|Vol 4, Issue 1||www.ElCaminoWomen.com||January 22, 2019|
All of us at El Camino Women’s Medical Group are excited to welcome in the New Year!
We’ve already had the first federal holiday of the year, I hope everyone took advantage of Martin Luther King Jr. Day, to reflect on the power of one individual to inspire so much good in his community and nation. How a deep commitment to the humanity of all people can lead a person and those he inspires to benefit so many others. May his life inspire all of us to do what good we can to address the social, political and economic disadvantages of our time.
The most exciting thing on our list: moving into our new office. Expected to be open in July of 2019, we’ll be happy to move in by fall. Having been at our current location for almost 5 years, we have completely outgrown it and are desperately in need of space. One of the exciting additions is a space for classes. We currently offer a breastfeeding class in our Mountain View office and are considering adding nutrition classes when we move into our new space. If you have ideas for classes you’d like offered, please let us know at firstname.lastname@example.org or here.
For the first newsletter of the year, Dr. Katrina Chaung has contributed an article for Thyroid Awareness Month. There’re also articles on where to start to lose weight in a lasting way as well as what to do for smoother skin. Hoping we are all healthier, happier and more beautiful in 2019!
As always, feedback is always welcome on our practice, customer service, and even this newsletter!
In this issue:
We are excited to have added Zainab Hosseini, Ed.M. ASW to our practice. Under the supervision of Dr. Awaad, Zainab will be providing therapy as a Licensed Associate Social Worker to our patients with mental health needs. With a very long list of patients waiting to see Dr. Awaad, we’re hoping that Zainab will be able to improve access to mental health services for the appropriate patients. She brings several years of experience in providing mental health counseling and therapy to our team and started seeing patients in our San Jose office in November of 2018. Her services are in network for the insurances we currently accept under Dr. Awaad’s contract as her supervising physician. To request an appointment, please call the office or email email@example.com.
Our future home in the IMOB has made a lot of progress. A parking garage has finally shown up!If you’re interested in seeing the progress, you can see pictures here. We’re currently in our third home since we opened in July of 2009 and looking forward to settling down in our fourth (and hopefully final) home next summer.
JANUARY IS THYROID AWARENESS MONTH!
The thyroid gland is a butterfly-shaped gland that sits in front of the trachea, or windpipe. This gland secretes a hormone called Thyroid Hormone that affects virtually every organ in your body from your brain to your heart to your skin.
In general, there are two categories of problems that can arise with your thyroid gland:
- The thyroid can make too much (HYPERthyroidism) or too little (HYPOthyroidism) hormone
- The thyroid gland can grow in size (also called a goiter) or develop “lumps and bumps” (called thyroid nodules).
Thyroid issues usually affect women more often than men.
HYPOthyroidism occurs when the thyroid gland makes too LITTLE hormone to meet the body’s needs. Women are at least eight times more likely than men to suffer from this, and the risk increases with age, particularly in people over 60 years old. Hypothyroidism can cause symptoms ranging from fatigue, hair loss, weight gain, cold intolerance, and constipation.
Less commonly, the thyroid can make too MUCH hormone causing HYPERthyroidism. Symptoms can include unintentional weight loss, rapid heartbeat, increased heat sensitivity, and tremors. This also affects females more often than males.
Thyroid nodules are lumps that grow in the thyroid gland. They are three times more common in women than men. The frequency of nodules also increases with age: 50% of 50-year old women have at least one nodule, and 70% of 70-year old women have at least one nodule.
While some nodules can be seen or felt with your fingers on the neck, many are not noticed until they are found on a test like a CT scan that is performed for a completely different reason.
If thyroid nodules grow in certain locations or grow large enough, they can cause symptoms such as pressure in the neck, a strangling sensation, difficulty swallowing and, in extreme cases, difficulty breathing.
Fortunately, over 95% of thyroid nodules are benign.
When a thyroid nodule is suspected or found, an ultrasound is usually the first test ordered. This can help define the size, number, and characteristics of the nodule or nodules.
If a nodule grows to a certain size or has certain characteristics, further testing like a special biopsy called a fine needle aspiration (FNA) may be recommended to ensure that it is not a thyroid cancer. Depending on the results, sometimes nodules only need to be monitored while sometimes thyroid surgery is recommended. Other factors such as family history of thyroid disease or history of radiation exposure may also influence what tests are ordered.
If you are having symptoms of thyroid disease or nodules, you may need to see your primary care doctor or an Ear, Nose & Throat physician.
Katrina Chaung, M.D.
Board certified, Otolaryngology-Head and Neck Surgery (Ear, Nose, & Throat)
2204 Grant Road, Suite 102
Mountain View, CA 94040
TOXIC EXPOSURE IN PREGNANCY
When most people think about toxins or toxic substances the image in our minds is some bottle of chemicals with bright orange labels or skull and crossbones. This image does us a disservice because toxins can be in the air, in our food, in our things, and can feasibly be anywhere. Recent studies have shown strong correlations between toxins and worse health in us, our children, and long-term health outcomes. This is especially true for women in preconception stages, pregnant women, and postpartum women because your baby can be affected as well, sometimes even more significantly due to all the cell division and changes occurring during fetal development. For example, methylmercury, a toxic chemical that can be found in high levels in seafood, can accumulate in the body while you are pregnant and can have a direct impact on brain function.
These toxins can be in foods, water, containers, cosmetics, your house, the air, etc.
Many pesticides found on the food we eat have been shown to lead to impaired fetal growth and neurodevelopment and increases the risk of cancer in childhood. In adult men it has been linked to prostate cancer, sterility, and altered semen quality. For women some pesticides can interfere with reproductive function at all levels, from puberty to menstruation and fertility to menopause.
Besides pesticides, there are several other toxic substances we should be aware of. Some plastic containers and cosmetics can have phthalates, chemicals that can interfere with our endocrine system, and may increase the risk of premature birth and impaired neurodevelopment in babies. For example BPA (or bisphenol-A) is a phthalate you may have heard of in plastics that has been shown to be harmful and is comparable at the cell and developmental level to diethylstilbestrol (DES). This was a drug prescribed from 1938-1971 which was connected to clear cell adenocarcinoma (CCA), a rare vaginal cancer.
Older pipes in homes can have higher levels of lead which could lead to lead poisoning.
Air pollution; which can include second-hand smoke, exhaust from vehicles, smoke from wildfires, gases, and small particles; has been linked to altered gene expression which influenced neurodevelopment.
What to do?
Now before you all rush out to buy giant BPA-free plastic bubbles to live in, there are less extreme and very successful ways to reduce toxic exposure in your day to day life. The issues arise from great exposure and significant levels of any of these chemicals accumulating in the body. Experts suggest several different things to help reduce toxic exposure. While not everyone has the ability to implement them all, being conscious of your decisions can really make an impact.
- Wash hands frequently and always before meals. Not only will this reduce germs but also toxic chemical residues that can accumulate from the things we touch daily.
- Dust and wet mop regularly. Dust can be filled with all sorts of toxic particulates.
- Avoid heating and cooking food in plastic. To avoid the phthalates use safer containers like glass to heat up your food. Try to reduce contact with plastic and your food in general. As an example: have reusable safe ceramic or glass at work to heat up your food, then wash and leave at work if it is too difficult to buy all new containers.
- Remove shoes before entering the house. Many cultures already do this, and it is a great way to keep all the toxins you may have walked in out of most of your home.
- Look for organic foods to buy or reduce the levels of pesticides. Some known to contain high levels (and therefore better to buy organic) are strawberries, spinach, nectarines, apples, grapes, peaches, cherries, pears, tomatoes, celery, potatoes, sweet bell peppers, and hot peppers. Some that are fine to buy non-organic are avocados, sweet corn, pineapples, cabbages, onions, frozen sweet peas, papayas, asparagus, mangoes, eggplants, honeydew melons, kiwis, cantaloupes, cauliflower, and broccoli. It may be difficult to afford all-organic-everything but striving to avoid the non-organic “dirty dozen” mentioned above can prevent a more substantial portion of pesticides than you may realize.
- When it comes to seafood AVOID shark, swordfish, king mackerel, and tilefish. These can have higher levels of methylmercury and are teratogenic which means they can harm a fetus.
- Better fish options are shrimp, canned light tuna, salmon, pollock, catfish, wild fresh and canned salmon, sardines, Atlantic mackerel, and trout.
- Avoid chemical “non-stick” cookware. Many new chemicals that make “non-stick” wares are unknown on whether they are harmful or not so it is best to avoid.
- Avoid fragrances and “unscented” cosmetics and cleaning products. Many fragrances have phthalates in them and “unscented” may still have chemicals to mask odors, so only “fragrance-free” is phthalate free. An occasional perfume spritz for a special occasion or infrequent cleanings with heavier chemicals isn’t going to make as much difference as everyday fragrances and cleaners.
- Avoid exercising outside during rush hour when more cars are about and therefore more exhaust is in the air. Also, avoid outdoor exercise on days with more air pollution like “save the air” days or during wildfires.
- Avoid fast food and processed foods whenever possible.
- Avoid home renovations without proper gear, especially in older homes.
- In older homes, run tap water for 60 seconds to avoid sediment and sitting water that may have higher levels of lead.
- Avoid using pottery or ceramics that may have lead.
- Make sure any wood burning stoves, space heaters, or fireplaces are well ventilated.
There may be no way to completely eliminate toxic exposure in your life but there are ways to decrease contact with these toxins. For instance, just living and breathing the air in big cities like Beijing, New York, and San Francisco can expose you to toxins. A survey from 2003-2004 found that virtually every pregnant woman was exposed to at least 43 different chemicals in the USA. These chemicals can cross the placenta and harm not only you but your baby in the short-term and long-term. Although some toxic exposure is unavoidable, being conscious of and trying to avoid toxins can really make a difference. Talk to your doctor to learn more or use the links below:
DERMATOLOGIST-RECOMMENDED TIPS FOR SMOOTHER SKIN
By Dr. Lillian Soohoo
The Menkes Clinic, Mountain View
1. What are the major causes of rough skin?
Dry skin can be a result of environmental factors such low humidity in certain climates as well as prolonged exposure to substances that we apply to our skin that contain drying ingredients like benzoyl peroxide and alcohol. There are also many common genetic dry skin conditions such as eczema, ichthyosis, keratosis pilaris and psoriasis which result in rough skin for individuals who suffer from these diseases.
2. What nutrients/components does it lack that causes it to become rough?
The uppermost layer of the skin is called the stratum corneum which contains dead skin cells embedded in a waxy matrix of ceramides, cholesterol and fatty acids. These essential substances are all types of fats (also known as lipids) that help keep the skin moist and an effective barrier. Creams which contain ceramides and ointments such as petrolatum are often very effective in moisturizing the skin and reducing roughness.
3. Who’s more susceptible to rough skin?
People with sensitive skin such as eczema, and those who live in dry climates with low humidity. Also, those who use foaming cleansers, bubble baths, bar soaps in addition to prolonged water submersion. These skin products all strip fats (lipids) from the skin, causing it to feel dry and rough.
4. How does food affect our skin?
A healthy well-balanced diet with appropriate daily nutritional allowances is best for overall skin health maintenance.
5. What are the key nutrients that affect skin smoothness/roughness?
Key nutrients for skin health are those necessary for overall body maintenance and when part of a normal diet, do not necessarily require additional supplementation to achieve noticeable benefit. These include essential fatty acids (omega-3 fatty acids found in salmon and tuna), vitamin C (fruits and vegetables), zinc and selenium (nuts).
. How does sleep affect skin quality? How do sweating and exercise affect skin smoothness?
Healthy lifestyle habits such as sufficient nightly sleep and regular exercise boost skin health as well overall health and well-being.
7. How essential is cleansing and exfoliation in achieving a better complexion and smoothness? Aside from facial skin, what’s the best way to exfoliate lips, hands, elbows, and the rest of the body?
Cleansing and mild exfoliation can give skin a smoother more radiant appearance by removing dead skin cells at the surface and allowing light to reflect from the skin. Consult a dermatologist to determine the most appropriate products to achieve gentle, non-irritating cleansing and exfoliation to achieve best results.
8. What are the best in-office procedures if you want a deeper kind of exfoliation?
Laser resurfacing, chemical peels, and microdermabrasion are all effective procedures available to smooth rough and photo-damaged skin. Superficial (non-ablative) lasers are also effective–including the Fraxel and Clear and Brilliant devices. All of these will help to smooth rough skin with minimal downtime.
9. How do lotions and creams work to smooth out skin? How do we use them for best results?
By themselves, lotions and creams are merely oily products that when applied to the skin can plump some of the dead skin cells and provide a smoother-feeling texture by adding an oily layer to the skin’s surface. This is a temporary effect and is made much more effective by adding active ingredients to the lotion or cream. Think of the lotion or cream as “the base” or vehicle for a more effective exfoliating ingredient such as a retinoid, growth factor, vitamin C or alpha/beta hydroxy acid.
10. What are the key ingredients to look for?
There are several ingredients that work well to smooth and soften dry skin. Your skin type and your skin’s sensitivity will help to determine the best moisturizer for you. It is important to know whether you will also be treating other skin conditions such as acne, brown spots and eczema before trying anything new since choosing the wrong moisturizer can make your skin worse. A dermatologist can help you wade through all the different choices and products to find the most effective moisturizer for your skin. Common mild ingredients include Hyaluronic acid, glycerin and ceramides.
11. How does hydrating from within affect skin quality? How much water or fruits do we have to include in our diet for best results?
Hydrating skin from within is not necessarily as beneficial as you think. Since our skin is a lipid (fat) based organ, drinking lots of water although helping to keep the body well/hydrate doesn’t add more oil (moisture) the skin. Drinking water instead of non-nutrient fluids (alcohol, sugary drinks) is better for overall health which may in turn, give skin a more radiant appearance.
At The Menkes Clinic, together with my colleagues Dr. Andrew Menkes and Dr. Krystle Wang, we strive to answer questions clearly and to provide the latest, scientifically proven treatments for our patients.
MAKING WEIGHT LOSS LAST IN THE NEW YEAR
It’s not surprising given that a third of Americans are overweight and another third are obese. As physicians, helping people achieve their best health often includes a discussion on food choices and exercise. From a perspective of general well-being, feeling good about one’s self and having energy to engage in the activities a patient wants to, diet and exercise are the most important first step. Most of the medical illnesses that Americans deal with are also much improved (and some cured) with changes in diet and exercise. Weight also affects a person’s risk of at least 13 cancers, including the more common breast and colon cancers.
But what to do? The problem is that most people know this. Most people know, generally, what’s healthy and what’s not, so what’s the problem?
In the next few months, we’ll be putting out a series of blog articles on weight loss. There won’t be detailed calorie counting or required meals. But we’ll cover some of the general ideas people need to learn to sustainably lose weight and keep it off in the long run.
Recognize it’s important
Accepting that this issue is important is critical. It’s essential for feeling more energetic, for feeling healthier, and most importantly for brain space. Think about it, how much of your daily thinking is about your food, your weight and your activity levels? Or about problems you deal with that you know would be so much better if only you were xx lb lighter
Just as a final exam is important or planning a birthday party or working towards a promotion or deciding to buy a new home, losing weight may be the most important life change you need to make right now. Putting it in context as to how you deal with other life decisions helps to understand what it’s going to take from you to change your thinking and action around food. If you can change your thinking about food, the weight will come off. But this is going to take some work.
Recognize that the problem is not you, it’s the system
If your child came home with a C in math class, you recognize that your child needs some help, you talk with them about study habits, make sure they’re doing their homework, maybe get them a tutor. If you find out that 1/3 of the class got a C and 1/3 a D, then you call the school to complain about a teacher.
If a staff member comes in an hour late one day, she need to explain herself. If every staff member comes in an hour late, our first thought goes to “what’s going on out there”. It’s probably traffic or a construction or something else. And usually all our patients and even physicians are late too!
The culture around talking about weight issues in America focuses on personal failings. People need to just stop eating so much. People need to just stop being so lazy. People need to just stop the fast food. As you start your journey, you need to recognize that while it’s true that diet is the key to weight loss, the system is designed to make you fail. Two-thirds of Americans are overweight or obese. How can that be solely due to “personal failings”?
If you realize you are working against the system to get to your goal, you’ll be more realistic about how hard this is going to be. You’ll also realize that you can’t expect help from most places. “Healthy” restaurants, “healthy” snacks, “good, supportive” friends, even many popular diets and nutritionists may not be able to help you. You really have to accept that this change has to come from within, from how you think about food so that you are a thoughtful, mindful eater at all times, even when every part of our culture and system around food seem designed to make you gain weight.
Make a commitment, a real commitment
Nearly everyone who’s tried to lose weight before knows that it’s hard. People can be top of their class, get promotions at work, be a most beloved family member that always shows up for others, and always accomplish what they put their mind to, until they try to lose weight.
Anyone who’s taken a major test understands you need to make sacrifices in the time leading up to the exam. Maybe skipping out on social events, dedicating evenings to study or avoiding certain stressful situations so they don’t throw you off track. Anyone who’s planned a big event, knows there’s a LOT of time dedicated in the months and especially weeks leading up to the big night. It’s called “preparing”.
If you want to make a lasting change in your life, working against the way you’ve eaten for the last few years and often last few decades, working against a food culture that wants you to just eat more, and to achieve something you’ve likely tried and failed at before, you need to make a commitment.
Honestly, for at least the first 2-3 months, you have to be prepared to give 1-2 hours a day to this project. You have to read about what is going on in your body, what are the different types of diets out there that you might find sustainable, what kinds of foods are better or worse for you, and you’re going to have to learn how to grocery shop and cook.
On a daily basis, at the beginning, you’re going to have to make sure you have support. If you can afford a weight loss coach, great. But for the rest of us, listening to a daily podcast can be life-changing. It’s 20-90 min a day of listening to motivating, helpful information on why this is important, confirming it’s hard, and pushing you to stick with it. After a while you’ll notice, the days you skip a podcast, you tend to eat less healthy. Having ongoing, daily support is a big deal.
This also means, at least at the beginning, that you need to avoid situations you just know will derail you. If you had an exam coming up and your friends were going out a few nights before and you just KNOW you’ll be out late with them and throw off your study schedule, most people would take a rain check. As you start your journey to lasting weight loss, if you’ve got a choice to join friends or attend an event where you just KNOW you’re going to throw off your healthier eating choices, just don’t go.
And like exams, events and house hunting, the sacrifices aren’t forever. You work hard to get a finite goal, then you go back to your routine. So, when 1-2 hours of thinking of, learning about and listening to food and diet information gets tedious, remember, it’s not forever. It’s just for the first 2-3 months. And after that, if you’ve successfully changed your thinking, you’ll no longer need so much time every day. You’re eating will be better, the weight will continue to come off. Of course, you’ll still need support, podcasts, good friends and company will be a big part of staying healthy, but it’ll come a lot more naturally.
There are many books to read about your body’s physiology and to help you understand why this is so hard. The first book I recommend everyone read is The Obesity Code. But here’s a longer list if you want more:
- The Obesity Code by Jason Fung, MD
- The South Asian Health Solution by Ronesh Sinha, MD
- The Complete Guide to Fasting by Jason Fung, MD
- Good Calories, Bad Calories by Gary Taubes
- The Big Fat Surprise by Nina Tiechholz
- The Telomere Effect by Elizabeth Blackburn, PhD and Elissa Epel, PhD
There are also a lot of weight loss podcasts out there. Not every podcast is for every person. But it’s important to find one (or five!) that you enjoy listening too and that you find enjoyable. Here are a few to consider:
- Weight Loss for Busy Physicians
- The Life Coach School
- Losing 100 lbs with Phit-N-Phat
- The Obesity Code Podcast
- The Low Carb Cardiologist Podcast
- 2 Keto Dudes
Learning about Food:
There is no magic pill to get you to a BMI of 22 in 2 weeks. But there is a very real, effective way to start to lose weight that makes you happier, feel more in control of your life and improve your sense of well-being. Most importantly, if you can change your eating habits by changing your thinking—not just sheer willpower—you can keep it off for good.
What are you waiting for? Make your commitment and get started!
MIGRAINES IN PREGNANCY
Headaches are one of the most common medical complaints. Affecting at least 40% of women in their childbearing years. Though most headaches are episodic, tension-type headaches, women complaining about a headache at their physician’s office are usually suffering from migraines. Over 90% of women seeing their doctors for a headache have some component of a migraine. Nearly 20% of American women suffer from migraines.
Fortunately, over the years, there are many, effective medications that have been developed for both the prevention and treatment of migraine.
But what about during pregnancy?
Fortunately, most women with migraines get better during pregnancy due to the changes in estrogen levels. Up to 70% report improvement in the frequency and/or severity of their migraines. Many women stay the same and 5% report worsening disease. The postpartum period is the most common time for exacerbation.
Pregnancy outcomes are nearly the same between women with and without migraines.
It is important early in pregnancy to share with your Obstetrician that you have a history of migraines. For women who are past 20 weeks of pregnancy, the presence of a new headache or a more painful headache raises concerns for pre-eclampsia. Depending on a variety of factors, changes in your migraines after 20 weeks may initiate other testing, from a blood pressure reading to blood work.
Prevention of migraines
Except in severe cases, medications used to prevent migraines are stopped in women trying to conceive or once they’ve confirmed a pregnancy. Due to the possible risks or lack of data, for most women the safer, more cautious choice is to stop preventative meds.
There are several medications effective for the prevention of migraines. A few are contraindicated in pregnancy. But for women with severe disease, three: amitriptyline, verapamil and propranolol are options for discussion. Amitriptyline and verapamil each have been shown to be low risk from animal studies but lack safety data in humans. Propanolol has a similar issue, but in higher doses may be associated with growth restriction in the fetus
Treatment of migraines
The safest treatment for headaches and migraines in pregnancy is acetaminophen (Tylenol). The maximum dose in a 24 hours period is 3000mg. That allows for up to 1000mg every 8 hours.
When acetaminophen alone doesn’t work, adding 10mg of metoclopramide to each dose works well for many women. Acetaminophen with codeine (Tylenol #3) also works well but should be limited to 8-9 days of use in a month. A combination of butalbital, acetaminophen and caffeine (Fioricet) can also work well but should be limited to 4-5 days per month.
What if none of this works?
There are more options than these available for the treatment of the unresponsive migraine. But more detailed discussions on risks and benefits need to be added to the conversation. If the above three regiments don’t work well, it may be wise to follow up with your neurologist first before discussing additional medications. What is important to understand is that there ARE options.
THE GENITOURINARY SYNDROME OF MENOPAUSE IMPACTS QUALITY OF LIFE (AND IS TREATABLE)
Menopause has always been around. Nowadays some of it is depicted in pop culture: the hot flashes and mood swings. The transition from pre to post-menopause is a finite period (very short for some, much longer for others). The symptoms are well known and subside. But there are other significant symptoms that don’t resolve, they progress and have a substantial impact on quality of life.
In 2015, a new term was coined: the genitourinary syndrome of menopause (GSM). GSM includes genital and urinary symptoms associated with the decline in estrogen during and after menopause.
The drop in estrogen affects the labia, clitoris, introitus, vagina, urethra and bladders. Over half of menopausal and postmenopausal women develop some aspect of GSM. These include:
- Vaginal dryness
- Irritation/burning/itching of the vulva or vagina
- Decreased lubrication a
- Pain with sex or sexual activity
- Postcoital bleeding
- Reduced arousal, orgasm and desire
- Pain with urination
- Urinary frequency
- Urinary urgency
Some physical changes include:
- Decreased moisture
- Loss of elasticity of the vaginal wall
- Labia minora resorption
- Pallor or erythema of the vulva
- Loss of vaginal rugae
- Fragility of the vaginal and vulvar tissue
- Eversion or prolapse of the urethra
- Recurrent urinary tract infections (UTI)
Menopause recently published a study evaluating the impact GSM has on the well-being and quality of life of post-menopausal women. As expected, they found that women with any symptoms of GSM were twice as likely to report effects on their well-being, quality of life, sexual function and body image.
What’s important is recognizing that while these changes are natural and normal, there are many things women can do to help prevent, decrease or treat the symptoms they find disruptive.
When menopause begins: regular use of the vagina can help maintain normal diameter and natural lubrication. This includes by stretching the vaginal walls through penetrative intercourse or the use of a dilator as well as blood flow to the vaginal walls through orgasms.
As dryness, pain or any of the above symptoms begin, it is important to see your gynecologist. There are so many treatment options out there now, you will likely find a solution that fits your goals and lifestyle. On average, women in the US will spend over 30 years in menopause, learning how to best take care of ourselves is an integral part of enjoying these years.
HIGHLIGHTS FROM OUR WOMEN’S HEALTH BLOG
Our Women’s Health Blog is a way for us to put out up to date information on various topics we find important for all of you. There was a popular article on the basics of bacterial vaginosis (BV), as well as one on our view on using an app for birth control (don’t do it!). Follow us on Facebook or Twitter to hear about new blog posts.
GENERAL OFFICE INFORMATION