practice in Atlanta, Georgia and is a clinical professor at the Medical College of Georgia. Contact Dr. Sullivan at (404)255-2918 or www.trittbreatheandsleep.com.
Rosalynn CrawfordMcKendall, DDS

Assistant Professor in the Department of Pediatric Dentistry at LSU Health Sciences Center New Orleans School of Dentistry. Dr. Crawford-McKendall received her doctor of dental surgery and certification in pediatric dentistry from New York University (NYU) College of Dentistry. She was a clinical assistant professor in the Pediatric Dentistry Department of NYU College of Dentistry.
Vicki Lyons, MD
Founding member and chairman of the editorial advisory board of What Doctors Know, Dr. Lyons is a board certified and fellowship trained allergist and immunologist practicing in Ogden, Utah. She has been practicing for 20 years. Contact Dr. Lyons at (801)387-4850 or www.vicki-lyonsmd.com.
Brian Wansink, PhD

Director and the John Dyson Professor of Marketing of the Cornell Food and Brand Lab in the Department of Applied Economics and Management at Cornell University in Ithaca, New York. Contact Dr. Wansink through the Cornell Food and Brand Lab website at www. foodandbrandlab@cornell.edu.
Scott K. Thompson, MD
Board certified in both facial plastic and reconstructive surgery, as well as otolaryngology. Dr. Thompson has joined a select group of surgeons from Boston and Rochester, New York who travel to Ecuador and Guatemala twice a year on a charitable journey to correct congenital ear deformities on local children. Visit Dr. Thompsons website for more information at www.utahfacialplastics.com
Copyright 2012 by What Doctors Know, LLC. All rights reserved. Reproduction of this magazine, in whole, or in part is prohibited unless authorized by the publisher or its advertisers. The Advertising space provided in What Doctors Know is purchased and paid for by the advertisers. Products and services are not necessarily endorsed by What Doctors Know,LLC.
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LeGrand Belnap, MD, FACS

A member of several medical societies including the American College of Surgeons, the American Society for Bariatric Surgery and The American Society of Transplant Surgeons. Dr. Belnap is a board certified general surgeon who has received extensive training at the University of Utah, University of Minnesota, University of California and the University of Pittsburgh. He is currently a clinical professor of surgery at Utah-LDS Hospital.
Haydee OjedaFournier, MD
Assistant professor of clinical radiology and medical director of breast imaging at University of California San Diego Moores Cancer Center.
Published by What Doctors Know, LLC Publisher and Chairman Steve Porter, MD Editorial Advisory Board Vicki J. Lyons, MD, Chairman Timothy J. Sullivan, MD Editorial and Design Director Bonnie Jean Myers Senior Designer Suki Xiao
Russell A. Foulk, MD
Internationally renowned expert in the treatment of infertility. Dr. Foulk is an associate clinical professor at the University of Washington, Department of OB/GYN and at the University of Nevada, School of Medicine. He has set up several IVF centers in Nevada, Idaho, Utah, Hawaii, Belgrade and Serbia. Recently serving as President of the Pacific Coast Reproductive Society, Dr. Foulk has been on the Board of Directors of the Society for more than eight years. Visit Dr. Foulks website at www.utahfertility.com
Design Associate Cayden Chan Executive Director, Marketing Larry Myers Production Kai Xiao, Vice President IT Manager Eric Lu
Jeffrey Kahn, MD, PhD

Childrens Medical Center of Dallas Infectious Disease Expert and UT Southwestern Medical Center Professor. Dr. Kahn is a pediatrician, board certified in both general pediatrics and pediatric infectious diseases.
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"Head On"
A
grant from the NCAA will kick off a groundbreaking, long-term study of concussion and other head injuries among athletes, led by University of Michigan researchers and their colleagues around the country. The NCAA will provide $400,000 to begin to fund a longitudinal study by the National Sport Concussion Outcomes Study Consortium, a new group that includes three founding members from the University of Michigan: Jeffrey Kutcher, M.D., associate professor of neurology; James T. Eckner, M.D., assistant professor in physical medicine and rehabilitation; and Steven Broglio, Ph.D., assistant professor of kinesiology. With the NCAA grant, the Consortium will study more than 1,000 male and female college athletes who compete in 11 sports at three schools. Researchers hope to track those athletes throughout their lifetime to monitor long-term effects of head injuries. But the Consortium has even bigger plans. Kutcher says the group is seeking funding to expand the effort and begin enrolling athletes as early as high school, then follow them through college and even into professional careers.
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Hitting Sports Injuries
Groundbreaking study of head injuries among athletes kicks off with NCAA grant
risk to brain health for those who play sports. There is no data like this, its groundbreaking. It will define the landscape. Kutcher and the U-M faculty founded the Consortium with Kevin Guskiewicz, Ph.D., chair of the Department of Exercise and Sport Science at the University of North Carolina; Chris Giza, M.D., of the Department of Neurology at UCLA; and Michael McCrea, Ph.D., professor of neurosurgery and neurology and director of brain injury research at the Medical College of Wisconsin. Theres a tremendous need for data that describe both the short and long-term health consequences of concussions, says Kutcher, who also is director of the Michigan Neurosport Concussion Program at U-M. There are some hints, and a series of case reports in the literature, but no well-controlled study that addresses the long-term questions. To do that study, and do it correctly, requires following a population of athletes over time and documenting their brain function, while controlling for other variables. David Klossner, the NCAAs director of health and safety, said supporting the consortiums study
Were hoping this could become a Framingham heart study for sports concussion, says Kutcher, referring to the study that began in 1948 with more than 5,000 people and has led to the identification of major cardiovascular disease risk factors. This study will be essential to improving our understanding of the
will aid efforts to promote a safe competitive environment. The NCAA is seeking to foster innovative research among its member universities to increase knowledge about the short-term and long-term neurological consequences of playing sports, Klossner said. In addition to monitoring trends in concussions through the Associations injury-surveillance system, this research is another important step to enhance studentathlete safety. In this first phase of the study, the Consortium researchers will study athletes in contact sports in mens football, soccer, basketball ice hockey, and lacrosse; womens water polo, soccer, basketball, field hockey, and lacrosse. Noncontact sport participants also will be recruited from the track and field and swimming and diving teams. Kutcher believes the data the study collects will provide a more comprehensive understanding of concussions. The short-term effects have been examined for several years, and technological advancements have
helped improve the understanding of impacts on the brain by using shock sensors embedded in players helmets. There has been considerable attention paid to concussion recently, by the media and others, spurred by reports of National Football League players, hockey players people who have had a long history of contact having a very particular kind of dementing illness, says Kutcher. But that story is only beginning to be told. We need to do the appropriate research to figure out the scope of the problem. Kutcher also directs the NBAs concussion program, is a consultant to the NHL Players Association and the team neurologist for the University of Michigan Athletic Department. He has been instrumental in crafting the concussion policies of the NCAA, Big Ten and Mid-American Conference. He has testified before U.S. Congress on helmet and equipment safety. For more information and free online courses about recognizing and responding to concussions, go to http://www.michiganneurosport.com/ -This information provided courtesy of the University of Michigan Health System
Dr. Jeffrey Kutcher, M.D., examines one of his young patients at the Michigan Neurosport Concussion Program.
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How to Handle My Child's Dental Emergencies

long term problems. It is key to establish a dental home for your child by age 1, so that you can learn about your childs dental health and receive information on trauma prevention.
What should I do if my child has a toothache?

Call your childs dentist immediately to schedule an emergency appointment if your child is having a toothache. In cases of visible swelling to the face with or without a fever, you can call your dentist on the way to your nearest hospital emergency room. It is important to get your child seen, because infections spread quickly in children. Some children require a hospital stay to be given Intravenous (IV) antibiotics.
What should I think about if my child falls and breaks a tooth?
C

hildren experience dental emergencies daily. Most pediatric dental emergencies involve cavities and trauma. Dental emergencies can range from a toothache and swelling, to trauma of teeth, surrounding bone, and any soft tissue, such as lips. According to the American Academy of Pediatric Dentistry (AAPD), children
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experience the greatest amount of trauma to the primary (baby) teeth during the ages of 2 to 3 when they are developing their motor coordination. The AAPD also mentions that injuries to permanent teeth most commonly happen secondary to falls, traffic accidents, violence, and sports. All sports have some risk for injuries to the face and teeth. Proper management of dental emergencies could prevent
First, if your child lost consciousness during the fall, is vomiting, or is behaving abnormally he or she will need to go to the emergency room to be evaluated for head trauma and any internal bleeding. Also, look for other cuts and injuries to the body. If you did not witness the accident and are not sure, take the child to the emergency room. After the child is stabilized, they will be sent for a consultation with the dentist. Know when your childs last tetanus was given.
What if my childs tooth is knocked out (avulsed)? Primary (Baby) tooth knocked out:
Do not reimplant an avulsed baby tooth back into the mouth. Placing an avulsed baby tooth back in the mouth can cause damage or possible infection to the permanent tooth underneath. If you are not sure the tooth is a baby or permanent, call your childs dentist immediately.
Permanent tooth knocked out:

Time is critical for an avulsed permanent tooth. It is very important for the tooth to be reimplanted immediately. If you see the tooth is avulsed, immediately try to locate the tooth. Once you get the tooth, identify the crown which is the short part of the tooth and the root (the longer portion of the tooth). The tooth should be cleaned quickly and placed back into the tooth socket. Have the child bite down to get the tooth into place. It is better to transport the tooth partially in the socket as long as the child is not at risk of swallowing the tooth. I you are unable to reimplant the tooth; it can be stored in cold milk and transported. If you dont have milk, contact solution or saline is an alternative. The tooth should never be transported in water or in a dry paper towel. The child should still present immediately to the dentist or emergency room for stabilization of the teeth. Your child will need a splint for the teeth and will likely need a root canal in the future. -Rosalynn Crawford-McKendall, DDS. Louisiana State University Health Sciences Center.
Primary (Baby) broken tooth:

For a tooth with a small chip or a large chip with or without bleeding, you can try to have the child bite on a clean towel or gauze to stop the bleeding and call your dentist regarding the emergency appointment. If the bleeding does not stop, you will need to proceed to the emergency room with your child. Any damage to a baby tooth during trauma can have an effect on the permanent teeth ranging from a discolored tooth, to a white spot, or defect on the tooth. The damage caused will not be seen until the tooth erupts into the mouth.
Permanent broken tooth:

Call your dentist for an emergency appointment if your child has a recent broken tooth. If there is a large broken piece, place it in milk and take it to the dentist with you. The sooner these teeth are restored, even with a temporary, the more likely they will be able to keep them.
Some helpful tips: Stay calm in the emergency. Try to calm your child down and evaluate your childs situation so that you can seek the care needed for them. Establish a dental home for your child by age one or within 6months of the 1st tooth erupting dental emergencies are best managed by your own dentist who is known and trusted. Make sure your child is using a mouthguard and protective gear when playing sports When choosing a dentist, make sure they see children for after hours emergencies. Do not ignore your childs complaints of toothaches Keep the names and phone numbers of your childs dentist and pediatrician nearby Know the location of your closest hospital Know when your child had their last tetanus vaccination Place an ice pack to the area, if there is a recent injury to the lips or soft tissue to help decrease swelling on the way to the dentist/ER/or pediatrician
Some dental emergencies may be temporarily managed with medications. It is best to establish a dentist for your child and contact them first in an emergency to see what is best for your childs individual needs.
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Otoplasty for Outstanding Ears
Big ears are not funny. In fact, the American Society of Plastic Surgeons reported that nearly 40,000 teens in 2001 had Otoplasty surgery to reduce the prominence of their ears.
C
10 whatdoctorsknow.com
hildren and teens with prominent ears are often teased and ridiculed by their peers. Boys grow tired of having to grow long hair to cover their ears while girls affected by the problem are reluctant to even tuck their hair behind their ears or wear a pony tail in fear of being ridiculed. Otoplasty gave these children more balance to their facial features, but there are many patients and parents who are unaware that overly prominent ears can be corrected by means of a simple surgical procedure. Otoplasty, or ear pinning, is a surgical procedure for individuals whose ears are abnormally large or overly prominent. The
condition ranges from very mild, to the complete absence of an ear (microtia) in severe cases. For the majority of patients with cupped, malformed, or even injured ears, dramatic improvement can be achieved through otoplasty surgery. The procedure takes between one and two hours, depending upon the specific condition being addressed. It can be done under local anesthesia in the office setting, but for younger children or according to patient wishes, surgical anesthesia can be used. In any case, hospitalization is not required, recovery is quick, and pain control is easily achieved with mild analgesic medications. Ear pinning can be performed at any age but is best done when patients are at least six or seven years old and can be involved and invested in the decision and surgical process. Ive performed this operation on children as young as four, but I prefer them to be closer to six, when they are more aware of their bodies and become excited about the change to their ears. Although I do see some adults seeking improvement to their ears, the majority of patients are children. Concerned parents, most often prompted by their children, bring them in for evaluation during their school years. As with all elective surgery, to me its very important for the patient to be part of the decision making process. When the patient is excited about the change to their ears, he or she is motivated and able to smoothly navigate the surgical process. As I see them back in my office following recovery with improved confidence and big smiles on their faces, Im happy to know that Ive contributed to that happiness in some way. As for numbers of people affected, studies cant isolate any race or gender for the condition, but some data, as well as empirical evidence, suggests that genetic inheritance is often involved. There also seems to be no gender predilection. Available data suggests that 53 percent of teens undergoing otoplasty procedure are males. Approximately 33 percent of all otoplasty procedures are performed on boys and girls in their teens. However, as mentioned above, I have had numerous adult cases. In fact, one patient was in his 70s when he presented for surgery. I knew the procedure had been successful when he cut his hair short enough to expose his ears for the first time in years. Otoplasty brings a lot of joy to both the patient and the doctor. As a fellowship trained Facial Plastic Surgeon and Otolaryngologist, I see many patients interested in improving this aspect of their faces, and I find great satisfaction in assisting them in their desires -Scott K. Thompson, MD
Before
After
As I see them back in my office following recovery with improved confidence and big smiles on their faces, Im happy to know that Ive contributed to that happiness in some way.
Before
After
Two of Dr. Thompsons otoplasty patients. Photos used with permission. whatdoctorsknow.com 11
Hearin g L Contrib oss u t Demen e to tia
Could
O
lder adults with hearing loss may be missing out on more than just whats being said. A study by Johns Hopkins and the National Institute on Aging suggests that hearing loss could increase the risk of dementia.
making individuals more socially isolated, a known risk factor for dementia and other cognitive disorders. Whatever the cause, the scientists report, their finding may offer a starting point for interventions even as simple as hearing aids that could delay or prevent dementia by improving patients hearing. Researchers have looked at what affects hearing loss, but few have looked at how hearing loss affects cognitive brain function, says study leader Frank Lin, M.D., Ph.D., assistant professor in the Division of Otology at Johns Hopkins University School of Medicine. There hasnt been much crosstalk between otologists and geriatricians, so its been unclear whether hearing loss and dementia are related. To make the connection, Lin and his colleagues used data from the Baltimore Longitudinal Study on Aging (BLSA). The BLSA, initiated by the National Institute on Aging in 1958, has tracked various health factors in thousands of men and women over decades.
Seniors with hearing loss are significantly more likely to develop dementia over time than those who retain their hearing, a study by Johns Hopkins and National Institute on Aging researchers suggests.* The findings, the researchers say, could lead to new ways to combat dementia, a condition that affects millions of people worldwide and carries heavy societal burdens. Although the reason for the link between the two conditions is unknown, the investigators suggest that a common pathology may underlie both or that the strain of decoding sounds over the years may overwhelm the brains of people with hearing loss, leaving them more vulnerable to dementia. They also speculate that hearing loss could lead to dementia by
The new study, published in the February 2011 Archives of Neurology, focused on 639 people whose hearing and cognitive abilities were tested as part of the BLSA between 1990 and 1994. While about a quarter of the volunteers had some hearing loss at the start of the study, none had dementia. These volunteers were then closely followed with repeat examinations every one to two years, and by 2008, 58 of them had developed dementia. The researchers found that study participants with hearing loss at the beginning of the study were significantly more likely to develop dementia by the end. Compared with volunteers with normal hearing, those with mild, moderate, and severe hearing loss had twofold, threefold, and fivefold, respectively, the risk of developing dementia over time. The more hearing loss they had, the higher their likelihood of developing the memory-robbing disease. Even after the researchers took into account other factors that are associated with risk of dementia, including diabetes, high blood pressure, age, sex and race, Lin explains, hearing loss and dementia were still strongly connected. A lot of people ignore hearing loss because its such a slow and insidious process as we age, Lin says.
Even if people feel as if they are not affected, were showing that it may well be a more serious problem. Johns Hopkins is embarking on a long-term study to search for a definitive link and to learn whether treating hearing loss might delay the onset of dementia. In the meantime, Lin encourages people to address signs of hearing loss. Hearing aids are essentially no-risk therapies, he explains, and they clearly improve your quality of life. -This information provided courtesy of Johns Hopkins Medicine.
*This research was supported by the intramural research program of the National Institute on Aging.
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13
A cure for Parkinsons disease is closer than ever. The Michael J. Fox Foundation needs your help to make it a reality.
" The Answer Is In All of Us"
ts spring in New York City, and the downtown offices of The Michael J. Fox Foundation for Parkinsons Research are vibrating with activity. April is Parkinsons Awareness Month, and a palpable sense of purpose and intensity attend preparations in every corner of the floor-through space. Development staffers stuff envelopes for mailings and prepare welcome packets for grassroots community fundraisers soon to run marathons or host pancake breakfasts. Onstaff PhDs lead grant review meetings and teleconferences with academic and industry scientists from around the world. No one seems to feel there is a moment to spare. As it turns out, they dont. Urgency some would call it impatience is a core aspect of the Foundations culture. For those of us in the patient community, Parkinsons is not a time-neutral situation, explains Michael J. Fox. Its a ticking clock. If thats what youd call impatience, then I guess were impatient.
ENTREPRENEURSHIP, ACCOUNTABILITY, EFFICIENCY

Parkinsons disease is a chronic, degenerative neurological disorder that affects one in 100 people over age 60. While the average age at onset is 60, Fox was diagnosed at age 29 at the height of his fame and success as an actor and some are diagnosed as young as 18. Estimates of the number of people living with the disease vary, but recent research indicates that at least one million people in the United States, and more than five million worldwide, have Parkinsons. There is no known cure for the disease. Available treatments mask some symptoms, bringing serious side effects, while the underlying disease continues to worsen over time.
With more than $285 million in Parkinsons research funded to date, this months launch of Fox Trial Finder a next-generation Web tool to help the PD community get involved in research to speed treatment breakthroughs and a $50-million fundraising challenge in effect, theres never been a better time to join The Michael J. Fox Foundation in its quest to put a cure for Parkinsons disease within reach.
Photography by Mark Seliger
In just over 10 years since Fox launched it with co-founder Deborah W. Brooks, who had transitioned from a high-powered career in the world of business and finance, The Michael J. Fox Foundation (MJFF) has grown rapidly to become the largest private funder of Parkinsons research in the world. Today the Foundation is helmed by CEO Todd Sherer, PhD, Fox and Brooks. It is the only U.S. Parkinsons nonprofit with an exclusive focus on research a nimble, problem-solving and entrepreneurial player with a mission to take charge of streamlining and orchestrating Parkinsons drug development for patients benefit. I joined the Foundation with a desire to do something impactful for patients rather than for an individual lab and individual projects, says Sherer, a formally trained neuroscientist, who joined the Foundations research staff in 2004, transitioning from a career as an academic bench scientist. When you have to be the worlds expert on that particular project, you can lose sight of the context. Sherer became CEO in May 2011. The Foundation has inherited humility as a core value from Fox (I try not to pat myself on the back, even though I sometimes do it by accident, he jokes a reference to the excessive, sometimes twisting movements brought on by Parkinsons medications). But it is widely credited with having pioneered a new model for speeding drug development. MJFF is recognized as the model for how patient-driven research should be conducted and fostered, according to Anders Bjrklund, MD, PhD, of Lund University in Sweden, one of the worlds foremost Parkinsons experts and a member of the Foundations Scientific Advisory Board. The Foundation has had a hand in developing more than 100 Parkinsons therapeutic targets to date, pushing dozens of these closer to the clinic and practical relevance in patients lives. MJFF has built a staff of PhDtrained neuroscientists, each paired with business-trained project leaders.
Science to Get Excited About Recent research supports the hypothesis that genetics plays a greater role in PD than was previously believed. New understanding of genetic targets such as LRRK2, the most common genetic contributor to PD, have opened entirely new avenues for PD drug development over the next decade. A biomarker is a measurable physical trait used to indicate the effects or progress of a disease. Currently, there is no known biomarker for PD. This poses real problems in testing potential drugs that might slow or stop the course of the disease, a major unmet need for those living with PD today. MJFF is tackling the critical search for biomarker head on through a landmark clinical study, the Parkinsons Progression Markers Initiative (PPMI), currently enrolling people with and without Parkinsons disease in 24 cities around the world. Dyskinesias are the involuntary, uncontrollable, and disruptive movements that are a common side effect of many treatments for PD. Researchers are working to improve on existing drugs, and over the past few years, with MJFF support, several new therapeutic targets to treat dyskinesia have advanced from early-stage testing into the clinic.
Parkinsons Disease: The Basics Parkinson's disease was first characterized extensively by an English doctor, James Parkinson, in 1817. Today, we understand Parkinson's to be a disorder of the central nervous system that results from the loss of cells in various parts of the brain, including a region called the substantia nigra. The substantia nigra cells produce dopamine, a chemical messenger responsible for transmitting signals within the brain that allow for coordination of movement. Loss of dopamine causes neurons to fire without normal control, leaving patients less able to direct or control their movement. Parkinson's is one of several diseases categorized by clinicians as movement disorders.
People are generally most familiar with the motor symptoms of Parkinson's disease, as they are the most evident signs of the disease from the outside. These symptoms, which are also called the "cardinal" symptoms of PD, are resting tremor, slowness of movement (bradykinesia), postural instability (balance problems) and rigidity. Some other physical symptoms such as gait problems and reduced facial expression are also of note. These are due to the same discoordination of movement that causes the betterknown tremor and slowness. There is also increasing recognition of the importance of other symptoms of PD that are sometimes called "non-motor" or "dopamine-
non-responsive" symptoms. While neither of these terms is ideal, these symptoms are common and can have a major impact on people with PD. For example, cognitive impairment, ranging from mild memory difficulties to dementia, and mood disorders, such as depression and anxiety, occur frequently. Also common are sleep difficulties, loss of sense of smell, constipation, speech and swallowing problems, unexplained pains, drooling, and low blood pressure when standing. Parkinson's symptoms manifest differently in different patients. Many patients experience some symptoms and not others, and even the pace at which the disease worsens varies on an individual basis.
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15
Sitting at the global hub of Parkinsons research, this team comes to work every day with the single-minded purpose of prioritizing limited resources for maximum impact on patients lives in the nearest possible term. We dont outsource funding decisions to other experts, says Brooks. We have a team of scientists eight PhDs and one MD and we understand the business of drug development and not just neuroscience. We ask ourselves, How we can speed progress? We pair the doctors with business people to help them understand the business of science. This is part of what helps us keep things moving. Were really trying to figure out what its going to take to go from the a-ha moment in the lab to the drugstore shelf. Efficiency and accountability also are core values. Since inception, 87 cents of every dollar spent by the Foundation has gone straight to the research effort. And MJFF deliberately holds no endowment. Every dollar raised is immediately deployed to push forward research with the best chance of leading to new PD therapies and, ultimately, a cure. We believe that donor-raised capital has an obligation to advance the state of the science today, explains Sherer.
FOX TRIAL FINDER AND THE RESEARCH PARTICIPANT SHORTAGE

Working with the patient and researcher communities, The Michael J. Fox Foundation has developed a strategic roadmap to speed Parkinsons therapeutic development, providing both financial and intellectual leadership that has galvanized the scientific field and moved it tangibly closer to definitive clinical trials and breakthrough treatments. The need for high-impact investment in research has never been more urgent. But while financial investment is critical, dollars alone will not take carry therapeutic breakthroughs across the finish line. The active involvement of Parkinsons patients and their loved ones in clinical research is vital to finding the cure. Clinical trials and studies play a critical role in the development of new and better medicines. Currently, 80 percent of clinical trials finish late due to difficulties enrolling participants. Even more alarming, nearly one-third of trials fail to recruit a single subject and cannot ever begin. Underenrollment in clinical research, by people with and without Parkinsons, is slowing research progress and patients pay the price in terms of higher costs and longer time horizons to treatment breakthroughs. The Foundation has stepped up to answer this challenge with the development of a next-generation Web tool, Fox Trial Finder (foxtrialfinder.org), a user-friendly solution to connect willing volunteers with the specific trials that need them. Fox Trial Finder makes it easier than ever to find information about trials specifically matched to individual volunteers characteristics. The tool compares information entered by the user, such as geographical location and medical history, with trial needs and location to provide users with a short list of their best potential matches. Volunteers can review these matches and use the in-site messaging functionality to anonymously connect with trial personnel. New trials launch all the time, and registered users receive
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notification of new matches in real time without having to return to the site and repeat their search. The tool also enables research coordinators to review volunteers de-identified profiles and reach out to eligible volunteers to further explore the qualifications and appropriateness of the volunteer for their trial. Throughout this process, volunteers privacy is protected by the highest level of security protocols; personal information such as name and contact information remains private unless volunteers choose to share this information with a trial team. Launched in beta version last July, Fox Trial Finder currently includes over 190 clinical trials in its system. Nearly 4,000 volunteers have already registered, but more are needed the Foundation hopes to reach 10,000 by the end of 2012 in order to make serious inroads into the volunteer shortage that stands in the way of progress.
Fox Trial Finder sends the Parkinsons community an invaluable message: Theres something you can do, says Fox. Participating in research makes you an agent of change. Fox Trial Finder is a practical tool to help you get started. Thats a message we want everyone affected by Parkinsons to receive loud and clear.
TEAM FOX AND THE COMMUNITY FOR A CURE

The Foundations grassroots fundraising network, Team Fox, was launched in 2006 as a response to the incredible outpouring of support we saw from people all over the world and as a way to help them help us, says Fox. It has grown dramatically since then, with $16 million raised to support the Foundations ambitious research agenda. Today, Team Fox is the collective voice for the Foundations message of can-do optimism and action across the country and around the world and its
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numbers continue to increase. Each year, more than 1,500 Team Fox members worldwide turn their passions and interests into unique fundraising events and athletic feats. From putting on fashion shows and parading vintage cars to summiting mountains, Team Fox members have done it all. In 2011, Sam Fox (no relation to Michael J. Fox) ran from Canada to Mexico in two months (averaging about 40 miles a day), raising $150,000, in honor of his mother, Lucy, who has Parkinsons disease. On the trail, I thought about my mother and what she goes through, Sam says. She lives with the symptoms of Parkinsons every day with a smile and with strength I tried to emulate that. He has since joined the Foundations staff as Outreach and Engagement Officer, helping inspire others to get involved to speed a cure. (What did Lucy think of Sams plan? At first I thought he was nuts, she says. Now Im tremendously proud.) We know how passionate people feel about this cause, says Brooks, and extreme events reflect a desire to translate that into a physical challenge. But Pancakes for Parkinsons is also a signature Team Fox event. Were grateful for every lemonade stand and bake sale, golf tournament and walkathon, birthday party and art gallery opening that becomes a Team Fox event. Theres room for everyone in Team Fox.
GET CONNECTED
The Foundation has always been committed to bringing knowledge and expertise directly to patients and families and engaging with them in their own communities through educational offerings such as Research Roundtables, a Seminar Hot Topics Call Series and support group presentations. With the addition of a Digital Strategies team in 2011, the Foundation is working to leverage the growing sense of community among patients in the virtual realm. With our sole research focus we arent chapterbased and we dont offer support groups or patient care programs. But advances in technology present an amazing opportunity for us to communicate our goals and engage with a greater portion of the Parkinsons community, says Sherer. Digital platforms provide opportunities to spread the word and offer tools like Fox Trial Finder to match patients with the clinical trials that need them. The Foundations Web traffic grew by over 30 percent in 2011, and it is in the process of redesigning its Web site (www.michaeljfox.org) for greater interactivity and to better reflect the patient and caregiver experience (the redesigned site is expected to launch next month). MJFF is also active on the major social networks, with over 100,000 Facebook fans and over 10,000 Twitter followers. Our Facebook community has truly come alive we
see patients asking questions and commenting on others posts, says Brooks. Its a real community. The Foundation has also launched a blog, which is updated several times a day with Parkinsons research news analysis, updates on Foundation leadership, information on Team Fox events, and generalinterest news for the Parkinsons community.
December 31, 2012, will be matched. Brins mother and aunt have Parkinsons disease, and he carries a genetic mutation linked to increased risk for PD. [The Challenge] is truly a radical act of generosity, says Fox. Were obviously thrilled and grateful to Sergey and Anne, not only for their gift, but for the care and thought they put into how they structured it to bring more people onboard with our work. I dont think we knew when we set out just how broken our medical research system was, he continues. We came to realize over time that there are all these different players on the field but no single entity orchestrating their efforts to speed the best results for patients. Theres no Department of Cures. I had this vision of a new kind of organization that would be built for speed and impact. From the earliest days everything for us has come down to a streamlined focus on moving the needle, on purity of motive. It turns out that message speaks to a lot of people, and were just trying to do our work and find as many of those people as we can to be part of it. Because when the cure for Parkinsons is found and it will be it wont be because of me, or our Foundation, or any one individual. It will be because of all of us, working This information together. The answer is in all of us. provided courtesy of The Michael J. Fox Foundation.
THE ANSWER IS IN ALL OF US

Darkness is settling over the city, but the lights are still on at MJFF headquarters. Staffers work into the evening, refining plans and strategies for Parkinsons Awareness Month and beyond. For now, the groups impact on the trajectory of Parkinsons drug development remains a work in progress. But while everyone is sober about the work that remains to be done, theres a tangible feeling of optimism. That probably has something to do with the organizations most significant supporters, who have kept the Foundations revenues growing throughout recent economically challenging years. In fact, thanks to the support of MJFFs largest donors, Sergey Brin (co-founder of Google) and Anne Wojcicki (co-founder of personal genetics company 23andMe), donors to the Foundation can double their impact in the search for a cure. Thanks to the Brin Wojcicki Challenge, up to $50 million in gifts to the Foundation through
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Setting the Record Straight: Why Remain the Gold Standard in Breast Cancer Detection
Mammograms
time consuming than a mammogram, on average taking 40 minutes per case, compared to eight to 10 minutes for a typical mammogram. In addition, ultrasound screening has many false positives, which could result in unnecessary biopsies, and unnecessary anxiety for women. Most importantly, eight large, randomized clinical trials looking at women over a 30-year period have shown mortality due to breast cancer decreases as much as 30 percent as a result of mammographic screening. We also know that digital mammograms, which were not available until 2005, are even more sensitive in detecting cancer in women with dense breasts. Most studies, and my personal experience with patients at the University of California, San Diegos Moores Cancer Center, support the American Cancer Society's recommendation that women get regular mammograms beginning at age 40 as an important part of a breast cancer screening plan. Such screenings are done in women with no symptoms of breast cancer in order to find the disease early, when treatments are more likely to be successful. For now, it is my view that the role of ultrasound in breast cancer remains most useful in differentiating cysts versus solids lesions or to guide specialists in conducting breast biopsies. -Haydee Ojeda-Fournier, MD. UC San Diego Moores Cancer Center.
f there is only one thing you take away from reading this article, here it is: in the fight against breast cancer, mammograms are the standard diagnostic tool known to detect even the smallest cancers more than five years before they can be felt. Women over 40 are encouraged to be tested yearly. Period. A recent article in The Atlantic magazine reported that, for women with dense breasts, mammograms only detected cancer 40 to 50 percent of the time, and that breast ultrasound should be added as a diagnostic tool. This recommendation is based on a single, small study, and the findings focused on women with dense breasts and who were already considered high-risk for breast cancer. Ultrasound is more expensive and
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t a e r h t t u b , t n e r e f f i d First signs r men and women similar fo
W
hile heart disease continues to receive a lot of attention, certain myths surrounding the disease persist.
well-known symptoms like chest pain or tightness and a shooting pain in the left arm, there are differences in symptoms by sex, according to McLaughlin. The more obvious symptoms are more prevalent in men, which might be why research shows that men go to the emergency room with symptoms much earlier in than women. More subtle symptoms are more likely in women. These include shortness of breath, sweating or dizziness, nausea, severe fatigue, sudden sleep disturbances, pain radiating through the jaw, small of the back or between the shoulder blades. Women with diabetes are about twice as susceptible to heart attacks as men with the condition, says McLaughlin. Increased risk factors for women also include having an autoimmune disorder and a history of gestational diabetes or preeclampsia during pregnancies.
A couple of the most common myths are that heart disease is more common in men than women, and that the first signs of a heart attack are the same for both men and women, says Dr. Mary Ann McLaughlin, medical director of the cardiac health program at The Mount Sinai Medical Center in New York. Heart disease remains the leading cause of death in men and women in the United States, affecting both sexes relatively equally. Women are more afraid of dying from cancer, says McLaughlin. But in fact, they are much more likely to die from heart disease. Also, the first signs of a heart attack can manifest themselves in different ways between men and women. While both men and women can experience the more
Knowing the first signs of a heart attack is important, but reducing your risks for heart disease is the best way to avoid experiencing one. McLaughlin offers the following tips for a healthy heart:
* Reduce salt intake. Limiting your consumption of processed foods can help with this, as they are often high in salt. * Choose your fats wisely. Use olive oil instead of butter, snack on nuts instead of other sugary and high-fat snacks, and take supplements like flax seed oil that can boost your levels of omega-3 fatty acids, which can reduce artery inflammation. Consuming more omega-3s can also help you reduce your LDL (bad cholesterol) levels.
* Ask your doctor whether a daily regimen of lowdose aspirin would be appropriate for you, as it could lower your risk of a heart attack.
* Get regular exercise. A good rule of thumb is when balanced with a proper diet, 30 minutes of exercise a day will help you maintain your current weight, while 60 minutes will help you lose weight. If that seems like a lot, try to work exercises in to your daily tasks by taking the stairs instead of the elevator or walking or biking to work. Maintaining a healthy weight lowers your risk for cardiovascular disease.
* Maintain a daily intake of 1,000 mg of vitamin D, which can be found in some of the same fatty fish that contain high levels of omega-3 fatty acids. Vitamin D supplements can also help you achieve this, as low levels are associated with heart disease and high blood pressure. Exposure to sunshine also helps your body produce vitamin D, but dont forget your sunscreen.
* Know your numbers. Your doctor can help you get your readings and give you advice on how to meet the following goals for optimum heart health: Total cholesterol: less than 200 LDL (bad cholesterol): less than 100 HDL (good cholesterol): greater than or equal to 40 Total cholesterol to HDL ratio: less or equal to 4.4 for women and less than or equal to 5 for men Triglycerides: less than 150 Blood pressure: less than 120 systolic and less than 80 diastolic Non-fasting glucose: less than 120 Fasting glucose: less than 100 Hemoglobin A1c: less than 7
To learn more about heart disease and care, and to hear stories from patients who have experienced heart disease, visit www.mountsinai.org/heart. -This information provided courtesy of Mount Sinai Medical Center.
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Don't Let Your Bloom This Spring
Allergies
Seasonal allergic rhinitis causes fatigue in approximately 80 percent of patients, and depression in 30 percent. Seasonal allergic rhinitis, caused by tree and grass pollen in the spring and weed and ragweed pollen in the fall causes several other problems to flare. Active seasonal rhinitis nearly doubles patients needs for doctor visits and new medications for anxiety, depression, asthma, sinus infections, middle ear infections, and tonsil infections (Crystal-Peters, et.al. Annals of Allergy, Asthma & Immunol. 2002;89:457-462). Migraine headaches are more frequent when allergies are active. Embarrassing symptoms occur in at least 25 percent of patients.
he term allergic rhinitis means allergic reactions occurring in the nose and surrounding tissues. These reactions are caused by airborne substances such as seasonal pollen, mold spores, house dust mites, dust from animals, and dust from cockroaches. Everyone breathes these materials, but some people make IgE antibodies (allergic antibodies) and become allergic to these substances. An estimated 60,000,000 people in the United States have allergic rhinitis, approximately 19 percent of the population. The symptoms of allergic rhinitis are nasal itching, sneezing, runny
nose, nasal congestion, obstruction of the nose at night resulting in poor quality sleep (allergic inflammation becomes much more intense during the night), snoring, postnasal drainage, dry throat in the morning, popping and ringing and pressure sensations in the ears, and sinus pressure headaches. Some people with allergic rhinitis also have allergic conjunctivitis and experience intense itching and burning of the eyes, excessive tearing, swelling around the eyes, and dark discoloration beneath the eyes (allergic shiners). Some allergy sufferers develop a crease across the bridge of the nose (where the cartilage joins the nasal bones) because of constant rubbing of the nose to relieve the itching.
The economic impact of allergic rhinitis includes 3,500,000 workdays lost each year and approximately 2,000,000 days of school lost because of allergic rhinitis. When allergic rhinitis is active, productivity at work or school is impaired by fatigue, distraction by allergic symptoms, and sometimes by the sedating properties of over-the-counter allergy remedies.
Is self-care effective? For some individuals, self-care provides acceptable relief from symptoms, protection against sleep disturbance, and protection against complications such as sinusitis. Physician care: Approximately 20 percent of patients with allergic rhinitis see a physician for more powerful interventions. Prescription medications proven to be effective for allergic rhinitis include intranasal steroids, intranasal antihistamines, intranasal nerve blocking agents, oral medications that block leukotrienes (allergy mediators that along with histamine account for most of the allergic manifestations), and in extreme cases, oral or injected steroids. If the allergic rhinitis symptoms are suppressed, sleep isn't disturbed, and there are no complications, the goals reasonably expected have been achieved.
How to control of allergic rhinitis

We have gained a detailed understanding of the mechanisms of allergic rhinitis. This has led to the development of a broad range of powerful interventions can provide nearly complete control of allergic rhinitis symptoms and methods to eliminate these allergic reactions, with mild or no adverse reactions from medications. Reasonable expectations of these interventions:
No symptoms. Symptoms of allergic rhinitis usually can be suppressed to the point that they are of little consequence in most patients. No sleep disturbance. Aggressive interventions can eliminate nocturnal nasal obstruction which leads to poor quality sleep. This seems to be the main reason for fatigue and other allergic rhinitis complications. No complications. Aggressive management of allergic rhinitis should minimize the chance of complications such as bacterial sinusitis or flares of asthma. Three levels of care for allergic rhinitis: Self-care, physician care, and specialist physician care
Self-care: Approximately 80 percent of people with allergic rhinitis either endure the problems or use over-
the-counter medications. Keeping the windows in the home and car closed helps. HEPA air filters in the bedroom may help. Oral antihistamines can be helpful for itching, sneezing, runny nose, and itching and burning of the eyes, reducing symptoms 25% better than a placebo. Older sedating antihistamines such as diphenhydramine can be helpful, but also have been shown to impair our ability to drive and learn. Newer, nonsedating antihistamines are available over-the-counter that provide relief and are much safer. Antihistamines have little effect on nasal or sinus congestion. Oral decongestants can provide some relief from the congestion, but they also disrupt normal sleep architecture, and can cause heart rhythm problems, dizziness, anxiety and tremors. Nasal spray decongestants can be effective for congestion, but many people quickly become dependent upon the decongestant sprays. Once the effect of the decongestant spray wears off, the nose swells shut and is very uncomfortable unless the spray is used again. Intranasal cromolyn and intranasal saline also help some individuals.
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Expert care: When symptoms are not well controlled, and sleep is disturbed by nocturnal nasal obstruction, or when complications of allergic rhinitis such as asthma or sinusitis are present despite these interventions, an Allergy and Immunology specialist is able to provide effective relief. Accurate diagnosis is necessary to establish that the problem really is allergic rhinitis, to guide specific measures to avoid exposure to the causes and aggravating factors, and to identify patients whose problems can be minimized or eradicated by immunotherapy (allergy shots). The evaluation also includes searching for complications or concurrent problems such as nasal polyps, nasal septal deviation, other anatomical problems in the nasal passages, bacterial sinusitis, medication effects on the nose, and multiple other factors that modify or mimic allergic rhinitis. Concurrent problems such as asthma, sensitivity to non-steroidal anti-inflammatory drugs, Vitamin D deficiency, and antibody immunodeficiency should be identified and corrected. Interventions selected and adjusted for individualized care usually provide excellent control of allergic rhinitis.
The likelihood allergic rhinitis will spontaneously go away is approximately 1-2 percent per year. Seasonal allergies usually return and being prepared is essential to the longterm management of this problem. Starting intranasal steroids before the pollen season can markedly reduce or eliminate the flare in some patients. Immunotherapy (allergy shots), especially rush immunotherapy, may be useful to greatly reduce the severity or completely eliminate seasonal allergic rhinitis. Patients with allergic rhinitis severe enough to require the help of an allergist are usually excellent candidates for therapy aimed at cure, rather than relief.
Dont accept disrupted quality of life because of allergic rhinitis.

We now have a large array of overthe-counter, prescription, and specialist interventions to suppress, and even, eliminate seasonal allergic rhinitis. You do not have to put up with seasonal allergies anymore. Dont let your allergies bloom Timothy J. Sullivan, this spring. MD and Vicki J. Lyons, MD
Symptoms of Seasonal Allergic Rhinitis and Conjunctivitis Nasal itching Sneezing Clear nasal secretions (runny nose) Poor quality sleep Snoring Sinus pressure headaches Ear symptoms -popping, ringing, congestion, variable hearing changes Eye symptoms itching, burning, tearing, swelling around the eyes
Complications of Seasonal Allergic Rhinitis Fatigue (80%) Depression (30%) Anxiety Sinus Sinus infection Middle ear infection Migraine headaches Public embarrassment because of obvious symptoms (25%)
Luella : New Lungs for a New
Love Life
Despite CF, Luella had never excused herself from life. She ran five miles morning and evening in her 20s. When she could no longer run, she walked. She worked in customer relations for a bank until chronic respiratory and digestive issues requiring hospitalizations signaled that CF was winning. By May of last year her body was showing signs of shutting down. She prayed for new lungs. Reluctantly. Im a long-time organ donor myself, and I had real mixed emotions when I prayed for new lungs, Luella said. Never will I forget that my getting a second chance at life means someone lost theirs. Still, I wanted the call that there were lungs for me. The call came early on Nov. 11 and during a 14-hour surgery, Benjamin E. Haithcock, MD, assistant professor of surgery at the UNC School of Medicine and lead lung transplant surgeon at the UNC Center for Transplant Care, transplanted the new lungs into Luellas chest. Fifteen to 20 lung transplants are performed at UNC Hospitals each year.
f Luella Love believed in lucky numbers, she would pick 11.
I got my new lungs on November 11, 2011, during a surgery that started at 11 p.m., said Love, 48, of Concord, NC. I dont believe in lucky numbers, but I do believe in God. Love, a petite Indiana native who has lived in North Carolina seven years, was born with cystic fibrosis (CF), a life-shortening inherited disease that causes abnormally thick, sticky mucus to build up in the breathing passages and in the pancreas, resulting in breathing difficulties and related digestive system issues. At Luellas birth, life expectancy for CF patients hovered in the teens. I was diagnosed at 18 months old and my mother was told I wouldnt live to see kindergarten, Love said. My mother died of lung cancer in 1996, and I celebrated my 48th birthday days after my transplant. My new chance at life feels like a miracle to me.
To learn about becoming an organ donor, contact Carolina Donor Services, the federally designated organ procurement organization serving 6.1 million people in 79 counties in North Carolina and Danville, Va. (www. carolinadonorservices. org, 919-489-8404)
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Luella expects that soon, too. Her diligence in all post-transplant therapies rivals her pretransplant dedication because she sees time that she didnt expect to have stretch before her. Before the transplant, my best day would be someone elses bad day, Luella said, remembering the difficulty breathing when not even exerting herself, the digestive issues, some bladder- and bowel-control issues. Im free of all that now. And I have time. I want to ramp up my advocacy for organ donation. I want to work with support groups for CF patients because I know what its like not to have that. I want to be there to hold someones hand when they need it most. I want to learn to dance, to run yes, a 5K, and to learn to crochet. Learning to crochet helped pass the time during Luellas required 90 to 100 days post-transplant stay at SECU Family House, the 40-bedroom hospital hospitality house minutes away from UNC Hospitals that provides comfortable, convenient and affordable housing for seriously ill adult patients and their family member caregivers. Transplant patients are monitored closely for signs of organ rejection and other complications and have multiple therapies weekly to help their minds and bodies adjust to the new normal. A shuttle takes patients to and from the hospital regularly, and emergency transport is arranged as needed. I will always remember Dr. Haithcock telling me my new lungs were pristine and the perfect size for my small frame, Luella said. When the time is right, I want to thank the family of the donor for their loved ones priceless gift. Dr. Haithcock credits Luellas diligence with pre-transplant physical therapy with getting her back in the game of life. Our lung transplant patients are required to be up and moving around as much as possible, Dr. Haithcock said. Luella followed those instructions to the letter, and it shows. Four to six hours after transplant, she was raring to go, the breathing tube came out and she was walking. Unexpected gallbladder and liver issues required additional surgery and extended her recovery, but Luella sees them as distant bumps in the road. Often the steroids and anti-inflammatory drugs that transplant patients must take make them less sensitive to pain, and its sometimes hard to diagnose when there are post-transplant infections or issues, Dr. Haithcock said. Still, shes really done great, and I fully expect to see her on a track or running a 5K soon.
As excited as I am about going home, I am sad about leaving Family House, Luella said, as she headed home to Concord on March 1. Im treated like family here, with love and respect. I know without this place my recovery would have been slower. The food provided by volunteers is always excellent, and the after-dinner entertainment is always nice. There are places for solitude and places for coming together. I have to figure out a way to give back for all theyve given me. Luella was joined at Family House by her sister, Crystal, from Indiana, who stayed by Luellas side since the transplant. Crystal is a blessing to me, Luella said. Shes lifted me, bathed me, done my laundry, organized my very large pillbox, gone with me to every appointment and helped me think, and shes taught me to crochet. Shes missed her sons birthdays, and Thanksgiving, Christmas and New Years with her husband and their family. She misses them greatly, and I cant thank her enough for what shes done for me. Shes been a little bit of everything to me, and at the end of the day, shes still my sister. -Written by Elizabeth Swaringen for UNC Health Care
FLU, COLD OR VIRUS Questions & Myths Cleared Up
t's been an unseasonably warm winter, and with January and February days in the 60's and 70's, flowers are blooming early and grass hasn't completely gone dormant. The warm winter has also kept flu season from hitting most of the country, but the experts assure us the virus is still sure to hit. It's not an issue of if the flu will hit, but when.
So, are you protected? The easiest, and safest way to keep you and your family protected from the flu this season, even this late into the winter, is to get a flu shot. And it's not too late, says our Infectious Diseases expert, Dr. Jeffrey Kahn.
What time of year is flu typically at its peak? And why?
Influenza, or the flu, typically circulates in the late fall and winter months in the northern hemisphere. During most years, the flu season can last up to 3 months with peak activity lasting 1-2 weeks or more. There is some variability in the start of the flu seasonsome years it starts in November, while in others (like this one) it can start in February or later. The seasonality of the flu remains one of the great mysteries in infectious diseases. Several potential explanations have been proposed (air temperature, humidity, etc) but none have been proven.
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wet hair actually make you Q Does more likely to catch a cold/the flu?
A
Q
Thats what our mothers and grandmothers tell us and I am not going to argue with them. So dry your hair and wear a hat!
Can you get the flu by being out in cold weather? And why is there a flu season?
The flu is typically spread from person to person (so temperature and weather may not have a direct impact) and as we learned with the swine (H1N1) flu, cold weather is not required. The peak of H1N1 activity in Dallas in 2009 was early September when the daily temperatures were in the 80s and 90s!
Why do kids fevers tend to spike at night? Why do their stuffy noses and coughs seem to get worse at night?
While these are common observations, there is no single answer to these questions. Increase in cough and congestion at night may be the result of position effecting nasal drainage (upright vs. lying down). As for fevers being worse at night, I am not sure that there is solid evidence for this but we know that body temperature varies with the circadian rhythm.
How can you tell Q the difference between a cold, the flu or some other respiratory virus?
Tamiflu Q Does really work?
Typically, the flu has a sudden onset with high fevers and body aches. However, it is difficult at times to tell the difference between infection with influenza and infection with other respiratory viruses. But, if it is in the middle of flu season and you suddenly get sick with high temperatures and feel like youve been hit by a bus, its most likely the flu.
Absolutely! For maximum effect, it should be taken within 48 hours of the onset of symptoms.
Does getting a flu shot give you the flu virus? Will you get sick from the flu shot or flu mist?
A
Q
The injectable flu vaccine is inactivated (killed) virus so you cant get the flu from the shot. Flumist is a weakened form of the virus that can only replicate in the nose and does not result in flu symptoms in the VAST majority of recipients. Bottom line: either flu vaccine is SAFE and EFFECTIVE.
Is it too late to get a flu shot?
Since we are just beginning to see flu activity, there is still time to get vaccinated. So if you have not already done so, GET THE VACCINE! Its the best way to protect yourself and your loved ones from getting the flu. -Jeffrey Kahn, MD, PhD. UT Southwestern Medical Center.
Acid Reflux The Burning Issue

Pharmacy shelves are full of medications for reflux "heartburn." Most of us know the symptoms: a burning sensation in the chest with belching, sour stomach fluid coming up into the mouth, or worse yet, awakening suddenly, choking on burning acid in the airway. Reflux affects 40% of Americans monthly and 18% of Americans weekly.
Too many people blow off Acid Reflux or Heartburn as no big deal. Does this sound familiar? You go out to dinner and eat a large meal consisting of fried and fatty foods, accompanied by a glass of wine. You follow dinner with a beautiful chocolate dessert and a cup of coffee. Of course, you grabs some mints on the way out and go to bed an hour or two later. Do I pop an antacid or take some pink liquid so everything will be fine in the morning? In reality, acid reflux can affect the esophagus, the stomach, or the digestive tract, and untreated, can eventually lead to cancer. So what are the signs to ignore? What are the signs to worry about? What can you eat? What should you avoid? These are pardon the pun burning questions we have asked several leading experts to answer in detail in the next section. Before you start tasting that meal a second time around, read on:
n addition to the symptoms, untreated reflux can cause death due to esophageal cancer, which is one of the most deadly cancers, affecting about 14,000 Americans every year and growing rapidly. Research shows the increase in reflux and cancer is directly related to the nations increase in obesity. There is a correlation between increased weight and heartburn, and between weight loss and the improvement of heartburn symptoms. In 1991, 15% of Americans were considered obese and 30% were considered overweight. Today, 30% are obese with 60% overweight.
What is Heartburn or Reflux?

The stomach produces acid to aid in the digestive process. The problem is not the acid itself, but when the acid comes up, or refluxes, into the esophagus. To understand the nature of acid reflux it is helpful to understand a bit of human anatomy. We are able to breathe because the rib cage and diaphragm function like a bellows. The diaphragm is a sheet of muscle separating the chest cavity from the abdominal cavity. In the middle of this muscle is a hole, or hiatus, allowing the esophagus to join with the stomach. When you inhale, your diaphragm contracts, expanding the chest cavity, creating negative pressure allowing air to flow into your lungs. Downward contraction of the diaphragm increases abdominal pressure forcing liquid up the esophagus. Of course, our bodies are designed to keep this from happening. Acid reflux occurs only when something goes wrong. Factors that allow reflux include:
from the esophagus. Saliva also contains growth factors that heal the esophagus from the damage of acid. Reduced resistance to injury. Once your esophagus is injured, it loses its protective defenses and is much more susceptible to further injury. Delayed stomach emptying. Food and acid can sometimes sit in the stomach longer than usual. This is what happens when you go to bed with a full stomach. Sleep apnea. The partial blockage of your airway by the soft palate and uvula can cause your chest to expand harder than normal to overcome the resistance. This pulls more acid into your esophagus. Hiatal hernia. A portion of your stomach protrudes into your chest cavity through the hiatus. It forces the lower esophageal sphincter open and basically allows the food and acid up into your chest.
TLESR, or Transient Lower Esophageal Sphincter Relaxation. The lower esophageal sphincter is a weak ring of muscle that closes off the bottom of the esophagus from the top of the stomach, preventing acid from rising. But sometimes the sphincter relaxes when it shouldnt.
Acid Clearance. When sleeping, we stop producing saliva and stop swallowing which helps clear acid
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Cigarette smoke and alcohol. The esophagus is protected from toxins in cigarette smoke by a mucus lining, as well as the rinsing effect of saliva, which washes acid out. Alcohol dissolves the mucus layer and also dissolves the smoke toxins so they are adsorbed (not absorbed) directly to the esophageal surface.
In the long term, acid reflux can lead to ulceration or stricturing (narrowing) of the esophagus, which makes it difficult to swallow. It can also lead to Barrett's esophagus, a mutation in the lower esophageal tissue that can eventually develop into esophageal cancer.
How is Reflux Diagnosed?

Your doctor may suspect reflux based on your symptoms, and will typically confirm the diagnosis with an upper endoscopy, especially if any red-flag symptoms are present. These red flags may include:
Difficult or uncomfortable swallowing Unintended weight loss Vomiting blood or material that looks like coffee grounds Black, tarry stools An onset of symptoms after age 50
Disappearance of reflux symptoms without any change in lifestyle, body weight or medication may suggest the development of Barrett's esophagus, a mutation that will protect you against reflux symptoms, but can lead to cancer. Medication Options
There are many options, which promise different results. Its important to have a basic understanding of how they work and what can be expected of each type.
* Acid neutralizers such as Tums, Rolaids, AlkaSeltzer, Maalox and milk of magnesia. These medications work by neutralizing the acid already produced in the stomach and are largely available over the counter. They can be effective for occasional symptomatic reflux. If you have other medical conditions--especially kidney disease--use caution with over-thecounter preparations containing calcium, magnesium or phosphate. Its also important to know that Alka-Seltzer contains aspirin. For acid reflux, use the Alka-Seltzer Heartburn preparation, which does not contain aspirin. * H2 blockers, or histamine blockers, such as Pepcid, Zantac, Tagamet and Axid. These medications work by blocking much of the acid produced in the stomach. They are available in both over-the-counter and prescription strength. H2 blockers are more
The following foods are fine to eat:
Mineral water (neutralizes the acid) Most vegetables except fried

potatoes and raw onion
Lean, non-fried meat Apples Bananas Multi-grains Low-fat dressings (vinegar and olive oil) Low-fat desserts like sorbet
effective for frequent heartburn treatment and for healing injury to the esophagus than the acid-neutralizing medications. * Proton pump inhibitors (PPIs), such as prescription-strength Prilosec, Nexium, Aciphex, Protonix, Zegerid, Prevacid and Kapidex. They block the final common pathway of acid production in the stomach and are the most effective for the healing and maintenance of symptoms. Prilosec has an over-the-counter option but its not timereleased and therefore not as effective as the prescription strength. Most of these medications should NOT be taken with Plavix, an antiplatelet agent for the prevention of heart attack or stroke. PPIs may interfere with the effect of Plavix. If you take Plavix and are on a reflux medicine, check with your doctor or pharmacist to be sure its safe. Prilosec and Nexium are also contraindicated with Celexa also known as Citalopram. Non-Medication Treatments
If you want to avoid taking prescription medication or if youve tried it and your reflux is still a problem, you might consider the following treatments:
Surgery can tighten the junction of the stomach and the esophagus. (For more information on surgical options, refer to Dr. LeGrand Belnaps article on Acid Reflux Surgery in this issue) Lifestyle modification, primarily weight loss, can have dramatic results. But even if you dont have a lot of weight to lose, eating smaller meals and going to sleep with an empty stomach can help. Elevating the head of the bed a few inches with wooden blocks can make a difference. Let gravity help you.
If you have acid reflux, I recommend the following dietary cautions:
Eating large volumes of food Eating less than three hours before bedtime Caffeine, including coffee and soft drinks Liquor, including wine and beer Citrus, tomato, and cranberry fruits and juices Ice cream or milkshakes Chocolate (one of the worst offenders) Sour cream High-fat desserts Peppermint (one of the most potent esophageal sphincter
relaxers of all! Avoid those after-dinner mints)
It is not lost on me that foods to avoid are more appealing.
The following medications may also cause or worsen acid reflux: Nonsteroidals such as aspirin or Motrin Calcium channel blockers Anticholinergics Beta agonists Dopamine Bisphosphonates such as alendronate for osteoporosis Sedatives Progesterone Antibiotics Antihistamines simple
-Steve Porter, MD
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When Surgery is Needed to
Correct Acid Reflux
romantic evening in town, an excessively rich meal late in the evening, wine, and a couple of peppermints from the checkout counter sets the stage for a night of discomfort, indigestion, and choking on undigested food and sour acid regurgitated into the mouth...You have just crossed over into the Twilight Zone of gastroesophageal reflux disease (GERD).
GERD refers to the regurgitation of stomach contents into mouth and airways.
Food and acid are typically prevented from reflux by competent function of the lower esophageal sphincter, a ring of muscle in the lower esophagus, which is assisted in its job by the diaphragm, maintaining a mechanical barrier at the top of the stomach and lower esophagus to prevent backflow of acid and symptoms of reflux. Heartburn, also called acid indigestion, is the most common symptom of GERD. However, if left untreated, GERD can cause esophageal ulcers, esophageal bleeding, and narrowing of the esophagus (peptic stricture).
Once GERD is identified, a number of treatment options can be prescribed.

Surgical Options
Nissen fundoplication is an anti-reflux operation that helps patients who have persistent symptoms despite medical treatment. The upper part of the stomach (gastric fundis) is wrapped around the lower esophagus and is sutured to the stomach, which helps the lower esophageal sphincter (the valve between the esophagus and stomach) close more effectively. This prevents the gastric acid backflow which causes GERD. The esophageal hiatus is also narrowed using sutures to treat hiatal hernia, preventing the upper part of the stomach from sliding up through enlarged esophageal hiatus of the diaphragm. This procedure is usually done laparoscopically, i.e., without actually opening the abdomen. Studies have shown fundoplication to be a safe and effective procedure with nearly 90% of patients being symptom-free after 10 years. Post-surgery complications can include trouble swallowing
What causes GERD? GERD results due to a failure of the mechanical barriers to reflux: 1. Incompetent (overly relaxed) esophageal sphincter which no longer controls backflow. 2. A hiatal hernia (top of the stomach bulges over the diaphragm) 3. Overly filled stomach with delayed emptying (because the stomach does not empty while we sleep.)
The interaction of all of these factors is a fairly complex mechanical and physiologic interchange. For more in depth information about physiologic, dietary, and weight loss options for GERD, please see the article in this issue by Dr. Steve Porter on pages 29-31 titled "Acid Reflux: The Burning Issue".
(dysphagia), irritable bowel (which may last 2 weeks), and the fundoplication can come undone over time in 5-10% of cases, which may warrant a repeat surgery.
Laparoscopic (videoscopic) Procedure

A videoscopic surgical procedure is an alternative to the traditional or what is known as "open" surgery, in which a large incision is made. This technologically advanced option allows the surgeon to use minimally invasive surgery to treat GERD. Videoscopic surgery eliminates the need for a long incision. Small incisions only millimeters in size are made to accommodate small tubes called "trocars." These create a passageway for special surgical instruments and a laparoscope. A fiberoptic instrument called a laparoscope is inserted into the abdominal wall. This device transmits images from within the body to a video monitor, allowing the surgeon to see the operative area on the screen. In a laparoscopic Nissen fundoplication procedure, small surgical tools and a laparoscope are used to repair the muscle that separates the stomach and esophagus. This procedure has many advantages over a traditional surgery including minimal scarring and reduced recovery time. Hospital stays are reduced and total recovery time is reduced to half. The risk of infection is also minimal because of very small puncture sites. Best yet, the laparoscopic surgery often requires a hospital stay of less than 24 hours instead of four
to five days as in the case of traditional surgery. In many cases, a patients total recovery time can be as little as one to two weeks, compared to the four to six weeks time for traditional surgery.
If you have failed to respond to conservative therapy, or suffer from complications of reflux disease such as ulcers, strictures or Barretts esophagus, it may be time to consider a surgical approach. Who are good candidates for the procedure?
Surgical candidates are those whose heartburn is not well controlled with medicine, those who want to fix the problem without having to take medicine long term, and those who have complications from reflux such as ulcers, strictures, hernias or Barrett's esophagus.
What can I expect before and after the surgery?

Patients are counseled before the operation about lifestyle and dietary adjustments that are needed for the first six weeks following surgery. They are advised to eat smaller amounts of food at each meal, chew their food well, and avoid chewing gum and drinking carbonated beverages to make sure that they heal properly from the surgery. The success rate for the minimally invasive surgery is 90 to 95% for patients who have typical symptoms of GERD such as heartburn, regurgitation, and belching. For those with less typical symptoms, including hoarseness and chronic cough, the surgery is about 70 to 80% effective in relieving their symptoms. -LeGrand P. Belnap, MD, FACS
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Reflux in Redux
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henever I try to simplify a subject for patients, I find myself struggling to find a balance between adequately explaining, overly explaining, overly simplifying etc. If this seems too simple I apologize. If this is too complex, I apologize. Bear with me, it is important to understand digestion in order to understand the nature of reflux. There is a tendency to think of the digestive process as being magical. From a design perspective it is elegant and simple.
is not that relevant, so you have permission to substitute a sandwich or something else that combines carbohydrates, proteins and fats. This piece of pizza contains what our bodies consider to be the three major food groups: Carbohydrate is present primarily in the bread, but also in vegetables and some of the components of the cheese and most of the tomato sauce. Carbohydrates are basically long complex chains of sugars, some digestible in our bodies, others not. Carbohydrates also include plant fiber, which is of no nutritional value. The value of fiber in the diet is to act as a scrub brush in the lower intestine to help clean the lining
How We Convert Food into Nutrition

To illustrate this point, we will use a piece of your favorite pizza. The choice of the example
Fat is present in the cheese, meat and oil. Fats are complexes of cholesterol and various glycerides and fatty acids that must be broken down and made soluble (dissolvable in water) to be absorbed into the body. This calls for bile, which functions as a detergent to emulsify fat or break it down into tiny fragments called micellar units that can be absorbed into the lymphatic system of the intestinal tract and brought to the liver for further processing. 1 g of fat provides about 7 kcal of energy. (The highest kilocalorie per gramyield comes from alcohol at about 9 kcal per gram. We really don't recommend it as a basic food group). If you are hungry, looking at the picture above triggers your eyes, which are highly developed specialized skin connected through the nervous system to the base of the brain, then the occipital lobe of the brain with subsequent connections to the cerebral cortex. This fact is important because the first phase of digestion is triggered by either sight or smell, or just hearing about food. The thalamus in the base of the brain, in conjunction with the medulla oblongata in the brainstem exert control over the vagus nerve, which is a nerve that controls the movement of the entire digestive system. This is known as the cephalic phase of digestion and stimulates the initial production of acid and leads to salivation in the mouth and movement of the GI tract, particularly a growling, rumbling sensation in the stomach itself.
The Mouth
Now we have the pizza in our hand, we can feel it, and we can smell it, furthering the production of saliva and then we take the first bite. Our mouth is now awash with saliva and we are chewing the food like there is no tomorrow. This process of mixing of saliva and chewing is very important for digestion. Saliva is a mixture of glycoprotein mucus, with water, in conjunction with two enzymes called Salivary Amylase and Salivary Lipase. The function of salivary amylase is to start breaking down complex carbohydrates into smaller fragments of sugars and starches. This happens at neutral pH and is inhibited once the food reaches the acid of the stomach. Salivary amylase allows us to taste the sweetness of sugars in the food immediately. Salivary lipase allows us to taste the buttery or oily fats in the food. Sour and bitter are separate taste bud functions that we will discuss later, in regard to bile and acid reflux.
of the colon. It is this fibrous matter in conjunction with dead cells from the intestinal lining that make up the majority of our bowel movement volume. The digestible carbohydrates are of relatively low potency for energy production with 1 gram of carbohydrate yielding between 3 and 4 kcal of energy. Protein is present in some of the plant products such as vegetables, but also in the cheese and in pepperoni or sausage or ham. Proteins are long complex chains of amino acids folded in tight packages and protected by connective tissue boundaries that must be broken down further to derive the amino acids actually used by the cells of the body. 1 gram of protein provides about 5 kcal of energy.
The Purpose of Saliva: Moisturizing food Initiation of minor digestion Washing bacteria off teeth Washing acid out of the esophagus
Once we have chewed adequately, its time to swallow and this is one of the most underappreciated and dangerous tasks our bodies are required to perform. The vagus nerve is part of what is called the autonomic
nervous system. Some people mispronounce it as automatic and they are not really wrong. It takes care of the things we take for granted such as maintaining our blood pressure when we rise from a seated or lying position, as well as allowing us to breathe and carry on our basic functions of daily living without having to think about it. We never really think about the danger of moving food and liquid from the mouth past the airway into the esophagus until something goes wrong with the process and we find ourselves choking. Heres how you swallow:
factor (EGF) promoting repair of the esophageal tissue damaged by acid reflux.
Now the Pizza Is in the Stomach, Hallelujah!

(If youre like us, youre probably getting hungry. Take your own pizza break, come back to finish reading.) Our piece of pizza will spend quite a bit of time in the stomach, which is not a passive adventure at all. It is a very dark, harsh chemical and mechanical environment.
First the sides of the tongue curl up and the tip of the tongue flips backward tossing the bolus of food or liquid into the back of the oropharynx and top of the hypopharynx. With perfect synchronization the oropharynx and palate and hypopharyngeal wall relax to receive the food bolus as the hyoid bone is lifted upward closing the epiglottis across the airway and forming an air and watertight seal to prevent food or liquid from going down the trachea into the lungs. Next there is a small swallow of saliva followed by rinse and repeat, rinse and repeat, rinse and repeat. Those of us who are overweight are rinsing and repeating too much. The Esophagus
Now the food is in the esophagus. The function of the esophagus is to propel the chewed food and saliva mixture past the lower esophageal sphincter, which opens then closes off to prevent reflux up from the stomach. This is accomplished through the motor function of the esophagus with peristaltic waves propelling downward. The esophageal muscles relax ahead of the contractile wave allowing easy passage. Even between meals the esophagus rinses itself with swallowed saliva, which washes out any acid that might reflux up from the stomach. The saliva also contains epidermal growth
During the first 40 minutes, the middle and the lower stomach are contracted while the food is stored in the upper dome of the stomach (the fundus) under the heart on the left side. Acid is working on the food, breaking down connective tissue and cellular barriers, and unfolding long chains of proteins, large globules of fat, and long chains of carbohydrates.
In the next 40 minutes, the body of the stomach relaxes to allow the food to enter the middle portion where most of the folds are located. There is increased acid production as well as enzyme production. In this area, the food will be further ground mechanically into smaller and smaller pieces. Finally, the antrum relaxes and the food enters the lower portion of the stomach where there is further exposure to acid and grinding. Stomach Acid
This is a good opportunity to discuss stomach acid production, since its one of the most interesting things our body does for us. That might seem to be an unusual statement given acid is considered to be a villain these days, when in fact, it is not. Gastric acid, also called HCL (hydrochloric acid) is produced by parietal cells in the lining of the stomach. This production of acid requires an energy driven system within the cell called a proton pump. The proton pump actively moves hydrogen protons into the stomach that will couple with chloride to become hydrochloric acid. In between meals the stomach does not contain acid. Acid is created on demand by three primary stimulators.
3) Gastrin is a hormone produced by G cells in the stomach in response to perceived need for acid production.
All three of these pathways converge at the proton pump and will be blocked by proton pump inhibitors, stopping the final common pathway of acid production.
Stomach Enzymes Pepsin. The stomach lining produces a pre enzyme called pepsinogen, produced by chief cells. This pre enzyme is converted in the presence of stomach acid into pepsin, which is a potent digestive enzyme. Gastric Lipase. Works on fat breakdown, similar to salivary lipase.
These enzymes, while produced in the stomach, activate in the more neutral pH in the small intestine. They will combine with additional digestive enzymes coming from the pancreas.
1) Acetylcholine stimulates movement of the stomach wall. Movement of the stomach stimulates acid production anticipating incoming food. 2) Histamine 2 is the pathway blocked by Zantac, Tagamet or Pepcid, and is a major mediator of acid production.
The Gastric Hormones Gastrin is produced in the G cells of the stomach, stimulating acid production from the parietal cells. Low levels of acid output stimulate gastrin production and can stimulate development of additional G cells to increase acid production. Somatostatin produced in the D cells of the stomach decreases gastric blood flow and stops gastric activity and acid production. Basically this hormone shuts down the GI tract.
Duodenum
We should first talk about the anatomy of the duodenum, which is controlled at the entry by the pylorus. From the pylorus we enter into the bulb of the duodenum and then we move around a very sharp turn to what is called the duodenal sweep. About 8 inches down, we run into a nipple or valve on the left wall, which is the entry of the common bile duct and pancreas duct. The probable reason for the placement of the valve at this position is that the S-trap of the duodenal sweep prevents enzymes and chemicals coming from the pancreas and gallbladder from backwashing into the stomach, which would neutralize acid in the stomach and disrupt the mechanical phase of digestion. After about an hour and a half in the stomach, our pizza and acid has been reduced to a sludge know as chyme. The pyloric sphincter winks open allowing about a half a teaspoon of chyme, three times a minute, into the duodenum. In between each small entry, the pylorus closes again. The presence of acid, fat, carbohydrate and protein within the duodenum triggers release of three hormones. Now the chemical digestion begins.
Duodenal Hormones
The function of chemical digestion is controlled by three primary hormones produced in the duodenum in response to the drop in pH, as acid and chyme pass through the pylorus. These hormones and their resulting effect on digestion are outlined below:
Secretin. This is a hormone produced in the first part of the duodenum triggering release of pancreatic enzyme and bicarbonate into the lower portion around the S-trap of the duodenum. There is significant flow of bicarbonate and digestive enzymes including trypsin and chymotrypsin, which are initially secreted in their inactive form and converted in the presence of each other and of acid into their active form. These enzymes are necessary for the further breakdown of proteins into basic amino acids, which can be readily absorbed in the microvilli in the surface of the small bowel, completing the digestion of proteins. At the same time secretin will cause the release of pancreatic amylase and pancreatic lipase. The function of
pancreatic amylase being the further breakdown of starches and complex sugars into more basic simple sugars that can be readily absorbed into the small intestine lining as well. Pancreatic lipase performs a similar function on certain types of fat causing hydrolysis or breakdown to create more absorbable forms with some of the simple fatty acids being able to be absorbed into the duodenal lining directly while more complex fats will require further processing. Cholecystokinin (CCK). Causes contraction of the gallbladder and bile duct and possibly the pancreas duct as well as relaxing of the sphincter of Oddi muscle, to allow the flow of bile and pancreatic enzyme into the duodenum. The purpose of bile in our digestion is to function as a detergent. Bile can break grease down into tiny fragments surrounded with a shell of detergent through a process known as micellar formation. This allows the micellar units to be ingested into the lining of the small intestine. In the absence of bile, fats would not be properly broken down to the
smallest units and would pass through to the large intestine, presenting a rich diet to the bacteria of the colon. This would result in the release of byproducts that cause diarrhea, abdominal pain, bloating etc. This was the case in the ill-fated attempt to use a nonabsorbable oil called Olestra in preparation of potato chips several years ago that resulted in diarrhea after eating the chips. The synthetic form of CCK is used to study the function of the gallbladder in a test called a CCK HIDA scan. The test looks for abnormal gallbladder function and problems with the bile duct opening, also known as sphincter of Oddi dysfunction. Gastric Inhibitory Peptide also known as GIP. This hormone is a member of the secretin family and has a motor effect to decrease stomach emptying, slowing the digestive process, allowing chemical digestion to proceed at an acceptable rate in the small intestine. This exertion of control is why it takes three or four hours for most meals to empty the stomach. This hormone is also involved in the stimulation of the production of insulin in response to food entering the duodenum, particularly proteins and carbohydrates. Insulin allows the cells of the body to take in sugar absorbed into the bloodstream through the lining of the small intestine. Insulin is absent in Type 1 diabetes. In Type 2 diabetes, the cells are resistant to insulin.
This basically completes the process of digestion. The nutrients from our pizza have now been broken down mechanically and enzymatically and absorbed.
on a regular basis. Unfortunately, people who actually need medication are concerned about taking it and the people who don't need it, eat it like M&Ms.
What Happens to the Stomach Acid

The secretin causes stimulation of sodium bicarbonate production in the pancreas, which flows into the third portion of the duodenum and neutralizes the stomach acid. After mixing of stomach acid with pancreatic juices, the resulting mixture is neutral pH and therefore does not cause injury to the rest of the small intestine. The neutralization of acid involves the following basic equation from chemistry.
HCL+ NaHCO3 yields NaCL + H2CO3

So What Does This Have To Do with Acid Reflux
Quickly reverting to salt and water and carbon dioxide. We have discussed acid reflux, but we haven't talked about everything else that can reflux. All of the enzymes and bile are capable of refluxing from the duodenum into the stomach and from the stomach into the esophagus. This type of reflux is not covered by antacid medication and there is some data to suggest that the proton pump inhibitors might actually facilitate reflux of bile and digestive enzymes. It is even speculated that bile may play a significant role in the production of the precancerous transformation of the esophagus known as Barrett's esophagus. It is important therefore to consider the entire digestive process in esophageal reflux disease. Bile will not respond to antacid medication, but can respond to alginic acid also known as Gaviscon liquid over-the-counter, which is worth a try in patients who are not responding to acid suppression, or have taken acid suppression with good results and are now having breakthrough symptoms.
The Importance of Stomach Acid

Stomach acid occurs naturally and is responsible for some very important functions. These include:
The already mentioned assistance with uncoiling of larger molecules for exposure to enzyme activity. The conversion of iron and calcium into a form the body can absorb in the first portion of the duodenum. This is a pH-dependent phenomenon meaning that in the absence of acid, calcium and iron cannot be rendered into the appropriate absorbable form, resulting in problems with anemia or osteoporosis. Stomach acid kills most bacteria, allowing for a sterile small intestine. A small intestine full of bacteria, competes with our body for nutrient absorption producing harmful metabolites that can lead to problems with bloating, gas, and diarrhea-a condition known as bacterial overgrowth. This lack of acid can also lead to increased susceptibility to more pathogenic bacteria such as Salmonella, Vibrio, and Clostridium Difficile. Activation of digestive enzymes.
I am frequently asked about all the problems of acid suppression in terms of taking long-term proton pump therapy such as Prilosec. These medications are grossly overused. If they are needed they should be taken and we will deal with the possible associated risk. If they are not needed they should not be used
Differentiating Acid Reflux from Bile Reflux Acid is sour like lemon juice but bile is bitter like green herbs. Acid responds to proton pump inhibitor therapy. Failure to respond to acid therapy should lead to consideration of the possibility of bile reflux. Treatment with proton pump inhibitor that is no longer responsive, should likewise trigger consideration of bile reflux. Food triggers acid production. When the stomach is empty there is no acid therefore if you are awakening in the middle of the night or have not eaten for many hours but are having reflux it may well be bile. How Does the Stomach Protect Itself
We have discussed the harsh chemical environment in the digestive system, particularly in the stomach. It is not magic that the stomach does not digest itself. The stomach produces a 7 micron thick layer (about the thickness of a bacteria) of mucus and bicarbonate. This completely protects the stomach lining from acid and enzymes. We have problems
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when something happens to prevent or eliminate this barrier, some examples of which are:
Aspirin and nonsteroidals are famous for producing stomach ulcers. They do not directly ulcerate the stomach lining but they block inflammation in the body by blocking a biochemical pathway called the cyclooxygenase pathway. Unfortunately, there is a biochemical crossover, as one of the resulting products is responsible for the production of this mucus and bicarbonate slime that covers and protects the stomach lining. Blocking this production of slime, allows the acid and digestive enzymes to come into contact with the stomach lining creating ulcers or significant inflammation known as gastritis. Helicobacter pylori infection. This bacteria gets a lot of press because of its role in ulcer development and its role in cancer development. It causes ulcers because
it produces an enzyme called urease that breaks down the mucus and bicarbonate protective slime allowing injury to occur. It is very important to know that the presence of H. pylori in the stomach actually suppresses acid production. Eradication of the bacteria will result in worsening of acid reflux rather than improving it. Bile Is a Detergent. It does not belong in the stomach. The anatomy and physiology of the human body tries its best to prevent that. As a detergent, it easily washes away the protective slime allowing damage to occur and also probably washes away a similar protective mucous lining in the esophagus allowing injury to the cells. Where Do We Go from Here
The piece of pizza we started with is now chemicals and a small amount of waste. We will deal with the waste in later issues. Until then, Bon Appetit. -Steve Porter, MD
Grumbling Guts?
Understanding Irritable Bowel Syndrome
ost of us feel some discomfort in our guts from time to time. It may be because were nervous about something, or perhaps we ate something that didnt agree with us. But if you regularly feel aches in your abdomen, it might be a sign of a disorder called irritable bowel syndrome. Irritable bowel syndrome affects about 1 in 5 Americans. It occurs more often in women than men, and begins before the age of 35 in about half the people who get it. Theres no medical test to identify irritable bowel syndrome. Instead, doctors make a diagnosis based on the patients symptoms. The most common symptoms include bloating and pain in the abdomen, along with changes in bowel habits. People with irritable bowel syndrome may have constipation, diarrhea or both. Irritable bowel syndrome doesnt lead to cancer or other health problems. But its discomfort can be difficult to live with. The severe or frequent abdominal pain it can bring often leads people to visit a doctor. Physicians and researchers dont know for sure what causes irritable bowel syndrome. One possibility is that it comes from changes in the way that the brain and the gut communicate. Dr. Emeran Mayer at the University of California, Los Angeles, is an NIHfunded scientist whos working to find treatments to correct altered brain-gut interactions. Most people would agree that stress plays an important role in triggering symptom flares in irritable bowel syndrome, says Mayer. Many patients first notice symptoms after a stressful event, like losing a loved one or changing jobs. People with irritable bowel syndrome often report higher levels of stress or anxiety. Stress reduction strategies and cognitive behavioral therapy, a type of talk therapy, can help relieve the symptoms of irritable bowel syndrome. Some researchers suspect that irritable bowel syndrome can be caused by a change in gut bacteria. The gut is usually filled with helpful bacteria, which our bodies need to digest food. But sometimes the types of bacteria can change, like after taking certain medications. For people with this type of irritable bowel syndrome, a supplement of probioticsa collection of live, healthful bacteria might help. Probiotics are available as capsules, tablets
Signs of Irritable Bowel Syndrome Bloating Distension and discomfort of the abdomen Abdominal pain Constipation Diarrhea
and powders, and theyre found in some dairy foods, such as yogurts with live active cultures. The potential benefits of probiotics, however, are still under study. Many people with irritable bowel syndrome find that certain foods can make them feel worse. There is no specific irritable bowel syndrome diet, says Mayer. Irritable bowel syndrome patients are generally more sensitive to a variety of foods. If you have irritable bowel syndrome, try keeping a diary of the foods you eat and how they make you feel. Then, you and your doctor can decide together if you should try making changes to your diet. Every case of irritable bowel syndrome is unique, so if you have symptoms that disrupt your life, dont suffer in silence. Your doctor can work with you to find the treatment that works best for you. -Source: NIH News in Health, February 2012, Published by the National Institutes of Health and the Department of Health and Human Services. For more information go to www.newsinhealth.nih.gov
Boys Get Eating Disorders, Too

In Young Boys, Eating Disorders May Look Like Picky Eating
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Warning signs Potential triggers
hen teen-age girls get eating disorders, they often declare themselves to be "fat." But when young boys develop eating disorders, they do not usually use words.
Ensuring good nutrition

If young boys want to become vegetarian, "take them to a registered dietitian so they can learn to be a healthy vegetarian," says Dr. Rome. "They need to know how much tofu or other non-meat protein it will take to make up the protein they formerly got in meat." She also suggests that children with a sudden diet change be checked for physical problems that may be causing pain when they eat, such as irritable bowel disease. "Also, remember that reducing food intake can cause painful gastric slowdowns and constipation, further reducing a childs desire to eat," she says. Treatment usually requires a team approach involving a dietitian, a pediatrician or adolescent medicine expert and a therapist to coach parents on forging new eating patterns. "Look for professionals who are experienced in disordered eating in children," notes Dr. Rome.
"They may become extremely picky eaters and the list of foods they will eat grows smaller and smaller," says Ellen Rome, MD, a Cleveland Clinic expert in adolescent medicine. "They may avoid many foods and may even gag on some things." One strong warning sign is when a child suddenly cuts entire food groups out of his diet, such as declaring himself to be a vegetarian. When this starts to happen, parents must be alert to additional symptoms such as failure to gain weight or grow, she says. "With girls, the cessation of menstrual periods is often a red flag. That is obviously missing in boys, but older boys may notice a decreased libido, Dr. Rome says. She adds that this is a detail they are not likely to share with family or friends. Many things can trigger eating disorders in young boys. The most common is being teased about their weight, especially at home. "This leads to low selfesteem, which puts them at even greater risk for obesity and eating disorders," Dr. Rome says. Stresses such as parental divorce, sexual abuse or a general fear of growing up can contribute to an eating disorder as well.
Underlying problems
She adds that "in kids under 12, eating disorders may just be the tip of the iceberg. Younger boys and girls are more likely than older patients with eating disorders to have an underlying anxiety disorder, depression or obsessive-compulsive disorder." Concerned parents should get help from a pediatric psychologist or psychiatrist, because these disorders respond very well to treatment once they are recognized. -This information provided courtesy of Cleveland Clinic Heath.
Family Life
I
nfertility is a common, yet complex, problem affecting approximately 15 percent of couples trying to have a baby. Too often, blame for the inability to conceive is placed on the women when in reality, men and women share the burden equally. In up to 50 percent of infertile couples, the problem is partly related to male reproductive issues. Fortunately, with today's high-tech procedures and powerful medications, a diagnosis of infertility means the road to parenthood will be challenging but not impossible. After another non-productive year, their OB/GYN referred the couple to an Infertility Specialist. The McClearys OB/GYN is a very good physician, but recognized he didnt have the proper training nor equipment necessary to help the couple. He knew all about womens health and delivering babies, but making babies was an entirely different discipline. He did the right thing in referring the couple to someone he thought could help. While their hopes were high, the results were not. Unfortunately, they then spent another 3 years visiting several other specialists who could not provide the care they needed. Insurance hassles and continued unsuccessful treatments led to much disappointment.
The Emotional Road To
Infertility clinics in the United States using Assisted Reproductive Technology (ART) reported the success of 61,426 infants in 2008. This is about 1% of all babies born each year nationally.
Many of those who suffer from infertility describe overcoming the disease is like riding an emotional roller coaster. Cassee and Patrick McClearys story exemplifies this well. Cassee and Patrick decided to have a baby in 2002, but after a year of trying and no luck, they began the emotional trek of exploring infertility options. The first stop was their family OB/GYN. Under his care, Patrick had surgery and Cassee had a few procedures.
There were so many roadblocks at almost every turn, Cassee said. But we werent going to give up. We werent going to back down.
In Patricks mind the worst frustration was the suboptimal quality of care they received. Patrick works for a major pharmaceutical company and knows the practice of medicine well. They were looking for a physician and clinic that would
demonstrate the same care and passion that they have in their quest to become parents.
Patrick said, We often talk about medical care, but the element of care was noticeably absent in most practices. We want to feel good about our doctor. We even visited a major University and walked away. The lack of individualized care and concern was a major turnoff.
Cassee and Patrick felt they lost five valuable years. They were determined to experience the joy of bringing a new life into the world, but they also realized they had to be more cautious and do a little more homework. They didnt give up. After talking to friends, other doctors and anyone who listen, they somehow found information about my clinics in Boise, Idaho and Pleasant Grove, Utah. I met the McClearys in 2007 and it was obvious from the start that they were determined, yet cautious. They were educated, patient and had gone through a great deal in their quest for pregnancy. I learned they had been thorough in their research and had been to a number of treatment centers. Having suffered personally from infertility, I believe that infertility puts a couple in an emotional state that, quite frankly, requires an emotional connection with their doctor. Patrick was obvious in his frustration when he said: Dr. Foulks office was different. It seemed he and the staff were passionate about what they did and we felt like we were their only patients. I give a lot of credit to Patrick who recognized, through testing, that he was a major part of the problem. Looking back on the issue, he explains the problem with a smile, most sperm are active little swimmers looking for an egg to impregnate, and my swimmers ended up being the lazy kind who simply laid at the bottom of the pool. Infertility is treatable--virtually every cause can be overcome to help every couple have a baby of their own. The most common cause of infertility problems are ovulation defects and male factors. Couples must understand why they can not get pregnant and have a plan to overcome it. They should begin with the easiest step and understand exactly why any treatment is not successful. It is crucial to identify the problem, then treat it proactively each month. Many people become frustrated and quit if they dont get the right kind of help.
Infertility treatment is affordable. Most couples can achieve pregnancy with minimal and affordable treatments. Too often, unwary couples get pushed into treatments that are not best for them or do ineffective treatments that waste their time and money.
Less than 10% of infertile couples need the expensive high tech treatments like IVF.
Infertility is an emotional burden. The best way to cope is to understand the dysfunction, know all the options and then develop a plan that is realistic and based on the ones history and needs. After five years of frustration, the McClearys took a pragmatic approach and the roller coaster eased into a smoother road. For the McClearys, after we identified the problem, the solution was easy and effective. They were undaunted in their quest and the results were beautiful. Cassee gave birth to the couples first baby in 2008. Recently, the couple came to me again and we were able to produce a second pregnancy. This time, Cassee gave birth to twins at the end of April this year. Happily, Cassee and Patrick will tell you that marriage and kids go together. In spite of all the trials and tribulations the couple went through, the end result has been three healthy children. They will tell you it was a fun, yet often trying, experience. Evidently the journey with my staff was more enjoyable than I had realized. Cassee referred her 40-year-old sister and another cousin to me, both who are now pregnant and happily expecting their first children. -Russell A. Foulk, MD
We are meant to have children; there is always a reason why we can not. The key is to know the reason and overcome it.
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Update: Patrick and Cassee McCleary have been spreading the word about Dr. Foulks ability to give hope to families who have been through the difficulty of infertility.
Among those the McClearys have referred Dr. Foulk have been Cassees sister Andrea and brother in-law Brian. The Stahelis were blessed with twin boys this past January.
The McClearys also referred Patricks cousins, Kristin and Jeremy Colter to Dr. Foulk. This past March, Kristin had twins as well a boy and a girl.
With the McClearys three children and the four children born to cousins and in-laws, Dr. Foulk is credited with helping bring seven new McCleary family members into the world. There is hope.
When Eating Goes to Extremes

The Excesses of Eating Disorders
ith summer just around the corner, we see constant reminders about getting in shape for swimsuit season. Magazines offer annual tips for slimming down. Pencil-thin models show us the bodies we cant possibly achieve. We may feel inspired to shed a few pounds, but most of us dont take these media messages too seriously. For the small minority of people with eating disorders, however, the relentless pursuit of an ideal body can have dire or even deadly consequences. Scientists had long believed that eating disorders were primarily triggered by cultural pressures or psychology. But over the past decade, theres been a real revolution in thinking about the factors that lead to eating disorders, says Dr. Cynthia Bulik, director of the Eating Disorders Program at the University of North Carolina at Chapel Hill. We now have evidence of the substantial role that genes can play. People who are genetically vulnerable may be more susceptible to cultural cues. They may start extreme dieting or binge eating. That could lead them down the path to an eating disorder, says Bulik. The result is that, when faced with a full-length mirror, people with eating disorders take self-criticism to extremes. They excessively focus on body weight and shape. They have an out-of-control urge to eat either far too much or far too little. Accurate data on the number of people with eating disorders has been scarce. Earlier this year, however, Harvard scientists reported results of the first nationally representative study of eating disorders in the U.S. They found that, overall, 4.5% of adults, or over 9 million people, have struggled with eating disorders at some point
in their lives. The study also found a surprisingly high number of men with eating disorders (see Statistics box). Eating disorders are complex conditions. The three most widely recognized are anorexia nervosa, bulimia nervosa and binge-eating disorder. Anorexia nervosa is the least common but most deadly of the three. People with this disorder become dangerously thin, often by severely limiting their food intake, exercising excessively or using selfinduced vomiting, laxatives or other
purging techniques. Malnourishment may lead to osteoporosis and anemia. Women lose their menstrual periods. People with bulimia nervosa are often normal weight. They feel an uncontrollable urge to eat large amounts of food, or binge eat. Then they compensate by purging, fasting or exercising too much. Dr. Susan Z. Yanovski, director of NIHs Obesity and Eating Disorders Program, says, Bulimia nervosa can cause a lot of medical problems, such as heart irregularities and difficulties with the digestive system. Selfinduced vomiting can wear away tooth enamel. The third disorder, binge-eating disorder, also involves frequent episodes of binge eating, but without the compensatory behaviors seen with bulimia nervosa. As you can imagine, Yanovski says, if you frequently eat large amounts of calories without compensating in other ways, youll gain weight. Thats why bingeeating disorder is often associated with obesity. And with obesity comes an increased risk for diabetes, stroke, heart disease and certain cancers. Binge-eating disorder, unlike anorexia nervosa and bulimia nervosa, is not officially recognized as a psychiatric disorder. But the Harvard study found that bingeeating disorder is by far the most common of the three, affecting
nearly 3% of the population. In contrast, anorexia nervosa affects 0.6% and bulimia nervosa 1%. Eating disorders are treatable, but better treatments are needed. Current therapies usually involve a combination of medical and psychological approaches. Doctors sometimes use antidepressants or other medications. But the only one approved by the U.S. Food and Drug Administration is fluoxetine (Prozac), for the treatment of bulimia nervosa. Yanovski and her colleagues hope to take a preventive approach to binge eating by spotting risky behaviors before a full-blown disorder and obesity develop. Yanovski explains, If we can identify kids who may not yet be obese but who have problems with loss-of-control eating, they may be in a high-risk group. Were looking at ways to intervene to prevent obesity as well as eating disorders. One path to improved therapies is a better understanding of the underlying genes and biology. Studies of families and twins provide strong evidence that genes contribute to all three major eating disorders. An international research team led by Dr. Walter Kaye, now at the University of California, San Diego has found regions of DNA that may hold genes associated with anorexia nervosa and bulimia nervosa. Their findings inspired a 5-year NIH-funded study to identify specific genes that influence anorexia nervosa risk in hundreds of U.S. families. The initial results are expected later this year. If you suspect someone you care about may have an eating disorder, Bulik says, the most important thing is to talk about it with them directly. In a firm
Know the Signs of Eating Disorders Anorexia Nervosa Refusing or unable to maintain at least 85% of normal body weight. Repeatedly checking body weight, carefully portioning foods and eating only very small quantities of only certain foods. Bulimia Nervosa Recurrent episodes of binge eating at least twice a week for 3 months. Going to extremes to compensate for eatingfor example, making yourself vomit or abusing laxatives. Binge-Eating Disorder Feeling out of control when eating a large amount of food, at least twice a week, for 6 months. Experiencing extreme distress about overeating.
but compassionate way, let them know that youre concerned about their wellbeing. Do whatever you can to get them in for an evaluation as soon as possible. Yanovski notes that most people with bulimia nervosa or binge-eating disorder will admit to their behaviors if asked directly. In contrast, those with anorexia nervosa often deny their symptoms. If you ask why theyre not eating, they may say theyre not hungry or theyve already eaten, Yanovski says.
If youre the parent of a child you suspect may have anorexia nervosa, dont hesitate to act. Given that anorexia nervosa has the highest death rate of any psychiatric illness, it always should be taken seriously, Bulik says. Never assume its a passing phase. -Source: NIH News in Health, May 2007, published by the National Institutes of Health and the Department of Health and Human Services. For more information go to www.newsinhealth.nih.gov
In a study of nearly 3,000 U.S. men and women, Harvard scientists found: Men account for 25% of Americans with anorexia or bulimia and 40% of those with binge-eating disorder. The median age of onset for eating disorders is 18-21 years. Eating disorders are often accompanied by other psychiatric conditions, like depression, drug abuse and anxiety disorders. Fewer than half of people with bulimia nervosa or binge-eating disorders have sought treatment for their condition.
Did you know... Nearly 10 million females and 1 million males in the U.S. are battling eating disorders such as anorexia and bulimia, while millions more suffer from binge eating disorder. The peak onset of eating disorders occurs during puberty and the late teen/early adult years, but symptoms can occur as young as kindergarten. More than one in three normal dieters progresses to pathological dieting.
h g u Thro n i h & T ick
h T
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recently received a book in the mailit was the first copy of my new book, a memoir of anorexia nervosa. I picked it up off the front door mat where it lay swaddled in brown cardboard like baby Jesus in a basket. When my husband came home and I unwrapped it and held it bare in my hands for the first time, I said, "It feels a bit thin! I expected it to be thicker." We both immediately recognized the irony in my statement, coming from the mouth of a recovered anorexic, and we laughed. Society accepts thicker books, "fatter" books, we call them tomes and consider them to be intelligently written, of value, containing substance. My book of 264 pages, however "thin" it feels, contains the weight of the decade of my Anorexia, which started at age fourteen and waned at age 24. I'm now 34 and ten years recovered. I was born and raised in Johannesburg, South Africa where I grew up in an all-female, diet-free, nutrition-filled eccentric, artistic household. I attended a private Jewish school where I belonged, miserably and involuntarily, to the "odd ones out" and not the "popularati." My parents had divorced, when I was nine, on our return to South Africa after a short, failed immigration to Israel and it was then that I suffered my first unofficial depression. I remember the feeling of being in a place (physical and emotional) that I didn't want to be and having absolutely no power to change it. I can tell from photographs of that time by the look on my face, my demeanour, the way my clothes sag on my sad childish frame that I had lost the happiness that I had suddenly discovered in Israel and there was no way out. On top of that my father moved out and my already precarious world ripped in two. I felt it rip. Suddenly we were a family of three sisters: my mother a young thirty-something woman, herself struggling with depression, my sister and me. On the periphery was my distant and emotionally unavailable father whom I wanted more than anything in the world to show me love. Over the years when the pain of being the pariah at school persisted, I wanted out. Out of the pain of feeling like the odd one out, the awkward one, the sad one. I decided at age fourteen after a humiliating incident at school to change schools and my life took a new turn.
I suddenly found myself popular at my new school a multi-racial (which in those days was unheard of in apartheid South Africa) Catholic, co-ed convent as different from my elite, all-white Jewish school as could be. I hooked up with a group of girlsmany of whom came from "dysfunctional" families, all of whom were teens on the verge of daunting womanhood, struggling to find their true identities, craving to fit in, to be loved and accepted by one another, wanted by the boys. In those days, however, there were no online sites dedicated to girl empowerment movements or self-esteem boosting organizations to which to belong as there are now. The girls in my clique only had each other to rely on, to turn to in crisis and we were all stuck in the same boat of teenage naivety and the insatiable desire to belong. It was at the convent that I first heard about dieting. And within months I latched onto this once utterly foreign concept and was unexpectedly on a sudden mission of weighing myself and on a downward spiral of weight loss that caused amenorrhea, depression as well as a high, an illusory sense of control, and focused my attention on something other than my daily stress and my inner turmoil. Nine months later, I should have been hospitalized but the doctors in those days wouldnt have known what for. I didn't know what Anorexia was, nor did I know anyone who was anorexic. Growing up in South Africa, I wasn't inundated with Hollywood "thin" extravaganza and Anorexia was nowhere to be found in the media. That was 1991. An almost (unbelievable) twenty years ago and yet that so-called teenage "diet" set the stage for the rest of my life. Soon enough I became a reclusive, defiant, angry, aggressive, unhappy teenager. I started to lie, steal, sleep around and drink in secret pursuit of some unattainable escape, all the while conspiring with an invisible entityAnorexia that had overtaken my life, my being and was becoming me or me Her. Yet she remained nameless.
For six years I lived in denial of my disorder. I refused to label it or define it although I knew there was a problem. I knew my starving was all-consuming. But I didn't believe (like others thought) that my intention was to starve to death. I know it wasn't. Instead, starving, for me, was an act of survival. In my mind, I honestly believed that Anorexia was the only thing protecting me. Anorexia became my identity. Years later, after moving to Israel after high school and being recruited to the Israeli army (a decision Anorexia agreed to on my behalf), I returned to South Africa and my mother, who had not seen me in months, took one long at me and realized the severity of my situation. After six years of watching me waste away and being powerless to stop it, she managed to track down someone in the field of eating disorders to speak to me. For some obscure reason, I agreed. That man, in one conversation, broke my denial and a few months later while actively pursuing a dead-end career in raving and doing drugs, I had an epiphany that woke me up to the reality that my sense of self, "I" was being lost to Anorexia. And from there, I knew that if I crossed the line, there would be no return. I realized that if I didnt stop starving, I would experience something worse than death. "I", my sense of self, would die forever. Yet I would be alive, for a little while, to realize it. Shani Raviv
It took another three years of reckless behavior and debilitating confusion before I finally, after ten years, and some serendipitous happenings, made the conscious decision to want to be well. However, I didn't think it meant letting Anorexia go, as though she meant nothing. I just knew that I could no longer hold on. After ten years of fighting the disorder alone, almost every day, believing I had the will power to stop it, while paradoxically "feeding" it with my starvation, I finally gave in. I surrendered. That was the start of a long, emotionally excruciating and exhausting recovery. It was the start of my journey back to my true self. My story is not a misery memoir, it's not a to-helland-back story, it's strangely enough a wild ride that I am lucky to have survived. I am lucky to have had the undying support of my amazing, loving family who believed in me every step of the way and incredible therapists and nutritionists who supported my recovery. I could never have done it alone. Especially valuable was the support group I attended for years where girls and women with eating disorders gathered to share their stories. It was there that someone planted the seed for me to share mine. That was in 2002, the year that I started writing being Ana, which is ultimately a story about one girl's search for her Self, through thick and thin. I wrote being Ana to share what I learned about this complex and controversial disorderAnorexia. I hope that it inspires readers to find compassion for their loved ones and friends suffering from Anorexia, and maybe that it encourages sufferers to want to find a way out. Because there is a way outa clear-cut, albeit painful and messy, way out. But the journey out requires tenacity, courage and endurance, which I believe every Anorexic has. Rabbi Nachman, who lived in the eighteenth century, once said, "If you believe you can spoil, then believe that you can repair." He also believed that the purpose of sharing one's story, one's dark secrets with others is to take a weight off the soul as part of the healing process. On that note, it is also my hope that readers of this Story of Hope or of my book will walk away with the will to want to share their own stories so they can lead lives in which they are true to themselves. Shani Raviv worked as a freelance writer in South Africa. She currently lives in Seattle where she is marketing her book, being Ana: a memoir of anorexia nervosa, leading creative writing workshops, practicing yoga, hiking and camping in rainforests and volunteering at NEDA where she is working on outreach for NEDA Awareness Week 2011. Visit her website: www.shaniraviv.com -This story is reprinted courtesy of the National Eating Disorders Association.
www.NationalEatingDisorders.org Toll-free Helpline: 800-931-2237

Bring
Help Hope
sponsored by the National Institutes of Health (NIH), which is testing two oral medications, clomiphene citrate (Clomid) and letrozole (Femara), to determine which is the most effective in inducing ovulation and enhancing fertility in women who have irregular cycles, dont ovulate regularly, or exhibit signs of hormone imbalance. Were thrilled to be part of this group, Bates says. There is no other center in the Southeast participating, and we think its a great way
Fertility Advances and
ometimes it takes a little science to help fulfill a dream. At least thats what it often feels like for people who turn to UABs Division of Reproductive Endocrinology and Infertility for answers, help, and hope.
Now more of those dreams are coming true. In less than 10 years, UABs success rate for in vitro fertilization (IVF) has more than doubled. Division director G. Wright Bates, M.D., credits much of the success to refinements in IVF techniques. We have come a long way in treatment cycles, he says. Back in 2002, less than one in four women with a good prognosis got pregnant within a month. Now we often exceed 50 percent in a month with IVF. He adds that increased awareness of infertility issues and more widespread information on potential solutionsalso has helped educate the public and encouraged more patients to learn about their options.
Increasing the Chances

Today, the division, which provides individualized care to both women and men, continues to investigate new advances in fertility treatment that will increase the chances of conceiving and carrying healthy babies. One avenue of research is the multicenter PCOS-II Trial,
for us to improve our treatment options, and better serve the women of Alabama. The trial covers basic fertility testing for both women and men and provides four months of treatment. Patients interested in enrolling in the trial can call study coordinator Susan Mason at (205) 801-8207 for more information and a phone screening. Another revolutionary development, Bates says, is preimplantation genetic screening, which examines embryos for disease and potential developmental problems. This doesnt mean designer babies, or choosing hair color and eye color, Bates explains. Were talking about ensuring a normal chromosomal number and avoiding major developmental issues to enhance the chances of producing a normal, healthy offspring. Bates is quick to underscore the divisions emphasis on healthy pregnancies. UAB is committed to avoiding high-order multiplestriplets or morethat can pose a threat to both the woman and the fetuses, he says.
parenthood. And both women and men can benefit from a variety of fertility preservation techniques, Bates says, including banking sperm, eggs, embryos, or an ovary before cancer treatment begins. The newest and most experimental of these techniques is ovarian tissue cryopreservation, in which a womans ovary is harvested and frozen. Following successful cancer treatment, the frozen tissue is transplanted back to the remaining ovary in the womans body. While only about two dozen pregnancies worldwide have resulted from this technique, Bates says that it is particularly promising for women and young girls for whom reproduction may not be a priority now, but who may want children in the future. Bates adds that the majority of patients who have sought information regarding fertility preservation prior to cancer treatment have chosen to not pursue fertility preservation or use traditional IVF with embryo freezing, with only a small number pursuing egg or ovarian tissue banking. However, it is very important to note that simply having the options discussed and their questions addressed may allay some common fears about cancer treatment, he explains. We want to help people go from surviving cancer to surviving parenthood, Bates says.
Fertility After Cancer

Beyond assisting couples who are struggling to conceive, Bates and his colleague Janet McLaren, M.D., are focusing on ways to help cancer patients who have concerns about their future reproductive capabilities. UAB is participating in the National Physician Cooperative and Oncofertility Consortium, an NIH program working to develop techniques to improve the reproductive prospects of people who have undergone treatments such as chemotherapy or radiation that can be detrimental to fertility. As treatments for cancer have improved, survival has become more commonplace. People are going on to live full lives, and for many of them, that includes having children, Bates says. A very successful solution for these patients, he notes, is fertility restoration, in which donated eggs or sperm allow couples who are infertile from treatment to experience pregnancy and
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Infertility Common Causes
Some common causes of infertility include: Male Infertility

Infertility in couples is not always confined to the woman. In fact, research data suggests that nearly half of all infertile couples have a male component. When facing infertility, a male semen analysis is one of the most important tests that a couple can have, and should be completed early in the infertility evaluation.
There are several complex processes that must occur in order for you to become pregnant and carry a baby to term. Disruption of any of these processes can lead to infertility. The physicians in UABs infertility program are specially-equipped to diagnose the cause of infertility and begin treatment to help you and your partner get pregnant.
Ovulatory Disorders
There are numerous conditions that can lead to irregular or absent ovulation. Treatments for ovulatory disorders seek to correct the underlying cause and/or stimulate ovulation. This is usually accomplished by correcting any behaviors associated with the disorder and by prescription drugs.
Polycystic Ovarian Disease (PCOS)

PCOS, also known as polycystic ovarian disease (PCOD), is a common cause of infertility in women. PCOS is characterized by a cluster of symptoms that are seen in most women who have the syndrome.
Endometriosis
Endometriosis occurs when cells that line the uterus (endometrium) attach to organs such as the ovaries and intestine. Endometriosis is a common cause of infertility and is often accompanied by severe menstrual cramps, painful bowel movements or urination, pain during intercourse, and pelvic pain. Endometriosis may cause no pain yet still cause infertility.
Recurrent Miscarriage
Approximately 15 percent of pregnancies end between week four and week 20 in miscarriage, also known as spontaneous abortion. Spontaneous abortion means the pregnancy ends due to natural causes, versus surgical or medical. Recurrent miscarriage is defined as three or more consecutive spontaneous abortions. Recurrent miscarriage in fertility patients is especially tragic because they have often undergone months of fertility treatment to achieve pregnancy.
Cervical Factor Infertility

Cervical Factor Infertility can occur when the mucus lining the cervix is too thick, therefore impeding the mans sperm from progressing past the cervix. It can also occur when a woman produces antibodies that attack and kill the sperm before it can enter the cervix. Intrauterine insemination (IUI) is often the first line treatment for cervical factor infertility.
Tubal Factor Infertility

Tubal disease occurs when conditions, such as endometriosis, cause damage to the tubes. Scarring from endometriosis can constrict and damage the tubes. Pelvic inflammatory disease can create scarring of the tubes and other internal organs. In rare cases, some women are born with only one, or no, fallopian tubes. Some women also want to have previous tubal sterilization reversed because of changes in their life situations.
Uterine Factor Infertility

Several disorders of the uterus may cause infertility. Large polyps, fibroids, or scar tissue may obstruct the uterus. In most instances, times these conditions can be corrected by hysteroscopic surgery. Some women are born with congenital abnormalities of the uterus including conditions such as the unicornuate uterus (half uterus) and uterine septum (vertical barrier inside uterus). Uterine abnormalities can be diagnosed by hysterosalpingogram, ultrasound, sonohystogram, MRI, or hysteroscopy with laparoscopy. -This information provided courtesy of the University of Alabama at Birmingham Medicine
Female Age and Infertility

Advancing age, which is ultimately accompanied by reduced ovarian reserve, is a common cause of infertility. As eggs age they lose their capacity to fertilize and develop, which results in low estrogen levels and irregular or no ovulation. If you are in your thirties, are having regular intercourse and are not pregnant after 6-12 months, you are strongly urged to seek care from a reproductive endocrinologist. Our specialists conduct a thorough diagnostic evaluation and rapidly implement the treatments most likely to result in pregnancy.
Unexplained Infertility
First level treatment of unexplained infertility may involve stimulated IUI. If this is not successful, many patients become candidates for in vitro fertilization. In many cases, intracytoplasmic sperm injection or assisted hatching will also be employed.
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Identifying
Parkinson's Disease
New Imaging Test Give Physicians a Better Tool to Diagnose Parkinson's Disease
hanks to a new diagnostic imaging technique, physicians now have an objective test to evaluate patients for parkinsonian syndromes, such as Parkinsons disease. Northwestern Memorial Hospital is among the first institutions in the country to offer DaTscan, the only FDA-approved imaging agent for assessment of movement disorders. Until now, there were no definitive tests to identify the disease, forcing physicians to rely on clinical examinations to make a diagnosis. This technology allows doctors to differentiate Parkinsons from other movement disorders. The scan by itself does not make the diagnosis of Parkinsons but it allows us to identify patients who have loss of dopamine, the major chemical responsible for the symptoms, from those who have no dopamine deficiency, said Tanya Simuni, MD, a neurologist at Northwestern Memorial and director of Northwesterns Parkinsons Disease and Movement Disorders Center. This is a very important step in being able to accurately identify and treat movement disorders and hopefully allow us to better understand these diseases over time. Parkinsons disease is a neurodegenerative disorder that afflicts nearly 1.5 million Americans, with an additional 50,000 to 60,000 new cases identified each year. People with Parkinsons lack dopamine in the brain, which leads to tremor, slowness of movement, muscle stiffness and balance problems. Clinical examinations, particularly early in the disease when symptoms are slight, can be inconclusive or lead to misdiagnosis of another movement disorder, such as essential tremor, which share similar symptoms to Parkinsons, but require different treatment. Developed by GE Healthcare, DaTscan is a substance used to detect the presence of dopamine transporters (DaT) in the brain. A patient is injected with the contrast agent and then undergoes a
single-photon emission computed tomography (SPECT) scan. The test captures detailed pictures of the brains dopamine system and can provide visual evidence of the presence of dopamine transporters. Scans of patients with Parkinsons disease or another parkinsonian syndrome will show very low dopamine levels. A SPECT scan examines brain function, rather than structure, and can show change in the brains chemistry. In Parkinsons patients the brains anatomy remains largely normal, unlike other conditions such as stroke, where damage to the brain is visible, explained Simuni, who is also an associate professor of neurology at Northwestern University Feinberg School of Medicine. DaTscan attaches to dopamine neurons which illuminate on the SPECT scan; the more light areas that exist, the more healthy dopamine brain cells remain. If the areas of the brain that should show dopamine remain dark, it may indicate the patient has some type of parkinsonian syndrome. An accurate clinical diagnosis for patients with neurodegenerative
movement disorders, such as Parkinsons, can take up to six years. While symptoms often mimic Parkinsons, other movement disorders, such as essential tremor, occur in different areas of the brain and do not involve the dopamine system. Even though they may appear similar, other movement disorders require different management. DaTscan allows us to confirm our diagnosis earlier and start the correct course of treatment sooner, said Simuni. We are hopeful that this will lead to improved quality of life for these patients with better long term outcomes, as well as protection from unnecessary treatments initiated because of misdiagnosis. While Simuni does not believe it is necessary for every patient to confirm their Parkinsons diagnosis with DaTscan, she does see it as a valuable tool for patients with uncertain syndromes, or those who have not responded to treatment. She also sees it as a means for improving Parkinsons research by ensuring those enrolled in studies actually have the disease. DaTscan is already being used by the Michael J. Fox Foundation for its landmark biomarkers study, the Parkinsons Progression Markers Initiative (PPMI), to validate that the subjects have Parkinsons disease. Northwestern is one of the 14 U.S. medical centers enrolling for the PPMI, which is among the first clinical trials using DaTscan in this way.
Currently, we are not able to say with certainty that those enrolled in Parkinsons studies have the disease, said Simuni. With the addition of DaTscan, we can be much more confident in the status of research subjects in both the control and experimental groups. By having a better understanding of these populations, we should be able to have clearer outcomes and hopefully that will translate sooner into treatments and eventually a cure. Researchers are also hopeful that DaTscan will prove to be useful in following the progression of Parkinsons throughout a patients lifetime. The disease is clinically measured at certain points of time to help physicians understand its development, said Simuni. A lot of questions about how Parkinsons disease progresses can be answered if DaTscan is able to show us changes in the brains chemistry over time. Northwesterns Parkinsons Disease and Movement Disorders Center is the only National Parkinson Foundation Center of Excellence in Illinois. The center provides innovative, multidisciplinary care, while also conducting research to extend knowledge and treatment of movement disorders. There is an emphasis on education and support for patients, families, caregivers, healthcare providers and the community. For more information, visit Northwesterns Parkinsons Disease and Movement Disorders Centers at www.parkinsons.northwestern.edu -This information provided courtesy of Northwestern Memorial Hospital
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Partial Hearing Loss and the Hybrid Cochlear Implant

The hybrid cochlear implant works in the same way as traditional cochlear implants, stimulating nerve endings in the cochlear so that high-pitched sounds can be heard. In addition, it also involves amplification for low-pitched sounds, similar to a hearing aid. Like traditional cochlear implants, the hybrid version is worn outside the ear and converts sounds into acoustic and electric signals. The surgical implantation of cochlear devices is typically done on an outpatient basis, and usually with non-serious complications, aside from mild discomfort following surgery, said Northwestern Medicine otolaryngologist Alan Micco, MD, coinvestigator of the study and chief of otology/neurotology at the Feinberg School of Medicine. A few weeks following surgery, the activation process and fine-tuning take place to determine what audio thresholds work best for the individual, and sounds can usually be perceived shortly thereafter. Post-activation evaluations take place at three, six and 12 months following the initial activation process to assess progress of the cochlear implant. An audiologist will also test the implant to determine if participants are able to understand words, sentences in noisy and quiet environments, as well as experience music recognition. A few months post-surgery, Groves is happy to have some of his hearing restored. Im very excited and encouraged by my experience with the implant. I know Im hearing better than I have for many, many years, and for that Im very grateful. -This information provided courtesy of Northwestern Memorial Hospital
earing loss can affect anyone at any time. But it can be especially frightening for someone who suddenly starts to lose hearing during adulthood. Tom Groves, 77, first noticed his diminishing hearing when he was in his early 40s. He was unable to hold conversations with large groups of people, found it nearly impossible to socialize in high-background noise environments like restaurants. and couldnt enjoy radio, TV and movies unless they were captioned. Now, Groves is hearing much better than he has in 30 years, thanks to an experimental hybrid cochlear implant. Northwestern Memorial Hospital is one of nine centers in the U.S., and the only in Illinois, that is participating in a study investigating the effectiveness of a new cochlear implant device that aims to restore hearing for individuals with high-frequency hearing loss and functional low-frequency hearing. This group of patients doesnt meet the criteria for conventional cochlear implants because they have near perfect residual hearing in low pitches that allows them to perform well on tests used to determine candidacy for traditional implants. However, their hearing in high pitches is so poor that a hearing aid is not helpful, making them ideally suited for the hybrid implant, which addresses both issues. We are hopeful that the hybrid cochlear implant will provide a subset of people who were previously not candidates for an implantable device the opportunity to test the device to determine if they can experience
sound again, said Northwestern Medicine neurotologist Andrew Fishman, MD, principal investigator of the study, staff in the departments of otolaryngology and neurosurgery at Northwestern Universitys Feinberg School of Medicine, and Mr. Groves cochlear implant surgeon. The potential for patients with a significant amount of residual hearing, but a large amount of high-frequency hearing loss, to have an alternative to hearing aids would be a great improvement over what is currently available. Cochlear implants were FDA approved in 1984 as a treatment option for restoring hearing in people with severe and profound hearing loss. The surgical implant system is designed to stimulate the auditory nerve by bypassing damaged parts of the ear. A small battery-operated mini computer and microphone are worn on the outside of the ear and convert sounds into electric signals. The signals are then transmitted to implant electrodes in the cochlea, which stimulate the nerve endings so sound can be perceived by the brain.
"Brain Pacemaker" -Bringing Hope to Parkinson's Patients
tudies have shown that a "brain pacemaker" called deep brain stimulation (DBS) is an effective treatment for Parkinson's disease.
But there's been debate over what region of the brain to stimulate -the globus pallidus interna or the subthalamic nucleus. Now, a major study published in the June 3, 2010 New England Journal of Medicine is showing that stimulating either region resulted in similar improvements in motor function. There were small differences in non-motor effects such as mood and cognitive function. "Both targets in the brain are viable for improving motor function. This is great news for patients," said Frances Weaver, PhD, of Edward Hines Jr. VA Hospital and Loyola University Health System. Weaver, one of the study's lead investigators, is a professor and director of the Program in Health Research at Loyola University Chicago Stritch School of Medicine and director of the Center for Management of Complex Chronic Care at Hines VA Hospital. DBS is a treatment for Parkinson's patients who no longer benefit from drugs, or who experience unacceptable side effects. DBS is not a cure, and it does not stop the disease from progressing. But in the right patients, DBS can significantly improve symptoms, especially tremors. DBS also can relieve muscle rigidity that causes decreased range of motion. "DBS increases the percentage of time that a patient is functional," said
Loyola neurosurgeon Dr. Douglas Anderson, who has an active practice in DBS and movement disorders. "It also improves a patient's ability to move arms or legs in a more coordinated fashion. And there is a lessening of bradykinesia [slowness of motion]." Anderson is a professor in the Department of Neurological Surgery. In the DBS procedure, a neurosurgeon drills a dime-size hole in the skull and inserts an electrode about 4 inches into the brain. A connecting wire from the electrode runs under the skin to a battery implanted near the collarbone. The electrode delivers mild electrical signals that effectively reorganize the brain's electrical impulses. The procedure can be done on one or both sides of the brain. Weaver was first author of a pivotal 2009 study, published in the Journal of the American Medical Association, which found that DBS was more effective than medications in treating patients with advanced Parkinson's disease. The new study included 299 Parkinson's disease patients at 7 VA and 6 university hospitals. Patients were randomly assigned to receive DBS in either the globus pallidus interna or subthalamic nucleus. While there were no significant differences in motor function, researchers did find differences in other areas. Patients who received
subthalamic stimulation required lower doses of L-dopa medications. But the subthalamic group also had slower visuomotor speed, which measures how quickly a patient thinks and acts on information. Also, depression got worse in the subthalamic group, but lessoned in the pallidal group. "Based on the findings of this study, we expect that doctors will consider factors other than motor function when deciding what region of the brain to target," Weaver said. In addition to Weaver, the study was led by first author Dr. Kenneth Follett of the University of Nebraska Medical Center and Dr. Matthew Stern of the University of Pennsylvania and Philadelphia VA Medical Center. It was funded by the Department of Veterans Affairs, the National Institute of Neurological Disorders and Stroke and Medtronic Neurological, which makes DBS systems. -This information provided courtesy of Loyola University Health System.
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HealthWatchMD
with Dr. Randy Martin
Provided courtesy of Piedmont Healthcare
Arthritis
One in four people suffer from this painful condition
Dr. Randy Martin: Lately it seems like almost everyone has or at least knows someone who has arthritis. According to a recent report, we may not be far off base nearly 25 percent of Americans suffer from some form of arthritis. To learn more, I met with Dr. William McClatchey, a rheumatologist at Piedmont Hospital.
he Centers for Disease Control and Prevention reported in 2010 that two out of every nine Americans have arthritis (approximately 50 million people), making it one of the leading causes of disability in the country. But what exactly is arthritis? William McClatchey, M.D., a boardcertified internist and rheumatologist at Piedmont Hospital, says that arthritis refers to a symptom, not a diagnosis. He adds that it is important to distinguish between osteoarthritis and rheumatoid arthritis. It makes a big difference in terms of treatment and prognosis, he says. Osteoarthritis is the most common type of this condition. It is a term that describes the same process as degenerative arthritis, he says. An Increasingly Common Condition Its a huge problem, Dr. McClatchey says. Clearly, the obesity epidemic affecting Americans today has a tremendous impact [on the increase in cases of osteoarthritis]. Proper care and treatment of your body is crucial, he says, comparing the aging process to car maintenance. If [you are] 65 years old, [its like having] 65,000 miles on your tires, he explains. If youve gone licketysplit around a lot of curves, youre
going to have more trouble than if youve gone at a low speed. Osteoarthritis typically occurs in the weight-bearing joints, such as the lower back, hips and knees, as well as in the hands. Common symptoms include pain after engaging in moderate physical activity and crepitus, which is a creaking in the joints caused by cartilage irregularity. To treat osteoarthritis without surgery, the first thing we do is make the accurate diagnosis and exclude other forms of arthritis (such as rheumatoid arthritis), says Dr. McClatchey. Beyond that, [we recommend] antiinflammatory medication. These medications are really good at helping people with comfort level, pain and functionality. There are also lifestyle changes you can make to improve your arthritis symptoms, such as weight loss and even though it sounds counterintuitive exercise. Its really not [counterintuitive], he explains. Exercise to maintain range of motion in the affected joints is really important, with one caveat: avoid [high]-impact exercises. If you are concerned that you may have arthritis, Dr. McClatchey recommends talking with your primary care physician first. For people who have more difficulty and need help, rheumatologists are here, he says. Thats what we do.
Dr. Randy Martin: If you experience joint pain, talk with your primary care doctor to determine if you suffer from a form of arthritis. To prevent joint damage in the first place, maintain a healthy weight and stay active to maintain range of motion in your joints.
The Nutritional Gatekeeper and the Solution
72%
I cant control what my kids eat!
Ive heard this from: a mother who was eating a bicycle wheel-sized pepperoni and sausage pizza in Rochester, NY a father who was eating cheese fries with Ranch dressing outside of Green Bay, WI. two parents eating a bucket of fried calamari with sun-warmed tarter sauce on the boardwalk in Santa Cruz, CA
All of them were eating with their kids. Actually, all of them were controlling what their kids ate. But just not for the better.
y Food and Brand Lab at Cornell University did a study on Nutritional Gatekeepers. These are the critical people who purchase and prepare most of the food their family eats at home. Id bet youre that person, or you wouldnt be reading this magazine. We studied over 400 Nutritional Gatekeepers in the US and Canada. One discovery was that the average Nutritional Gatekeeper even if they claimed to be a terrible I-cant-boil-water cook controlled 72% of what their family ate. This was for better or worse.
making me reconsider this 30 year old habit. Every time I have a can in my hand, my two and four year old daughters grab for it saying, Sip of pop, sip of pop. Im 100% sure they dont ask for a Diet Coke or Pepsi if Im not around. I cant control what my kids eat. It was for better if they had a fruit bowl in the kitchen out instead of a cookie dish. It was for worse if they ate at a restaurant and ordered BBQ ribs and white bread instead of going to a place that served something green. It was for the better if they packed their kid a school snack pack of some carrots, crackers, and a cheese stick instead of waving 2 bucks at them and saying Buy what you want. What if they dont take a plum from the fruit bowl, or they dont order a salad, or they dont eat their snack pack. Well, chalk that up to the 28% we dont control. At least you have them a healthy option they wouldnt have otherwise considered. Herein lies the power of the Nutritional Gatekeeper. Its not in being a perfect cook, its in giving kids an option and modeling this. If we want our little gooblets to eat better, the first place to start is with us. If we dont have cut-up fruit in baggies in the fridge, they probably wont ask for it. If we dont order lean meat and vegetables, they wont either. If were eating a duffle bag of chips while watching the Biggest Loser, why shouldnt they? Because Im not a coffee drinker, one of my indulgences is Diet Coke and Diet Pepsi. I drink one before breakfast every day - Gross, is what youre thinking. I dont think its gross, but heres whats
We control what our kids eat more than we think its just going to be for the better or the worst. -Brian Wansink, PhD. Cornell Food and Brand Lab.
nearly doubles survival in majority of patients
New melanoma drug
nvestigators from Vanderbilt-Ingram Cancer Center (VICC) and 12 other centers in the United States and Australia have found that a new drug for patients with metastatic melanoma nearly doubled median overall survival.
referred to VICC for mutation testing. Her tumor was BRAF-positive and after more than a year on the drug, the wife and mother from New Site, Miss., says her scans are clear and there is no visible evidence of disease. This treatment has been an answer to my prayer, said Johnson. The majority of patients had at least one adverse event related to the drug, but most of these were minor. The most common side effects were joint pain, rash, sun sensitivity, fatigue and hair loss. More than a quarter of the patients (26 percent) also developed cutaneous squamous-cell carcinomas a less serious form of skin cancer - which were surgically removed. A Phase III trial of this same drug confirmed significant improvement in both progression-free survival and overall survival with vemurafenib over chemotherapy in an interim analysis. The Phase II study is the first to confirm the durability of the response. While the clinical trials for vemurafenib have been positive to date, the great majority of patients eventually experience disease progression. We are trying to determine what is causing this drug resistance and are searching for new therapies that we can use, perhaps in combination with vemurafenib, said Sosman. -This information provided courtesy of Vanderbilt University Medical Center
More than half of patients who were treated with the novel drug vemurafenib, known commercially as Zelboraf, responded to treatment and experienced an impressive median overall survival of nearly 16 months far longer than the typical survival of just six to 10 months for most patients whose melanoma has spread beyond the initial tumor site. Results from the Phase 2 trial, led by co-principal investigators Jeffrey Sosman, M.D., director of the Melanoma Program and co-leader of the Signal Transduction Program at VICC, and Antoni Ribas, M.D., professor of Hematology/Oncology at UCLAs Jonsson Comprehensive Cancer Center, were published in the Feb. 23 issue of the peerreviewed New England Journal of Medicine. This study confirms what we have discovered in our earlier trials. Many of our patients are exhibiting a strong, immediate response to this drug and some are living significantly longer, with manageable side effects, said Sosman, professor of Medicine at Vanderbilt University Medical Center. It was interesting to note that a few of the patients were treated with the drug for up to six months before showing convincing evidence of response. This study shows that Zelboraf changes the natural history of the disease, said Ribas. These results tell us that this drug is having a very big impact, and this changes the way we treat metastatic melanoma. Approximately half of all patients with metastatic melanoma the most deadly form of skin cancer have a BRAF V600 mutation in their tumor. Vemurafenib is an FDA-approved oral drug which works as a kinase inhibitor of the BRAF V600 mutation. While vemurafenib induced clinical responses in a significant number of BRAF-positive patients when it was approved last year, the initial clinical trials had not followed patients long enough to determine overall survival. A total of 132 patients with stage IV, BRAF-positive melanoma were enrolled in the Phase II trial. All of the patients had received at least one form of systemic treatment before enrollment in the trial. Forty-seven percent of patients had a partial response to the drug and six percent exhibited a complete response, for an overall response rate of 53 percent. Debra Johnsons melanoma had already spread to one of her lungs and her lymphatic system when she was
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Osteoporosis
Get The Facts
A
QWhat is osteoporosis?
Osteoporosis (OS-teeoh-poh-ROH-sis) is a disease of the bones. People with osteoporosis have bones that are weak and break easily. A broken bone can really affect your life. It can cause severe pain and disability. It can make it harder to do daily tasks on your own, such as walking.
What bones does osteoporosis affect?
Osteoporosis affects all bones in the body. However, breaks are most common in the hip, wrist, and spine, also called vertebrae (VUR-tuh-bray). Vertebrae support your body, helping you to stand and sit up. See the picture below. Osteoporosis in the vertebrae can cause serious problems for women. A fracture in this area occurs from day-to-day activities like climbing stairs, lifting objects, or bending forward. Signs of osteoporosis:
Sloping shoulders Curve in the back Height loss Back pain Hunched posture Protruding abdomen
What increases my chances of getting osteoporosis?
There are several risk factors that raise your chances of developing osteoporosis. Some of these factors are things you can control, while some you cant control.
Factors that you cant control: Being female Getting older Menopause Having a small, thin body (under 127 pounds) Having a family history of osteoporosis Being white or Asian, but African American women and Latinas are also at risk Not getting your period (if you should be getting it) Having a disorder that increases your risk of getting osteoporosis, (such as rheumatoid arthritis, type 1 diabetes, premature menopause, anorexia nervosa) Not getting enough exercise Long-term use of certain medicines, including: o Glucocorticoids (GLOO-koh-KORti-koids) medicines used to treat many illnesses, including arthritis, asthma, and lupus o Some antiseizure medicines o Gonadotropin (GOH-nad-ooTROO-pin) -releasing hormone used to treat endometriosis (en-doh-mee-tree-O-sis) o Antacids with aluminum the aluminum blocks calcium absorption o Some cancer treatments o Too much replacement thyroid hormone
Factors you can control:

Smoking Drinking too much alcohol. Experts recommend no more than 1 drink a day for women. A diet low in dairy products or other sources of calcium and vitamin D Not getting enough exercise You may also develop symptoms that are warning signs for osteoporosis. If you develop the following, you should talk to your doctor about any tests or treatment you many need: Loss in height, developing a slumped or hunched posture, or onset of sudden unexplained back pain. You are over age 45 or a postmenopausal and you break a bone.
can I find out if QHow I have weak bones?
There are tests you can get to find out your bone density. This is related to how strong or fragile your bones are. One test is called dual-energy X-ray absorptiometry (DXA or dexa). A DXA scan takes X-rays of your bones. Screening tools also can be used to predict the risk of having low bone density or breaking a bone. Talk with your doctor or nurse about this test or tools to assess risk.
doctor will consider factors such as:
Your age and whether you have reached menopause Your height and weight Whether you smoke Your daily alcohol use Whether your mother or father has broken a hip Medicines you use Whether you have a disorder that increases your risk of getting osteoporosis
1. Get enough calcium each day.

Bones contain a lot of calcium. It is important to get enough calcium in your diet. You can get calcium through foods and/or calcium pills, which you can get at the grocery store or drug store. Getting calcium through food is definitely better since the food provides other nutrients that keep you healthy. Talk with your doctor or nurse before taking calcium pills to see which kind is best for you. Taking more calcium pills than recommended doesn't improve your bone health. So, try to reach these goals through a combination of food and supplements. Heres how much calcium you need each day.
When should I get a bone density test?
can I prevent QHow weak bones?
If you are age 65 or older, you should get a bone density test to screen for osteoporosis. If you are younger than 65 and have risk factors for osteoporosis, ask your doctor or nurse if you need a bone density test before age 65. Bone density testing is recommended for older women whose risk of breaking a bone is the same or greater than that of a 65-year-old white woman with no risk factors other than age. To find out your fracture risk and whether you need early bone density testing, your
The best way to prevent weak bones is to work on building strong ones. No matter how old you are, it is never too late to start. Building strong bones during childhood and the teen years is one of the best ways to keep from getting osteoporosis later. As you get older, your bones dont make new bone fast enough to keep up with the bone loss. And after menopause, bone loss happens more quickly. But there are steps you can take to slow the natural bone loss with aging and to prevent your bones from becoming weak and brittle.
Daily calcium requirements Ages Milligrams(mg) per day 9-18 1,300 19-50 1,000 51 and older 1,200 Pregnant or nursing women need the same amount of calcium as other women of the same age.
Here are some foods to help you get the calcium you need. Check the food labels for more information.
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Foods containing calcium Food Portion Milligrams Plain, fat free yogurt 1 cup 452 Milk (fat-free) 1 cup 306 Milk (1 percent low-fat) 1 cup 290 Tofu with added calcium 1/2 cup 253 Spinach, frozen 1/2 cup 146 White beans, canned 1/2 cup 106 The calcium amounts of these foods are taken from the United States Department of Agricultures Dietary Guidelines for Americans. 2. Get enough vitamin D each day.
It is also important to get enough vitamin D, which helps your body absorb calcium from the food you eat. Vitamin D is produced in your skin when it is exposed to sunlight. You need 10 to 15 minutes of sunlight to the hands, arms, and face, two to three times a week to make enough vitamin D. The amount of time depends on how sensitive your skin is to light. It also depends on your use of sunscreen, your skin color, and the amount of pollution in the air. You can also get vitamin D by eating foods, such as milk, or by taking vitamin pills. Vitamin D taken in the diet by food or pills is measured in international units (IU). Look at the pill bottle or food label for the IU amount. Heres how much vitamin D you need each day:
Do weight-bearing physical activity, which is any activity in which your body works against gravity. There are many things you can do:
Walk Dance Run Climb stairs Garden Jog Hike Play tennis Lift weights Yoga Tai chi 5. Dont smoke.
Smoking raises your chances of getting osteoporosis. It harms your bones and lowers the amount of estrogen in your body. Estrogen is a hormone made by your body that can help slow bone loss.
6. Drink alcohol moderately.

If you drink, dont drink more than one alcoholic drink per day. Alcohol can make it harder for your body to use the calcium you take in. And, importantly, too much at one time can affect your balance and lead to falls.
7. Make your home safe.

Reduce your chances of falling by making your home safer. Use a rubber bath mat in the shower or tub. Keep your floors free from clutter. Remove throw rugs that may cause you to trip. Make sure you have grab bars in the bath or shower.
Daily vitamin D requirements Ages IU per day 19-70 600 71+ 800
Although its difficult to get enough vitamin D through food, here are some foods that can help. Check the food labels for more information.
8. Think about taking medicines to prevent or treat bone loss.

Talk with your doctor or nurse about the risks and benefits of medicines for bone loss.
Foods containing vitamin D Food Salmon, cooked Milk, vitamin D fortified Egg (vitamin D is in the yolk)
Portion 3 1/2 oz 1 cup 1 whole
IU 360 98 20
These foods and IU counts are from the National Institutes of Health Office on Dietary Supplements. White milk is a good source of vitamin D, most yogurts are not.
A
Q
How can I help my daughter have strong bones?
3. Eat a healthy diet.

Other nutrients (like vitamin K, vitamin C, magnesium, and zinc, as well as protein) help build strong bones too. Milk has many of these nutrients. So do foods like lean meat, fish, green leafy vegetables, and oranges.
Act now to help her build strong bones to last a lifetime. Girls ages 9-18 are in their critical bonebuilding years. Best Bones Forever! is a national education effort to encourage girls ages 9-14 to eat more foods with calcium and vitamin D and get more physical activity. There is also a website for the parents . This site gives parents the tools and information they need to help their daughters build strong bones during the critical window of bone growth ages 9-18.
4. Get moving.
Being active helps your bones by:
What if dairy foods make me sick or I don't like to eat them? How can I get enough calcium?
Slowing bone loss Improving muscle strength Helping your balance

If youre lactose intolerant, it can be hard to get enough calcium. Lactose is the sugar that is found in dairy products like milk. Lactose intolerance means your body has a hard
time digesting foods that contain lactose. You may have symptoms like gas, bloating, stomach cramps, diarrhea, and nausea. Lactose intolerance can start at any age but often starts when you get older. Lactose-reduced and lactose-free products are sold in food stores. Theres a great variety, including milk, cheese, and ice cream. You can also take pills or liquids before eating dairy foods to help you digest them. You can buy these pills at the grocery store or drug store. Please note: If you have symptoms of lactose intolerance, see your doctor or nurse. These symptoms could also be from a different, more serious illness. People who are lactose intolerant or who are vegans (eat only plant-based foods) can choose from other food sources of calcium, including canned salmon with bones, sardines, Chinese cabbage, bok choy, kale, collard greens, turnip greens, mustard greens, broccoli, and calcium-fortified orange juice. Some cereals also have calcium added. You can also take calcium pills. Talk to your doctor or nurse first to see which one is best for you.
How is osteoporosis treated?
If you have osteoporosis, you may need to make some lifestyle changes and also take medicine to prevent future fractures. A calcium-rich diet, daily exercise, and drug therapy are all treatment options. These different types of drugs are approved for the treatment or prevention of osteoporosis: Bisphosphonates (bis-fos-fo-nates) Bisphosphonates are approved for both prevention and treatment of postmenopausal osteoporosis. Drugs in this group also can treat bone loss, and in some cases, can help build bone mass. SERMs A class of drugs called estrogen agonists/ antagonists, commonly referred to as selective estrogen receptor modulators (SERMs) are approved for the prevention and treatment of postmenopausal osteoporosis. They help slow the rate of bone loss. Calcitonin (kal-si-TOE-nin) Calcitonin is a naturally occurring hormone that can help slow the rate of bone loss. Menopausal hormone therapy (MHT) These drugs, which are used to treat menopausal symptoms, also are used to prevent bone loss. But recent studies suggest that this might not be a good option for many women. The Food and Drug Administration (FDA) has made the following recommendations for taking MHT: Take the lowest possible dose of MHT for the shortest time to meet treatment goals. Talk about using other osteoporosis medications instead. Parathyroid hormone or teriparatide (terr-ih-PAR-a-tyd) Teriparatide is an injectable form of human parathyroid hormone. It helps the body build up new bone faster than the old bone is broken down. Your doctor can tell you what treatments might work best for you. -This information provided courtesy of the US Department of Health and Human Services, office on Women's Health www.womenshealth.gov
Q Q
A A
Do men get osteoporosis?
Yes. In the U.S., over two million men have osteoporosis. Men over age 50 are at greater risk. So, keep an eye on the men in your life, especially if they are over 70 or have broken any bones.
How will pregnancy affect my bones?
To grow strong bones, a baby needs a lot of calcium. The baby gets his or her calcium from what you eat (or the supplements you take). In some cases, if a pregnant woman isnt getting enough calcium, she may lose a little from her bones, making them less strong. So, pregnant women should make sure they are getting the recommended amounts of calcium and vitamin D. Talk to your doctor about how much you should be getting.
I suffer bone loss QWill during breastfeeding?
Although bone density can be lost during breastfeeding, this loss tends to be temporary. Several studies have shown that when women have bone loss during breastfeeding, they recover full bone density within six months after weaning.
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Steer Children Clear of Lawn Mower Injuries

National Medical Societies' Safety Tips Help Kids Avoid Becoming a Statistic
A
s the school year draws to a close, thousands of children across the country will take on a familiar chore: mowing the lawn. June is National Home Safety Month and five national medical organizations are warning Americans that the routine task of lawn mowing can be extremely dangerous to children, the operator, and those nearby if proper safety precautions aren't taken. Sadly, 253,000 people were treated for lawn mower-related injuries in 2010, nearly 17,000 of them children under age 19, the U.S. Consumer Product Safety Commission reports. Lawn mower-related injuries are up 3 percent since 2009. "Lawn mower injuries to children are easily preventable," said ASRM President Keith Brandt, MD. "Children
should remain inside the house or under the direct supervision of another adult, whenever a lawn mower is being used. If no other adult is available, create a danger zone of 20 feet around the mower. Shut down immediately if anyone enters the danger zone." To help prevent injuries, the American Society for Reconstructive Microsurgery (ASRM), American Society of Plastic Surgeons (ASPS), American Society of Maxillofacial Surgeons (ASMS), American Academy of Pediatrics (AAP), and American Academy of Orthopaedic Surgeons (AAOS) are educating adults and children about the importance of lawn mower safety. "The ASMS is a proud partner in the coalition for lawn mower injury prevention," said ASMS President Steven Buchman, MD. "The significant number of devastating injuries that occur to both children and adults can be life changing events." Many lawn mower-related injuries require a team of physicians from various specialties to properly repair them. Often, patients must endure painful reconstructive operations for months, sometimes years, to restore form and function. "I've seen broken and dislocated bones, deep cuts, missing fingers and toes, limb amputations, burns, and eye
injuries from lawn mower accidents," said ASPS President Phillip Haeck, MD. "The best way to treat a lawn mower-related injury is to prevent it." "I cannot stress the importance of operating a lawn mower properly. The dangers are very real, but very preventable," said AAOS President Daniel J. Berry, MD. "Always remember to wear sturdy shoes never sandals - when mowing and make sure your children are at a safe distance and that they don't operate a mower until they are old enough to control the machine."
Lawn mowers can be a cause of serious eye injury. This year the AAP Section on Ophthalmology has added the following to its safety tips: Children in the vicinity of running lawn mowers should wear polycarbonate protective eye wear at all times. "Every year at this time, it is common to see children operating or playing around lawn mowers in unsafe ways. And every summer, thousands get hurt," said AAP President O. Marion Burton, MD, FAAP. "We want parents and kids to be more aware of precautions to take so that injuries can be prevented." To help educate the public, the ASRM, ASPS, and ASMS offer a video, "When Lawn Mowers Attack," with tips on how to avoid injuries. -This information (originally released 6/01/2011) provided courtesy of The American Society of Plastic Surgeons
Lawn mower injury prevention tips include: Children should be at least 12 years old before they operate any lawn mower, and at least 16 years old for a ride-on mower. Children should never be passengers on ride-on mowers. Always wear sturdy shoes while mowing - not sandals. Young children should be at a safe distance from the area you are mowing. Pick up stones, toys and debris from the lawn to prevent injuries from flying objects. Use a mower with a control that stops it from moving forward if the handle is released. Never pull backward or mow in reverse unless absolutely necessary - carefully look for others behind you when you do. Always wear eye and hearing protection.
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SUNSCREEN: LOOKING BEYOND THE NUMBERS
eems pretty obvious if a sunscreen with an SPF of 30 is good, then an SPF of 100 should be at least three times as good. Unfortunately, that is not the case. There are other important details to consider when you are purchasing a sunscreen.
contain the ingredients necessary to offer protection against sunburn, but not skin cancer or aging. Recently, the Food and Drug Administration created new regulations to establish standards for sunscreen manufacturers to follow before they label their products. Under the new regulations, which will go into effect in 2012, sunscreen products that protect against all types of sun-induced skin damage will be labeled broad spectrum and SPF 15 or higher on the container. Only products that have been tested to ensure they protect against both UVA (ultraviolet radiation A) and UVB (ultraviolet radiation B) radiation will be allowed to use this labeling. Broad-spectrum sunscreens of SPF
People have become much more educated about the importance of using sunscreen, and manufacturers have responded with an abundance of products, says Carl Washington, MD, associate professor of Dermatology at Emory University School of Medicine. Unfortunately, the labeling can be confusing and many of the current sunscreens only
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15 and higher can also be labeled as protective against skin cancer and premature aging. The maximum SPF value is set at 50-plus because the FDA says anything higher doesnt provide a significant amount of additional protection. Manufacturers will have to include warning labels on products that are not broad spectrum. Products that claim to be water resistant must indicate how long the consumer should expect to be protected in the water, and using such language as waterproof or sweat proof will not be allowed. Skin cancer is the most common form of cancer in the United States, and the number of people affected keeps rising. Simply getting into the habit of using a sunscreen every day with the appropriate levels of protection can make a significant difference in preventing many skin cancers, as well as premature aging, says Washington. These new regulations will help consumers understand the difference in degrees of sun protection, and choose carefully. Washington also suggests staying out of direct sunlight between 10 am and 2 pm, seeking shade when you are outdoors, remembering to reapply sunscreen every This two hours and wearing protective clothing. information provided courtesy of Emory Healthcare.
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Every breath tells a story
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Important note: NIOX instruments are medical devices regulated in the United States by the US Food and Drug Administration. Complete Labeling for our devices may be found at FDA.gov. The cleared Labeling is the nal authority for Indications, Directions for Use, Risks, Limitations, Performance, and other information. NIOX MINO, NIOX, and Aerocrine are registered trademarks of Aerocrine AB. 2012 Aerocrine Inc
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What Doctors Know - Vol 1 Issue 4

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What Doctors Know - Vol 1 Issue 4

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Science to Get

Fertility Advances Bring Help & Hope

THE MONSTER ISNT UNDER THE BED. ITS IN THE fRIDgE.

National Eating Disorders Association

On Call with Dr. Porter

Steve Porter, MD Publisher and Chairman

Special Thanks To:

10 Otoplasty for Outstanding Ears 12 Could Hearing Loss

14 The Answer is in All of Us

29 Flu, Cold or Virus 32 Acid Reflux: The

22 Heart Disease 24 Dont Let Your Allergies

Needed to Correct Acid Reflux

27 Luella Love: New Lungs

BELOW THE BELT

48 The Emotional Road

64 Brain Pacemaker Bringing

MIND, BODY, AND SOUL

56 Fertility Advances Bring Help & Hope

Fertility Advances Bring Help & Hope

Cover photography by Mark Seliger

Meet Our Doctors

Rosalynn CrawfordMcKendall, DDS

Brian Wansink, PhD

WHAT DOCTORS KNOW

LeGrand Belnap, MD, FACS

Jeffrey Kahn, MD, PhD

Hitting Sports Injuries

How to Handle My Child's Dental Emergencies

What should I do if my child has a toothache?

What should I think about if my child falls and breaks a tooth?

Permanent tooth knocked out:

Primary (Baby) broken tooth:

Permanent broken tooth:

Otoplasty for Outstanding Ears

Hearin g L Contrib oss u t Demen e to tia

" The Answer Is In All of Us"

ENTREPRENEURSHIP, ACCOUNTABILITY, EFFICIENCY

Photography by Mark Seliger

FOX TRIAL FINDER AND THE RESEARCH PARTICIPANT SHORTAGE

TEAM FOX AND THE COMMUNITY FOR A CURE

THE ANSWER IS IN ALL OF US

t a e r h t t u b , t n e r e f f i d First signs r men and women similar fo

Don't Let Your Bloom This Spring

How to control of allergic rhinitis

Dont accept disrupted quality of life because of allergic rhinitis.

Luella : New Lungs for a New

f Luella Love believed in lucky numbers, she would pick 11.

FLU, COLD OR VIRUS Questions & Myths Cleared Up

What time of year is flu typically at its peak? And why?

Tamiflu Q Does really work?

Is it too late to get a flu shot?

Acid Reflux The Burning Issue

What is Heartburn or Reflux?

How is Reflux Diagnosed?

The following foods are fine to eat:

Mineral water (neutralizes the acid) Most vegetables except fried

When Surgery is Needed to

Correct Acid Reflux

Once GERD is identified, a number of treatment options can be prescribed.

Laparoscopic (videoscopic) Procedure

What can I expect before and after the surgery?

How We Convert Food into Nutrition

Now the Pizza Is in the Stomach, Hallelujah!