 We're going to start with Dr. Barbara Turner and chronic pain and move through Dr. Denise Dom, Dr. Cassiano, Elizabeth Cassiano, and Dr. Sandra Oswald and they're each going to give their presentation and then they're going to join us up front and we'll have an opportunity for questions and answers after their presentation. So to get us started, Dr. Turner. Thanks very much. Ten minutes is going to fly by but I want to apologize for those of you who've already heard this talk. I actually have an hour version of this so count yourselves lucky I suppose. So I'm talking about chronic pain and it's not the most upbeat of topics and yet it's extraordinarily relevant. Most of us don't really think about it but the definition is that it lasts at least three to six months. It disrupts what you do pretty much on a daily basis but often sleep is the harbinger of chronic pain and it doesn't really have to be constant so think about it as a disease in and of itself. In other words we think of arthritis and you know a little back pain etc but really pain becomes its own problem and it has now been designated as a disease that causes changes in nerves and the thing is it's very hard to treat. So it got the attention of national experts in the Institute of Medicine. They wrote a treatise on this to raise awareness as a national priority. So I want to summarize a couple of their points which is that one in three Americans will experience chronic pain at some point so it's very common and when it starts it lasts. In other words in older folks when they start to get pain 60 percent have it a year later. So it is really common. If you look at the diseases that we focus on as being our big health priorities here, chronic pain outstrips them all in terms of prevalence and yet the community awareness is like completely less than the other ones and it even affects our Hollywood stars. So no one is spared really. So what does it do to your lifestyle? It affects all of those aspects. For example in sleep about 20 percent of adults describe in a response in a national survey that they have pain at least a couple of nights a week and that's 42 million people. Other health effects are overall compromising your health. So you report fair or poor health and almost a third problems with work problems as I mentioned not only with quality but duration of sleep and mental effects. And as a result it actually has a really enormous economic implication for the country not only in direct medical expenses but in work days lost and lost productivity. So why are women particularly the target of my talk about pain? Well that's because it's probably worse. In other words at the age of about 45 women are just about the same as men in terms of having arthritis but then as they reach into their fifties and sixties more women are diagnosed with physician than men with arthritis and the same is true for joint pain. So arthritis is one thing but is it painful? And here you can see that women in the Lyme are starting about the age of 40 more likely to have joint pain than men by the time they're over 65 they're up to almost 50% having joint pain. Now you may say well maybe women are heavier than men and in fact it is true that the probability of having arthritis goes up with your weight so if you're obese you're up to about 30% but women have more pain regardless of their weight than men do. And here again the same colors you can see that here men who are obese 31% and this is a national survey had problems with pain but 43% of women had pain regardless of their weight. So this is kind of a funny slide but you've probably been to the doctor's office where they say tell me your scale you know how bad your pain is from one to ten and I wish they'd show this picture but anyways just to give you a little thought about what we used to do and what we are doing with pain back in a couple of centuries ago we had very easy access to opium and the usual Ladanum user which is a combination of alcohol and opium was a Caucasian woman here's the stuff and that's because men had their own substance which is alcohol and ready access to it because women weren't supposed to go to bars so they went to their doctors and they got these drugs and they got addicted. So what's happening now well opioid prescriptions are just exploding back in 1991 there were 76 million a couple of years ago 219 million the CDC estimates that there's enough of these narcotics out there to treat every man woman and child for at least a month with a pretty heavy dose so we have massive amounts of these drugs around and that's because a lot of people with these common conditions are treated with pain medication up to about a quarter of adults get prescription pain medicines and when you look at it for by age and gender women are significantly more likely to get these medications than men really striking in the 20s with only 10% of men and 22% of women the difference is narrow but still women are more likely to get pain medicine for their joint pain remember we're more likely to have joint pain so that what we found actually in our analysis here in Texas is that 46% of women with diabetes who had received had received one of these more potent narcotics compared to 38% of men so we're definitely in the crosshairs of getting these drugs and when we are women who are on these drugs have a lot of mental health issues compared to men on these drugs too depression anxiety in other words there are a lot of downsides to narcotics and some of them are death so you can see here this is the proportion of deaths per 100,000 going up through 2006 and this is the sales of these drugs it's pretty much collinear so not only do we have deaths from these drugs but it really is specifically opioids narcotics here these are deaths from different classes of drugs down here like benzodiazepines are like valium heroin the deaths are down here to all the other drugs this is the narcotics in women and over here emergency room visits narcotics are up there most common cause along with the valium type drugs so what do we do I mean this is sort of a very negative problem but there really are things that we should be thinking about in a prevention mode and it has to do with your everyday lifestyle to try to avoid getting caught in this problem of what to do about pain is try to prevent it and here one of the things that I want to emphasize is that when you're managing it don't just take pain pills it's much more complicated than that and it requires these are all evidence-based things to do but when I have patients who come in and I say so what else are you doing besides taking you know hydrocodone for your pain they go huh so it really has to have a multi-disciplinary approach or that one I suppose would be another option and really trying to stay away from those things they're not a panacea surgery or injections you know there was a terrible a lot of people who had fungal infections from these spinal injections so the prevention goals are the CDC's and I don't know about you but they say vigorous walking 150 minutes a week if you're more active vigorous like running jogging 75 minutes the thing that I fall down on and I don't you is that muscle strengthening exercises and they want us to work out all of our muscle groups at least a couple of days a week but the whole package is to prepare your body to function better and to avoid this trap of chronic pain and you can do it at home it actually doesn't require dragging yourself into a gym there are lots of these things I find you know television music etc are all and heavy gardening but not this time of year are all a shoveling are all options for you to start to use your body so here's the rewards endorphins as you probably have heard or feel good hormones you're a role model as a mom and your kids start to exercise and you live longer and this is kind of scary data from the UK where they looked at how good your physical activity is in age 53 like standing from a chair or walking a certain amount of time and it was highly predictive of how whether you would be alive at age 66 about two times more likely to die if your exercise tolerance was compared to excellent very good good or poor and man if you're in poor shape you're almost four times more likely to be dead at the time of the age of 66 so take charge and avoid this all right thank you well thank you very much for inviting me here today I'm going to be talking about dementia which just like Dr. Turner mentioned is not a really upbeat topic but probably relevant I just wanted to ask how many of you are currently caring for someone with dementia here in the audience okay so it's already touched the lives of several of you and a lot of people that I run into are also really worried about themselves so that's what I thought we'd talk about today when should I be concerned about myself or a loved one I'm just going to define dementia talk a little bit about the epidemiology how do you tell what's dementia what's normal aging um and then we'll do some question and answer so as a physician I don't diagnose dementia until I see two things memory loss and another cognitive difficulty that affects daily life and so that's going to be kind of the common refrain when you want to know if something's rising to the level of dementia or a memory problem of concern what we will always look at is how is it affecting daily life so when folks come into my office I evaluate their memory and then I ask about these things here disorientation which is confusion about time and place disturbance in executive function those of you who visited with me know a little bit about what executive function is but it's those things that require some planning and forethought to execute so making change in a restaurant without using a calculator looking at a map and negotiating a path while driving are examples of executive function tasks and then there's the a words aphasia apraxia agnosia so those are basically difficulty doing tasks that were previously learned difficulty recognizing familiar people or objects and then aphasia difficulty speaking problems with activities and daily living and so their activities of daily living are the things we do first to get up and get out of bed so we get out of bed we get dressed we go to the bathroom we shower and then there are the things we do out in the world so we drive we go to the store we take care of our bills we manage our medications we use the telephone the computer those are both different examples of activities of daily living and then the last domain we'll look at is one's ability to attend or focus and concentrate but the bottom line is we diagnose dementia when thinking has become so impaired it affects your ability to do daily life so I'll have you know folks come into my office and they might be really concerned about their memory their testing might not be quite right but when we look at their their daily life day by day they really haven't lost an ability to function um and so we don't really call that dementia on the other hand I'll have folks who don't really perceive any problem at all um their family may perceive quite a problem and when we look at their daily function they've actually given up quite a bit of what they used to do and that is concerning for dementia and again I'll show the scary graphs about prevalence of things going up but we all know there are probably about five million folks living with Alzheimer's disease today in America and that's just projected to increase as baby boomers age until we have over 14 million people in 2050 and I had several great questions about this already dementia is sort of the umbrella term that we use for any progressive cognitive decline disorder um Alzheimer's disease is the most common type of dementia and that's going to be um what most people you know the only way we definitively know what type of dementia somebody had is to do a brain autopsy and very very few people will actually go through that but we we know today that probably most people have Alzheimer's disease second most common cause for a long time has been vascular dementia which is caused by many strokes or repeated small strokes over time but there's a third type called Lewy body dementia um which is there we go which is rapidly overtaking vascular dementia it made the news lately because they think that Robin Williams might have um recently been diagnosed with Lewy body dementia and that might have contributed to his um suicide however um Lewy body dementia is a little bit of a different animal than um Alzheimer's disease and vascular dementia um and as I said it's rapidly surpassing vascular dementia is the second most common cause so anyway a lot of people will throw kind of interchange these terms but dementia is sort of the umbrella and then under it we have Alzheimer's disease vascular and Lewy body okay but this is probably the most common question I get is well how do I know if it's dementia or if it's normal aging if you ask 160 year olds about half of them are going to tell you they think they've got a problem with their memory and certainly not all of them have dementia so some normal changes with aging are absent my did this so walking into the living room and forgetting what did I come in here for misplacing your keys I mean you know I do that like at least once a week so um the thing is is there's not a persistent pattern of these things happening more and more frequently over time and it's not interfering with my ability to function eventually I do find them and I get to work transient is um the ability to forget details over time okay and so all of us you know if you asked me about a party that I went to yesterday I'm going to remember quite a few details about that if you asked me about it again in a month I'm not going to remember as many details about the party I might get the date a little bit you know I might say it was you know Friday the 18th Friday the 17th instead of Friday the 18th because I forget the date that kind of thing is not necessarily abnormal um blocking or word finding difficulty is really really common with aging and again if it doesn't affect your ability to daily function and if you eventually come up with the right answer that's normal what I mean by that is somebody says you know um what was the name you know um that um you know thing you uh you use it to dry lettuce um it goes around and it's a salad spinner you know you just can't think of the word of so that is not necessarily abnormal okay um slightly slower processing speed okay so that is not necessarily abnormal with aging so you get to the right answer it may just take you a little bit more time a little bit more deliberation and new learning is thought to be slower but does occur so you get a new computer it takes a little bit longer to master all the bells and whistles than it would have you know five or ten years ago I just want to say there's one bright note about um about memory and cognition with aging is that folks in their 50s and 60s are often shown um to have a better ability to synthesize information so that when they look at high-level exact female executives uh physicians professionals they're often much more skilled than their younger colleagues that like coming into a situation and immediately kind of knowing what's going on and how to handle it so there is a bright there is a bright spot um so so that's like all the like 25 year olds you know that right so um but when do you need to be concerned about your mom or dad or about yourself you know uh you want to again probably number one two and three is memory loss that affects daily life okay so um you always did your taxes yourself um this year you sat down to do it and it just kind of seemed overwhelming or you just couldn't get get through it uh trouble planning and problem solving like I mentioned that's executive function so um more difficulty or more struggle with that difficulty completing familiar tasks so I've had you know some patients that are retired professors and their their tip off was that you know for fun they used to go and do physics problems and now they take them you know an hour and a half to do a problem they used to do in you know 20 minutes again disorientation which is confusion with time or place we're all going to mix up dates occasionally of appointments but it's something that's a recurring pattern new problems with vision or spatial relations that's an interesting uh not altogether common but sometimes they're presenting uh feature of dementia or Alzheimer's that folks um report new difficulty with vision that's not initially related to an eye problem or their spatial relations so more difficulty judging time or uh judging distance in space a new problem with speaking or writing again this um is not altogether common but can be so um one gets less fluid with their language may use simpler words simpler sentence construction and their writing might change it might just become more simple and probably the best um example I can recall of this there was a really famous physician a famous writer in britain um she had a movie made about her called iris I don't know if it was judy then she don't think they saw that movie but um she anyway one of the ways they diagnosed her with dementia is they compared her early writing to her later writing and her senate structure and everything was much more simplistic so she was still publishing and yet she had um signs of dementia um now misplacing things more frequently okay so this is again we're all gonna you know lose our glasses lose our keys so forth but um again getting to the point where it's interfering with your ability to function at home or at work trouble with judgment or decision making so for your parents this is the oh you know the nice man called last week and wanted you know they wanted help with the fireman's fund and so I wrote them a check for six thousand dollars you know spinning that's really out of character and doesn't really track with the preview now I mean if that's something they would have always done that's one thing but um uh difficulty with those with judgment and decision making social withdrawal is a really common one okay because often folks know there's a change in memory they kind of see the slippage and they don't want to be around other people who might pick up on that or notice that or it's just too effortful it's just it takes a lot of work to participate in the conversation and try to work so hard to remember and to try to seem quote normal um so a lot of folks will just kind of withdraw and um so really common presenting signs for me as you know my mom really took pride in leading the bible study at her church and she just hasn't wanted to go the last you know a few months or she used to sing in the choir and um for some reason she did you know she said it was the practice was too late at night but you know anyway as we dig deeper we kind of realize it may have been the memory um and then change of mood or personality uh so again um depression may often be one presenting sign it can also complicate the diagnosis of dementia but um folks again as they realize memory is changing may show the change in mood or personality such as being a little more irritable sometimes more paranoid suspicious um and so all those things would be would be signs and so I have this um tool at my booth but uh you can also look on the Alzheimer's website these are the top 10 warning signs or signs to be concerned about dementia and this is if you ask folks who have early dementia what it feels like they often feel perplexed kind of fuzzy foggy unsure of themselves they lose confidence they're not they don't feel like they can trust their brain anymore or their their trusty tool they're fearful of making mistakes they feel a lot of frustration they have a lot more trouble multitasking so now they have to do one thing and then move on to the next uh familiar things become challenging and as you can imagine that's just really tough to deal with uh and unfortunately in the early stages most folks with Alzheimer's disease realizes this happening and it's often the most painful and difficult stage for them the difficult stage for you as a caregiver will be later um but for them this early part is the most challenging uh they may initially try to write it off as quote old age um and you know for a lot of them when their parents were aging they may have had signs of dementia we didn't really diagnose and won't you know do much about dementia um until lately so they may say I don't know why you're making all this fuss about me um and as I said the realization something's wrong is just extremely painful and often folks will say you know I'm just afraid of losing my mind I've I think I heard that quote twice at my booth today although everyone has screened normally so far so it's a really big scary thing um and often how folks are going to go through this process depends a lot on their current activity level their uh what they their occupation and how much support they have and how much embeddedness they have in a community all right so if you are worried about yourself or worried about a loved one I think your first step is to talk to your primary doctor make an appointment for yourself make an appointment for your loved one and educate yourself I can't say enough positive things about the Alzheimer's association that's where I get all my materials and everything they have is public domain so you can zerox it to your heart's content um and then reach out to others friends and family who might have dealt with this they're honestly going to be your best practical resource the doctor makes the diagnosis but your friend whose mom had dementia is going to be the best person to know what do I do at 2 a.m when my mom wakes up and she you know is trying to get dressed for work and um how do I handle those kind of things uh because caregiver support networks are just absolutely vital if you're caring for someone and when you go to the when you or your loved one goes to doctor they'll do a history physical they'll ask about those functional things I mentioned um they'll do some lab testing and they may or may not do imaging of the brain if the person's younger than 65 things have seemed to come on really quickly or really suddenly and then again not to be such a Debbie Downer what can we do to prevent dementia the two most important things are to exercise your mind which we all might think is logical so it doesn't have to be crossroads or to do go it can just you know be anything that you enjoy crocheting um uh working is a great way to continue exercising your mind um anything that's beyond sitting and watching tv or just sitting by yourself in a chair okay so talking to others anything that actively engages the brain counts and then exercise your body exercising is probably just as good if not better than the medications that we have to treat dementia and that's just you know it's going to be the broken record that you'll hear um I went to a three-day meeting in geriatrics and for every problem from diabetes arthritis to dementia to osteoporosis exercise is sort of the elixir of life um if you have chronic conditions manage those high blood pressure diabetes depression and you know eat healthy so if you do that uh but those are really the the most tried and true things that we can do to prevent dementia um there's just a brief summary of what we talked about in time and then I'll be happy to take any questions um at the end thank you very much all right so we're going to talk about incontinence and pelvic organ prolapse um I just have some pictures always nice story and people with normal anatomy here um just to get an idea of what it is that's coming down um and then I have some pictures here of what could be coming down um so these are all things that you know it's embarrassing to talk about but I talk about it because it is important and because it happens so often um why do they occur there's basically been a weakening of the ligaments and strong tissues that hold everything up so pelvic organs are able to fall down people most people are familiar with hernias the same idea except in the vaginal area instead of the abdomen where most people's hernias occur um we know there's an association with these pelvic floor disorders with age pregnancies and deliveries loss of estrogen doing activities over time things like chronic cough chronic straining uh heavy lifting for long periods of time and for most women these are things that all have experienced at some point over another one or more of these things there's also a genetic component so a lot of people say the same thing my mom had a hysterectomy for the same reason that's really common and that's going to be even more important for women younger women with the prolapse as you get older it's probably more environmental factors but there is still some genetics in having to do with it so there was a big study in salt lake city where they do a lot of genetic studies and they did find several areas that are associated with it so definitely does run in families and the twin studies have shown the same thing very common again I have a lot of women who come into my office and say you know yes this has been happening and most women think you know yes it's happening it may or may not need treatment and that's true we'll talk about that as well but it is very common so ranging from I've seen prevalence rates anywhere between 25 and 65 percent with stress and condensate 20 to 55 percent of women so this is a lot of women this is happening too when they looked at a nursing home study 31.8 percent had urinary incontinence alone 40 percent had both urinary incontinence and fecal incontinence and those all a lot of those go hand in hand severe incontinence is a lower prevalence in young women they do have it but that seems to be more commonly severe as you get to ages 70 to 80 one study looking at 497 women found the mean age of these problems and symptoms to be at about age 44 and again it's important because it affects the quality of life and I tell patients you know this is this is important not because it's something that's going to kill you like some of the other things that we've talked about today but it's a quality of life issue affects daily activities sexual function exercise has a detrimental effect on their body image and sexuality they looked at one nursing home study and they look at quality of life measures and they have found that measures of mood and dignity and autonomy were affected and it's actually a reason why women can get it put into nursing homes that one of those things that caregivers you know they've they've been doing all these things for women and it's kind of the all those things that come in common they say okay I've had it it's time to go to a nursing home treatment requires significant resources annual cost of care for public floor disorders in the United States from 2005 to 2006 was almost 300 million dollars so this is a huge problem and again as similar to some of the other programs as the baby boomers age is going to be even more common what symptoms do they have it can be any variety of symptoms and some women have no symptoms at all so that's the other important thing to remember it might be diagnosed on an annual exam they may not even notice and that's okay doesn't that necessarily have to have symptoms to go along with it but what you might notice is bolder pressure difficulty emptying the bowel or bladder you can have recurrent infections bleeding or inability to have intercourse and some of those are the some of the reasons people will present to my office types of incontinence the first three are the most common the stress incontinence that's the coughing laughing sneezing lift a heavy box this is probably the most common in young women and the most common most common type of incontinence that women live with for 10 years 15 years and don't do anything about urging incontinence so you get an urge to go you can't defer it it's probably something you've heard on tv a lot the gotta go gotta go medications that goes with the urgent incontinence and the third one is the other most common and that's the combination of the first two and that's probably what most women have they have some sort of combination of the stress and urge there's also overflow incontinence we see that a lot I think in san Antonio especially with our high diabetes population you can get a lot of neuropathy that bladder is not working as well as it should and some of that's also going to go along with aging so you're leaking because you're not emptying completely and you have overflow there's just it's leaking on its own because you're not emptying fully or the functional incontinence basically unable to get to the toilet due to functional reasons or cognitive impairment or you had a reasonable amount of time to get there but you're in a wheelchair or a walker whatever it is you're just not getting there on time treatments for prolapse again if it's not bothering you doing nothing and reassurance is often a reason people come in they come in because they felt something they thought it was a mass they thought maybe it was cancer it's something enough for people just to say yep that's okay you know we have stages of prolapse and talk to them about the stage and things you can do to prevent vaginal estrogen and kegel exercises kind of go in that where it's not necessarily doing nothing but you're trying to prevent future prolapse and actually help symptoms better so it's not going to get it back to before you had children for when you're 18 not going to go back all the way but it's going to get to a point where it's not bothering you. Pestries which I have a picture of it's a little rubber-like device that holds everything up the nice thing about this is it avoids surgical options and something you get fit for in the clinic very easy to take care of yourself and then there is surgery so here's a picture of a pesterie in this picture that what is in place is the one you can also use for stress incontinence in addition to prolapse and basically different shapes and sizes it's a fitting visit that you come into the office for we try the different shapes and sizes depending on what's falling down and then teach you how to use it best case scenario is somebody's taking it out themselves once or twice a week but I do have some women who can't do it themselves and they can come into our office and do that as well surgical repair is very common for patients who either don't get benefited by the pesterie or take a look at that and say there's no way I'm doing that which you do have a lot of women who say that as well surgery is a great option and that's for prolapse and incontinence so approximately 200,000 women undergo surgery for prolapse another 135 have surgery for stress incontinence annually in the United States so it is very common unfortunately 30% of these are going to need repeat surgery but of course the good way to look at that is 70% of women are good for the rest of their lives and they have the one surgery and they're happy but it is again very common so it's the most common inpatient procedure performed to women older than 70 from 1979 to 2006 how do we treat stress incontinence so those kegels again go back to exercise this is a little bit different exercise than you might have been talking about but kegel exercise is good for all sorts of things it's going to help your prolapse stress incontinence and urging continence the pesterie the picture I showed you there and then I've got a picture of the next three these are this first picture let's see here we've got a slings up here it's a bulking agent so you're actually injecting in something through a scope is this the scope into the urethra to close off that opening and then this is a little device kind of similar to a pesterie except it goes into the urethra and it's really good for just very temporary stress incontinence so I have I'm fine except I can't I'm not going to the gym anymore because for that hour I can't do exercise this is a great option for women like that because it again voids surgery it's something we fit you for in the office and something you take care of on a daily basis finally treatment of urgent continence so again kegels this is going to be a message of the day kegels help everything avoiding things that irritate the bladder caffeine carbonation citrus fruits and again this goes back to quality of life I'm not saying taking all the things out of your diet that you enjoy your cup of coffee in the mornings your most important thing by all means go for it but if you're somebody who's on your third or fourth or fifth cup of coffee by the end of the day that might be something to look at say okay if I cut back do I feel better does my bladder feel better there's plenty of women who can have five cups of coffee and their bladder is just fine and that's that's you that's great there's no reason to stop it but it's something to look at your diet and see what you're doing making sure you're going often enough or for women who are going to often learning how to suppress that so I tried again go to can you complete an activity can you sit through a two hour movie you don't have to go if you don't want to that should be something that everyone should have the goal for doing medications anti-cholinergic medicines and then I have some pictures of the next two the botox and sacral modulation anti-cholinergic so the ones again you've seen on tv um increasing bladder capacity by blocking some of the receptors in the bladder so that the truser muscle that squeezes when you don't want it to when it's not full we're going to relax that muscle and it's a point where it's relaxing it some it's not going to relax it all the way that you don't empty but it's enough that you can have that so the goal is to decrease the number of voids and the number of leaks unfortunately there are some side effects dry mouth constipation and some of them have some effects on memory and cognition so if that's an issue that's something that we'll talk about before starting medications and there is very few contraindications basically the only one is the only big one that we see is if you have uncontrolled glaucoma this is a picture of botox this is something that's done in the office similar to what you do botox for for wrinkles you're basically relaxing a big muscle so you're injecting into the bladder wall itself and the goal is to try to get to that point where it's relaxed enough that you're not leaking but not so much that you're not able to go so that's where you're trying to balance those this is a great little device it's called interstam it's good for an overactive bladder this botox and over and sacral neuromodulation are good for patients who have failed the usual therapy so you've tried the the taking the coffee out you've tried the medication tried the physical therapy that's not working for you so the next step would be this the same company that makes the pacemaker for the heart makes the pacemaker for the bladder and this is a nice option because it's very there's nothing you have to do to it once it's implanted you're good to go you don't have to do something every day you're not changing any settings but it basically sends a little impulse into your spine it gets implanted there and you have a little battery pack that sits in the upper buttock it's good for stress i'm sorry good for urgent continence good for women who don't empty all the way for people who have retention it's now also FDA approved for fecal incontinence and they're working on it for constipation so it gets a lot of bang for your buck and it's really great for again not having to worry about doing something on a regular basis very few side effects and really the only big contraindication of women who need to get MRIs it's a battery so they haven't made it MRI compatible yet and there's an outpatient version of the same therapy except you go through your ankle through the tibial nerve up to the same place that you end up with that the other lead so it's going to your back but it's just a little bit more to do basically it's 12 30 minute sessions that you do in the clinic and then from there there's some maintenance but it's really good for those women who cannot get the need MRIs or who don't want the implant for some reason who are scared to have something implanted in there but it also again it's just a little bit more time intensive in terms of having to come into the office unfortunately they haven't made a outpatient want to take to your house yet but maybe that's the next step thank you very much wonderful thank you so much for inviting me now I know I have a lot to look forward to so here I go with another happy talk but we're going to talk about skin cancer and skin cancer prevention and one of the things I like to do when I give these talks is to help people understand what skin cancer looks like and who's at risk and then what kind of things can you do to prevent it because out of all the different cancers in the world skin cancer is one that is the most preventable so we're going to start with our objectives which is to where raise awareness to recognize or at least identify some what are some lesions then we're going to look at the risk factors and then again measures that you can do to help prevent yourself from getting skin cancer so what is the most common cancer in people it's actually skin cancer very good and over two million people are diagnosed annually with skin cancer so it's a very very common and large problem the skin cancer foundation will say that one in every five americans will develop skin cancer in their lifetimes and there's many millions and millions of people who are living with the history of either non-melanoma skin cancer or with melanoma and out of these types we're going to start with basal cell carcinoma because that's one of the most common types of skin cancer there is and it's about represents approximately 80 percent of all skin cancers and basal cells have many different looks and that's why I like to show these pictures when the most common look for basal cell will be a very pearly translucent lesion and often you'll have a little ulcer or erosion in the middle they used to call that a rodent ulcer a rodent bite you know and that used to be a signal to people that they may have had a worrisome lesion so basal cells are very commonly pearly or translucent with a little ulcer erosion in the center however it doesn't have to have any erosion it could just be a growing lesion that's a little translucent the other thing you might notice are these little blood vessels and so when you have a lot of blood vessels that are torturous going within a bump that's growing you can actually see them then you might want to be concerned and go ahead and get that checked now this is a type of basal cell that you all might not recognize or and many doctors don't recognize it either it can look like a plaque of eczema okay this is a superficial type of basal cell that spreads slowly but it starts it's just like a red plaque a red growth and it can or cannot be itchy but it can scale and this is the kind that often grows larger and larger before it's realized or sometimes they'll come to me having treated it with multiple steroids it's not getting better and then I'll look at it and say well you know what it may be time to do a little buy-ups because maybe this is not what we think it is so I like to bring attention to this type of superficial basal cells that can look like chronic dermatitis or rash some basal cells can look like scars so I just want to bring this up in that sometimes you'll have a what looks like a scar growing on the face but no history of previous injury or trauma and so new scars is actually something to consider might be dangerous so something that you might want to be checked for and then I want to mention that some can also look like melanoma some basal cells can actually be what we call pigmented or brown in coloration and so you might think this is bad but you might think it's a melanoma where it's actually a basal cell in this case I don't mind as long as you recognize it's a growing lesion that's brown because you're going to come in to get it checked but I just want to bring attention to the fact that basal cells can actually be brown also now basal cells are actually one of the better skin cancer to have because they tend to stay in their place and grow slowly you don't tend to metastasize other places like some of those skin cancers we're going to talk about today but why do we worry about it well because it can grow gradually gradually but then become big enough where it can metastasize or can cause significant destruction to surrounding structures like it's by your nose or by your eye you know so you don't want to wait until it's this big you see this one has a lot of the features I told you about translucency it has those dilated ugly looking vessels and a big ulcer in the center now this one has been there for a while and you'd be surprised how big sometimes you know I'll see that you think why don't you come earlier well there's a lot of reasons why people won't want to come in right there's a lot of denial you know I don't want to know what it is it's like maybe it'll go away oh it's a spider bite you know I hear that all the time it's just I got bit by a spider and I go what's a spider doing in everybody's houses I don't really understand I always get this history and I say did you see it no I didn't see it but it must be and I said well you know in they wait you know they wait they don't get better they ask their friends and family they put antibiotics on it they put stabs on it they do all sorts of things and but ultimately there's a little bit of fear you know and that's something I want to tell you guys about don't wait don't be fearful the earlier you catch these things the better it is okay we can take care of it a lot easier when it's smaller okay so what are the risk factors of course sun sun exposure is the primary risk factor for all types of skin cancer basal cell included both uvb and uva wavelengths cause problems and it's on the perias where you get a lot of sun in the head right the face the nose the ears okay it's one of my one of the people helped mind me to tell you that and so you want to look carefully in those areas but also think about the hands or other areas and basal cells don't have to be limited to sun exposed areas it could be also in covered areas and those at higher risk are those with a family history of skin color if you have fair eyes like blue eyes light light skin um if you're easy to burn or tan um if you have a previous fifth year skin cancer you're you have increased risk if you've had radiation to your skin that does give you increased risk for skin cancer in that area and if you've been um had a transplant a bit your own chronic immunosuppression hiv all those things in your immune system is down increases your risk for skin cancer let's talk about the next type squamous cell carcinoma can occur anywhere again more frequently on sun exposed areas and it has a little bit more metastatic potential a little bit more serious in terms of the type of skin cancer and these look a little different they often are just a rough scaly layer area pink area that has a little bit of scale growing you don't know why why is it growing scale the skin is always making scale but sloughing off imperceptibly but instead you get a spot that's growing scale repeatedly it can be as a big thick bump with a lot of scale and keratin or we call it keratin debris but a lot of crust in the middle you have to be very careful about persistent sores on the lip you know because these are a little more aggressive in terms of squamous cells so if you have someone has a scaling spot that keeps scaling on the lip or a sore that's not not viral you know it's persistent you might want to get it checked out I know a lot of you are feeling your lips right now I noticed immediately but this is something we see commonly because it'll start off as little scaly areas okay ears okay and we were just talking about this outside is that a lot of people wear ballcaps right and they think you know in Texas they're always wearing a ball cap well what does that not protect your ears you know your ears are hanging out there so make sure and we're going to talk about that protecting your ears because they're actually more aggressive when they develop on the ears if you have a chronic wound actually that does increase your risk for this particular type of skin cancer people are diabetic and have a lot of ulcers on their legs I always pay attention to that make sure it's healing there's a non-healing area or area that grows within that ulceration I might want to buy up see make sure it's not developing a secondary skin cancer within that wound all right what are these actinic keratosis have I don't have to raise your hand but a lot of people have these actinic keratosis with these scaly growths and we want to treat them why well because most of us believe that they're very early skin cancers early squamous cells some you know sometimes you'll hear pre-cancerous lesion they're very early if you leave them alone a certain percentage of them will develop into more invasive squamous cell carcinomas so scaly areas you may see that on you know elderly people's hands and arms a lot of scaly spots that just keep me growing so who's that risk similarly the basal cell you're older you have fair skin light eyes you've sunburn easy you had a history of skin cancer or maybe a family history of skin cancer that increases your risk and then I already mentioned radiation and chronic immunosuppression even more so for squamous cells are people with transplant patients who are immunosuppressed can have that there's also one that I will add human papilloma virus that's a virus that causes common warts people have genital warts or or persistent long-standing warts you can actually develop skin cancer from having chronic abort infection so what do we do again I want to re-emphasize if you get a newer changing growing lesion don't wait don't wait don't worry it's actually actually the earlier I can get to it the better it'll be for you if lesion does not heal or bleed go ahead and get evaluated don't just get one get them serially you know get your regular follow-ups because it's very important like I say the earlier the better now we're going to move on to the worst skin cancer that we have and follow is melanoma okay so melanoma I just have to let you know is increasing in incidence as we speak it does increase the mortality has sort has been increasing but now it's almost stabilized but the increased incidence of melanoma has been occurring throughout the years even to today and melanoma is not the most common but it's the most deadly skin cancer we see it represents maybe five to ten percent of skin cancers it's the sixth most common cancer in us and look at this the most common cancer among 25 to 29 euros I'm going to talk about that a little bit more later and melanomas can develop in existing moles nevi means mole or it can arise new okay we call it de novo when it rise newly on the skin there's actually a lot of information on melanoma is now the multiple pathways multiple genetic abnormalities and this would become very important for treatment if you're interested we could talk about that more a little bit later but for instance b raft is a very common mutation and now we actually have some medication that targets that particular mutation so early detection is the key to survival for melanoma as is for all skin cancers in the survival rate if you're detected early is about 99 percent or five years but it falls to maybe 15 percent through those with advanced melanoma so again earlier the beller and I'm going to show you different kinds of melanomas because I think they also have different looks and one is called the superficial spreading type and these tend to be brown areas brown gross that can be a little bit raised and then we also have the nodular ones these are ones that grow as a big like mushroom on the skin and they grow pretty fast and this is called a nodular melanoma and this is probably represents most of our more thicker melanomas we also have something called lentic or malignant melanoma all of you have probably some sunspots and as you get older you get more and more sunspots well those aren't necessarily bad but they can become bad and I mean they do and these sunspots become either larger or more irregular in coloration or regular on the edge you see how the regular edge regular coloration or even little bumps within it those are dangerous changes that you should let your doctor know about I want you to know that you can get them on your feet you say but that's not sun exposed whether they told you there's different mutations and there's some particularly if you have skin of color Asians Latinos African-Americans you can get a different type of melanoma that can occur on the feet or the hands or in the nail beds and so I always or I always try to look at feet not because I particularly feel I need I want to but I always do because this is one that goes unnoticed okay and I have seen bad melanomas on the feet or between the toes that people just didn't notice and then I want to mention this one which is an AMelanog melanoma that means that it's not colored or pigmented and this is the one that goes unnoticed that people again think this is something else and they get big okay so these these AMelanotic or non-colored melanomas often come to my office already larger than what I would like so I bring that to your attention all right whether the risk factor is similar to the other skin cancers we talked about but in addition if you have changing moles or lots of moles that's a lot of atypical moles it may increase your risk if you have large congenital moles over 20 centimeters it might increase your risk if you've already had a melanoma it can increase your risk and then these are the same things that you saw on the other slides light hair light eyes older and blistering sun blistering sunburns when you're a little those do increase your risk I do want to mention that even if you have colored your skin and have some natural protection you're not immune to having any of these skin cancers okay and as a matter of fact because you think and you do know that your risk of skin cancer is less than maybe someone whose lighter skin you may delay your diagnosis right may come in later and that's when I find like again the ones between the toes I found one between the toes that was so big he had to get a part of his foot removed and and he thought it was he thought it was just fungus or something you know he just didn't want to believe that he had melanoma because he was Latino and he had never burned in his life he never burns you know and so I just have to caution you especially here in South Texas we have strong sun but we also have a lot of patients with color to their skin and they do have risk for melanoma and the other skin cancers it may not be as much but it's still present okay so the most sensitive clinical marker is a change in a pigment lesion or a new lesion so what do I say you or your significant other this is where it's nice to have a partner who can look at your back in other areas should perform a skin examination I always say monthly course it's hard to do it monthly yourself but try your best you monthly or have an annual visit and one way to make sure you do it is to on your birthdays check your birthday suit okay that's nice I always think when my birthday comes around I do everything I get my my skin exam my dental I go see my primary care doctors I just think it's my it's birthday time it's time to go check it all right and then now quickly things that we ask of you to look for when you're looking at your moles is is it asymmetric see how this side is darker than this side is the border starting to get irregular it's not smooth and round it's more irregular you have different colors you know if you have red white and blue in your melanoma that's not good that's maybe pay track it's not good for a changing skin lesion and you actually can get those colors and changing melanomas I'm not so concerned about this one although it is true if it's bigger you should pay more attention to it but just because it's big doesn't mean it's a melanoma but pay attention to it this is the one that would be the most helpful for your dermatologist if you can look at involving or changing more okay that's the most sensitive marker if you tell me that moles changing I'm going to take that very seriously okay moles that are changing getting itchy bleeding by themselves all not good things right okay so what are you going to do you're going to seek the shade between 10 and 4 those are the high peak hours of sun exposure try not to burn we don't have you cover up you know big broad wind halves two three inches um they're very fashionable now you know you can put decorated um and you can wear UV protective clothing okay long sleeves they have lots of uh companies that have UV protective clothing where are those big you know jack you nested sunglasses just protect this whole area it's really a nice remember broad broad sunscreen protection it has to say broad that's the best kind and it won't say it unless it's true now FDA makes it so that it has to say if it is broad then it can say it and it can't say it if it's not so you're lucky if it says broad then you're good to go at least 30 or I say now at least 50 but apply two tablespoons you know that's like a shot glass full of sunscreen how many use a shot glass full on your skin that's not a lot right little pea size that's not enough you gotta use a lot you gotta smear it on you know make sure you put on 30 minutes before they get a chance to sink in try and wear sunscreen protection on your lips how many y'all wear SPF in your lipstick good or your chapstick they have it now why not use it I see a lot of people with brown spots they want me to remove them get rid of them I said you know we really gotta protect yourself okay and keep newborns out of the sun if possible you can use sunscreens maybe after six months you might want to try a physical sunscreen first without chemicals make sure they don't have reactions to it and again examine yourself okay all right and the last thing I want to say hope I didn't take too much time is to ban the tan how many you know somebody who's in the tanning booth no way just a few oh my goodness so there's over a million girls in tanning booths every day okay and they're responsible probably this this tanning booth in such as increasing the risk of melanoma particularly on the backs of women and I've seen younger women who has more atypical lesions now so ban the tan no tanning is good no none of that tanning booth stuff is good for anybody so spread the word be my advocates tell people don't do it don't do it and um and also it's also protective helps you with fine wrinkling and everything to use sunscreen some protection so do your best and I'm happy to answer any questions after that's all I have for the the evidence for uh chiropractic care outside of low back is not terrific in other words what we really are looking for a randomized trials and it's kind of hard to do a placebo when you're doing these things so um but I you know in general I think that manipulation can be helpful it's dangerous in your neck though I just want to put that plug in um you have these enormous vessels that go up to your head and sometimes they get dissections when they're doing major manipulation so I wouldn't do that you know it's interesting though about chiropractors I mean I like anybody related to one but um it's that they have a business model that's a little disturbing because it's pretty much see me every week and I'll take care of your physical problems and I want to emphasize and I think we all will that this actually takes your being engaged and thinking about what you can do on pretty much a daily basis how do you integrate this into your lifestyle because a lot you can adopt without having someone else doing something to you try it hello okay you can probably hear me anyway so that's a really good question she asked what about changes in penmanship as a marker for dementia so writing getting smaller is certainly a marker for Parkinsonism or Parkinson's disease and sometimes we'll pick up tremor which can again be associated with Parkinson's or other types of sort of more rare types of dementia I'm not familiar with any other definite signs in terms of change in handwriting as I said right and that may go to again changes in verbal fluency or sentence construction those are things I'll look at so somebody um when I do a cognitive screen in my office one of the things I'll have somebody do is write a sentence and I follow patients over time so when somebody first comes to see me they might write um I got up this morning and it's a beautiful day today and then a year later when I repeat repeat the screen they might write um I am here you know see again you know I see a change in sort of more construction type stuff so I'm not really aware of certain definitive changes but um in the actual handwriting itself other than as I said writing getting smaller um or uh being able to see a tremor or tremulousness in the handwriting some of them are the the harder thing with men is the prostate um and that makes things a lot more complicated so in terms of who's a candidate for it but yes I actually did my training with a general urologist and we did regularly put those in on men um I don't know I would assume the the outpatient version is is good for them as well but it would just mean a little bit different evaluation than what I would do in terms of making sure they're a candidate for it that's a good question so she asked when we do the lab evaluation for dementia what are we actually looking for so what we're looking for or what we call reversible or treatable causes of dementia so they're not dementia but they can cause a patient to look like they have dementia thyroid disorders such as hypo or hyperthyroidism b12 deficiency um temporal arthritis or giant solar arthritis of asculitis condition our um conditions that will cause somebody to present with memory problems but don't represent dementia so what we're looking for are things that we can treat um to reverse or to ameliorate the dementia so we're we're kind of ruling other things out when we do the lab evaluation yes dementia really is a diagnosis of of exclusion so we rule out all these other medical or what we call metabolic problems vascular problems with lab tests and then we feel more comfortable saying okay um this is probably a dementing illness it's within the frame framework of chronic pain it's one of the less common ones although it is extraordinarily disabling it's it's a complicated disease as you probably are aware but um when i'm managing it one of the most difficult things is with fibromyalgia it's painful uncomfortable to exercise and yet it's one of the most important things you can do so um you know i it's hard to get people to do things that they find really um you know uncomfortable but the feedback once you get into it is so significant but fibromyalgia you know is poorly understood um and probably another one of these things where the nerves take on a life of their own so um you're right and in 10 minutes that's where you go to the one hour talk and hand hand and be happy to do things so there's a question about uh trials for managing chronic pain how much is lifestyle versus diet versus genetics in in general the trials are looking at specific um approaches like yoga or acupuncture or chiropractic care and you can imagine they're difficult to do so what's the placebo for yoga um you know and and can you really make them equivalent but um in in general the evidence is more from looking at predictors of who does well um and looking in cohorts and so we know that people who assume a more active lifestyle have lower predictors of being in chronic pain you know down the road and even more shockingly more likely to be alive down the road oh there are a lot of things that go into it but anyways um so i think that it's important just to understand that it all fits together these these lifestyle behaviors um when you think except for my jogging out in the sun um so i um but i think that it's really important for us to be advocates for this lifestyle way beyond just avoiding diabetes and weight control it's it's a whole package that that i think women are leaders in trying to promote sorry for the proselytizing that's a very good question um there's going to be a lot more ingredients coming out in the market so i think that you can try to focus on those but really the most important thing is the is the broad spectrum um labeling of it and and and the spf to some degree so basically what i tell people with sunscreen because there's going to be new ones on the market that's out spf 100 spf 120 and this muxoro and this is and these other ones and and there's going to be i know in the next year a few additional ones the most important thing for you to give you adequate protection is just make sure it says broad screen broad spectrum and it's at least 50 because if it says broad spectrum you're covering the uva and uvb spectrum and they have to have a chemical profile to fit that and if you look at the backs it'll be composed of either physical or chemical blockers of both and i've told some other individuals out here that it's nice to have a combination of a physical and a chemical blocker in your sunscreen for for instance physical blockers are our zinc oxide and titanium dioxide and to have a component of that which reflects the light and then chemical blockers to make up the rest of the spectrum is good and that what that does is that it absorbs light you know it absorbs and changes the light so you have a combination of features but most of my people have serious um what we call photosensitizing conditions or conditions where they're very sensitive to the sun i almost always have them put a physical blocker in with with the other chemicals and then all those other ones it doesn't really matter exactly which one as long as they forge you that broad protection you want it in the end the spf 50 at least is great because it absorbs most or takes care of most of the the sunlight that you'll be exposed to but if you even get the 100 don't think that you're more protected necessarily okay so some people put the 100 and think they're good for the whole day it's not true any sunscreen you put on from 50 on it's going to give you the most protection and then you need to be applied every couple hours if you're going to be out there because it does degrade degrade on the skin or wear off and that kind of thing so i hope that's helpful it's a very good question so in in a sense you're talking about um how do i protect protect my skin from now on and how to maybe try to reverse some of the changes that have occurred over time because of the previous sun exposure the single most important product is still going to be sunscreen and sun protection so sunscreen for your face every day and i tell my women you just get a regimen you wake up you clean your face dry first goes on your sunscreen and then you can put your makeup or other products on top another product that's somewhat rejuvenating is going to be your retinase and so out of in the literature sunscreen and retinoids or retin a of some sort probably give you the most bang for your buck in terms of helping to treat your fine wrinkling and such but then there's a whole slew after that of medications or products antioxidants that have been used to treat the fine lines around the eyes and other places and there's a tremendous amount of market in those kind of things they have they're called cosmaceuticals so there's not as much research actually behind those treatments okay they're going to they're going to provide you some data that the companies do and everything and we do have several that we like to to provide or have available for our patients but that's going to be very variable in terms of actually how much benefit you're going to get from them but we do have some of those available too but they're still the most common will be your sunscreen some protection and retin a no matter what age okay as long as you tolerate it and then those others after that can be rejuvenating and then of course there's many other procedures and she talked with every way there's go so you know mild peeling and laser therapy things like that that can rejuvenate the face of quite a bit out there you have to probably set up a little evaluation if you're interested search in terms of what's most helpful for women and I think one of the things that they've found is working with somebody we have physical therapists through the urology department and then our physical therapy department here who actually teach women how to kegel and I think that one's important because a lot of times women will say I'm doing them for years and then as part of my exam I look and I test people to see how well they do it and I'd say maybe about 50% are not using the right muscles at all and so I think you know having that is good but the problem is is once you're on your own it is easy to forget so I think just the more benefit you see and the better you're at at them you'll maybe see some benefit and it'll be worth your while to continue if you're if you're noticing that yes it's helping you're going to be more likely to keep doing it but I think if you have any doubts as to whether you're doing it right having a referral to a physical therapist or one of our nurses is really helpful for that well the way you would think about it is is if you're if you're if you're just trying to stop your stream of urine those are the muscles you want to use and a lot of women will lift up their entire buttocks I do it on examining table when I test them so if you squeeze my finger but you're lifting up your entire buttocks you're moving all of your body your some people will actually balsalva or bear down when you're asking about and it's exact opposite of that so those are the kinds of things you want to try to do but we stopped sort of telling people to stop their stream of urine because you don't want to do it while you're urinating because that's actually going to put you in a bad pattern for urinating but imagining it if you're imagining it right now in your head saying okay how would I stop my stream of urine that those are the muscles you want to use right yeah I'm sure there is and also they have all kinds of little weights vaginal weights and things that aren't necessary but some people use them for just to have that feedback to say yes I'm doing the right thing and the physical therapists use biofeedback so they actually have little sensors that they can put on and you can actually see it on a little screen am I using the right muscles how strong am I squeezing and that helps you kind of figure out where those muscles are and how to use them