Next Generation Cholesterol Drugs: Costly but Effective

Like many cardiac patients, Randy Poitra struggled with high cholesterol. His LDL, or bad cholesterol, was through the roof. While the optimal LDL level is less than 100 mg/dL, Poitra’s was in the 500s.

His doctor, Trinity Health cardiologist Emad Dodin, MD, and nurse practitioner, Amanda Weidler, FNP-C, counseled him on dietary changes. He also prescribed a statin, a class of drugs (think Crestor or Lipitor) that have long been best practice therapy for managing elevated cholesterol.

“We tried statins. I think they work well for most people, but I developed kidney trouble,” Poitra said.

Poitra was among a small percentage of patients for whom statins either don’t work or produce unwelcome side effects.

“Statins are very effective for most patients, but 10 to 15 percent can’t tolerate them because of adverse side effects, most commonly muscle pain,” Dr. Dodin explained. “Another three to four percent don’t respond because of genetic conditions. We’ve needed an alternative for these people.”

Dr. Dodin knew of one. He quickly recognized that Poitra might be a candidate for a new generation of cholesterol-lowering medications called PCSK9 inhibitors. Approved by the FDA in 2015, this new class of drugs lowers LDL or “bad cholesterol” using a different approach than statins.

Whereas statins work by blocking a substance the body needs to make cholesterol. PCSK9 inhibitors lower cholesterol by targeting a protein (PCSK9) that binds itself to LDL cholesterol and prevents the liver from clearing it away, thus causing LDL to build up in the bloodstream. PCSK9 inhibitors produce antibodies that inactivate the PCSK9 protein and allowing the liver to perform its normal LDL-clearing function.

“We were part of the Odyssey trial that put these medicines to the test,” Dr. Dodin said. “The data from these patient trials are ready to be published. It’s going to be exciting once the data is out. More than 30 of my patients are on these medications, and the results have been very promising.”

According to Dr. Dodin, preliminary research shows that PCSK9 inhibitors, used as an add-on therapy to statins, can produce very good results. “Taking the maximum dose of Crestor can lower baseline cholesterol by 60 percent,” Dr. Dodin noted. “A PCSK9 inhibitor can lower it an additional 50 to 60 percent on top of that.”

Some clinical trials have even reported reduced death, heart attack, and stroke rates among patients taking the PCSK9 inhibitor compared to a placebo group.

The two PCSK9 inhibitors currently approved by the FDA are sold as Praluent and Repatha. They’re taken via injection once or twice a month, which hasn’t been an issue for Poitra. “It’s very simple,” he said. “The medication comes in pen form. You press it onto your shoulder, squeeze the top of the pen, and let it go.”

The downside is the cost. While statin drugs are fairly cheap, PCSK9 inhibitors are quite pricey, costing over $14,000 a year. Dr. Dodin and other cardiologists are hopeful the price will eventually come down, but time will tell.

“My nurses are very helpful when it comes to the paperwork and working with the patient’s insurance company. But even with insurance coverage the co-pays can run as high as $100 a month, and a lot of patients aren’t able to manage that,” Dr. Dodin added.

But patients like Poitra who have no other option aren’t necessarily thinking about the cost.

“Twenty-two weeks ago, my cholesterol was very elevated. Now my bad cholesterol is down to 75 to 150, and I haven’t experienced any side effects,” Poitra said. “It’s changed my life quite a lot. I have a lot more energy and feel a lot better. I think Dr. Dodin saved my life.”

For more information about Trinity’s Cardiology Services, contact Emad Dodin, MD, Valentine Chikwendu, MD, or Samir Turk, MD, at 857-7388. Their offices are located at Health Center – Medical Arts, 400 Burdick Expressway East, in Minot.

Early Pre-Activity Checkups

The annual physical – a requirement for schools and extracurricular sports – is more often confused with a quick look over when in fact it is more thorough.

“You think of the typical evaluation where the kids line up and see the doctor for two seconds and go off and have been cleared for sports,” explained Melissa Messerly, MD, a pediatrician with Trinity Health. “When we do it, we do an entire exam.”

Complete physical examinations – or “physicals” – are offered year-round, since children often need them to participate in sports and sports are offered throughout the year.

“A lot of the younger kids need it for the camps, but it’s not generally required until junior high, depending on what sport they are playing,” Messerly said. “I recommend an annual health evaluation for all my patients.”

The purpose of such an examination is to provide a general health evaluation, to manage chronic illness, and to address particular health issues that may arise – “all the things that kids can have over time.”

Dr. Messerly reminds parents to bring required paperwork at the time of the appointment.

“We have the standard North Dakota school forms, but we do not have the specialized forms for the colleges or camps.” she said.

Parents should also bring shot records. “Be prepared to talk about your child’s overall health,” and not just health in relation to a sport, she added. “A big challenge is having a family come in for a full evaluation who hasn’t been to the doctor in many years. There may be many different concerns that need to be addressed and that may require additional appointments,” she said.

“I am strongly in favor of a child and family having an ongoing relationship with a pediatrician and thus having ongoing management of their health concerns on an annual basis.”

Dr. Messerly explained that parents should act quickly in scheduling appointments for these physicals. “Don’t wait until the last minute. The schedule fills up fast,” she said. “It is best to have the appointment scheduled well in advance of the need.”

To schedule an appointment for physicals, call 857-5413 or 857-7380.

Parents should check with their insurance provider about their child’s well-care coverage for physicals.

Greek Marinade and Tzatziki

Greek Marinade

¼ cup olive oil

3 Tbsp fresh lemon juice

1 Tbsp red wine vinegar

3 cloves garlic, minced

2 tsp dried oregano

½ tsp dried basil

½ tsp dried thyme

½ tsp ground coriander

  1. In a bowl, whisk together the above ingredients.
  2. Place desired food to marinade in a gallon size resealable bag.
  3. Pour olive oil mixture over the food.
  4. Close bag. Press marinade into food.
  5. Refrigerate 45 minutes to 2 hours.
  6. Cook food as desired (grill on kebabs, sautee, bake, etc).
  7. Enjoy!

Tzatziki

1 medium cucumber, peeled, seeded, and grated

2 (5.3 oz) containers plain Greek yogurt (about 1 heaping cup)

1 clove garlic, finely minced

1 Tbsp fresh lemon juice

1 Tbsp extra virgin olive oil

1 Tbsp chopped fresh parsley or 1 tsp dried parsley

1 Tbsp chopped fresh dill or 1 tsp dried dill

Salt and pepper as needed to taste

  1. Grate cucumbers into a mixing bowl.
  2. Add the rest of the ingredients into the mixing bowl.
  3. Stir to combine.
  4. Add salt and pepper to taste if desired.
  5. Store in refrigerator in airtight container.
  6. Enjoy!

Cord Blood Awareness Month

The goal of Cord Blood Awareness Month, which is observed this month, is to raise awareness of the medical value of newborn stem cells from umbilical cord blood.

These stem cells have been used successfully for more than 20 years to treat more than 80 diseases, the Parent’s Guide to Cord Blood Foundation states.

What is cord blood?

Cord blood is the blood that remains in the umbilical cord and the placenta after the birth of a baby, the foundation’s website explained. “Up until recently, this afterbirth was discarded as medical waste,” it added. “Cord blood contains stem cells that may be cryopreserved for later use in medical therapies, such as stem cell transplants or clinical trials of new stem cell therapies.”

In addition to the previous option – discarding cord blood – parents nowadays have options as to how the cord blood can be used.

Banking cord blood

Banking cord blood can be beneficial because the cord blood contains stem cells that can save lives, the website said.

“Patients requiring a stem cell transplant can receive stem cells from one of three sources: bone marrow, circulating blood, or cord blood. The first two exist in all healthy adults, but cord blood can only be harvested and stored at birth. It is much easier to match transplant patients with cord blood than with the two sources of adult donors. This is important for patients who come from minority or mixed race backgrounds. Hence, diverse cord blood donations to public banks can save many lives right now.”

Additionally, cord blood could be beneficial if a close family member is in need of blood.

“Transplant patients recover better when they receive stem cells from a related donor, instead of an unrelated donor,” the website said.

“If a first degree relative of your baby needs a stem cell transplant, the baby’s cord blood stem cells could be a suitable match. Plus, there are now emerging therapies in which children use their own cord blood stem cells to help the body repair itself. In the future, children whose parents saved their cord blood will have better access to those treatments.”

There is only one opportunity to bank cord blood, and that is after birth.

“Traditionally, cord blood banking is arranged by the patients,” said Lorrie Antos, RN, BSN,Director of Women’s and Children’s Services at Trinity Health. “Patients are responsible for obtaining the kit and sending it out. We act as a facilitator; however, we do not have kits. If any patient has a question about this we do offer informational pamphlets in the OB/GYN and Midwifery offices. Please contact your provider if you have additional questions.”

Donation

While banking cord blood can be done for private reasons, parents can also opt to donate cord blood for the public good. (The closest hospital that serves as a cord blood donation location is in Chicago, Illinois.) Public cord blood banks accept cord blood donations for free. However, most require the mother to register by the 34th week of pregnancy, as well as pass medical eligibility guidelines.

For more information on cord blood, visit: http://parentsguidecordblood.org/.

Beware of Ticks

It’s beginning to be that time of year again.

The sun is out. The weather is nice. It’s only natural that everyone leave their homes, where they were sheltered during the cold winter months, to enjoy the great outdoors. As barbecues get turned on and long pants are traded for shorts, there is one thing to keep in mind this season: ticks.

Casmiar Nwaigwe, MD, an infectious disease provider with Trinity Health, warns that Lyme disease is a tick-borne illness. It can happen in the spring and summer months, and even sometimes in the autumn. Even in the winter, if temperatures are above freezing, Dr. Nwaigwe said.

Lyme disease is transmitted by certain kinds of ticks, such as a black-legged tick (also known as a deer tick). There is an endemic in parts of the United States, such as northeastern United States and the upper Midwest, including North Dakota.

“It tends to bite during the spring and summer – sometimes the fall,” he said.

There are particular environments where ticks can be found, such as in low lying brush or bushes, or wooded areas with pale vegetation. If a lawn is not well-mowed, ticks can also be found in grass. They attach to the tip of vegetation, waiting to find a place to bite and feed – this can include humans and animals. Engaging in activities, such as hiking or hunting, would further increase the chances of bringing a person into contact with them.

Ticks attach themselves to the skin and begin to feed; disease can be transmitted usually 24 to 48 hours after first contact. As some ticks “are small and can be mistaken for a freckle,” you may not even notice thetick, Dr. Nwaigwe explained. The bite is often painless, unlike a mosquito bite which you feel right away. “You may not feel the tick bite.”

“As it engorges and fills with blood,” the tick becomes more noticeable, he said.

Dr. Nwaigwe warns that if you find a tick that has attached itself, it is important to remove it gently, instead of yanking it out.

“Wash your hands and the site of tick attachment with soap and water after removing the tick,” he said. “If you start feeling ill, consult a doctor. In the case of Lyme disease, you may not feel symptoms until one to three weeks after the contact with the tick. It’s also a good idea to save the tick in a plastic bag to help establish a diagnosis.”

Aside from finding the tick, the most recognizable symptom of a tick bite is a painless and itch-less rash around the site of the bite, stated Dr. Nwaigwe. Depending on the part of the body where the tick bit, you may not see the rash, especially as it is painless and it doesn’t itch. The infection then spreads to other parts of the body, which can lead to neurological symptoms, such as head and neck pain, joint pain, and memory problems.

Post-Lyme disease can include chronic fatigue, lupus, rheumatoid arthritis and depression, according to Dr. Nwaigwe.

The Centers for Disease Control and Prevention (CDC) stated that approximately 30,000 cases of Lyme disease are reported to them annually.

Statistics from the CDC show that between 2005 and 2014, there were 107 cases of Lyme disease in the state of North Dakota. A map, showing reported cases of Lyme disease in the United States in 2015 shows the area of New England and the Upper Midwest – mainly Minnesota, Wisconsin and northern Illinois – as a hotbed of activity.

Dr. Nwaigwe said he usually sees anywhere from two to five patients with Lyme disease each year. “That’s not a lot,” he said. “Lyme disease is not very common in North Dakota, fortunately.”

Lyme disease is curable, especially at early stages. “You can have it for a number of years before you know what it is,” he said. “You can live with it.”

Nwaigwe said that once a patient develops the bulls-eye rash, they can be treated with doxycycline, an antibiotic used in the treatment of a number of types of infections, early Lyme disease included.

However, if a patient cannot tolerate doxycycline, or if they are pregnant or a child under the age of eight, they would be treated with amoxicillin, he added.

“It should get rid of the symptoms,” Nwaigwe said. “Even if you don’t have symptoms, it should get rid of the bacteria preventing late complications.”

Nwaigwe stressed that the moment a person thinks they have Lyme disease, they should seek treatment.

“The earlier the treatment, the better the outcome,” he said. “If you wait longer, there may be more complications and the treatment may be longer.”

Casmiar Nwaigwe, MD, Infectious Disease, has his office at Health Center – Medical Arts, 400 Burdick Expressway East, Minot. A referral from a physician is needed for appointments.

 

Eagle Awards

Nora Rasmussen, FNP-C, a Family Medicine provider at Trinity Health South Ridge, and her nurse, Carmen Wheeling, LPN, were nominated to receive the Minot Area Chamber of Commerce’s Eagle Award for Excellent Customer Service.

Rasmussen “went above and beyond to help her patient resolve an insurance issue,” the nomination letter read. “Thank you, Nora, for taking personal care of your patients and not treating them as another number. You’re the best.”

Wheeling, the nomination letter said, also helped a patient resolve a problem with an insurance issue. She “gives top notch personal care and is a very caring person. Hats off to a great work team! Thanks, Nora and Carmen.”

The nominations came from the same person.

Receiving the Eagle Award is validation of the pursuit of the mission of Trinity Health, which values exceeding professional quality standards.

Trinity Health Earns Award for Cardiac Care

Trinity Health has been recognized by the American Heart Association for exceptional performance in caring for people with STEMI heart attacks – the kind caused by a sudden blockage of a coronary artery.

Trinity earned the “Mission: Lifeline® Silver Receiving Quality Achievement Award” for consistently carrying out practices that are most effective when it comes to quickly identifying STEMI heart attacks and streamlining processes to promote rapid treatment.

“We commend Trinity Health for this achievement award, which reflects a significant institutional commitment to the highest quality of care for their heart attack patients,” said James G. Jollis, MD, Chair of the Mission: Lifeline Advisory Working Group. “Achieving this award means the hospital has met specific reporting and achievement measures for the treatment of their patients who suffer heart attacks and we applaud them for their commitment to quality and timely care.”

The American Heart Association’s Mission: Lifeline program’s goal is to reduce system barriers to prompt treatment for heart attacks, beginning with the 9-1-1 call and continuing through hospital treatment. Trinity Health earned the silver award by meeting specific criteria over a designated period of time, including administering therapeutic drugs at critical junctures during a patient’s care and shortening “door-to-balloon” times – the interval between the patient arriving at the hospital and the moment the artery is reopened through coronary intervention via balloon angioplasty.

Each year in the U.S., approximately 250,000 people have a STEMI, or ST-segment elevation myocardial infarction, caused by a complete blockage of blood flow to the heart, according to the AHA. To prevent death, it’s critical to immediately restore blood flow, either by opening the blocked vessel with interventional cardiology or by giving clot-busting medication.

“We’re pleased to be recognized for our achievements in cardiac care,” said Jeffrey Sather, MD, medical director of Trinity’s Emergency/Trauma Center and Chief of the Department of Medicine. “We were the first region in the state to create a STEMI network. I’m very proud, not only of our team here at Trinity, but of our EMS partners all across the region. Together we’ve been able to save lives.”

Baby’s First Test

Who would have guessed that five drops of blood contain enough information to save a baby’s life?

Newborn screening- previously known as a metabolic screen or PKU test- is performed shortly after birth and can help look for a number of devastating diseases, explains Melissa Messerly, MD, a pediatrician with Trinity Health.

“We’re testing for minimally symptomatic diseases that are treatable,” Messerly says. Diseases include cystic fibrosis, amino acid disorders, hypothyroidism and more.

Babies with disorders identified through newborn screening may seem healthy at birth, and you many not be able to tell they have a disorder just by looking at them, explains Joyal Meyer, RN, MSN, director of the North Dakota Newborn Screening Program. But testing early is important because by the time symptoms appear, irreversible damage may have already occurred.

“The illnesses we are screening for are uncommon, but most of them are very serious, often resulting in seizures, intellectual disabilities or death,” says Michael Holland, MD, a pediatrician with Trinity Health.

The screening looks for about 50 diseases, which, if caught early, can be treatable.

“So we’re not screening for things we can’t do anything about,” Holland adds. “We’re screening for illnesses we can fix.”

The screening is performed 24 to 48 hours after birth and is done by collecting blood from the child’s heel- often referred to as a heel stick. The drops of blood are put on a card with five circles, each smaller than the size of a dime. After the card has dried for three hours, it goes by courier to the State Hygienic Laboratory in Iowa. At the lab, different machines are used to detect different analytes- substances whose chemical constituents are being identified and measured. Depending on gestation period, weight and time the blood is collected, the machines look for particular principles.

“Any abnormal screening is followed up by the lab, who notifies the short-term follow-up nurse, based out of Iowa,” Meyer says. “The nurse calls the baby’s primary care physician in North Dakota with follow-up recommendations or for further testing to confirm whether or not the baby has a disorder.”

Time is of the essence for the screening- so much so that if the specimen is sent to the lab in Iowa within 24 hours after collection, the physicians can be notified of a possible time-critical disorder by the time the baby is three or four days old. Parents are notified by the doctor’s office to bring their baby in for further testing right away.

“We want babies identified early so that treatment can begin immediately to avoid any long-term consequences,” Meyer says. “If babies are not identified early, the disorders can cause brain damage, coma or even death.”

One disorder screened for is medium-chain acyl-CoA dehydrogenase deficiency (MCAD), an illness that causes blood sugar to get too low if the child doesn’t eat often enough. “Frequent feedings prevent the problem, and IV fluids can be given if the child can’t eat due to an illness,” Holland says. “But if the family and physician are not aware of the illness, the first symptoms would be when the child is having seizures due to low blood sugar levels.”

According to Meyer, it’s more common to have a normal results. “The disorders we are screening for are very rare,” she says.

In 2015, there were 12, 842 births in North Dakota. Of the newborns tested, 142 disorders were detected through screening.

When a child is born at Trinity Hospital, parents get an information form that explains the screening process. Rarely, a parent will decline to have the test done, but this is usually because of the misconceptions about the testing, the use of the blood sample or insurance concerns,” Holland says.

The testing is safe, and the blood is not used for anything else. The blood specimen is stored securely until the child is 18 years old, and then it’s destroyed, he adds. “If the family has concerns about the retention of the blood specimen, they can request their baby’s specimen be returned to them and destruction would be their responsibility. The information obtained is only shared with the family and the medical care provider.”

“The risks for not doing the test are immense,” Holland says. “It would be unfortunate if the child had an easily correctable problem that was unrecognizable until the child was permanently damaged.”

To learn more about the disorders tested for during a newborn screening, visit the State Hygienic Laboratory’s website at shl.uiowa.edu/screening/newborn/index.xml

 

 

Sick Beyond Their Years

Heart disease used to be a problem almost exclusively for adults. But according to the Texas Heart Institute, risk factors for heart disease- like high blood pressure, high cholesterol and diabetes- have been showing up more frequently in children.

The cause? Childhood obesity, which Diana Peterson, MD, a pediatrician with Trinity Health, says is a huge problem. And she has good reason. According to the Centers for Disease Control and Prevention, one in three children in the United States is considered overweight or obese.

Peterson says when she was training from 1989 to 1992, childhood obesity was never discussed.

“We didn’t even talk about it, because we didn’t see it much, ” Peterson says. Now, especially over the past five to 10 years, it is an issue at the forefront of pediatrics.

“I’m seeing children with type 2 diabetes, hypertension, lipid problems, sleep apnea- all because of obesity, and it’s just sad,” Peterson says. “They’re like little adults.”

In addition to the physical impacts to a child’s health, mental health can also be affected. With the stigma of being overweight, children may be more likely to be bullied, Peterson points out. “It’s a nasty problem.”

Being Overweight vs. Being Obese

What is the difference between being overweight and being obese?

The CDC defines being overweight as having a body mass index (BMI) at or above the 85th percentile and below the 95th percentile for children and teens of the same age and sex.  Obesity is defined as having a BMI at or above the 95th percentile.

Though BMI tables start at age two, obesity can begin ever earlier, Peterson says. “I don’t usually start talking to parents about it until children are around two, but if there are children who are really high risk, I’ll talk about it sooner,” she says.

According to an online report, The State of Obesity: Better Policies for a Healthier America, in 2015, North Dakota was ranked as having the 17th highest adult obesity rate in the nation- 31 percent of adults were obese, up from 11.6 percent in 1990.

The report also showed that in 2011, North Dakota had a childhood obesity rate of 13.1 percent for children between the ages of two and four, and 15. 4 percent for children between the ages of 10 and 17.

Despite the potentially severe impacts, Peterson says that parents sometimes don’t’ see childhood obesity as a health problem and may think it’s something their children will outgrow.

Childhood obesity isn’t a phase, though.

“Statistics are showing that they aren’t growing out of it,” Peterson says.

According to the CDC, children and adolescents who are obese are likely to be obese as adults “and are therefore more at risk for adult health problems, such as heart disease, type 2 diabetes, stroke, several types of cancer and osteoarthritis.”

How to Fight It?

In Peterson’s opinion, lifestyle choices- such as how people exercise and eat- have contributed to childhood obesity rates.

“Kids don’t go outside and play anymore. Nobody walks to school anymore,” she says. “A lot of extra calories and not doing a lot seems to be the problem.”

Peterson says she encourages parents to get rid of junk food and to follow the 5-2-1-0 rule:

5- Five or more servings of fruits or vegetables a day

2- Limit screen time to two hours a day (for preschoolers, this should be one hour)

1- One hour of physical activity every day

0- Zero sugar-sweetened beverages

No sugar-sweetened beverages includes juice, Peterson says.

“Parents think juice is OK and give kids lots of it,” she says. “We’re pushing for milk or water only; juice, pop and Kool-Aid should all be treats and very limited.”

Michelle Fundingsland, RD, LRD, a clinical dietitian with Trinity Health, offers similar tips for combating obesity.

“Start with diet modifications, eating more nutrient-rich foods- such as fruits, vegetables, whole grains, low-fat dairy products, lean meat, poultry and fish- and limit foods that are less nutritious,” Fundingsland says. “We also need to move more and be less sedentary.”

Jazzing up fruits and vegetables by making them bite-sized can help get  kids to eat them, she says. “They can eat them with their fingers or they’re easier to eat with silverware. A big chunk of broccoli might be a little overwhelming.”

Fundingsland admits that getting more physical activity is easier in North Dakota’s warmer months.

“We have a problem because we tend to shut down for wintertime and say, ‘I’m going to wait until the spring.’ We can’t do that,” Fundingsland says. Though there are days when it’s just too cold to be outside and people cant help being cooped up, she says “we have to be more creative with findings things around the house to keep us active. Make it fun; make it a game.”

And now that warmer weather is here, “We can go outside and go walking,” she says.

 

 

Skin Safety for Summer

Summer weather is here and with that comes warm temperatures.

As one in five Americans will develop skin cancer over the course of their lifetime, it is important to follow safety measures to ensure you don’t become a statistic.

Jennifer Hunter, MD, a dermatologist with Trinity Health, has these tips to help you beat the heat and save your skin:

• Apply sunscreen at least 30 minutes prior to needing it.

• Reapply sunscreen, regardless of the SPF, every two hours if outside or in a vehicle or sitting inside by a window. (UVA penetrates window glass.)

• The goal of sunscreen is to prevent sun damage and thus any form of tan or sunburn. When your skin tans, it is actually trying to prevent MORE sun damage from occurring.

• Use an SPF of at least #30 or higher (higher SPFs of #45-100 are favored).

• It is important not to allow sunscreen to become too hot – such as from sitting in a hot vehicle – or too cold, since that may make sunscreen become less effective.

• Sunscreen works as well as one applies and reapplies the preparation. This includes timing, the amount applied, areas of the body to which it is applied, and the SPF#.

• It is important to apply an SPF#30 or higher to lips and to wear sunglasses. “All sunscreen that is applied should be a dedicated or ‘full fledge’ sunscreen, and not a moisturizer with a sunscreen in it or makeup with sunscreen,” Hunter warned.

• All sunscreens expire. “Do not purchase a sunscreen or lip balm with sunscreen if an expiration date is not listed,” Hunter said. “Also, be sure to honor the expiration date listed on the sunscreen.”

The Skin Cancer Foundation also has these recommendations:

• Add a broad brimmed hat and UV-blocking sunglasses to your wardrobe so you can cover up out in the sunshine.

• Keep newborns out of the sun and use sunscreen on all your kids, from tots to teens.

• Avoid the sun between 10 a.m. and 4 p.m. Seek shade during this time.

• Remember: No matter your skin tone, everyone has the potential to get a sunburn, which can increase your cancer risk.

Trinity Health’s dermatology department includes Jennifer Hunter, MD, who can be reached at 857-5760. Her office is located at Trinity Health South Ridge, Suite 1028, 1500 24th Avenue SW, in Minot. Ann Welch, FNP-C, can be reached at 857-7382. Her office is located at Health Center- Medical Arts, 400 Burdick Expressway East, Minot.