Dear Doctor Blogs

Presenting Your Personal Health Journal

Fri, 23 May 2025 15:20:28 GMT

Each member of our practice receives a monogrammed leather bound personal health journal which includes an inventory of all his/her tests, tabulated tracking of important results, a narrative of what each condition means to him/her personally, and a brief compendium of state of the art medical knowledge along with references for additional pursuits.

Did You Hear the Tone?

Mon, 02 Dec 2024 15:34:04 GMT

Over the years, we have been frustrated with how little hearing screening is done. It seems to get done as an infant, perhaps with crude tonometry as a child, and then off it goes to audiology. Most don’t go. What a missed opportunity. The American Academy of Audiology recommends annual screening after the age of 3 years. We are pleased to announce that in our office we have an excellent device to screen for hearing deficits, and it can be used for all ages.

This is the actual device, an over the ear headset that plugs into a laptop. We will set you up in a quiet room and within a few minutes, the autopaced program will have tested each ear individually at frequencies ranging from 250 – 8000 Hertz and at intensity ranging from -20 to 100 Decibels.

With positive and negative controls, the only thing it doesn’t seem to do is bone conduction. We will leave that to the professionals. Should there be a problem, our specialty colleagues are nearby and we will help get you an even more thorough exam for consideration of cause and treatment.

Should things seem OK, then we just repeat it annually and follow along. This is the report that will be generated, which you can have and which we will save to the chart. We will incorporate this into the annual preventive care visit and of course use it on demand.

There are many reasons to have hearing loss, and most of us have some degree thereof. It could be from machinery at work, recreational music, firearms and military service, head trauma, illness, or genetic tendency. Knowing what degree of loss is present today helps make sense of all sorts of things:

Maybe a child is pronouncing words wrongly.
Maybe you can’t hear in a noisy environment
Perhaps family says you turn up the TV too loud
Maybe you can’t understand why everyone has to be told to speak up
Perhaps your parent is not as alert because of profound hearing loss.

There is an old adage in medicine: Don’t guess when you can measure. Let us measure your hearing.

Focus On: RestoreU Method

Fri, 06 Sep 2024 15:44:58 GMT

Brain health is extremely important. A large part of what we do at Alliance is focused on maintaining and improving brain health. As we age, we all slow down, both physically and mentally, and we want to decrease the decline of both as much as possible. One of the ways we are able to evaluate cognitive changes is by doing lab work, then evaluating that in context with the entire person. We have partnered with Quest Lab and UMethod to provide a test known as RestoreU Method in order to have a more inclusive way of evaluating someone’s cognitive function. This is used in conjunction with the Cognivue test, other labs and possibly imaging, which were described in a previous blog.

There are many causes of cognitive decline, including but not limited to, aging, metabolic derangements, cardiovascular issues, nutrient deficiencies, hormone imbalances, sleep issues, metal toxicity, and medications. By running this test, along with other appropriate tests, we can evaluate these issues, and provide a plan to refine what can be improved.

Just as we did with the cholesterol profile, let’s use a real patient scenario to walk through the results of a test. As always, not everyone’s test will look the same – we always personalize what we order based on the individual.

Zelda is a 66 year old post menopausal female who has a normal body mass index (BMI), and her blood pressure is currently in the normal range. She does have a medical history of diabetes, hyperlipidemia, hypertension, COPD, chronic pain, peripheral nerve disease, and she presented with a chief complaint of short term memory issues. She is on multiple medications to treat her multiple medical conditions.

Zelda had what we consider a reasonable set of labs to evaluate for potential reversible or treatable conditions. The tests included the majority of what is shown below (we add or remove certain tests based on the level of appropriateness or because they have been done previously).

It is a fairly comprehensive search for vitamin deficiencies, mineral deficiencies, heavy metal exposures, hormonal aberrations, vascular inflammation, and includes some very specific tests related to an illness we all fear, Alzheimer’s disease.

The RestoreU report itself starts with a summary of what tested areas are likely contributing to or not likely contributing to cognitive impairment or memory loss:

As seen above, the areas of most concern for her include issues not only related to the blood and urine tests that were run, but also known medical problems, including depression, diabetes, smoking and medication use (this is shown by the anticholinergic cognitive burden).

Next, an action plan is listed. In Zelda’s case they list several supplements that they consider helpful for her, as well as why she should be taking them.

Then there are useful lifestyle modifications which can help cognitive function, including stress relief, restful sleep, overnight fasting, appropriate exercise, balanced nutrition, good hygiene and brain exercise.

Given how important nutrition is to brain health, an entire section is dedicated to discussing an appropriate diet, including food groups that are recommended to include and food groups recommended to avoid.

Finally, many of the labs that were tested are presented along with the optimal or target value identified. The report also includes a discussion of how each lab affects cognition.

Zelda has several areas of concern identified by reviewing her personal history, medications and lab results. From these areas, an action plan has been developed, which can help her to maximize her cognitive potential, by minimizing the medication reactions, working on fixing abnormal lab values, improving diet, sleep, exercise and other areas in her life.

Cognitive decline is complicated. Multiple tools need to be integrated in order to provide a complete understanding of why it is happening and any interventions that may be possible. As modern medicine advances, there is a better understanding of the multimodal causes of this decline, but it takes a lot to sort it all out. At Alliance, we have both the time, the experience, and the resources to take a deep look and formulate a comprehensive plan.

The purpose here was to highlight one of the tools we are using, the RestoreU Method. As good a tool as it is, we feel the need to complement it with other tests (some of which are highlighted in other blogs on our website at alliance-phc.com), such as the Cognivue test, the pharmacogenomic test, the advanced lipid profile, imaging studies such as MRI and ultrasound, physical therapy consultation and potential genetic screening.

It seems like a lot, and it is. What we will then do is interpret the results with you, and then formulate a plan with you, in order to optimize your cognitive function and hopefully slow any decline already noted. This is what we do, and we always do it with you.

Inside Your Cholesterol Profile

Tue, 20 Aug 2024 15:55:27 GMT

We venture to say that most patients are familiar with the word cholesterol and have some concept of the importance it plays in cardiovascular health. It is also likely that most people have heard that there is more to it than simply measuring total cholesterol. After all, when was the last time your doctor ordered anything other than a four-way profile of LDL, HDL, Triglycerides, and Total Cholesterol? And for those of you who like math, did you know the formula (roughly) is: HDL + LDL + 0.2(Triglycerides) = Total?

It can be helpful to use a real patient scenario. This is the result from someone we will call “Jose”. It looks pretty good on the surface. But it may be helpful if you knew that Jose has a lot of vascular problems. Could there be something within the cholesterol profile to explain things, you may ask. Of course there is! Otherwise, we wouldn’t be having this discussion.

It is already getting complicated. But oh how much more we can learn by breaking down each of those components AND adding some related components not yet discussed. Keep in mind that it is all about vascular health, preventing hardening of the arteries (arteriosclerosis) by preventing clotting of the arteries (atherosclerosis). If you want to learn more, then read on, and we will try to relate a distilled version of what WE know, acknowledging there are others with more advanced understanding of this evolving science called “lipidology”.

Here at Alliance, we recommend that you get your cholesterol checked on a periodic basis, which timeline can vary based on your personal history, family history, and specific risk factors. There are several commercially available advanced tests for cholesterol assessment that will break down the three particles mentioned above and add those other factors that affect vascular health. It may be appropriate to do one of these more advanced tests, based on your personal risk factors and your discussion with your physician. Based on several criteria, we have chosen to work with a product called CardioIQ, offered by QuestLabs (located in the building adjacent to our office).

To get started, let’s talk about LDL (Low Density Lipoprotein), commonly referred to as the “bad cholesterol”. Note how the full name implies it is not a single molecule, rather a merger of lipid (“lipo”) onto a carrier protein (“protein”). Starting with the lipid component, not all low density lipids are the same. When you get a report back indicating that the LDL level is “69” (as in the example above), that does not tell the whole story. Think of that number like naming the size of a jar. A jar of size “69” IS bigger than 50 and smaller than 100, but it’s time to ask what is INSIDE the jar. Two individuals could have the same report of an LDL of 69, which accurately reflects that the volume of LDL IS 69, but if we line up the two same sized jars, they may be completely full of DIFFERENT SIZE lipids. Think of it like jars of candy. Same size jars (that’s the “69”). But inside there is clearly a difference as one jar holds a whole lot more pieces of candy (smaller bites) than the other jar.

As it turns out, that’s important. The smaller the lipid particles, the easier they penetrate the walls of the arteries. We don’t want them inside the walls, as that sets up atherosclerosis. The advanced lipid profiles will break that down, reporting things like this. The LDL of 69 seemed great (goal for someone with Jose’s condition is <70). But, it is mostly made of small dense particles. That jar holds a lot of them. Maybe Jose should try for an even lower level of LDL.

Even then, the story is not complete as the lipid component is bound onto a protein component called apolipoprotein. In the case of LDL, it’s apolipoprotein B, and there are several of them. They are not all the same with regards to atherogenicity. If we stick with the candy analogy, it would be like breaking open two different patients LDL that may appear almost the same on the surface, only to find something different on the inside. Think gumballs.

Let’s stop the discussion at that point. Jose’s report shows that the ApoB level is reasonable. If it wasn’t, then the discussion gets a bit more complicated.

Then, there is HDL, commonly referred to as the “good cholesterol”. The same understanding can be had there. We want the lipid component to be large and we want the apolipoprotein component to NOT be one called “little a” (I know, real original). And the apolipoprotein profile can be broken down further as well. Note how Jose’s report shows a healthy size HDL, reflected in his original decent volume number of 43, BUT the core has a lot of lipoprotein (a), a highly atherogenic particle. It is very hard to treat, though there are meds in clinical trials that offer great promise. Even without the medicine though, it certainly changes how we approach this patient. His cholesterol profile is NOT good.

It helps a lot to move past the cholesterol itself and consider other markers that increase inflammation at and inside the wall of the artery. As we learn more and more, inflammation is at the core of many disease processes. The CardioIQ profile will report a helpful graphic.

We find it helpful to measure some or all of these markers depending on the clinical situation. They are a mixture of blood and urine tests, which can let us know if there is little active inflammation but highly irritating particles, probable plaque presence, or some evidence for active inflammation (which is more dangerous and which may change the treatment plan). Back to Jose. Here are his inflammatory marker results, and you can see there is some evidence of vulnerable plaque.

A natural question is to ask what causes such degree of inflammation. The answer is, A LOT OF THINGS, including the size of the lipids, the type of the apolipoproteins, lifestyle choices such as smoking and being sedentary, as well as other disease processes such as diabetes. It turns out the CardioIQ can also check for insulin resistance as well, and here is Jose’s result. Note the educational graphic.

That completes the basic tour of an advanced lipid profile and what can be gained. In the case of Jose, note how much more there is to the story behind what looks like an excellent lipid profile. What did he and his doctor decide to do?

Well, we changed the statin, increased the dose, and added two other lipid lowering agents that might affect the lipoproteins and particle numbers. We added an exercise regimen to promote arterial health and lower the glucose, made additional dietary recommendations, emphasized smoking cessation, and we will repeat things in a few months for comparison. We suspect he will be a great candidate for the forthcoming new medications that will treat lipoprotein (a). None of this would be known or likely have been done without the more advanced profile.

Not everyone needs the testing. Sometimes inquiring minds just want to know. All of that is within reason. At Alliance, we want to work WITH you in order to make a joint decision on when to test, what to test, and what to do with the results of that test. It’s good to know what is really out there and available

The Microbiome

Wed, 07 Aug 2024 16:00:02 GMT

I once heard a microbiologist say that the human is nothing more than a transport medium for the microbiological world. What he is inferring is that though we use our 30 trillion cells to orchestrate physical movement in this world, the 40 trillion microbes that live within us lack that mobility. That’s not a type-o … there are likely more microbes living within the gut than there are human cells for any individual. And it would be too anthropocentric of us to think we should ignore them. Though small in size, they do outnumber us, and what they lack in size they make up for in a complicated world of symbiotic relationships, outright battle for dominance, and production of by-products to improve their own environment which directly affects our gut health and overall sense of well being.

Let’s talk about some common maladies for which we should consider the microbiome. There are many who suffer from recurring or constant difficulties involving nausea, pain, change in bowel habits, and food intolerances. So often, an extensive workup finds no severe problem that needs intervention. After that good news, the focus turns to managing symptoms. And that’s where things remain difficult for years, involving medications with side effects and expense. Of course, it’s in vogue to talk about food allergies and to adjust our diet, but why does that matter when it’s not a true allergy? Remember those trillions of microbes? Could they be part of the problem or part of the solution? Turns out, the answer is yes. Not always, but a lot of the time. For what we call functional abdominal pain (anatomically fine, no obvious disease, just doesn’t function smoothly), it can often be from “dysbiosis”, an imbalance in the groups of microbes. We humans function smoother when the various groups of organisms remain in a steady state. When one group outmaneuvers another or migrates location within the gut, it can create dysbiosis and functional abdominal pain. That’s where probiotics get their credibility. But which probiotic (hundreds to choose from) and in which combination? The reason there is so much confusion is that each of us is unique. Imagine that; one size does not fit all.

It’s easy to understand how the microbiome may influence food allergies, irritable bowel syndrome, and inflammatory bowel disease. But, believe it or not, the microbiome is now being looked at as being one of the overarching areas that can be manipulated to improve conditions as diverse as autism, chronic fatigue syndrome, immunodeficiency, autoinflammation, and certain cancers. How much it can help is definitely unclear. Most have heard about the benefits of taking a probiotic following oral antibiotics. It certainly CAN help, as long as the proper probiotic is used and as long as it makes it past the acidic environment of the stomach. In choosing that probiotic, it’s tough to decide which one is the best, the one with the red label, the blue label, the green, the orange, the live cultures, the spores, the one with prebiotic AND probiotic. It’s almost impossible.

And unless you have a degree in microbiology, you may be unaware that those 40 trillion organisms are a mixture of bacteria (aerobic, microaerobic, anaerobic), viruses (both those that affect humans and those that affect the bacteria), fungi (in both yeast and spore forms), protozoa, helminths (worms (yuck)), and archaebacteria (the ancients). Many maladies in medicine have treatments and some have cures, but sometimes all we can do is alleviate symptoms. The microbiota can be part of all of these. Sometimes there is ONE microbe that is the offender. We try to eliminate it with an oral medication. However, it is very unlikely that the medicine acts like a “magic bullet or a smart bomb”. The treatment is far more likely to act like a “nuclear bomb” and kill both its target and a whole lot of innocents. Smarter would be to recruit some microbes to engage in battle with their neighbors or to foster an increase in certain microbes numbers so as to produce metabolites that will benefit us. We just don’t know how to do that yet.

What we can do is analyze the stool and generate a complex report that shows what percent of each known microbe is present, similar to this. After testing tens of thousands of patients, we pretty much know what is normal. Often, in an ill patient, there will be an overgrowth of a microbial family that coincides with known symptoms. Let’s say there is a lower concentration than normal of “Bacteria A (an aerobe)” and there is a higher than normal concentration of “Bacteria B (an anaerobe)”. Let’s also say that the profile is from a patient suffering from a lot of bloating and secondary pain. Let’s also say that Bacteria A is known to compete for the same living space as Bacteria B. Seems like Bacteria B is overpopulated. It may be known that Bacteria B is a gas producer. Suddenly things make more sense. The natural tendency is to want a medication to eliminate Bacteria B. Wrong call though (nuclear bomb scenario). A better answer would be to deliver substrate (food) that is preferred by Bacteria A and let it grow in numbers. That’s what I mean by recruiting certain bacteria to benefit us. Often, that can alleviate the patient’s symptoms.

However, a random supplement off the shelf is not likely to be the solution. Trial by error is fine and sometimes it works well. My family found one specific probiotic that helped some of them. But the others it didn’t. I’m sure many of you have similar stories. This is one of the new frontiers in medicine: knowing what lives within us, and working with them to help improve our lives. A lot of that will be diet (we are what we eat). A lot of that can be the right supplements. As a microbiologist before becoming a doctor, I couldn’t be more excited to finally see this frontier opening up with a lot of research. In the news, we have seen fecal transplants, phage therapy (viruses that kill bacteria), prebiotic therapies, low inflammatory diets, amino acid therapies, and of course probiotics.

They have several products, but we recommend one called “GI SereniT”, available via a prescription from us. On a six month trial, they will have you send in a stool sample (I know, gross, but how else?) via a very simple auto disposing sanitary towel collection method. They analyze the stool to generate a profile of YOUR microbiome. A naturopath health care provider then reviews the health survey that you returned with the sample.

A matching pattern of microbial overgrowth/undergrowth and patient symptoms is searched for.

Then, a custom blend of probiotics is made to adjust that pattern. I specifically asked them how many formulations they have. The response was that they have zero on the shelf, but thousands of possibilities based on the recipe recommended by the doctor. It is truly custom. They then package a huge number of live probiotics (higher than just about anything over the counter) and most of it is not spores, so it will be shipped cold and kept in the refrigerator. One capsule daily, inside a personalized container (nice personal touch).

But like the infomercials have said for years, “but wait, there’s more!”, they also provide the PREbiotic for the PRObiotic. That is the food for the probiotic to flourish and populate (think of a new plant outdoors au natural or with some fertilizer). After three months, they want another sample and another medical report. That will assess whether the blend actually accomplished the goal of both normalizing the microbial pattern and relieving the patient’s symptoms. If that didn’t work, they reblend and try again. If that did work, then it settles into a daily probiotic that shows up at the house.

And how does it just show up? YOU talked with US. There it is again, merging YOUR story with OUR experience, while engaging MODERN TECHNOLOGY. When we say things are different at our practice, we mean it.

Confused? No problem. It’s extremely complicated. Come on in. Take a seat. Have a drink from the cooler. We can explain it all.

Cognivue Spotlight

Mon, 29 Jul 2024 16:11:29 GMT

Introducing a new tool we have added to our clinic, filling a gap in the screening for early cognitive deficits … dementia. For an overview of the full screening process, please see our blog titled Neurocognitive Screening.

It is challenging to make a diagnosis of dementia in the earliest stages. For some forms, there are specific findings that can lead toward early diagnosis, and some of these are visual findings.

Whereas there are a few diagnostic markers available once a problem has been identified, such as p-tau 217, Beta amyloid, ApoE gene markers, and MRI, they are basically “late to the game”. It’s EARLY SCREENING that is needed.

Typical screening involves a paper based test that misses a significant component … visuospatial, and how that is integrated into what we call executive function. It is known that visuospatial tracking and visual memory correlate fairly well with early disease onset before some of the other things become apparent. It is the visuospatial screening that has been difficult to do in a primary care setting, but finally there are ways to get that done … one of those is via the machine called Cognivue.

(The next few paragraphs get a bit technical. It’s always hard to know who wants to know how much detail. But, forewarned …)

The machine tests what we call visuospatial function. Broadly defined, visuospatial function is the ability to specify the parts and overall configuration of a percept (a mental concept that is developed as a consequence of the process of perception), appreciate its position in space, integrate a coherent spatial framework, and perform mental operations on spatial concepts. Visuospatial function is commonly conceptualized in three components: visual perception, visual construction, and visual memory.

Visual perception involves light perception, contrast sensitivity, stimulus orientation, visual acuity, detection of color and motion, and processes mediated primarily by the occipital cortices.
Visual construction involves multiple areas of the brain putting things together (the parietal, temporal, and frontal cortices).
Visual memory consists of two main components: recall of visual information and topographical memory.

Visuospatial dysfunction is among the earliest manifestations in some dementias, eventually affecting >20% of those patients. One study showed disabling visuospatial disorientation in more than one-third of dementia patients, while almost half of patients complained of visuospatial problems when questioned directly. Patients may describe impaired discrimination of form, colors and contrast, motion detection, as well as disturbances of higher order functions such as reading, visuospatial orientation, and visual search strategies.

You can see how complicated the entire process is, and traditional testing does not engage this aspect. That is why we are so pleased to have an additional tool. Now that we have reviewed the what and the why, let’s discuss the machine itself.

It’s called Cognivue and it is in our office. The device is a self-administered, digital cognitive assessment that standardizes the patient’s experience and removes the bias that can exist with traditional testing methods. The technology collects over 130,000 data points and is highly sensitive to each individual patient. It uses something called adaptive psychophysics, creating a unique patient experience customized to each patient’s individual visual and motor skills. It has been validated against other recognized gold-standard cognitive assessment tools, while providing an experience customized to each patient. The custom experience is important to what we do at Alliance, and the self-administered computerized process fits seamlessly into the clinic workflow. You may note that rather than using a keyboard, the entire test is done via what they call a CogniWheel. It is a simple, intuitive, and easy-to-maneuver wheel.

The test process itself takes the patient through a series of exercises to assess the domains of Visiospatial: Memory, Executive Function/Attention, and Discrimination, as well as two speed performance parameters. The computer screen with which the patient interacts will look a lot like the following (notice how the activity presented changes depending on the specific aspect being tested):

The Cogniwheel is the control that allows the user to maneuver a highlighted area to select the response they wish to enter. The results are calculated via the computer, taking into account the patient error rates, reproducibility of the errors, and reaction time. Those results are compared with a large data set, placing the patient on a curve of what would be considered normal or outside of the normal range, and generates a score for each section. This is helpful because should a narrow problem be identified, it can be followed by additional investigations and potential referrals to neurology or ophthalmology. Should the test be considered “normal”, then the score is helpful as a marker for repeat screening at a later date (perhaps annually). A decline would also lead to additional investigations and potential referrals.

We then incorporate this information with the remainder of the cognitive screening visit, and merge all of that with what we know about you.

That concludes the overview of one more tool we have available at Alliance. This is perhaps a perfect example of integrating modern technology with your story and our experience … something we continually strive to deliver.

Neurocognitive Screening

Mon, 29 Jul 2024 16:07:07 GMT

Neurocognition refers to the functional aspects of the brain. That includes receiving proper input from the senses (hearing, vision, touch, smell). It involves the processing of received information. It certainly involves the orchestration of complex movements, emotional interactions with others, and complex thought processing.

At Alliance, we believe in screening for problems in this area rather than waiting for symptoms to surface. Neurocognitive decline is far more common than most realize. Here are some facts:

The prevalence of subjective cognitive decline is 11%, or 1 in 9 adults.
The prevalence by age breakdown is: age >65 years = 11.7%, age 45-64 years = 10.8%.
The prevalence by sex breakdown is: 11.3% among men and 10.6% among women.
The prevalence increases steadily with age, so that by age 90, about 33% have dementia.

Note how early the decline is reported. So, when we think we are not processing information as fast or our reaction times are not as fast as they were just a few years ago, it may be accurate. It may not be a problem that needs to be fixed, but there are ways to optimize our well being so as to compensate for minor changes. If you are wondering about those early symptoms, here is a graphic.

Adding to the surprise of how early in life decline is noted, is the following:

Less than half of adults with Subjective Cognitive Decline (45.3% of adults aged 45 years and older) reported discussing symptoms of confusion or memory loss with a health care professional.

At Alliance, we won’t wait for you to “bring it up”. We will ask you directly, and then put some science to the subject. And here is a big part of the why:

28% (1 in 4) with Subjective Cognitive Decline have coronary heart disease or have had a stroke, 33% (1 in 3) report frequent mental distress, and 66% (2 in 3) have at least two chronic diseases.

So, if a deficit is noted on screening, that’s why such an extensive evaluation begins. It’s to uncover the other things that are going on.

The Basic Screening Tests Done at Alliance

I mentioned screening tests. Here are the tests you can expect on a periodic basis inside our office (perhaps annually after the age of 50):

Hearing (In office, computer based, 250-8000 Hz, 0-100 dB)
Vision (typical eyechart or referral to ophthalmology)
gait/balance assessment (often the BERG test, usually done via visiting physical therapists in our office
paper based cognitive testing (MOCA/SLUM/MMSE). Either test is administered by medical staff, takes about 10 minutes, and has a 90% sensitivity for detection of early cognitive decline. There are 8-11 questions, scored individually and as a composite, that assess the areas of visuospatial discrimination, executive function, naming, immediate and delayed recall, attention, language, abstraction, and orientation.
various blood tests
screening for anxiety (GAD-7). It scores seven criteria for generalized anxiety. It is self-administered and scored as 0-3 in each area. It has over 80% sensitivity and takes about 2 minutes to fill out.
screening for depression (PHQ-9). It scores nine criteria for major depression. It is self-administered and scored as 0-3 in each area. It has over 80% sensitivity and takes about 3 minutes to fill out.
screening for sleepiness (Epworth Sleepiness Scale). Often overlooked is sleep quality. We use the Epworth Sleepiness Scale, which tests 8 areas for a total score of 0-24. Should a significant problem be noted, then a more intense focus on sleep hygiene or wakefulness promotion can be engaged.

Corelated with memory decline is visual processing of different inputs. Previously, this has been hard to test in a primary care clinic, but such is not the case anymore. We are pleased to have in our office, a device called Cognivue. The test is a self-paced, computerized test that takes 10 minutes. The test uses visual cues and manual responses to assess fine motor skills, basic visual acuity, perception discrimination of letters/words/shapes, and short-term memory of letters/words/shapes/motion. All in all, this adds significantly to the established norms. Supposing that tests return normal, then we will score it, record it in your chart, and then retest in a year.

Workup for Cognitive Decline

If you think that sounds like a lot for generalized screening, take a moment to think how much of your everyday activities involve the brain. Virtually every waking moment AND every sleeping moment. As we know, early detection helps just about everything. Should a deficit be identified, then a plethora of additional tests may be called upon (at which time you won’t think the generalized screening was all that much). These next level tests could involve:

Pharmacogenomic Testing (genetic testing done in our office of 40+ genes used to metabolize medications). No one has a completely normal test, and it allows for custom medication management.
Imaging tests of brain, vasculature, and more. This may involve a myriad of choices involving xray, ultrasound, CT, and MRI.
Extensive blood tests for infection, autoimmune disease, vitamin/mineral deficiencies, hormonal abnormalities, toxicities, and even occult malignancy
Potential genetic panel testing
Dietician Consultation in our office
Sleep Study
Referral to Psychology
Referral to Occupational Therapy, Physical Therapy, Neurologist, Neurocognition Specialist and others as indicated.

Helpful in this evaluation process is our access to a panel of tests, which subsequently generate a report for you that is colorful, descriptive, and breaks things down for better understanding. The same test will integrate measurements of p-tau protein, beta-amyloid proteins, and apoE gene testing (all correlated with progressive forms of dementia).

As you can see, things can get quite complicated. But the brain is at the center of everything. Therefore, everything influences its’ function. Understanding how all that interacts and engaging early in the process is why we do these assessments.

Should we encounter a problem, it will likely involve a multimodal approach. We will guide you through what is needed and orient you to valuable resources moving forward. Exactly what will be needed varies. Some things are universal. But we will also focus on YOUR associated medical problems (remember, 66% have multiple other medical problems). Healthcare is not “one size fits all”.

And knowing that most will not have an active issue, there are plenty of proactive interventions to help reduce the risk of one day getting there. Meanwhile, we screen periodically. You worked hard to build the mind that you have; we will work hard to help you keep it.

Cancer Screenings

Mon, 17 Jun 2024 17:07:06 GMT

The Big “C." No one likes the word, but if we can’t say it, then we can’t look for it … and finding it early is everything. Let’s talk about Cancer Screenings

Prevention and early detection are most important when it comes to these maladies. Statistics suggest that most cancers in humans will develop after the age of 50 years. Regrettably, routine screening is only done for far less than half of all cancers. The American Cancer Society, United States Preventive Task Force, and others, all recommend screening the general population for cancers of the skin, breast, prostate, cervix, and colon. To that, add lung cancer screening for those at increased risk, and still less than half of new cancer diagnoses are actually screened for; the remainder are not, relying on suspicion that arises from early symptoms.

As precision medicine comes to fruition, additional testing IS available. We are pleased to have ready access to enhanced cancer screening via molecular studies of your blood. Some tests detect suspicious DNA profiles in the blood whereas others detect abnormal proteins. Add additional imaging for specific suspicions, and potential full body MRI, and it is now possible to screen for many additional different cancers. As with everything, what and when to test is a personal discussion to be had with your physician. We will help you assess risk factors and track screening results.

We thought it helpful to discuss a few of the many proprietary tests that are now available.

These are companies we are familiar with, and we can help you decide if such tests are suitable for consideration. The most important thing is to be aware that the technology is coming of age, and its’ potential as a tool for better wellness is forthcoming. Let’s discuss three of which you may be unaware.

Galleri looks for a signal associated with cancer.

There is some amount of free floating DNA in our blood (technically, the plasma). Both normal cells and abnormal cells shed this DNA, and it can be detected through molecular analysis. Normal DNA has a very “normal appearance”, sort of like a well organized house, or an evenly spaced bar code we see with purchases. Cancer is “ugly” and generates a different appearance. It can be picked up on and sorted into where it may have originated. Though the body likely develops minor cancers frequently during our lifetime, we have a tumor surveillance network within our immune system that takes care of the problem … until that fails. So if something shows on the blood work that is abnormal, does it mean it WILL be a cancer fight? Nope. And that’s where the confidence and discussion with your doctor comes into play. When should we look, where should we look, or should we look at all.

The Galleri test screens a blood sample for cell-free DNA and identifies whether it comes from healthy or cancer cells, via methylation pattern. The test checks more than 100,000 DNA regions and over one million specific DNA sites to screen for a signal shared by 50+ cancers that may be present at the time of the blood draw. If a cancer signal is detected, results from the test can predict the tissue type or organ associated with the cancer signal. It is important to note that Galleri is a screening test and does not diagnose cancer. Diagnostic testing is needed to confirm cancer. Nor is the Galleri test a genetic risk assessment tool, meaning it does not determine future risk of developing cancer. It is an early detection tool for something that may be present at that moment in time only.

There are two possible results to the test:

No Cancer Signal Detected
Cancer Signal Detected

You will not receive a list of the 50+ types of cancer and a result for each one. If Galleri detects a cancer signal, your result will include one or two Cancer Signal Origins which predict the tissue type or organ associated with the cancer signal. From there, your doctor will order additional, more refined tests.

The Galleri test does not detect a signal for all cancers and not all cancers can be detected in the blood. False positive and false negative results do occur.

Galleri advertises the ability to detect the following cancers: Adrenal Cortical Carcinoma, Ampulla of Vater, Anus, Appendix Carcinoma, Bile Ducts Distal, Bile Ducts Intrahepatic, Bile Ducts Perihilar, Bladder, Bone, Breast, Cervix, Colon and Rectum, Esophagus and Esophagogastric Junction, Gallbladder, Gastrointestinal Stromal Tumor, Gestational Trophoblastic Neoplasms, Kidney, Larynx, Leukemia, Liver, Lung, Lymphoma (Hodgkin and Non-Hodgkin), Melanoma of the Skin, Merkel Cell Carcinoma, Mesothelioma, Nasal Cavity and Paranasal Sinuses Nasopharynx, Neuroendocrine Tumors of the Appendix, Neuroendocrine Tumors of the Colon and Rectum, Neuroendocrine Tumors of the Pancreas, Oral Cavity, Oropharynx (HPV-Mediated, p16+), Oropharynx (p16-) and Hypopharynx, Ovary, Fallopian Tube and Primary Peritoneum, Pancreas, Penis, Plasma Cell Myeloma and Plasma Cell Disorders, Prostate, Small Intestine, Soft Tissue Sarcoma of the Abdomen and Thoracic Visceral Organs, Soft Tissue Sarcoma of the Head and Neck, Soft Tissue Sarcoma of the Retroperitoneum, Soft Tissue Sarcoma of the Trunk and Extremities, Soft Tissue Sarcoma Unusual Histologies and Sites, Stomach, Testis, Ureter, Uterus carcinoma and sarcoma, Vagina, and Vulva

The Galleri Test is something that we stock in our office, and courtesy of our relationship with SignatureMD, it is available for a discounted price from what is advertised on the internet. We will draw the blood in our office.

NodifyLung helps specifically with sorting out benign lung nodules from lung cancer.

It is a common and frustrating situation. Chest xrays are done often for various reasons. Sometimes they are done in people who have an increased risk for lung cancer. Sometimes the xray finds a spot. They call it a nodule if it is under 3 cm; a mass if it is bigger. A mass is a problem, and all stops are pulled out to pursue its’ identity. But the nodules are another matter. Have they been there for years, residual from a long forgotten infection? Or are they new and the beginnings of what will become a monster? It’s easy to say biopsy the area, but it’s always the details of how to get to that small target and how much risk is involved (it is in the chest with things like the lung, the heart, and the arteries) vs just waiting and repeating the test later. If it grows, then action will be taken. But if it grew …. Arrgghh!

There are some proprietary technologies available to help lean that decision. One that we are acquainted with is specifically for lung nodules (that 1-3 cm) “spot”. It is called NodifyLung, also stocked in our office; also a blood test that we will draw. The way it works is as follows: It is an integrated classifier that measures the ratio of two proteins (LG3BP and C163A) and combined with several clinical and radiological factors provided by your doctor, helps score those nodules into those that are more or less likely to be benign. It will literally give the percent chance that those nodules will go one way or another. Sometimes it is very helpful, where a flip of the coin before the test results in a 10% chance the nodule is a problem. That in turn makes the decision to wait a few months and repeat CT scan much more comforting. Of course, if the test result is just the opposite, say 90% chance the nodule is a problem, then it makes the more risky procedure of biopsy far more acceptable.

For those who are wondering about these two proteins… like everything, it is complicated. The LG3BP is a beta-galactoside-biding protein that has been implicated in modulating cell-cell and cell-matrix interactions (cancer likes to grow). The C163A is a scavenger receptor that helps clear iron complexes, and is a marker of local inflammation (cancer is highly inflammatory). Somewhere in the math, this can estimate risk.

And then there is Total Body MRI.

A technology, that in the past was cost prohibitive and not detailed enough to sort out normal lumps and bumps from serious concern. We don’t want to pursue every lump on the inside of the body as most are not a problem (think about the skin and how not every wart, mole, or spot is actually a serious problem), except for the ones that ARE a problem. Again, arrgghh! But, today’s MRI is not your grandfather’s MRI (wait, were there MRI back then? The first MRI was in 1977).

There are a few companies out there that do this and it can require travel. The tests aren’t cheap and they aren’t for everyone, but it IS a technology available for the right situation, and it merits discussion. In general, these machines use an average power magnet (measured in teslas) but do a lot with the computer programming to generate extra spins and weightings. It takes an hour inside a tube, and the result is a lot of “voxels” (ie 3D pixels) with multi parametric and diffusion weighted images. The product is a reasonable look inside the body, with enough detail to give some indication as to the risk of what is seen.

Well, that is a tour of just three proprietary tests that are available. They are not suitable for everyone, and certainly not part of the universally recognized set of recommended screening tests. Which, if you were wondering, the universal screening tests are aimed only at: breast, prostate, and colon. Most doctors add to that anyway, including general screening for leukemia, some for kidney and liver, along with a focus on risk factors that lead to skin checks, lung tests, and focused testing. Most doctors try to go above the basic need. But, basic needs and universal recommendations trail modern science by years. At Alliance, we want to make you aware of what else is available now, work together on whether to pursue those options, and help to optimize your health.

Body Composition

Wed, 12 Jun 2024 17:34:46 GMT

We would like to discuss body composition analysis, dietary choices, exercise regimens, and the integration of that into the Personalized Health Care Plan.

Body Composition

At Alliance, we believe in looking at the whole person when we evaluate any part of health, and this includes body composition. We all know that weight can affect our health, and for years, people have heard the medical community telling them to eat healthy, exercise more, and lose weight (for most people). The BMI (body mass index) has been used as a way to measure this, but we have known for a long time that does not tell the whole story as the BMI just takes into account a person’s height and weight, which is then put into a formula to give a number It does not look at muscle mass or body fat. This means that a person who is a body builder, for example, would be classified as obese based on the BMI, while someone who is considered normal or underweight, may actually have too much fat, which is detrimental to their health.

A healthy body composition can decrease risk for many metabolic conditions such as high blood pressure, diabetes, cardiovascular disease, and contributes to a stronger immune system. As you can see in the picture above, someone of the same height and weight can have very different body fat percentages, which would give them a very different risk profile, although if you just look at weight and height, this would not be apparent.

Measuring body composition gives a more accurate idea of what is going on inside the body. There are multiple ways of measuring body composition including skin calipers, hydrostatic weighing, air displacement plethysmography, dexa scan, MRI, and bioelectric impedance analysis (BIA). We use BIA, as the other methods are more expensive, time consuming or not as accurate (in the case of skin calipers). BIA applies low-level alternating electrical currents to an individual to measure the volume of water through impedance values. The device measures how the electrical signal is impeded through different types of tissue. Muscle has high conductivity while fat does not. BIA provides estimates of body water based on the conduction rates, and then body fat is calculated via equations done by the machine.

A healthy body composition is different for men and women, mostly as women need a higher amount of fat for their bodies to function optimally. Essential fat, as the name implies, is essential for normal body functions, which includes insulation, protecting internal organs, storing vitamins, regulating hormones and childbearing.

Male
45% Muscle tissue
3% Essential fat
12% Non-essential fat
15% Bone
25% Other

These numbers are not exact, and there is generally a range of acceptable normal values. Age also plays a part in ideal body composition, with slight increases in body fat being normal as we age (the increase in body fat can be somewhat protective during acute illness). For example, total body fat (essential plus non-essential) ranges for males aged 20-39 are 8%-19%, while females are 21-32%, but when they are aged 40-59, males should be 11-21% and females 23-33%, and with ages 60-79, males should have 13-24% and females 24-35%.

Our testing measures various aspects of body composition, as seen on the report above, including:

Body fat percentage (PBF) : This tells how much fat mass makes up your total body weight.
Skeletal Muscle Mass (SMM) (also shown as segmental lean mass) : this shows how much skeletal muscle mass you have in each body segment (left, right, upper body, lower body and trunk), allowing you to focus on building more muscle or correcting imbalances to ensure you have a healthy muscle mass balance. Skeletal muscle is essential for mobility, posture and assists in metabolism.
Total Body Water (TBW) : this includes both extracellular water (ECW, water outside the cells) and intracellular water (ICW, water inside the cells). A healthy balance is needed, and if it’s not balanced, this may need to be addressed.
Visceral fat : this is the fat that surrounds the organs, and while it is necessary to have some to protect the organs, too much can lead to significant health problems. Visceral fat can increase inflammation, which can lead to hypertension and has been linked to higher rates of heart disease, dementia, high cholesterol, cancers and insulin resistance. Studies have linked visceral fat to a three times higher risk for developing dementia. The goal is to have this level less than 10, which is based on a proprietary formula from InBody.
Basal Metabolic Rate (BMR) : this is the number of calories that your body needs to just exist (lying on the couch, not doing anything). This is a very useful number to know, as if you eat too few calories, you are likely to break down muscle tissue and worsen your body composition. We can use this number along with your specific goals to determine how many calories per day you need to achieve your goals.

How to Improve Body Composition

Once you know your numbers, you can decide whether you want to make changes, and if you do, what you want to change. For example, if you want to add muscle mass, then having a higher caloric consumption is necessary, while if your goal is fat loss, then you would require less calories. The types of macronutrients is also important, especially protein, as it is important for both muscle growth and fat loss. Exercise is also essential for everyone, and the type of exercise you choose to do can affect your body composition.

Following the generation of the report, we will sit down to discuss details and together generate an action plan that may involve dietary changes, cardio training, muscle building, or recruitment of additional professionals

Improving Your Body Composition Through Diet and Exercise

Nutrition :

There is not one right way to eat. There is a myriad of dietary patterns. One size does not fit all. There are many factors that contribute to what and how you eat, including work, family, lifestyle, budget and preferences. What and how you eat can definitely affect your health. Certain ways of eating put you more at risk for certain conditions, and if so, it is important to get certain labs checked to ensure that you are not deficient in any area. Although we have listed a few dietary choices below, there are other dietary styles that people either choose to follow or are instructed to follow due to medical reasons (such as low FODMAP, gluten free etc).

Dietary Choices:

Mediterranean : The Mediterranean diet has been shown to reduce cardiovascular disease and is more of a way of living as well as a way of eating. There is no one definition of this, but it tends to be high in vegetables, fruits, whole grains, beans, nuts, seeds, olive oil, seasoning with herbs and spices. Fish and poultry are eaten in moderation along with beans, legumes and eggs as sources of protein. Moderate portions of dairy products are included, but red meat and foods with added sugar are limited. They also recommend that meals are shared with family and friends, drink moderate amounts of wine if you drink alcohol, and exercise regularly.

Vegetarian/plant based : All vegetarians exclude meat products, but there are many variations of vegetarianism beyond this. It is possible to eat a very healthy diet as a vegetarian, especially if it is plant based, or it can be not so healthy and filled with highly processed foods. Variations of being vegetarian include Vegan (strictly no animal products at all, including wearing animal products or using animal products around the home); Lacto-ovo (containing milk and eggs); Pescetarian (including fish and seafood); Flexitarian (allows occasional meat or seafood)

Calorie Counting : This is exactly how it sounds. Setting a calorie goal and trying to meet it. This may or may not also look at the types of foods that are eaten. We do not endorse following a very low calorie diet for most people, as this tends to mess up your metabolism longer term. Some examples of this include weight watchers (who use points as a surrogate for calories) and many apps which help you to track your calories.

Time restricted eating (AKA intermittent fasting) : Time restricted eating involves only eating at certain times of the day. Many people choose to restrict their eating to 6 or 8 hours, and fast the rest of the day. For some, that can be as simple as skipping breakfast, or finishing eating after lunch. This type of eating can be combined with many of the other eating strategies mentioned here.

Paleolithic : this way of eating emphasizes whole and unprocessed foods.

Macro based: These diets focus on the ratios of protein, carbohydrates and fats. The following four diets all fall within this category:

Ketogenic : This focuses on a high fat, moderate protein and very low carbohydrate (often below 20gms per day) in order to allow your body to get into ketosis

Low carbohydrate : similar to a ketogenic diet, but generally not as low a carbohydrate level as ketogenic. Tends not to be high fat.

Low fat : The focus is on keeping fat levels low.

Carnivore : A carnviore diet refers to the consumption of animal-based foods. People who follow a carnivorous dietary pattern eat almost exclusively only meat and other animal-based foods. This would include meat, fish, eggs, low lactose dairy, and may include honey, salt, pepper and zero carb seasonings. It generally excludes fruits, vegetables, grains, high lactose dairy, sugars and plant based oils.

We can provide more information on any of these or other dietary plans, as well as refer you to a dietician.

Using the InBody to measure your body composition and determine your BMR helps you to decide how many calories per day you need to change your body composition. Naturally, the types of food you eat will affect how your body composition changes, and remember that protein helps to build muscle and too little protein will lead to muscle loss.

And there are so many more dietary options, but we have to stop somewhere.

With regards to exercise, there are just as many options, but let’s discuss some aspects of the purpose.

Exercise :

Exercise is always recommended to be part of a healthy lifestyle. The current physical activity guidelines for Americans recommends that all adults (including those who have chronic illnesses or disabilities) get at least 150 minutes of moderate exercise per week, which can translate into 75 minutes of vigorous activity per week, or a combination of moderate and vigorous exercise. In addition, adults should also do 2 days per week of exercise that strengthens muscles. There are many options, but the biggest recommendation is to find an activity that you enjoy (or hate the least), and just do it. Scheduling physical activity like it is an appointment or meeting can help some people to ensure it is done and allows you to dedicate time for exercise. Finding a time which works well in your day (eg early morning before the rest of the household wakes, immediately after work before you go home). Simple strategies such as parking further away from your destination or taking stairs rather than an elevator allow you to increase the amount of physical activity that is done in the day. Short bursts of exercise throughout the day can significantly help your body’s metabolism. Below are some suggestions of different kinds of activities, but it is not all inclusive, and there are many crossovers between categories (eg depending on how you lift weights, that can also provide a decent cardiovascular workout although it’s in the strengthening group).

Different types of exercise:

Cardiovascular :

Running, jogging, walking, bike riding, swimming, basketball, football, baseball, hiking, walking the dog, gardening, mowing the lawn, stairclimbing, kayaking, dancing, HIIT (high intensity interval training), martial arts, pickleball

Strengthening: machine weights, hand weights, dumbells, kettle bells, resistance bands, bodyweight exercises (eg push ups, pull ups, squats, lunges, digging), pilates, HIIT (high intensity interval training)

Stretching : yoga, pilates, stretching with bands, tai chi

Whether it’s the dietary styles or the exercise regimens, there are so many options. One is better for you – another is better for me.

We are all unique with regards to:

body compositions
dietary patterns
exercise preferences
medical conditions

What Alliance can do for you:

assess that body composition in detail.
discuss various dietary patterns and get you a personal consultation with an allied dietician, right in our office.
discuss various exercise options and recommend trainers and gyms in the area.
discuss medical limitations and get you a personal consultation with an allied phy sical therapist, right in our office.

In summary, let us help you personalize a diet and exercise plan to more optimize your health.

Meet Our Dietitian

Thu, 06 Jun 2024 17:11:12 GMT

We are excited to share that we have a dietitian that we work closely with, who is helping our patients achieve their nutrition goals. Lauren comes and sees our patients in our clinic, or if you prefer, you can meet her at her office. We highly recommend reaching out to her to accomplish your goals.

In her own words…”Welcome to a personalized nutrition approach to help you reach your goals! My name is Lauren, I’m a Registered Dietitian passionate about helping people implement realistic nutrition strategies that are sustainable and results driven.

I believe in a personalized nutrition approach when working with my clients to support them wherever they are in their journey. Whether you’re just getting started with nutrition changes or have tried every diet out there, let’s work together to reach your health goals one step at a time.

Now accepting patients for:

Weight Management
PCOS
Meal Planning
Diabetes, Hypertension, Heart Disease
Healthy Lifestyle Changes
Sports/Performance Nutrition (Adult and Adolescent)”

*Insurance accepted: Anthem BCBS, Unitedhealthcare, **Medicare
*Verify that your insurance policy covers visits with a dietitian
**Medicare only covers diabetes and kidney disease

Pharmacogenomics

Fri, 24 May 2024 17:16:04 GMT

At Alliance, it’s all about having personalized health care.

Part of that personalization frequently involves prescription medications.

Knowing the chemistry and genetics of each individual can significantly influence the response to those therapies.
At Alliance, we are literally aiming to hit the mark as close as possible without undue side effects.

Science is finally catching up to modern prescription management and we are pleased to offer our patients pharmacogenomic testing.

The concept is foreign to many, so we thought it worth a short primer:

First, let’s start with WHAT IS pharmacogenomics?

Pharmacogenomics is an important example of precision medicine, which aims to tailor medical treatment to each person or to a group of people. Pharmacogenomics looks at how your DNA affects the way you respond to medications. In some cases, your DNA can affect whether you have a bad reaction to a medicine, whether a medicine helps you, or whether it has no effect. Pharmacogenomics can improve your health by helping you know ahead of time whether a medication is likely to have its’ predicted affect or be more likely to cause side effects.
Next, what does the genetic profile MEAN ?

Medications interact with the body in numerous ways. After taking a medicine, the body needs to absorb it, process it, get it to the intended area, and then eliminate the excess and the metabolites. DNA can affect any of these steps and thus influence the response to a given medication. Some examples:

Drug Receptors. Some medications need to attach to proteins on the surface of cells, called receptors, in order to be absorbed and/or be converted to work properly. Your DNA determines what type of receptors you have and how many, which can affect your response to the medicine. You might need a higher or lower amount of the medication than most people or a different medicine entirely.
Drug Presence. Your DNA can also affect how quickly some medications are removed from the cells in which they act. If medicines are removed from the cell too quickly, they might not have time to function effectively. If they persist longer than needed, side effects happen.
Drug Breakdown. Your DNA can affect how quickly your body breaks down and eliminates a medication. If you break the medicine down more quickly than most people, your body gets rid of the medicine faster and you might need more of the medicine or a different medicine. If your body breaks the medication down more slowly, you might need less of the medicine.
Metabolites. Many medicines get processed into another chemical form, which can also be metabolically active, and which follows its’ own pathway for breakdown and elimination. And then there are the metabolites that interact with one another or with a separate medicine.

Knowing this, test results infer a genetic profile of a specific enzyme that would be consistent with a poor, normal, or rapid metabolizer of medications utilizing that enzyme pathway. To make things even more complicated, someone may be a poor metabolizer via one enzyme, but an extensive metabolizer for another, all involving separate processes followed by the same medication. So complicated.

Doctors will then use this information to better predict which medications may require dose adjustments, may be less likely to work, or may have an increased risk of side effects based on your genetic makeup.

The science is just now catching up with what all doctors knew, that some medicines work for some people and those same medicines don’t work or cause harm to others. Doctors routinely assess benefit/risk of a medication via frequent follow up visits with questions and lab testing. But now, at the time of choosing to medicate, a decision can be made ahead of time. A decision influenced by science, that certain medications may work better with your unique genetic profile, some may be more likely to have side effects, and some might not work at all.

There are several laboratories that offer such testing, though each is different on what they test, how many genes they test, how many meds they cross reference, and how much distillation of the data they provide. It can be overwhelming.

It is a lot of data and difficult to summarize, which is what you (the patient) and all doctors, are going to want. But it still lacks the specifics of what THIS report means TO YOU. That’s where we do our best, using our experience and our professional opinion, to distill that data into something specific and meaningful. From there, we make a joint decision on whether to change anything or to change a lot of things. Little within these profiles is crystal clear. In fact, at this time it should be considered a dull tool, filled with nebulous suggestions, but we find that it frequently sheds light on why certain meds were not tolerated in the past and it certainly helps to choose meds that are predicted to be metabolized in a normal fashion.

Immigration Medical Exams

Wed, 07 Feb 2024 17:21:45 GMT

We are now offering a new service to the community. Dr Palley is a Civil Surgeon for the U.S. Citizenship and Immigration Services, and will be conducting medical examinations for individuals seeking a status change.

For those wishing to do this medical examination, you will need to:

Bring picture ID (can be a passport, driver’s license, work authorization card, etc.)
Bring any medical records if they are easily available
Bring an interpreter if needed for any language other than English or Spanish. We are fluent in both English and Spanish, but if another language is spoken, you will need to bring an interpreter
Bring all vaccination (immunization) records
We only accept cash for payment of the fee, which covers the medical exam and all required labs, as well as completion of the I-693 form. Additional labs may be recommended which are not included in this fee. Required vaccinations are not included in this fee.
All fees must be paid in full prior to the I-693 form being released.
Most people will need to have a blood draw for required testing. Some adults may be required to provide a urine sample. Which tests are run are based on the USCIS medical testing requirements. It’s OK to eat or drink before the exam, and being well-hydrated will make it easier to obtain blood and urine specimens.

Breast Cancer Awareness Month

Mon, 09 Oct 2023 17:24:11 GMT

1 in 8 women in the United States will be diagnosed with breast cancer in their lifetime.

This is a really scary statistic, and most likely, you know someone who has been diagnosed with it. It is estimated that in 2023, 297,790 women and 2,800 men will be diagnosed with invasive breast cancer. About 85% of breast cancers are in women with no family history of breast cancer.

The biggest risk factors for developing breast cancer include being female and growing older, two things that you have no control over. However, other things, such as not exercising regularly, smoking and drinking alcohol are all things that can be addressed, and can decrease your risk of developing breast cancer.

Fortunately, if breast cancer is found early, then it is frequently curable. In fact, the 5 year survival rate is 99%, when breast cancer is found at its earliest, localized stages. It is recommended that women do regular self breast exams, have an annual clinical breast exam done by your doctor, and yearly mammograms so that any breast cancer is found, and able to be treated, early