Medical Insider Blog

Do We Say Goodbye to Pelvic Exams?

  • Posted Jul 30, 2014
  • Anele R. Manfredini, MD

American College of Physicians logo

After a review of studies conducted between 1946 and 2014, the The American College of Physicians (ACP) - which represents 137,000 internal medicine physicians and related s
pecialists - recently released new guidelines regarding an annual pelvic exam.

A pelvic exam consists of inspection of the external genitalia; speculum examination of the vagina and cervix; bimanual examination of the adnexa, uterus, ovaries and bladder; and sometimes rectal or rectovaginal examination.

Pap smears on the other hand is a method of cervical screening used to detect pre-cancerous and cancerous cells from the cervix  and endocervix.

The new guideline concluded that the risks posed by pelvic exams may outweigh the benefits for most healthy women since they may result in false positives, leading to unnecessary tests and procedures. Also the ACP states that the exam "rarely detects important disease and does not reduce mortality." Having a pelvic exam can cause women discomfort, anxiety, pain and additional medical costs.  Studies also showed little benefit in detecting ovarian cancer or other disorders.

As a result the ACP “recommends against performing screening pelvic examination in asymptomatic, non-pregnant, adult women” who have no elevated risk of cancer or other disease.

The American College of Obstetricians and Gynecologists, however, immediately responded in favor of doctors’ continuing to perform routine pelvic screening on healthy women. That group “continues to firmly believe in the clinical value of pelvic examinations,” it said in a statement, which helps physicians to diagnose incontinence, sexual dysfunction, and allows them to explain a patient’s anatomy.

This topic is still controversial among different organizations, therefore, you should discuss with your primary care physician or gynecologist if having an annual pelvic exam, in addition to pap smears, is appropriate for you.

Dr. Anele Manfredini is a family physician who specializes in women’s health, and she practices at the Dorothy Mangurian Comprehensive Women’s Center. For a referral to Dr. Manfredini, please call 954-900-6653.

Ask the Doc - Audrey Liu, MD, Internal Medicine: Vaccine if You've Had Shingles?

  • Posted Jul 22, 2014
  • Audrey Liu, MD

Q: Last time, you wrote about Zostavax as a vaccine that prevents shingles. Can it be given if you've had shingles before?

Dr. Liu: Yes, Zostavax can be given even if you have had shingles before.

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

Shingles and How to Prevent It

  • Posted Jul 17, 2014
  • Audrey Liu, MD

Shingles is a painful blistering rash caused by the same virus that causes chickenpox (varicella-zoster virus). After chickenpox the virus stays in the body and quietly lives in the nerve endings in the spine, but at times it can reactivate to cause shingles. The virus comes out along the nerve, causing swelling and damage to the nerve. A painful, blistering rash appears along the path of the nerve. The acute pain lasts for a few weeks, but approximately 10-15% of people will have a prolonged pain syndrome called postherpetic neuralgia, which can last from months to years. While shingles is not considered a life-threatening infection, the nerve pain associated with shingles is very difficult to treat and can cause much suffering.  Shingles tends to occur as people age due to weakening immune systems. Approximately 50% of people after age 50 will develop shingles.

Can it be Prevented?

The Zostavax vaccine can prevent shingles. The vaccine has been available since 2006 and uses a live - but weakened - version of the varicella-zoster virus. This is the same vaccine that has been given to children to prevent chickenpox since 1995, but in a much stronger dose.

Zostavax is FDA-approved for use in adults after the age 50. The Centers for Disease Control and Prevention recommends that Zostavax be given to adults after age 60 as a one-time dose.  Side effects of the vaccine include pain and irritation at the injection site, a small rash at the injection site and headache.

Check back for my next posts, as I will be answering some frequently asked questions about the shingles vaccine.

Dr. Audrey Liu is an internal medicine / primary care physician who practices in Pompano Beach, FL at 2700 NE 14th St. Causeway, Suite 103. For a referral to Dr. Liu, please call 954-900-6653.


Gain Control Over Back Pain

  • Posted Jul 08, 2014
  • Shannon Hastings, MSPT

Photo from Web MDChances are either you or someone close to you has experienced back pain.  Most people will tell you how debilitating it can be and have sought treatment to help reduce their pain.  Treatments can range from conventional medications, physical therapy, massage, acupuncture, chiropractic care, and can sometimes require surgery.  Most patients opt for the least invasive method to treat their condition.

Physical therapists are board certified medical professionals that utilize exercise and equipment to help patients regain or improve their physical abilities.  Physical therapy can help you improve your mobility and strength, while reducing your pain to enable you to return to your active lifestyle.  The key to successful therapy requires an extensive evaluation to identify each client’s specific problems.  Once indentified, it is imperative to customize a program specific to a patient’s needs to accurately treat their diagnosis. Our job is not only to help you regain your function, but also to educate you about the specific condition you may be dealing with to better serve you moving forward in your own treatment.

The McKenzie method is an indepth assessment of the spine to develop treatment and preventative strategies for patients with spinal pain.  By identifying certain motions that can reduce or eliminate pain, it enables patients to gain control over their specific issue.  This method focuses on self treatment through exercise and stretching, which empowers the patient by enabling them to be an active participant in recovery.  It can be effective in reducing the recurrence of future episodes of pain and ultimately decreasing the length of treatment time needed with physical therapy.

Physical therapists utilize a variety of treatment options to combat back and neck pain including exercise, manual therapy, joint mobilizations, ultrasound, electrical stimulation, and traction.

Physical therapy can be utilized for a variety of spinal conditions including, but not limited to: spinal stenosis, scoliosis, sciatica, cervical or lumbar radiculopathy, spondylolisthesis, degenerative disk disease, degenerative joint disease, and arthritis.  It is also commonly prescribed following whiplash injuries from motor vehicle accidents and after spinal surgery.

If you are looking to regain your active lifestyle and would like to try physical therapy to help understand and manage your back or neck pain, speak with your medical doctor to discuss if physical therapy is the right treatment for your condition.

Shannon Hastings, MSPT, is a staff physical therapist at Holy Cross Hospital's outpatient physical therapy clinic in the Rio Vista neighborhood of Fort Lauderdale, FL (1309 S. Federal Hwy.) and may be reached at 954-267-6819.

Avoiding Weight Gain During Menopause

  • Posted May 14, 2014
  • Anele R. Manfredini, MD

Why am I gaining weight?
Despite all their efforts, most women gain weight during the menopause transition, especially around the abdomen, even while eating correctly and exercising. This weight gain is usually related to a variety of lifestyle and genetic factors, not just hormonal changes.

Menopausal women tend to be less physically active, which can lead to weight gain. Muscle mass naturally diminishes with age and decreased activity. If a woman continues to eat as she always has but reduces her activity level, she will gain weight. Furthermore, unlike body fat, lean body mass decreases with age.

Apple and Pear PhotoFor many women, genetic factors also play a role in this weight gain. If their parents or close relatives carry extra weight around the abdomen, they are likely to do the same.

Apples and Pears
Menopause plays a role in many women's midlife transitions from a pear-shaped body (wide hips and thighs, more weight below the waist) to an apple-shaped body (wide waist and belly, more weight above the waist). However, further study is needed on the exact role of menopause in body composition.

Cause and Effect
Cause of weight gain include:
• Certain drugs
• Insulin resistance
• Emotional eating: depression and stress
• Estrogen loss
• Thyroid imbalance
• Cushing's syndrome
• Lack of exercise
• Excessive eating
• The natural course of aging

Most women in the U.S. and Canada are overweight at midlife. Additional weight gain increases risk of:
• Cardiovascular disease
• Type 2 diabetes
• High blood pressure
• Osteoarthritis
• Some types of cancer, including breast and colon

What You Can Do
Make physical activity a priority. Aerobic activity can help you lose weight or maintain a healthy weight. Strength training is also important: Gain muscle, and your body burns more calories. Women should exercise for a minimum of 2.5 hours per week of moderate exercise or 1.25 hours per week of vigorous exercise (or a combination of vigorous and moderate activity), as recommended by the American Heart Association in the April 2014 Update of the Guidelines for Cardiovascular Disease Prevention in Women. Thirty minutes per day, five days a week is an easy way to break up this exercise and manage your time.

Eat less, and eat right. Reduce calories without skimping on nutrition. Eat fruits, vegetables, whole grains and lean sources of protein. Don't skip meals, which may lead you to overeat later.

Seek support from friends and family.

Turn to your doctor for support in guiding you to a healthy diet, increasing physical activity and ruling out any disease that causes weight gain.

Anele R. Manfredini, MD, is a Family Medicine physician who specializes in Women's Health.

To Stretch or Not to Stretch?

  • Posted May 06, 2014
  • Rafael Gutierrez DPT COMT

People stretch because it feels good or because they think it will increase flexibility and maybe prevent injury. Static stretching has been shown to improve flexibility, but these effects are usually temporary and may only become permanent with a consistent stretching program. For most individuals, however, stretching before exercise does not have many benefits. Much research has demonstrated an increase in flexibility following a stretching regimen because our bodies, via the nervous system, have adapted to tolerating the stretch; however, stretching did not necessarily increase joint range of motion (ROM) or muscle elasticity.

People wonder if stretching prevents injury or if it decreases muscle soreness, strength or peak sports performance (specifically in sports where flexibility is not required, such as running).

What’s the verdict?
Whether or not to stretch is entirely up to the individual, but based on the literature, it is not necessary unless you are someone who requires consistent flexibility, like dancers or hockey goalies.

There is contradictory information on stretching recommendations, but if you decide to stretch, it should be done following a warm-up or after performing low to moderate activity. It also may be more beneficial to move the joints involved in an activity through the required ROM and movement pattern for that specific activity as opposed to any type of stretching.

Although there are few studies on the correlation of warm-up and injury prevention, some research show it is possible that warming up can assist in preventing injuries. Active individuals who participate in strength or dynamic performance activities should wait to stretch after their activity is finished because of the immediate decreases in strength and performance following stretching. If you do stretch, the American College of Sports Medicine recommends the following guidelines:

• Adults should do flexibility exercises at least two or three days each week to improve ROM.
• Hold each stretch for 10-30 seconds to the point of tightness or slight discomfort (should not be painful).
• Repeat each stretch two to four times, accumulating 60 seconds per stretch.
• Static, dynamic, ballistic and PNF (proprioceptive neuromuscular facilitation) stretches are all effective.
• Flexibility exercise is most effective when the muscle is warm. Try light aerobic activity or a hot bath to warm the muscles before stretching.

Rafael Gutierrez, DPT is a staff physical therapist at Holy Cross Hospital’s outpatient physical therapy facility in Boca Raton. He may be reached at 561-483-6924.

Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, Nieman DC, Swain DP. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011 Jul;43(7):1334-59. doi: 10.1249/MSS.0b013e318213fefb.

Herbert RD, Gabriel M. Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review. BMJ. 2002 Aug 31;325(7362):468.

Kamandulis S, Emeljanovas A, Skurvydas A. Stretching exercise volume for flexibility enhancement in secondary school children. J Sports Med Phys Fitness. 2013 Dec;53(6):687-92.

McHugh MP, Cosgrave CH. To stretch or not to stretch: the role of stretching in injury prevention and performance. Scand J Med Sci Sports. 2010 Apr;20(2):169-81. doi: 10.1111/j.1600-0838.2009.01058.x. Epub 2009 Dec 18.

McNeal JR, Sands WA. Stretching for performance enhancement. Curr Sports Med Rep. 2006 May;5(3):141-6.

Pope RP, Herbert RD, Kirwan JD, Graham BJ. A randomized trial of preexercise stretching for prevention of lower-limb injury. Med Sci Sports Exerc. 2000 Feb;32(2):271-7.

Safran MR, Garrett WE Jr, Seaber AV, Glisson RR, Ribbeck BM. The role of warmup in muscular injury prevention. Am J Sports Med. 1988 Mar-Apr;16(2):123-9.

Safran MR, Seaber AV, Garrett Jr WE. Warm-Up and Muscular Injury Prevention An Update. Am J Sports Med Oct 1989, Volume 8, Issue 4, pp 239-249.

Sainz de Baranda P, Ayala F. Chronic flexibility improvement after 12 week of stretching program utilizing the ACSM recommendations: hamstring flexibility. Int J Sports Med. 2010 Jun;31(6):389-96. doi: 10.1055/s-0030-1249082. Epub 2010 Mar 22.

Shrier I. Does stretching improve performance? A systematic and critical review of the literature. Clin J Sport Med. 2004 Sep;14(5):267-73.

Wallmann HW, Christensen SD, Perry C, Hoover DL. The acute effects of various types of stretching static, dynamic, ballistic, and no stretch of the iliopsoas on 40-yard sprint times in recreational runners. Int J Sports Phys Ther. 2012 Oct;7(5):540-7.

Weppler CH, Magnusson SP. Increasing muscle extensibility: a matter of increasing length or modifying sensation? Phys Ther. 2010 Mar;90(3):438-49. doi: 10.2522/ptj.20090012. Epub 2010 Jan 14.

Thyroid Problems – Are They Serious?

  • Posted Mar 28, 2014
  • Matthew Shlapack, MD

Different types of thyroid problems
Thyroidal illness is a broad medical category that includes both structural problems such as thyroid nodules and hormonal illnesses such as hypothyroidism and hyperthyroidism.

Is it serious?
Thyroid nodules, commonly called “goiters,” are very common but can contain thyroid cancer and should be worked up. Thyroid nodules can be seen as a generalized enlargement of the lower front of the neck or as a mass in this area, but nodules are not always visible to the eye. Thyroid cancer is not usually aggressive but if present and untreated it can be progressive, placing an individual at serious risk. Fortunately, the workup and treatment is straightforward, and in the hands of a good care team, it can be dealt with and usually cured.

How do I know if I have a disorder of thyroid function?
Abnormalities of thyroid function can cause a wide range of symptoms ranging from fatigue and weight gain in the case of hypothyroidism, to heat intolerance, anxiety, and palpitations with hyperthyroidism.

Normalization of thyroid hormone levels with treatment is important for preservation of good health, avoidance of complications and resolution of these symptoms. Talk to your doctor if you are concerned about your thyroid.

Dr. Matthew Shlapack is an endocrinologist (a physician specialist who treats diseases and illnesses involving the endocrine system – thyroid, hormones, metabolism, diabetes, etc.).

Rehab, Relax and Restore

  • Posted Feb 17, 2014
  • Rafael Gutierrez DPT COMT

Orthopedic manual physical therapy is a hands-on approach to treating musculoskeletal and neuromuscular dysfunction. Physical therapists trained in manual therapy use specific techniques, such as joint mobilizations, manipulations, soft tissue techniques and therapeutic exercises for improving mobility and function throughout the body.

Conditions Treated

Manual therapy is effective for a wide range of ages and can be used to treat many conditions, including:

• Orthopedic and sports injuries
• Cervicogenic headaches
• Neck and back pain
• Radiculopathy
• Sacroiliac dysfunction
• Postural dysfunction
• Postsurgical issues
• Osteoarthritis
• Ligament sprains
• Muscle strains
• Tendinopathies

How it Works

Manual therapy is effective because it helps restore normal mobility to affected joints and muscles. Joint mobilizations and manipulations help reduce stiffness, increase circulation, decrease pain, and restore mobility in joints to improve biomechanical motion. Soft tissue techniques also increase circulation and relax muscles so they can move through the normal range of motion without restrictions.

Therapeutic Exercise

Therapists who have undergone advanced training in orthopedic manual therapy have also received training in therapeutic exercise geared specifically toward rehabilitation. These exercises may differ from your typical exercise routine because they are dosed and targeted specifically toward the problem areas. Therapists will also address other areas in the body that may be adding to the problematic site during the therapy sessions. Through manual therapy and therapeutic exercise, physical therapists can help patients reduce pain and restore normal function to help patients return to their daily activities.

Rafael Gutierrez, DPT, COMT, is a staff Physical Therapist at Holy Cross Hospital’s outpatient physical therapy clinic in Boca Raton. He may be reached at 561-483-6924. Meet our other therapists and learn how we can help you get moving again at www.HolyCrossOrthoRehab.com.

Holy Cross Hospital Receives UnitedHealth Premium® Cardiac Services Specialty Center Designation

  • Posted Apr 08, 2013
  • By Holy Cross Administrator

Holy Cross Hospital in Fort Lauderdale has received the UnitedHealth Premium® specialty center designation in recognition of quality care.

UnitedHealthcare® developed the UnitedHealth Premium specialty center program to give its members information and access to hospitals meeting rigorous quality criteria. Designed to help members make informed decisions should they need cardiac services care, the designation is based on detailed information about specialized training, practice capabilities, outcomes and cost efficiency of care.

To receive this designation, the non-profit hospital met extensive quality and outcomes criteria based on nationally recognized medical standards and expert advice. The criteria incorporate measurements of breadth and depth of care, staff experience, emergency care, quality and outcomes reporting.

“We are proud to be one of the leaders in cardiac care,” said Patrick A. Taylor, M.D., President and CEO of Holy Cross Hospital. “Our focus on clinical excellence, leading edge technology and state-of-the-art procedures continues to be recognized nationally.”

Holy Cross Hospital offers comprehensive cardiac services through the Jim Moran Heart and Vascular Center and progressive research at the Jim Moran Heart and Vascular Research Institute.

About Holy Cross Hospital
A member of Catholic Health East, Holy Cross Hospital in Fort Lauderdale, Fla. is a full-service, non-profit Catholic hospital, sponsored by the Sisters of Mercy. Since opening its doors in 1955, the 559-bed hospital has offered progressive services and programs to meet the evolving healthcare needs of Broward County. Today, Holy Cross has more than 600 physicians on staff representing more than 40 specialties and more than 3,000 employees. To learn more about Holy, visit holy-cross.com, “like” Holy Cross Hospital, Fort Lauderdale on Facebook, or follow @holycrossfl on Twitter.

Holy Cross Hospital  is a participating hospital in the UnitedHealthcare network but is not owned or otherwise affiliated in any way with UnitedHealthcare: a UnitedHealth Group company.


Really? Fat is better?

  • Posted Jan 08, 2013
  • Alan Niederman, MD, FACC, FACP

It didn't take long for this year's first article to give me an example to show why I write this blog.  And to top it off, this one is a real beaut.

It was funded by The National Cancer Institute and by the Centers for Disease Control and Prevention.  This article was published in JAMA 2013: 309:71-82 and is titled "Association of all cause mortality with overweight and obesity using standard body mass index categories:  A systematic review and meta-analysis."  What the study said was that if you are overweight, you live longer.WHAT!  I kid you not.  This is why people and patients are all confused.  Coffee is good, coffee is bad.  Chocolate will save your life, chocolate will kill you.  Don't eat eggs, eat eggs.  Next week it will be smoking makes you live forever.  Seven out of 10 adults in this country are felt to be overweight.  In 2010, the CDC (the same people who paid for this foolishness) stated that 74% of men and 65% of women were overweight or obese.

How does this foolishness start?  It starts with using the BMI.  Now, close readers of my blog know that I dealt with the BMI foolishness back on 11/08/11 and 11/10/11 in blog posts titled "The tyranny of a number."  I explained how the BMI came into being and that, in general, it is a flawed number that yields silly results.

So why would anyone use it to do a study?  Further, why would we use tax dollars to pay for it?  Don't we have better things to do with our money?  Wait until the Republicans find out.

The study used a total of 97 studies and then discarded 44 of them because of methodical problems.  That left a total of 2.88 million subjects and 270,000 deaths.  The authors claim that severe obesity was associated with an increased risk of death from all causes.  At least they got that part correct.  "Normal" BMI is 18.5 -25 kg/m2.  It is known that a BMI of 18.5-22 has a higher mortality than a BMI of 22-25.  A BMI of 30-35 was associated with the same risk as the BMI of 22-25.  If you were overweight, you had a 6% decrease in mortality.  If you had Grade 1 obesity, it was a 5% decrease in the risk of death.  Kate Moss is doomed.

To have a better understanding of this true insanity, go to the BMI tables and check your number and see where you fall.  Are you happy now?

If you were really interested in this concept you would find 100,000 40 year olds and measure them.  You would then follow them for umpteen years and find out what their weight was when they died.  However, you really need to find out what their weight was when they became sick as patients are often quite emaciated after long illnesses.

This study was an "all cause mortality" study.  This means that it includes all death not just that from illness. The articles came pouring forth.  Weight Watchers stock took a nose dive.  Commentators went on to say that the likely reason for this finding was that if you were overweight, you were already in your doctor's office being treated for all the problems that might kill you. Realistically, as an article in the New York Times on January 3rd written by Paul Campos pointed out, "there is no reason to believe that the trivial variations in mortality risk observed across an enormous weight range actually have anything to do with weight or that intentional weight gain or loss would affect that risk in a predictable way."

Common sense and the fact that we can't fit into our clothes tell us that we are too heavy.  Just look around you and see for yourselves what we look like as a society.  For a real eye opener, go to any other country and look around.  Articles like this and the reporting that they receive don't do us any good.  We can all stand to lose a few pounds.  We all need to eat less and exercise more.  We all need to grow up and take some responsibility for ourselves.

Don't believe everything you read.


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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