News:

Surgeon earns recertification - Read Article
Moderation is the key in tanning - Read Article
Childhood aspirations leads to long-term career - Read Article
Endocrinologist encourages screening for osteoporosis: Are your bones at risk? - Read Article
Midlands Clinic Three Specialties, One Special Place - Read Article
20 questions with a surgeon Mike Wolpert - Read Article
Energy to burn - Thyroid problems could cost you - Read Article
Post-surgery recovery begins with first visit - Read Article
Vitamin D - Let the sunshine in - Read Article
Surgery is an option - The Mercy Weight Loss Center offers bariatric surgery for obese patients - Read Article
Diabetologist Dr. Tareq Khairalla of Midlands Clinic, P.C. uses his knowledge, understanding to help patients reduce their risk of complications from the disease - Read Article
Dr. Khairalla receives Board Certification - Read Article
Expert wound care - Mercy Wound Center provides personal care - Read Article
Dr. Robert E. Anderson received his recertification from the American Board of Surgery - Read Article
Skin cancer can be treated successfully if caught early, dermatologist says: Don't wait - Read Article
Bad nerves, bad skin go together - Read Article
Stress triggers cold sores - Read Article
Look your best, New Midlands Laser Center in Dakota Dunes treats skin conditions, performs hair removal - Read Article

Surgeon earns recertification - Back to Top

Sioux City Journal article featuring Dr. William A. Rizk
Posted: Sunday, March 28, 2010 12:00 am

Dr. William A. Rizk, a general surgeon at Midlands Clinic P.C. in Dakota Dunes, received his recertification from the American Board of Surgery. His recertification is active until 2020. He received his original certification in 2000.

The Board, an independent, non-profit organization, was founded in 1937 to certify surgeons who have met a defined standard of education, training and knowledge.

Rizk, who has practiced in Siouxland since 1999, has a strong professional interest in general surgery, laparoscopic surgery, trauma surgery and bariatric surgery.

Moderation is the key in tanning - Back to Top

Sioux City Journal article featuring Dr. Daffer
By Joanne Fox | Posted: Thursday, March 11, 2010 11:38 am

All things in moderation.

That's the motto Alison Kirkpatrick, 15, uses when she talks about her tanning regimen at SunSations Tanning, 1551 Indian Hills Drive.

"I'll come in twice a week for 12 minutes to maintain my tan," she explained.

The teenager has her parents looking over her shoulder with her tanning frequency, since Mark and Gayle Kirkpatrick own the salon.

Gayle said a lot of restrictions accompany teenage tanning.

"Absolutely no one 13 and under will be allowed to tan, even with a parent signature," she said. "And 14- to 16-year-olds must have parental consent."

Even that approval has restrictions, Gayle noted.

"The teenager has to bring the parent in and they sign the form in front of us," she said. "There's none of this take the form home and return with a signature."

Most of Alison's friends use a tanning salon, whether it's getting ready for homecoming, prom or other dances.

"But they're smart about it," the West High sophomore clarified. "They know to cover up their eyes. They also know to use lotion to keep their skin from drying out."

The U.S. Food and Drug Administration and the Federal Trade Commission are government agencies that implement and uphold laws and policies regarding skin tanning establishments. Iowa is among a handful of states that actively pursue and implement tanning legislation and regulations.

According to the Indoor Tanning Association (ITA), which represents indoor tanning manufacturers, distributors, facility owners and members, tanning should be regulated. Overexposure of the skin to ultraviolet radiation from both natural sources (the sun) and artificial means (tanning beds or booths) may subject the skin to different forms of skin cancer or an accelerated aging process, said Dr. Michelle Daffer, a dermatologist who practices at the Midlands Clinic, Dakota Dunes.

"Before tanning beds, skin cancer was surfacing in men and women in the same amounts," she said. "Now, we're seeing an increase in melanoma in women from age 20 to 40, but not in men. The question is: What's different? The answer has to be the link to young women using tanning beds."

Gayle said SunSations Tanning never offers unlimited tanning or other promotions that encourage too frequent visits.

"You can't fall asleep in the bed and go over the allotted time," she explained. "Also, our computer will not allow you to use a bed if it's prior to 24 hours since your last tanning session."

Dapper cautions any use of a tanning bed can be hazardous.

"It's like smoking," she said. "How can you smoke safely? You can't. There is no safe tanning. The best alternative is spray tans. Those are perfectly safe."

Some critics have described ultraviolet rays as harmful and possibly addictive, particularly for teenagers. Tanning salons tend to stay away from promoting any health benefits from tanning, but Gayle said there is research that notes positive results from tanning.

"Some studies indicate that UV rays can fulfill the recommended daily Vitamin D requirements," she said. "Some other research shows tanning can help with acne problems. Others indicate the exposure to UV rays will help with your mental health."

"I think the arguments against using tanning beds outweigh any benefits," Dapper said. "You don't absorb that much Vitamin D from tanning. Drink more milk or take a Vitamin D supplement.

"It's not clear either if tanning beds help with seasonal affective disorder and depression," she added. "There's research that says people feel better when the 'see' the sunlight. You can't expose your eyes to the light of a tanning bed. That will damage them."

Because teens are using the salon, Gayle said the business offers special rates for tanning sessions.

"We have a student package and a college package for people with a valid ID," she said. "We want to keep fees reasonable so young people can use us if they choose to."

Although some people might think teenagers spend their spare time getting a bronze look, Gayle said most of their clients using the nine tanning beds are older.

"They're coming in to get ready for a cruise or a wedding," she said. "About 75 percent of our clientele are not teenagers. Most are in the 20 to 40 age range."

Childhood aspirations leads to long-term career - Back to Top

Hawarden Independence article featuring Dr. Carlton

Endocrinologist encourages screening for osteoporosis: Are your bones at risk? - Back to Top

Sioux City Journal article featuring Dr. Khairalla
By Jean Hansen - Advertorial writer | Posted: Wednesday, January 13, 2010

If you are of advancing age, you may be at risk of developing osteoporosis.
Osteoporosis is the thinning of bone tissue and loss of bone density over time. Bone thinning renders a person more susceptible to fractures, which may be multiple, silent or occurring because of low trauma.

Dr. Tareq Khairalla, an endocrinologist at Midlands Clinic in Dakota Dunes, said osteoporosis is a threat for more than 50 percent of the population over age 50.

About 10 million Americans live with the disease as well as 18 million more who have low bone mass, or osteopenia, which may lead to osteoporosis eventually if left untreated.

Khairalla said osteoporosis is a silent disease, which means that people who are affected are usually unaware they have it until a fracture occurs or until it is detected by screening. The major sites for osteoporotic fractures are the wrist, the hip and the spine, although fractures may occur at any skeletal site and may be caused by minimal trauma.

"The best way to detect osteoporosis is to screen for it before any fractures occur. Women and men of certain age as well as people at risk for osteoporosis should have their bone mineral density measured using a method called Dual Energy X-Ray Absorptiometry (DXA), which measures the degree of penetration of bone by X-ray and thus indirectly measures the density of the bone. Individuals who have a bone density that is a certain degree below a pre-determined normal value are considered to have osteoporosis and have an increased risk for fractures," he said.

Screening is recommended in women over age 65 or men above age 70 since bone loss progresses with age.

"Osteoporosis in women most commonly occurs after menopause due to the loss of the protective effects of estrogen on bone. In men, osteoporosis can be caused by low testosterone levels," he said.

Other hormonal disturbances also affect the skeleton and result in bone loss. For example, an abnormality of the parathyroid gland can lead to one-directional calcium flow from bone into the blood, causing bone loss that can progress over time to osteoporosis. An overactive parathyroid gland can be detected with a simple blood test. Treatment involves identification of the overactive gland and its removal by surgical resection.

"A family history of osteoporosis also increases the risk of having the disease," he said.

Other risk factors for developing osteoporosis include smoking, excessive alcohol intake and physical inactivity.

"Medications can sometimes affect bone density and lead to bone loss as well. These include steroids and thiazolidinediones (TZDs), a class of medications for diabetes that includes pioglitazone and rosiglitazone. Any of those conditions, along with a history of previous fractures, should raise the suspicion for osteoporosis," he said.

Some practices may help slow the progression of bone loss and are recommended for any person who has or is at risk for the disease; regular weight bearing exercise, for example, can help strengthen the bone or at least slow bone loss. It is also important that the individuals affected or at risk maintain an adequate intake of calcium and vitamin D. They are essential for a healthy skeleton and stronger bone. Calcium is best found in milk products, nuts and some vegetables such as broccoli. A minimum intake of 1,200 mg calcium daily is needed. Vitamin D is naturally synthesized in the skin upon exposure to sunlight. Only 15 minutes of sun exposure a day is sufficient to maintain a healthy vitamin D level in most people. However, sunlight in Sioux City is very limited during winter months and vitamin D deficiency is extremely common. Food is not a reliable source of vitamin D, and thus if replacement is needed, it should be taken in pill form including vitamin D tablets and multivitamins. A minimum of 800 units of vitamin D daily is advised in patients and people at risk. However, diet and exercise are often insufficient by themselves to halt the disease and thus additional treatments are often needed. Risk factors should also be identified and should lead to testing for osteporosis. A list of the more common risk factors is outlined in the box below.

If a person already has been diagnosed with osteoporosis, some medications are available that can help stop the progression of osteoporosis and increase bone density. Bisphosphonates are the most commonly prescribed medications for osteoporosis.
"They function to seal in the bone to prevent further bone loss with age advancement," he said. "They are effective in reducing the incidence of hip and vertebral column fractures. These medications can be given orally once weekly or once monthly, or intravenously every three months or annually."

Bisphosphonates have side effects, however. They can cause stomach ulcers, especially if not taken appropriately, as well as heart rhythm abnormalities. Fortunately, these side effects are very uncommon, but they need to be considered for patients who have already had those complications or are at risk to contract them.

Estrogen is used in women to prevent osteoporosis if contraindications are not present.
Raloxifene (Evista) works also on the estrogen receptor and can prevent osteoporosis but, unlike estrogen, it reduces rather than increases a woman's risk of breast cancer.

Both estrogen and raloxifene have serious side effects and should only be prescribed after a thorough evaluation of the overall health of the patient's condition, he said.

The latest medication that has the ability to increase bone mass dramatically in osteoporosis patients is Teriparatide (Forteo). This medication is given by injection using a very fine needle daily for two years. If there are no contraindications for its use, forteo provides the best option for osteoporosis treatment given its excellent results. However, its use is limited to the most severe cases of osteoporosis because of the treatment's excessive cost.

Some medications are still being studied that have proven to be effective in treating osteoporosis, but they are not yet available for public use. More options should be available in the future, he said.

If you have some of the risk factors for osteoporosis, discuss the need to have a screening test with your primary care physician.
"If osteoporosis is diagnosed, a treatment plan should be designed carefully according to the patient's health status, severity of osteoporosis and other health problems that may influence the choice of medication to be used.

"A consultation with an endocrinologist is needed in severe osteoporosis if bone density does not improve with treatment or if other factors or diseases are suspected that can cause osteoporosis. An endocrinologist can help choose the best treatment plan to maximize the gain in bone mass and at the same time lower the possibility of side effects and complications," he said.

For more information about osteoporosis or other hormone-related conditions, call Khairalla at (605) 217-5500. Midlands Clinic is located at 705 Sioux Pt. Road in Dakota Dunes

Midlands Clinic Three Specialties, One Special Place - Back to Top

M.D. NEWS South Dakota article featuring Midlands Clinic

20 questions with a surgeon Mike Wolpert - Back to Top

Siouxland Life article, featuring Dr. Michael Wolpert
by Nick Hytrek Photograph by Jerry Mennenga | Posted: Tuesday, September 1, 2009

When it's time for surgery, you probably don't know what questions you should ask - or even much about the person wielding the scapel. Nick Hytrek caught up with Dr. Mike Wolpert, director of trauma at Mercy Medical Center and private practice general surgeon, and did some digging.

1. What made you want to be a surgeon?
My dad was a primary care physician in Onawa. My intent was to join my father in practice. At the time it was three years residency for general care physicians and with four years of residency you can be a surgeon. With all the automobile accidents on I-29, I figured that would be helpful. My father died three to four months before I graduated from my residency program, and my brother Paul had a general surgery practice in Sioux City so I decided to join him.

2. What are the educational requirements?
Normally it's four years of undergrad, four years of medical school and five years residency.

3. When you're in medical school or residency, how do you practice surgery?
That starts your first year of residency. You're learning how to evaluate patients. During the course of time, you will see patients who need surgery and you will assist the surgeon in the operating room. As time goes on, you get to do more of the surgery.

4. What type of personality does it take to be a surgeon?
There are different types of personalities everywhere. It takes all kinds to take care of a patient. For the most part, you have to have good communication skills, listen to what the patient has to say.

5. What types of surgeries do you do?
I do several different types. I do trauma surgery. For elective cases I do breast surgery, thyroid surgery, parathyroid surgery, colon surgery, varicose vein surgery, laparoscopic gall bladder surgery. I do all kinds of surgery on the skin and I do adjustable lap band surgery for obesity. I also do a lot of dialysis catheter work.

6. What's the most common surgery you do?
Probably in addition to appendectomies, probably laparoscopic gall bladder surgery is the most frequent.

7. Is there such a thing as "routine surgery"?
No, there isn't. Any type of surgery that is done is very, very serious.

8. What's the most complex surgery you do?
Probably the abdominal perineal resections. That's the most extensive surgery one has done. That's when someone has cancer of the rectum and you have to remove the rectum and part of the colon and create a permanent colostomy.

9. What's the shortest?
The shortest surgery is probably hernia repair. A normal hernia repair takes about 30 minutes.

10. Are there surgeries that you can't do?
A surgeon has to know his limitations. There are certain things I can do but I choose not to. If you don't do enough of them, then you're not proficient. I don't do heart surgery even though I used to assist with that for years.

11. Is it harder to be a general surgeon rather than have a specialty?
Some would say it is much more difficult because you have to be able to treat a number of illnesses. But each subspecialty has a tremendous amount of information that has to be mastered.

12. Why did you choose to be a general surgeon rather than one of those subspecialists?
At the time I thought it would help my dad with all those accidents along I-29. It's fun to do surgery. It's a joy to do surgery every day.

13. In your career, what's the most revolutionary technological advance that you've benefited from?
It's been the laparoscopic surgery, surgery through small holes.

14. What advances are on the horizon?
I think that as time goes on they will be more advanced in laparoscopic surgery with techniques. We do gall bladder surgery through four incisions. Now they're coming out with surgery that does that through one incision.

15. Do you get called out in the middle of the night very often?
Oh yes sir. I'm on call for 24 hours once or twice a week.

16. Every now and then, there will be a story about surgeons operating on the wrong limb or removing the wrong organ. What do you do to make sure you're operating on the right body part?
There are many fail-safe methods that we have now. The doctor must mark the patient in the exact place they're going to operate. They must put their initials on it. The nurse before the operation starts must stop everyone. They identify the patient, then the physician has to tell the nurse exactly what type of operation is to be performed.

17. Have you ever had a patient wake up during surgery?
Sure. For the most part, they stir and wake up, but there's so much sedation on board that they don't remember it. It is so rare.

18. What TV show or movie that you've seen has come the closest to really capturing the operating room atmosphere?
Of all the movies that I've ever seen, probably "MASH," the original "MASH" movie. Those shows like "ER" and other trauma shows, I tend to flip the channel because I see so much of that, it's not very relaxing.

19. It's always so intense in those scenes. Are you more relaxed?
Most of the time, elective procedures go along pretty well. We have conversations, but I like to keep that down because I don't want to have too many distractions.

20. When not in the operating room, what do surgeons do?
I usually have a pretty full day. I get up at 6 and usually make some rounds by 8. I have office hours, then do surgeries, then see patients. I operate five days a week and see patients five days a week.

Energy to burn - Thyroid problems could cost you - Back to Top

Dr. Khairralla Sioux City Journal article, featuring Dr. Khairalla
By Nick Hytrek | Posted: Thursday, June 5, 2008

For some unknown reason one evening in 2002, Rick Wollman put his hand to his neck, discovering a swollen area just above his collar bone.

After seeing the bulging area in the mirror, he made a trip to the emergency room. A series of tests and X-rays showed a mass growing on his thyroid.

The funny thing, Wollman said, was that he felt fine.

"I wasn't having any of the symptoms of an underactive or overactive thyroid," said Wollman, Morningside College director of public relations.

Doctors determined the mass had to go. Once the surgery had begun, the surgeon also removed Wollman's thyroid gland because the mass had invaded it. Fortunately, the mass was benign, and now Wollman takes a daily pill to provide the hormone his thyroid once secreted.

Before his doctor visit, Wollman, like many people, gave little thought to his thyroid, a butterfly-shaped gland at the base of the neck that produces the hormone thyroxine, which helps regulate bodily functions such as metabolism and energy production.

"It remains a disease in the shadows in terms of not many people know about the thyroid," said Dr. Tareq Khairalla, an endocrinologist at Midlands Clinic in Dakota Dunes.

For most of us, we don't give a second thought to our thyroid until something is wrong. Even then, thyroid problems can go overlooked because the symptoms are so generic.

"They are very nonspecific. That's the problem is that they're frequently missed," Khairalla said.

Such was the case with Janet Flanagan, owner of Perry Creek Communications in Sioux City.

A little more than three years ago, Flanagan said she began feeling fatigued, especially in the afternoon. She felt cold much of the time. A health- and weight-conscious person, she gained a few extra pounds and saw her cholesterol numbers triple.

"I thought maybe that was stress," Flanagan said. "What really sent me to see the doctor, was I was walking up a hill, and I walk a lot, and I could barely get up the hill. I thought, 'That's it, I obviously need open-heart surgery. Something is seriously wrong.'"

A quick blood test at her doctor's office showed something much less serious. Her TSH, or thyroid-stimulating hormone, level was out of whack. Flanagan had hypothyroidism, or an underactive thyroid. With medication, her TSH level was brought back to normal levels, she lost the extra weight and regained her energy.

"A simple pill. That's all I needed," she said.

Women are more likely to have thyroid conditions, Khairalla said. Researchers have yet to determine why. But a blood test at the time of an annual physical isn't a bad idea if you suspect you might have a thyroid problem or if someone in your family has one.

"You can tell if you have a high or low thyroid level with a simple blood test," Khairalla said.

Those tests could show hypothyroidism - the underactive condition - or hyperthyroidism - an overactive thyroid, which produces more energy in the body, leading patients to feel anxiety and a rapid heart rate. Both can easily be treated, Khairalla said.
Other common thyroid conditions include goiter, which means a large thyroid. If enlarged, Khairalla said the thyroid should be checked via ultrasound for nodules, or growths.

Nodules are common, Khairalla said, and most people never realize they have them. They are discovered if they grow to a noticeable size or if doctors find them while doing ultrasounds or CT scans for other medical conditions. Though usually benign, 5 percent of nodules are cancerous.

"This is why every nodule needs to be evaluated," Khairalla said.

The nodule can be checked with a needle biopsy, an outpatient procedure. If benign, the nodule doesn't always require removal unless it has the potential to grow and put pressure on other body parts such as the trachea.

If cancerous, the nodule is removed. Thyroid cancer is very treatable, Khairalla said.

"When we start treating, we aim for a cure," he said.

Treatment involves surgery to remove the nodule, a radioactive iodine treatment and routine follow-up exams.

Though often overlooked, Khairalla said, thyroid conditions are not rare.

"It is very common actually," he said.

It's a fact Wollman discovered after the discovery of his own thyroid condition.

"I think it is surprising the number of people who have thyroid issues," said Wollman.

Fortunately, thyroid conditions generally don't prevent one from leading a normal, active lifestyle.

"Since I've had surgery, once a year I have blood work in which they check my level of TSH," Wollman said. "As far as medical situations go, in my viewpoint this is no big deal."

Post-surgery recovery begins with first visit - Back to Top

Dr. Keith Volstedt Sioux City Journal article, featuring Dr. Keith Vollstedt
By Joanne Fox | Posted: Monday, June 1, 2009

DAKOTA DUNES - Post-surgery recovery begins long before an incision is made.

"It actually starts with the first visit to your surgeon," said Dr. Keith Vollstedt, a surgeon with Midlands Clinic. "It begins with educating the patient."

Too often, an individual is so relieved to be rid of pain and discomfort and so ready to leave the hospital and return home, that he/she doesn’t hear what the health care providers are saying about what to expect during the recuperation process, Vollstedt pointed out.

"We do our best to have patients, prior to surgery, learn about what limits should be placed on them, what physically they can expect," he said. "We encourage them to visit Web sites and especially talk to others who have had the surgery."

Forewarned is forearmed, Vollstedt said.

"We have numerous pamphlets on several types of surgery, treatment options and post-operative conditions. And people are pro-active in bringing in pages they’ve printed off the Internet on a health issue."

That can be both a blessing and a curse, Vollstedt said.

"Medical sites are good to visit because most have accurate information. Blogs can have some misinformation, but even that can be verified or discounted if it’s presented to us."

In his 17 years of practice, Vollstedt has seen a dramatic change in the post-surgery approach between doctors and patients.

"A hospital stay was longer after surgery, so conditions were monitored better," he recalled. "Then, it evolved to, perhaps following a same-day surgery, patients were sent home, left to their own devices with merely a set of instructions. Education prior to the surgery was clearly necessary so the patient would realize if things weren’t quite right."
One should expect some pain, certainly some discomfort, upon returning home, Vollstedt said.

"Most physicians will prescribe a narcotic to relieve pain," he said. "It’s interesting that many from our 'Greatest Generation" fear an addiction might result, but that is very rare."

Although some patients would prefer rest and relaxation, Vollstedt stressed it’s important to return to normal activity, at a reasonable pace.

"We want the patent walking around and doing breathing exercises," he said. "However, it’s important to realize that recovery is a slow process."

People will sometimes fret they are tired, they can’t seem to "get their motor going," Vollstedt said. That might be normal.
"No matter how simple or straightforward the surgery might be, you have to remember you are getting an anesthetic that is putting you to sleep and, more than that, relaxing the muscles of your body," he said. It’s going to take a while for that to wear off. You need to pace yourself."

Vollstedt sees a wide spectrum of time in the recovery process between a variety of folks.

"Our Greatest Generation may be more frail, but they seem to take surgery stronger mentally than younger folks," he said.

"Women are tougher than men," Vollstedt added. "That could be just having more interactions or being comfortable with the health care environment."

The strongest reason for the pre-surgery approach to post-surgery recovery is retention of information, Vollstedt stressed.

"Patients can "hear" details better. Concentration is better. Although pain might be present, their thinking isn’t as clouded," he said. "It’s all about alleviating anxiety."

WATCH IT!

Dr. Keith Vollstedt suggested a phone call to the surgeon would be in order for any or all of these situations. Call well before 5 p.m., if you can, he recommended. Don’t wait if some issue is truly causing you worry. "Peace of mind is well worth a phone call," he said. "Trust your intuition if something seems wrong."

Incision area is red, swollen or drains
A low-grade fever that doesn’t go away with a few doses of Tylenol or a triple-digit fever.
Pain that isn’t alleviated after a few doses ibuprofen
Leg pain (could be blood clots)
Fatigue that seems beyond what might be normal
Suddenly feeling much worse

Vitamin D - Let the sunshine in - Back to Top

Sioux City Journal article, featuring Dr. William Blankenship
By John Quinlan Photographs by Tim Hynds | Posted: Thursday, May 14, 2009

For a vitamin that isn’t really a vitamin, Vitamin D is a "very, very hot item in the medical community" these days. In fact, medical literature is filled with sunny Vitamin D stuff, said Dr. William Blankenship, a specialist in endocrinology at the Midlands Clinic at Dakota Dunes.

For years, researchers have suspected Vitamin D is beneficial in the fight against cancer. And new research has shown that it may aid in preventing certain cancers, but scientists remain split on how much the vitamin is responsible.

The problem comes with "causality," said Blankenship.

"Causality is a very difficult concept to prove medically," he said. "We’ve been led astray by many other studies that suggested causality, but the proof wasn’t solid. I can only mention the swing back and forth, back and forth with post-menopausal estrogen as a classic example of where associations have been mistaken for causality. I think the final report on that has still yet to come, on where we stand with that.

"The tolerance for taking Vitamin D is very high. It is difficult to become toxic or poisoned from Vitamin D from substantial doses of supplements."

On the other hand, he said he would hesitate to recommend more than 2,000 units a day to an adult without proper medical supervision, meaning blood level work.

Sun exposure, however, remains a critical source of this vitamin.

Low Vitamin D levels are associated with diabetes, obesity, heart disease, hypertension, gout, infectious diseases, cancer (breast, colon, lung and prostate), and such auto-immune diseases as lupus. But despite the associations between these diseases and Vitamin D, "they have not been proven to be causal in either direction," Blankenship said.

Low levels of Vitamin D have also been "associated" with rickets in children.

Despite claims to the contrary from some quarters, further study is needed across the board to figure out where the causality lies and to see if we can utilize that association therapeutically, he said, "because we’re not saying that taking more Vitamin D will prevent that long list of conditions."

Occasionally, though, researchers present some positive pieces of information.

"For example, in Finland, a study was performed over 31 years where children were given Vitamin D prospectively," he said, "and the study looked at the risk of developing Type 1 diabetes, juvenile type of diabetes. And it did find a reduction when supplementation was given in a prospective fashion.

"The difference between population surveys and prospective intervention is very important here to understand - and is basically the foundation of evidence-based medicine, where everything is going."

At the moment, Vitamin D is capable of treating Vitamin D deficiency and a few other metabolic diseases and, in topical form, it is useful for skin disease, but the causality elsewhere is still not proven, he said.

"It’s still a long ways off, but I think the future is very bright for Vitamin D, and not just in the sun but in the lab," he said.
Not a vitamin!

The first thing to understand about Vitamin D is that it’s not a vitamin, Blankenship reiterated.

"A vitamin is a micro-nutrient that is required for metabolism in the body that is required to be supplied from outside the body," he said. "And we are capable under the right circumstances of providing our own Vitamin D to completely satisfy our needs. But for a lot of reasons, Vitamin D is going to become a vitamin because of the changes in our lifestyle."

Structurally, it bears more resemblance to other sterol hormones in the body, ones that we are familiar with such as cortisol, testosterone, estrogen, aldosterone and progesterone, he said.

Though technically Vitamin D is a hormone, as we emerge into this generation of people living in lifestyles that don’t allow them to make Vitamin D themselves, it is becoming more of a vitamin, "meaning it’s going to have to be supplied from outside the body," he said.

The "enormous changes" in lifestyle he mentioned are related to the increasingly higher numbers of people becoming Vitamin D deficient over the past few centuries. These changes include the Industrial Revolution in which people moved their workplace from outdoors, a process that has continued through today’s digital age.

"More and more people are doing their jobs at screens like this," he said, pointing to a nearby computer. "Even in medicine, we’re becoming more digital as time passes. And that means we have less exposure to sunlight, which is the necessary factor for manufacturing Vitamin D."

Other factors in the increasing risk of Vitamin D deficiency, he said, include increases in obesity, air pollution and immigration. Vitamin D is a fat soluble substance and tends to get lost in the larger and larger pool of storage fat in the body, he noted. As for pollution, the more the air is polluted, the less ultraviolet rays or light will impact the skin and produce the needed Vitamin D. And as individuals with high levels of skin pigment move toward higher latitudes, they find themselves more and more unable to produce their Vitamin D.

"Between the highest and lowest levels of skin pigments, equatorial Africa versus northern Scandinavia, the difference in the ability to produce Vitamin D is 99.9 percent," he said. "So if you take an individual with equatorial pigmentation and move him to a high latitude, he or she is simply unable to produce the Vitamin D that he or she needs."

Deficiency symptoms

Nausea
Fatigue
Aching muscles
Aching bones and joints
Lack of energy
High blood pressure
Kidney ailments
Vomiting
Poor appetite
Constipation

Sources: National Institute of Health. Dr. William Blankenship

Sun’s yin and yang

Home windows block ultraviolet light. Clothing and sunscreen also limit sun exposure. But that’s not a bad thing, cancer researchers will point out.

"Sun exposure leads to skin cancer and skin aging," Dr. William Blankenship said, while noting that such exposure is a critical source of Vitamin D. "There’s always a push/pull, yin/yang, risk/benefit in sun exposure. So to simply say that people aren’t getting enough sun and need to go out in the sun without sunscreen is not technically correct. You have to find the right balance."

His own personal recommendation: Individuals should wear sunscreen on face, ears and any uncovered parts they might have at the onset of exposure to sunlight, Other areas of the body, arms, legs and torso are going to need exposure for a varying period of time, depending on latitude, date, time of the day, state of the atmosphere and their pigmentation.

In some latitudes, such as 37 degrees latitude north or greater, which includes Siouxland, the sun is insufficient six months of the year to provide Vitamin D no matter what your pigmentation. Hence the need for supplementation, he noted.

Most dairy products are fortified with Vitamin D. Animal products contain small amounts, plant products even smaller amounts. And oily fishes are a good source, which works out well for Eskimos’ and other Arctic and Antarctic neighbors who eat a steady diet of such fish in a climate where the sun offers no help at all, he noted.

Surgery is an option - The Mercy Weight Loss Center offers bariatric surgery for obese patients - Back to Top

Siouxland Lifestyles article
Jean Hansen, Advertorial writer | Posted: Thursday, May 28, 2009 12:00 am

Obese people who have tried unsuccessfully to lose weight and maintain their weight loss with diet and exercise alone may find that surgery is a useful tool to help them make lifestyle changes, say the medical professionals at the Mercy Weight Loss Center in Dakota Dunes.

"Statistics show that only 5 percent of morbidly obese people with a Body Mass Index1 of 40 or greater can lose weight and maintain their weight loss greater than five years with diet and exercise alone. That's why surgery is needed," said Jennifer Black, R.N., C.B.N., bariatric nurse coordinator at the Mercy Weight Loss Center.

The National Institutes of Health Consensus Development Conference concluded, "Only surgery has proven effective over the long term for most patients with clinically severe obesity."

The need for surgery has increased because the number of obese people has increased. According to the Centers for Disease Control (CDC) in January 2009, "There are now more Americans that are obese than overweight or normal weight. Obese Americans now represent the largest weight category."

For the obese population, weight loss (bariatric) surgery comes with many benefits. According to the American Society for Metabolic & Bariatric Surgery, studies show on average bariatric surgery resolves type 2 diabetes in 83 percent of patients, and it cuts the risk of developing coronary heart disease in half. In addition, it is an effective treatment for obstructive sleep apnea and resolves the condition in 95 percent of patients.

Morbidly obese individuals who have bariatric surgery also increase their longevity, as compared to those who do not have surgery. Patients can improve their life expectancy by 89 percent, and patients can reduce their risk of dying by 30 percent to 40 percent, the ASMBS stated.

Furthermore, bariatric surgery is effective over the long term for the life-threatening disease of obesity.

In general, bariatric surgery patients experience most of their weight loss 1-2 years after surgery and maintain a substantial weight loss, with improvements in obesity-related conditions, for years.

The Mercy Weight Loss Center offers two types of weight loss surgeries: Laparoscopic Adjustable Banding (Lap-Band) and Laparoscopic Roux-en-Y Gastric Bypass.

The surgeries are performed by Dr. William Rizk, Dr. Keith Vollstedt and Dr. Michael Wolpert at Mercy Medical Center-Sioux City. Dr. Wolpert performs the Lap-Band surgery, and Drs. Rizk and Vollstedt perform both the Lap-Band and laparoscopic gastric bypass surgeries.

During the Lap-Band surgery, a silicone band is placed around the upper part of the stomach, and a small pouch is created. As a result, the stomach holds less food and the patient feels full faster and longer. The size of the restriction can be adjusted after surgery.

During gastric bypass surgery, six small incisions are made to hold laparoscopic instruments, then the stomach is separated through the use of staples to create a small pouch. The smaller stomach is attached to the middle of the small intestine, bypassing the section of the small intestine (duodenum) that absorbs the most calories. Patients eat less because the stomach is reduced from the size of a football to the size of a golf ball and they absorb fewer calories because food does not travel through the duodenum.

To qualify for weight loss surgery, individuals must be between the ages of 18 and 64 at the time of surgery, have a BMI of 40 or greater, or have a BMI between 35 and 39 along with any one of the following medical conditions: high blood pressure, high cholesterol, type 2 diabetes, gastroesophageal reflux disease (GERD), or sleep apnea with the use of a CPAP machine.

The above-mentioned medical conditions have to be diagnosed by a physician, and the person has to be taking medications to treat them, said Black.

Before individuals have weight loss surgery at Mercy Medical Center, they go through an educational process, Black said. The first step is to attend a free obesity seminar. The seminars are offered twice a month: the first Thursday and third Monday of the month. The meetings are open to the public, but patients do need to call Melinda at Midlands Clinic to register, (605) 271-5511.

"The seminars are to provide the public with the benefits and risks of weight loss surgery so they can decide if weight loss surgery is right for them." she said.

Realistic weight loss expectations after surgery are 40 to 60 percent of a person's excess body weight for Lap-Band patients and 60 percent to 80 percent of their excess body weight for a gastric bypass patient. These numbers are averages. People can lose more or less weight based on their exercise habits and lifestyle changes.

After the seminar, the next step is a one-on-one consultation with the physician, who then writes a letter to the patient's insurance company stating why the patient medically needs weight loss surgery.

Every step is very necessary to ensure that a patient will be successful after weight loss surgery.
"Weight loss surgery is a tool, not a 'cure all.' You really have to make lifestyle changes to be successful," Black said. "Regular exercise and good eating habits are essential."

Prior to having surgery, patients complete the extensive educational process. The Mercy Weight Loss program requires several appointments including sessions with a registered dietitian, athletic trainer and bariatric nurse, behavior modification classes and support group sessions. Some of the classes are held before surgery and others afterward.

"We offer such an extensive educational process because it makes people successful," said Black, the first certified bariatric nurse in the tri-state area. "Weight loss surgery is not a 'quick fix.' It's a tool to help people lose weight and maintain their weight loss. The reason they decide to have weight loss surgery is they're trying to avoid or improve medical problems they're having. It's not a cosmetic procedure."
Of course, everyone will lose weight with weight loss surgery because it is such a shock to the system, but the whole key is to keep the weight off after surgery, said Dr. Keith Vollstedt, a general surgeon who has been performing weight loss surgery since 1993.

"In my personal opinion, a weight loss operation is designed to facilitate patients' desire to lose weight. It's permanent in a way that it's not easy to go off a diet. The most success is in patients who make lifestyle changes with the operation itself," he added. "They need to watch the amount they eat and increase their activity levels. That is why we push preoperative education. I always tell patients during our seminars, 'If you're not ready to give up certain foods or change your lifestyle, you should not have this operation. You will probably be frustrated.'"

Dr. William Rizk, medical director of Mercy Bariatric Services, agreed. He said if patients are going to be successful, they have to give up their previous lifestyle.

"They must be willing to be open minded and change their behavior," he said. "Otherwise, nothing we are going to do is going to work. They will gain weight back."

Complication rate is low on bariatric surgeries. Like most surgeries, some risks are involved in the Lap-Band procedure. Complications include band slippage, band erosion, port site infection, blood clots in the legs or lungs, or death, which is very rare (0.07 percent). Complications from gastric bypass surgery include gastric leaks, blood clots in the legs or lungs, bleeding, hernias or death (0.14 percent).

Since the surgical program at Mercy Weight Loss Center started in 2002, Rizk, Vollstedt and Wolpert have performed 750 weight loss surgeries - 224 Lap-Band and 526 gastric bypass surgeries. The Mercy Weight Loss Center team has had lower complication rates than the national averages.

Vollstedt said he attributes the lower complication rate to extensive education and the support after surgery.

"Back when weight loss surgeries started, people would fail because they had no support and they had no idea how to eat. People would be frustrated. There wasn't a push to eat plenty of protein or maintain muscle strength. Doctors didn't tell people to exercise regularly. I think a weight loss operation today is very safe for patients. We used to make larger incisions and now we make much smaller ones. Weight loss surgery is no more dangerous than a knee or hip operation, which carries the risks of a blood clot, pneumonia or infection. Compared to 20 years ago, when patients would just show up and we'd do the surgery next week then do a little teaching in the hospital, weight loss surgery today has been very successful."

Why use the Mercy Weight Loss Center program for bariatric surgery?

Rizk said the Mercy Weight Loss Center is a good place to go if you're considering bariatric surgery because of the staff's medical and empathy training.

"We're thoughtful of obesity related issues," said Rizk, who has been performing bariatric surgery since 2002 and oversees the bariatric education of nurses in the hospital. "We have experienced, dedicated surgeons and a support team that has a strong interest in obesity. We provide a multidisciplinary program with experienced nurses so the surgery doesn't involve anxiety. The results have been exceptional."

The Mercy Weight Loss Center is located at 705 Sioux Point Road in Dakota Dunes. For more information about Mercy Weight Loss Center's surgical program, call (605) 217-5566 or check out our Web site www.midlandsbariatric.com.

If weight loss surgery is not an option for you, the Mercy Weight Loss Center also offers a physician-supervised nonsurgical weight loss program. You may call (605) 271-4567 or visit the Web site www.mercywlcenter.com for more information.

The body mass index (BMI) is a statistical measurement which compares a person's weight and height. Though it does not actually measure the percentage of body fat, it is a useful tool to estimate a healthy body weight based on how tall a person is. Due to its ease of measurement and calculation, it is the most widely used diagnostic tool to identify weight problem within a population including: underweight, overweight and obesity. (source:Wikipedia)

Diabetologist Dr. Tareq Khairalla of Midlands Clinic, P.C. uses his knowledge, understanding to help patients reduce their risk of complications from the disease - Back to Top

Sioux City Journal article, featuring Dr. Khairalla
By Jean Hansen / Advertorial writer | Posted: Friday, July 11, 2008

Emily Moser of Onawa, Iowa, has juvenile diabetes. Like many youth with the disease, she must carefully watch her diet and monitor her blood sugar regularly to avoid serious complications. She feels confident in her ability to do those things because of the help she receives from diabetologist Dr. Tareq Khairalla of Midlands Clinic, P.C., in Dakota Dunes.

"He knows what he's doing," Moser said. "He gives me pointers on my insulin pump and how to make my diet better. He tells me how many Bolus doses I need to cover the carbohydrates I eat. I have a wizard on my pump that says how much insulin I should give myself. It will beep if my blood sugar is too high or too low. It eliminates a lot of problems with low blood sugar."

Since she has been referred to Khairalla from her doctor in Onawa, she rarely has an episode in which she has low blood sugar to the point of becoming unconscious. Besides his helpful pointers, she appreciates his personality, she said.

"He's very nice and he likes to joke around some. He understands that being a teenager, it is hard not to eat what you want and do some of the things other kids do. He knows the struggles that people go through with diabetes. He is there to help you and make you feel good about having a handle on diabetes," she said.

Cases of diabetes are growing

Moser is not alone in her struggle with diabetes. According to the American Diabetes Association, diabetes has reached epidemic proportions in the United States, with about 7 percent of the population dealing with complications from this disease. An estimated 14.6 million people have been diagnosed with diabetes, and another 6.2 million people are unaware they have it.

"The number of new diabetes cases being diagnosed is rising sharply,"said Khairalla. "It's a phenomenon that is having a significant impact on health care costs."

Diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. There are two types of diabetes: type 1 and type 2. Type 1, also known as juvenile diabetes, occurs when a group of cells called beta cells in the pancreas gland fails to produce insulin, the hormone that "unlocks" the cells of the body, allowing glucose to enter and fuel them. Type 2 diabetes develops when the body becomes resistant to the actions of insulin but still produces some insulin. Most Americans who are diagnosed with diabetes have type 2.

Genetics, environment increase susceptibility to diabetes development

Khairalla said he has seen an increase in both types of diabetes because of genetic (hereditary) and environmental factors. While individuals may be unable to control the genetic aspect of the disease (a person is either susceptible or not), they can modify their environmental risk, he said.

"As people live their lives, it's their exposure to environmental factors that triggers the development of diabetes. Family history is significant, but so is lifestyle. If a person lives a sedentary lifestyle and doesn't have good healthy diet habits, he or she is more likely to develop diabetes. Genetic factors are stronger in type 1, but it looks like the environment is a dominant factor for type 2," Khairalla said.

Khairalla attributes a sedentary lifestyle to technologies that require little or no physical effort to use. He said a great dependence on fast food is one of the factors that has attributed to Americans' poor diet habits.

"People are moving away from cooking at home because of the American lifestyle. They need to look at eating more vegetables and fruit and change the way their food is cooked. Baking and grilling are much healthier than frying. Fast foods are low quality and lead to obesity," he said. "They're an important cause of obesity and the development of diabetes. It's essential to limit your calorie intake and prevent weight gain. Avoidance of fried food and high amounts of carbohydrates can help."

Moser, mentioned earlier, said following Khairalla's advice on eating a low fat diet with few carbohydrates has been beneficial in controlling her weight and improving her health.

How to tell if you have diabetes

According to Khairalla, diabetes usually develops slowly, taking several years before it is diagnosed. However, high blood sugar can damage organs if ignored or untreated. Symptoms of diabetes include excessive thirst, frequent urination, extreme hunger, increased fatigue, irritability and blurry vision. If you have any of these symptoms, or you have a family history of diabetes and risk factors for the disease, you should check with your physician to have your blood sugar checked, Khairalla said. High blood sugar can affect small blood vessels in the eyes over time and lead to blindness. It can also cause kidney disease, which may necessitate dialysis, and affect the nerves in the legs, leading to ulcers and amputations. To diagnose diabetes (both pre-diabetes and the full-blown types), physicians use a Fasting Plasma Glucose Test or an Oral Glucose Tolerance Test. The American Diabetes Association recommends the fasting blood glucose test because it is easier, faster and less expensive to perform. A blood glucose level between 100 and 125 mg/dl signals pre-diabetes and a level of 126 mg/dl or higher signals diabetes.

Treatment options

Once diabetes has been diagnosed by a physician, it can be treated. Type 1 diabetes is controlled with insulin shots or insulin pumps. Type 2 diabetes may be treated first through non-pharmacological methods, such as diet and exercise. A person's diet should take into account total grams of carbohydrates and glucose. Khairalla recommends that individuals with diabetes have no more than four to five carb servings a day.

"Generally, individuals with diabetes can eat whatever they want, as long as they don't exceed a certain limit," he said.

Along with a healthy diet containing a combination of carbs, proteins and fats in every meal and plenty of fiber, exercise - no matter what type it is - has a positive effect on blood sugar levels.

"The important thing is whether you will continue to exercise or not," he said. "The best way to stay motivated to exercise is to pick a type that you like doing and keep doing it. Walking is as good as any other activity."
If diet and exercise alone become less effective at controlling high blood sugar, a variety of oral medications may be prescribed for type 2 diabetes.

"Each has certain side effects," Khairalla said. "As a diabetologist, I can help determine which treatment is the most suitable."

Oral medications may become less effective over time. In 10 to 20 years or so, patients may eventually require insulin shots, he said.
Khairalla said new advances in recent years have been used to control diabetes, including insulin that comes inside of a pen.

"There's a needle at the end of the pen instead of a point," he said. "You simply dial the amount of insulin that you need. Old methods used vials and syringes. The pen offers convenience, ease and portability, especially for people who travel a lot or need to take insulin at work or other activities."

Other treatments include Byetta and Symlin, medications that are administered by injection and used with other blood sugar control methods. Byetta helps the body produce the right amount of insulin at the right time, while Symlin slows the movement of food through the stomach. It affects how fast the amount of sugar from food enters the blood, and is used with insulin to control high blood sugar.

"It also helps to reduce appetites and helps patients lose weight. It is only approved for use in diabetes, however," he said.

Patients diagnosed with diabetes are best treated under the supervision of an experienced physician such as a diabetologist who can select the type of medication that is most suitable for their special situation to ensure control of high blood sugar, preventing complications and avoiding the risk of low blood sugar during treatment.

"If you seek the help of a doctor who specializes in diabetes and follow what they say, it is very helpful and easy to live a normal life," Moser said.

For more information about diabetes and other endocrinology-related disorders, or to make an appointment, call Khairalla at (605) 217-5500. Midlands Clinic is located at 705 Sioux Point Road in Dakota Dunes.

Dr. Khairalla receives Board Certification - Back to Top

Dr. Khairalla Sioux City Journal
Posted: Sunday, February 03, 2008

Dr. Tareq Khairalla of Midlands Clinic in Dakota Dunes has passed the 2007 Certification Examination in Endocrinology, Diabetes and Metabolism and is now certified as a Diplomate in Endocrinology, Diabetes and Metabolism.

To become certified in the subspecialty of Endocrinology, Diabetes and Metabolism, physicians must have been previously certified in internal medicine by the American Board of Internal Medicine, completed graduate medical education fellowship training, demonstrated clinical competence in the care of patients and met the licensure and procedural requirements. The American Board of Internal Medicine certifies one out of every three practicing U.S. physicians.

Khairalla received his medical degree from the University of Jordan, Amman, Jordan in 1999 and did residency and fellowship at Henry Ford Hospital, Detroit. His areas of specialty are adult diabetes, thyroid disorders, pituitary dysfunction, adrenal gland problems, metabolic difficulties, Dyslipidemia, endocrine diseases, disorders of calcium, osteoporosis and bone metabolism.

Expert wound care - Mercy Wound Center provides personal care - Back to Top

Siouxland Health article, featuring Dr. Paul Johnson

Time doesn't necessarily heal all wounds. Sometimes expert intervention is also necessary. Fortunately for the Siouxland area, the Mercy Wound Center provides specialized, state-of-the-art evaluation and treatment of a wide range of wounds.

Dedicated in 2005, the Mercy Wound Center is experienced in treating patients with chronic wounds, those caused by traumatic injury, burns, venous arterial insufficiency and vascular disorders, as well as diabetic ulcers, pressure ulcers and post-surgical wounds.

The outpatient center's patients benefit from a wide range of treatment options, depending on their individual needs. When appropriate, treatment is coordinated and integrated with consultations with Mercy's Diabetes Education program, the hospital's Infectious Disease

Clinic, and other specialty clinics and departments.

Dr. Paul Johnson, an experienced general surgeon in practice with Midlands Clinic in Dakota Dunes, serves as medical director for the Mercy Wound Center.

"The center fills an important niche in the region by offering specialized wound treatment at a time when there is a growing demand for those services because of the increased prevalence of diabetes and other conditions that can cause chronic wounds," Johnson said. "What's more, we are highly successful in providing those specialized services. The Mercy Wound Center realizes outstanding clinical outcomes for its patients. Statistically, our outcomes are better than the national average."

Since it was founded more than two years ago, the Mercy Wound Center has continued to evolve in order to better serve patients in the larger region around Sioux City.

Not only does Johnson see patients at the center two days a week, but the recent addition of a board certified mid-level provider, Mike Garrett, A.R.N.P., has allowed the outpatient center to serve more patients and better coordinate and oversee their care.

"We are taking the time and consciously working to provide outstanding customer service," Garrett said. "First and foremost, we want to bring patients with chronic wounds the reduced pain and improved comfort that comes with healing. We do everything we can to encourage and expedite that healing process.

"At the same time, we follow-up with the patient's physician or provider to make sure there is very good coordination of care."

Along with Johnson and nurse practitioner Garrett, two registered nurses who are board certified in wound care serve the center's patients. Those WOC (Wound Ostomy Continence) nurses average 18 years of experience.

For patients with chronic or traumatic wounds, burns, venous arterial insufficiency, or diabetic or pressure ulcers, the Mercy Wound Center offers not only help, but also hope. With healing comes comfort and a better state of mind.

"It is our mission to provide that kind of quality care and to address needs where we see them," Garrett noted. "We are here to help people - one patient at a time."

The Mercy Wound Center is located on the fifth (ground) floor of the North Hospital Building on the medical center's main campus. That location offers patients quick, easy access at the hospital's Jones Street entrance where free valet parking services are available.

The Mercy Wound Center is open Monday through Friday from 8 a.m. to 4:30 p.m.

If you think you might benefit from the specialized services of the Mercy Wound Center, talk to your doctor or healthcare provider. A physician referral is first needed.

Or, for more information, call the center at (712) 279-2512 or visit the center's Web page at http://www.mercymedicalclinics.org.

Dr. Robert E. Anderson received his recertification from the American Board of Surgery - Back to Top

Dr. Robert E. Anderson Sioux City Journal
Posted: Sunday, January 27, 2008

Dr. Robert E. Anderson, a general surgeon at Midlands Clinic, P.C. in Dakota Dunes, received his recertification from the American Board of Surgery.

He received his original certification in 1989. Anderson received his medical degree in 1983 from the University of Minnesota. He has practiced in Siouxland since 1988.

Anderson has a strong professional interest in general surgery, laparoscopic surgery and trauma surgery and holds membership in other professional societies, including American College of Surgeons, Iowa Academy of Surgery, Iowa Medical Society, Woodbury Medical Society and Throckmorton Surgical Society.

The American Board of Surgery is an independent, non-profit organization, founded in 1937 for the purpose of certifying surgeons who have met a defined standard of education, training and knowledge.

Skin cancer can be treated successfully if caught early, dermatologist says: Don't wait - Back to Top

Sioux City Journal article, featuring Dr. Michelle Daffer
Jean Hansen - Special Section Editor | Posted: Thursday, January 25, 2007

Of all the cancers, skin cancer is the most common, but depending on the type you have, it can be treated successfully if caught early, a local dermatologist said.

"Skin cancer is the No. 1 type of cancer that people get," said Dr. Michelle Daffer, a dermatologist at Midlands Clinic in Dakota Dunes.

"Considering that 1 in 5 Americans will develop skin cancer in the course of a lifetime, it's definitely a topic that is relevant to everybody. It almost includes anyone you know."

A person diagnosed with skin cancer will have one of three basic types: basal cell carcinoma, squamous cell carcinoma or malignant melanoma.

Basal cell carcinoma is the most common type of skin cancer. Considered the "good type," it usually doesn't spread to the blood, liver or brain. It usually appears as raised, translucent lumps and develops in 300,000 to 400,000 people each year. Although it does not usually spread to other parts of the body through the blood stream, it can cause considerable damage by direct growth and invasion.

Squamous cell is the second most common type of skin cancer. This type is a little more aggressive and can spread into the blood, liver or brain. Squamous cell carcinoma is usually distinguished by raised reddish growths. This form of cancer develops in 80,000 to 100,000 people and causes about 2,000 deaths each year.

Basal cell and squamous cell carcinomas generally show up on the face, head and neck, Daffer said.

And last, but not least, malignant melanoma is the most serious type of skin cancer. Because malignant melanoma also has a hereditary base, a person has double the risk of developing it if first degree relatives have had melanoma.

Malignant melanoma typically first appears as a light brown to black irregularly shaped blemish.

Most deaths from skin cancer are from malignant melanoma because it spreads rapidly. However, the survival rate for those with early detection is about 99 percent. The survival rate falls to between 15 percent and 65 percent with later detection depending on how far the disease has spread.

"Your chances of survival are based on how deep the melanoma is when it's diagnosed," she said. "When it starts to go inside (spread into other areas of the body), treatment is difficult. Chemotherapy is not very effective, and the cancer continues to spread."

Daffer said the treatment options for skin cancer include curettage, surgical excision, cryosurgery, topical chemotherapy, and Mohs Micrographic Surgery.

Curretage is shaving and scraping away malignant tissue with a sharp instrument. This method is effective for small, superficial cancers that were not treated previously and is often followed by destruction of the cancerous tissue with an electric needle.

"This procedure is often used for older people who can't tolerate more invasive procedures, but there's a higher rate of the cancer reoccurring," she said.

Surgical excision involves cutting into the skin, removing the growth completely so there are no borders left, and closing the skin with stitches.

"You do this technique to get rid of the cancer so it doesn't spread," she said. When excising melanomas, Daffer said she cuts 1-2 centimeters around the margins to get as much of the cancerous tissue as possible.

Cryosurgery is applying liquid nitrogen directly to the skin to freeze cancerous tissue.

Topical chemotherapy is applying chemicals to the skin surface that are capable of destroying precancerous growths. Cryosurgery and chemotherapy are used for only very superficial skin cancers.

Another procedure, Mohs Micrographic Surgery, is excising a tumor and its surrounding skin with the help of a microscope. This method, developed by Frederick Mohs in the 1970s, allows the dermatologic surgeon to trace the outline of a cancerous growth, layer by layer, with exceptional accuracy.

"Mohs surgery has a 99 percent cure rate," said Daffer, the only dermatologist in the Sioux City area who performs the procedure. "For basal cell and squamous cell carcinomas - non-melanoma types, it's the most definite treatment."

Mohs surgery isn't used to treat all skin cancers, she said. It's recommended for skin cancer removal in anatomic areas where maximum preservation of healthy tissue is desirable for cosmetic and functional purposes. In addition, it may be selected for lesions that have recurred following prior treatment, or for lesions that are likely to reoccur.

The procedure takes three to four hours, because the surgeon freezes, cuts and stains the tissue.

"If the tissue is clear of cancer, we can stitch up," she said. "When you leave here, you know it's gone. There's a 1 percent chance it will come back. It has the best cure rate overall."

Daffer noted that all types of skin cancers are caused by cumulative sun exposure.

"The more sun exposure you have, even before age 20, puts you at risk of developing skin cancer. Five or more sunburns double your risk of developing skin cancer. It doesn't matter if you get sun exposure every day or sunburned on the weekends.

"Sun protection is key," she said. "It involves avoiding the sun between 11 a.m. and 3 p.m. when it's at its peak, using sunscreen with an SPF between 15 and 30, wearing protective clothes, hats and glasses, and avoiding tanning beds."
For more information about skin cancer types and treatments, call Dr. Michelle Daffer at Midlands Clinic, (605) 217-5500.

Bad nerves, bad skin go together - Back to Top

Sioux City Journal article, featuring Dr. Michelle Daffer
John Quinlan, Journal staff writer | Posted: Friday, December 29, 2006 12:00 am

Psychodermatology.

The word conjures images of deranged medicine men, killer warts and a scalpel-wielding Corbin Bernsen. No, wait, that was the psycho dentist movie, you might say while blushing. And by blushing, you have a clue to the true meaning of this study of medicine that involves the interaction between the mind and the skin.

That emotional trouble might show up as skin trouble was the basis for an article in the recent issue of Harvard Women's Health Watch. Although cause and effect can be difficult to pin down, considerable data suggest that in some people, psychological factors can activate or worsen certain skin conditions.

Recognizing and treating these psychological issues might help the skin, too, the study reports. And this has led to a field called psychodermatology, its aim being to recognize emotional issues that may affect the way skin problems respond to medical treatment.

The mind/skin connection isn't news to the nation's dermatologists, the front-line doctors who see it on a daily basis, said Dr. Michelle

Daffer, dermatologist with the Midlands Clinic in Dakota Dunes.

Seeing 40 or 50 patients a day as one of the metro area's three dermatologists, Daffer says she finds the problem once or twice each week. It affects about 1 percent of her patients.

There are several factors related to having nervous conditions associated with skin problems, Daffer said. The result is that a number of people see skin lesions on themselves without actually having rashes.

"We see people come in who complain of non-healing areas on their arms, and it's usually because it's all self-induced," she noted.

One of the outlets for some anxious or depressed people is to scratch their skin enough that they get lesions, Daffer said. Due to the constant scratching, the lesions never heal and, in fact, become so thick that they are raised. It is a condition doctors call neurodermatitis, which refers to the joining of the nerves and the skin.

"That's actually been an interesting condition because a lot of times people will come in and say they don't understand why their skin keeps breaking out," she said. "It itches, and the more you scratch at something, the more it itches. So if you actually start scratching that area, it will continue to itch and it will continue to break open -- and they'll never heal."

And the itching brings more problems, with people coming in because they think something seriously wrong is happening under their skin.

"Typically, when you look at these people and you have them take off their shirts, they'll have a line of it across their back, but it'll end because places where they can't reach actually won't have any spots," she said.

Some people, she noted, will break an arm and suddenly one side of their body will clear up because they are unable to reach -- and scratch -- it.

"All of that is kind of self-induced lesions," Daffer said.

In such cases, treatment can involve the use of medications to help control the itch and to help calm down their nerve endings.

Depression and anxiety

"Usually, these people have problems with depression and anxiety. And they have these sensations that their skin is itching and a lot of it is kind of a physical sensation of their emotional state," she said.

Consequently, when horrible things happen in their lives -- deaths in the family, divorces or children going off to college -- suddenly their skin will get worse, the result of scratching; and they'll say they're breaking out with a new rash.

Even such common skin problems as acne can be made worse by constant scratching and picking. It is a condition called acne excoria in which mild acne is made worse by constant scratching -- one or two pimples magnified a hundredfold through scratching. In many cases, facial scars so inflicted will never heal.

"Some people will have something that sets them off, that starts that picking and scratching, like chicken pox. But because of their underlying nervous state of either anxiety or depression, instead of just letting it heal and go away, they pick at them until it never heals," Daffer said.

This forces dermatologists to look at the issues more intensely and ask the patients about their state of mind. And some patients must be started on antidepressants or antipsychotic-type medications, she said.

Unfortunately, at first glance, it is difficult to distinguish the people suffering from emotional problems from those with true skin conditions. Even a biopsy can't always show if the problem is self-induced or caused by underlying inflammatory problems. So first-time visitors are given the benefit of the doubt.

"It often takes several visits to get a feel for their emotional state, too -- and when it gets bad and when it gets better," Daffer said.

"Then when I realize that no medicine gets them better and that when they come in and oftentimes as they get to know you, they're able to tell you more about their emotional state. And usually these people are a little more emotional, too."

Old-time doctors used to tell nervous patients just to go home. After all, it's only nerves. "But nobody wants to be told that there's nothing you can do," Daffer said. "There are ways that you can make it better."

Delusions of parasitosis

Dermatologists also find some patients with a related condition called "delusions of parasitosis," which involves people who actually believe that they have bugs in their skin.

"Usually these people do have some uderlying type of psychotic state," Daffer said. "They are very difficult because they truly feel that things are crawling inside of them. They think their skin is infected with some type of bugs. And they will pick and dig their skin open and try to find things that are in there."

These patients will bring in pieces of hair, fuzz or maybe sock lint that they are convinced is some type of bug that they cut out of their skin. In mosts cases, the evidence is nothing more than scabs.

People suffering from delusions of parasitosis often have to be followed more closely by a psychiatrist and put on higher doses of psychiatric medicines, anti-psychotics, to help them with their delusions.

These people are particularly tough to treat because they don't realize they have any type of depression or anxiety problem, she said, "and if they don't recognize that, then oftentimes treatments aren't very helpful."

Emotionally activated skin problems can affect all age groups and both sexes, Daffer said, but women are more likely to seek help than men. Women come in because their skin breaks out, she said, while men come in for different reasons, a skin cancer, appendicitis or something, and then are asked about their rash by the physician. She said she also tends to see fewer men in their 30s and 40s because, in general, they tend to avoid physicians as long as they can.

Stress triggers cold sores - Back to Top

Sioux City Journal article featuring Dr. Michelle Daffer
Bret Hayworth | Posted: Thursday, December 7, 2006

Kim Deichmann knows that itch, that tingle on her lip means one thing.

The nagging sensation will almost surely result in a cold sore in short time. Deichmann, a Marcus, Iowa, resident, said the "tingling" will be followed by a cold sore near her mouth, most generally on the right side.

By contrast, "my sister usually gets them all over," Deichmann said.

Kevin Jacobs of Akron, Iowa, also knows the feeling, which means he'll quit shaving for several days until the cold sore departs.

There are a few misconceptions about cold sores, says dermatologist Dr. Michelle Daffer of the Midlands Clinic in Dakota Dunes, S.D. It is not true that if you've made it to a certain age without a cold sore, you're free. And they aren't most prevalent during winter.

"People can get them 12 months a year," Daffer said, adding "that there are different triggers" for a cold sore, including stress in life, sunlight and diet.

"A lot of times it deals with stress, so on a wedding day or a big vacation or a big speech, they will say, 'Oh, I just knew I was going to break out,' because they could tell it was coming on," Daffer said.

Regardless of the source, cold sores "can be painful, and they are unsightly and people can have them for weeks at a time," although a week is about average.

They often appear on the face, especially near the mouth, but can be on backs or arms too. Generally, the sores can return often to the same region. They can run from a few millimeters to inches. "They can be anywhere and large," she said.

Daffer, who sees about a patient per day with cold sores, also known as fever blisters, said "some people have cold sores every 10 years, some get them every week."

Cold sores emerge as a result of the herpes virus. Herpes Type 2 is the virus that involves sexually-transmitted herpes, while Herpes Type 1 generally has effects above the waist, thus it is the cold sore virus causer.

"By the time people are in their teens or 20s, about 90 percent of people have been exposed and carry the herpes virus," she said. "Once you get the virus, you always carry the virus. It tends to live in nerve endings."

Cold sores are contagious, since the virus is spread by contact, such as drinking out of a cup or kissing. Daffer said "some people have a genetic tendency" to breaking out with cold sores, "but most of the time the virus is passed between family members and oftentimes from parents to their children."

Some people with the virus break out often with cold sores, while some rarely if ever get one, "so it really kind of comes down to your immune system" and the ability/inability to suppress the virus.

Daffer said "we are working on different vaccines," but at this point, "you can never cure it, you can only control" a cold sore. Control generally comes either through a topical antiviral cream or oral medicine, either over-the-counter or as prescribed by a doctor. A simple Chap Stick is a popular balm for many cold sore sufferers.

"The thing I stress with my patients is to treat them early," since "the medicines work most effectively when they can get the virus before it has really started to replicate and when their immune system is just at the point of trying to suppress it."

As more research goes into how to control the virus, she is hopeful a vaccine will be available for cold sore sufferers.

Daffer posited that once a vaccine for Herpes Type 2 is found, one for Herpes Type 1 will follow. She's optimistic, since "the virus that causes (cold sores) is related to the virus that causes chicken pox, and we found a vaccine for chicken pox."

Look your best, New Midlands Laser Center in Dakota Dunes treats skin conditions, performs hair removal - Back to Top

Siouxland Health article featuring Dr. Michelle Daffer
Jean Hansen - Special Section Editor | Posted: Thursday, April 21, 2005

Laser treatments for unsightly skin blemishes and excess hair are now available at the new Midlands Laser Center in Dakota Dunes.

The laser treatments are administered by Dr. Michelle Daffer and laser technician Jane Olson, R.N., using a state of the art Nd:Yag laser.

Daffer, a board-certified dermatologist with Midlands Clinic, has dedicated a large amount of her time to learning about lasers. She recently completed three years of residency training in Dermatology at Texas Tech University, which focused on skin conditions, and hair and nail disorders, and included comprehensive instruction on the many types of lasers used today. Part of her training involved learning how to perfect the settings and understand the physics behind the laser.

The word "laser" stands for light amplification by stimulated emission of radiation. Lasers emit one wavelength of light, typically in the visible spectrum. They work by one wavelength of light targeting one of three substances in the body known as chromophores. These chromophores include water, brown pigment (melanin/age spots) or red pigment (blood). The laser light is absorbed by the chromophores and heated until it is destroyed.

Daffer said each laser's target determines which conditions it will treat. If water is the target, it can destroy skin cells, the keratinocytes. Doing this will completely resurface the area of skin treated. This type of laser works well for acne scarring and deep wrinkles. It can also be used to destroy the skin that is infected with the wart virus. This laser requires weeks of recovery to allow the skin to heal.

If brown pigment is the target, it can treat lesions that have increased amounts of a person's natural coloration, melanin or foreign coloration, and dark tattoo dyes. Several different wavelengths of light can heat and destroy this brown pigment. These types of lasers can treat brown age spots ("liver spots") and tattoos, and can be used for hair removal. However, one type of laser cannot be used for all three, said Daffer, a fellow of the American Academy of Dermatology.

"Hair removal requires the type of laser to heat slowly, whereas tattoos require a sudden burst of intense light. Age spots improve with either form. The recovery time is quick with these types of lasers, and often only mild discomfort is experienced during the procedure," she said.

If the target is red pigment, it can treat blood vessel growths. Several different wavelengths target red blood cells. These lasers can treat spider veins on the legs, angiomas, red birthmarks and increased blood vessels on the face. The recovery time is very short for these procedures, and patients typically experience a small amount of redness and mild bruising for one to two days, she said.

The Nd:Yag laser used by Midlands Laser Center has a wavelength of 1064 nanometers (nm), and targets both brown and red pigments.

One laser can treat many different conditions by adjusting the settings. Even though the wavelength is essential to getting the target chromophore, how the chromophore is heated is also important, she said.

Daffer and Olson can adjust the size of the treated area with the laser, the strength or intensity with which the laser hits, and the length of time the laser hits an area.

These features allow the laser to act differently depending on what is being treated, she said.

"Again, if the laser is set at low intensity for a longer period of time, it will heat up hair follicles and cause hair loss, but if the same wavelength of light is stored and then fired very intensely and quickly, it will destroy tattoo pigment," she said. "These two examples are on the extreme ends of the changes in intensity and time, and most machines do not have the capability to do both hair removal and tattoos."

The Nd:Yag laser at Midlands Laser Clinic treats age spots, blood vessel growths, red birthmarks, facial blood vessels and spider veins, and removes hair. Their laser also has a feature that stimulates collagen growth to treat fine lines, wrinkles and acne scarring. It does not treat tattoos.

The number of visits required to treat a condition varies. For the majority of patients, it takes one visit for facial veins and at least two visits for leg veins. For patients seeking hair removal, it can take anywhere from five to eight visits. It depends how large the area is and how much hair must be removed, said Daffer, who also treats skin cancers, and performs cosmetic procedures such as Botox and chemical peels.

"With a normal hair cycle, not all hair shows at one time," she said. "The hair cycle has three phases, the growth, resting and falling out phases. By repeating treatments every five to six weeks, it helps get the cycle of growth that was missed last time. It ensures that you get the hair follicle at the right stage to treat it effectively."

Daffer said patients may experience a warm sensation when the laser is used, but any mild discomfort dissipates within a couple of seconds. Any redness usually goes away in a short amount of time as well. Individuals can resume their normal activities after the laser treatments, but Daffer recommends that they use sun protection and apply moisturizer to affected areas.

For more information about the laser treatments available at Midlands Laser Center, call (605) 217-5500. Midlands Laser Center is located inside of Midlands Clinic, 705 Sioux Point Road, in Dakota Dunes. The Laser Center is open 9 a.m. to 2:30 p.m. Monday and Wednesday, and other times by appointment.