Medical Insider Blog

Abnormal Uterine Bleeding: Advances in Treatment

  • Posted Aug 12, 2015
  • Ghea Adeboyejo, MD

Chronic abnormal uterine bleeding is a problem that plagues 20% to 35% of women at some time in their lives, and generates 2.7 million office visits each year in the U.S. This chronic heavy or chronic prolonged vaginal bleeding exerts a heavy price in terms of quality of life, lost time from work and healthcare resources. Initial management usually begins with pharmaceutical treatment. While some patients are adequately treated with medical therapy, others may require or desire a longer acting, lower maintenance option. In the past, treatment options were limited and many women required a hysterectomy to control abnormal bleeding. While some cases of abnormal bleeding are still best treated with hysterectomy, newer minimally invasive procedures may offer women relief from chronic benign bleeding without long recovery times or the risks of surgery and general anesthesia.

Endometrial Ablation

Endometrial ablation is a minimally invasive option for the treatment of heavy or prolonged vaginal bleeding. The first generation non-resective endometrial ablation device was FDA-approved in 1997. Ablation of the endometrium is performed by inserting a device into the uterine cavity to uniformly destroy the uterine lining. The gynecologist can accomplish this with extremes of temperature—either heating or cooling.

There are currently five non-resective ablation devices available in the U.S. All of these devices reduce bleeding in 80% or more of women who undergo treatment. Once it is confirmed by biopsy that uterine bleeding is not due to endometrial malignancy, the gynecologist may select the most appropriate device for that patient. Uterine size and the size of any sub-mucosal fibroids are factors that affect device selection. The ability to perform endometrial ablation in an office setting offers the benefit of reduced patient costs, greater patient acceptability and ease of scheduling. All non-resective ablation procedures can be performed in the office setting under local anesthesia; however, cryoablation appears to be associated with the least pain during the procedure.

Cryoablation

Cryoablation offers two distinct advantages over the heating modalities—decreased operative pain and the fact that it is performed under direct ultrasound guidance. A Heroption device cools the endometrial tissue to sub-zero temperature. This extreme cooling destroys the basal layer of the endometrium and causes numbness. Less operative pain allows us to perform cryoablations in the comfort of an office setting using only oral and local analgesics. In addition, the use of perioperative ultrasound helps to ensure complete ablation and avoid many complications.

Other methods of endometrial ablation use high heat, thus stimulating pain fibers and are therefore usually performed in the operative suite under general anesthesia. In addition, thermal ablations are not routinely performed with ultrasound assistance.

Benefits of Cryoablation

In-office endometrial cryoablation is a safe and effective treatment for benign, heavy or frequent uterine bleeding. Its advantages include avoidance of potential complications associated with general anesthesia or hysterectomy, less pain, and extremely short recovery time.

Recovery Time After Endometrial Ablation

Most patients are able to return to work in one to two days after endometrial ablation. In addition, most studies have shown an 85%-90% satisfaction with treatment after ablation. In one study, 30% of women reported no further periods, 39% reported scanty, infrequent periods, and 29% reported a return to normal light periods at one year follow up.

Dr. Adeboyejo is an OB/GYN with the Holy Cross Medical Group in Fort Lauderdale, FL. For referral information, call 954-900-6653.


Innovations in Neurosurgery: Providing Quality Care in South Florida

  • Posted Jul 20, 2015
  • Ali Jourabchi Ghods, MD

In this video, Dr. Ali Jourabchi Ghods, Neurosurgeon in the Holy Cross Neuroscience Institute, discusses how neurosurgery and the technologies involved in treatments of brain cancer and brain tumors have evolved over the years. Dr. Ghods compares Whole Brain Radiation Therapy and compares it with current treatment – Stereotactic Radiosurgery, which uses focused radiation during surgery. He also explains the O-Arm technology and Stealth Navigation and their benefits, which include less radiation and offers 3-D imaging and navigation that improve precision, accuracy, efficiency, and safety during surgery.  Dr. Ghods expresses the importance of being able to offer innovative treatments to ensure that patients do not have to seek quality care outside of their own community: 



Dr. Ali Jourabchi Ghods is a neurosurgeon who practices at Holy Cross Neuroscience Institute (Holy Cross Hospital) in Fort Lauderdale, FL. For referral information, call 954-900-6653.


The Fading Fad Diet

  • Posted Jun 29, 2015
  • David Zekser, MD

Many women feel forced to try to follow that strict, unyielding and frequently unhealthy short-term weightloss regimen that we lovingly know as THE DIET. The words bring regret and loathing to the minds of many women, like some disastrous relationship of the past. They might recall feeling jilted by all the fad diets they have loved and lost when the promise of miraculously stepping out of a pair of plus-size jeans into a bikini and high-heel shoes is replaced with the reality of modest weight loss, rapid regain and a sense of defeat.

The concept of the diet is outdated and redundant. A healthy weight is the byproduct of eating better, eating less of some foods and more of others, making better choices, consistency, and accepting the reality that a short-term solution will not solve a long-term problem. A few of the core concepts for weight loss that I find to be benefi cial and that I use in my own weight-loss program are:

Finding The Good MonsterSM

This relates to the concept of “damage control.” There will always be times when you are forced to eat the best option available, even if it is not a perfect one. If you are hungry and have 10 minutes to get to an appointment, you may have to choose between a slice of pizza, fast food places or not eating at all. Finding The Good MonsterSM means finding what works best for you in any situation and then moving forward while figuring out how to plan better meals and snacks.

Don’t expect a salad to fall out of the sky

Prepare in advance for busy times at work and leisure time at home by making good food choices more accessible and convenient than bad ones. It is just as easy to take the peel off a banana as a wrapper off a candy bar.

Cut back on the "bad" carbohydrates

This includes pasta, bread, rice and potatoes. Replace them with carbohydrates such as vegetables and fruit. Think about replacing food items instead of simply trying to eliminate them.

Think differently about dinner

Expectations of eating a big dinner or snacking before bedtime cause people to eat more at that time of the day simply out of habit, even when they are not hungry.

There are a lot of options for weight loss, but no matter what path you take to reach your goal, knowing how to stay there is the most crucial component to long-term success.

Dr. David Zekser is a primary care physician (Internal Medicine) practicing in the Rio Vista area of Fort Lauderdale. For referral information, please call 954-900-6653.


Contact Sports and Concussions (Part 2)

  • Posted Jun 22, 2015
  • Fernando Manalac, MD, MMM, CAQ...

If you missed “Part 1” of this post on how to prevent concussions, how they occur and symptoms  you may experience, you can read it here.

Concussion Management

Preseason

Pre-Participation Evalutation (PPE): in my office, we conduct PPEs to establish a medical background from which medical decisions about physical activity may be made and medical clearance may be provided.

Baseline Testing: also available in my practice is a 20-minute computerized neurocognitive test (ImPACT testing) designed to measure the effects of concussion. After an athlete completes a baseline test, his or her data is stored on a secure, HIPAA compliant server. If a concussion is suspected in the future, a follow-up test is administered to see if the results have changed from the baseline. Traditional imaging procedures (CT or MRI) are helpful in identifying serious brain injuries, but they are not able to identify the functional effects of concussion. ImPACT can detect subtle changes in cognitive functioning that cannot be accurately measured by relying on athletes to report symptoms.

Other preseason testing include Maddox Questions (checks for memory), SAC (Standard Assessment of Concussion), BESS (Balance Error Scoring System); Sideline Concussion Assessment Tool (SCAT2); and NFL SCAT.

Assessments

In addition to any necessary emergency response, the medical personnel on the field may perform various on-field and sideline assessments, such as a physical exam, neurocognitive and balance assessments, Neuropsychological (NP) Testing/Sideline Concussion Testing, and Return to Play evaluation.

At Home

• Dim/Quiet room

• Allow patient to sleep/rest!

• Very limited role of medications (OTC acetaminophen is most commonly prescribed)

• Seek medical attention if symptoms worsen acutely

Return to School/Play

Returning to school or play is a case by case management. Cognitive rest is needed – decreased concentration, reduced academic workloads, days off or shortened school days, extended test taking times and return to full academics when symptom-free. There should also be a progressive return to play: crawl -> walk -> run -> practice -> play. Talk to your doctor about treatments based on symptoms, age and medical history.

Before returning to school or play, there must be a medical clearance, be symptom-free, not taking medications and there must be a return to baseline based on the neurocognitive / physical / balance exams.

Keep in mind that a premature return to play can lead to a more severe concussion/prolonged symptoms. “Second Impact” syndrome is a second episode of brain trauma before the brain heals from the first. Cerebral arteries lose their ability to autoregulate (vasoconstrict), resulting in diffuse brain swelling/increased intracranial pressure. Second Impact syndrome involves a high incidence of brain herniation, coma and/or death.

Chronic Traumatic Encephalopathy

This condition is known in boxing as Dementia Pugilistica or Punch-Drunk Syndrome. It’s a progressive degeneration of the brain secondary to multiple brain injuries (concussions). Symptoms involve a change in mood (depression/suicidal ideation), cognition (memory loss), movement (parkinsonianism/balance dysfunction) and behavior (aggression).

Protect Yourself

Before engaging in activities or sports in which head injuries are common (football, soccer, basketball, volleyball, baseball, hockey, etc.), consult with a sports medicine physician regarding how to prevent head injuries, your risks for concussion, a PPE, and baseline testing to be proactive in managing possible concussions.

Dr. Fernando Manalac is a board certified sports medicine physician who practices at the Holy Cross Orthopedic Institute in Fort Lauderdale, FL. For referral information, call 954-900-6653.


Why Do My Shins Hurt When I Run?

  • Posted Jun 16, 2015
  • John Angus, MS, ATC

Marathon Runners

Running is a popular exercise; we are running more frequently and for longer distances than we ever have, so we’re seeing an increase in lower leg injuries. Many people have pain on the inside of their lower legs that they classify as “shin splints.” Although shin splints are common, this may not be the correct diagnosis for the cause of your pain. There are many different structures that can succumb to overuse injuries including bone, muscle, tendon, fascia or some combination. Some of the more common injuries experienced in the lower leg are medial tibial stress syndrome, tibial stress fractures and tibialis posterior tendonitis/dysfunction. All of these conditions tend to appear in very close physical proximity, but each should be managed differently.

What are the differences?
Medial Tibial Stress Syndrome (MTSS) is a repetitive stress injury that is commonly correlated with the term shin splints. People that experience MTSS are usually doing something different with their activity like starting a new workout regimen, increasing workouts too rapidly or changing another aspect (shoes, surfaces, etc.). The etiology of the injury is still somewhat debated, but most experts believe that the end result is a combination of tendonitis, stress reaction of the tibia, and periostitis (inflammation of the connective tissue lining the bone).

Athletes continuing to push through the pain without modification or those increasing their activity can increase the likelihood of a tibial stress fracture (TSF).  This is a more advanced version of MTSS that will have a raised portion of the lining of the bone or fracture lines within the bone.

A third common condition - Tibialis posterior tendonitis/dysfunction (TPT) - can increase the risk of developing MTSS and TSF but can also be found as a problem on its own. The tibialis posterior muscle attaches under the foot to help support your arch and helps to plantar flex the foot while running. Fatiguing as you run puts more stress along this tendon which leads to dysfunction and inflammation.  The pain can run anywhere along the muscle from the calf, inside aspect of the lower leg, and/or under the foot.

What do I do?
Prevent the injury from occurring with a smart training regimen that does not increase loads too quickly. The best treatment once MTSS has set in is rest or a few weeks of activity modification. Some people use orthotics to reduce excessive pronation and perform ankle-strengthening exercises.  If the condition worsens to TSF, a cast or boot is needed and non-weight bearing until the fracture heals.  TPT can be treated with RICE (Rest, Ice, Compression and Elevation), but a good physical therapy regimen for ankle and foot strengthening can speed up the healing. Orthotics may also help to relieve pain and dysfunction until the tendon can return to normal activity. These are not the only lower leg conditions you may experience with running, especially if you have other symptoms; therefore, a good physical exam and history is always needed to tease out the diagnosis and get you back to your normal activities as fast and safely as possible.


John Angus, MS, ATC, is an Athletic Trainer practicing at the Holy Cross Orthopedic Institute in Fort Lauderdale, FL who works closely with our Holy Cross Medical Group sports medicine specialist. For physician referral information to a sports medicine specialist, call 954-900-6653.


Contact Sports and Concussions (Part 1)

  • Posted Jun 09, 2015
  • Fernando Manalac, MD, MMM, CAQ...

Dr. Manalac with nurse in helmet at concussion lectureContact sports like American football have long been known for brutal head injuries. As much education that our athletes still need today, we have come a long way since the sport’s origins in the 1860s - when the world lacked understanding of concussions and how to care for those with such head injuries. Over the years we have gained a much better understanding of the pathophysiology of concussions, symptoms, management, and more importantly, how to prevent the injury.

 


How Concussion Occurs

A concussion is caused when there is impact from which the brain shifts within the cerebrospinal fluid and strikes the skull, causing direct injury. The brain then whips back and strikes the opposite side of the skull. Commonly, there are rotational components to the force, which cause “twisting” of the brainstem and is associated with loss of consciousness. Microscopically there is shearing of the axons in the brain and excessive release of neurotransmitters - the brain’s attempt to start repairing itself or reach homeostasis. This is when you will experience a huge imbalance of energy supply and demand needed for recovery. It is also during this time that the brain is most vulnerable to a “Second Impact.”

Preventing Concussions

My patients and their family members may be surprised to know that protective equipment has not shown to reduce the number of concussions. Direct head trauma is not necessary to develop concussion; any impact that causes the brain to strike the skull or a rotation of the brain stem can cause a concussion. Neck strengthening programs may help in theory, but no studies have been done at this time. Limiting contact / cutting down on the number of contact practices has been shown to reduce concussions. Player behavior modification can help to prevent this head injury – educate players, coaches and trainers and adjust the rules to ensure proper technique and injury management.

Symptoms

If you do suffer from a concussion, the most commonly reported symptom is headache. Dizziness and nausea / vomiting may also occur, as well as visual disturbance. Cognitively, there may be memory loss, some have decreased concentration, confusion, and loss of consciousness. You may also experience emotional symptoms such as irritability, depression and anger. It is also common to feel drowsy or tired and have difficulty sleeping (insomnia). It is important to know, however, that with all possible symptoms, it only takes one symptom to constitute a concussion after a head injury.

Check back for Part 2 of this post for details on concussion management.

Dr. Fernando Manalac is a board certified sports medicine physician who practices at the Holy Cross Orthopedic Institute in Fort Lauderdale, FL. For physician referral information, call 954-900-6653.


Brain Aneurysm in Women

  • Posted Jun 02, 2015
  • Laszlo Miskolczi, MD

woman with headache
Brain aneurysm is a balloon-like structure that develops in a weak spot on the wall of a brain artery. Approximately two to five percent of the population has a brain aneurysm. Although only one to two percent of those aneurysms ever rupture, over half of the patients with ruptured aneurysms die within 30 days.


How it affects women


Brain aneurysms occur much more frequently in women. According to a study published in Stroke, the highly regarded journal of the American Heart Association, more than two thirds of all patients with ruptured aneurysms were women. Half of them were between ages 30 and 60.

Aneurysms grow slowly, over decades. Women with aneurysms that ruptured during their retirement already had a well-defined aneurysm before they even reached 60.


The statistics are shocking


Between ages 60 and 69, women are three times more likely to have an aneurysm than men. Between 70 and 79, it is close to five times more likely for women.


Signs and symptoms


Brain aneurysms grow silently from a weak spot of the artery. The most important signs are sudden onset double vision, a hanging eyelid, or a sudden onset severe headache with nausea that may or may not go away. People with any of these symptoms should seek immediate help.


Who is at risk?


Compared with the 230,000 yearly cases of breast cancer, only about 30,000 aneurysm ruptures occur in the United States each year. Therefore, a screening test for the general population would not make sense. However, testing may be important for people with family members who have had brain aneurysms, especially if one relative had more than one brain aneurysm. Patients who smoke or have high blood pressure are also at higher risk of developing and rupturing brain aneurysms.


Treatments


According to an article published in the American Journal of Neuroradiology, among 65,000 patients reviewed, treatment risk is much lower today than 10 to 20 years ago. Patients who underwent minimally invasive coil embolization had three times less risk for a bad outcome than patients undergoing surgical clipping. It is important, however, that an individual approach based on patient-specific anatomy be followed in every case.

The technological requirements and expertise of diagnosing and treating brain aneurysms are available only at select institutions. Holy Cross Hospital is a comprehensive stroke center that has received the Gold and Gold Plus awards from the American Stroke Association every year since 2009. These are the highest levels of the American Stroke Association’s acknowledgement of excellence in stroke and aneurysm care.

Laszlo Miskolczi, MD, is a world-renowned neurointerventional radiologist who practices at Holy Cross Hospital's Comprehensive Stroke Center. For physician referral information, call 954-900-6653.


I'm Not Sitting this One Out

  • Posted May 14, 2015
  • Fernando Manalac, MD, MMM, CAQ...

How many of you Road Runners have ever experienced pain or soreness in the back of your thigh (hamstrings), in the back of your ankle (Achilles) or the side of your thigh (iliotibial band)?  If so, there’s an excellent chance that it’s caused by a tendinopathy:

Tendon = the white stretchy tissue that attaches muscle to bone 

opathy = condition or disease process.  

There are three main types of tendinopathy: tendon strain (tear), tendinitis and tendinosis. Runners who run long enough will probably experience every type of tendinopathy.

Traditional treatment for tendinopathy

RICE (rest, ice, compression, elevation) and NSAIDS are the mainstay of Mom’s management for the strains and inflammation (the “itis”). However, the degeneration of the tendon, otherwise known as tendinosis, doesn’t always respond to these traditional treatments.

When tendon is not healing

Your race is in three or four weeks, the last thing you want to do is sit this one out. Platelet rich plasma (a.k.a. PrP or blood-spinning) may be an option. PrP is a procedure done in my office where I draw your blood; place that blood into a centrifuge to spin down and separate the platelets from the rest of the blood; and inject only the platelets (which house growth factors) with some plasma with a few white blood cells into an injury site to help heal tissue.

Factors that affect PrP

This procedure has helped some of the biggest professional athletes, as well as non-athletes alike. Research has shown mixed results, and most experts believe this is because not all PrP is created equal. Varying levels of platelets exist in everyone. At your next blood test, compare your platelet level to your family member’s level, or even to your own last blood test results…much different, right? Also, some PrP kits can control the amount of platelets, red blood cells, and white blood cells, which have an affect on success of treatment. 

Taking Advil or Aleve could also render your platelets dysfunctional; stop all NSAIDS before and after the procedure. Not eccentrically loading tendons within the first couple weeks after the procedure has also provided suboptimal results. PrP is very promising - as evidenced by the abundance of available literature and by studies in the pipeline - and may be the right therapy to successfully treat your tendinopathy.

Fernando J. Manalac, M.D., MMM, CAQSM, CMQ, is a fellowship trained non-surgical sports medicine physician at Holy Cross Orthopedic Institute in Fort Lauderdale, FL. Board certified in Internal Medicine, Sports Medicine and Medical Quality, Dr. Manalac specializes in non-operative management of musculoskeletal issues at any age. Learn about the Sports Medicine program at Holy Cross Orthopedic Institute by visiting HolyCrossOrthopedics.com. For physician referral information, call 954-900-6653.


What is a Faith Community Nurse?

  • Posted Apr 20, 2015
  • hchadmin

Nurses are a compassionate and transforming healing presence within our communities.

By building alliances between two healing communities – the medical facilities and faith communities – faith community nurses focus on the intentional care of the spirit as part of the process of promoting holistic health and preventing or minimizing illness; they promote the fullness of life that God intends for each individual.

Guided by the Scope and Standards of Faith Community Nursing, faith community nurses serve in communities that are diverse in denomination, size, race and ethnicity. They assist each community to develop their vision for promoting health as wholeness in the context of the values, beliefs and practices of their faith tradition and to provide support for implementing and sustaining their vision.

Specific services of faith community nurses may include:
• Integrator of faith and health
• Health educator and counselor
• Referral advisor
• Provider of screening tests/risk assessments
• Community liaison and patient advocate
• Coordinator of volunteers
• Facilitator of support groups

Upcoming Continuing Education Opportunity from Holy Cross Hospital's Faith Community Nursing Program:

Advance Directives and End of Life Care
April 27, 2015 | 7:30am – 8:30am  or  5:30pm – 6:30pm
Jim Moran Heart and Vascular Building, 2nd Floor Multi-Purpose Room
Holy Cross Hospital

This activity has been approved by the Florida Board of Nursing for one (1) contact hour. (FBN# 50-951)

RSVP:  Valerie Fox, Faith Community Nursing Coordinator | 954-267-9551

FREE to Holy Cross Associates, community members and students


Ask the Doc - Audrey Liu, MD, Internal Medicine: Who Can Get Shingles Vaccine?

  • Posted Apr 09, 2015
  • Audrey Liu, MD

Q: Can everyone receive the shingles vaccine?

Dr. Liu: Zostavax is FDA-approved for use in adults after the age 50. The CDC recommends that Zostavax be given to adults after age 60, as a one-time dose. 

Shingles vaccine should not be given to people allergic to gelatin or neomycin. It should not be given to people with weakened immune systems, such as pregnant women, or patients with leukemia, lymphoma, or myeloma, patients actively receiving chemotherapy or radiation, transplant patients, patients with AIDS, or patients on medications to suppress the immune system.

Dr. Audrey Liu is an internal medicine physician who practices at the Holy Cross Medical Group Pompano Beach Practice. For referral information on Dr. Liu, please call 954-900-6653.


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About Holy Cross Hospital

Holy Cross Hospital is a nonprofit, Catholic hospital in Fort Lauderdale, Florida, dedicated to innovative, high quality and compassionate care. For nearly six decades, Holy Cross has continuously expanded its services to provide leading-edge care for their patients in Florida and for those from elsewhere in the United States. Holy Cross also offers an International Services program to ensure that patients from outside the U.S. receive the care they need.

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