For Breast Cancer - Early Detection is the Best Medicine

  

Susan Uhle, CNP
Richmond Surgical

Early detection is currently the cornerstone of the arsenal in the war against Breast Cancer.  This is accomplished through annual Mammographic Screening, and, at times, other imaging methods such as Ultrasound and Breast Magnetic Resonance Imaging (MRI). Combined with genetic screening, we look to identify signs of the disease early and improve the chances for a favorable patient outcome.

Screenings and tests tell us many things about a patient’s overall risk, and findings from Mammography can lead to Needle Biopsy, where results can range from benign, to benign but abnormal, to cancer.  These results dictate the next action, which may include surgery or closer surveillance.  The results also allow us to better stratify individual risks, and determine next steps for investigation or treatment.

There are many paths that further tests and detection can take. As an example, Christina undergoes a Screening Mammogram, leading to a Needle Biopsy; results show Atypical Ductal Hyperplasia (ADH), which is a benign lesion of the breast that indicates an increased risk of Breast Cancer.  Her risk of developing cancer is now known to be four times that of a woman her age without those findings.  There are certain measures she can take to decrease that risk, including lifestyle modification, surveillance, and chemoprevention (the use of natural, synthetic, or biologic substances to reverse, or prevent the development of cancer).

Family history plays a significant role in incidence of Breast Cancer, and there are individuals with a personal or family history, who should be further evaluated at the time of Mammography or during the office visit.  We know that a family history in a first degree relative (mother, sister, or daughter) confers an increased risk for development of Breast Cancer. 

There are many available options to pursue if unfavorable results are found after Mammography or other screening activities. If we find that there is a malignant tumor, and the Breast Cancer was one of several types (early onset, two separate Breast Cancers, Male Breast Cancer, Ovarian Cancer, Multi-Generational), we would consider whether there is an inherited mutation in the family. Although this is present in only 5 to 10% of individuals, the Breast and Ovarian Cancer risk is as high as 87% and 44%, respectively, in the patient’s lifetime, depending on many factors.

Fortunately, there are many options for treatment and future preventive activity. Preventive Mastectomy and removal of ovaries is the choice of many, but not all, women. This reduces the risk of Breast and Ovarian Cancer, but not to zero. This prevention, one form of risk management, was chosen by Angelina Jolie after she discovered she carries a mutated copy of the BRCA1 gene, with wide media coverage after the announcement. This is a personal decision, to be made with all facts in place and with information from a health care provider with extensive knowledge in this area. For those at a lesser risk, at the opposite end of the continuum, one would start with lifestyle changes and medication.

Because more data allows us to make informed decisions regarding the next steps in the path to prevention, early detection is the most important piece of the puzzle, and options have never been more readily available for preventive care.

For further inquiries about breast cancer and genetics, or to set up a consultation for breast health screening, contact Susan Uhle, CNP, of RichmondSurgical, at 804.285.9416.

The 39-Week Initiative - Redefining a Term Pregnancy

Courtney Legum-Wenk, DO
Commonwealth Ob/Gyn Specialists

Are you pregnant, or do you know someone who is pregnant? Is the final due date approaching? Do you ever wonder what this means, exactly?  Keep reading to learn what the final weeks of pregnancy really entail, and the optimal time to have a baby. In humans, singleton (one baby) pregnancy lasts, on average, 40 weeks, or 280 days from the first day of the last menstrual period, and this is how we determine the estimated due date. By comparison, elephants can be pregnant for up to 2 years!

Until recently, anyone between 37-42 weeks of pregnancy was considered “term” and safe to deliver. This conventional wisdom existed because it was believed that the outcomes for both the baby and the mother during this interval of time were uniform and good, or safe with few risks. However, a large amount of research has now shown this is not uniform during these five weeks, and great risks exist from both a maternal and neonatal standpoint. As a result, in 2012, a group of professional societies convened and redefined what exactly “term” means, and provided recommendations regarding delivering for medically indicated and non-medically indicated circumstances.  In addition, national initiatives now exist to decrease complications to babies and the mothers when delivery occurs too early without a medical reason.

In defining term pregnancy, it is now recommended to use the following: EARLY Term is between 37 weeks through the 38th week, FULL term is 39 weeks through the 40th week, LATE Term is 41 weeks up to the 42nd week, and POST term is greater than 42 weeks. These definitions are supported by The American College of Obstetricians and Gynecologists, The Society for Maternal Fetal Medicine, and many neonatal and pediatric societies as well.  These definitions are important because research shows that adverse neonatal outcomes, especially regarding respiratory issues, is the lowest among uncomplicated pregnancies delivered between 39 weeks of gestation and through the 40th week. Lung development continues into early childhood, and elective early term deliveries increase the incidence of Respiratory Distress Syndrome, ventilator use, infections such as Pneumonia, respiratory failure, NICU admissions, low blood sugar, decreased APGAR scores, and possibly infant mortality. Unless one enters labor naturally, or a medical reason exists for early term delivery, elective delivery prior to 39 weeks is discouraged.

What does all of this new data really mean for your pregnancy? Unless delivery is medically indicated before 39 weeks, including natural labor, elective deliveries before this gestational age should be discouraged and/or avoided, thus reducing the amount of elective inductions and unplanned cesarean sections.  Be prepared that the desire for delivery on or by a certain date, or because things are getting difficult and uncomfortable is not a reason to welcome your new bundle of joy early into this world. Following these updated recommendations should only contribute to a more successful and healthy delivery for both mother and baby, which is the outcome all involved providers desire.

One final issue to consider when examining the changing delivery landscape is the impact of insurance coverage. In this era, as new systems of coverage are defined, obstetrical care is changing. At the time of this article, at least one state Medicaid agency has stopped reimbursement for non-medically-indicated deliveries before 39 weeks. If there is a medical reason for you to be delivered, or you go into labor on your own, this does not apply to you. However, if neither of these requirements exist, you may be financially responsible for much more of your care than anticipated.  Although this currently only applies to one agency, out of many, it’s something to consider, and will ultimately affect health care providers, obstetrical practices, midwifery, and hospitals.

In conclusion, the last couple of weeks of pregnancy are exciting, but exhausting, and you really want to meet your new addition to the family. Yet, remember to be patient and think about the benefits of a little delay in meeting those ten tiny fingers and toes, if everything is progressing normally. We all want a healthy and beautiful outcome, and if your body is telling you that you need a little more time, take those last days to rest and relax.  Always communicate with your practitioner, and if there are medical conditions, which support recommendations to deliver, then be confident in the research governing such recommendations. When patients and health care providers are on the same team, it provides a positive delivery experience and better outcomes for all. 

For further inquiries about pregnancy, obstetrics, or general gynecology, contact Dr. Courtney Legum-Wenk of Commonwealth Ob/GynSpecialists at 804.285.8806.

Obesity – A Disease You Can Live Without

Gregory Schroder, MD, and Matthew Brengman, MD
Advanced Surgical Partners of Virginia

Obesity is a complex, misunderstood, and mistreated disease, and with over 30% of the United States adult population suffering from it, it has become the number one public health concern, according to the Centers for Disease Control. The World Health Organization defines Obesity as a disease in which excess fat is accumulated to an extent that health may be adversely affected. Measured by a person’s BMI (Body Mass Index), a person is diagnosed as Morbidly Obese when their BMI is over 40. This presents significant health risks as well as opens the door for co-morbid conditions such as Type 2 Diabetes, High Blood Pressure, Heart Disease, Asthma, and Obstructive Sleep Apnea, among others. Morbid Obesity is the second leading cause of preventable adult death in the United States, behind cigarette smoking.

There are two treatment methods for Morbid Obesity – medical and surgical. Medical management involves tactics such as a very low calorie diet, exercise, anti-obesity medications (appetite suppressants, fat absorption blockers, etc.), and behavior modification. These are all overseen by a physician or a medical professional, but do not have a very high long-term success rate. Surgical management of Morbid Obesity is intended to induce substantial, clinically significant weight loss that is sufficient to reduce obesity-related medical complications to acceptable levels. Options for bariatric (weight-loss) surgery include Adjustable Gastric Banding, Vertical Sleeve Gastrectomy, and Gastric Bypass procedures.

The benefits of bariatric surgery are many, and research continues to positively evolve on this topic. Bariatric surgery tames hunger, enabling patients to feel satisfied with small amounts of food. It helps to eliminate or prevent many medical problems, and improves mobility, energy, self-image, and the ability to lead an active life. When accompanied by sensible behavioral changes of prudent nutritional choices and regular exercise, bariatric surgery patients achieve and maintain greater than 50% of excess weight loss for ten years and longer.

Some impressive statistics regarding post-bariatric surgery outcomes include:

-          Type 2 Diabetes remission in 76.8% and significantly improved in 86% of patients.

-          Hypertension eliminated in 61.7% and significantly improved in 78.5% of patients.

-          High Cholesterol is reduced in more than 70% of patients.

-          Obstructive Sleep Apnea is eliminated in 85.7% of patients.

-          Joint Disease, Asthma, and Infertility are dramatically improved or resolved in patients.

-          Bariatric surgery patients, on average, lost between 62-75% of excess weight.

What makes someone a good candidate for bariatric surgery? Our patient selection criteria are based on National Institute for Health (NIH) and American Society for Metabolic and Bariatric Surgery (ASMBS) standards for consideration of weight loss surgery. Prospective patients will have tried and failed at non-surgical treatments for Severe and Morbid Obesity, have a BMI greater than 40 or greater than 35 with significant presenting co-morbidities. Patients must complete and comprehensive medical, psychological, and nutritional evaluation before surgery, and must be well-informed and show an understanding and acceptance of the operation’s benefits and risks. Most importantly, to ensure post-operative success, patients must be willing to commit to a long-term lifestyle focusing on physical, psychological, and nutritional healthy living. This is supported by long-term follow-up post-surgery.

When is bariatric surgery not the best option? Contraindications for bariatric surgery include cases where the procedure represents an unacceptable risk to the patient, the patient doesn’t understand or accept the risks and commitments that accompany such a life-changing procedure, there is active evidence of alcohol and/or drug abuse, the patient has untreated or unmanageable psychiatric disability, patients who have not tried non-surgical potentially effective treatments, and those with reversible endocrine disorders that can be the root cause of their Morbid Obesity or Metabolic Disease.

The bariatric surgery program at Advanced Surgical Partners of Virginia and Parham Doctors’ Hospital offers a comprehensive clinical approach to weight loss management for the morbidly obese. Our program has a full complement of resources for surgical weight loss to help provide every patient with personalized attention and compassionate care. Our continuum of care includes highly experienced weight loss surgeons who are trained in the latest minimally invasive surgical techniques, a caring and specially trained nursing and support staff, pre- and post-operative nutritional counseling, in-depth pre-operative dietary and behavioral modification education, an individualized plan of treatment and care to assure consistent and successful outcomes for patients, monthly support group meetings, and long-term follow-up with all of our patients.

For further inquiries about obesity, weight loss surgery, or metabolic disease, contact Drs. Matthew Brengman and Gregory Schroder at Advanced Surgical Partners of Virginia, at 804.360.0600.

Colorectal Cancer: What You Need to Know

  

Richard F. Carter, MD
Richmond Surgical

In 2014, about 143,000 people in the United States will be diagnosed with colorectal cancer, and it is estimated there will be 50,000 deaths. Common in both men and women, it carries an average lifetime risk of 5%. Most colorectal cancers develop slowly over several years, but with the implementation of effective screening, early detection is leading to better outcomes and better chances for a cure. The exact causes of colorectal cancer are unknown; however, research has shown that certain factors do indicate higher risk. These risk factors include being over age 50, colorectal polyps, family history, and certain genetic alterations.

Colorectal cancer is a disease in which cells in the colon or rectum become abnormal and divide without control, forming a mass called a tumor. Before a cancer develops, a growth of tissue usually begins as a non-cancerous polyp on the inner lining of the colon or rectum, which can ultimately develop into cancer.

The wall of the colon and rectum is made up of several layers. If cancer forms in a polyp, it can eventually grow into the wall of the colon or rectum. When cancer cells are in the wall, they can grow into blood vessels or lymph vessels. Once cancer cells spread into blood or lymph vessels, they can travel to nearby lymph nodes or other parts of the body, such as the liver. Physicians describe colorectal cancer by stage, or extent of the disease. The stage is based on whether the tumor has invaded nearby tissues, whether the cancer has spread and, if so, to what parts of the body.

Polyps may be small and produce few, if any, symptoms. Additionally in its early stage, colorectal cancer usually produces no symptoms. Some important warning signs include:

• Any notable change in bowel movement consistency or frequency.
• Dark or light blood in the stool or rectal bleeding.
• Abdominal discomfort or bloating.
• Unexplained fatigue, loss of appetitie, and/or weight loss.

Because symptoms may not be present in early stages, doctors recommend regular screening tests to help prevent colon cancer by identifying polyps before they become colon cancer. Treatment is more likely to be effective when the disease is found early. The choice of treatment depends mainly on the location of the tumor in the colon or rectum and the stage of the disease. Treatment for colorectal cancer may involve surgery, chemotherapy, biological therapy, radiation therapy, or some combination thereof. 

The U.S. Preventive Services Task Force (USPSTF) recommends regular screening for colorectal cancer using high-sensitivity fecal occult blood testing, sigmoidoscopy, or colonoscopy beginning at age 50 years and continuing until age 75 years. People at higher risk of developing colorectal cancer should begin screening at a younger age, and may need to be tested more frequently. The decision to be screened after age 75 should be made on an individual basis. To find polyps or early cancer, health care providers may suggest one or more tests for colorectal cancer screening:

• Flexible sigmoidoscopy every 5 years. Physicians use a flexible, lighted tube (sigmoidoscope) to look at the interior walls of the rectum and part of the colon.
• Colonoscopy every 10 years. Physicians use a flexible, lighted tube (colonoscope) to look at the interior walls of the rectum and the entire colon. During this procedure, samples of tissue may be collected for closer examination, or polyps may be removed.
• Double-contrast barium enema every 5 years. Patients are given an enema with a barium solution, and air is pumped into the rectum. Several x-ray pictures are taken of the colon and rectum, where polyps or tumors may present.
• CT colonography (virtual colonoscopy) every 5 years. This method is under investigation. Advanced CT scan of the colon and rectum that produces 2 and 3-dimensional images of the colon and rectum that allows a doctor to look for polyps or cancer. 
• Fecal occult blood test (FOBT) every year, checking for hidden blood in three consecutive stool samples.
• Digital rectal exam, often part of a routine physical examination.

For those with increased or high risk of colorectal cancer, screening should begin before age 50 and/or more frequently. Patients at higher risk include those with a personal history of colorectal cancer or adenomatous polyps, history of inflammatory bowel disease (ulcerative colitis or Crohn's disease), strong family history of colorectal cancer or polyps, or a known family history of a hereditary colorectal cancer syndrome (HNPCC or FAP).

While screening rates have increased in the U.S., not enough people are being screened still.  In 2009, only approximately 63% of adults aged 50–75 years were screened as recommended. While screening rates continue to rise in the U.S., 22 million people are still not up-to-date with colorectal cancer screening. Patients should talk to their doctor about when to begin screening for colorectal cancer.

For further inquiries about colon health or colorectal cancer, contact Richard Carter, MD, of Richmond Surgical at 804.285.9416.

The March for Babies: Infant Prematurity

Barbara Head, MD, and JT Christmas, MD
Commonwealth Perinatal Services

Over 4 million babies are born in the United States each year and unfortunately, 1 in 9 is delivered prematurely, prior to 37 weeks of pregnancy. Prematurity can be the result of either spontaneous preterm birth from spontaneous preterm labor or preterm premature rupture of the membranes. It can also be indicated because of serious maternal or fetal complications, such as fetal growth restriction, hypertension, uncontrolled diabetes, or preeclampsia. Regardless of the reason for delivery, prematurity has significant impact both in terms of potential life-long medical complications, including infant mortality, as well as profound impact on families and society.  Preterm birth is the leading cause of neurologic handicaps of childhood. Efforts have been underway for years to identify pregnancies at risk for preterm birth so that measures can be taken to avoid premature delivery.

Prematurity is a complex problem with no clear single pathway.  We are aware of many risk factors, including, but not limited to, enlargement of the uterus from multiple (twin, triplet, or more) pregnancy, conditions which cause increased amniotic fluid volume, a previous premature delivery, previous cervical surgery, uterine abnormalities and tobacco use. However, many pregnancies with these risk factors do not deliver prematurely; and many patients who deliver prematurely do not have any of these risk factors. In addition, ethnicity appears to play a role in preterm birth with an increased risk of preterm delivery in African American women regardless of their other risk factors.  Researchers have identified genetic differences in African American women which may contribute to this increased rate of preterm delivery.

Women with a history of prior preterm delivery are at particularly high risk for recurrence. Research studies have demonstrated that therapy with a hormone called progesterone can significantly decrease the risk of recurrent preterm birth in this group.  Beginning in the middle of the second trimester, patients with prior preterm deliveries may be offered progesterone to be continued through the term of the pregnancy. Additional research has shown that in women who have already delivered prematurely, as the cervix of the uterus thins out or shortens, the risk of premature delivery increases. In such pregnancies felt to be at the highest risk of preterm birth, glucocorticoids, a type of steroid, may be administered to enhance the maturity of the fetal lungs.  Studies both in the United States and Europe have shown that administering magnesium sulfate to women at risk of imminent preterm birth can help to decrease the risk of infant death or moderate to severe cerebral palsy.

Interestingly, multicenter research initially performed in and published by the Hospital Corporation of America revealed that a large number of babies admitted to the neonatal intensive care units (NICUs) were because of non-medically indicated deliveries prior to 39 weeks gestation. With the efforts of the March of Dimes, a nationwide initiative is under way to reduce the practice of elective delivery prior to 39 weeks, resulting in a significant decrease in NICU admission.

Unfortunately, the majority of babies delivered prematurely are not delivered to women at increased risk. Ongoing efforts in Maternal-Fetal Medicine are directed at appropriately identifying those pregnancies well before they present in active preterm labor. Ultrasound evaluation of cervical length in the mid-trimester has promise to identify such women. In women with a shortened cervix at mid-trimester, ultrasound therapy with vaginal progesterone has been shown in several studies to decrease preterm birth risk. Decreasing the risk of cervical surgery by immunizing women against human papilloma virus (HPV) and avoiding abnormal pap smears may significantly impact the preterm delivery rate in years to come. Public education regarding the ill effects of tobacco use in pregnancy, the impact of obesity on pregnancy outcomes, and the signs and symptoms of preterm birth may have a further role in decreasing infant prematurity rates.

The March of Dimes, now devoted to helping mothers have full term births and healthy babies, was originally established by Franklin D. Roosevelt to fight polio. Originally called the National Foundation for Infantile Paralysis, the organization’s original mission was accomplished when polio vaccines were developed by Jonas Salk, MD, and Albert Sabin, MD. After accomplishing this revolutionary mission, the March of Dimes shifted its focus to the prevention of birth defects and infant mortality. Since 2003, the Prematurity Campaign has been the hallmark of the March of Dimes, having raised awareness of prematurity locally, nationally, and internationally. Thanks to the efforts of the March of Dimes, the work of numerous researchers, and obstetric care providers in every community, the rate of prematurity has finally begun to decrease nationwide to a recently reported rate of 11.5%. All states have signed a pledge to continue work toward this goal by decreasing the number of uninsured women, decreasing the rate of smoking in pregnancy, increasing the use of progesterone in at-risk women, and decreasing unnecessary inductions and cesarean deliveries prior to 39 weeks.

For further inquiries about infant prematurity or high-risk pregnancy, contact JT Christmas, MD, or Barbara Head, MD, at Commonwealth Perinatal Services at 804.289.4972.

Training for a 10K While Staying Healthy and Avoiding Injury

Jonathan Wilson, DPT

HCA Virginia Sports Medicine

You just clicked the “submit” button on the website, your credit card was charged, and you get a confirmation on your screen: “Congratulations! Your Monument Avenue 10K Registration was Successful!” You are now either ecstatic, or terrified, and definitely aren’t worrying about your chances for injury.

Research shows that more than 50% of runners will incur an injury during training, and more than 1 out of every 5 runners will sustain a stress fracture. With a few simple suggestions, we can help your remaining weeks until Saturday, March 29th be filled with great runs, more smiles, and lack of injuries.

A 10K is a logical next step from a 5K, a good bridge towards longer races, and a wonderful way to get in shape and become healthier. Everyone is capable of running a successful 10K with a good program, including exercises and stretches. You will learn to listen to your body, and know when you are feeling tight, stiff, or sore. Running can be painful at times, but with proper training, can be quite enjoyable and fun.

There are many different types of 10K training plans; make sure to choose one that fits your goals and available time, whether you’re a beginner or an elite runner looking to shave precious seconds from your PR. To find a suitable plan, look online (Sports Backers is a great resource) or talk with a friend with running experience. Seek a program including a variety of distances, times, and paces. Mix up your route, so you don’t become bored. Running with a program is important, but basic preparatory warm-ups, exercises, and stretching are also key components to a successful injury-free training plan.

Dynamic warm-ups such as sidestepping, high-knees, and butt-kickers are an effective way to assess yourself before a run. Remember, these are warm up drills, so remained relaxed. You can also run your first mile, or first few minutes, at a slower pace before you ramp up to your goal pace. Although you should be comfortable with your pace during training, don’t fear picking it up and pushing yourself. Try to run once a week without a watch, just to listen to your body. We become very focused on pace and metrics, and easily forget that the most important indicator of how we’re doing is how we feel. If you feel great – pick it up and go for it. If you feel tired or tight, use that run to focus on relaxing your stride and loosening your muscles.

If you have time, try to find a nice grassy field, and complete some easy barefoot striders, reminding yourself how it feels to get your feet dirty and act like a kid again. It is nearly impossible to do this without a smile on your face. One word of caution – if you choose a soccer field or any other maintained area, watch out for hidden sprinkler heads or other obstructions.

There are exercises all runners should complete, and can be done at home in just a few minutes each day. These will help you feel better on your runs, and possibly prevent injury. Many use body weight as resistance, improve proprioception, and also try to engage the activation of core musculature. Runners need good strength and endurance from the foot all the way up to proper posture and position of head and shoulders, so look for specific exercises for foot intrinsic (flexor hallucis longus), calf, quads, hamstrings, piriformis, gluteus medius and maximus, and core. If you’re ambitious, look for exercises for the QL (quadrates lumborum) and TFL (tensor fasciae latae). You can search online for good instructional images and accompanying explanations. These exercises should help train the body to work together as an efficient unit from start of your training to crossing the finish line of the race. Don’t forget to find exercises for lower back (lumbar spine), mid back (thoracic spine), as well as neck (cervical spine) and shoulders.

Stretching should target these same muscles.  There is research to support a correlation with calf tightness and increased risk of metatarsal stress fractures, and basic stretching goes a long way toward injury prevention. Every runner will feel tight in different muscles, so find where you usually feel tight, sore, or restricted, and spend extra time loosening up these areas. Lastly, don’t forget the foam roller after your workout. This fantastic piece of equipment can be used for deep tissue work and freeing up restricted structures.

Most running injuries are due to overuse, and ignoring your body. Many look back on their training post-injury and recall yellow flags of pain or stiffness that lead to an injury. Spend an extra 5-10 minutes stretching or completing a few exercises today, and maybe and prevent a visit to your doctor or physical therapist, tomorrow. See you out on the course!

For further inquiries about running injuries or performance, contact Jonathan Wilson, DPT, at HCAVirginia Sports Medicine’s Boulders location, at 804.560.6500.

Prioritizing Health, Family, and Wellness: Keeping it All Together in 2014

Hayden Pasco, MD
Primary Health Group - Short Pump

Everyone spends so much time running around completing the tasks of the day that we often de-prioritize being healthy with our families, and for ourselves. Anything that is fun for the whole family creates a bonding experience that will become a healthy habit, and there are several areas of our lives that present these opportunities.

Children learn by watching other people — especially their parents. Set an early example for them by taking the time to eat healthy, exercise, and rest well. A common problem is that parents want the best for their kids, but they make different choices for themselves because it is easier. Don’t make separate meals for different members of the family, and encourage eating together. Food choices, eating behavior, and habits that we see in adults are directly related to what we were exposed as a child. Parents have the power to shape those patterns by making healthy lifestyle choices for their family and children early.

Women are especially guilty of putting everyone else’s needs before their own. Sick mothers are often bringing mildly ill children in for appointments and not being seen personally because they “just don’t have the time” to get to the doctor themselves. Being the backbone of most fast-paced families, women need to pay special attention to their own diet, exercise, and sleep regimen because otherwise they won’t have the energy they both want and need to care for their families. Sleep is an especially important factor in this equation as it becomes difficult to think clearly and function at 100 percent without it. Ultimately, sleep deprivation, in the name of putting the family first, will result in reduced immune function, welcoming more illness and crippling fatigue.

Parents should agree what type of lifestyle goals they want to instill in their family while prioritizing their own health needs. Raising healthy, happy kids requires a well-planned strategy to which everyone commits. There are several ways to include everyone in healthy activities on a regular basis – take the dog for a walk after dinner, ride your bikes together (with helmets, of course!), or just play catch in the yard. Another avenue to spend time together, while instilling the values of healthy nutrition, is to start a backyard garden. This will not only be fun for everyone, but will ensure easy access to fresh vegetables. We are actually heading into a garden-planning season, so it’s a good time to visit your local garden store and get educated.

We eat a lot of processed foods because they are convenient, and often simple diet modifications can not only improve our general health, but prevent more serious diseases later in life. Try to shop around the outside of the grocery store aisles and eat natural foods. Make cooking healthy meals part of the family routine. There are tremendous online resources for natural recipes and ways to eat well without breaking the budget.

The American Heart Association notes that roughly one in three American children today is overweight. This epidemic is a significant issue both nationwide and locally here in Richmond. We start looking at Body Mass Index (BMI) in children at the 2-year well-child visit. If we find that the child is trending towards overweight at an early age, we work with families to come up with a plan that addresses both nutrition and exercise, ensuring a healthy trajectory going forward. Because children naturally want to be active, most of these behaviors can be easily modified by motivated parents, reducing issues later in life.

Weight can be an emotional issue for all involved, and children become increasingly aware of this as they get older. It is important to communicate effectively with children about healthy lifestyle choices and try to structure family activities to appropriately encourage them. Your thoughts on weight issues may be different than those of your child, and it is important to reach a common ground because everyone internalizes the issue differently.

Instilling healthy habits and maintaining them as a lifestyle is actually pretty easy and manageable when done with the proper amount of planning and commitment. A simple first step is cooking at home and eating meals as a family, leading into spending quality time in the evening after the hustle and bustle of the day is over.

If you have any questions about wellness, or would like to schedule a consultation with Dr. Pasco, please call Primary Health Group –Short Pump at 804.217.9091.

Atrial Fibrillation (A Fib) and Hybrid Maze: Advanced Measures for Treatment

Charles A. Joyner, MD, FACC, Virginia Cardiovascular Specialists

Graham M. Bundy, MD, FACS, Cardiothoracic Surgical Associates

David M. Gilligan, MD, FACC, Virginia Cardiovascular Specialists

February marks the 50^th anniversary of American Heart Month and we continue to celebrate significant strides made by the medical community to enhance and lengthen the lives of those who suffer from heart disease. Atrial Fibrillation (Afib) is the most common type of cardiac arrhythmia, which is the incidence of the heart beating irregularly. Afib is caused by a multitude of factors, some environmental, some behavioral, and some genetic. It is often found in those with atherosclerosis, angina, hypertension, and patients with lung problems, including asthma, emphysema, pulmonary blood clots, and COPD. Afib is also commonly associated with diseases such as stroke and heart failure, and as Afib becomes permanent in a patient, mortality rates increase.

Afib, specifically, occurs when rapid, disorganized electrical signals cause the heart’s two upper chambers (the atria) to contract at a fast and irregular pace, or, fibrillate. This can lead to blood pooling in the atria, and not passing smoothly to the heart’s two lower chambers (the ventricles), ultimately leading to a disruption in the heart’s normal electrical harmony.

Not only is Afib of serious concern for affected patients, but it is also a burden to the healthcare system, needing long-term treatment and management to address its rapidly increasing prevalence. Afib care costs nearly $15,000 annually in incremental direct and indirect costs per patient, an unacceptable growth trend. In order to reduce healthcare costs, hospitalization rates, and improve quality of life, innovative treatment solutions, such as the Hybrid Maze procedure, aim to help facilitate the management of Afib without relying on repeat treatments such as radiofrequency ablation therapy, cardioversions (ongoing electrical manipulation of heart rate), or continued adjustment of medications.

Hybrid Maze, so named for the maze-like set of incisions made on the left and right atria, is a multidisciplinary, closed chest, minimally-invasive endoscopic procedure that creates scar lines (lesions) on the epicardium (the outside of the heart) without compromising the pericardium (the membrane sac enclosing the heart and other major surrounding vessels). The lesions work to divert the abnormal electrical impulses in the heart which cause the arrhythmia, isolating them, and allowing the heart to return to its normal cadence.

The endoscopic approach allows epicardial access and ablation to be accomplished without violating the chest or deflating the lungs. It also enables a single-setting procedure to be performed in the electrophysiology laboratory, potentially reducing post-procedure pain, decreasing length of hospital stay, and improving patient recovery.

During the operation, after anesthesia, the surgical team first performs the epicardial ablation portion of the procedure, creating the lesions around the heart. This is performed through an endoscopic incision in the diaphragm using a radiofrequency technique, allowing the heart to continue its normal function throughout the operation. The opening in the diaphragm is sized specifically to facilitate the passage of the epicardial ablation device and an endoscope, allowing the surgeon to visualize both the atrial surface and the space around the heart during the procedure.

Upon completion of the epicardial ablation, a drain remains in place around the heart and the abdominal access site is closed. At this point, the electrophysiology team takes over the procedure to perform the endocardial ablation, creating any necessary lesions on the interior walls of the heart, using irrigated tip catheters to access the multiple sites. After the operation, the pericardial drain is left in place for 36-48 hours, and patients are observed for a further 24 hours post drain removal.

Patients are evaluated after the procedure at six and twelve month follow-up intervals, and seen on an as-needed basis thereafter. Because the Hybrid Maze procedure is performed in a single setting and can fit within the normal practice requirements of catheter ablation, it avoids the downfalls of complex surgical procedures, including the pain associated with large chest incisions or ports. This demonstrates the ability to treat persistent and longstanding Afib with minimally-invasive techniques, better patient outcomes, and reduction of long-term recurrence.

For questions about Afib, Hybrid Maze, or to schedule a consultation, please contact CardiothoracicSurgical Associates, the practice of Graham M. Bundy, MD, FACS, at 804-320-2751.