Spinal Fusion

by: Winston T. Capel, M.D., MBA, FACS, FAANS

Spinal Fusion
The definition of fusion means to unite; in spinal surgery, fusion is to arrest motion between vertebrae. The spine was designed to be mobile and allow motion while at the same time protect the neural elements: the spinal cord and spinal nerves.

Why would fusion be necessary?

Fusion is necessary when the stabilizing elements of the spinal column: bone, disc, ligaments can no longer provide the protection of the neural elements (spine is unstable). These stabilizing elements can be compromised by:

  1. Trauma: fractures, dislocations and ligament injury
  2. Tumor: primary tumor (originating in the vertebra) or metastatic (spreading from other organs)
  3. Infection: bacterial infection can weaken bone and cause neural compression
  4. Degeneration: degeneration (osteoarthritic) changes can weaken supporting structures and cause instability resulting in intractable pain and or neural compression requiring the removal of disc, ligament or bone. Decompression (the removal of bone, ligament and disc) is required if symptoms are intractable and there is failure of non-surgical treatments to relieve pain. If instability exists before decompression or results from decompression reconstruction then fusion is necessary to restore or maintain stability. Stability being grossly defined as the spine’s ability to move physiologically without jeopardy of the neural elements. Sometimes it is necessary to fuse the lumbar spine because normal motion produces intractable pain that has not responded to nonsurgical treatments such as: exercise, physical therapy and medications.

Examples of Some Common Fusion Scenarios
Cervical Disc Herniations
The cervical segment of the spinal column is very mobile and subject to excessive and early degenerative changes. These degenerative changes are accelerated by: genetics, wear and tear, repetitive trauma, heavy labor and nicotine exposure. When the disc breaks down in degenerative disc disease it can lose its mechanical integrity and start to migrate and fragment. This can lead to nerve and spinal cord compression. There is opportunity to manage the nerve compression nonsurgically with things such as: time, traction, neuromodulation drugs (Neurontin, Lyrica), and injections. Often, symptoms of nerve compression (radiculopathy) will improve and surgery can be avoided. If not, the problem is most commonly treated by an anterior approach where the disc is removed to decompress the symptomatic nerve. The removal of the disc has resulted in instability. There are 2 options: fusion and non-fusion. Fusion is to replace the disc with a polymer, autograft (from the patient) or allograft (bone bank) with the intent of growing bone where disc was. This bone growth requires bone forming cells (osteoblasts) to be protected from shear forces that interfere with bone growth. A metallic plate (titanium) is used to provide immediate stability while bone is growing over the next 3-4 months. If bone growth fails, the fusion fails and the plate will usually fail at the bone metal interface (loose screws) or less commonly metal fatigue (broken screws). Almost all fusions require or are greatly facilitated by the use of metallic instrumentation to optimize osteoblast activity.
It is not uncommon for more than one disc (level) to require this decompression, reconstruction and fusion. The non-fusion option involves the use of an artificial disc (Total Disc Replacement) where a combined metal plastic designed unit preserves motion and replaces the mechanical stability of the disc. Disc replacement surgery is limited to one level and insurance coverage is still variable.

Lumbar Spondylolisthesis
Spondylolisthesis is the forward displacement of one vertebra on another. This is most often a degenerative process that occurs later in life but can be due to defect in the vertebrae at the pars interarticularis which results in premature disc degeneration allowing the slippage to occur. Spondylolisthesis is commonly associated with stenosis (narrowing) of the exiting foramen and or the spinal canal. The combined spondylolisthesis and stenosis can often be managed non-surgically with exercise, physical therapy, medications and injections. When these measures fail a decompression is required. Decompression tends to make the spondylolisthesis globally unstable resulting in progressive slip and reoccurrence of the stenosis. A fusion at the time of the decompression has been shown scientifically to result in a better clinical outcome than decompression alone. There are various techniques and surgeon preferences that determine the method of fusion. All of the techniques will require the application of bone or bone forming substances and most often instrumentation. This is usually done from a posterior approach but occasionally a combined anterior and posterior approach is required. If the degree (grade) of the spondylolisthesis is high, oftentimes a reduction (realigning) of the vertebra to maintain proper balance of the spine is required. Corrective forces are generated by the applied instrumentation.

Fusion for Chronic Low Back Pain from Degenerative Disc Disease (DDD)
The application of fusion to the treatment of low back pain (LBP) can be controversial. In general, the perceived failure of spine surgery can most often be attributed to this application of fusion. In my opinion, it is the proper selection of which patients receive this type of surgery that can be a great challenge. Often the failures to achieve the expected outcomes can be reduced to patient selection. It is known that patients with certain characteristics do not do as well clinically when fusion is applied for the treatment of chronic LBP secondary to DDD. The expected and desired outcome is: pain reduction, improved quality of life with increased functionality. This is less like to occur statistically in patients with these characteristics:

Secondary Gain:
Worker’s compensation patients and third-party personal injury patients do not do as well generally as patients without this attribute. The spine literature in describing efficacy for fusion almost always will separate these patients out of patient populations to better understand clinical efficacy and outcomes. Litigation plays a significant role in perceived and or real outcomes for fusion in chronic LBP for DDD.
Psychology of the patient:
Patients with depression and anxiety do not do as well statistically. In the process of patient selection many spine surgeons will send patients to a pain psychologist to screen for the presence of psychopathology that can jeopardize a good outcome. Functional issues (including marital conflict) can factor into a poorer outcome if the chronic pain issue is interconnected to the social support system for a patient.
Nicotine Usage:
In all fusions, bone growth is the primary determinant of outcome. Nicotine antagonizes osteoblastic activity and is strongly associated with poorer clinical outcomes. Most spine surgeons will not do elective fusion procedures in smokers. In general, the fusion rate for a smoker is 30% lower than for a nonsmoker.

Opioid Dependence:
This is a complex issue especially given the current environment. The reality is that many patients with chronic LBP will be opioid dependent. An expected outcome by most is the reduction or elimination of the need for opioids after successful fusion surgery. The quantity used and the duration of chronic opioid maintenance therapy have predicted poorer outcomes in fusion surgery for chronic LBP secondary to DDD.
Obese patients have poorer outcomes due to a number of reasons. There is a lower fusion rate with morbid obesity with a higher rate of complications. Surgery on obese patients is more technically demanding for the spine surgeon.

In my opinion, a highly motivated patient, (without the above characteristics) with intractable pain can do well with lumbar fusion or TDR. Patient selection is a critical determinant of a good clinical outcome in elective fusion operations especially in the treatment of chronic LBP secondary to DDD.

The Breast Cancer Diet

The Breast Cancer Diet

by Traci McCormick, MD


This should include two to three pieces of fruit, one cup or more of vegetables with lunch and dinner and 8-fluid-ounces of vegetable juice. There is extensive and consistent evidence that diets high in fruits and vegetables are associated with decreased risk of many cancers.

  • CONSUME 30 TO 40 GRAMS OF FIBER DAILY. You are likely to meet your fiber goal if you eat 8 to 10 servings of fruits and vegetables plus one serving of beans/legumes, one serving of chia and/or flax seed, or at least two servings of whole grains daily. Fiber binds to toxic compounds and carcinogens and helps eliminate them from the body.

Keep white off your plate: bread, pasta, rice, cream sauces,

cakes, and more. High sugar foods are usually highly processed and refined, low in nutrient value, and low in dietary fiber. These foods also increase serum insulin and serum insulin-like growth factors, which stimulate cancer growth.


By including a lean protein with each meal, insulin levels

will be kept more steady. Studies, however, have linked the consumption of animal protein to breast cancer, so plant based protein is ideal.


Studies have found that a reduced fat intake decreases the risk of breast cancer and of breast cancer recurrence.

  • INCLUDE HEALTHY FATS LIKE COLD-WATER FISH, CHIA SEEDS, FLAXSEEDS, WALNUTS, SOYBEANS, OLIVE OIL AND AVOCADOS. These foods are high in omega-3 fatty acids. Research is growing supporting a protective relationship between omega-3 fatty acids against the risk of breast cancer.

Chia and ground flax are excellent plant-based sources of omega-3 fatty acids.

  • CONSUME HERBS AND SPICES DAILY. Herbs and spices are full of anti-inflammatory nutrients that have been shown to reduce cancer risk.

As little as 1 serving of alcohol per day has been shown to increase breast cancer risk.

  • DRINK 1 TO 4 CUPS OF GREEN TEA DAILY. Green tea contains phytonutrients known as polyphenols that provide antioxidant and anticancer properties.

Maintain your level above 40 ng/ml through diet and, if needed, supplements.


Adequate fluids are needed for the body to function optimally.


Excess body weight, as well as low levels of physical activity, have been linked to an increased risk of breast cancer in multiple studies.

Head & Neck Cancer

Head & Neck Cancer

by, Noel C. Estopinal, MD

A sore throat is usually a sign of a relatively minor problem like spring allergies or the common cold. But if you have a sore throat that lasts for more than two weeks, you should make an appointment to go see your family physician.

That’s because persistent sore throat can also be a sign of head and neck cancer, according to Dr. Noel C. Estopinal, a radiation oncologist with Alliance Cancer Care in Huntsville.

   Head and neck cancer, which includes cancers of the mouth, throat (pharynx), voicebox (larynx), sinuses, nasal cavity and salivary glands, accounts for about 5-7 percent of cancer cases nationally. 

   But Dr. Estopinal said it’s more common in states with the highest rates of smoking, smokeless tobacco and alcohol use – including Alabama.

   “It weighs more heavily in the South than in other parts of the country,” he said.

   Tobacco smoke contains more than 70 chemicals that have been shown to cause or promote cancer. Mean-while, alcohol irritates the mucous-covered surfaces of the mouth and throat, making them more vulnerable to those carcinogens.

   Not all head and neck cancers are linked to cigarette and alcohol use. Dr. Estopinal said human papilloma-virus (HPV) is now a leading cause of oropharyngeal cancer affecting the base of the tongue, soft palate, tonsils and side and back walls of the throat. 

   HPV can be spread through sexual contact, including oral sex.

   In addition to persistent sore throat, head and neck cancer warning signs include persistent difficulty swallowing, a growing lump in the neck, chronic hoarse-ness, sores in the mouth that won’t heal, changes in 

how your voice sounds, and unexplained weight loss. Early detection is the key to successful treatment of head and neck cancers, so get to your doctor if you have any of the above symptoms that last for more than a couple of weeks.

   “When the disease is caught in the earliest stages, we can often achieve excellent long-term control with less aggressive therapy,” said Dr. Estopinal. “For patients with very small lesions on the vocal cords, a short course of radiation alone can result in a cure rate of better than 90 percent. Other patients may only need to have the tumor surgically removed with no further treatment.

   If your doctor suspects you have head and neck can-cer, the first step is usually a tissue biopsy of the affect-ed area.

   Once the diagnosis is confirmed, the radiation oncologists at Alliance Cancer Care can develop a customized treatment plan. In addition to Dr. Estopinal, the Alliance physician team includes Drs. Harry James McCarty III, Elizabeth Falkenberg, Hoyt A. “Tres”

“It weighs more heavily in the South than in other parts of the country,” he said. Childs III, John F. “Jack” Gleason Jr., Traci McCormick and Stanley Clarke.

    Depending on the stage and location of the disease, the treatment plan for head and neck cancer may include surgical removal of the tumor by an ear, nose and throat specialist, targeted radiation therapy at one of Alliance’s six locations across North Alabama, and chemotherapy overseen by a medical oncologist. 

“Head and neck cancer is one of the most intensive multidisciplinary cancers that we treat,” said Dr. Estopinal. “We’re fortu-nate in Huntsville to be staffed with  many experienced  surgeons, radiation and medical  oncologists who have successfully treated  head and neck cancer.”

If radiation is recommended, Alliance Cancer Care uses Intensity Modulated Radiation Therapy (IMRT) and Image Guided Radiation Therapy (IGRT) to de-liver the treatment. A CT scan of the patient is taken before and during treatment to make sure the radiation beam hits only the tumor and not the surrounding healthy tissue.

 The standard regimen for head and neck cancer is 25-35 radiation therapy treatments over a period of five to seven weeks.

Side effects may include fatigue, dry mouth, skin irritation in the treated area, pain or difficulty swallowing, and loss of appetite due to changes in the way food tastes.

   “With IMRT and IGRT, we’re able to steer the radiation dose around the salivary glands, jaw bone, spinal cord and other sensitive organs while targeting the tumor,” said Dr. Estopinal. “That helps to minimize any side effects from treatment and improves the opportunity for cure.”

Cancer Warrior

Cancer Warrior

Not all of us will be presented with the opportunity to look death in the face and rise up to fight.

Life always gives you a choice. Lay down and die or stand up and fight. Fighting is not a given. It’s a choice. A choice to become a warrior. But we are not born warriors. Life presents challenges and obstacles, and we make the choice to go to war. Webster’s Dictionary defines a warrior as a person engaged in struggle or conflict. But it is how that person enters into battle that makes them a true warrior. Rather than fighting out of obedience or allegiance, a true warrior engages in battle out of personal choice.

On February 21, 2019, Pammie Eagle Jimmar was faced with the battle of her life. On that day, she heard the one word that would change her life forever. Cancer.  Through all the amazing advancements in medical science, this one word can shake a person to their core. Pammie was diag-nosed with Stage 2 Invasive Ductal Carcinoma. A mil-lion thoughts went through her mind as her doctor laid out the unnerving news. “I am human. All kinds of things were going through my mind. I cried and cried and I cried!”  Pammie’s thoughts immediately jumped to those she loved. “How would I tell my family and friends? Should I just keep silent?” After crying for what seemed like an eterni-ty, Pammie drove home and told her Mom. Together they decided that this was just a bump in the road and that she, with the help of her family, would get through this. “I remember saying God’s got my back and I’ve got so much FAITH, so let’s get this battle started!” Rather than taking her new diagnosis lying down, Pammie took on this fight with grace, passion, intensity, and intelligence. She had unwavering faith that God’s grace and mercy would see her through.  Pammie chose to become a warrior.

   The next few days were a blur. MRIs, CTs, Bone Density Scans, lab work and doctor appointments flooded Pammie’s schedule.  She remembers the fear that came with each test. “It was scary because the machines were so huge, sterile and cold.” Pammie recalls crying at every doctor’s visit in the beginning because of fear of the unknown. This was a new diagnosis. New terminology. She had no idea what to expect. Luckily, she was placed in the care of a compas-sionate oncologist at Clearview Cancer Institute.  The phy-sician immediately told Pammie that together they would win this fight. His main goal was to keep her alive.  This was music to her anxious ears. Soon after, Pammie underwent placement for a port-a-cath and began chemotherapy. She underwent a total of 4 treatments of Adriamycin to target he tumor. Better known as the Red Devil, she renamed it the Red Angel. “This treatment drained all of the en-ergy from me, took my appetite away, and made me sick, however I knew it was working in my favor. Next, Pammie endured an additional 16 rounds of chemotherapy and a lumpectomy, followed by 16 more rounds of treatment in combination with radiation. A series of tests were arranged to determine the amount of tumor regression. Pammie and physician were faced with difficult news. The cancer began to grow in a contained area of the breast. “He went over several options, and I decided to go with a unilateral mas-tectomy; coupled with 16 rounds of chemotherapy.” After the 11th round of chemo she began to develop neuropathy in her fingers and toes.   Her physician again reviewed her options and together they made the decision to stop the chemo treatments.  The decision paid off. On September 13,2019. Pammie was considered cancer free.

   Pammie says she has always had faith. “Faith is believing. I won this battle because of my faith in knowing that I would be cured of cancer coupled with lots and lots of prayer.” A dear friend and cancer survivor gave Pammie a book by Christine Caine called “Unshakable”. She read the little book during her meditation hour daily. She recalls what she calls a “golden nugget” from the book –“Unshakable faith is impossible to change, shake, or beat down. The kind of faith that is confident in knowing Jesus, our Rock and Mighty Fortress. The One who promised to never leave us nor for- sake us. The One who causes us to triumph over any hurdle or situation trying to destabilize us or stop us from fulfilling our God-given purpose.” She triumphantly says “I Thank God for saving me. Because of him I am cancer free!”

   Pammie has been overwhelmed by the support she has received from family and friends. “They have been amazing. My mom is my HERO! She has been with me through- out this entire journey. She has never once left my side.” Pammie moved to the Huntsville area 7 years ago knowing only family members and her boss. “I’d have to say this is the best community I’ve ever lived in. Everyone rallied for me and just stepped in and helped me and my family in more ways that you could ever imagine. My heart is full just thinking about it. I never knew how much people loved and cared about me and my family. I am so blessed to have witnessed the love and support this community has given me.” Pammie says she has surrounded herself with the most positive people. “They radiate positive vibes,” Pammie feels God knew this is exactly what she needed in her life to complete this journey. Pammie is grateful to her coworkers at Huntsville-Madison County Chamber of Commerce for their tremendous moral support.

   When asked who the most inspirational person in her life is, she answers with grace and pride. “My beautiful mom inspires me every day of my life. “She has been my rock throughout this entire journey and my loudest cheerlead- er.” She never missed an appointment, scan, test, or chemo treatment. Pammie also says that all survivors of cancer inspire her daily. “They are mighty, fierce warriors.” Cancer warriors.

   It is possible to fight more than one battle at a time. “I ha- ven’t shared this with many people but not only was I about to put on all of my armor and fight the battle of my life, I was also going through a divorce. I know this sounds crazy, but I never really got the opportunity to process the divorce because so much was going on in my life. The divorce, the cancer diagnosis, preparing a house to be sold, preparing my baby boy to head off to college 1,300 miles from home, and trying to wrap my head around the changes in my life was a huge pill to swallow.” Pammie’s faith never wavered. “I just knew God would take care of me through all of this.” Pam- mie knew that He had a plan and purpose for all of this and if she would just have faith and know that He would not put more on her than she could bear she would be protected on this journey.

   Pammie has helped others by sharing her courageous battle with cancer publicly. She radiates grace and keeps faith that God is always working in her favor. “Cancer is an awful dis- ease and I feel once people know you have it, they begin to feel sad and sorry for you. I never wanted people to feel this way about me. I wanted them to feel hopeful that I would beat this disease. Hands down, I wanted them to know that I had faith and that this too would pass. God was helping me along with their prayers to win this battle. I love this community and after a while, everyone began to see that I was strong and mighty and had faith to get through this journey.”

When asked what she would tell someone with a new di- agnosis of breast cancer, she replies, “I would first tell them that I am on the battlefield with them, battling this disease with them and that they don’t have to go through this alone. Let your family and friends help you on this journey. Stay positive and surround yourself with positive people, and don’t forget to sprinkle all of the above with a lot of faith.”

   Pammie has been chosen as the honorary guest speaker at the 2019 Tie the Ribbons Luncheon supporting Hudson Alpha’s breast and ovarian cancer research. She says she is also honored to be recognized as a Breast Cancer Survivor and to be able to share her story with others in hopes of in- spiring someone who may be going through the same jour- ney. When she meets those she has encouraged, she calls it receiving Golden Nuggets. “Going through this journey, these were very powerful for me to receive – little blessings from God.”

Kari Kingsley, MSN, CRNP is an otolaryngology nurse practitioner with over 8 years of ENT experience. She is a medical writing consultant for Inside Medicine and enjoys writing articles on pertinent material to keep the residents of North Alabama up to date on the forefront of medicine.

Pammie  Eagle  Jimmar  is  the  Vice  President of Small Business  &  Events  at  the  Huntsville Madison County Chamber of Commerce. She would like to especially thank the amazing team at Clearview Cancer Instituutti and Hudson Alpha for continuing their fight to cure cancer. She would also like to thank Inside Medicine for affording her the opportunity to share her journey.

Photo credits: Savannah Pedersen

Pammie is the most courageous of 

warriors. Not only has she taken on the battle to save her own life and beat breast 

cancer, she has also taken on the battle of bringing awareness to her journey in the hopes of supporting and helping others.

Blessed be the LORD, my rock, who trains my hands for war, and my fingers for battle – Psalm 144:1.

STOP… in the name of love!!!

STOP… in the name of love!!!

Everybody has heard of mammogram screening for breast cancer. Everybody has heard of Pap smear screening for cervical cancer. Everyone probably knows about screening for colon and prostate cancer. What you might not have heard about is screening for lung cancer. Why is this important?

Lung cancer kills more men and women than any other type of cancer. It accounts for 27% of all cancer deaths–more than deaths from cancers of the breast, prostate, and colon combined. Yet, until recently, there was no screening test for lung cancer.

Being diagnosed with lung cancer is scary. However, lung cancer does not have to be a death sentence. In 2011 the National Lung Screening Trial reported that individuals who were screened for lung cancer with a low dose CT scan had a 20% lower risk of dying from lung cancer than those individuals who were screened with a standard chest x-ray. This study was finally proof that early detection of lung cancer can result in increased cure.

For lung cancer screening to be effective, it is important that only those persons at high risk be screened. High risk is defined by age, years of smok- ing, duration or years since the person may have stopped, as well as by other possible exposures. Sim- plified – anyone between 55-74 who has smoked the equivalent of 30 pack years is at high risk (# of packs you smoke per day times # of years smoked = pack years). If someone who has smoked at least 30 pack years has quit smoking within the last 15 years, that person is still at sufficient risk to be screened.

Additional risks may also play a role. If a person is 50 or older, with at least 20 pack years of smoking and any other exposure or factor that adds to their risk such as a previous malignancy, radon exposure, or asbestos or other occupational exposure – he has sufficient risk to be screened.

The program involved in the screening is im- portant. Clearview Cancer Institute launched its lung screening program in 2012 after seeing the devastating effects of diagnosing lung cancer in its later stages. We really felt we had a mission and obligation to the community to make lung cancer screening as universally accepted as mammography is for breast cancer.

We were joined by our colleagues in- volved in the diagnosis and care of patients with possible lung cancer, as well as the Huntsville Hospital Health System. With support and effort of all and additional funding from the Russel Hill Cancer Foundation and the Alpha Foundation, we developed the Southeast Lung Alliance. This is a program dedicated to increasing the awareness of Lung Cancer Screening and supporting tobacco cessation as the mainstay in prevention of this most lethal disease.

In our community hundreds of your family, friends, and co-workers have already been screened and, yes, some have had their lives saved by finding an unsuspected cancer early enough to be cured.

If you or any of your loved ones smoke – stop! But whether you stop now or not, enroll in a screen- ing program for early detection of lung cancer. It could save your life or the life of the one you love.

For more information, go to www.selungalliance.org or www.clearviewcancer.com

or discuss lung cancer screening with your physician.

by Marshall T. Schreeder, MD , MPH Clearview Cancer Institute



by Bobi Jo Creel, MSN, CRNP

(a note to myself at 17)

The world will speak at you in many ways. You will read how the medical world is full of red tape, rules, ratios and never ending charting, but there are a few things they are missing. The world needs good nurses called into the profession; and you, girl, can make a  difference. Here is what no one tells you…

No one tells you that you will be scared–Of the pressure. 

Of messing up. 

Of not knowing something. 

Of doing the wrong thing. 

Of letting down your medical team. 

No one tells you this will make you a better nurse. 

No one tells you the ways patients will affect you–

With their struggles. 

With their stories. 

With their faith. 

With their determination. 

With their fight. 

No one tells you this will make you fight harder. 

No one tells you there will be days when your faith becomes shaken–When you don’t think you can. 

When you don’t know what to do next. When you just want to walk out of the patient’s room. 

When you think, “Why am I here and how do I fight harder for this life?”

No one tells you that you will start to believe in you. 

No one tells you that patients and families will change you–

With their harsh words as they are at their worst. 

With their loss as if it’s your own. 

With their happiness in the successes of small daily battles. 

With their joys in new beginnings and the miracle of life. 

No one tells you that your character will strengthen through empathy and grace. 

No one tells you how your coworkers will influence you–

To want to be a part of a work family. 

To understand sometimes all there is left to do is pray. 

To learn to be a better listener and supporter. To realize that you are not in control. 

To realize who is. 

No one tells you that you will learn another side of the meaning of love. 

No one tells you that you will have days when you feel the fragile flicker of mortality–

When a patient gets better and then back to worse in the blink of an eye. 

When you code a patient for the first time. When you have your hands on a chest praying for that life to stay grounded. 

When that life breaks it’s earthly chains. 

 No one tells you that you will, in these moments, recognize that there are two types of patients–those who should be able to be saved, and despite all medical resources, aren’t. Those that shouldn’t have a chance to survive, and by divine medicine, do. 

No one tells you that you will go to church in a patient’s room–

When your patient just needs to talk or hold your hand. 

When your patient’s family members want answers you don’t, and won’t ever, have. When you and your team have exhausted all efforts and you gather around the bed and pray…and cry. 

No one tells you you will find your beliefs in those walls because you finally understand He is never far away. 

No one tells you of the days when–You find peace in your calling. 

You finally see why you are in this role. You realize that you are a tool and an avenue for great work to be done. 

You understand that you are human and your best IS good enough. 

You believe. 

No one tells you that you’ll look back at your journey with a heavy heart at the ones who branded it and are no longer with you, of the ones who stay with you for all the best reasons, or the days when you felt like you were right where you needed to be. 

No one tells you that when you are doing what is your calling, that it is all that matters and, most importantly, all that ever will. 

No one tells you that you will find peace in your work because it is far more than just a job. 

No one tells you that sometime later you will look back at how it all started, with tears in your eyes, and realize–

That the days of doubt were trials and you passed, not always prettily, but you did it and you have built character as a result. That the positive far outweighed the negative. 

That the days of not knowing your purpose are over. 

That you are the mother, daughter, sister, and spouse you are because you endured. That the pieces of all these experiences you have carried with you now quilt your being. 

And, lastly–that even on those long days and nights over the years when you felt your heart breaking and healing, that those on this adventure with you saved a piece of you as well. Your journey is not over, it has only begun; the trail is merely better marked now as a result of your experiences. It can only make your footprints clearer for those who travel along it with you and for those who follow after you.

Bringing Back the Disappearing Doctor: time has changed medicine

Bringing Back the Disappearing Doctor: time has changed medicine

Giving Control Back to the Patients

by: Crystal Barber MBA & Heather Morse MS, ATC, OTC

There’s little doubt that the front line of medicine — the traditional family or primary care doctor and the patient relationship— has been under siege for years.

   Choice is what we all want, as most would say. There is a growing cognizance that patients can and should play an important role in deciding their own care, in defining optimal care, and  in improving healthcare delivery. There is much growing evidence that engaging patients in treatment decisions and supporting their efforts at self-care and preventative care, can lead to more beneficial long-term outcomes. Patients who are active participants in a shared decision-making process have a better knowledge of treatment options and more  realistic  perceptions  of treatment effects.

    The resulting treatment choices are more likely to concur with their preferences, lifestyles, and attitudes to risk. Actively engaged patients are also more likely to adhere to treatment recommendations, and less likely to select expensive procedures.

The Modern Primary Care Model

One would assume all of the above benefits would shape a modern, successful model of healthcare. Yet this is not the model patients are exposed to in this modern era. Higher healthcare costs, skyrocketing drug prices, and lower reimbursements for physicians have created an environment that does not support a patient-centered model of care. Doctors are working under more pressure than ever before. Recent changes in health care – such as ramped-up productivity requirements, increased documentation, and new quality metrics have left physicians scrambling to see more patients on a daily basis to cover rising supply costs, higher malpractice rates, and increased staff costs. Even so, patients deserve their undivided attention. These conditions have many patients feeling dissatisfied by the quality of the office visits with their physicians due to time restraints and longer wait times. While the ballpark office visit time is about 11-15 minutes, patients are not getting as much time as they need to address healthcare concerns. By all accounts, shorter visit times take a toll on the doctor-patient relationship and may represent a missed opportunity for getting patients more actively involved in their own health. There is less of a dialogue between patient and doctor, studies show, increasing the odds patients will leave with a prescription for medication, rather than a behavioral or lifestyle change — like trying to lose a few pounds, going to the gym, or electing alternative for pharmaceutical treatments.

What We Can Learn From Old School Practices

The term “old school” in many facets of life has negative connotations. We live in a modern, technologically advanced and fast- paced world — and there’s  no  room  for things that hold us back.How did we get to the stage where a genuine and caring doctor has become the odd one out? The old school physician pulled up a chair, took the time to sit face-to-face with their patient, maintained eye contact, and asked  open-ended questions. They allowed the patient  to express genuine healthcare concerns, directing them when necessary towards the questions that need to be asked to benefit them as an individual. It included some good old-fashioned talking and learning about the patient’s lifestyle and choices. At the end of the encounter, they were given a chance to ask any questions, offered education, and given multiple treatment options. In  the former healthcare era, herbs and alternative medicine treatments were offered along with education to help the patient understand all the options available. The treatments were then used in conjunction to offer the patient the best outcome possible. The modern era of medicine has lost some of the key components that made  medicine  successful in the first place. Methods like  house  calls and alternative forms of medicine offered patients options to get involved with their healthcare, alternative medicines that  would not cause additional addiction and further harm the body, and face to face time to be educated and heard.

“In 1930, about 40% of doctor-patient interactions were performed through house calls, but by 1980, the rate was down to only 1%.”

Physician House Calls: An Old Model with a Modern-Day Twist

The concept of a doctor coming to a patient rather than a patient going to a doctor is hardly a revolutionary concept yet could be the answer the modern era of healthcare is looking for. In 1930, about 40% of doctor-patient interactions were performed through house calls, but by 1980, the rate was down to only 1%. We now live in a time of convenience and speed. We have grown so accustomed to instant information, feedback, entertainment and more, that we’ve grown impatient with waiting. This transition to an easy access and fast pace life has actually helped to bring back the nostalgic house call.

“The new era has also brought the ability to reach information quickly about better healthcare choices that are now being offered to patients via concierge medicine. While we want instant access to our doctor, we also want more time with them to discuss all of our health and wellness concerns.”

A New Spin on Healthcare for Your Lifestyle

The young adult population is very tech-savvy. They are accustomed to using apps and quickly scheduling appointments with a few clicks. They are also very busy working and caring for young children, so a model that doesn’t require them to leave their homes when they have a sick child is very appealing. The search for affordable, convenient healthcare has now brought advancements such as tele-med visits and house calls to the forefront. Patients want healthcare options that suit their lifestyle and are of a higher quality of care. Patients are now seeking out practices that offer not only technology based patient interaction for more affordable rates, but also practices that offer a more patient-centered approach. Services such as house calls and same day telemedicine visits from the comfort of their own home are now what patients are seeking the most.

Traditional Medicine Concepts Meet New Age Lifestyles in North Alabama

Old school traditional medicine concepts work. These concepts help patients feel more at ease with treatments, obtain better long-term outcomes, and cut individual healthcare costs. With this knowledge and experience in mind, the owners of Traditional Family Medical Center will open its first location in Huntsville Alabama, in late March 2020. The vision started with traditional family medicine concepts and has grown to include a long list of services including holistic, integrative medicine. This service puts patients at the forefront of their healthcare again. Traditional Family Medical Center offers patients the choice of conventional pharmaceutical treatment options as well as an avenue where patients can choose to treat illnesses with holistic options. Their goal is to truly get to the root problem and not only manage  symptoms  but work on a reversal of the problem. One very valuable service that will be implemented is telehealth, whereby providers use email, phone, text, or video  for consultations, reducing the need for time-consuming in- office visits.

However, TFM does not fall into the trap of all-or-nothing thinking, expecting patients only to see their providers either in the office or remotely. With a little creativity, we can envision mobile health technologies such as telemedicine leading to the restoration of an almost forgotten medical tradition: The House Call. Imagine the connected provider traveling to patients as needed, with a portfolio of cloud-enabled diagnostic, therapeutic, and decision-support tools at their disposal. Blending the importance of conventional medicine, as you know it today, with the proven results of traditional (the old ways) we can truly bring healthcare back to the patient. Simply managing treatments is no longer acceptable for many in our population. Patients want answers, they want options, and they want to know they are being heard when they voice their concerns.

You can learn more about Traditional Family Medical Center on their website 


Crystal Barber, MBA, is a co-owner of Traditional Family Medical Center & Heather Morse MS, ATC, OTC owner of Salt on the Rocks and co-owner of Traditional Family Medical Center

For Better or Worse- How genetics can affect relationships 

For Better or Worse- How genetics can affect relationships 

By: Neil Lamb, PhD

Marriage requires working as a team, tackling challenges like joint finances, work-life balance and parenthood. Navigating these challenges impacts how satisfied a couple is in their relationship. Successful problem solving is shaped by factors like communication style, level of trust and a couple’s prior history. Now scientists say genetics might also be a player.

   Social support – feeling that one partner understands the views, opinions and abilities of the other – is an important measure of marital satisfaction. Another is attachment security, the feeling of emotional safety that comes from others being responsive to our needs. Two scientific publications – one in the Journal of Family Psychology and the other in PLOS One – illustrate how variations in a gene previously linked to personality can also be associated with patterns of behavior and emotional response that ease or increase marital pressures. However, before you conclude that genetics predetermines the fate of our relationships, let’s dig a little deeper in the findings.


The most recent papers build on already-published research into the effect of variations in OXTR, the Oxytocin Receptor gene. The receptors can modify a range of responses to so- cial stimuli, such as stress or anxiety. DNA changes in OXTR have been connected with several personality traits associat- ed with sociability and bonding. For example, a 2009 paper found people with one specific variation in the OXTR gene thought and behaved less empathetically. That same variation also led people to have a stronger stress response, both men- tally and physically.

   As you can imagine, people with less empathy and high- er stress relate differently to other folks and the world at large. Intuitively, those effects would carry over to marriage. Now researchers can demonstrate that carry-over through careful study.


The team of scientists leading the Journal of Family Psychology study recruited 79 couples and asked each partner to come up with a pressing issue to discuss with the other – a personal problem not linked to their partner or partner’s family. For example, they might discuss a problem with a coworker. The scientists recorded ten minutes of conversation on the subject then analyzed the interaction to see how the partners sup- ported and accepted support from one another. They also surveyed the individual partners to get a broader sense of each spouse’s perceptions about their marriage and obtained saliva samples for genetic testing.

   Variation along the OXTR gene influenced both the actions and the perception of those actions for men and women. That said, husbands with a specific genetic change (defined as the TT genotype at SNPrs1042778) reported less satis- faction with the recorded interaction with their wives, and lower marital satisfaction overall. The scientists hypothesize that husbands with this variant may have trouble identifying and interpreting the social support signals coming from their partners, and therefore perceive them as being less responsive. The PLOS One study examined 178 midlife and older married couples. Here too, participants provided saliva samples for genetic testing and completed surveys about their feelings of marital security and satisfaction. The study focused on the OXTR variant described above in the 2009 paper (rs53576). When at least one partner had the GG genotype – the opposite of the variation that led to less empathy and more stress – the couple reported higher satisfaction and security in their marriage than couples without this variant. Individuals with the GG genotype also reported lower levels of anxious attachment, which prior research has shown to be associated with a lower likelihood of jealousy and better relationship quality. Of course, this is still just a small portion of the marriage equation. 


Genes may have an influence on marriage, but that impact shouldn’t be overstated. The researchers found that the genotypes of both partners combined to account for about 4% of the variance in marital satisfaction. Because both studies analyzed relatively homogeneous populations of caucasian couples, it’s important to replicate these experiments using larger, more diverse populations.

   However, it’s worth noting that this gene shapes both behaviors and perception of a partner’s behaviors. The the authors of the PLOS One study even suggest that the patterns of each partner can rub off on one another over time.

   Further research could examine how those same genetic variants shape our interactions with positive and negative relationship experiences. After all, marriage often revolves around understanding and context. The genetics likely do as well.


The way we love stems from all kinds of factors, from our upbringing to our genome to the way we respond to the large and small stressors of the moment. Some pieces of our genetic code influence how we process feelings like empathy. So it’s understandable that our DNA recipes play a role in our most important relationships.

   It’s interesting that we can link genetic variation to how supported a partner feels in a marriage. That certainly seems like a factor that could boost relationship satisfaction. Still, it’s important to realize that the science isn’t saying two people are genetically incompatible because of this one variation — or any other genetic information for that matter. Love, marriage and long-term relationships are complex and we’re just starting to learn more about how genetics play into the way we relate to others.

To see more stories like this, visit www.shareablescience.org

Retrain the Parkinson’s Thinking 

Retrain the Parkinson’s Thinking 

Fight back against Parkinson’s! 

by Jeffrey Hull, M.D.

After practicing pediatric medicine for 35 years, I was looking forward to the approach of retirement. About five months before the date for my retirement, I was experiencing some mild but puzzling symptoms. 

   Thinking back, these symptoms had been very subtle for about 12-18 months or so. I was noticeably weaker and had a mild tremor (shaking) in my hand when holding a fork at meals. I also had a couple of other mild but mystifying experiences, such as loss, years earlier, of my sense of smell. I literally could not smell a dirty diaper that mothers would instantly notice. Another common symptom was writing very small, no matter how hard I tried to write larger. However, it was a sharp eyed nurse, and problems playing pool that motivated me to go to a neurologist. I felt sure that my tremor and other symptoms were simply age related. My wife went with me to see the neurologist and left an hour and a half later. The neurologist diagnosed Parkinson disease, confirming my worst fears. I was numb. Gradually, shock changed to sadness, anxiety, and depression.

   By about three months after my diagnosis, I was at a low point, physically and emotionally. I was on anti-Parkinson medication, which seemed to help to some degree with the symptoms of mild tremor and weakness, but I felt depressed and alone. It did not help that while I worried about my illness I was very busy with the closing of my medical practice. I thought there must be something to do more than waiting for new tremors.

Then one day the local newspaper printed a human interest story about the Rock Steady Boxing therapy for Parkinson disease. A group was just forming in Decatur. I called the contact number right away, and I have been in the program for six months.

What is Parkinson disease?

Parkinson (or Parkinson’s) disease, or Parkinsonism, is a chronic degenerative disease of the brain for which there is so far no cure. It is caused by death of certain types of brain cells which manufacture a substance, dopamine, which is essential for normal function of muscles. Progressive loss of dopamine proceeds over a typical course of 10 to 15 years, although some patients have much slower progression of symptoms. The disease most often affects people 50 years or older, but may appear in younger persons as well.

   Physical findings in Parkinson disease include a characteristic stooped, shuffling gait; facial weak- ness (called “mask face” that makes one appear to be angry); eventual trouble swallowing properly; and most characteristic the tremor. This shaking of- ten involves one hand first, and will eventually affect all muscles of the body after a number of years.

The Rock Steady program

The main method of treatment of Parkinson disease has largely been the use of drugs. Chief among these medicines is L-dopa, a pill that can relieve tremor and other symptoms temporarily, but does not alter the underlying and ongoing deteriora- tion that remains. Side effects are com- mon, requiring careful monitoring and medication adjustments.

   Parkinson patients have generally been encouraged to exercise to stay as limber as possible. But in the last few years, research has been found that a program of more strenuous exercise combined with fine motor drills, gait training, and a variety of similar drills targeting significantly extend better well-being. The program is called Rock Steady Boxing. As the name implies, it is centered around non-contact boxing drills, meaning that participants do not hit each other, but spend time practicing flexibility and balance, then fitness and strength, and finally boxing moves and punches on the heavy bags, speed bags, shadow boxing, and a variety of boxing moves that teach the body to restore movement, and reduce tremor. Since   beginning   the   program, Rock Steady Boxing has been a God- send for me. Rock Steady is a physical training program to retrain the nervous system to cope with long term effects, but it is a lot more than that. It is a close knit group from diverse backgrounds and different stages in the disease but bound by a common enemy, Parkinson disease. It is about group members helping one another, encouraging, listening – more like a “family” than I ever expected. And most importantly, the program works. Muscle strength increases, balance improves, and joint movements are more fluid. Ask us what we are doing, and we say: fighting back!


Rock Steady Boxing is a nationwide pro- gram with programs scattered through- out the country. In our area there are lo- cal groups in Decatur and Huntsville. Each leader has been trained at the national headquarters in Indianapolis, Indiana.

In Decatur, sessions are from Noon to 1:30pm on Monday, Wednesday, and Friday at Bender’s Gym where they gen- erously provide the use of the gym space at no charge. In Huntsville, sessions are from 9:15 – 10:30am on Monday, Tues- day, and Thursday at a local gym located at 3228 Leeman Ferry Road, Huntsville, AL (Behind Matrix Gym).

The phone number for the Decatur lo- cation is 256-303-0710, or visit their website at www.decatur@rsbaffiliate.com. For the Huntsville location, the phone number is 256-513-8164, or visit their website at www.rocketcity.rsbaffiliate.com.



by, Victor Chin, MD

Imagine you are being treated for cancer with a chemotherapeutic drug. You assume the drug is approved by the U.S. Food and Drug Administration (FDA) to be safe and effective for your particular cancer condition based upon results from medical research trials. Did you know if you are a person of color your cancer drug may have never been tested in your unique ethnic or racial group? In essence, you could be an unwitting participant in an unregistered medical experiment.


Cancer specialist Dr. Jonathan Loree and colleagues in the August 15, 2019 edition of Journal of the American Medical Association Oncology reviewed 230 cancer drug trials conducted from 2008-2018 that involved over 112,293 participants. Only 7.8% of the 230 studies documented participants from the 4 major races in the United States (white, Hispanic, black, Asian). The percentage of trials including participants from different racial groups did not change significantly over the 10 year period. The percentage of Hispanic and black participants in the cancer studies was far lower than the proportion of Hispanic and black patients who would have disease in the general population. The burden of disease among minority groups was not addressed in the makeup of participants in cancer research studies.


Why is it important to study medications in various racial/ethnic populations? A particular medication’s efficacy may vary depending on the patient population. For example, current guidelines from the American Heart Association recommend that for treatment of hypertension in black patients a physician starts with a thiazide-type diuretic or a calcium channel blocker. In research studies, these medications have shown relative greater efficacy in blacks for hypertension as opposed to an angiotensin converting enzyme (ACE) inhibitor, which is often used first-line in other patients.


Numerous advocates raise the issue of social justice in medicine – the idea that racial group disparities in the delivery of healthcare and outcomes in health should be eliminated. The inclusion of people of color in medical research is crucial to improving health for all people in our society. The FDA has recognized the importance of diversity in medical research and in 2016 issued a non-legally-binding guidance statement encouraging study sponsors to include more racially/ethnically di- verse participants in trials:

“FDA expectations are that sponsors enroll participants who reflect the demographics for clinically relevant populations with regard to age, gender, race, and ethnicity.” In June 2019 the FDA released a new draft guidance statement furthering its encouragement of diversity in medical research in which it stated:

“Broadening eligibility criteria and adopting more inclusive enrollment practices will open clinical trials to a diverse participant population reflective of the population that will use the drug if the drug is approved.”

Personalized healthcare and medicine have brought this issue front and center. The keyword here is ‘personal’ which for me involves the reality that every male on my biological father’s side of the family died from cancer. The fact that I have sons that may be affected by the lack of racial diversity in medical research hits home. I could no longer be a bystander when witnessing the lack of ethnic diversity in both genomic research and clinical trials. I thought that if government and policy makers will not address this form of health disparity and health inequality, then it is up to me to intervene and make a positive impact. I want to ensure the treatments of the future apply to people of color.”

-Delmonize “Del” Smith, founder and CEO of Acclinate Genetics explaining his inspiration to diversify medical research.


Calls for social justice alone in medicine have resulted in inadequate results. It is time to utilize the unique problem-solving abilities of the world of business to reduce racial differences in health.

More than just a headhunter to match people of color to medical trials, Acclinate Genetics aims to build and maintain relationships with college graduates of color. Acclinate Genetics serves as a liaison between the medical research industry and well-educated patients of color by vetting research opportunities and educating its participants about medical research. Acclinate Genetics strives to bridge the lack of trust many minority patients have in the medical research system.

By having well-educated active participants of color in research trials, pharmaceutical companies can produce better quality research trials with fewer patients lost to follow-up. By testing in a diverse population, unique efficacies/toxicities of drugs may be found in specific racial/ ethnic groups that would go undiscovered if only a white male study population were used.

Acclinate Genetics

601 Genome Way Huntsville, AL 35806 acclinategenetics.com