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  1. Why We Need Vaccines

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    Vaccines might be controversial right now, but historically they have always been a part of our lives. From the early polio and smallpox vaccines that were part of life in the 1960s to the current measles, mumps and rubella vaccines that are administered to infants and toddlers, we rely on vaccines to keep us healthy and save lives. Dr. David Totton, Ambulatory Pharmacist with Shore Physicians Group in Somers Point, weighs in on vaccines and provides some clarity and guidance.

    Why do we need vaccines?

    According to Dr. Totton, “Vaccination is a preventative tool that allows us to build immunity to a variety of infectious diseases without first becoming infected and getting sick. Much of what we do in medicine today is preventative. We would much rather be proactive and prevent illness than be reactive and deal with the negative consequences of the illness.”

    Should I get a vaccine if I feel a cold coming on?

    “In general, vaccination should not be delayed in the event of a mild illness such as the common cold as long as there is no fever. However, in light of the Covid-19 pandemic, it would be prudent to first speak with your primary care provider who will assess your symptoms and recommend Covid testing prior if necessary,” said Dr. Totton.

    The flu vaccine

    Flu clinics are opening up in the region. Dr. Totton said typically flu season will run from November through March. The peak of flu season typically falls in February. He suggests getting the vaccine annually no earlier than September and no later than the end of October if at all possible to provide maximum protection through the length of the flu season.

    The 2020 flu season was mild, leaving people to wonder if they should plan to get a flu shot this year. Dr. Totton said, “Luckily we saw that our infection mitigation efforts through mask-wearing and social distancing were fairly effective last year which resulted in a mild flu season. This, however, may not be the case going forward. Pandemic restrictions are generally more lax at this point than they were this time last year and we will likely see a bit of an uptick in flu cases. In addition, there is some concern that with such low exposure to the influenza virus over the past year, our natural immunity may be a bit lower than normal, potentially leading to more serious outcomes. In addition, we are still concerned about overwhelming the healthcare system and reaching hospital capacity. A big focus going forward will be to reduce unnecessary hospitalizations due to preventable diseases such as the flu.”

    Will the flu shot give me the flu?

    A big question many people have every year is ‘will the flu shot give me the flu?’ Dr. Totton said emphatically, “No. Currently, 99% of all influenza vaccinations given are classified as ‘inactivated influenza vaccines.’ This means that they contain no intact influenza virus or genetic material that would allow the virus to replicate. For these reasons, it is physically impossible to contract the flu from an inactivated influenza vaccine.”

    He added that some patients may experience mild flu-like symptoms post-vaccination, however this is due to the body’s natural and expected immune response to the vaccine. This is evidence that the vaccine is being recognized by the body, actively building immunity to the virus, and should only last for a day or two.

    The concern is also, ‘can I get the flu even if I have a vaccine?’ Dr. Totton explained the influenza vaccine contains four of the most common strains of the flu that are expected based on previous flu seasons and variants seen in the southern hemisphere, which has its flu season during what is summer for us up north.

    “There are, however, many other strains of the influenza virus that can potentially infect humans. Another factor to consider is that the influenza virus tends to rapidly mutate which can reduce the effectiveness of current vaccines. On average the flu vaccine is about 40-60% effective in preventing illness in any given year. So yes, it is possible that you can still get the flu even if you have received the vaccine; however, the infection will likely be less severe, you will recover more quickly, and your risk of hospitalization and death is much lower,” said Dr. Totton.

    Pneumonia vaccine

    The older population is at somewhat of a greater risk for complications from diseases such as pneumonia. There is a pneumonia vaccine and it is available only to those 65 and older. Dr. Totton said current Centers for Disease Control and Prevention (CDC) recommendations are that everyone over the age of 65 should receive one dose of Pneumovax-23. Those at higher risk of pneumonia may also be advised that they should receive a dose of Prevnar-13 one year before Pneumovax. This means that they would get Prevnar-13 on or after their 65th birthday and then Pneumovax after turning 66.

    Dr. Totton explained that the pneumonia vaccine is used beyond the over-65 population as well. “The pneumococcal vaccination is actually part of our routine pediatric vaccination schedule these days. We also commonly administer this vaccine to smokers and those with high-risk conditions including heart and lung disease. Pneumococcal vaccination does become more important as you age because both the risk of pneumonia and potential risk of negative outcomes increase as you get older.”

    Dr. Totton advised even those who receive a pneumonia vaccine should absolutely plan on getting a flu shot as well. “The agents that cause pneumonia and the flu are completely different. Pneumonia is caused by a host of bacterial and viral organisms, however, we only vaccinate against bacterial causes. In contrast, the flu is only caused by the influenza virus. This means that getting vaccinated against one will not protect you from the other,” said Dr. Totton. Getting both shots at the same time is acceptable and he added, “There is usually only concern over co-administration of vaccines when using a live vaccine product. Since all injectable flu vaccines and all pneumonia vaccines are inactivated, patients can receive both vaccines at the same time. In the event of simultaneous administration, it is advisable to request that one vaccine is administered in each arm to reduce the risk of adverse effects such as pain at the injection site.”

    HPV vaccine

    The human papillomavirus or HPV vaccine used to only be available for girls age 12 to 16 and now it is recommended for boys and girls with the first dose around 11. Dr. Totton said, “It is important to receive the HPV vaccine as early as possible. This is because HPV is a sexually transmitted infection and once a person becomes infected, the virus stays locally inside the cells where it can evade the immune system. There is currently no cure for HPV meaning the earlier we can vaccinate and protect our teens, the less likely they are to have problems down the line and spread the virus to others.”

    The current HPV vaccine contains inactive proteins from nine strains of HPV that have been implicated in the development of various cancers. It is administered in a three-dose series. No booster doses are recommended at present. HPV infection has been associated with many serious complications including cervical, vulvar, vaginal, anal, head, and neck cancers, as well as genital warts.

    Dr. Totton explained how the HPV vaccine helps keep an individual from developing certain cancers 30 years after it is administered.

    “HPV infection is usually asymptomatic, meaning a person will not immediately become aware that they were exposed. Once infected, certain strains of the virus may cause changes to the cells they contact and force them to divide rapidly. If left unchecked, this will develop into cancer down the line. HPV infection is typically only discovered years later when a patient goes for a routine pap smear or develops a complication such as cervical cancer. In our eyes, this is much too late and can be prevented with a few simple vaccinations,” said Dr. Totton.

    Shingles vaccine

    Shingles, much like HPV, can lie dormant in your body for years and then suddenly appear. Not everyone will develop shingles, so why is it prudent to get the shingles vaccine?

    Dr. Totton explained, “Shingles occurs when the varicella virus (the virus that causes the chickenpox) reemerges from nerve cells where it lays dormant. Due to how widespread the varicella virus is, even if you have no recollection of getting chickenpox, it is believed that we are all exposed at some point and therefore are at risk of developing shingles. Active shingles infection causes an often very painful and uncomfortable rash and may leave some patients with lasting nerve pain even after the rash subsides. The newer shingles vaccine, Shingrix, is recommended for everyone age 50 and up and I encourage all of my eligible patients to receive the vaccine.”

    But patients ask, ‘if I had the chickenpox vaccine, should the immunity from the chickenpox vaccine keep me from getting shingles?’ Dr. Totton said, “Unfortunately, no. Even though the virus that causes chickenpox and shingles is the same, the dose of the shingles vaccine is larger and it also contains an adjuvant. These both help your body produce a strong enough immune response to protect against the emergence of shingles.”

    Covid-19 vaccine

    The biggest question of the year is ‘why is it important to get the Covid vaccine?’ Dr. Totton said, “The Covid vaccine is the best tool in our fight against Covid. A recent study from the Department of Health and Human Services reports that the vaccine has prevented an estimated 265,000 infections, 107,000 hospitalizations, and 39,000 deaths among just the Medicare population in the first five months of 2021. These are promising numbers, however the longer it takes to get everyone vaccinated, the longer the virus is allowed to mutate and potentially reset the clock on all the progress we have made. Getting vaccinated is the only way we are going to suppress new Covid cases enough to return to normal life.”

    We hear in the media about Covid-19 variants. Why are variants like delta and mu showing up? Dr. Totton said, “We know that, unfortunately, the Covid virus tends to mutate quickly. When a virus mutates, it changes the proteins on its surface to evade our immune system and, in some cases, the vaccines that target the virus. This is not a new concept and we now have a lot of experience with influenza which requires constant monitoring for variants and routine changes to annual flu vaccinations to correspond with these mutations. These mutations only occur when the virus is allowed to spread and continue to proliferate inside each new host. What this means is that the best way to slow the emergence of new variants is to protect yourself and others from the current strain through vaccination, mask-wearing, and distancing as recommended.”

    Covid-19 booster shots

    The status of booster shots is changing in concert with CDC recommendations. Those over 65, immune-compromised and front-line personnel are eligible. Dr. Totton said on the expansion of booster shots, “This is where some distinction between additional doses and booster doses is needed. We consider a third dose of an mRNA vaccine in someone who is immunocompromised to be an ‘additional dose.’ This is because we have seen that 2 doses of an mRNA vaccine do not produce the same immune response in these patients when compared to the normal population. The third dose is acting to bring their immunity to the level of those who are not immunocompromised,” said Dr. Totton.

    Recently, the FDA and CDC authorized booster doses for those who received the Pfizer vaccine. They recommend the booster dose six months after their second dose for people over the age of 65; those who reside in a long-term care facility; or those aged 50-64 with certain underlying conditions. They also say that those aged 18-49 with underlying conditions or those 18-64 at increased risk of occupational exposure may get a booster dose.

    “Keep in mind that at the current time, this only applies to those who received the Pfizer vaccine. We are still awaiting data from Moderna and Johnson & Johnson before a booster dose is approved. However, stay tuned, from what I am hearing we should expect to see more on this by the end of October,” said Dr. Totton.

    As for booster shots, Dr. Totton said there is some good news. “From what we have seen in the booster dose trials, we can be fairly confident that a third dose of mRNA vaccine should produce similar effects as the second dose.”

    Breakthrough cases of Covid-19 in vaccinated persons persist. While a vaccinated individual may still contract a mild version of Covid-19, can they spread the virus to someone as well? Dr. Totton said, “While the Covid vaccines are our best tool in the fight against Covid, nothing is ever 100%. There is still a small chance that you will become infected, especially in light of some of the newer variants we have been seeing. However, it is much more likely that you will have a mild case that does not result in hospitalization, ventilation, or even death. We are also seeing that in the event of a breakthrough infection, the virus is still able to be transmitted and cause further infection. This is the reason that the CDC still recommends following all pandemic precautions whether you are vaccinated or not.”

    Can I get the flu vaccine and the Covid vaccine at the same time?

    It is safe to get the flu and Covid vaccine at the same time. “Recently the CDC has made the official recommendation, based on the experience we have with other vaccines, that it is safe and actually encouraged to receive both vaccines at once if eligible to ensure all required vaccinations are received on time,” said Dr. Totton.

    Dispelling myths

    The Covid-19 vaccine has become a flashpoint with wide-ranging opinions and claims on its use, whether it should be mandatory and even claims of alternate cures for Covid-19. Dr. Totton offered his scientific opinion on several of the claims that have been made about the Covid-19 vaccine.

    • Myth: The Covid vaccine has aluminum in it and 5G technology will be able to track individuals that receive the vaccine.
    • Fact: Dr. Totton said this is a baseless conspiracy theory and has no grounds in reality. The ingredients in the vaccine are readily available online and all components of each vaccine are rigorously tested for safety and evaluated by the FDA.
    • Myth: The Covid-19 vaccine is putting Covid into my body and will give me Covid.
    • Fact: According to Dr. Totton, this is false. The Moderna and Pfizer vaccines are mRNA-based, meaning that the only part of the Covid virus that is injected is a small strand of genetic material that codes for the outer “spike” protein. They do not contain any other components of the virus that would allow it to replicate and cause infection. The Johnson & Johnson vaccine contains a weakened viral vector. This is a special viral vector that is incapable of replication and expresses Covid virus proteins. In both cases, there is no way for the virus to multiply and cause illness.
    • Myth: The approval of the vaccine was rushed so it is not safe.
    • Fact: The Covid vaccines that are in use today were approved through what’s called an emergency use authorization (EUA). Much of what is expedited in the approval process of an EUA involves advertisement, marketing, and planning about the rollout and distribution of the medication/vaccine. Safety and efficacy trials are virtually the same as a normal FDA approval process and may just be lacking in long-term follow-up data. Due to the nature of this global pandemic, many companies were able to work together with the federal government to speed up some of the unnecessary or time-consuming steps of the full approval process and instead focus on the important clinical data to get the vaccine out quickly. The FDA will only approve products that have shown that their benefits outweigh the risks.
    • Myth: Ivermectin kills the Covid-19 virus.
    • Fact: Dr. Totton said, “At the present time, there is not enough data to say whether or not ivermectin is safe or effective for treating Covid-19. Historically, ivermectin has been used as an antiparasitic medication (dewormer) and has never been used against viral illness. For now, it is not recommended to take ivermectin for Covid-19 outside of a clinical trial designed to test its effectiveness. We simply have little-to-no data about whether this medication works against Covid-19 and it does come with its own risks. Recently, I have also seen news stories about people taking things into their own hands and purchasing ivermectin meant for animals to self-treat Covid. This has already led to multiple hospitalizations as the doses and inactive ingredients may not be consistent or even safe for human consumption. If you have any concerns about the treatment or prevention of Covid-19, I highly encourage you to speak with your primary care provider about your options and discuss which is right for you.

    David Totton, PharmD, is the ambulatory care pharmacist on staff with Shore Physicians Group. He consults with physicians regularly about medication management, conducts Medicare annual wellness visits, provides comprehensive medication reviews, and more. Dr. Totton sees patients in Marmora, Ocean City, Somers Point, Margate and Northfield. Click here to learn more about how an Ambulatory Care Pharmacist can help you. To find an SPG primary care provider, click here.

  2. Can You Reverse Your Prediabetes?

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    Diabetes by the Numbers

    The diabetes numbers in the United States are staggering. The Centers for Disease Control and Prevention indicates that 34.2 million adults in the U.S. are living with diabetes, a number that has more than doubled over the past 20 years, with one in five not even knowing they have it. Diabetes is the leading cause of kidney failure, adult blindness and lower limb amputation. But the number of people who are prediabetic, meaning they have a higher-than-normal blood sugar level, is nearly one in four Americans and more than three-quarters of them are unaware of their risk. Take this CDC diabetes risk assessment to see if you may be one of the 88 million Americans whose blood sugar is elevated enough to be considered prediabetic https://www.cdc.gov/diabetes/prevention/pdf/Prediabetes-Risk-Test-Final.pdf

    Type 1 diabetes, often diagnosed in children and young adults is where your body does not make its own insulin. The insulin helps cells in use up the glucose from blood. According to the CDC, a normal blood sugar level is below 140. A person is considered to be prediabetic with a blood sugar level of 140-199. A blood sugar level of 200 or above would be qualified as type 2 diabetes. Those diagnosed with type 2 diabetes are normally adults when diagnosed. Their bodies do not use insulin well and that caused their blood sugar levels to fluctuate. Those who may be prediabetic, their insulin is not working properly and too much glucose builds up in the blood.

    In Somers Point, Shore Physicians Group registered dietitian and certified diabetes educator Tiffany Rios said while the patient’s blood sugar level may not be high enough to be considered type 2 diabetes yet, without lifestyle changes, adults and children with prediabetes are more likely to develop type 2 diabetes.

    Don’t Just Blame the Genes

    Rios said, “Much like diabetes, genetics does play a role in prediabetes. But environment and lifestyle are key and they can reverse the diabetes process or they can push it toward type 2 diabetes.” So what are the steps to take to avoid developing diabetes?

    Rios said, “Exercise and diet are key. Exercise helps the muscle cells absorb glucose (sugar) more efficiently, thereby normalizing the blood sugar level. Consuming healthy portions and watching the types of carbohydrates make a big impact on our ability to normalize glucose levels.”

    Sugar Lurks in Many Places

    Added sugars are a big culprit that factor into people developing type 2 diabetes, according to Rios. “Added sugars and refined carbohydrates like enriched wheat flour, processed foods like cereal, crackers, pretzels, cookies, breads, pizza, pancakes, waffles, donuts, cakes, pie and ice cream are obvious foods that contribute to type 2 diabetes. But there are also some not so obvious foods that contain added sugars like ketchup, sauces, dressings and yogurts.”

    Rios said a balanced diet coupled with an exercise regime can prevent type 2 diabetes from developing. If someone has been diagnosed with type 2 diabetes, it most certainly can help a person to manage their diabetes.

    The Job of Insulin

    As Rios explained, “Insulin is a hormone that is responsible for helping us utilize the sugar (glucose) from the food we eat. When we eat too many carbohydrates or highly processed carbohydrates it spikes the amount of sugar in the blood and forces insulin to work a bit harder to normalize our blood sugar level. It can also desensitize our cells to insulin if our blood sugar continues to spike. Insulin acts as a lock and key. It has the key to our cells where the food digested from the stomach is then absorbed into the cells and tissue”

    Why Diabetes is so damaging to Heart and Kidneys?

    Diabetes takes a real toll on the body. “When blood sugar levels are high, our blood can run like molasses. This viscous blood damages the arteries and capillaries feeding our major organs-the heart, nervous system and kidneys” said Rios.

    Help Yourself

    Consuming moderate levels of carbohydrates and tailoring them to your activity level are Rios suggestions to keep type 2 diabetes as bay. “A good place to start is 100-150 grams a day,” according to Rios. “Vegetables and proteins are two potent fighters against type 2 diabetes because they help us to absorb sugar at a slower pace, which improves insulin sensitivity and the ability to burn carbohydrates as fuel.”

    Start keeping a food journal. Rios said, “A food journal is incredibly helpful for noting patterns between what foods are spiking your blood pressure. It gives direct feedback on how you are doing daily. You can use a food journal to count your carbs and ensure you are getting enough protein and fiber from vegetables.”

    For help getting your blood sugar under control, creating your food journal and keeping your prediabetes from becoming type 2 diabetes, make an appointment with Tiffany Rios at 609-365-5300.

  3. Can You Take the Weight Off and Keep It Off?

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    The barrage of ads for fat-burning diets are unavoidable whether it is on your phone, your tablet or just while waiting in the checkout line at the supermarket. Claims of shedding unwanted pounds from taking one miracle fat-burning pill a day are enticing, but is that sustainable? Shore Physicians Group Ambulatory Pharmacist, Dr. David Totton said, “Fat burning diets are thermogenic. That simply means ‘generating heat.’ Heat is a byproduct of al metabolic processes in the body, including fat breakdown. These diets and supplements aim to boost your metabolism, speed up the breakdown of fat and ultimately help you lose weight.”

    Will Fat Burning Produce Weight Loss?

    “Burning fat through these thermogenic diets is a quick way to shed some pounds,” said Dr. Totton. “However, for sustainable weight loss that lasts, lifestyle modification is necessary.” As Dr. Totton explained, “If you rely on a short-term, highly restrictive diet to lose weight and then return to normal eating habits once you reach your goal, there is a high probability that you will put the pounds back on over time. In addition, if you do not limit your caloric intake, it will still be difficult to lose weight no matter the diet you choose. This is why it is generally better to make smaller changes over time that you will be able to adhere to and move toward a healthier lifestyle overall.”

    The fat burning weight loss programs claim they churn up the body’s metabolism to rapidly reach a state of ketosis and increase energy level and the ability to focus at the same time. But can the fat burning process aid in that? Dr. Totton said, “Yes and no. The body’s source of readily available energy typically comes from glucose which the product of carbohydrate metabolism. Since the keto diet entails greatly reducing carbohydrate consumption, this pushes the body to find alternative energy sources including the fat stores in the body. This fat is broken down into ketone bodies that are used as an alternative energy source in the absence of glucose. These ketones are used by the brain and heart for energy so it is very possible that patients feel energized and focused once they are stable on the keto diet. However, when starting the keto diet, or it your macronutrient ratios are off, you may experience what is known as ‘keto-flu.’ Dr. Totton explained, the “keto-flu” occurs because the body no longer has access to adequate glucose and has not yet ramped up the fat burning process leaving an available energy deficit. The “keto flu” typically causes mild, flu-like symptoms as well as upset stomach, dizziness, decreased energy and mood swings.

    Will the Weight Come Back?

    In general, the most effective and safe way to lose weight is caloric restriction along with an increase in aerobic activity, according to Dr. Totton. “Artificially boosting metabolic activity in the body without changing diet and exercise habits may produce a slight reduction in weight in the short-term, however this is likely unsustainable and once the supplement is stopped, the progress made will quickly be lost.”

    Everyone is different and what works for one person may not work for everyone. Dr. Totton warned, Keto diets are notoriously hard to keep up with and typically require that a person get 70-90% of their total caloric intake from fats with only 5-10% coming from carbohydrate sources. This is very limiting and requires constant awareness of all components of the products you consume. In general, less restrictive diets relying on caloric deficit and increased activity will be easier to maintain and therefore, may be more effective in helping reach your weight goals.

    Insulin Resistance

    Looking to lay blame on gaining weight, some diet programs say insulin resistance is the reason you may be having difficulty losing weight. Dr. Totton explained, insulin is a hormone made by the pancreas that helps glucose in your blood enter cells in your muscle, fat and liver where it is used for energy. Insulin resistance, as the name implies, is when your body does not respond as well to insulin causing excess glucose to remain in the blood where it may contribute to weight gain and the risk of diabetes. We do know some of the factors linked to insulin resistance. These would include some that you cannot change such as genetics, family history and race as well as some that you can change such as being overweight and inactive in your daily life. Ultimately it is know that insulin resistance that is not addressed through healthy lifestyle modification puts you at a much higher risk of developing type 2 diabetes and obesity late in life and can definitely make it more difficult to lose weight going forward.

    The Stress of Rapid Weight Loss of the Body

    Dr. Totton explained that rapid weight loss through a keto or any intensive low-carb diet can definitely put a strain on the body. Both the liver and kidneys are involved in the metabolism and breakdown of fat and proteins in the body. Such rapid breakdown of fat and increased protein intake associate with these diets may put stress on these organs and make any underlying conditions worse. Another concern we have is an increase in LDL (or bad) cholesterol levels. If time and attention is not takento limit saturated fat consumption, this may lead to an increased risk of cardiovascular disease and stroke. Additionally, such a limiting diet can put you at risk of nutrient/vitamin deficiencies which can lead to a host of unwanted side effects including constipation, muscle cramps, heart palpitations, and in some severe cases, arrhythmias. “Given the risks associated with this diet it is highly recommended that you discuss with your doctor and possibly a nutritionist before starting a ketogenic diet in order to assess your specific needs and risk factors to determine if it is the right diet for you.

    Organic Does Not Equate to Safe

    Many of the weight loss supplements are organic. But does organic mean the product is safe? Dr. Totton said, “Organic is not always synonymous with safe. An organic product is produced without the use of chemical fertilizers, pesticides or other artificial agents. There are however plenty of naturally occurring substances that are detrimental to your health, and many synthetic and artificial ingredients that are completely safe to take.” The best way to know if a product is tested and safe to consume is to look for the United States Pharmacopeia (USP) seal on the bottle as well as only taking products that are recommended by your primary care provider that have gone through the rigorous FDA approval process. Many dietary supplements that are available online or over the counter do not require FDA approval and the companies are not required to show any safety or efficacy data before marketing and sale of the product, explained Dr. Totton.

    Weight Loss Supplements and Prescription Meds

    Anyone taking a prescription medication should be wary of introducing a weight loss supplement. Dr. Totton said, “Certain weight loss supplements can certainly interfere with prescription medications and may not be safe for patients with a history of cardiovascular disease or who are taking blood thinners. I would recommend that you discuss any supplements that you plan on taking with one of your healthcare providers prior to use.”

    Is Rapid Weight Loss Sustainable?

    Some people are able to rapidly lose weight and then maintain these changes for long periods of time. Unfortunately, this is usually the minority, according to Dr. Totton. “We have seen time and time again that small changes over time and consistency with your diet and exercise habits are the best way to achieve and maintain your weight loss goals. Even strong proponents of the keto diet will tell you that it is not intended to be a long-term solution.”

    With respect to Keto-speed specifically, Dr. Totton explained, the supplement includes beta-hydroxybutyrate (BHB) which is one of the ketone bodies produced during the breakdown of fat in the body. It is thought that supplementing this product will cause the body to recognize that fats are being broken down and speed up ketosis. These products are also marketed as an energy supplement as you are introducing extra fuel into the body from the supplements. However, it has been found that BHB actually negatively reinforces fat breakdown, meaning that the more BHB that is present in the blood, the more your body wants to slow down fat burn so that you don’t go through your backup energy reserves too quickly. This means that artificially supplementing BHB may actually negatively impact your keto weight loss efforts and make it harder to burn your natural fat stores.

    Dr. Totton went on to explain, another concern is that the BHB in these products is typically bound to electrolytes such as sodium, calcium and magnesium. The dosing recommended by the supplement manufacturers can often lead to excessive levels of these electrolytes in the blood which may lead to kidney stones, high blood pressure, muscle cramps, constipation/diarrhea and conduction abnormalities in the heart.

    Additionally, those with diabetes will likely require a reduction in the dose of their medication given the strict carbohydrate limitations. If blood sugars are not closely monitored during initiation of a low-carb diet, these patients are at a very high risk of hypoglycemic episodes.

    David Totton, PharmD, is the ambulatory care pharmacist on staff with Shore Physicians Group. He consults with physicians regularly about medication management, conducts Medicare annual wellness visits, provides comprehensive medication reviews, and more. Dr. Totton sees patients in Marmora, Ocean City, Somers Point, Margate and Northfield. CLICK HERE to learn more about how an Ambulatory Care Pharmacist can help you. To find an SPG primary care provider, click here.

  4. What That Swelling in Your Leg Could Be Telling You

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    Deep Vein Thrombosis

    Deep Vein Thrombosis or DVT is a serious condition that results from a blood clot forming in one or more of the deep veins. It is most commonly found in the lower leg veins but according to Dr. Leonard Galler, Chairman of the Department of Surgery at Shore Medical Center in Somers Point and a General and Vascular Surgeon with Shore Physicians Group, blood clots can occur in any vein such as those in arms, legs, pelvis, and even renal veins and portal veins. If DVT is untreated significant morbidly and even mortality can occur. An example of a complication is a pulmonary embolism, which is a blood clot that breaks off and dislodges in a pulmonary vein leading to respiratory compromise.

    DVT is a Significant Health Problem

    “DVT is a major vascular problem,” said Dr. Leonard Galler. “It is the third leading vascular issue behind cardiac and stroke issues. Approximately 400,000 incidents of DVT occur in the United States each year. Dr. Galler again emphasized, “There are significant consequences if DVT is not treated. People can die from untreated blood clots.”

    He added that varicose veins can become thrombosed but does not have the risk of a DVT. A varicose vein, which is a dilated vein under the skin where blood can pool, will not break off and travel to the lungs.

    Early symptoms of a DVT blood clot may include swelling and tightness in the legs. There may be a persistent throbbing or a cramp-like feeling in the leg along with some pain or tenderness in the area when walking. There may be some warmth to the affected leg as well. According to Dr. Galler, it is normally noticed by the patient that one leg is more swollen than the other. DVT blood clots can occur bilaterally, in both legs but it is more common to occur in a single location. Patients who experience these symptoms need to be seen by a physician or nurse practioner for evaluation quickly.

    Reasons a DVT May Develop

    As Dr. Galler explained, DVT blood clots may develop for several reasons. There are blood clots that are classified as unprovoked, meaning there is no identifiable, causative reason. There are blood clots that are provoked. A provoked DVT can occur from trauma, a cancer diagnosis, obesity, malnutrition, advanced age, extended bedrest post-surgery, genetic factors, and from medication, such as contraceptives or hormone replacement treatment.

    Genetics may also play a role in the formation of DVT. Dr. Galler said, “Blood factor deficiencies such as Factor V Leiden can cause DVT. Patients who give a family history of DVT need to be worked up for genetic deficiencies of clotting disorders.”

    Finding the Blood Clot

    Dr. Galler explained, if there is a concern of a possible blood clot, an ultrasound, computed tomography (CT scan) or magnetic resonance imaging (MRI) scan may be prescribed to confirm the diagnosis. The most common modality is the ultrasound as it shows the blood flow in the veins and any blood clot that may be there. D Dimer blood tests can also help diagnose a blood clot. According to Dr. Galler, Shore Medical Center and the Vascular Lab at Shore Physicians Group have availability in the hospital and the office setting to perform these diagnostic tests.

    Treating DVT Blood Clots

    Dr. Galler said the standard of care for treating DVT is the administration of blood thinners either by pill, IM injection, or IV infusion. The anti-coagulants block specific clotting proteins from forming clots thus allowing regression and resolution of the clot. Treatment is individualized and may require a three to six month regimen. Some patients may need to take blood thinners for the rest of their lives to keep clots from forming. He added that at times there will be adjustments needed because of an allergy or a patient’s intolerance for one medication over another.

    For those who do not benefit from blood thinners or have contraindications to blood thinners, there are other methods to remove or dissolve blood clots. In some cases, patients may need an IVC filter implanted that will stop a clot from traveling to the lungs thus reducing mortality and morbidity.

    Patients will often be told to wear compression stockings after the start of blood thinners and improvement is noted. Compression stockings are specially designed socks or sleeves. They squeeze or compress the leg in a way that improves blood flow and reduces swelling. The stockings tend to apply the most pressure at the ankle and then the pressure decreases farther up the leg, forcing blood upward. The stockings are designed to ease swelling and engorgement in the lower leg as well as reduce discomfort.

    To make an appointment with Dr. Galler at his office located at 649 Shore Road in Somers Point visit call 609-365-6239.

    The Shore Physicians Group Vascular Lab hours are Monday-Wednesday-Friday 8 a.m.-5 p.m., Tuesday-Thursday 8 a.m. -7 p.m. and the second Saturday each month is 8 a.m.-2:30 p.m.

  5. Could a New Diabetes Drug Help You Lose Weight?

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    Maintaining a healthy weight is not just about the size you wear or the reflection in the mirror – it’s also about keeping your body healthy. Statistically, as a nation, we have a problem with maintaining a healthy weight. Two-thirds of the U.S. population is overweight, with 36.5% suffering from obesity, defined as a BMI over 30. Obesity means having too much body fat, which can lead to heart disease, diabetes, stroke, and more. For many, weight is a constant struggle, but a new medication on the market may help.

    In June, the Federal Drug Administration approved Wegovy (semaglutide), a drug that has proven effective in helping reduce weight. Shore Physicians Group Ambulatory Pharmacist Dr. David Totton said Wegovy was approved for weight loss for patients with a BMI of 27 or greater who also have type 2 diabetes, high cholesterol, or high blood pressure. Patients with a BMI over 30 do not need a second contributing health problem for approval. In both cases, the patient must also adopt a lower calorie diet and increase exercise, with the potential to lose up to 20% of their body weight.

    How Wegovy Aids Weight Loss

    Wegovy belongs to a class of medications called GLP-1 agonists. According to Dr. Totton, these medications mimic the action of glucagon-like peptide, a hormone produced in the intestine that helps regulate appetite and control blood sugar. Another form of the same medication, Ozempic (semaglutide), was originally created for diabetics, but many of these patients also lost weight. That prompted an investigation into its potential to aid in weight loss for non-diabetic patients. Researchers found that GLP-1 agonists are also able to slow the movement of food through your digestive tract and suppress appetite centers in the brain, decreasing food cravings and helping patients (diabetic or not) reach their weight-loss goals.

    Wegovy is not the first medication in this class to be approved for weight loss, in fact. The medication Saxenda (liraglutide) has been used for weight loss for years, however, it only provides a minor benefit, around a 5% reduction in weight compared to Wegovy, which can result in a 15-20% weight reduction in some patients.

    BMI is an Important Number

    Dr. Totton explained a patient is considered overweight when their body mass index (BMI) is 25-30 and obese when their BMI is >30. If you are unsure of your BMI, you can quickly find out by inputting your height and current weight in the CDC’s online BMI calculator.

    “Being overweight or obese greatly increases your risk of heart disease, stroke, and a host of other related conditions, including hypertension, high cholesterol, and diabetes. In addition, holding onto so much weight can cause joint pain and make it even harder to lose weight, especially as you get older. Interestingly, for obese patients with Covid-19, they are five times more likely to require ICU admission and two times more likely to experience respiratory failure than those who are not obese.”

    When you have a combination of obesity, high blood pressure, high cholesterol, or type 2 diabetes, this is known as “metabolic syndrome”, according to Dr. Totton. “The concern is that each of these comorbid conditions can contribute to vascular damage, inflammation, and greatly increase the risk of heart attack, stroke, disability, and untimely death. The reason that weight loss is so important is that obesity can contribute to, and worsen, all of these conditions, further compounding the negative effects.”

    Research Found the Dual Purpose

    Originally Ozempic was solely a drug for treating type 2 diabetes effectively. After examining the findings, the FDA has given the green light to treating obesity with the medication, rebranded for weight loss as Wegovy. Dr. Totton said finding another use for a medication is proof that continuing research may yield many useful results.

    “This is how we discover uses for many different medications. For one condition, a side effect may have a beneficial impact on a different condition. This is just really smart use of an existing medication.”

    Is It Worth The Side Effects?

    Novo Nordisk, the Wegovy manufacturer, has a lengthy list of possible side effects. Dr. Totton weighed in on whether the ultimate goal of losing up to 20% of body weight is worth the possible side effects. Dr. Totton said, “The most common adverse side effects from Wegovy are gastrointestinal and include abdominal discomfort, nausea, vomiting, constipation, and diarrhea. Most of these side effects are rare or self-limiting, meaning the longer a patient remains on the medication, the less severe the side effects should become and, for the majority of patients, will completely resolve.”

    Because Ozempic/Wegovy was originally designed for diabetes to reduce blood sugar, the risk of hypoglycemia was also carefully analyzed. According to Dr. Totton, “It was found that the effects of the medication are highly dependent on the presence of food, meaning that there is little risk of low blood sugar in the general population.” Dr. Totton added, “There are some rare instances where I would caution a patient against taking Wegovy. These include patients with a personal or family history of medullary thyroid cancer, those with multiple endocrine neoplasia syndrome type 2, and anyone with a history of pancreatitis. If you have any of these conditions, an alternate weight-loss medication may be a better option for you.”

    Wegovy is a once-a-week injection, given in increasing amounts as a means of limiting side effects. Dr. Totton explained that slowly increasing a medication dose is a tried and true method for reducing adverse effects when starting medication.

    “We administer the dose in increasing amounts over a period of time as tolerated until we reach the desired effect. This is essential so we don’t shock the system by introducing large amounts of an unfamiliar substance.” Dr. Totton said this strategy was well tolerated in the clinical trials leading to the medication’s approval and thus is the current recommendation when starting Wegovy.

    Do Not Mix With Any Other Weight Loss Products

    The manufacturer stresses Wegovy patients should not take any other weight loss product, including over-the-counter or herbal supplements.

    “The concern with taking multiple weight-loss medications at once is that most of these are not studied together and it is unknown whether the combination will be safe or effective,” said Dr. Totton. “In addition, most of the over-the-counter or herbal weight loss supplements are not regulated by the FDA and are not required to prove their effectiveness in clinical trials.”

    Dr. Totton said, in his opinion, these products are often ineffective and a waste of money. “I recommend you discuss any medications or supplements that you are considering with your primary care physician.”

    Long-term Use and How to Access Wegovy

    “Looking at the trials that led to the approval of Wegovy for weight loss, we can see that patients who came off the medication eventually gained a majority of the weight back. This tells us that patients must stay consistent to see sustained weight loss. This is of course in addition to maintaining proper diet and exercise habits.” Dr. Totton added that if patients decide to discontinue, they do not need to wean off Wegovy.

    To determine if you are a candidate for Wegovy for weight loss, speak with your primary care physician. Dr. Totton shared that the company is offering a discount card to all patients on commercial insurance that guarantees a maximum of $25 co-pay per week for the first six months of therapy. Another important tip from Dr. Totton is that when using an injectable medication such as Wegovy it is important to remember to rotate the injection sites to ensure proper drug absorption. Appropriate injection sites include the abdomen, thigh or upper arm and should be injected under the skin.

    David Totton, PharmD, is the ambulatory care pharmacist on staff with Shore Physicians Group. He consults with physicians regularly about medication management, conducts Medicare annual wellness visits, provides comprehensive medication reviews, and more. Dr. Totton sees patients in Marmora, Ocean City, Somers Point, Margate and Northfield. Click here to learn more about how an Ambulatory Care Pharmacist can help you. To find an SPG primary care provider, click here.

  6. Men’s Health the Focus of Shore Physicians Group’s Nov. 13 “Be Well Connected” Education Breakfast

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    In honor of Men’s Health Awareness Month, also known as Movember, Shore Physicians Group (SPG) is dedicating its November “Be Well Connected” education breakfast at Greate Bay Country Club to the topic of men’s health. The event will be held from 10 am to noon and will include a light breakfast. Greate Bay Country Club is located at 901 Somers Point-Mays Landing Rd., Somers Point, NJ. All guests who attend will be entered to win a complimentary haircut and close shave gift basket, valued at $100, from Gas Up Barber Shop & Shave Co. in Somers Point.

    According to the National Center for Health Statistics, men die on average five years earlier than women and are more prone to chronic illness. With greater awareness of the causes of this health disparity and more diligent attention to their health, men can potentially live longer, healthier lives.

    Leading the program is SPG primary care physician Dr. Ulices Perez, who will focus on the unique health needs of men. Following Dr. Perez is SPG endocrinologist Dr. Matthew Corcoran, who will talk about low testosterone, which affects 1 in 4 men over age 30. Closing the event will be a discussion with Mike Costello of Gas Up Barber Shop & Shave Co. on men’s grooming.

    To RSVP, please contact Jessica Giles at 609-653-3986 or jgiles@shorephysiciansgroup.com.

  7. Can Some Fats be Good for Your Diet?

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    Are you afraid of fats? Until recently, fat in foods has been vilified in America. For decades, we were told that cutting even healthy fats out of the diet would help us get the body we want. This couldn’t be further from the truth. Our bodies need fat—more specifically, they need healthy fats. The truth is, according to Registered Dietitian and Certified Diabetes Educator, Tiffany Rios of Shore Physicians Group, “good” fats can lower cholesterol levels, reduce inflammation, promote satiety, and boost brain function. These healthy fats mostly come from unprocessed sources that are high in unsaturated fats as well as omega-3 fatty acids, such as avocados, extra virgin olive oil, nuts, seeds, and wild caught salmon.

    Not all fats are the same
    The rap on fat is that it will add inches to your waistline, raise cholesterol and lead to a long list of health problems. Fat is a type of nutrient, and just like protein and carbohydrates, your body needs some fat for energy, to absorb vitamins, and to protect your heart.

    “Bad” fats, such as artificial trans fats and saturated fats, are guilty of the unhealthy things all fats have been blamed for—weight gain, clogged arteries, and an increased risk of certain diseases.

    “Healthy fats are an essential component of a healthy diet. In fact, they are required in order to properly absorb fat soluble vitamins A, D, E, and K,” said Rios. “What’s more, our bodies synthesize many fats but there are two types of fatty acids that your body is unable to synthesize: linoleic acid (omega-6 fatty acid) and alpha-linolenic acid (omega-3 fatty acid). These are called ’essential fatty acids’ because, unlike other fats, our bodies cannot create them and we must get them from our diet.”

    The bad and even some good about cholesterol
    It helps to understand the difference between good and bad fats and how to include healthier fats in your diet and reduce the bad fat. Dietary fat also plays a major role in cholesterol levels. Cholesterol by itself is not bad. It is a fatty, wax-like substance that the body needs to function properly. But too much of it can have a negative health impact. As with dietary fat, there are good and bad types of cholesterol.

    High density lipoproteins or HDL cholesterol is the “good” kind of cholesterol found in blood. The HDL cholesterol is good because it carries cholesterol from other parts of the body back to the liver. The liver then removes cholesterol from the body. According to Harvard Health, an HDL cholesterol of 60 mg/dL or higher gives some protection against heart disease.

    Low density lipoproteins or LDL cholesterol is the “bad” kind. Patients with elevated LDL levels may have cholesterol clogged arteries and may have an increased cardiovascular risk. The key is to keep LDL levels low and HDL high, which may protect against heart disease and stroke.

    Fats influence cholesterol levels
    Rather than the amount of cholesterol you eat, the biggest influence on your cholesterol levels is the type of fats you consume. So instead of counting cholesterol, it’s important to focus on replacing bad fats with good fats. When Rios is creating a dietary plan for her patients, she includes some fats.

    “As part of a heart healthy dietary plan I recommend a diet high in unsaturated fats and moderate in healthy types of saturated fats. Avocados, nuts and seeds are mainly unsaturated while fats like coconut oil are saturated. Despite its saturated association, coconut oil is also classified as a medium chain triglyceride and the method in which it processes through the liver does not allow for it to be stored like most saturated fats, making it a healthy alternative to some more saturated oils.”

    While every dietary plan that Rios creates for her patients is individualized, the registered dietitian has some go-to saturated fats that have worked well, including grass fed beef, coconut oil, 85% dark chocolate, pasture-raised eggs and chicken.

    To make an appointment with Tiffany Rios RD, CDE for a personalized dietary plan or healthy assistance managing your diabetes, call 609-365-5300. The office is located at 2605 Shore Road in Northfield..

  8. Can Joint Injections Keep Patients Out of Surgery?

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    Chronic knee, hip, ankle or shoulder pain does not necessarily mean your next step is into the operating room. For many patients who have sports-related injuries, osteoarthritis, and a family history of OA or who may be overweight and suffer with joint pain, delaying that joint replacement may be an option. Physical therapy and injections into the knee, shoulder, elbow, ankle, wrists, hip bursa, and even some hand injections are possible to combat joint pain according to Shore Physicians Group Orthopedic Surgeon, Dr. Tuan Mickey Bui. “The idea is to delay joint replacement as long as possible while still being bearable,” said Dr. Bui.

    Why there is joint pain

    All of the body’s joints have their own shock absorbing system. The joint cartilage has special molecules of aggrecan and hyaluronic acid that together provide a hydrated gel structure that gives cartilage load-bearing properties. Dr. Bui says over time those built-in shock absorbers will begin to thin out and break down. “As we age, these molecules degrade. A thinner cartilage is more prone to damage,” said Dr. Bui. “Ironically, when there is ‘full thickness’ area of damage in the cartilage, fluid seeping out from the bone can cause extra fluid in the joint. All of these events increase inflammation in the joint and are the ingredients to make arthritis.”

    The body is a great machine with different categories of joints including synovial joints where the bones join together in a cartilage lined cavity filled with fluid. There are pivot, hinge, saddle, plane, condyloid and ball and socket synovial joints. The knee, elbow and fingers are all hinge joints. The neck and vertebrae are pivot joints and the larger ball and socket joints include the hip and shoulder.

    Where to start

    Before beginning any treatment Dr. Bui said it is first determined where the patient’s joint pain is coming from. “We make sure your pain is due to cartilage damage and not due to anything else in your knee (or other joint). We can prescribe anti-inflamatories, which are stronger versions of what is available over the counter. There are also other types of nerve medications that have shown promising results,” said Dr. Bui.

    Physical therapy is another option open to patients experiencing joint pain. “Strengthening the right muscles allows your joints to operate with minimum stress on them. It is like getting a wheel alignment on your car which can lengthen the life of your tires,” said Dr. Bui.

    There is help for that pain

    Dr. Bui explained that hyaluronic acid used in the injections, also called viscosupplimentation, helps to draw fluid back into the cartilage and helps to restore the joints shock absorbing properties as well as act as a lubricant of sorts. There are a number of different blends of hyaluronic acid, some are made from roosters and the physician said anyone with an allergy to eggs should advise their doctor prior to receiving their injection as there are other formulations available.

    Cortisone steroids serve as an anti-inflammatory. (It is not the same as body builders use). Dr. Bui said that reducing the inflammation will reduce the pain. He said his office also gives the hyaluronic acid or viscosupplimentation injections. “In my office, we can give a combination shot of both using only one needle to give the patient the maximum benefit with a minimum of needles,” said Dr. Bui. The normal course of injections is one a week for three or four weeks.

    How long can surgery be delayed

    There is no set number of times a patient can receive the joint injections before they will need surgery. Dr. Bui said, “There is no limit to the number of times a patient is able to receive the viscosupplimentation but I normally recommend joint replacement when relief from the injections last less than six to eight weeks before the pain returns,” said Dr. Bui. “There are many factors in the decision to have surgery through, and this should be discussed with an orthopedic surgeon.”

    To set up an appointment and consultation with Dr. Bui, call Shore Physicians Group-Orthopedic Surgery, 609-365-6280.

    Dr. Bui’s specializes in hip and knee pain, minimally invasive knee replacement, unicondylar knee replacement, anterior or posterior hip replacement, anatomic and reverse total shoulder replacement, long bone fractures in fingers and hands, carpel tunnel, trigger fingers, sport related injuries and bursitis of elbow, sport related injuries of the foot and ankle, cortisone injections and viscosupplimentation.

  9. Shore Physicians Group to Host Education Event on Joint Replacement Surgery & Recovery Sept. 25

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    New SPG Orthopedic Surgeon Dr. Mickey Bui to Keynote the Event

    In September, Shore Physicians Group will welcome orthopedic surgeon Dr. Mickey Bui to its Surgical Division making him the first orthopedic surgeon to join the practice group. Bui will be the lead speaker at Shore Physicians Group’s community education breakfast on Joint Replacement Surgery & Recovery on Wednesday, Sept. 25 from 10 am to noon at Greate Bay Country Club in Somers Point. The event is a continuation of Shore Physicians Group’s popular “Be Well Connected” education series.

    Bui received his Doctor of Medicine from Northeast Ohio Medical University and completed his residency at Hahnemann University Hospital. In addition to general orthopedics and surgical treatments of the shoulder, hip and knee, he is also passionate about helping people with sports injuries and recently completed a Fellowship in Sports Medicine.

    Joining Bui is Erin Bennis, PT, DPT, of Shore’s Center for Outpatient Rehabilitation, who will share different techniques used in physical therapy for patients with total hip and knee replacements. Shore Emergency Department Social Worker Tracy Fooks, LCSW, LCADC, will speak on managing post-operative pain, and the appropriate use of pain medication.

    The event includes a free continental breakfast, question and answer session, and information on additional resources. To RSVP, call 609-653-3986.

  10. Help for Varicose Veins

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    If you have varicose veins, you may feel a little uncomfortable about showing off your legs. You may also feel pain, discomfort and swelling along with tired and achy legs. It is a myth that varicose veins are a problem only women will have; men can suffer from varicose veins as well, according to Dr. Leonard Galler MD, Board Certified General Surgeon with Shore Physicians Group and Chairman of the Dept. of Surgery at Shore Medical Center.

    How veins work

    The body has what amounts to a system of conduits or tubes that allow for oxygen-rich blood to flow from the heart throughout the body. The blood flows from the heart via arteries and the oxygen depleted blood is carried back to the heart to be reoxygenated through veins. The veins work efficiently by utilizing a series of valves that keep the blood moving. According to Dr. Galler, when those valves do not perform the job they were designed for, blood may leak back. This can weaken the vein walls, cause veins to bulge and may result in swelling or even blood pooling in the lower extremities, according to Dr. Galler. He advised that anti-inflammatory drugs along with other medications may be given to the patient to help reduce the swelling, inflammation and pain.

    How varicose veins normally develop

    Dr. Galler explained that in the legs soft vessels with minimal muscle can collapse over time. “The veins can get dilated,” said Dr. Galler. “There can be a number of other reasons for the veins to dysfunction and lead to the development of varicose veins. There could be a genetic predisposition to varicose vein development. Galler indicated that if parents have varicose veins, their offspring is likely to manifest varicose veins in their lifetimes. There could be damage to the deep system of veins from trauma or surgery that can lead to vein dysfunction. Often after a blood clot, deep vein thrombosis (DVT), varicose veins can develop because of physiological changes.

    Contributing factors for some patients can be obesity, pregnancy, chronic straining and constipation.

    Cosmetics and Symptomatic

    “Most patients do not like how varicose veins look and seek solutions for cosmetic reasons. Many patients have symptomatic varicose veins. They complain of aching legs that are often accompanied by swelling, burning and itching symptoms which can be severe enough to seek help. There are also patients who have developed severe swelling and edema with ulcers who need surgical care. These patients are at risk for infections and significant morbidity. Dr. Galler added that there are multiple recommendations that can be offered from a vascular surgeon to help all these patients regain quality of life.

    Important first steps

    Dr. Galler explained the importance of finding the causes of the varicose veins by ultrasound studies to determine vein anatomy and functionality. The ultrasound will determine blood clots and reflux from the values which will guide treatment.

    Compression stockings are the first line of treatment and often advised by surgeons. Dr. Galler said the compression stockings will help with the swelling by compressing the dilated veins, removing the pressure gradient and reducing weeping of fluid from the veins. Using the stockings along with medication to help with the swelling is beneficial to many patients.

    Treating Symptoms of Varicose Veins and Spider Veins

    Dr. Galler explained that there are several procedures that he performs frequently and that have proven to be very beneficial to his patients. These range from sclerotherapy of veins and spiders veins, laser ablation of veins and sealing of incompetent superficial veins with radiofrequency energy, and surgical removal of veins with minimal invasive techniques. Each of the procedures have their roles with benefits.

    Help Yourself

    There are a number of things someone suffering with varicose veins can do to gain relief of symptoms and help with cosmesis. If simple maneuvers such as exercise, weight reduction and support hose is not effective, it is then best to discuss options with a vascular surgeon such as Dr. Galler who would perform a full evaluation and direct a treatment plan.
    To learn more about what might be the best course of action to help with varicose veins, spider veins, and more or to make an appointment with Dr. Leonard Galler call 609-927-8550.