Hoag Presents: "Ask the Doctor" for Spring 2014

Jennifer Birkhauser, M.D.

Q: Why do schools require a sports physical and is this exam different from my child's yearly well exam?

A: ​If your child plays volleyball, baseball, or some other spring sport, it may be time for yet another sport physical. You might be asking: Why does my child need another physical? We just did that before school started! Even though he or she may have just had a physical prior to the start of the school year, this visit has a very different focus than the yearly well child exam.

The adolescent sports physical focuses on your child’s readiness to participate in athletics and seeks to identify any issues that need to be addressed to ensure well-being and safety during intense physical activity. Your pediatrician will obtain a detailed history from you regarding previous sports participation, medical issues and injuries sustained, in addition to asking many screening questions. There are some medical conditions and situations that may prevent your child from sports participation, and it is important that we identify any that may exist at this visit.

We then perform a comprehensive physical exam, paying special attention to your child’s heart, lungs and musculoskeletal system. Close attention will be paid to your child’s heart in order to detect signs of serious, though rare, conditions that may put athletes in danger. We will also check for any breathing problems (such as asthma) as well as evaluate the athlete’s joints, bones and muscles for strength, flexibility, and previous injury.

Once we have all of the above information, we can then work with you to formulate a plan for your child’s safe sports participation. Sometimes further testing or medication will be needed at this point. We also may refer your child to physical therapy if we feel that this will help maintain your child’s ability to safely participate. With your child’s best interests at heart, we may delay clearing him or her for activity until certain items are completed. Counseling and further anticipatory guidance are also done at this point. Most times, all that remains is for us to sign the form and wish your athlete good luck on the upcoming sports season!

​Jennifer Birkhauser, M.D., is a pediatrician at Hoag Medical Group and provides same day appointments. Her office is located at 19582 Beach Boulevard, Suite 210, Huntington Beach, CA 92648. For more information, please visit www.HoagMedicalGroup.com or call 714-477-8001.

Dilruba N. Haque, M.D.

Q: What can I do to reduce my risk of breast cancer?

A: While breast cancer can be inherited, the majority of cases develop at random. The genes BRCA1 and BRCA2 are frequently associated with hereditary breast cancer. The probability of inheriting a damaged BRCA1 or BRCA2 gene varies from family to family and can be gauged by family history. For individuals with no family history of breast cancer, there are a number of ways to reduce your risk for developing breast cancer.

Being overweight or obese also increases breast cancer risk, so maintain a BMI between 18.5 and 24.9.

Studies have also established an association between having one to two alcoholic drinks per day and breast cancer. Try to avoid alcohol or at least limit your intake to less than two to three drinks per week.

Physically active women have a 20 percent reduced risk of breast cancer when compared to those who are sedentary. I generally recommend five hours of moderate intensity exercise per week.

Current data suggests that higher intake of vitamin D (especially during the adolescence) reduces the risk of developing breast cancer. Try to take 800 IUs of Vitamin D daily.

Risk reducing surgery to remove the breast tissue can be an option for those with a family history of developing breast cancer. Getting screened for a related genetic mutation may help you determine if such a procedure is appropriate for you.

Hormone replacement therapy has been shown to increase your risk for breast cancer. Therefore, in general I recommend trying alternative therapies for treating symptoms of menopause.

Lastly, if appropriate, a doctor may prescribe medications called selective estrogen receptor modulators that reduce your risk for breast cancer. As with most drugs, these modulators can have some unwanted side effects. Accordingly, discuss the risk vs. benefits of these therapies with your doctor.

If you are ever concerned about your risk for developing breast cancer, talk to your doctor. A review of your personal and family history will help your doctor make valuable recommendations.

Dilruba Haque, M.D., is a Hoag-affiliated medical oncologist located at 520 Superior Ave, Suite 300, Newport Beach, CA 92663. To schedule an appointment, call 949-646-6441.

Sheetal Gavankar, M.D.

Q: As a Rheumatologist, what are the three most common conditions you treat?

A: ​The field of Rheumatology is a subspecialty of Internal Medicine and Pediatrics that focuses on the diagnosis and therapy of complex rheumatic problems involving the joints, soft tissues, connective tissue disorders, and autoimmune conditions. There are more than 200 types of these diseases, and as a Rheumatologist, I see and treat many of these conditions. But as in every field, there are always specific disease processes I see more than others. For me, the three most common conditions I see and treat are Rheumatoid Arthritis (RA), Osteoarthritis (OA), and Fibromyalgia. Let’s delve into each one to provide some clarity.

1.Rheumatoid Arthritis (RA) is a chronic inflammatory condition that causes joint pain, stiffness, swelling, and limited mobility and function of many joints in approximately 1% of the population. The stiffness seen in RA is described as difficulty moving the joints after prolonged inactivity, therefore it is often worst in the morning when getting out of bed and tends to improve with activity. RA commonly begins between 40-60 years of age, however, signs and symptoms can start at any time. Diagnosis is based on laboratory data, physical exam, and imaging studies. If left uncontrolled, RA can lead to destruction of the joints resulting in erosion of the cartilage, among other deformities. While Rheumatoid Arthritis was once considered the most disabling arthritis, many new treatment advances have now enabled those with RA to lead very active and functional lives.

2.Osteoarthritis (OA), on the other hand, is a chronic non-inflammatory arthritis, typically affecting middle-age and elderly people. This type of arthritis is often referred to as the “wear and tear" of the joints. This description is inaccurate, however, as OA affects the entire joint, involving the bone, cartilage, ligaments, and joint lining. The joints most commonly affected are weight-bearing joints, such as the hips and knees, but it can also affect the hands, feet, shoulders, and spine. Risk factors include previous trauma, overuse of joints, obesity, having family members with OA, and being older in age. In contrast to those who have RA, patients with OA will say their pain is worst at the end of the day and improves with rest. There is no cure for OA, so treatment is directed at improving functionality and minimizing pain by focusing on exercise, patient education, and weight loss, as well use of various medications and surgical interventions. The ultimate goal is to improve functionality and minimize disability.

3.Fibromyalgia is a chronic pain processing disorder that is often characterized by widespread pain involving the muscles, ligaments, and tendons at specific points on the body, eventually progressing to generalized body pain. It is often associated with fatigue and difficulty sleeping, and some patients may have a constellation of other symptoms such as depression, anxiety, headaches, irritable bowel syndrome, and TMJ pain. Patients with fibromyalgia will often say “I hurt all over” or “I feel like have the flu all the time.” Fibromyalgia has no identifiable cause and affects approximately 2% of the population, most commonly women. It is important to note that fibromyalgia is not physically damaging to the body, meaning that it can be extremely difficult to live with but is not a fatal condition. There is no cure for fibromyalgia, but with mechanisms such as a light graded exercise, aquatic therapy, medications, and coping skills, people with fibromyalgia can lead happy and fulfilling lives.

Whether you have Rheumatoid Arthritis, Osteoarthritis, or Fibromyalgia, the goal is to improve quality of life and minimize pain. The most important thing to remember is that by being educated and informed about your condition and treatment options, you have the power to be engaged with your Rheumatologist in your treatment plan.

​Sheetal Gavankar, M.D., serves as a rheumatologist for Hoag Medical Group. She works at the Newport Beach and Huntington Beach locations. To schedule an appointment, call 949-791-3002 (Newport Beach) or 714-477-8020 (Huntington Beach) or visit www.HoagMedicalGroup.com.

​Hien Nghiem M.D.

Q: What words of advice do you have for people who are physically active?

A:​ In my experience as a sports medicine physician, I have found that an increasing number of people are actively taking advantage of the health benefits exercise has to offer. But for some, these benefits may come at a price: sports injuries. Most sports injuries are preventable, and below, I’ve provided some tips to help keep you injury-free while being active:

Conditioning: To avoid injuries, proper conditioning is important when starting any new exercise or sports activity. For example, increased body weight is a significant risk factor for low back pain in golf players. Developing your core muscles to help reduce stress on the back is a great way to help prepare your body for the increased physical activity.

Pre-Exercise Activity: Warming up and/or stretching for at least five to ten minutes prior to play or exercise is essential to increase circulation and help prepare muscles for activity.

Form: Taking the time to learn proper form and technique is critical in reducing your risk for overuse injuries resulting from poor technique.

Listen to your body: If you are over-fatigued or in pain, don’t “push through the pain.” This type of mindset often leads to many unnecessary injuries.

Gear: Proper safety equipment and footwear will ensure protection and help minimize injuries to your body.

Remember, if at any time you sustain an injury, make sure you consult your doctor and complete proper rehabilitation before restarting any activity.

Hien Nghiem M.D., C.A.Q.S.M. serves as a family practitioner and sport medicine physician at Hoag Medical Group. She works at the Irvine location and can be reached at 949-791-3103. For additional information, visitwww.HoagMedicalGroup.com.

Vinita Speir, M.D.

Q: What is minimally invasive gynecologic surgery and what are the benefits?

A: In gynecology, minimally invasive surgery (MIS) refers to surgery that is done without a large incision in the abdomen. Usually, the same surgery that was traditionally done through a large abdominal incision (usually 5-10 inches) is performed using very small incisions in the abdomen or an incision in the vagina. Surgical instruments are placed through these “mini” incisions (1-2 centimeters) and are able to be manipulated to remove or correct the problem.

The benefits to MIS are two-fold. First, for the patient there is usually a shorter hospital stay, faster recovery, less risk of a wound infection and less pain. Often patients undergoing MIS can go home on the same day of surgery or the next day. With a traditional abdominal incision, the patient would often stay three to four days postoperatively in the hospital.

Second, for the surgeon often MIS can actually have better visualization of the internal organs because of the great quality of the camera lens and ability to zoom in on areas in the abdomen that are harder to see through a traditional incision.

Some gynecologic surgeries, including hysterectomies, removal of the tubes and ovaries, removal of some types of fibroids, sterilization and surgeries for pelvic organ prolapse can be done through the vagina without any incisions in the abdomen at all. This is also considered minimally invasive and has the benefits of less complications and faster recovery. Of course there are limitations to who would be an appropriate candidate for this approach.

The other two types of MIS besides vaginal surgery are "straight-stick" laparoscopy and robotic-assisted surgery. Both of these use carbon dioxide gas to fill up the abdomen and then the surgery is performed through the mini-incisions mentioned earlier. Most gynecologic surgeries that are performed with traditional laparoscopy use three small incisions in the abdomen. Laparoscopic surgery has advanced significantly with new devices and technologies to make surgeries easier, faster, and safer. Some surgeons prefer traditional laparoscopy to robotic-assisted surgery because of the tactile feedback that they get with the instruments and less set-up time.

The biggest difference with robotic-assisted surgery is that the surgeon controls the surgical instruments from a console that is not attached to the patient at all. The instruments in robotic-assisted surgery are "articulated" which means they can move more similarly to a surgeon's wrist instead of in a straight line. There has been some recent controversy about the Da Vinci Robotic platform; however, most surgeons will agree that the visualization and ease of suturing allow this minimally invasive approach to be superior to traditional abdominal surgery-- especially in complex surgical cases.

Of course, the surgeon's experience and operating room team in addition to the specifics of each patient's case is very important when deciding what approach is the safest. Patient characteristics such as height, weight, number of prior surgeries, and other medical history can make certain patients better or worse candidates for one or more of these minimally invasive surgical techniques.

​Vinita Speir, M.D., is a Hoag-affiliated gynecologist located at 1441 Avocado Avenue, Suite 301, Newport Beach, CA 92660. To schedule an appointment in Newport Beach, call 949/644-2722 or for her Irvine office 949/559-4870.