Monday, September 29, 2014

Gastroparesis - More Common Than You Think

Matthew Brengman, MD
Advanced Surgical Partners of Virginia
Parham Doctors' Hospital
Gastroparesis is a relatively common disorder in which the stomach has trouble emptying its contents properly, causing food to remain for an unusual amount of time. In a properly functioning digestive tract, the stomach muscles contract in a coordinated fashion to break up food and gradually move the food into the next portion of the intestine, requiring a coordinated action of the muscle of the stomach and the valve at the exit from the stomach.

In the digestive tract of a person suffering from gastroparesis, one or more of these processes are not functioning correctly, the food stalls, inducing common symptoms such as nausea, vomiting, abdominal pain, bloating, reflux, and a general feeling of being uncomfortably full. When severe, these symptoms can lead to little no food intake. This ongoing lack of nutrition resulting from gastroparesis can result in significant weight loss, hospitalization, dehydration and malnutrition.

Gastroparesis is generally a diagnosis suspected by the above symptoms and confirmed with x-ray, endoscopy and most commonly gastric emptying scans. The severity of the symptoms is highly variable, as two people with diagnosed gastroparesis can have vastly different presentations, health management needs, and quality of life.

Normally, three types of gastroparesis exist, idiopathic, diabetic, and postsurgical, and sufferers are usually female. Idiopathic gastroparesis is that of unknown origin and is the most common. Sometimes it can follow gastric illness or respiratory diseases, but most often is characterized by symptoms alone. Diabetic gastroparesis affects both type 1 and type 2 diabetics, with obesity being a major predictor of the disease in type 2 diabetes. Diabetic gastroparesis has multiple root causes, all involving the impairment of gastrointestinal motility and nerve functions. Postsurgical gastroparesis is considered a complication of routine procedures such as those to correct reflux, peptic ulcer disease and common weight loss surgeries.

Other defined causes of gastroparesis include radiation therapy, neurologic disorders (Parkinson’s, stroke, multiple sclerosis, spinal injuries), eating disorders, smoking, pregnancy, hormonal disruption diseases, Crohn’s disease, and other gastrointestinal afflictions. Children are rarely affected by gastroparesis, but may develop it as a result of viral infections.

There are many treatment options for gastroparesis. Most patients can be managed with dietary changes. When symptoms cannot be managed through dietary changes, medication management is indicated. The most common recommended dietary change is to eat smaller, more frequent meals, and avoid high fiber and high fat foods, as they naturally cause delays in stomach emptying. Your physician can help tailor your diet to meet your nutritional needs while addressing the symptoms of the disease. Common medication management for gastroparesis includes prokinetics (drugs that enhance gastrointestinal motility), insulin changes for those with diabetes.

Unfortunately, some patients with severe gastroparesis will fail these therapies. When the symptoms and nutrition cannot be managed through medical therapy, surgical therapies are considered.  Surgical therapies include feeding tubes, botox injected into the pylorus, pyloroplasty (surgical division of the muscle at the end of the stomach) and gastric stimulation (“gastric pacemakers”).

The combined therapies listed above commonly lead a person suffering from gastroparesis back to a more normal body function after treatment. These therapies have been shown to improve and stabilize nutrition, reduce hospitalizations and improve quality of life.

For further inquiries about surgical therapies for gastroparesis, diabetes, obesity, or other metabolic disorders, contact Matthew Brengman, MD, at Advanced Surgical Partners of Virginia at 804.360.0600.

Thursday, September 25, 2014

Joan Lunden and Triple Negative Breast Cancer

Joan Lunden made the brave choice to remove her wig and pose on the cover of People magazine for a glimpse into her fight with breast cancer.

Her form of breast cancer is especially unique, and is called Triple Negative Breast Cancer (TNBC). What this means is that the cancer is negative for three different “receptors” that are known to drive most breast cancers: estrogen, progesterone, and human epidermal growth factor receptor 2 (HER2).

This type of cancer is usually responsive to chemotherapy, but not to targeted treatments, which are considered to be the most successful. Depending on the cancer stage at the time of diagnosis, it can be especially aggressive, and more prone to recurrence. Joan is particularly courageous to share her experience with TNBC with the world, and stands as an inspiration to everyone suffering from the disease.

For more information on TNBC and understanding treatment options, whether you are newly diagnosed, a survivor, or a loved one of someone afflicted by the disease, visit the Triple Negative Breast Cancer Foundation website, where you will find a wealth of knowledge, forums, and even information on clinical trials.

For more information on Triple Negative Breast Cancer, diagnosis, and treatment options, contact Eric Melzig, MD, of Richmond Surgical at 804.285.9416.

Monday, September 22, 2014

Obesity - A Disease You Can Live Without

Gregory Schroder, MD
Matthew Brengman, MD
Advanced Surgical Partners of Virginia
Parham Doctors' Hospital
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.

Monday, September 15, 2014

Preventing Heart Disease

Denise M. Dietz, MD, MS, FACC
According to the American Heart Association, Heart disease – also called cardiovascular disease and coronary heart disease – is a simple term used to describe several problems related to plaque buildup in the walls of the arteries, or atherosclerosis. As the plaque builds up, the arteries narrow, making it more difficult for blood to flow and creating a risk for heart attack or stroke.

Men and women experience similar symptoms for heart attack, with the most common being chest pain and discomfort. Classic angina, or chest pain due to low blood flow to the heart muscle, is typically described as uncomfortable pressure, fullness, squeezing or heaviness over the left anterior chest.  It can radiate to the left arm or jaw, and is usually brought on by exertion.  It can last for several minutes, it may come and go.

Women can experience a heart attack without these typical symptoms.  Instead, they may experience atypical symptoms such as pain or discomfort in both arms, back, neck, and stomach. They may develop shortness of breath, with or without chest discomfort.  Other signs may include breaking out in a cold sweat, nausea, or lightheadedness.  Their symptoms may be more subtle.  Diabetic women are more likely to present with atypical symptoms.

There are many steps you can take to help prevent heart disease, but they all require being proactive and taking action to control your risk factors. Start with the following activities:

1.   If you smoke, quit. Smoking is one of the strongest risk factors, and thereby strongest predictors of not only heart disease, but almost all vascular disease, including peripheral vascular disease. Talk with your primary care doctor about programs and products that can help you quit. Also, try to avoid secondhand smoke.
2.   Manage your blood pressure. Hypertension, or elevated blood pressure, is a risk factor for heart disease.  Seeing your primary care doctor for routine wellness checks will provide screening blood pressure readings.  If your blood pressure is elevated talk to your doctor about treatment – which will include therapeutic lifestyle changes and can include pharmacologic treatment.
3.   Know your cholesterol. Hyperlipidemia, or elevated cholesterol numbers, is a strong risk factor for heart disease.  Get a screening lipid panel and talk to your primary care doctor about the results.  Based on your results and risk factors, your doctor will decide if you warrant further treatment. 
4.   Avoid diabetes. Diabetes patients are at high risk for developing heart disease, so much so that diabetes is considered a heart attack equivalent. Get screened for diabetes.  If you have already been diagnosed with diabetes, manage your condition collectively with lifestyle changes (diet and exercise) as well as pharmacologic treatment. A diagnosis of diabetes brings about unique indications for pharmacologic treatment of cholesterol and blood pressure. 
5.   Know your family history.  Family history of heart disease, particularly at younger ages, puts you at risk for developing heart disease yourself, and is taken into consideration by your doctor to determine your overall risk for heart disease.
6.   Maintain a healthy and nutritious diet. A healthy diet includes a variety of vegetables and fruits. It also includes whole grains, fat-free or low-fat dairy products, and protein foods, such as lean meats, poultry without skin, seafood, processed soy products, nuts, seeds, beans, and peas.
7.   Reduce stress, as stress can bring about heart disease. Find ways to manage your stress, by engaging in activities that you enjoy.
8.   Exercise. Regular exercise will help prevent heart disease, and it will help prevent you from developing risk factors that are associated with heart disease. 

For further inquiries about heart disease or cardiovascular health, contact Denise M. Dietz, MD, MS, FACC, of Cardiology Associates of Richmond, at 804.560.8880, or visit their website at cardiologyrichmond.com.

Monday, September 8, 2014

Training for a Race 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 Race 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 training be filled with great runs, more smiles, and lack of injuries.

Everyone is capable of running a successful race 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 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 self-assess 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, performance, or physical therapy, contact Jonathan Wilson, DPT, at hcavasportsmed.com, or HCA Virginia Sports Medicine’s Boulders location at 804.560.6500. hcavirginia.com

Thursday, September 4, 2014

Quick Fact - What stroke factors cannot be controlled or changed?

Alan Schulman, MD
Neurological Associates, Inc.
Age is the single most important risk factor for stroke overall. Stroke rates steadily increase after age 55. There is also a likely genetic component to stroke, which is an area of active research. The good news is that there are many known modifiable stroke risk factors. The most important one is hypertension, or, high blood pressure. Others include diabetes, atrial fibrillation, carotid artery disease, high cholesterol, obesity/physical inactivity, and excessive alcohol use. 

If you have any questions about stroke treatments or diagnosis, general neurologic disorders, or would like to schedule a consultation with Dr. Alan Schulman, please call Neurological Associates, part of HCA Virginia Physicians, at 804.288.2742. 

Tuesday, September 2, 2014

ALS Basics - History, Risk Factors, and Living with the Disease

Robert White, MD
Neurological Associates, Inc.
In 1865, Jean-Martin Charcot, who is considered to be the father of neurology, described a patient with muscle spasms that ultimately led to the establishment of ALS as a specific disease entity. The public’s attention was drawn to this disorder in 1939.  During the 1938 baseball season, Lou Gehrig went into a hitting slump that worsened as the season progressed. In June of 1939, because of then apparent muscle weakness, he and his wife went to the Mayo Clinic for evaluation. On June 14, 1939, on his 36th birthday, he was told that he was suffering from Amyotrophic Lateral Sclerosis (ALS). Yankee fans made July 4th of that year "Lou Gehrig Appreciation Day." He passed away on June 2, 1941.

Currently, there are about 7,000 new cases diagnosed in the United States each year. There is an inherited form ("familial ALS") that accounts for 5-10% of these cases. There is no racial or ethnic predisposition, and the peak occurrence is the seventh to eighth decades with men and women being affected equally.

The initial symptoms of ALS can occur in any segment of the body (arms, trunk, legs, or head and neck muscles). Limb weakness that is much more prominent on one side versus the other is the most common presentation, occurring in 80% of patients. When symptoms began in the upper extremities, the most common finding is painless hand weakness and atrophy. The most common lower extremity presentation is a so called "foot drop" in which the individual cannot cock up the ankle. Finally, 20% of patients will have initial symptoms of slurring of words or difficulty swallowing.  Later symptoms can include cramping, muscle stiffness, poor balance, and poor dexterity, to name a few.

Over the years, a host of factors have been thought to increase the risk of acquiring ALS. These have included exposure to welding, mercury, lead, aluminum, electric shock and many others. However, to date, the only established risk factors are age and family history. There are a number of gene mutations being studied in non-familial ALS. These have provided clues to identify possible susceptible genetic influences, but they are not definitive and further research is needed.

There is no single test that exists today to specifically diagnose ALS. Physicians make the diagnosis when it is suggested by the history rendered by the patient, their general and neurological examinations, electrodiagnostic studies (EMG) and exclusions provided by neuroimaging (MRI) and laboratory studies. The history one most commonly hears is that of painless weakness in a limb. Physical exam can show any one of a number of findings including weakness, atrophy, brisk reflexes (when using the reflex hammer) and fasciculations (involuntary muscle twitching). EMG (electromyography) can be very helpful but, in and of itself, cannot confirm the diagnosis. Finally, laboratory studies done to exclude conditions that mimic this disorder are also essential. It is only after a thorough evaluation as outlined above that one can arrive at this diagnosis. It is important to note that there are a number of medical conditions that can look very similar to ALS and most always be considered and excluded.

Unfortunately, at the present time, there is no cure for this disorder, but that is not to say that there is nothing to offer individuals who have this diagnosis. Physical, occupational, and speech therapy can be beneficial. The most effective approach to patient management has been the team concept which may consist of the neurologist, physiatrist, pulmonologist (to address respiratory issues), physical, occupational and speech therapists, psychologist, and social worker. Pharmacologic options (medicines), in terms of disease treatment, are quite limited.

The words of Lou Gehrig are perhaps the most fitting way to conclude:

"When the New York Giants, a team you would give your right arm to beat, and vice versa, sends you a gift - that's something. When everybody down to the groundskeepers and those boys in white coats remember you with trophies - that's something. When you have a wonderful mother-in-law who takes sides with you in squabbles with her own daughter - that's something. When you have a father and a mother who work all their lives so you can have an education and build your body - it's a blessing. When you have a wife who has been a tower of strength and shown more courage than you dreamed existed - that's the finest I know. So I close in saying that I might have been given a bad break, but I've got an awful lot to live for.”

If you have any questions about ALS symptoms of diagnosis, general neurologic disorders, or would like to schedule a consultation with Dr. Robert White, please call Neurological Associates, part of HCA Virginia Physicians, at 804.288.2742. hcavirginia.com