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Cut down on late night snacking to avoid GERD. METRO photo
Increased fiber and exercise improve symptoms

By David Dunaief, M.D.

Dr. David Dunaief

After a large meal, many people suffer from occasional heartburn and regurgitation, where stomach contents flow backward up the esophagus. This reflux happens when the lower esophageal sphincter, the valve between the stomach and esophagus, inappropriately relaxes. No one is quite sure why it happens with some people and not others. Many incidences of reflux are physiologic (normal functioning), especially after a meal, and doesn’t require medical treatment (1).

Gastroesophageal reflux disease (GERD), on the other hand, is long-lasting and more serious, affecting as much as 28 percent of the U.S. population (2). This is one reason pharmaceutical firms give it so much attention, lining our drug store shelves with over-the-counter and prescription solutions.

GERD risk factors range from lifestyle — obesity, smoking and diet — to medications, like calcium channel blockers and antihistamines. Other medical conditions, like hiatal hernia and pregnancy, also contribute (3). Dietary triggers can also play a role. They can include spicy, salty, or fried foods, peppermint, and chocolate.

One study showed that both smoking and salt consumption added to the risk of GERD significantly (4). Risk increased 70 percent in people who smoked. Surprisingly, people who used table salt regularly saw the same increased risk as seen with smokers.

Let’s examine available treatments and ways to reduce your risk.

Evaluate medication options

The most common and effective medications for treating GERD are H2 receptor blockers (e.g., Zantac and Tagamet), which partially block acid production, and proton pump inhibitors (e.g., Nexium and Prevacid), which almost completely block acid production (5). Both classes of medicines have two levels: over-the-counter and prescription strength. Let’s focus on proton pump inhibitors (PPIs), for which just over 90 million prescriptions are written every year in the U.S. (6).

The most frequently prescribed PPIs include Prilosec (omeprazole) and Protonix (pantoprazole). Studies show they are effective with short-term use in treating Helicobacter pylori-induced peptic ulcers, GERD symptoms, and gastric ulcer prophylaxis associated with NSAID use (aspirin, ibuprofen, etc.) as well as upper gastrointestinal bleeds.

Most of the data in the package inserts is based on short-term studies lasting weeks, not years. The landmark study supporting long-term use approval was only one year. However, maintenance therapy usually continues over many years.

Side effects that have occurred after years of use include increased risk of bone fractures and calcium malabsorption; Clostridium difficile, a bacterial infection in the intestines; potential vitamin B12 deficiencies; and weight gain (7).

Understand PPI risks

The FDA warned that patients who use PPIs may be at increased risk of a bacterial infection called C. difficile. This is a serious infection that occurs in the intestines and requires treatment with antibiotics. Unfortunately, it only responds to a few antibiotics and that number is dwindling. In the FDA’s meta-analysis, 23 of 28 studies showed increased risk of infection. Patients need to contact their physicians if they develop diarrhea when taking PPIs and the diarrhea doesn’t improve (8).

Suppressing stomach acid over long periods can also result in malabsorption issues. In a study where PPIs were associated with B12 malabsorption, it usually took at least three years’ duration to cause this effect. While B12 was not absorbed properly from food, PPIs did not affect B12 levels from supplementation (9). If you are taking a PPI chronically, have your B12 and methylmalonic acid (a metabolite of B12) levels checked and discuss supplementation with your physician. Before stopping PPIs, consult your physician. Rebound hyperacidity (high acid produced) can result from stopping them abruptly.

Increase fiber and exercise

A number of modifications can improve GERD, such as raising the head of the bed about six inches, not eating prior to bedtime and obesity treatment, to name a few (10). In the study that quantified the risks of smoking and salt, fiber and exercise both had the opposite effect, reducing GERD risk (5). An analysis by Journal Watch suggests that the fiber effect may be due to its ability to reduce nitric oxide production, a relaxant for the lower esophageal sphincter (11).

Manage weight

In one study that examined obesity’s role in GERD exacerbation, researchers showed that obesity increases pressure on the lower esophageal sphincter significantly (12). Intragastric (within the stomach) pressures were higher in both overweight and obese patients on inspiration and on expiration, compared to those with normal body mass index.

Avoid late night eating

One of the most powerful modifications we can make to avoid GERD is among the simplest. A study showed a 700 percent increased risk of GERD for those who ate within three hours of bedtime, compared to those who ate four hours or more prior to bedtime (13). Therefore, it is best to not eat right before bed and to avoid “midnight snacks.” While drugs have their place in the arsenal of options to treat GERD, lifestyle changes are the first, safest, and most effective approach in many instances. 

References: 

(1) Gastroenterol Clin North Am. 1996;25(1):75. (2) Gut. 2014 Jun; 63(6):871-80. (3) emedicinehealth.com. (4) Gut 2004 Dec; 53:1730-1735. (5) Gastroenterology. 2008;135(4):1392. (6) Kane SP. Proton Pump Inhibitor, ClinCalc DrugStats Database, Version 2022.08. Updated August 24, 2022. Accessed October 11, 2022. (7) World J Gastroenterol. 2009;15(38):4794–4798. (8) www.FDA.gov. (9) Linus Pauling Institute; lpi.oregonstate.edu. (10) Arch Intern Med. 2006;166:965-971. (11) JWatch Gastro. Feb. 16, 2005. (12) Gastroenterology 2006 Mar; 130:639-649. (13) Am J Gastroenterol. 2005 Dec;100(12):2633-2636.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.

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Stock image from Metro

October began on a somber note with several days of rain, cloudy weather and blustery winds. For many people, short-term inclement weather can lead to lethargy and depressed moods.

Dr. Veronique Deutsch-Anzalone, clinical assistant professor of psychiatry at Stony Brook University Renaissance School of Medicine, is a clinical psychologist who has researched the weather’s effect on people. The doctor said the first thing many think of regarding lousy weather and mental health is seasonal affective disorder, more commonly known as SAD. Deutsch-Anzalone said SAD is not technically considered a disorder anymore in the “Diagnostic and Statistical Manual of Mental Disorders,” but now what patients are diagnosed with is depression with a seasonal pattern. She added seasonal pattern is considered a specifier.

“Why not just throw on some raincoats and galoshes, go out and just jump around in the puddles and make those mud pies with them. They’re going to remember that and enjoy it.”

— Dr. Veronique Deutsch-Anzalone

“There are actually a lot of conflicting views on whether or not the lack of sun and the increase in cold and darkness causes us to have a depressed mood,” she said, adding that a 2016 study showed no objective data to support that depression is related to either latitude or season or sunlight. The doctor added that some people get depressed only in the summer.

However, due to many having depression that tends to follow a seasonal pattern, the disorder of depression with a seasonal pattern remains in the “Diagnostic and Statistical Manual.”

She said similar symptoms that people feel in the winter could be experienced even during short-term weather patterns, such as the recent period of rain, as lack of sunlight has been a factor in psychiatric problems and depression, with females and the elderly being particularly susceptible.

There are a few reasons, the doctor said, that support cloudy, rainy days being accompanied by depressed moods which involves serotonin, a body chemical that has to do with body functions; and melatonin, a hormone that induces sleep.

“We have our circadian rhythms where we’re programmed to be alert when the sun is up and be drowsy when it’s gone, and that is because when the sun goes down our bodies produce melatonin,” she said.

On darker days, the body produces less serotonin. On sunnier days, more serotonin is made, and it’s a neurotransmitter, Deutsch-Anzalone said. She added, on a cloudy day, people tend to keep the lights low in their homes and cuddle up on the couch to watch TV, which increases sleepiness. In turn, she said, a person may crave carbohydrates, sugar and salt.

“Unfortunately, when we turn to that kind of food that actually kind of makes us go into more of a slump, and can also cause some people to feel guilty and not very happy with themselves,” the doctor said.

Comfort foods raise serotonin but only briefly, Deutsch-Anzalone said. The best approach is eating healthy and drinking water. The doctor also advised against excess alcohol and caffeine intake, which can cause inflammation and dehydration.

She added an increase in aches and pains during stormy weather also doesn’t help matters. The drop in atmospheric pressure causes body fluids to move from the blood vessels to the tissues, creating more pressure on nerves and joints.

“That can lead to more increased pain or stiffness or reduced mobility, which then of course, makes us a little bit less likely to want to move,” she said.

She said on gloomy days, it can help to turn the lights on inside to increase serotonin and have more energy. Deutsch-Anzalone added some people might need a light therapy lamp or doctors may prescribe vitamin D.

She said it also helps to engage in enjoyable activities to lift one’s spirits. When a person is feeling down and can’t even think of pleasant activities, she suggests googling to find a list of things to do. Some, the doctor added, might be ones a patient hasn’t thought of, such as picking up an instrument, writing poetry or decorating a room. Exercise is also recommended as well as socializing or calling a friend.

Even in the rain, she suggested embracing nature, especially for people who have young children.

“Why not just throw on some raincoats and galoshes, go out and just jump around in the puddles and make those mud pies with them,” she said. “They’re going to remember that and enjoy it.”

Getting a good night’s sleep is also imperative, she said, since human’s circadian rhythms are thrown off when it’s dark outside for long periods of time. Napping and lying around the house most of the day also throws off a person’s sleep schedule.

“If you’re able to keep that good sleep hygiene and get a good night’s sleep, that will continue to give you a good amount of energy throughout the day, and it’ll ward off any sort of irritability.”

Deutsch-Anzalone advises anyone who is struggling with their mental health to seek professional help.

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Recently, 1,150 members of the LGBTQ+ community participated in including Micah Schneider, from Ronkonkoma, above. Photo rom Lisa Czulinski

In a first of its kind survey of 1,150 members of the LGBTQ+ community on Long Island, Stony Brook Medicine found that people in this group struggle with numerous health care challenges.

Stony Brook Medicine’s Dr. Alison Eliscu was the principal investigator of the study that 1,150 members of the LGBTQ+ community recently participated in. Photo from Stony Brook Medicine

Over two in five people responding to an online survey between June and September of 2021 said they were in fair to poor mental health. Additionally, about one in three people had thoughts of self harm, while 23.9% had seriously considered suicide within the past three years.

People in the LGBTQ+ community are struggling with mental health and access to care, while they also have had negative experiences with health care providers, who may have been making incorrect assumptions about their lives or who haven’t respected them, said Dr. Allison Eliscu, principal investigator of the study and medical director of the Adolescent LGBTQ+ Care Program at Stony Brook Medicine.

Partnering with 30 Long Island-based community leaders and community organizations, including Planned Parenthood, Stony Brook Medicine created the survey to gather the kinds of data that could inform better health care decisions, could provide a baseline for understanding the needs of the LGBTQ+ community in the area, and could shed light on the disparity in health care for this community.

“The idea [for the survey] came out when we were creating the Edie Windsor Healthcare Center” in Hampton Bays, Eliscu said, which opened its doors in 2021 and is the first such center for the LGBTQ+ population on Long Island. “We were trying to think about what we want [the center] to provide and what does the community need.”

Without local data, it was difficult to understand what residents of Long Island, specifically, might need.

The data suggests a disparity between the mental health of the LGBTQ+ community in the area and the overall health of the population in the country. 

Over half of the people who took the survey indicated that they had symptoms of chronic depression, compared with 30.3% for the nation, based on a 2020 PRC National Health Survey. Additionally, 23.9% of the LGBTQ+ community described a typical day as “extremely or very stressful” compared with 16.1% for the nation.

To be sure, the national data sampling occurred just prior to the start of the COVID-19 pandemic, in February of 2020, while the Stony Brook Medicine survey polled residents during the second year of COVID.

Nonetheless, Eliscu suggested that her anecdotal experience with her patients indicates that the LGBTQ+ community likely suffered even more during the pandemic, as some people lived at home with relatives who may not have been supportive or with whom they didn’t share their identity.

Additionally, the isolation removed some LGBTQ+ residents from an in-person support network.

Stony Brook Medicine has taken steps to provide specific services to residents who are LGBTQ+. People who are transitioning and have a cervix continue to need a pap smear.

Some members of the transgender community may not be comfortable going to a gynecologist’s office. Stony Brook Medicine has put in place extended hours to meet their needs.

Micah Schneider, a social worker who lives in Ronkonkoma, served as a survey participant and also as a guide for some of the wording in the survey.

Schneider, who identifies as nonbinary and transgender and prefers the pronoun “they,” said the survey can help people “recognize that we’re not alone.”

When Schneider was growing up, “I had a sense that I was the only person in the entire world dealing with this,” which included a struggle with identity and mental illness.

“We as a community have each other and we can lean on each other,” Schneider said.

As for medical providers, Schneider suggested that this kind of survey can alert these professionals to the need to honor names, pronouns and identities and not make blanket assumptions.

Despite some improvements, the local and national LGBTQ+ community remains at risk, Schneider said.

“There are any number of people who are actively considering suicide,” Schneider added. “It’s a very real crisis in our community.”

On a conference call announcing the results of the survey, Dr. Gregson Pigott, Suffolk County Commissioner of Health, described the survey, which Stony Brook plans to repeat in a couple of years, as “groundbreaking. What you have here is hard data based on the survey.”

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Stock photo

By Leah S. Dunaief

Leah Dunaief

This message is for older people who are reading this column and may get COVID-19. The information may save your life. It may have saved mine.

Especially for older people, COVID is a deadly virus. What defines older? Let’s say, beyond 50. Now there is a medicine that dramatically reduces severity and possible death from this virus, but many Americans are not taking it. Its name is Paxlovid.

“Never really in recent history for a respiratory virus can I think of an anti-viral medication being as effective, demonstrated in scientific literature, as what Paxlovid has shown,” stated Dr. Rebecca Wang, an infectious disease specialist at Dartmouth Hitchcock Medical Center, when interviewed by The New York Times.

Both random trials and data from electronic health records have shown this medicine to be effective, particularly among older patients. The medicine works by inhibiting the virus’s replication once it invades the body. Its underuse is already associated with thousands of preventable deaths, according to Dr. Robert Wachter, chair of the medicine department at the University of California, San Francisco.

“A large chunk of deaths are preventable right now with Paxlovid alone,” Dr. Ashish Jha, the White House COVID response coordinator told David Leonhardt of The New York Times. He predicted that if every American 50 and above with COVID received a course of either Paxlovid or monoclonal antibodies, daily deaths might fall to about 50 per day, from about 400 per day.

So why aren’t people taking the medicine?

For one reason, Paxlovid, which is taken twice a day for five days, does leave a metallic taste in the mouth. So I found that by eating half a banana after each dose, I got rid of the unwelcome taste. I also got the benefit of a banana a day, which is a healthy and nutritious fruit containing fiber and some essential vitamins and minerals.

Another possible reason is the association of Paxlovid with “rebound,” a second session of the disease which can occur a week to a month after the end of the first round. Experts don’t know what causes the rebound. A rebound is possible even if the patient never used Paxlovid. And even if he or she did, perhaps a longer duration of the drug is necessary for some patients than the five days currently administered.

Research has shown that out of sample of 568,000 patients, 0.016% over 50 who used Paxlovid died. For a similar cohort of patients who did not use the drug, the death rate was four times higher or 0.070. But only 25% of patients eligible to receive the drug actually took it, even though it is available and free.

Thanks to my son, Daniel Dunaief, who has spoken with two infectious disease experts, we also have some local reaction to the drug. Dr. Andrew Handel, pediatric infectious disease physician at Stony Brook Children’s Hospital, commented, “Hesitancy to take Paxlovid seems to fall in line with the general ‘COVID fatigue.’  COVID is clearly less lethal now than during prior surges, thanks in large part to vaccinations, but it still causes some hospitalizations. Those at highest risk of severe disease, particularly those who are unvaccinated, benefit from antiviral treatment if they are infected.”

Dr. David Galinkin, infectious disease expert at St. Charles Hospital, said, “The media has overblown this rebound experience. In the literature, about 10% of cases [have a rebound.] Like any other medication, people that could really benefit from Paxlovid [should consider it.] … We are still seeing people dying from this.”

Perhaps more doctors could be better informed about this drug. Additional information and encouragement are needed from the White House, and a lot more public announcements should be placed in the media to reach people. As has been the case throughout these last two-and-one-half COVID years, instructions have been changing, adjusted as the scientific and medical professions learn more about this pathogen. Proper treatment is still a work in progress.

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A Paint Port Pink display at Pasta Pasta
A Paint Port Pink display at Comsewogue Public Library.
A Paint Port Pink displays at Arame Salon and Spa
A Paint Port Pink display at Amy Tyler School of Dance
A Paint Port Pink display at Yoga Delish

Paint Port Pink, Mather Hospital’s annual month-long breast cancer community awareness outreach, kicked off Oct. 1 with the lighting of pink lights by community partners in Port Jefferson, Port Jefferson Station, and surrounding communities. Lamp posts along Main Street in Port Jefferson are aglow with pink lights, along with the Theatre Three marquee and many store windows.

Paint Port Pink’s goal is to raise awareness about breast cancer, encourage annual mammograms, and bring the community together to fight this disease.

A pink pumpkin by Kathleen Fusaro.

Breast cancer is the most common cancer in women in the U.S., except for skin cancers, representing about 30 percent (or one in three) of all new female cancers each year. It is the second leading cause of cancer deaths for women in the U.S. after lung cancer, according to the American Cancer Society. Every two minutes someone is newly diagnosed with invasive breast cancer (Breast Cancer Research Foundation).Only one in three women over 40 have an annual mammogram. 

Paint Port Pink will feature a special HealthyU webinar on Women’s Health on Tuesday, Oct. 11 at noon. Three physicians will talk about breast cancer, menopause, and mental health during the pandemic. Register at matherhospital.org/healthyu 

Oct. 14 is “Wear Pink Day” and everyone — and their pets — are encouraged to get their pink on to raise awareness. Post photos on social media with #paintportpink and send them to [email protected] to be posted on our Facebook page.

Decorate your business window for a chance to win tickets to a 2023 concert at Jones Beach. Send photos of your window by Oct. 20 to [email protected]

The event’s popular “Pink Your Pumpkin” contest returns and encourages everyone to get creative with their pumpkins for a cause. Photos should be emailed to [email protected] by Oct. 24 and posted on social media with #paintportpink. The winner will be chosen Oct. 25 and will receive a $100 gift card. 

Paint Port Pink community sponsors include New York Cancer & Blood Specialists, Lippencott Financial Group, Riverhead Toyota, and Accelerated Services Inc., Po’ Boy Brewery , Tuscany Gourmet Market, Bohemia Garden Center, Brookhaven Expeditors, C. Tech Collections,  Michael R. Sceiford  Financial Advisor/ Edward Jones, PAP Landscape and Design, Inc., Precision Lawn Irrigation, and Swim King Pools and Patios.

A full calendar of events and a list of Paint Port Pink community partners offering promotions to benefit The Fortunato Breast Health Center is available at www.paintportpink.org. Call 631-476-2723

From despair to hope: A breast cancer survivor’s story

By Jennifer Van Trettner

Jennifer Van Trettner

It was late Friday morning on a cool December day when my phone rang. It was the (Fortunato) Breast Center calling about my routine mammogram that I had two days prior. I took a deep breath and hesitantly answered the phone. Marianne, the nurse on the other end, introduced herself and told me in a kind, warm voice that the doctor saw something of concern on my imaging and asked if I could come in for a biopsy within the hour. I said yes before I even had time to exhale.

I drove to the Breast Center alone. All sorts of thoughts were running through my head. Shortly after arrival, I was escorted to the sonogram area by a friendly woman and was given a warm gown. I undressed, wrapped myself in the warm, pink gown, and sat in the waiting room. 

A few minutes later, I was called into the sonogram room. The technician, whom I had met on several occasions, was lovely. The doctor was the same one who did my last biopsy. She explained to me that six tissue samples would be taken from my left breast. 

On Tuesday, December 21, 2021, the Breast Center called. I felt my heart plummet into my stomach and knew my life was about to change forever. As if in slow motion, I answered the call. If I close my eyes, I can still hear Marianne’s voice saying they received my biopsy results and asking if I could come to the breast center that day. This time I didn’t want to go alone. My mother-in-law, a breast cancer survivor, went with me (my mother, also a breast cancer survivor, lives in Georgia). 

With masks on, we walked into the Breast Center and were immediately brought into the office. It was warm and inviting. The doctor came in, introduced herself to my mother-in-law and sat in a chair at the end of the desk, almost directly in front of me. I could feel my eyes welling with tears.

I was told my biopsy was positive for IDC (Invasive Ductal Carcinoma) breast cancer. It was stage 1, estrogen positive, and Her2+. Relatively speaking, it was a good scenario. Marianne held up a pretty, clear box of pearls ranging from 2mm up to 20mm. She took out a 10mm pearl, placed it in my hand and told me this was the approximate size of my cancer. As I held the pearl in my hand, I thought what a nice, kind, warm, and non-scary way to confirm a woman’s fear.

Marianne, having years of my personal information in front of her, explained how she already called and made appointments with the doctors I would need to see. 

I called my mom from the office. I really needed to hear her voice. I asked her to get dad and put the phone on speaker. Telling my parents, from hundreds of miles away, their eldest daughter had breast cancer was not easy. I found myself standing at the entrance to a new path, and I wasn’t quite sure how to take the first step. One thing I knew for sure was that I wouldn’t have to take the first step alone. After hanging up with my parents, I was escorted to have an MRI. A few hours later and completely emotionally exhausted, we headed home.

On the morning of December 30, 2021, I saw my surgeon who would remove the cancer and sentinel lymph nodes. In the afternoon I saw the oncologist who had done genetic testing on me two years earlier (all of which were negative). He explained my cancer and the treatment it would require. I would need 12 weeks of chemotherapy and Herceptin infusions once a week for three to seven hours followed by an additional 13 Herceptin infusions every three weeks. Once those were finished (anticipated finish date: 2/8/23), I would need 10 years of Tamoxifen. The same evening, I had a PET scan. Thankfully, there were no surprises.

I started to tell family, friends, and colleagues of my diagnosis. I was immediately touched by the outpouring of love and concern. Helpful gifts began to arrive. The best gifts of all were the arrival of my parents a few days prior to surgery. 

My surgery at Mather Hospital was scheduled for January 25, 2022, which at the time of diagnosis felt like years away. In the back of my head was a little voice wondering if my aggressive cancer would get larger and spread during those weeks of waiting. I started an online journal and invited those closest to me to follow. 

The warrior in me began to take charge of my treatment, familiarize myself with my cancer, mastectomy options, implant options, and read from cover to cover the amazing book the breast center gave me at time of diagnosis. I reviewed all possible side effects. After that I never looked back. 

On the day of surgery, I arrived at the hospital anxious, nervous, and prayed that waking up after surgery was God’s will. I worried about what would happen to my husband and adult children if I didn’t. 

I  was brought into a large operating room. I fell asleep within seconds of speaking to the anesthesiologist and woke up seven hours later in recovery. The nurses were wonderful. Two of my former students, now nurses working the night shift, visited me bringing with them my favorite sweets, Swedish fish. Seeing familiar, friendly faces that night made my heart happy

Since my surgery, life has had many challenges. The first two weeks post-surgery I spent on the couch with my parents taking care of all household things while my husband went to work. April 14th, I tested positive for COVID, which set me back a week in treatment. Thankfully my oncologist prescribed an antiviral. It helped with my recovery and got me back on track with the infusions.

Treatments began with inserting the IV needle, blood work, Herceptin, a bag of Zofran, a bag of Benadryl and lastly chemo. By treatment six, my hair was very thin, so I decided to take control and shave what was left. The last day of chemo was May 21st, and on May 28th, I began my tri-weekly Herceptin infusions.

Throughout this journey, I have posted consistently on social media. I was born a teacher, and as such I felt it important to share my journey with anyone who wanted to follow. I believe it’s important for me to show my strengths and weaknesses, to be real, raw, and honest. This is a club no one wants to join. In the United States breast cancer affects 1 in 8 women, and on Long Island it’s 1 in 6. I had a support system like no other to help me get through this.

Schedule a mammogram today!

The Fortunato Breast Health Center at Mather Hospital, 75 North Country Road, Port Jefferson uses state-of-the-art breast imaging technology in a warm and assuring environment with a commitment to giving you personalized breast healthcare. 

Their staff of professionals provides 3D mammograms and offers individualized follow-up care, education for patients, families, and the community, as well as breast cancer support groups. 

Their Breast Center radiologists are specialists who only read breast imaging studies and look back as far as possible at your history of breast images for any subtle changes or abnormalities to provide the most accurate reading.

The Breast Health Center has also partnered with the Suffolk Cancer Services Program (CSP) to provide free breast cancer screenings to individuals who qualify. The CSP provides breast cancer screenings to women age 40 and older without health insurance in Suffolk. If any follow-up testing is needed, the CSP will provide those tests too. If cancer is found, CSP will help enroll people who are eligible in the NYS Medicaid Cancer Treatment Program for full Medicaid coverage during treatment. 

To find out if you are eligible for free screenings or to schedule your annual mammogram, call 631-476-2771. 

All photos courtesy of Mather Hospital.

 

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The American Cancer Society recommends women 45-54 get annual screenings. METRO photo
New research on bisphosphonates helps clarify their role in prevention

By David Dunaief, M.D.

Dr. David Dunaief

Breast cancer is the most common cancer diagnosed in U.S. women. Experts estimate that 30 percent of 2022 cancer diagnoses in women will be breast cancer (1). Only 15 percent of cases occur in those who have a family history of the disease, and 85 percent of new diagnoses will be invasive breast cancer.

A primary objective of raising awareness during October is to promote screening for early detection. Screening is crucial, but it is not prevention, which is just as important. Prevention strategies should include primary prevention, preventing the disease from occurring by lowering your risk, and secondary prevention, preventing breast cancer recurrence.

Here, we will discuss current screening recommendations, along with tools to lower your risk.

What are current screening recommendations?

There is some variation in screening guidelines; experts don’t agree on age and frequency. The U.S. Preventive Services Task Force currently recommends mammograms every other year, from age 50 through age 74, with the option of beginning as early as age 40 for those with significant risk (2). These 2016 guidelines are currently undergoing a review and are pending publication.

The American College of Obstetricians and Gynecologists encourages a process of shared decision-making between patient and physician to determine age and frequency of exams, including whether to begin exams before age 50 or to continue after age 75 (3). Generally, it recommends beginning annual or biennial mammograms starting no later than 50 and continuing until age 75. 

The American Cancer Society’s physician guidelines are to offer a mammogram beginning at age 40 and recommend annual exams from 45 to 54, with biennial exams after 55 until life expectancy is less than 10 years (4).

It is important to consult with your physician to identify your risk profile and plan or revise your regular screening schedule accordingly.

When do bisphosphonates help?

Bisphosphonates, which include Fosamax (alendronate), Zometa (zoledronic acid) and Boniva (ibandronate), are used to treat osteoporosis. Do they have a role in breast cancer risk prevention? The short answer: it may help prevent recurrence but doesn’t appear to provide primary protective benefits.

In a meta-analysis involving two randomized controlled trials (RCTs), FIT and HORIZON-PFT, results showed no benefit from the use of bisphosphonates in reducing breast cancer risk (5). The study population involved 14,000 postmenopausal women from ages 55 to 89 women who had osteoporosis, but who did not have a personal history of breast cancer. In other words, bisphosphonates were being used for primary prevention.

However, it does appear that bisphosphonates have a role in preventing breast cancer recurrence. The recent SUCCESS A phase 3 trial considered the optimal time for treatment. Findings published in 2021 indicate that two years of treatment for patients with high-risk early breast cancer reduced recurrence risk as much as five years of treatment (6). This could alter the current paradigm of 3-to-five years of treatment to prevent recurrence of certain types of breast cancer, reducing incidences of troublesome side effects.

A Lancet metanalysis focused on breast cancer recurrence in distant locations, including bone, and survival outcomes did find benefits for postmenopausal women (7). A good synopsis of the research can be found at cancer.org.

What’s the role of exercise?

We know exercise is important in diseases and breast cancer is no exception. In an observational trial, exercise reduced breast cancer risk in postmenopausal women significantly (8). These women exercised moderately; they walked four hours a week over a four-year period. If they exercised previously, five to nine years ago, but not recently, no benefit was seen. The researchers stressed that it is never too late to begin exercise. Only about one-third of women get the recommended level of exercise every week: 30 minutes for five days a week. Once diagnosed with breast cancer, women tend to exercise less, not more. We need to expend as much energy and resources emphasizing exercise for prevention as we do screenings.

What about soy?

Contrary to popular belief, soy may be beneficial in reducing breast cancer risk. In a meta-analysis, those who consumed more soy saw a significant reduction in breast cancer compared to those who consumed less (9). There was a dose-response curve among three groups: high intake of >20 mg per day, moderate intake of 10 mg and low intake of <5 mg. Those in the highest group had a 29 percent reduced risk, and those in the moderate group had a 12 percent reduced risk when compared to those who consumed the least. In addition, higher soy intake has been associated with reduced recurrence and increased survival for those previously diagnosed with breast cancer (10). The benefit from soy is thought to come from isoflavones, plant-rich nutrients.

Hooray for Breast Cancer Awareness Month stressing the importance of mammography and breast self-exams. However, we need to give significantly more attention to prevention of breast cancer and its recurrence. Through potentially more soy intake, as well as a Mediterranean diet and modest exercise, we may be able to accelerate the trend toward a lower breast cancer incidence.

References: 

(1) breastcancer.org. (2) uspreventiveservicestaskforce.org. (3) acog.org. (4) cancer.org. (5) JAMA Intern Med. 2014;174(10):1550-1557. (6) JAMA Oncol. 2021;7(8):1149–1157. (7) Lancet. 2015 Jul 23. (8) Cancer Epidemiol Biomarkers Prev. 2014 Sep;23(9):1893-902. (9) Br J Cancer. 2008; 98:9-14. (10) JAMA. 2009 Dec 9; 302(22): 2437–2443.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.

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Stock photo

By Nancy Burner, Esq.

Nancy Burner, Esq.

Skilled nursing care is a high level of care that can only be provided by trained and licensed professionals, such as registered nurses, licensed professional nurses, medical directors, and physical, occupational, and speech therapists. 

Skilled care is short-term and helps people get back on their feet after injury or illness. Skilled nursing facilities are residential centers that provide nursing and rehabilitative services to patients on a short-term or long-term basis. Examples of the services provided at a skilled nursing facility include wound care, medication administration, physical and occupational therapy, and pulmonary rehabilitation.

Generally, patients who are admitted to skilled nursing facilities are recovering from surgery, injury, or acute illness, but a skilled nursing environment may also be appropriate for individuals suffering from chronic conditions that require constant medical supervision. If you or a loved one is interested in using Medicare for skilled nursing, though, there are specific admission requirements set by the federal government:

• The individual has Medicare Part A (hospital insurance) with a valid benefit period. The benefit period will start from the date of admission to a hospital or skilled nursing facility and last for up to 60 days after the end of the stay.

• The individual has a qualifying hospital stay. This generally means at least three in- patient days in a hospital.

• The doctor has recommended skilled nursing care for the individual on a daily basis. The care must be provided by skilled nurses and therapists or under their supervision and should be related to the condition that was attended to during the qualifying hospital stay.

• The individual is admitted to a skilled nursing facility that is certified by Medicare. A skilled nursing facility must meet strict criteria to maintain its Medicare certification.

Usually, the skilled nursing care services covered by Medicare include the room charges, provided that it is a semi-private or shared room, meals at the facility, and any nutritional counseling, as well as costs of medication, medical supplies, medical social services, and ambulance transportation. It also covers rehabilitative services that are required to recover from the condition, such as physical therapy, respiratory therapy, and speech therapy.

Medicare generally offers coverage for up to 100 days of treatment in a skilled nursing facility. Note that if the patient refuses the daily skilled care or therapy as recommended by the doctor, then the coverage by Medicare may be denied for the rest of the stay at the skilled nursing facility. Many patients are advised that they will not get the full 100 days of Medicare benefits because they had reached a “plateau” or that they failed to improve. This is known as the Improvement Standard and was a “rule of thumb” used to evaluate Medicare patients. 

Applying the Improvement Standard resulted in the denial of much needed skilled care for thousands of Medicare patients. The denials were based on a finding that there was no likelihood of improvement in the patient’s condition. This standard ignored the fact that the patients needed skilled care in order to maintain their current state of health and to prevent them from deteriorating. More often than not, if the patient was not improving, Medicare coverage was denied. While this standard was widely used, it was inconsistent with Medicare law and regulations.

A court case brought by Medicare beneficiaries and national organizations against the Secretary of Health and Human Services (Jimmo v Sebelius) sought to change this. The plaintiffs argued that even though the term “plateau” does not appear in the Medicare regulations, it is this term that is often used and relied upon to deny coverage. The appropriate standard should be: will the covered services “maintain the current condition or prevent or slow further deterioration,” not whether the individual was showing signs improvement.

As a result of this litigation and the settlement on Jan. 24, 2013, patients should be able to continue receiving services provided by Medicare, even where improvement in the patient’s condition cannot be documented. However, the old standard continues to be used. Patients and their advocates should educate themselves on the correct standard to make sure coverage is not cut prematurely.

Nancy Burner, Esq. is the founder and managing partner at Burner Law Group, P.C with offices located in East Setauket, Westhampton Beach, New York City and East Hampton.

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Eczema is more common in women than it is in men. METRO photo
Treatments are continually evolving

By David Dunaief, M.D.

Dr. David Dunaief

The causes of eczema are unknown, but it is thought that nature and nurture are both at play (1). Essentially, it is a chronic inflammatory process that involves symptoms of rashes, itching, pain and redness (2).

It’s estimated that over seven percent of the U.S. adult population suffers from eczema (3), with twice as many females as males affected (4).

While there is no cure, there are treatments its symptoms. These range from over-the-counter creams and lotions to prescription steroid creams to oral steroids and injectable biologics. Antihistamines can also be used to treat itchiness. Some use phototherapy for severe cases, but research on its effectiveness is scant. Interestingly, lifestyle, specifically diet, may play an important role.

Two separate studies have shown an association between eczema and fracture risk, which we will investigate further.

Let’s look at the evidence.

Does diet play a role?

Eczema is more common in women than it is in men. METRO photo

In a Japanese study involving over 700 pregnant women and their offspring, results showed that when the women ate either a diet high in green and yellow vegetables, beta carotene or citrus fruit there was a significant reduction in the risk of the child having eczema of 59 percent, 48 percent and 47 percent, respectively, when comparing highest to lowest consumption quartiles (5).

Elimination diets may also play a role. One study’s results showed when eggs were removed from the diet in those who were allergic, according to IgE testing, eczema improved significantly (6).

From an anecdotal perspective, I have seen very good results when treating patients who have eczema with dietary changes. My patient population includes about 15 to 20 percent of patients who suffer some level of eczema. For example, a young adult had eczema mostly on the extremities. When I first met the patient, these were angry, excoriated, erythematous and scratched lesions. However, after several months of a vegetable-rich diet, the patient’s skin significantly improved.

What about supplements?

There are two well-known supplements for helping to reduce inflammation, evening primrose oil and borage oil. Are these supplements a good replacement for – or addition to – medications? The research is really mixed, leaning toward ineffective – and with some important concerns.

In a meta-analysis of seven randomized controlled trials, evening primrose oil was no better than placebo in treating eczema (7). The researchers also looked at eight studies of borage oil and found there was no difference from placebo in terms of symptom relief. While these supplements only had minor side effects in the study, they can interact with other medications. For example, evening primrose oil in combination with aspirin can cause clotting problems (8).

The upshot? Don’t expect supplements to provide significant help. If you do try them, be sure to consult with your physician first.

Biologics

Injectable biologics are among the newest treatments and are generally recommended when other treatment options have failed (9). There are two currently approved by the FDA, dupilumab and tralokinumab-ldrm, with the latter recently approved in December 2021.

In trials, these injectable drugs showed good results, improving outcomes for moderate to severe eczema sufferers when topical steroids alone were not effective. Like any drug therapy, it does have side effects.

Deeper impacts of eczema

Eczema may be related to broken bones, according to several studies. For example, one observational study of 34,500 patients showed that those with eczema had a 44 percent increased risk of injury causing limitation and an even more disturbing 67 percent risk of bone fracture and bone or joint injury for those 30 years and older (10).

And if you have both fatigue or insomnia and eczema, you are at higher risk for bone or joint injury than having one or the other alone. The researchers postulated that the use of corticosteroids in treatment could be one reason for increased fracture risk, in addition to chronic inflammation, which may also contribute to the risk of bone loss.

Steroids may weaken bone, ligaments and tendons and may cause osteoporosis by decreasing bone mineral density.

A recently published study of over 500,000 patients tested this theory and found that the association between major osteoporotic fractures and atopic eczema remained, even after adjusting for a range of histories with oral corticosteroids (11). Also, fracture rates were higher in those with severe atopic eczema.

For those who have eczema, it may be wise to have a DEXA (bone) scan.

Eczema exists on a spectrum from annoying to significantly affecting a patient’s quality of life (12). Supplements may not be the solution, at least not borage oil or evening primrose oil. However, there may be promising medications for the hard to treat. It might be best to avoid long-term systemic steroid use, because of the long-term side effects. Lifestyle modifications appear to be very effective, at least at the anecdotal level.

References: 

(1) Acta Derm Venereol (Stockh) 1985;117 (Suppl.):1-59. (2) uptodate.com. (3) J Inv Dermatol. 2017;137(1):26-30. (4) BMC Dermatol. 2013;13(14). (5) Allergy. 2010 Jun 1;65(6):758-765. (6) J Am Acad Dermatol. 2004;50(3):391-404. (7) Cochrane Database Syst Rev. 2013;4:CD004416. (8) mayoclinic.org (9) Medscape.com. (9) JAMA Dermatol. 2015;151(1):33-41. (10) J Allergy Clin Immunol Pract. 2021 Sep 24;S2213-2198(21)01018-7. (11) nationaleczema.org. (12) Contact Dermatitis 2008; 59:43-47.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.

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Dr. John Clarke. Photo from BNL

By Daniel Dunaief

Live from Upton, New York, it’s … Dr. John Clarke.

While the arrival of the new Occupational Medicine Director and Chief Medical Officer at Brookhaven National Laboratory doesn’t involve late-night comedy, or a live studio audience, it does bring a medical doctor with a passion for bringing his rap and musical skills to a health care audience.

Dr. John Clarke. Photo from BN

Formerly the director of occupational medicine at Cornell University, Dr. Clarke joined the Department of Energy lab as Occupational Medicine Director and Chief Medical Officer for BNL in June..

“My role is to help maintain safety and wellness among the workers,” said Dr. Clarke. “If we have employees who start coming in for some sort of complaint and we see a pattern, that may help us identify who could be at risk of something we didn’t know about that we are detecting.”

A doctor who served as chief resident at New York Medical College in family residency and Harvard University in occupational & environmental medicine, Dr. Clarke said he plans to support a range of preventive efforts.

“I’m excited about the potential to engage in what’s considered primary prevention,” said Clarke, which he defined as preventing a disease from occurring in the first place.

Through primary prevention, he hopes to help the staff avoid developing chronic illnesses such as cancer, while also ensuring the health and responsiveness of their immune systems.

Through physical fitness, a plant-based diet including fruits and vegetables, adequate sleep and hydration with water, people can use lifestyle choices and habits to reduce their need for various medications and enable them to harness the ability of their immune systems to mount an effective response against any threat.

“Modifying your lifestyle is the therapy,” he said. “If you engage [in those activities] in the right way, that is the treatment.”

Dr. Clarke added that the severity and stage of a disease may impact the effectiveness of such efforts. For any vaccine and for the body’s natural immunity to work, people need a healthy immune system.

When Dr. Clarke practiced family medicine, he saw how patients lost weight through a diet that reduced the need for medication for diabetes and high blood pressure.

“Losing weight and staying active does provide a therapeutic impact, where you could be medication free,” he said.

To be sure, living a healthier lifestyle requires ongoing effort to maintain. After reaching a desired weight or cholesterol level, people can backslide into an unhealthier state or condition, triggering the occurrence or recurrence of a disease.

In the vast majority of cases, Clarke said, “you have to make a permanent lifestyle change” to avoid the need for pharmaceutical remedies that reduce the worst effects of disease.

BNL has an exercise physiologist on staff who “we hope to engage in consultations with employees,” said Clarke. He would like the exercise physiologist to go to the gym with staff to show them how to use equipment properly to get the maximum benefit.

BNL already has some classes and various initiatives that promote wellness. “One of the things we’d like to do is coordinate and try to publicize it enough where employees are aware” of the options available at the lab to live a healthier and balanced life, he added.

BNL also has a dietician on staff. Dr. Clarke has not worked with the dietician yet, but hopes it will be part of an upcoming initiative. As he and his staff respond to the demand, they will consider bringing on other consultants and experts to develop programs. 

Covid concerns

Like others in his position in other large employers around Long Island, Dr. Clarke is focused on protecting workers from any ongoing threat from Covid-19.

“We’re still learning more as [SARS-CoV2, the virus that caused the pandemic] evolves,” he said. BNL does a “great job about monitoring the prevalence and the numbers of cases in Suffolk County and among workers.”

Dr. Clarke said he and others at BNL are following the Department of Energy, New York State and Centers for Disease Control and Prevention guidance on these issues.

If the numbers of infections and hospitalizations increase in the coming months, as people move to more indoor activities, BNL may consider deploying a strategy where the lab provides more opportunities for staff to work remotely.

Prior to his arrival at BNL, Dr. Clarke worked as a consultant for a company that was looking to create numerous permanent jobs that were remote.

He suggested that workers need to remain aware of their remote surroundings and shouldn’t work near a furnace or any heater that might release dangerous gases like carbon monoxide. 

Additionally, people should avoid working in areas that aren’t habitable, such as in an attic. Dr. Clarke urges people to notify and consult their employer if they have concerns about working safely at home or on site.

Music vs. medicine

A native of Queens who spent three years of his childhood in Barbados, Dr. Clarke attended Columbia University, where he majored in sociology and music while he was on a pre-med track.

While he was an undergraduate, Dr. Clarke wrote, produced and performed original music. An independent label was going to help secure a major label deal.

He chose to attend medical school at Icahn School of Medicine at Mount Sinai.

Dr. Clarke has championed a program he calls “health hop,” in which he has used rap to reach various audiences with medical care messages. In 2009, he won a flu prevention video contest sponsored by the Department of Health and Human Services for an “H1N1 rap.”

Train commuters may also recognize him from his work for the Long Island Railroad, for which he created a “gap rap.” The public service announcement was designed to protect children from falling into or tripping over the gap between the train and the platform.

Dr. Clarke has produced music for numerous genres, including for a children’s album and a Christian album.

As for life outside BNL, Dr. Clarke is married to Elizabeth Clarke, who is a nurse practitioner and is in the doctorate of nursing practice and clinical leadership program at Duke University.

When he’s not spending time with his wife or their children, he enjoys home projects like flooring and tiling.

Dr. Clarke is pleased to be working at the national Department of Energy lab.“BNL is a great place, because the science and the work they do has an impact,” he said.

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Dr. Farquharson suggests showing a person experiencing a mental health emergency your hands with the palms open to show you are not a threat to the person. Stock photo

Long Island residents have taken CPR classes and learned lifesaving basics to help others with injuries through programs like “Stop the Bleed.”

But what about mental health emergencies?

Those may be more difficult to diagnose or understand, particularly for people who may not know the person in emotional distress.

While Suffolk County Police Department officers with specialized training, support service organizations like Diagnostics, Assessment and Stabilization Hub (known as DASH) and Family Service League, and mental health care workers are available to help, doctors offered suggestions for people who would like to provide assistance for a friend, coworker or relative while awaiting professional assistance.

Dr. Wilfred Farquharson IV, a licensed psychologist and director of the Child and Adolescent Psychiatry Outpatient Clinic at Stony Brook Medicine, helped create a two-page patient education sheet titled “Mental Health Emergency Response Guidance Sheet — Knowing Your Options.”

The guide provides suggestions on how to respond to a variety of emergencies, starting with lower level crises, which could include a change in mood or side effects from a medication that is not dangerous to a person’s health.

The options in that case are to contact a mental health provider to schedule an appointment, to use a safety plan or to schedule an urgent visit with a primary doctor.

In situations in which a person is destroying property, is threatening physical injury and is not in a position for a safe transport, the guide suggests calling 911.

To ensure effective help from emergency responders, the guide urges people to go to Smart911 to complete a profile for the household.

Additionally, people who call 911 should indicate that there is a mental health emergency. The person making the call should be prepared to offer the person’s name and location, the reason for the call, the person’s diagnosis (if known), things that upset the person, such as yelling at them or getting too close, things that might help soothe the person, and special considerations.

While people are waiting for first responders, they can try to deescalate the situation, using tools similar to the ones professionals practice.

“A lot of what we do is give the person space,” Farquharson said. “We show them our hands, with open palms, and let them know we’re not trying to be a threat. We don’t say too much. We allow the person to talk, as long as they’re being safe. We allow them to yell.”

Neutral tone

Dr. Adnan Sarcevic, chairman of the Psychiatry Department at Huntington Hospital, also urges people to provide “as much privacy as possible” for someone in distress.

Sarcevic recommended that supportive family, friends or community members be empathetic without being judgmental.

“Keep your tone and your body language neutral,” Sarcevic said. He urges people to remain calm and friendly.

People can help deescalate situations by acknowledging that someone else’s feelings are important and indicating that crying or being angry is okay.

Taking a cue from the person in distress can also help. If a person stops talking, “let him or her be there in silence. Let them reflect,” Sarcevic said.

Additionally, the Huntington Hospital doctor urged people to respect the personal space of someone who is struggling.

As far as his list of “don’ts,” Sarcevic said people shouldn’t use judgmental language or wag their fingers.

“Don’t ask, ‘Why’ or ‘How could you do that?’” Sarcevic advised.

Other resources

The Suffolk County Police Department implemented a 911 call diversion pilot program in 2021 which allows Emergency Complaint Operators to divert crisis calls, when considered safe, to the Crisis Hotline at Family Service League.

The SCPD collaborates with Family Service League on a 24-hour crisis hotline as well as a mobile crisis team of mental health professionals that can be deployed 24/7, officials from the SCPD explained in an email.

Additionally, the department said about 20% of SCPD officers are Crisis Intervention Team trained. Someone with that training is always on patrol. 

In addition to 911, people can reach out to DASH, which is the Diagnostic, Assessment and Stabilization Hub. A community crisis program with a Mobile Crisis Team for Suffolk residents, DASH is open every hour of every day and offers services for people who have mental health and substance abuse disorders.

For situations in which there are no safety risks, Stony Brook Medicine suggested that DASH is a good option. Residents can call the hotline at 631-952-3333.

Additionally, residents can call the Suicide and Crisis Hotline at 988 at any time.

Dr. Stacy Eagle, director of Psychiatry at St. Charles Hospital, cautioned that what deescalates one person might be different from what helps someone else.

Offering physical comfort to some people may help, while others might prefer to have their own space.

All three mental health professionals said the pandemic has contributed to higher levels of anxiety and depression among the population.

“The pandemic has increased the level of distress for those patients,” Eagle said. The pandemic could be the “stressful hit” that triggers discomfort or a mental health episode.

Farquharson has noticed an increase in the acuity of symptoms for some residents.

The mental health practitioners said the response to a crisis depends on the person involved and the type of problem he or she
is experiencing.

“You have to use [your] judgment”
when dealing with various circumstances, Sarcevic said.

Mental health professionals urged people to develop a plan that includes having phone numbers nearby, for 911, 988, DASH and the Family Service League, among others.

Additionally, doctors suggested people can help by being supportive and being prepared.

Farquharson said people should learn what to do if someone is not feeling well emotionally or mentally when a doctor’s office might be closed.

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