Medical Intel - SoundSage

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For many women, breast reconstruction is an important part of the healing process after breast cancer surgery. Plastic surgeon Dr. Kenneth Fan discusses the three reconstruction methods we use and why treatment often depends on patients’ unique expectations, goals, and needs.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Ken Fan, a plastic surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Fan.

Dr. Fan: Pleasure to be here.

Host: Today we’re discussing how breast reconstruction surgery, one that occurs after cancer surgery, works and what patients can expect from it. Dr. Fan, could you begin by explaining why women undergo breast reconstruction surgery after cancer surgery?

Dr. Fan: Well, that’s an interesting question. And I think a important point to point out at this juncture is that breast reconstruction after cancer is not cosmetic surgery. It’s a reconstructive procedure and it’s actually mandated by law as a result of the Women’s Health and Cancer Right Act. Therefore, I think it’s important for patients to know that their access to breast reconstruction surgery is not optional. There’s something about breast reconstruction after cancer surgery that really gives patients hope and an opportunity to feel whole again. And we see this in our research. After breast reconstruction, patients who have had reconstruction have the same quality of life as patients who haven’t even had cancer. And this has been shown in large, large series of data. And therefore, I think it’s important for a team of breast surgeons and plastic surgeons to discuss what the right option for breast reconstruction for that patient is.

Host: What is your patient population typically like?

Dr. Fan: I see patients for breast reconstruction with all sorts of lifestyles and requirements. And therefore, it’s very important for us to have a group discussion on what the best breast reconstruction modality is. For example, some patients have a very active lifestyle and want to get back to work right away. Therefore, we can do certain types of reconstruction that facilitate that. Other patients want this to be the last surgery they go to and really want that home run, so they don’t have any future operations in the future. And so, we also have surgeries for that breast reconstruction patient as well.

Host: How does breast reconstruction surgery work?

Dr. Fan: That’s a great question. So, globally speaking, there are three main ways that breast reconstruction can occur. The first one is an oncoplastic approach in which the breast surgeon takes out a small tumor and mere rearrange tissue within the breast. The second approach is after mastectomy. And this is usually with a, what we call, prosthetic-based reconstruction. We use an implant, or a temporary device called an expander, to reconstruct a breast mound. The third option is what we call autologous space reconstruction. And in autologous space reconstruction, we use patients own tissues, either from the abdomen or from the back, to reconstruct a breast.

Host: Following breast cancer surgery, how long does it typically take women before they have a breast reconstruction surgery?

Dr. Fan: So that’s a great question. Breast reconstruction can generally be done in the same operating room visit as the cancer surgery. However, there’s some rare cases in which patients will need what we call a delayed type of reconstruction. However, it’s important for patients to come see us before surgery and we can explore all the options together.

Host: How close can you get to making a breast look the way it did prior to surgery?

Dr. Fan: Depending on the cancer characteristics and the cancer excision, we can come pretty close. I think for patients and for us surgeons, our greatest hope is that patients, while clothed, can have the appearance of not having had breast cancer. And that is our ultimate goal. And, I think more often than not, we achieve this goal. However, if the patient were to look in the mirror unclothed, there are certain scars that would give away the fact that they had breast reconstruction.

Host: Is there anything women must do prior to breast reconstruction surgery?

Dr. Fan: Not necessarily. What’s important is to have a group discussion on what the best modality is for that patient. We practice a patient-centered approach, so we go through all the options and really discuss with the patients what is the best modality to make sure that they are happy with their surgery.

Host: Is there any new, exciting research related to breast reconstruction surgery?

Dr. Fan: At MedStar, we are constantly looking at how we can do things better. In particular, a lot of our research focuses on complications after breast surgery and improving the patient experience after breast surgery. Our second main point of research is improving the patient experience after surgery. In particularly, we are looking at use of enhanced recovery after surgery, short for ERAS protocol. This protocol, we have found, has decreased the amount of narcotic usage significantly that patients have to take after surgery. Patients find themselves walking post-op day 1 or 2 after a major operation and are leaving the hospital sooner. So much so that they are surprised at even how well they’re doing themselves.

Host: Why is MedStar Washington Hospital Center the best place to seek care for breast reconstruction surgery?

Dr. Fan: I think it’s important for patients to know, for perspective patients to know, that at MedStar Washington Hospital Center we’re focused, not just on disease, but on the patients themselves. We focus on the patients’ needs through a multidisciplinary approach and really engage patients to help understand their expectations and desires. This makes us such a special place as providers are constantly collaborating together to come up with the best solution for our patients.

Host: Thanks for joining us today, Dr. Fan.

Dr. Fan: Thank you.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

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About 800,000 Americans have a heart attack each year—and younger women account for nearly one-third of them, according to a recent study. Dr. Patrick Bering discusses what’s causing this rise in heart attacks.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Patrick Bering, a cardiologist at MedStar Washington Hospital Center. Thank you for joining us, Dr. Bering.

Dr. Bering: Thank you so much for having me. It’s a pleasure.

Host: According to a 2018 study, younger women are having more heart attacks. In fact, they’re accounting for nearly one third of all female heart attacks in recent years. Today we’re going to discuss why this is, and ways women can prevent heart attacks. Dr. Bering, could you begin by explaining why we’re seeing this rise in heart attacks among young women?

Dr. Bering: Absolutely. This is definitely an alarming trend that’s seen nationwide. One of the reasons why we think we’re seeing more young women hospitalized with heart attacks is that there has been an increase in the cardiovascular risk factors among young adult women. Among these would be things like high blood pressure, diabetes, obesity, smoking and poor lifestyle, including poor diet and low physical activity levels.

Host: And is this something you’re seeing only in young women or young men as well?

Dr. Bering: We see premature heart disease both in young men and young women. Unfortunately, we have been seeing a trend for increased hospitalizations for heart attacks in young women more so than young men. There may be some additional risk factors that young women have. And, when I say young women, I mean women and young adults, so between the ages of 35 and 55. And these can include women who have conditions such as polycystic ovarian syndrome, premature menopause or a history of preeclampsia during pregnancy.

Host: Are there certain demographics of young women that you’re seeing more than others?

Dr. Bering: That’s an interesting question and one that we’re still gathering information about. It seems to be important where you live from a socioeconomic perspective. In that way, your neighborhood may actually be a risk factor, positive or negative, for your development of heart disease. We do see a high amount of premature heart disease in African American women, which is a concern for us and we aim to combat this from many different facets, aiming at preventing the risk factors for heart disease. Or, if they develop, to try to optimize them to prevent any long-term consequences to cardiovascular health.

Host: Are there symptoms or warning signs of heart attacks that people should be aware of?

Dr. Bering: Definitely. You hear about classic symptoms which include pressure on the chest or some people describe it as an elephant sitting on the chest. These classic symptoms are more common in men. Unfortunately for women, the symptoms may be more atypical. They can include things like heartburn, fatigue, shortness of breath, low energy, acid reflux, nausea. Because women have more atypical symptoms of heart disease, they may be less likely to seek medical attention at the time that they’re experiencing something like a heart attack.

Host: Could you expand on some of the symptoms young women may have?

Dr. Bering: Certainly. As I said, this can be confusing, even for the healthcare community, at times. Since young women or even women post-menopause are more likely to have atypical symptoms that may be gastrointestinal, it has to be in context with the rest of their symptoms and well-being. If there’s been a change in their ability to do physical activity or exercise, that goes along with symptoms of heartburn or nausea, low energy or fatigue - those combinations are more worrisome than if it’s just heartburn after they’ve had, say, a spicy or acidic meal.

Host: Is there any point at which somebody should definitely see a doctor?

Dr. Bering: Absolutely. If someone is having significant shortness of breath or decreased energy, intractable nausea, or heartburn that doesn’t get better with usual methods such as an antacid, they should seek medical attention, especially if they have a history of premature heart disease in their family or if they have risk factors for heart disease that we described before - high blood pressure, diabetes, obesity, poor diet, poor physical activity, high cholesterol.

Host: What can young people do to prevent heart disease?

Dr. Bering: That’s a great question and one of our most important ones. At an individual level, young people can be aware of their health, in a way that prevents the development of risk factors for heart disease. That generally goes along five different related and intertwined steps to positive health. Those include things like healthy diet, regular physical exercise, control of blood pressure, control of weight and focusing on positive stress and mental health in their life. Even things like getting 7 to 8 hours of sleep per night is a very important step of focusing on your overall health.

Host: Could you explain how regular doctor checkups could go a long way in young people preventing heart disease?

Dr. Bering: Definitely. For young people, even though many of us feel well or healthy, or we may have a lack of medical problems, some of the risk factors for heart disease may actually be silent. Many people don’t FEEL that they have high blood pressure and instead, they discover it later in life once some of the consequences of high blood pressure have accumulated over time in the body. A regular checkup with your primary care health provider every year is an important way for you to have a dialogue and positive relationship with the health care community. We, in health care, are very excited about seeing patients where we can make positive influences to prevent disease. And, in fact, that seems to be one of our...or actually, our MOST successful strategy, when we are combating disease.

Host: Why is MedStar Washington Hospital Center the best place to seek care for heart disease?

Dr. Bering: At MedStar, we’re so proud to serve our community and we’re lucky that we have passionate healthcare providers that can focus on a variety of issues related to your cardiovascular health. In one sense, we have great primary care physicians, as well as cardiologists, who are focused on the prevention of heart disease. In another sense, if you are unfortunate enough to develop cardiovascular disease or the risk factors for it, we have a team of experts that are able to provide you with comprehensive, expert care in order to manage your conditions optimally in a strong dialogue with you. We like to make our care patient-centered so that everything is focused on goals that we can achieve with the patient themselves.

Host: Could you share a story in which a young patient received optimal care for heart disease at MedStar Washington Hospital Center?

Dr. Bering: Absolutely. I’ve recently had the privilege of taking care of a young woman who had initially thought that she had symptoms of acid reflux. As it turned out, this was actually a heart attack in its beginning stages. Since she presented with atypical symptoms, our emergency room physicians were keen enough to look for a cardiac cause and discovered the early signs of the heart attack. When she came under my care, I was able to get her the appropriate procedure that she needed in order to open up a blocked blood vessel supplying blood to her heart muscle. In that sense, we were able to successfully handle her care, both from the moment she hit the door in the emergency room to the point of discharge with minimal heart damage and overall good heart function.

Host: Thanks for joining us today, Dr. Bering.

Dr. Bering: It’s been a pleasure. Thank you again.

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Some of the most unexpected injuries in medicine are due to orthopaedic trauma, which involves problems related to bones, joints, and soft tissues. Discover what some of the most common orthopaedic trauma injuries are and how we treat them.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Robert Golden, Chief of Orthopaedic Trauma Surgery at MedStar Washington Hospital Center. Thanks for joining us, Dr. Golden.

Dr. Golden: Thanks a lot for having me.

Host: Today we’re discussing common orthopaedic trauma injuries which commonly affect bones, joints, ligaments, tendons and muscles, and how we diagnose and treat them at MedStar Washington Hospital Center. Dr. Golden, could you begin by explaining why orthopaedic trauma injuries generally occur?

Dr. Golden: Sure. They can occur from multiple different kinds of mechanisms, the most common being falls and motor vehicle crashes. But we also see a large number of injuries from bicycle related injuries, scooter related injuries. We also, in this area, see a fair number of gunshot wounds.

Host: What are some of the most common orthopaedic injuries that you see?

Dr. Golden: A lot of them depend on how the person was injured. We do see a fair amount of injuries from pedestrians being struck by cars. They tend to get injuries to their legs and lower extremities. A lot of people who just fall, and they can hurt anything including ankles and lower extremities, but then they also tend to have a lot of wrist injuries and shoulder injuries from falling and putting their arms out to protect them.

Host: And could you explain, giving specifics, some of those injuries?

Dr. Golden: Sure. A very common mechanism when you fall and you put your arm out is that you break what’s called your distal radius, which is just the bone at the end of your arm right before your wrist. It’s a very common injury in older people as well as in younger people when they suffer a high energy fall. Some of the injuries from the pedestrians being hit by cars involve what’s called a tibial plateau, which is the top part of your tibia, right below your knee. You can imagine the bumper of the car striking you on the side and that bumper is right about the level of your knee, so a lot of people get injuries that way. Once it gets a little warmer and people go back to motorcycles or riding bicycles, then you start to see a little more high energy injuries, especially from the motorcycles and those can involve injuries to your femur or your thigh bone. And, the higher energy crashes with motorcycles, and with cars, then you can get some of the pelvis injuries that people see. The other thing we’ll see is we’ll get patients referred in who have had complications from fractures that they’ve had in the past. Sometimes the fractures just don’t heal and then that’s called a nonunion. Sometimes they heal but they heal in a crooked position. So, we’ll also treat those patients. And, if they haven’t healed, a lot of times you need to figure out why that is. Sometimes that’s because the bone simply doesn’t have enough blood supply to it. Sometimes it’s because the patient doesn’t have the components necessary to actually heal that, be it enough vitamin D in their system or other reasons that can prevent bone healing. So, oftentimes we’ll have to take them back to the operating room and do other procedures to try to get them to heal, including taking some bone from another part of their body and bringing it into the area where it hasn’t healed. If they’ve healed but it healed crookedly, called a malunion, sometimes we’ll even have to re-break the bone or cut it at the area where it’s crooked - sometimes that can be done as a single procedure. Sometimes we have to put on different kinds of apparatus that go on the outside of the bone and interface with a computer program so that we can control how the bone is manipulated over time and we’ll slowly restore them back to a straight position to get them to heal. The other thing we’ll often see as orthopaedic traumatologists is we also specialize in bone infections, so we’ll get patients referred in who have had bone infections for lots of different reasons, sometimes as a result of trauma but sometimes just as a result of getting an infection, so we’ll treat those as well. Oftentimes, that requires a surgery to open up the bone, get out as much of the infection as possible so that then antibiotics can be used to control the infection for long-term cure.

Host: Could you discuss common treatments for these injuries and how they work?

Dr. Golden: Sure. A lot of the injuries depend on where in the bone it’s broken. Injuries that occur close to the joints, which are called periarticular injuries, generally require plates and screws to fix them so that you can align the bone, make sure the joint is re-aligned back as perfectly as possible. And then that’s held in place with small metal plates that are held on to the bone with screws. That allows the bone to stay in the proper position and then it heals around it, so the plates are functioned like scaffolding and hold everything in the right spot and then it’s still up to the person to actually heal the bone. If you break some of the long bones, like your tibia or your femur, then sometimes we’ll put rods into them. Those go on the inside of the bone and, like the plates, they form a scaffolding, but these...the bone heals around them, so they’re totally contained within the bone itself.

Host: And what kind of recoveries can these patients expect?

Dr. Golden: Some of it depends on what’s injured. In general, bones take about 12 weeks or 3 months to heal. Some of the injuries, the hardware that we put in is strong enough to support their weight. If that’s the case, we’ll get them up as soon as possible right after the surgery and get them moving to minimize their stiffness that they might get, minimize the amount of muscle loss that they may have from not being able to move around. Some of the injuries, you just simply can’t do that. Some of the plates and screws that we put in have to get very close to the joints in order to get the joint perfect and those aren’t strong enough sometimes to support the person’s weight. If that’s the case, then they may have to have a period of not putting weight on that limb, using crutches or a walker or sometimes even a wheelchair, until that bone heals strongly enough that then they can start putting weight back on it. Oftentimes, if that’s the case, then we’ll have the physical therapists involved to try to minimize their stiffness and minimize any sort of muscle loss they may have from not using that limb. A lot of times we get other services involved, as well, to try to maximize their recovery, minimize the impact onto their life. Unfortunately, a lot of these people weren’t expecting anything to happen that morning and leave for a normal morning and then they have a huge life interruption from these traumas. So, it’s a little bit different that going in for an elective surgery when you know when it’s going to happen and you can plan for it. So, often we have to have a lot of social work involvement to help them in terms of planning for disability insurance and time off of work until they can be strong enough to get back to their occupations.

Host: Do you have any tips to help people prevent these injuries?

Dr. Golden: A lot of them, it’s just being careful with what you’re doing, especially with the motorcycles and bicycle crashes, and sort of knowing your limits. Unfortunately, sometimes it is just a random occurrence that happens. You can’t do anything about it if you’re driving down the street and somebody runs through a red light and hits you. You had nothing to do with that but, unfortunately, you still have to deal with the consequences of it.

Host: Are there certain patient populations you see the most with orthopaedic trauma injuries?

Dr. Golden: Orthopaedic trauma tends to be what’s called a bi-modal distribution most of the time, meaning that we see a lot of younger people in their late teens and twenties, then we see a lot of older people. Those injuries occur for different reasons. The young people tend to be doing the more high energy, risky sort of things - riding motorcycles, riding bicycles, doing things fast with high energy. The older people just lose their balance and have less stability in their bones. So, when they fall, they may break their hip, when, if you fell, you would just get right back up and be fine.

Host: Why is MedStar Washington Hospital Center the best place to seek care for orthopaedic trauma injuries?

Dr. Golden: Well, we have a full staff of orthopaedic traumatologists here. There’s two of us who specialize...orthopaedic trauma and that’s pretty much exclusively what we treat. But we also are supported by a full orthopaedic department that has specialists in all the other disciplines. So, sometimes if you have a injury to the bone and the ligaments, we’ll take care of some of the bony issues, and then some of the sports medicine people will take care of some of the ligament injuries or the hand people will take care of those specific injuries. We are also plugged in to the MedStar trauma service network here with the trauma team that can provide a multidisciplinary approach to make sure that any other injuries you may have that don’t relate to orthopaedics - injuries to internal organs or other body parts - can be managed, as well.

Host: Could you share a story in which a patient received optimal care for orthopaedic trauma injury at MedStar Washington Hospital Center?

Dr. Golden: Sure. We’ve had tons of patients come through since I’ve been here and a lot of them have multiple injuries. I just saw a guy who we treated seven years ago now was just coming back essentially to get a checkup. But he had injured both of his limbs, again this was a motorcycle crash, both of his lower legs, both of his feet, some of them were open fractures, meaning the bone had come out through the skin. He also had a bunch of injuries to internal organs. So, he came in, was treated by the general surgery trauma team to stabilize all his internal organ injuries. We then treated his bones. He needed several surgeries to try to minimize any risk of infection and prevent that from happening. We then stabilized his bones with the plates and screws and rods. And then the plastic surgery team provided flap coverage to get that covered as well. One of our more well-known instances of treating patients has been both with the Congressional baseball shooting, prior to that the Navy yard shooting. We had victims of those shootings here, as well, and that was truly an interdisciplinary exercise where there were the general surgery trauma team was involved, vascular surgery teams were involved, we were involved - and all that care came together at the specific times when it was appropriate to make sure that we first saved the lives, then, eventually, got everything fixed and back to function and, you know, getting back in to life.

Host: Do you have any advice for what patients can do before EMS arrives?

Dr. Golden: Well, a lot of it is just staying calm and keeping the limbs that you think are injured still. Sometimes that involves you just staying still and not moving around. If there’s other things available to help with that - and that can be as simple as finding some cardboard and rolling it up to form sort of a make-shift splint, or sometimes even newspapers are enough, just to help keep everything still - generally that’ll make it feel more comfortable because if the bones aren’t moving around where they're not supposed to, it will hurt less. That could also help prevent some of the associated injuries to the soft tissues around the bones that can be injured if the bone is moving abnormally. So, that may help the person who is hurt, in terms of just pain control, as well as trying to prevent some of the issues to the skin and the soft tissues. Sometimes, if it’s an open fracture and there’s actually bleeding from the wound, you can just put some pressure on the area where it’s bleeding and that will help minimize that as well, until an EMS professional arrives.

Host: Thanks for joining us today, Dr. Golden.

Dr. Golden: My pleasure. Thanks for having me.

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Deep Vein Thrombosis (DVT), a condition in which blood clots form in the deep veins, affects as many as 900,000 Americans each year and can cause symptoms such as pain while walking and a burning sensation in the legs. Learn who’s most at risk of developing DVT and common treatment options.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Steven Abramowitz, a vascular surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Abramowitz.

Dr. Abramowitz: Thank you for having me.

Host: Today we’re discussing deep vein thrombosis, or DVT, a condition where a blood clot forms in one or more deep veins in your body. Dr. Abramowitz, could you begin by discussing how these blood clots form and where they typically arise?

Dr. Abramowitz: Sure. So, in our body, our veins are responsible for bringing blood back into our heart. Arteries take it away, veins bring it back. And, when we think of the veins in our body, there are veins that are superficial, or near the skin, and veins that are deep that run down near our bones or with our arteries. These deep veins - you could think of them, if you’re in the DC area, as our big roads - let’s say the New Hampshire’s or the Pennsylvania Avenues or the Georgia’s. And, some of our superficial veins are more like our side streets - like a T street or a U street. And, everything drains into these deep veins. But, sometimes there can be a traffic jam, and that traffic jam, in the case of our blood vessels, is a blood clot. And that blood clot can occur anywhere these deep veins are - in the arms, in the legs, essentially anywhere that you may name a deep vein. And what we find is that, depending upon where the clot is, it can lead to a variety of different symptoms. And, if that clot breaks free, it can travel back to the heart, where all the blood from our veins goes originally. And that can result in a pulmonary embolism, which can be a fatal condition.

Host: And what are some of the common symptoms of DVT?

Dr. Abramowitz: Most commonly, people who have DVT in the lower extremities, will experience swelling, pain when walking, a hot burning sensation as their leg gets warm or engorged and full of blood. And those typically are the most common complaints that people have.

Host: Who is most at risk of developing DVT?

Dr. Abramowitz: Anybody can fall victim to deep vein thrombosis. And really, it depends on what’s going on with someone else’s health. So, for example, there are plenty of patients that we treat here at MedStar Washington Hospital Center who are younger, maybe they’re in their teens, and the first time that they know they have a clotting disorder or a blood disorder that may make them more likely to make blood clots, would be the presentation with a DVT in one of their legs. Other times, patients who have had surgery or other conditions that make them less mobile or engaging in activity in their lives could be victims of DVT, as well. And, it can also be something that we find in hospitalized patients, people who are immobile in a hospital bed for extended periods of time. So really, it’s a condition that can affect anybody of any given age.

Host: How is DVT diagnosed?

Dr. Abramowitz: For the most part, it’s both a clinical diagnosis and a confirmation with ultrasound. And we use ultrasound as a simple way of diagnosing the presence of clot within the deep veins. And this is done, again, as a very quick test without radiation exposure, or dye, and it’s a simple procedure that we can do, even at the bedside, for someone who’s in the hospital.

Host: What treatment options are available for DVT?

Dr. Abramowitz: Right now, for patients who have deep vein thrombosis, we currently offer two therapies. First, most patients with deep vein thrombosis, will be treated with something that’s called an anticoagulation agent. In basic terms, it’s a blood thinner. And the reason we put somebody on a blood thinner is not that it actually gets rid of the blood clot, but that it makes it less likely for more blood clot to form because our bodies have the natural ability to break down clot over time. But for some patients who have extensive clot or a lot of clot throughout the vein, let’s say in a leg, we can actually go in with a wire and a small catheter, which is like a plastic tube or a hose, and we can give the medication directly into the clot, to make that clot go away faster for those patients, as well.

Host: And, how fast is faster for those blood clots, typically?

Dr. Abramowitz: Well, if we’re performing a procedure on a patient, usually we can get that clot away in a single session. For patients who have to have blood thinners, sometimes it can take the body up to 3 to 6 months to dissolve the clot on its own.

Host: Is there anything people can do to prevent DVT?

Dr. Abramowitz: For patients who are sick or at risk for DVT, meaning they’re not moving around a lot or they already have something else in their body that’s making them feel inflamed or more likely to develop a blood clot, those patients can both get up and walk and move around. If they can’t do that, engage in exercises so that they’re activating those muscles in their legs and circulating blood. For patients who are, let’s say younger, and they have a blood condition making them more likely for DVT, again, moving around is really important. And, a lot of times we talk about blood clots in a setting of travel or prolonged travel. So, if you’re getting on a plane, I always tell patients not to have that 2 or 3 glasses of wine and pass out, make sure you get up and walk every hour or so. And, if you’re in the hospital, or you’re in a sedentary job, or it could be you’re sitting at a desk, make sure you stand up and walk, too.

Host: Why is MedStar Washington Hospital Center the best place to receive treatment for DVT?

Dr. Abramowitz: Well, one of the great things we have here at MedStar Washington Hospital Center is an interdisciplinary approach to the management of deep vein thrombosis. People who have DVT, not only do they have symptoms now, but they can have symptoms in the future, too, because as the body breaks down that clot, it causes swelling and inflammation in the same way as if you were to get a sprained ankle - you’d have swelling and inflammation. And, that swelling and inflammation can lead to scarring of those veins. So, the deep veins - maybe they’re a four-lane highway before your blood clot, but afterwards they’re a two-lane highway. And that can lead to swelling and that sort of congested traffic for a long period of time. At Washington Hospital Center we offer all of the new therapeutic interventions for deep vein thrombosis management. Anything from sucking out the clot, which is called mechanical thrombectomy, to dissolving the clot rapidly, which we call pharmacomechanical thrombolysis, which is essentially like a little machine that injects that clot busting medication in and sucks the clot out. And, we also put those catheters in and leave them in overnight to slowly dissolve a clot that may have been around for a longer period of time. So, we have the tools to treat your DVT and, also then, take care of you because the DVT is a symptom of something else, most likely. Maybe you have something wrong with your veins that we can diagnose and treat with a stent. Maybe you have another underlying condition, like a blood disorder, or you’re sick with something else so the DVT is the first thing we diagnose. So, when you come to Washington Hospital Center with a DVT, it’s not just about treating your clot. It’s about making sure we understood why it happened. And, we have every single surgical and medical sub-specialty service you could want here to help you deal with that process.

Host: How often can DVT be a gateway to other conditions?

Dr. Abramowitz: Well, the DVT is a condition in and of itself, but you have to ask yourself why it happened. And, for a lot of patients, sometimes the first sign that they may have cancer, for example, is the blood clot. And so, they need to be screened for conditions that would make their blood more likely to clot. Or, for someone who’s younger, if they have a blood clot, it may be a sign that they’re actually more likely to have a genetic condition. So, anytime someone has a DVT, it always prompts us to ask the question, “Why did this happen?” and “What can we do to figure out, for THIS patient in particular, what led to this state of being?” So, I’d say 80 percent of the time someone has a DVT we’re able to figure out the reason why, be it another medical condition, an anatomic predisposition, meaning there’s something in their body maybe compressing a vein, or we find out that they have a genetic condition that’s related to their blood in and of itself.

Host: What are the risks of leaving DVT untreated?

Dr. Abramowitz: That’s a great question. So, really it depends upon where in the body the DVT is. For the most part, blood clots below the hip, those being in the top part of the leg or the bottom part of the leg, they tend to result in swelling in the short term, but don’t necessarily result in long-term damage to the leg that would cause wounds to form or prolonged swelling in the future. But what we find is blood clots that are above the hip or above your groin that affect the veins in your belly and in your pelvis. Those can lead to long-term drainage problems from the leg and that can result in long-term swelling or even wound-care formation. And we call that post thrombotic syndrome. So, it’s really important for us to identify the extent of the blood clot and where exactly in the body it is so that we can predict what someone’s risk is in the future for developing problems as a result of their DVT.

Host: Thank you for joining us today, Dr. Abramowitz.

Dr. Abramowitz: My pleasure. Thanks for having me.

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BPH, or an enlarged prostate, affects about 50 percent of men between the ages of 50 and 60, causing symptoms ranging from frequent urination to a weak urine stream. Dr. Daniel Marchalik discusses GreenLight laser surgery, a minimally invasive treatment for BPH.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Daniel Marchalik, the Director of Ambulatory Urologic Surgery at MedStar Washington Hospital Center. Thank you for joining us, Dr. Marchalik.

Dr. Marchalik: Thanks so much. Happy to be here.

Host: Today we’re discussing a newer treatment for benign prostatic hyperplasia, or BPH, which often is referred to as an enlarged prostate. This treatment is called greenlight laser surgery. Dr. Marchalik, could start by explaining what greenlight laser surgery is and how it works?

Dr. Marchalik: Yeah, of course. So, as a lot of listeners know, BPH is a really common issue. In fact, we know that half of all men in their 6th decade of life have signs of an enlarged prostate. And so, as a result, this is something that we have to deal with very often and treat very, very often. And there are different ways of treating BPH. Traditionally, BPH has been treated surgically by shaving the prostate down using an electrode that can actually shave it from the inside. Recently, in the past 5 to 10 years, we’ve started to use something called the greenlight laser to do a photo-vaporization of the prostate. Now what that means is that we use a laser to actually vaporize the prostate tissue. The greenlight laser is a really interesting device because the laser itself is absorbed by the hemoglobin molecules - those are the red cells...red blood cells. What that allows us to do is to actually make the tissue vaporize without causing as much bleeding as other ways of treating BPH.

Host: What’s the process in which you diagnose a patient with BPH, or enlarged prostate, and who are the best candidates for greenlight laser surgery?

Dr. Marchalik: The diagnosis is really usually made by symptoms. So, when somebody comes in and they complain of having difficulty urinating, waking up at night to urinate, feeling like their stream has gotten weaker, feeling like they’re always rushing to the bathroom - basically, like the guys in the commercial who are going to the baseball game and they always have to sit on the aisle because they need to know where the bathroom is at all times. Or, the guys that are running in and out of meetings because they feel like they’re just not going to make it through the whole meeting without peeing. Those are the symptoms that we tend to see with BPH. Now, we do questionnaires to try to get an objective measure of exactly how much this is bothering them. We can also measure the flow of their urine to see how strong their stream is. And, if we then diagnose them with issues urinating, we then go on and measure the size of their prostate to objectively demonstrate that it is enlarged and sometimes even look inside the prostate using a small camera called a cystoscope. Every patient is obviously going to be different. But, the general approach is to first establish what the symptoms are that the patient is experiencing, and then to get some objective data, like the size of the prostate and the way that the prostate looks.

Host: What is recovery typically like following greenlight laser surgery?

Dr. Marchalik: The big difference between a greenlight laser surgery and the traditional surgery called a TURP, a transurethral resection of the prostate, which is the way that prostates used to be treated more in the past and still are treated today, is that the greenlight laser surgery could be done as an outpatient, meaning it’s in and out surgery. The big difference there is that you don’t have to spend the night in the hospital. And, that means that the recovery tends to be a little bit smoother. Generally, patients who undergo a greenlight laser photo-vaporization of the prostate get sent home with a catheter that they can either remove themselves the next day or come back in to the hospital and we can remove it for them. Most patients will immediately see a difference in their stream. What I mean by that is that patients who have really struggled to try to push the urine out or felt like their urine just doesn’t tend to flow the way that it used to when they were younger, will often experience the return of that type of force right away, and so they might be able to see the results immediately. Now, of course, because they had the surgery and because their prostate was shaved down, that means that they need to abstain from things like heavy lifting and exercise, cycling, for the next four weeks or so to prevent them from developing bleeding from that raw area in the prostate.

Host: Are there any risks involved with greenlight laser surgery?

Dr. Marchalik: Of course. As with any surgery, there are inherent risks associated with anesthesia. But for the surgery itself, there are some things that tend to be risks for the procedure. For example, about three-quarters of guys who undergo this procedure will develop something called retrograde ejaculation. It means that when they ejaculate, nothing comes out or less comes out. Now, it doesn’t change their ability to have erections. It doesn’t change their ability to have an orgasm. But it does change the actual experience because there is no ejaculate. About 3 to 5 percent of guys can develop some leakage. It’s called incontinence, meaning when they sneeze or cough or do strenuous activity, some urine might leak out. For a lot of guys, it’s just a few drops and it tends to be transient, meaning it goes away after a few weeks. But there’s a small subgroup of guys that can develop a more long-lasting issue with the urinary leakage. Of course, there’s always a risk that the procedure doesn’t actually help someone, meaning even though we shave the prostate down, they have some underlying problems with their bladder that prevent their bladder from squeezing as well as it should. And in those cases, the procedure might help them but maybe not as much as we would hope that it would.

Host: When speaking of risks, is there usually any hesitancy from patients and how do you walk them through, you know, why maybe they shouldn't be hesitant?

Dr. Marchalik: It’s funny that you use the word “hesitancy” because urinary hesitancy is why the guys come to see me in the first place. But, I think that’s a good question. And, I think that as with any surgery, you have to remember that each individual patient is going to be different. There are people for whom this surgery is not ideal. For example, if somebody comes to me and they say, “I want a procedure for my BPH, but we want to have some more children.” And, for a patient like this, this is not a good procedure because the retrograde ejaculation certainly puts you at risk of not being able to have children anymore. Now, there are people that say, “Hey, I really want a procedure, but I can’t go under anesthesia. I’m scared of anesthesia. This is not something that I’m willing to do.” This is not a good procedure for them because this does require anesthesia. There are other people that come to me and they’ll say, “What type of procedure can I do that I know is going to last more than a few months or that has a lot of research behind it?” And then we talk about this procedure because I think this is a very good option for them. There are things that give people pause. For example, the retrograde ejaculation and the risk...the need to have a catheter for one day afterwards. But a lot of times, when we actually talk through this, this is not something that is an issue for most people that I see.

Host: What makes greenlight laser surgery superior t o other treatment options?

Dr. Marchalik: The biggest advantage that I see for a greenlight laser TURP is the fact that this could be done as an outpatient, meaning a patient gets to go home at the end of the procedure and spend the night at home versus the hospital. However, we still see the same benefits with greenlight laser TURPs as we see with regular TURPs, meaning we still see the same effectiveness of the procedure. Guys get the same urinary function that they have with the regular TURP with this greenlight laser TURP. They have the same side effect profile as a regular TURP. And, the same risk of having to need a surgery down the line. So, by that I mean that it is really a comparable procedure, just as good, but the risks are lower and there’s no need to spend the night in the hospital.

Host: Is there anything patients should do beforehand to prepare for greenlight laser surgery?

Dr. Marchalik: There’s nothing that they need to do in particular that’s different from any other surgery. And, of course, those instructions will differ by each individual patient. But usually it means having nothing to eat or drink after midnight and this is the same approach as they would for any other surgery. The big difference is they don’t need to pack a bag to bring with them to spend the night in the hospital.

Host: Why is MedStar Washington Hospital Center the best place to receive treatment for BPH through treatments like greenlight laser surgery?

Dr. Marchalik: We have a very good interdisciplinary team that discusses each individual patient. And, we have a good track record of performing this surgery that is an advanced greenlight laser surgery, including for some people who have larger prostates. Traditionally, the greenlight laser TURP has been reserved for smaller prostates, but we’ve been doing it with great success on guys with larger prostates and we’ve had really good patient outcomes. And, of course, we are very committed to our patients, which means that we continue to see them in our clinic and to make sure that their results are not just good successes initially but are durable and they maintain the good urinary function throughout the years afterwards.

Host: Could you share a story where a patient received an optimal outcome through greenlight laser surgery?

Dr. Marchalik: Yeah. I had a patient recently who had been in and out of the emergency room multiple times over the span of several months. He kept having difficulty urinating. It’s called urinary retention, where basically no urine comes out. It could be an extremely uncomfortable and extremely painful condition. So, he kept coming in to the emergency room, would have a catheter placed, the catheter would be removed, he would be OK for a few days, and then it would return. Leading up to it, he’s a guy who was in a lot of business meetings and he said that this was starting to really interfere with his job. He kept having to leave meetings early, he kept interrupting meetings because he had to rush to the bathroom. And, he said his quality of life just wasn’t what it used to be. He underwent this procedure and immediately, the next day when the catheter was removed, he saw a difference. He said that the stream was the way that it used to be when he was in his 20s, which I think is a pretty good endorsement. A few weeks went by and some of the initial urgency that he felt after the procedure, as he was going through the healing phase, went away. I saw him in clinic a few months afterwards and he told me about how he can now sit through a meeting with no problem. He feels like he can go to a baseball game and he can sit through all 9 innings and it’s not a big issue for him which, honestly, I don’t know a lot of guys who could sit through 9 innings without having to go to the bathroom, but I guess he’s not one of them.

Host: Thanks for joining us today, Dr. Marchalik.

Dr. Marchalik: Thanks so much for having me. My pleasure.

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One of the main concerns for surgical patients is how much pain they will experience after their procedure. Dr. Kenneth Fan discusses the Enhanced Recovery After Surgery (ERAS) protocol, which not only reduces pain after surgery, but also decreases the use of opioids.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Ken Fan, a plastic surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Fan.

Dr. Fan: My pleasure. Thanks for having me.

Host: Today we’re discussing ways to reduce pain after various types of plastic surgery. Dr. Fan, pain has to be one of the most common fears patients have prior to plastic surgery. Can you explain how much pain patients can expect from surgery?

Dr. Fan: Yes. With the enhanced recovery after surgery, multimodality, multidisciplinary protocol, the most important thing is to set the expectation of pain. So, the first part of the series of treatments is the pre-operative assessment of the patient. So, we go through a detailed discussion with how the patient has recovered in previous surgeries and how they tolerate pain. I discuss with them how they can see themselves recover from this particular surgery. This discussion is very important because not all patients perceive pain the same way and not all surgeries have the same amount of pain.

Host: How long does recovery normally take after plastic surgery?

Dr. Fan: Recovery varies, based on the type of procedure. Some procedures are out-patient, meaning that patients are discharged and go home. Some procedures require a 3 to 4-day in-patient stay. The benefit of using this ERAS multimodal analgesia protocol is that no matter how long the recovery, it’s shortened - patients return back to base-line functioning sooner and have decreased narcotic usage.

Host: What kind of treatments do you provide patients to help them deal with pain or discomfort after plastic surgery?

Dr. Fan: So, we use a combination of pre-operative non-narcotic medication that decreases the way the nerves fire. So, they don’t fire strongly, and they don’t fire as hard. Intraoperatively we work with our anesthesia colleagues and they provide a lot of medications that decrease nausea and vomiting after surgery and decrease the amount of pain. We also use wide-spread local blocks, meaning we use local anesthesia that also targets the nerves and prevents them from firing. This also decreases pain. After surgery, we usually provide a cocktail of medications that are also non-opioid anesthesia. They also target the way the nerves fire and they subdue everything and decrease the pain levels for patients. And we found with this ERAS protocol after major surgery, patients are only taking 1 to 2 narcotic tabs after surgery. And, this is research that is being published soon.

Host: Is this one way that MedStar Washington Hospital Center is trying to decrease narcotic usage in light of the current opioid epidemic?

Dr. Fan: Absolutely and thank you for asking. Yes, opioid use across America has reached a tipping point to where it’s been declared a health emergency. And this protocol especially addresses narcotic use across the board. With our research we’ve been able to demonstrate that application of this protocol has reduced opioid use significantly. And this is great because patients are not reliant on narcotic usage. This takes them out of the cycle of pain and opioid dependence that we unfortunately have seen as health care providers. And this also has the additional benefit of just returning patients to baseline and making them feel a lot better.

Host: Does pain tolerance vary from person to person? If so, to what extent?

Dr. Fan: Absolutely. I think some patients have higher pain tolerances, some patients have lower pain tolerances. Some patients have had extensive history of opioid use. And therefore, it’s up to us, the provider of the patient, before surgery, to have a discussion and so we can better manage their pain after surgery.

Host: Could you share a story in which a patient received optimal care for their plastic surgery with minimal pain at MedStar Washington Hospital Center?

Dr. Fan: Yes. There’s one patient in particular that comes to mind. This is a patient who has given permission for me to share her story. She previously has had more than six hernia operations. Her most recent one required a prolonged hospital stay, over two weeks, part of which was in the ICU. As you can imagine, she was not excited to come to the hospital after her hernia came back. In fact, she was putting off her surgery since July of 2018 and her hernia, subsequently, got a lot more complicated. But, long story short, because of the collaborations between the general surgeons, the anesthesia providers, and us, the plastic surgeons, we were able to devise a plan that decreased the amount of pain and decreased the amount of surgery that we had to do. She ended up doing great after surgery. She was with this ERAS protocol, was walking postoperative day 1. She said that this was the best she’s ever felt in her 7 previous surgeries and that she was very excited to tell all her friends that MedStar Washington Hospital Center offers this service.

Host: Thanks for joining us today, Dr. Fan.

Dr. Fan: Thank you for having me.

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Tree nuts are filled with high-quality nutrients, such as vitamin E, fiber, and phytochemicals. Dr. Patrick Bering discusses how tree nuts can decrease heart disease risk, particularly in people who have diabetes.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Patrick Bering, a cardiologist at MedStar Washington Hospital Center. Thank you for joining us, Dr. Bering.

Dr. Bering: Thank you for having me. It’s a pleasure.

Host: Today we’re discussing how eating nuts may lead to lower heart disease risk for people with diabetes. According to one study, people with diabetes who ate at least five small servings of nuts a week were 17% less likely to develop heart disease. Dr. Bering, what do you make of these results?

Dr. Bering: These results are very interesting, and they seem to add to our understanding of how diet plays a key role in our risk or avoidance of cardiovascular disease. These studies were observational in nature, meaning that they relied on self-reporting from a group of patients, but they were perspective, enrolling patients at a younger stage in their life and then, following up along with them over time to see whether or not they developed any heart disease. I think that they’re very exciting and add to our understanding of what constitutes a healthy diet, especially for our patients who have already developed diabetes.

Host: Why do you think these expanded on our understanding of what we already know?

Dr. Bering: Nuts are an interesting topic. There’ve been some health conditions where nuts were thought to be a food to avoid and that’s been debunked with time. That includes things like diverticulosis, which is a condition of your large intestine. One of the cornerstones of a very popular diet that is practiced by people in the Mediterranean region is the Mediterranean Diet. From our observations, populations who eat a Mediterranean diet have a lower incidence of cardiovascular disease. One of the key constituents of the Mediterranean Diet is actually the inclusion of nuts for regular consumption as part of their usual diet.

Host: Why are nuts so beneficial to our health?

Dr. Bering: Nuts are jam packed with lots of quality nutrients. They have unsaturated fatty acids. They have plant chemicals that are called phytochemicals. They have fiber. Certain vitamins including vitamin E and folic acid. They also have important minerals for our body like calcium, potassium and magnesium. They are really jam packed with all these great nutrients, great nutritional benefit. And, because of that, we get a lot of bang for our buck, so to speak, when we consume nuts.

Host: The study’s authors mentioned that tree nuts were especially associated with lower heart disease risks. What do you think makes tree nuts particularly beneficial for people with diabetes who want to lower their heart disease risk?

Dr. Bering: It’s interesting that this was seen more with tree nuts than other kinds of nuts. It’s important to note that probably one of the most popular nuts, so to speak, is the peanut, which is not a true nut, it’s a legume and it grows underground. Tree nuts grow above ground and they seem to have more of these high-quality nutrients that are beneficial to our health, especially for patients with diabetes. Certain of these minerals, fibers and chemicals are more likely to provide anti-inflammatory effects, and inflammation and diabetes is one of the key driving forces of a lot of the complications in the eye and the kidneys and the vasculature.

Host: For people with diabetes who want to lower their heart disease risk, what kind of nuts do you recommend?

Dr. Bering: That’s a great question. There are so many good ones out there. I think almonds are a great one, cashews, pistachios, walnuts, pine nuts or hazelnuts. And, you can get very creative in the ways that you incorporate these into your diet. My wife, who is a dietician and provides my expert advice at home, will often incorporate nuts either into our breakfast with some yogurt or will add it to a salad as a way to provide some extra texture, crunch and flavor to something that we’re eating. I think there are many great examples of recipes out there, especially with the internet, where you can see how incorporating these into your diet can be helpful. Another thing is that they’re also easy to transport and so they’re a good snack on the go if you’re a little bit hungry and a much healthier option than more food of convenience or junk food.

Host: Are there any potential downsides for people with diabetes when they start incorporating nuts into their diets?

Dr. Bering: It is important to recognize things like portion of nuts is, as well as what salt content they may have. For example, a usual guideline is that one serving of nuts is about a third of a cup. And, if you eat much more than that, you can actually be eating too many nuts. So, you want to make sure that portion control is an important part of your diet. Secondly, some nuts come pre-salted or pre-flavored and many of these flavorings contain salt in them. For patients with diabetes who may have other problems with their kidneys or their heart disease, it’s important to note the salt content and to prefer buying nuts that are unsalted. If you want to add additional flavor to your nuts down the line, you can often use a unsalted preparation in order to give them extra flavor.

Host: Nuts have been shown to lower high blood pressure. What is it about nuts that lowers high blood pressure?

Dr. Bering: That’s still something that’s under a little bit of some investigation, but it seems to be partly the anti-inflammatory effects, there inclusion of unsaturated fatty acids and, most importantly, probably the potassium content. A diet that’s rich in potassium is often one that is very useful at controlling high blood pressure. Potassium is a key component in our diet at making sure that we control blood pressure.

Host: What other diet tips should people with diabetes follow to prevent heart disease?

Dr. Bering: As we talked about before, I think portion control is a very big issue. Many of our portions that we receive outside the home or that we see in advertisements are much too large for what we should actually be consuming. And so, following recommendations, either on the American Heart Association website or the CDC, as far as what a certain portion of different nutrients is, can be very important. As I said before, an optimal portion of nuts when consumed a few days a week or, in this study, up to five days a week, is about a third of a cup. Additionally, a great thing to keep in mind and very simple is that ultra-processed foods - and, what I mean by that is foods that don’t look like anything that occurs in nature - those are foods that often have the worst health effects. Those are foods that have a lot of sugar-enriched sweetening or artificial sweeteners and colors and those are often the foods that lead to adverse cardiovascular health or obesity-related illnesses, such as diabetes or high cholesterol.

Host: Why is MedStar Washington Hospital Center the best place to seek care for heart disease?

Dr. Bering: We have a very comprehensive and passionate team that loves to serve their community here in the DMV. We have experts in every level of care, from primary care to preventative care as well as to emergency care, if you happen to have the misfortune of suffering from cardiovascular disease. I’m very honored to work with my colleagues, who inspire me every day. But, most inspiring to all of us is our interactions with the patients whom we serve.

Host: Could you share a story where a patient with diabetes started following a healthier diet and experienced a decrease in their heart disease risk factors?

Dr. Bering: Yes. Interestingly, I recently had the pleasure of taking care of a young man who was obese and had high blood pressure and diabetes, both of which were more recently diagnosed. He unfortunately came to the hospital with a small heart attack. But, after treating the heart attack, he made really positive health changes in his life. He started doing a cardiac rehab program, exercising on a regular basis, and made positive dietary changes, cutting out a lot of the food of convenience - things like fast foods or snacks that are not natural and are these ultra-processed foods. Since then, he’s lost a good deal of weight, says that he’s much happier and has improved energy and overall quality of life. He’s made great progress and it’s a nice journey to go on with him together, to help support him and his improved cardiovascular health.

Host: Thanks for joining us today, Dr. Bering.

Dr. Bering: Thank you. I appreciate it.

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Riding an electric scooter is fun and convenient. But it’s important to be careful, as accidents can result in serious injuries, such as fractures to the lower and upper extremities. Dr. Robert Golden discusses how we treat these injuries, as well as tips for riding safely.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Robert Golden, Chief of Orthopaedic Trauma Surgery at MedStar Washington Hospital Center. Thank you for joining us, Dr. Golden.

Dr. Golden: My pleasure. Thanks for having me.

Host: Motorized scooters are a growing form of transportation in the US. You see people riding them all around the streets and in traffic. As a result, injuries are always a possibility. Today we’re going to discuss some of these injuries, plus some key safety tips. Dr. Golden, could you start by explaining some of the most common injuries you see from people riding motorized scooters?

Dr. Golden: Well, we’ve seen a fair breadth of different injuries from them. It’s not a typical single pattern that we’ve seen from them, which you see in some other injuries. With the scooters we’ve seen everything from upper extremity injuries to lower extremity injuries and pretty much everything in between. It seems like part of this is probably because of the different mechanisms where you can get injured while on these. Depending on how you get injured and what you were doing at the time, what happened can really change what gets hurt.

Host: Can you share some specific examples of some of these injuries?

Dr. Golden: Sure. We’ve seen a couple people who have just fallen off of them, from simply not negotiating a curve right or hitting a bump in the street or in the sidewalk. Some of them have had fractures of their upper extremities and to their arms. A couple of them had been open fractures, meaning the bone came out through the skin. A bunch of wrist fractures, as well, for the same reason. The other sort of spectrum that we see from these are when they’re hit by cars. Some of them have had lower extremity injuries, in mostly their legs and their tibias, the bone below your knee and above your ankle. Again, sort of the same kind of mechanism that they’ve either simply hit a bump or didn’t negotiate a turn quite right and just fell off. Or, they get hit by a car, which you can imagine causes a lot more injuries. Some of them simply get on them and don’t realize how fast they’re going. Then, in haste to sort of slow down or to make a turn, kind of jump off of them without really slowing down and realize they’re going pretty fast after they’ve jumped off.

Host: Can you think of some of the most frequent treatments you’ve given patients for their scooter-related injuries?

Dr. Golden: Sure. Well, a lot of that depends on what’s been injured. Most of them have, or at least a lot of them, I guess, have required surgery for them which generally would then involve realigning the bone and then stabilizing it either with a nail or plates and screws to hold it still and in the right position until the bone can heal.

Host: What are some tips you offer patients to help them avoid getting hurt while riding their scooter?

Dr. Golden: I think a lot of it is just knowing the capabilities of the scooters themselves and realizing if they’re new to riding these, they’re not exactly the same kind of scooters you were riding when you were little - the little Razor scooters and you would just kind of push them along. Some of them pick up a fair amount of speed - kind of realize that, at that speed, if you hit something or you get thrown off, there’s a good chance that you could injure something. And then, of course, it’s a pretty busy city down here and you always have to watch out for the cars and the pedestrians.

Host: Are there certain people you would recommend not to use a motorized scooter?

Dr. Golden: I think if you’re careful and know your capabilities, you’d probably be ok. Probably not a great idea for anybody with a history of osteoporosis or issues with their fragile bones to try them out. And, I think if you DO, you should just start off slowly, figure out how fast these go, make sure you can maintain control on them before you really see how fast they can go.

Host: Why is MedStar Washington Hospital Center the best place to seek care for any motorized scooter-related injuries?

Dr. Golden: Well, we have the MedStar trauma unit here which allows us to provide a comprehensive care from multiple disciplines. So, the orthopaedic surgery teams are involved, the general surgery teams are involved in case they have any other injuries - internal organs, that sort of thing. And, we’re also plugged in with the physical therapists, the occupational therapists, to get people back to their jobs, get back to walking, depending on which injuries they have, as well as the plastic surgery teams because sometimes these injuries, when the bone comes through the skin, creates a defect that needs to be covered. So, fortunately, we have everything all in one place and all the teams are coordinated so whatever injury you have, we can service.

Host: Could you share a story in which a patient received optimal care for a motorized scooter-related injury at MedStar Washington Hospital Center?

Dr. Golden: Sure. We had one patient who came in - again, same kind of thing - he was riding one of these and fell off of it. Had a fairly complex fracture of his...what’s called his tibial plateau, which is the top part of your tibia, right by your knee. He had to go through several surgeries until that could be stabilized. Eventually, it required some coverage by the plastic surgery team, so they took care of that for him, as well, and, eventually, healed that up.

Host: Can you explain what recovery typically is like?

Dr. Golden: I mean a lot of it depends on what’s broken. In general, bones take about 3 months to heal, somewhere around 12 weeks. Some bones heal a little faster, some heal a little slower. But, in general, they’re looking at some sort of immobilization. Or, once they’re fixed, the point of fixing them is to get them up so that they can move, minimize any stiffness. Usually there’s a short period of immobilization right after the surgery, just to let the wound settle down. Then that’s followed by getting them up and moving and making sure they don’t get too stiff on the joints near where things were broken. We see them back in the office during the entire time that they’re healing to make sure that everything’s healing appropriately, that it’s staying aligned the way we left it, make sure that there’s no other complications coming up or they’re having difficulty with anything else as a result of these things.

Host: Is physical therapy usually a part of recovery?...

Dr. Golden: Yeah, often they do get some physical therapy. Some of it depends on where they were injured and what the treatment was. In general, if it’s in the middle of what’s called a long bone, generally your femur or your tibia, and we can put a rod into it to fix it, they can get up very quickly and put weight on it right away and the bone just heals around it. So, some of those people require less intensive physical therapy because they can just kind of get up and start walking around on their own. Some of the people, where it breaks into the joint and it kind of shatters - it doesn’t break in to clean fracture lines - a lot of those people do require a fair amount of physical therapy to get their joints moving again, minimize their stiffness, rebuild the strength that they lose.

Host: Thanks for joining us today, Dr. Golden.

Dr. Golden: Thanks for having me.

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Blood clots, prior abdominal trauma, or abdominal surgeries can lead to scarring in the iliac veins. Dr. Steven Abramowitz discusses how endovascular iliocaval reconstruction can restore healthy blood flow.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Steven Abramowitz, a vascular surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Abramowitz.

Dr. Abramowitz: Thanks for having me.

Host: Today we’re discussing endovascular iliocaval reconstruction, a treatment for iliocaval thrombosis and other vascular conditions. Dr. Abramowitz, could you begin by discussing who the best candidates are for endovascular iliocaval reconstructions?

Dr. Abramowitz: Sure. It’s a mouthful. Endovascular iliocaval reconstruction is our way of rebuilding the connection in the veins, the structures that bring blood back to your heart. And, when the veins drain from your legs, they merge in your belly, like an upside-down Y and they form one big vein called the inferior vena cava. So, when we say iliocaval, we mean the iliac veins, which drain your legs, and the inferior vena cava, the main vein that they form inside the belly. What can happen is, in certain patients who have had blood clots in the past, or a history of trauma - maybe a gunshot wound to the belly, or even things like radiation therapy for cancer, or prior surgery - scar tissue can form around those veins. And those patients present with significant swelling in their legs and that swelling can also result in significant wound formation in both of the legs, as well. So, what we can do is, in a minimally invasive way, reconstruct the pathway, restoring flow from the legs back up to the heart to alleviate that jam of blood that’s increasing pressure in the veins.

Host: Can you explain how endovascular iliocaval reconstruction works?

Dr. Abramowitz: Absolutely. So, as I mentioned before, when these veins scar down, or block off and narrow, there’s usually a thin little bit left. And the best example I can give is your veins, normally, are like four-lane highways. But let’s say there’s a massive snowstorm and a snowplow has to get through. And it only puts a small path and it piles up all this snow on the sides of the road. Maybe only a bicyclist can get by, or a single car. And that narrowing, when you think about how blood has to flow, is just too little and so the blood builds up in pressure. But what we can do is say we find that pathway, where that one snowplow went, and we can use a series of balloons and stents, which are metal tubes like tunnels, and we can expand and push that snow or scar tissue to the side, making sure that you get all four lanes flowing back again, and alleviating any pressure that’s built up in the legs.

Host: What is recovery normally like following this procedure?

Dr. Abramowitz: Recovery from this procedure is actually pretty easy. For the most part, we’re not making any incisions. So, this surgery is done through punctures, usually behind the knee or in the groin. So, people have some soreness at those puncture sites. The biggest complaint actually is back pain. We don’t really have nerves that tell us our veins are being stretched and so, after this procedure, the most common thing that people experience is a sense of muscle spasm that can last up to 2 to 3 weeks. And that’s really the stretch of that vein sitting in the body. So, you may not feel like you can get comfortable in your chair but you’re not going to feel like you’re in extreme pain.

Host: Are there any risks involved with the procedure?

Dr. Abramowitz: So, the biggest long-term risk from this procedure is actually tied to what caused the procedure to be needed in the first place. Most people who require iliocaval reconstruction - again, stenting and opening up those veins - had those veins shut down as a result of a blood clot. So, once we open those veins up again, we’ve reestablished a pathway from the legs back up to the heart. And so, it’s really important that people stay on their blood thinners. Now, for a variety of reasons, people can develop scar tissue or other ways that the stents can shut down over time. But the biggest danger is if they shut down suddenly through another new blood clot. And that’s if somebody maybe needs to stop their blood thinner to have another procedure. Or, they stop their blood thinner because they don’t think it’s important anymore. So, the biggest risk that I counsel people about is the risk of future DVT and future pulmonary embolism, or that clot moving back from the legs or from the stents to their heart.

Host: Is there anything patients need to do to prepare for surgery?

Dr. Abramowitz: No. For the most part, to prepare for this procedure, it’s to make sure that you’re ready for your surgical date - you have someone to come pick you up from the hospital - and you’re prepared to have your medications ready, which include your blood thinner and some pain control for those potential back spasms.

Host: Why is this procedure superior to other techniques used to treat similar conditions years ago?

Dr. Abramowitz: That’s a great question. I get asked that a lot. The old way of reconnecting these veins was actually to bypass around them. And a bypass in the venous system is a huge surgery. It means making a big incision, all the way from the bottom of your chest all the way down to below your belly button. And then it means opening up both of your groins, taking plastic tubing or a vein from someone who maybe just died recently and donated their veins for use in medical procedures, sewing them all together, closing you back up, and then waiting for you to heal. But not only was that the problem, the blood that flows in your veins doesn’t flow at a very high rate. It flows actually pretty slowly. So, when we talk about blood pressure, most of the time we’re talking about what it is in your arteries, or the pressure at which it comes out of your heart. And that’s 120 millimeters of mercury. So, just remember 120. On the veins, our pressures are much lower and they’re somewhere between 8 and 12 - so, one tenth that of what’s in your arterial system. So, not only did you just have this huge surgery to bring the blood flow back to your heart, with all this plastic tubing or donor vein, but then, on top of that, the blood that moves through it isn’t moving very fast. So, it’s a very big surgery. And, in the past, it wasn’t really worth it because the failure rate was so high. Over time, most of the things that were done from an open surgical standpoint thrombosed, or clotted off. Now that we can do this within the body, in its natural pathway, we find that the patency rate, or our stents staying open (is really what we call patency), is much higher. And 87 percent of people that undergo iliocaval reconstruction have open stents at five years, which is much, much higher than the previous open bypass rates. So, if you had the bypass, it’s a big, open surgical procedure, usually resulting in a hospital stay that’s anywhere from 5 to 7 days, and then there’s recovery time after that. And, as I said before, the likelihood of that bypass staying open is pretty low. Not to mention, once you have all that scar tissue from the bypass, it pretty much eliminates a lot of other surgical options you may have in that area. Whereas, on this endovascular side, we can do things in a minimally invasive way, via some punctures, you can go home the same day, and it doesn’t necessarily limit your options in the future, should, in the small case that you’re that 13 percent your stents don’t stay open at 5 years, they do fail.

Host: Why is MedStar Washington Hospital Center the best place for patients to seek an endovascular iliocaval reconstruction?

Dr. Abramowitz: Well, there are a lot of great facilities out there that can perform venous stenting. MedStar Washington Hospital Center was one of the first in the country truly performing endovascular iliocaval reconstruction in its entirety. Not only that, we also are engaged in a lot of novel techniques to do this in a way that improve patency and outflow. So, we’re really one of the leaders in this field and we have a lot of new technology that we’re developing, as well as new techniques for patients who may have failed therapy before at other institutions. So, we’re on the forefront of this field and we really do have a comprehensive program in place to care for patients, both before and after their reconstruction.

Host: Thank you for joining us today, Dr. Abramowitz.

Dr. Abramowitz: My pleasure. Thanks for having me.

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Each year, more than 500,000 people visit an emergency room because of a kidney stone, which can cause severe kidney pain and blood in the urine. Dr. Daniel Marchalik discusses outpatient tubeless mini PCNL, a minimally invasive procedure for large kidney stones.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Daniel Marchalik, the Director of Ambulatory Urologic Surgery at MedStar Washington Hospital Center. Thank you for joining us today, Dr. Marchalik.

Dr. Marchalik: Thanks so much. Happy to be here.

Host: Today we’re discussing percutaneous nephrolithotomy, or PCNL, a technique used to remove kidney stones. Dr. Marchalik, could you begin by discussing who would be a candidate for mini PCNLs?

Dr. Marchalik: Yeah, so PCNLs are...actually, it’s a very interesting procedure because traditionally we’ve always thought of PCNLs as being a very invasive and a very difficult procedure. But increasingly, what we’re finding is that PCNLs, or the indications for PCNLs, have been expanded. So, anyone who has a large kidney stone - and by that I mean a stone that’s bigger than 1-½ centimeters - is automatically a better candidate for a PCNL than other types of surgery, barring other considerations, of course. But for mini PCNLs specifically, what we’re finding is that patients that have intermediate-sized stones - so maybe a lower pole stone that’s a little bit bigger than a centimeter or other stones that are bigger than a centimeter and a half but maybe less than a full staghorn calculus, which is a stone that occupies the whole kidney - those are the perfect patients.

Host: What are some common symptoms people have before they’re diagnosed with kidney stones?

Dr. Marchalik: A lot of times people will present with pain in their kidney or in their back. They might feel like they are actually passing a kidney stone, in which case they will have spasms. In fact, people have actually compared kidney stone pain to childbirth. And, they did a study on this and it turns out that passing a kidney stone is as painful as giving birth. It’s one of the few times that guys can actually feel what women go through. Also, sometimes you can present with an infection in the urine or blood in the urine. And, all of those could potentially be caused by kidney stones.

Host: How does a mini PCNL operation work and what are its greatest benefits?

Dr. Marchalik: So, percutaneous nephrolithotomy - if you actually break the word down, it means that we are going percutaneously through the skin into the kidney. And nephrolithotomy means that we’re taking the stone out of the kidney. So, we put a small opening into the kidney, through the back, and through that opening we’ll put in a scope and a probe that can break the stone up into smaller pieces and actually suction those pieces out. The greatest benefit of the mini PCNL versus a regular PCNL is that with this procedure we still get all the benefits of a PCNL. So, we still can get patients out of the hospital with less stones or no stones at all. We can decrease the number of surgeries that they need to become stone free. But, it’s got some new benefits - meaning, we do it through a small opening so there’s less pain afterwards. We don’t have to leave a tube behind in the back a lot of times. And, a lot of times we can actually send patients out the same day. So, traditionally people would have to stay in the hospital for several days to get this procedure. But now we can actually get patients in and out and still be able to clear way more stone than we would be by other techniques.

Host: What can patients expect during recovery?

Dr. Marchalik: There are certain things that necessarily will happen whenever you have surgery - so, grogginess after anesthesia. Some people can get nauseous after the anesthesia and that happens with any type of anesthesia that you get for any procedure. With this particular procedure, sometimes patients can have pain in their back where the opening was. And they can see blood in their urine for several days. And, they can feel some discomfort in their stomach or in their back afterwards, and a lot of times that’s actually from a small tube that we call a stent that’s left behind to allow the area to heal.

Host: How is the way you perform mini PCNLs compared to traditional PCNLs or similar treatments from years ago?

Dr. Marchalik: The main difference here, the thing that really separates mini tubeless PCNL from a regular PCNL, is that we’re doing it through a smaller opening. Before, we would have to put a larger opening to accommodate our large instruments but as we began to miniaturize these instruments, we’ve been able to do this through a much smaller incision. And, as you can imagine, a smaller incision leads to a better recovery, less pain, less discomfort. The biggest difference is - and the biggest barrier to doing PCNLs traditionally - has been the length of stay, meaning you want the benefits of the PCNL to get as much of the stone out as possible, to do it quickly, but you don’t want the longer hospital stay, possibly coming in the day before, possibly staying a day after the procedure. With this procedure, we’re now able to send patients home the same day as the procedure itself. So, we get the benefits of the PCNL but not some of the barriers that we’ve seen in the past.

Host: Why is MedStar Washington Hospital Center the best place to receive mini PCNL and similar operations?

Dr. Marchalik: I think a lot of it comes down to us having a high volume of this procedure. It’s a procedure we do a lot of and we feel very comfortable doing. We also have a really fantastic interdisciplinary team. So, sometimes we’ll review these images with our interventional radiology partners, if it’s a more complex case. But more importantly, we also think about this holistically. It’s not just a surgery. At the end of the day, we also follow these patients for years after. We make dietary modifications and any type of other changes that we need to make to make sure that we don’t just treat the stone. We treat the patient. And we prevent these stones from coming back in the future.

Host: Could you share a story where a patient received optimal care at MedStar Washington Hospital Center through a mini PCNL?

Dr. Marchalik: Well, actually I had a really great case recently. This was a patient who had a large stone. It was blocking his kidney, causing a ton of pain in his back, some nausea and other discomfort. And he was really concerned because he thought that he would require multiple surgeries to get rid of the stone. We were able to do a PCNL - a mini tubeless PCNL - on him. He came in for an 8:30 case. He was home by 1 o’clock. No pain. No discomfort. No tubes left behind. I ended up seeing him in my clinic the week after and he reported that he actually had a great postoperative course. He didn’t have any discomfort or pain. No issues with his back. And all the pain that he had before the surgery was now gone. Now, we still have a long road ahead of us. We still have to figure out why it is that he was making stones in the first place, but at least this part is now over.

Host: Are there any risks associated with mini PCNLs?

Dr. Marchalik: As with any surgery, you have inherent risks associated with the anesthesia itself. And it doesn’t matter what type of surgery it is, anesthesia always poses a risk. But, there are some inherent risks to this procedure itself. Because we’re going through the back, there’s always risk of damage to the organs that are around the kidney. Now, that risk is small. The only time that this could be a little bit more concerning is with stones that are very high up in the kidney, but we take measures to mitigate that risk, as well. The real risk is that we don’t get all the stone out. And sometimes when you have a very large stone, even despite using this technique, not all the stone gets cleared. That being said, this is the procedure that gives you the highest chance of being stone free at the end. But, we still have to remember that, as with any surgery, every case is different. So, you have to always be able to adapt and do what’s right for each individual patient.

Host: Thank you for joining us today, Dr. Marchalik.

Dr. Marchalik: Thanks so much. Happy to be here.

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Treating cancer on the head or neck can seem intimidating, as people fear surgery could leave unwanted scars around their face. However, with the techniques we use today, people often end up cancer-free with very few changes to their appearance.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Jonathan Giurintano, a head and neck cancer surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Giurintano.

Dr. Giurintano: Thank you so much for having me today.

Host: Today we’re discussing reconstructive surgery for head and neck cancers. When a patient has cancer in such a visible area of the body, it’s important for them to have options to not only remove the cancer, but also keep them looking like themselves after surgery. Dr. Giurintano, what are some of the more common cancers for which patients might need reconstructive surgery after treatment?

Dr. Giurintano: So, while approximately 90 percent of cancers that occur in the head and neck region are a type of cancer called squamous cell carcinoma, this type of cancer can affect multiple areas within the head and neck. Some examples include the tongue, the jaw bones, the palate, the inner surface of the cheeks, the back of the throat, carotid or saliva glands, and the voice box. Oftentimes, the surgery required to remove tumors from these locations results in very large, noticeable defects that affect not only the patient’s physical appearance but oftentimes their ability to speak, breathe or swallow. More recently, legendary Buffalo Bills quarterback Jim Kelly has been in the news for his fight against head and neck cancer. His cancer was a squamous cell carcinoma located in the maxilla, or the upper jaw bone, and he initially underwent treatment consisting of chemotherapy and radiation therapy but unfortunately developed a recurrence of the cancer after his initial treatment. Because of this, surgery was performed to remove the recurrent cancer in his upper jaw bone and the salvage setting. And, in a patient who’s previously had radiation therapy, it’s very difficult for this area to heal after surgery and the result leaves a communication between the mouth and the nose, which can make speech abnormal, as well as swallowing. So, Jim Kelly underwent his surgery in New York by Dr. Mark Urken, who’s one of the most nationally known and most experienced surgeons, using what we call free flaps to reconstruct head and neck defects. So, a free flap is a piece of tissue that’s harvested from an area of the body outside of the head and neck, that often consists of either skin, fascia, muscle, bone, fat or a combination of all of these. And, it’s a piece of tissue that can be harvested with an artery and a vein that can supply blood to this piece of muscle or bone or fat. We can then take that tissue from the leg or the arm or the thigh and then transfer that up into the defect site and use it to reconstruct things like the tongue, the voice box or the jaw bone. Then, using a microscope, under very high magnification, we can actually sew the artery and the vein that are from the flap to an artery and a vein in the neck and that will actually provide that piece of tissue with its own blood supply. This is especially important in head and neck cancers because most of our patients receive radiation therapy as part of their treatment and without a robust, healthy blood supply, most pieces of tissue will die from the radiation therapy. We do know these pieces of tissue have a robust vascular supply and that they can withstand the radiation treatment, leading to very good results in reconstructing the donor site defect. In Mr. Kelly’s case, Dr. Urken performed what’s called a fibula free flap. And that’s when a piece of bone from the lower leg, called the fibula, is harvested with some overlying skin and an artery and a vein and he was actually able to use that bone to recontour the upper jawbone that was missing after the surgery. And he was able to use the skin from the flap to seal the hole in the palate so that Mr. Kelly was able to talk, eat and look normal essentially. In Mr. Kelly’s case, he was then able to have titanium dental implants inserted into that bone so that he could actually have teeth in his upper jaw again. And, if anyone’s seen him in the news lately, they did a fantastic job and he looks almost the exact same as he did before surgery. And, that is really the ultimate goal of cancer and reconstructive surgery nowadays.

Host: How do patients feel when they learn that their appearance might be affected by the surgery that will remove their cancer?

Dr. Giurintano: So, patients often feel a mixture of emotions. Receiving a diagnosis that you have cancer is very difficult. And, to add on to that diagnosis that you might require major surgery that might result in a physical deformity can be even more devastating to patients. Our facial structure is often a major part of our identity and it can be very psychologically devastating to learn that your visual appearance might be affected. This goes for the voice, as well. We all have unique voices that we can recognize very distinctly. And the possibility that you might lose your own unique voice can be very devastating to patients. In the past, patients would often have these tumors removed without any technology to reconstruct them and this could lead to crippling deformities that were very easily noticeable upon first glance. And this has a major psychological impact on patients. Some can often lead to depression and anxiety in our cancer patients. And while it’s impossible to perform a surgery that’s completely scar-less, all surgery requires at least an incision, today we have advanced techniques that limit the deformity that’s caused by removing cancers from the head and neck. We also have to give credit to the body itself. The body is pretty incredible in that anytime we take skin from the arm or the leg and we place it into the mouth, the body can actually recognize this change in the environment that the skin is in and it actually begins to change the cell types of that flap. And through a process that we call mucosalization, the flap actually begins to take on the appearance of the native tongue or the native surface of the mouth. In many of these patients, when you see them one or two years down the road, it is actually very difficult to tell which piece of tissue in the mouth came from the arm or the leg. It just looks like normal tissue.

Host: Is the reconstruction procedure performed separately from the cancer surgery?

Dr. Giurintano: So, we actually work together in what we call a two-team approach so that we can both remove the cancer and reconstruct the defect at the same time. This means that while the ablative, or the cancer removing surgeon, is working in the head and neck to take the cancer out, the reconstructive surgeon is, at the same time, working on the arm or the leg to harvest the flap so that as soon as the cancer is removed and the defect is made, the reconstructive surgeon can then take that flap, remove it from the arm or the leg and begin in-setting it into the defect. So, by doing the cases in this manner, we can typically finish an entire cancer removal and reconstruction in anywhere from 6 to 10 hours. Back whenever these types of surgeries were invented 20 or 30 years ago, the cases could often go over 24 hours. So, it’s actually been a big advance in our medical practice that we can finish these cases generally in under 12 hours. Our goal, essentially, is to limit the time the patient has to spend on the operating table under general anesthesia and to try to get patients back on their feet as quickly as possible after surgery to help quicken the recovery process.

Host: What does a patient have to do to prepare for head and neck surgery with a reconstruction?

Dr. Giurintano: Most of the preparation, from the patient standpoint, is more mental and emotional. We recommend that they have a good support system in place, whether it’s family or friends, to help them cope with the psychological impact of undergoing a major surgery and a, typically, 7 to 10-day hospitalization. There are some tests that we may perform in our clinic or in the radiology suite before we schedule a patient for a free flap. Nowadays we really try to tailor what type of free flap we are doing individually to each patient. In the past, physicians would often do one flap as their main flap, regardless of what the defect was or what the patient’s lifestyle included. But nowadays, for example, say if a patient of mine was a classically trained pianist and they wanted to continue playing piano after their surgery, I would be very hesitant to take any tissue from around their forearm or wrist. I would not want to interfere with their ability to play the piano at all. So instead I would go to a different donor site, either the side of the body or the leg. I’d take a similar piece of tissue and contour this to match the defect site. Occasionally, some patients require some tests such as angiography. This is a special test performed in the radiology suite to determine if the blood vessels are good enough to support a flap. For the fibula flap, especially - that’s a flap of the bone called the fibula in the lower leg that we often use to reconstruct the jaw- we know that there’s 3 distinct blood vessels that carry blood into the lower part of the leg to supply the foot. By taking the fibula, we have to take one of those blood vessels out to apply the flap, leaving 2 blood vessels to supply the leg. Normal patients - this is not a problem to remove this blood vessel. However, some patients only have 1 or 2 blood vessels supplying the lower leg, not 3. In these cases, it could be potentially disastrous to take the 1 blood vessel that’s supplying the lower leg. So, in this type of flap, we’ll always do a test before to make sure that the blood vessels are sufficient to sustain the flap. But otherwise, typically, we do not have many other special tests that are required before pursuing a major reconstruction.

Host: How long is the recovery time for these patients?

Dr. Giurintano: So, in general, our patients who undergo free flap reconstructions generally spend the first two days after surgery in the intensive care unit setting. During this time, it’s not that they’re so sick they require a stay in the intensive care unit. It’s actually that we have to frequently check the blood vessels supplying the flap to ensure that the blood is flowing to the flap and that the flap is getting the nutrients that it needs. Once the first two days have passed, as long as the patient is doing well, they often go to the floor. And from that point on, most patients spend anywhere from 3 to 5 days on the floor, receiving basic medical care as they recover. Oftentimes they’re receiving physical therapy or occupational therapy during this time to recover their strength. And all of the basic preparations for that patient to go home are being arranged. Typically, if all goes well during the surgery and during the hospitalization, most patients spend about 5 to 7 days total in the hospital and then either go home or sometimes go to a lower level of care, such as a rehabilitation facility to help regain their strength before they’re ready to go home. Once at home or in a rehab facility, it still takes a couple of weeks for the patients to completely recover. And, in general, the entire recovery process takes about 4 to 6 weeks total. But, most patients are back swallowing, speaking, and doing normal activities within 2 weeks of surgery.

Host: What additional treatment or care do patients need after reconstructive surgery?

Dr. Giurintano: Depending on the complexity of the case and how the hospitalization proceeds, some patients are able to go straight home and essentially require very minimal extra care. Occasionally, patients require the placement of feeding tubes or tracheostomy tubes. Tracheostomy tubes are special breathing tubes that are inserted into the neck that some patients may require because, occasionally, there’s too much swelling or the flap is too bulky inside of the mouth for them to breathe or to swallow well. Generally, this is a short-term procedure that patients do not require permanently, but sometimes this may require some extra care by a home health nurse or at a rehabilitation facility. Occasionally, if patients have trouble swallowing in the post-operative period and we a concerned that they might accidentally aspirate their foods, a tube can be placed into the stomach to help facilitate nutrition while they’re recovering. And, generally, this is also a short-term procedure that most patients are able to have removed after 6 to 8 weeks.

Host: How do the surgeons at MedStar Washington Hospital Center help patients achieve the best cancer related outcomes and cosmetic outcomes with these complex procedures?

Dr. Giurintano: So, at MedStar Washington Hospital Center, we work together as a team. Our team includes multiple members within the department of otolaryngology head and neck surgery. And this includes both ablative cancer surgeons (so those are surgeons who remove the cancer), reconstructive surgeons (such as myself), as well as facial plastic and reconstructive surgeons (so these are surgeons who are specially trained in cosmetic procedures of the head and neck). In caring for these patients, we, as surgeons, are responsible for the removal and the reconstruction of their cancer and the subsequent defects. But, in treating their cancer, we also share equal responsibility with our colleagues in the departments of radiation oncology and medical oncology. There are some types of head and neck cancer that can be managed through surgery alone, but most patients who have a head and neck cancer will also require either radiation therapy or chemotherapy as part of their treatment algorithm. We actually have a regular meeting at the MedStar Washington Hospital Center where the surgeons (such as myself), the medical oncologists, the radiation oncologists, the speech pathologists, the pathologists and the radiologists all meet to discuss new patients who have been diagnosed with cancer, as well as patients that have recently been treated for their cancers. And, during this meeting, which is what we call a multidisciplinary treatment conference, we are able to actually stage each patient’s cancer. We’re able to decide on a treatment that best suits that patient’s cancer. And, we’re able to put all of the right consults and all of the right steps in order so that patient can begin their treatment as soon as possible.

Host: Could you share the story of a patient who had a particularly successful outcome?

Dr. Giurintano: Yes. A patient, who had recently had several previous head and neck cancers, presented to the MedStar Washington Hospital Center, in my partner, Dr. Matt Pierce’s, clinic. This patient had previously undergone multiple surgeries and he had essentially received the maximum dose of radiation therapy that the body could receive in that area. And, unfortunately, there was a new cancer that had developed. This was a very devastating diagnosis to him, as he was a cancer survivor already. But, we were able to perform, essentially, a removal of the entire voice box and the entire back wall of the throat and then reconstruct that with tissue from his upper thigh. And, he had an absolutely amazing postoperative course. He was out of the hospital by postoperative day number 7. And this gentleman, who had not swallowed in 6 months, we had just obtained a swallow study to evaluate how the flap had healed, and he was able to swallow again - well - for the first time in 6 months. So, he was a particularly good outcome and we were very pleased with how he healed.

Host: Thanks for joining us today, Dr. Giurintano.

Dr. Giurintano: It was my pleasure. Thank you so much for having me.

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The adrenal glands respond to signals from the nervous system and produce hormones that regulate many of the body’s normal responses. Dr. Erin Felger discusses what happens when a tumor develops on the adrenal glands and how we treat it.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Erin Felger, an endocrine surgeon at MedStar Washington Hospital Center. Thanks for joining us, Dr. Felger.

Dr. Felger: Thank you for having me.

Host: Today we’re discussing adrenal surgery, or procedures to remove the adrenal glands. Dr. Felger, to begin with, what do the adrenal glands do?

Dr. Felger: The adrenal glands are located on the kidney. The adrenal glands make different hormones that help regulate different systems in your body. A hormone that everyone is familiar with is adrenaline and that is one of the main hormones that the adrenal gland makes.

Host: What symptoms might cause a patient to visit their doctor and ultimately lead to a diagnosis of an adrenal problem?

Dr. Felger: Well, it depends if the adrenal tumor is producing hormones or if it is not producing hormones. If it is what we call a functional tumor, the patient may have high blood pressure, headaches, palpitations, skin changes, weight gain, diabetes, fatigue or weakness. If the tumor is not producing hormone, the patient may not have and likely won’t have any symptoms at all.

Host: Why might a patient need to have the adrenal glands removed?

Dr. Felger: Usually, we only remove one adrenal gland. It’s very rare to have bilateral tumors that need to be removed from those adrenal glands. One adrenal gland with a tumor usually needs to be removed for one of two reasons, the first being that the tumor is producing hormone and causing the patient to be sick or the tumor is too large in size and needs to be removed because of concern for cancer.

Host: How do you advise patients to prepare for adrenal surgery?

Dr. Felger: Again, it’s first having a consultation with your surgeon and then following the steps that need to be completed prior to surgery, which usually include labs, EKG, physical, extra imaging and any clearances that need to be had by other physicians.

Host: What does recovery entail after a procedure?

Dr. Felger: Recovery is very straightforward for adrenal procedures that are done laparoscopically or retroperitoneally. The patient is able to eat and walk and do most regular activities except for heavy lifting. Laparoscopic adrenal surgery is done from the belly side and it includes using a camera and small instruments and small incisions to remove the adrenal gland and the tumor. Retroperitoneal adrenal surgery uses a camera and small instruments and incisions but is done from the back and not the front.

Host: Do patients need additional therapies after surgery?

Dr. Felger: It depends on what type of adrenal tumor a patient has. They may need to have follow-up with their endocrinologist to adjust medications. They may need further imaging studies and potentially treatment if they have a cancer.

Host: What sort of medications would they patients have to take ongoing?

Dr. Felger: Depending on the type of adrenal tumor, some patients may need to take long-term steroids in order to have normal function until their other adrenal gland wakes up. Other patients may need to have further imaging or frequent follow-ups and, potentially, medication if they have a cancer.

Host: Could you share a success story of a patient who overcame adrenal issues, thanks in part to surgery?

Dr. Felger: Yes. I had one patient who was a young man and he had excessively high blood pressures and was taking multiple medications and it was affecting his activities of daily living. His doctor did a full work up and found an adrenal tumor on one side. He came to see me and I completed the work up and had a good discussion with him about the operation to remove the adrenal tumor. I explained to him that it would hopefully help his high blood pressure but it may not cure it completely. The patient had the operation and he did very well during the surgery and afterwards. When he came back for his postoperative visit, he was doing quite well and he was off all of his blood pressure medications and he was quite thrilled because he was already getting back to his activities of daily living that he had been unable to do prior to the surgery.

Host: Why should a patient come to MedStar Washington Hospital Center for their care?

Dr. Felger: We have a multidisciplinary approach with our adrenal patients. They can be seen by our endocrinologists as well as have nuclear medicine studies done and then follow-up with the surgical team. We do an excellent volume of adrenal surgery at our institution and we are trained in both laparoscopic and retroperitoneal approaches so we can offer as many options as possible to our patients.

Host: Thanks for joining us today, Dr. Felger.

Dr. Felger: Thank you again for having me.

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Caregivers can spot dementia in numerous ways, ranging from a loved one forgetting about their favorite television program to suddenly not remembering to pay their bills on time. Learn who Dr. Cesar Torres says is most at risk of dementia and how to manage it.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Cesar Torres, a geriatric and house-call doctor at MedStar Washington Hospital Center. Thank you for joining us, Dr. Torres.

Dr. Torres: Good afternoon.

Host: Today we’re discussing dementia, a neurological condition that tends to develop in older adults and is characterized by memory loss and confusion. Dr. Torres, could you start by discussing how dementia develops in the brain?

Dr. Torres: Certainly. Dementia develops as a result of the production of a neurotoxic protein called beta amyloid and, as a result of accumulation of this protein, nerve cells in certain areas start to die, specifically the memory centers of the brain - the hippocampus, the parietal lobe - and, as a result, people start to experience neurocognitive deficits. The most dramatic ones tend to be in the memory realm, but there are other cognitive deficits that also develop. And these eventually lead to significant social dysfunction and impairment, and it’s, unfortunately, very progressive.

Host: Are there any populations of people who are at increased risk for dementia?

Dr. Torres: Well, the number one risk factor for dementia is age. The older you are, the higher the prevalence. Recent estimates - generally, by the time you’re 70-75, there’s upwards of a 20 percent prevalence rate. Dementia encompasses a few different pathologies. There’s Alzheimer’s dementia, there’s Vascular dementia, there is a dementia associated with Parkinson’s, there’s a Lewy body dementia and there are some other much more esoteric subtypes. The vast majority are Alzheimer’s-type dementia, generally in the range of 60, 70 percent. After that, Vascular dementia rounds off the list, mostly around 15 to nearly 20 percent. And then, all the others. So, each one tends to have certain predispositions. For Alzheimer’s, there’s a genetic predisposition. It’s not 100 percent correlative, but there is a genetic predisposition and it can run in families. Vascular dementia tends to affect folks who have vascular disease - hypertension, coronary artery disease, people who are more prone to strokes. Brain trauma can predispose people to another subtype of dementia, and there’s a lot of focus now on this Traumatic encephalopathy that we see in a lot of professional, high-contact sports. Some of the other more esoteric subtypes - probably more of a genetic predisposition. So, as far as high-risk groups are concerned, that’s not an all inclusive list but there are certain groups that are at greater risk. But like I said, age is the number one risk factor. So, if people could stop growing old, we wouldn’t have a problem.

Host: In these high-risk individuals and these aging individuals, what are some of the warning signs of dementia that families should start watching for?

Dr. Torres: That’s a very good question and unfortunately, it’s also a very broad question. Generally, the onset of Alzheimer’s tends to be extremely subtle. You’ll tend to see problems with the acquisition of new knowledge or new information, the retention of new knowledge and new information. A family member asks how to get to a grocery store over and over again, in spite of having been there not too recently. You can see difficulty with social functioning as well, as the disease progresses. An individual who was extremely capable of managing their finances suddenly forgets to pay their bills and the electricity gets turned off. As things progress, now you can see personality changes. Sometimes the person starts to retreat into themselves - more withdrawn as some awareness of the social dysfunction starts to creep into their consciousness. Generally, the family will feel something isn’t quite right with their loved one and that’s when they actually probably bring it to the attention of their primary care physician or caregiver. The social functioning piece becomes more dramatic and is more distressing for folks, and they tend to pick up on that fairly quickly because it’s a dramatic departure from previous level of functioning.

Host: If someone notices that a loved one is showing signs of dementia, where should they turn for help?

Dr. Torres: Generally, most primary care physicians can do at least the initial screening. This generally can include blood tests, neuro imaging - in the form of a CT scan or an MRI. There are some blood tests that can also help rule out reversible causes of memory loss. But generally, the primary care physician should be the first point of contact.

Host: Are there any treatment options available to help patients with dementia manage their symptoms or reverse the condition?

Dr. Torres: Well, unfortunately, we have no way to reverse it at the current time. And that’s the Holy Grail. There have been many, many, many attempts to find drugs and various treatments but none have really been successful up to this point. As far as medications to modify the progression of the disease, there are a few, the most famous one being Donepezil, trade name Aricept and Namenda, generic Memantine. If you make a diagnosis of dementia, you don’t automatically use the medication. It’s best to have a conversation with the patient and the family and to decide whether or not the patient has reached the stage where they would benefit from this medication because all of these medicines has toxicity. What the medicines offer, really, are slowing the progression. And, you may see unfortunately temporary improvements in certain memory functions. But, unfortunately, over time, the effect diminishes and the disease starts to progress again. If you look at it on a bell curve, most folks will fall in the middle. They will get some, but there are those who can get a lot and there are some who, unfortunately, don’t get anything. The middle is where the bulk of the patients will fall. But on an individual, case by case basis, you can get a substantial amount of improvement. The biggest benefit, I feel, from starting treatment with these medications is time. You buy time. And time is very precious for people. So, on the basis of that, if we’re at a relatively early enough stage, I think it’s a worthwhile choice.

Host: You mentioned a couple of different potential causes for dementia. What can patients do to reduce their risk of developing it?

Dr. Torres: We have looked at lots and lots of different options - herbal medications, anti-inflammatories, Vitamin E - and the list goes on. But, to date, the only two things that I can recommend honestly? A healthy lifestyle and daily exercise. Daily exercise actually has evidence behind it. So, among all the other benefits that a person can obtain from daily exercise, prevention of dementia is another one. There was a sub-analysis of the Women’s Health Initiative Study that was done a few years ago that looked at the impact of exercise and noted that it reduced their relative risk by about 40 percent, as a result of daily cardiovascular exercise. The reasons for that, the mechanism behind it - still remains a bit unclear but I suspect it has to do with just overall benefits of exercise and physical activity. And it doesn’t need strenuous exercise also, but some form of daily cardiovascular exercise would be a great benefit. Well, I would recommend being very judicious with alcohol intake. There is an Alcoholic dementia that exists. Otherwise, avoiding smoking. Smoking can lead to vascular problems that can lead to Vascular dementia. Good sleep, weight control - things like that.

Host: How do the dementia experts in the geriatrics program and the house-call program at MedStar Washington Hospital Center help patients and families achieve optimal outcomes?

Dr. Torres: The number one way is in the diagnosis of the condition because sometimes it can present atypically. Sometimes it can present, as I said, very subtly. So, sometimes it has to be teased out. And again, it’s time. We can gain time for better interactions, more complete interactions with the patient and the family member. And there are a few conditions that can masquerade like dementia that we can treat and reverse the symptoms that we associate with dementia - the memory loss. The one that is most well known is depression. Depression can manifest itself as a type of dementia with memory loss, with loss of concentration, with apathy, as well. And so by treating that, the patient -- effectively treating that -- the patient can regain their function and their memory.

Host: Could you give us an example of how you care for a dementia patient through the house-call program?

Dr. Torres: Well, we have a very focussed approach with really educating and helping the caregiver meet the needs and ease the process for the patient. There’s usually a lot of frustration that the caregiver feels with their loved one as the disease progresses. And the deficits become more and more overwhelming. So, we tend to review behavioral techniques that can ease the tension in the household. We can help them with treating comorbidities to maximize their time at home. And we do everything we can to help the patient age in place, which is often a great benefit for everyone - avoids unnecessary trips to the emergency department, unnecessary hospitalizations.

Host: Thanks for joining us today, Dr. Torres.

Dr. Torres: It was my pleasure.

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Transcatheter Aortic Valve Replacement (TAVR) has come a long way since it was introduced in the U.S. in 2007, as doctors’ experience and technological advancements have improved. But the medical community still has work to do. Dr. Toby Rogers discusses the current and future state of TAVR.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Toby Rogers, an interventional cardiologist at MedStar Washington Hospital Center. Thank you for joining us, Dr. Rogers.

Dr. Rogers: It’s a pleasure to be here.

Host: Today we’re discussing the future of transcatheter aortic valve replacement, or TAVR. TAVR is a treatment for patients with aortic stenosis, or narrowing of the aortic valve. Dr. Rogers, could you discuss how a doctor can replace an aortic valve without open-heart surgery?

Dr. Rogers: That’s a great question and it’s one that every patient wants to know. So, I think open-heart surgery makes sense. You open the chest, you stop the heart from beating, you cut out the old valve, you sew in a new one, you restart the heart beating again, you sew the chest up, and you have a new heart valve. TAVR is very different. In fact, we don’t actually take the old valve out at all. And, what we do is we thread a new valve through the artery from the leg, all the way up to the heart, and then we open the new valve inside the old one, just pushing the old one out of the way, and we leave the new valve behind, opening and closing inside the old one. And, the beauty of this is that obviously we’re able to that, as I said, thread it from the leg, without having to do open-heart surgery, without having to stop the heart from beating, without having to even put the patient asleep. And so, it’s much less invasive and much less of a stress on the body.

Host: What are some of the improvements in TAVR that you’ve witnessed or been a part of in your practice?

Dr. Rogers: So, I think you can divide the benefits into two broad areas. The first is technology. So, we are now on to the third generation of TAVR valves, meaning that the companies that develop these, and the doctors and scientists that work with them, have gone through three iterations now, or improvements, on the valve technology. And each iteration, each new improvement, has brought dramatic improvements to the whole procedure. Specifically, the catheters that we deliver the valves through from the groin have gotten smaller and smaller. And the smaller a catheter, the less invasive the procedure and the more patients are able to have this procedure because even patients now with very small...even patients with some blockages in the arteries down to the legs, are able to have TAVR whereas in the past they wouldn’t have been able to do so. There’ve also been some key technology improvements that reduce the need for pacemakers after the procedure, that reduce the risk leaking of blood around the new valve after the procedure. And, we know that all of these things put together make for a much more durable and lasting result. And then, the second area that there’ve been improvements is just in our comfort and our experience with the procedure. To the point that when we started doing TAVR, we actually used to put all the patients asleep with general anesthetic. We used to have an echo probe, an ultrasound probe, down the esophagus so that we could monitor the heart very, very carefully during the procedure. And, with experience, we’ve learned that those things are actually not necessary. And so now we do TAVR, as I mentioned before, under just a little bit of sedation. We don’t put patients to sleep. And we don’t even need the ultrasound probe to guide the procedure anymore. We can do the whole thing using x-rays, which is must less invasive. And so, if you put these technology advances and the procedural advances and experience together, it makes for a much less invasive...in fact, we use the word “minimally invasive” approach to TAVR now, and all of those things put together make for better outcomes, faster recovery, shorter time in hospital, and overall better results.

Host: Even with all of those amazing benefits, what do you think should be improved in the next generation of TAVR?

Dr. Rogers: So, we have great devices to replace TAVR valves that are tight, meaning they’ve gotten tighter and tighter over time. We see a lot of patients who have leaky valves, and actually, we don’t have great technology for those yet. That technology is just coming along and MedStar is actually one of just two hospitals in the country that is testing a new valve for this specific problem. But up until now, we’ve really been in a bind in that these patients with leaky aortic valves, we’ve had to say, “Sorry, we don’t have a minimally invasive treatment for you. Open-heart surgery is your only option.” So, that’s one area where I think there is definitely room for improvement. I mentioned the size of the catheters. Smaller catheters are always better because it makes for an even more minimally invasive procedure, so I anticipate that in years to come these catheters and devices will get even smaller, and I think that’s only a benefit for patients. There’s been a lot of work to improve how well these heart valves sit inside diseased aortic valves that aren’t completely round, and aortic valves that had a lot of calcium in them, which is something that we commonly see. And, those patients are particularly prone to having electrical conduction problems after TAVR, and needing pacemakers. And so, there’s still a lot of work to be done, I think, to improve the technologies so that patients really don’t need pacemakers after TAVR because again, if you do need a pacemaker, that often extends the time you’ve been in hospital and it’s an additional procedure that you have to undergo.

Host: What do you think will be the biggest challenges or barriers in improving or providing TAVR in the future?

Dr. Rogers: So actually, I think the answer to that question doesn’t have much to do with TAVR technology or the procedure itself. It’s about access and availability to TAVR. If you live in a big city that has a hospital like MedStar Washington Hospital Center that does TAVR, and you have aortic stenosis, then there is a hospital just down the road that can provide you this treatment. If you live far from a big city, then often your local hospital doesn’t have access to this technology because it is still a specialist procedure. And so, there are a lot of patients out there across the country who live far from hospitals and don’t have access to this. And so, I think there are a lot of patients who could benefit from this treatment, if only it was close to them. So, one of the big challenges we have going forwards, is finding a way to give patients access, to educate patients that TAVR is available, that open-heart surgery isn’t the only choice and then also, find ways to either bring the technology closer to where they live or find ways to make it easy for them to travel to where the technology is.

Host: How will you and your colleagues help overcome these challenges?

Dr. Rogers: The first answer has always got to be education. We have to educate other doctors that this is available so that doctors outside in the community, when they see patients, know that these options are available. As I said, this technology is moving very quickly and, those of us who work in this day to day, have to work very hard to keep abreast of all the new advances and the new technologies. And so, we have to work very hard to help other doctors who aren’t TAVR doctors to understand what’s available, what’s changed, what’s new. And then, that allows those doctors to teach their patients, “Look. These are the options for you.” As I said to you before, there are many areas in the country where patients live many hours from a hospital that offers TAVR and so, those patients may be tempted to say, “Well, I’ll stay close to home and have open-heart surgery,” when we all know that if you’re an elderly patient with lots of other medical problems, TAVR is a better option for you. And so, I think education’s got to be the first try. And then, at a bigger level, we have to think, as a society, “How do we improve access to these technologies?”

Host: Why is MedStar Washington Hospital Center uniquely positioned to offer TAVR?

Dr. Rogers: So, MedStar Washington Hospital Center has been at the forefront of TAVR since it was first introduced to the United States over a decade ago. And, we have great experience with all of the TAVR technology, right from the very early days. We’ve been involved in all of the major clinical trials of TAVR. We’ve run our own clinical trials, most recently in low-risk patients, so patients who would otherwise undergo surgery. And, we also - because of this - we have access to all the new technologies, so when a new valve becomes available, either under clinical trial or for just commercial use, as a hospital, we get access to that very early. And clearly that gives us an option when a patient comes to us to say that we have not just one option we have many options for you. And, I think research drives our day-to-day mission and that can only make patient care better.

Host: Thanks for joining us today, Dr. Rogers.

Dr. Rogers: Thank you.

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Skin cancer is common in the head and neck area because of exposure to ultraviolet (UV) radiation from the sun. Dr. Jonathan Giurintano discusses the most common types of skin cancers and how we treat them.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Jonathan Giurintano, a head and neck cancer surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Giurintano.

Dr. Giurintano: Thank you so much for having me today.

Host: Today we’re discussing treatment options for skin cancers of the head and neck. Dr. Giurintano, how common are skin cancers of the head and neck compared to skin cancers that affect other areas of the body?

Dr. Giurintano: Skin cancers in the head and neck region are extremely, extremely common. The most common types of skin cancers (these are basal cell carcinomas, squamous cell carcinomas and melanomas), are found in areas of the body that receive exposure to the UV radiation from the sun. As the head and neck are the most frequently sun-exposed areas of the body, it follows that these are also extremely common areas that we see skin cancers, often occurring on the scalp, the face, the ears, nose, cheeks or on the neck.

Host: In less visible areas of the body, cancerous moles, spots and other tissues often are removed. How do you approach treatment of the very visible tissue of the head and neck?

Dr. Giurintano: So, it’s similar to other areas of the body, especially for larger skin cancers. The best treatment is typically surgical excision. Our colleagues, the dermatologists, are often times specially trained to perform a procedure called Mohs micrographic surgery. So, this is actually a very special type of surgery in which the skin cancer is removed and normal appearing skin around the periphery of the skin cancer, and this is sectioned by the dermatopathologist and looked at under the microscope at the time of the surgery to confirm that there is no further cancer cell present. By doing this, the dermatologists are able to not only completely excise all cancerous cells from the region of the skin cancer, but oftentimes are able to limit the amount of normal skin that must be sacrificed in order to completely resect the skin cancer. In areas such as the nose, the ears or the cheeks, there oftentimes is not much elasticity to the skin that allows for the defect in the skin to be closed simply. Other times, the defect might be closed simply, however the resultant scar might result in an unattractive cosmetic appearance. So, for these types of patients, we do have special ways that we can rearrange the tissue on the face in order to not only reconstruct the defect left behind by the resection of the skin cancer, but also do so in a way that the scar is camouflaged and has the most cosmetically appealing appearance.

Dr. Giurintano: Well, basal cell and squamous cell carcinoma are the most common types of skin cancers that we treat. Other skin cancers such as melanoma require different types of treatment.

Host: What makes treatment different for melanoma?

Dr. Giurintano: So, one of the concerning features of melanoma is that we really cannot do Mohs micrographic surgery for melanomas. Whereas Mohs surgery relies on freezing the samples of normal skin from around the periphery of the tumor and looking at that sample under the microscope with very good success rates for ruling out the presence of cancerous cells, we know that that technology does not work quite as well for melanoma cells. As a result, most melanomas require pretty large resections. So, not only do you excise the melanoma itself, but oftentimes we excise at least one centimeter of normal appearing tissue around the periphery of the melanoma up to two centimeters of normal appearing tissue, dependent on how deep the melanoma is traveling underneath the skin. So, what initially starts out as a very small defect in the face, might soon become a defect that measures 4 or 5 centimeters and needs a major reconstruction. Another facet of melanoma is that it tends to spread very easily to lymph nodes in the neck. So, anytime patients have a melanoma in the head and neck region, very commonly we want to know what is the status of the lymph nodes in the neck. One of the special tools we have for helping determine the lymph node status in the neck is something called sentinel lymph node biopsy. So, this is a special procedure where, on the day of the surgery, before the melanoma is removed, the area around the melanoma is actually injected with a dye that has kind of a radioactive uptake. And then after the melanoma is excised, we can then actually go down to the neck and determine where the lymph nodes are that that melanoma was draining to. So, instead of having to do a large incision to take out all the lymph nodes in the neck without knowing if any of the lymph nodes are positive, we can actually pinpoint only one or two lymph nodes that we know the melanoma would have most likely been draining to and we can go take those lymph nodes out and then look at those lymph nodes under the microscope. And if those lymph nodes do not have any evidence of melanoma, then we know that it’s generally safe to watch the neck and not perform any major surgery or give any other therapeutic treatments. So, if that lymph node is involved with tumor, then we could go into the neck, make the incision larger and do a complete neck dissection or complete removal of the lymph nodes in the neck to help prevent recurrence of the melanoma in the future.

Host: Can these cancers spread to other parts of the body?

Dr. Giurintano: Yes. So, that is where my job as a head and neck cancer surgeon often takes the most importance in treating patients with skin cancers. For some people, they might have a small skin cancer on the scalp or on the ear. This is removed by a Mohs surgeon, with negative margins. The area is closed, the patient’s happy, and then 5 or 6 months down the road, that patient might develop a small lump in the parotid gland or in the neck. In short, yes, these skin cancers can also send metastasis to the lymph nodes in the face and lymph nodes in the neck. And whenever these lymph nodes do occur, they can often become very aggressive and distort the tissue surrounding them. So, my job as a head and neck surgeon in dealing with skin cancers, often occurs once the skin cancer has spread or metastasized to lymph nodes. And my job is to go into the neck or into the parotid gland and to remove these lymph nodes to remove all the cancer that has spread.

Host: How do you recommend that patients prepare for treatment?

Dr. Giurintano: A large part of the preparation for these patients is mental and emotional. Oftentimes, when the Mohs surgeon performs their portion of the procedure, which is the removal of the skin cancer, the resultant defect might be left in place with a bandage over it so that they can then be reconstructed secondarily by an otolaryngologist or by a facial plastic surgeon. It can be very distressing for patients to see a large hole in their face immediately after surgery, but they must be assured that this will be reconstructed in a manner that is both cosmetically appealing and functional. Occasionally, in order to repair defects in the skin on some parts of the nose, we have to take tissue from adjacent sites on the face, such as the skin on the forehead, and use that skin to resurface the lining of the nose. In order to do that sort of procedure, what’s called a local tissue flap, the patient has a very odd appearance immediately after surgery as the piece of skin still has a bridge connecting it where the artery, that is supplying the skin flap, is running. This can result in a very strange physical appearance for the 3 to 4 weeks immediately after reconstructive surgery while the skin is healing in to place on the nose. However, we have to encourage the patient that within 6 weeks, a second procedure is performed where that skin bridge is removed, and the remaining tissue is reoriented so that there is a normal cosmetic appearance with only a minor scar present on the forehead.

Host: What does recovery from head and neck skin cancer treatment entail?

Dr. Giurintano: So, aside from the actual recovery from surgery, which is often performed either on an outpatient basis or maybe with a 1 to 2 day hospital stay, if the lymph nodes in the neck need to be removed, recovery from head and neck skin cancer treatment, most importantly, requires a very close follow-up, with either an otolaryngologist or a dermatologist, in the future to ensure that no other areas of skin cancer arise within the head and neck. While it is impossible to completely reverse the many decades of damage the UV radiation from the sun has often done to patients’ skin, it is never too late to begin applying sunscreen and to do precautionary measures to help limit the amount of damage to the remaining skin and to help prevent further skin cancers from occurring in the future.

Host: You mentioned sunscreen. Are there any other prevention tips that you can offer to people in the community?

Dr. Giurintano: So, aside from wearing sunscreen daily, which should be part of all of our daily routines anytime we go out - the face, the ears, and, especially for men who might be balding, application of sunscreen on the scalp, a few other very good preventative measures are to wear a wide brimmed hat if you are going to be out in regular sun exposure and to not only apply sunscreen whenever it’s sunny outside. Even if it’s cloudy outside, the UV radiation from the sun can still cause damage to the skin, so sunscreen in encouraged and recommended anytime patients are going to be outside.

Host: Could you share a story about a patient who had a particularly successful outcome after skin cancer treatment?

Dr. Giurintano: So, I previously had a patient who was actually a transplant patient - previously had a kidney transplant - and, as part of his transplant protocol, he was required to take immunosuppressive drugs to ensure that the body did not reject the transplanted kidney. The unfortunate thing about immunosuppressive drugs is that if a cancer does develop in the body, the immune system is not present to help fight that cancer and it can spread very rapidly. So, I previously had a patient who was a transplant recipient, who developed what was initially a very small skin cancer present on his left face that very rapidly increased in size, to the point where nearly the entirety of his left face was involved with the skin cancer within only a few weeks. This patient required a large radical resection of the tumor as well as the underlying parotid gland and the lymph nodes in the neck. In this patient, we actually used a free flap (so, that’s a piece of tissue from the thigh that we connected with an artery and a vein in the neck), and we used that tissue from the leg to resurface the skin, fat and parotid gland that was resected during the cancer resection. And, the patient had an excellent cosmetic appearance afterwards and was able to complete radiation therapy and chemotherapy, and since that time, has not had any further skin cancers develop.

Host: Why is MedStar Washington Hospital Center the best place for patients to come to receive treatment for skin cancers of the head and neck?

Dr. Giurintano: MedStar Washington Hospital Center is an excellent place to come for head and neck skin cancer treatment as we have all the tools necessary to handle the most minor skin cancers up to the most complicated of skin cancers. While many small skin cancers can be handled in the community setting, for those type skin cancers which become very aggressive and which might invade locally into structures of the face - this includes the muscles of the face, the parotid gland or the large saliva glands on the side of the face and even the facial nerve, the nerve that controls all facial movements on one side of the face - for all these patients, even if the tumor is involving these structures, we have the surgical capability as well as the capability to provide adjuvant radiation therapy and chemotherapy, for even the most aggressive skin cancers to help patients have not only the best oncologic outcome possible but also the best cosmetic and physical outcome possible.

Host: Thanks for joining us today, Dr. Giurintano.

Dr. Giurintano: It was a pleasure. Thank you so much for having me.

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Symptoms of bunions include pain, restricted movement of the big toe, swelling and redness. Dr. Ali Rahnama discusses what causes bunions and how we treat them.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Ali Rahnama, a foot and ankle surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Rahnama.

Dr. Rahnama: Thank you for having me. It’s a pleasure.

Host: Today we’re discussing bunions, which are painful, bony lumps that can develop at the base of the big toes. Dr. Rahnama, what’s going on within a patient’s foot when a bunion forms?

Dr. Rahnama: So, as you very nicely said, a bunion is a large bump at the base of the great toe joint that forms. There are multiple reasons that can contribute to a bunion’s development. We think that, for the most part, the average patient that we see with bunions, it’s likely hereditary in nature. Most experts will agree that shoe gear and high heels and tight shoes - while they can exacerbate or make it more painful or symptomatic, they’re likely not the cause of why a bunion would form.

Host: Often, people think of older adults as most likely to develop bunions. Is that accurate?

Dr. Rahnama: Well, it’s true that by the time most people present for help and evaluation of their bunion, the bunion can become prominent and painful as early as the teen years. And, this is usually a condition called juvenile hallux valgus. These individuals are usually hypermobile or ligamentously lax, think of highly flexible people. So, to answer your question, no. The bunion can really affect people of all ages.

Host: Do patients usually know what’s going on with their foot, or are they surprised by the diagnosis when they come see you?

Dr. Rahnama: No, this is actually one of those things where usually people know exactly what is going on when they come and present to us. They’re really looking more so for an answer on what they can do about the pain and discomfort that they’re experiencing, more than wondering what’s going on. Pain is the number one thing at the base of the great toe joint. A lot of times it becomes red and hot and swollen, particularly after they do have to be in a pair of tight shoes. We see this a lot in females but certainly we do see it in our male patients as well. A lot of times, because of that bony prominence or protuberance that’s there, the body will produce a small bursa sac as a little cushioning or type-mechanism to help protect itself and so, that even, a lot of times, makes the bunion seem larger, more prominent than it actually is.

Host: Sort of like a blister?

Dr. Rahnama: Similar, but it’s more...it’s on the inside. It’s inflammatory tissue. The actual skin around the great toe joint can become thickened. So, these things can all contribute to the bunion becoming or appearing larger than it actually is.

Host: Could having a bunion indicate that something else is going on within the foot?

Dr. Rahnama: Absolutely. A lot of times, we can see that a bunion comes hand-in-hand with a larger orthopedic or foot and ankle deformity, such as a flat foot or a tightening or contracture of the heel cord, can contribute to the bunion’s formation as well.

Host: What are the most effective treatment options for bunions?

Dr. Rahnama: We can try things like toe spacers, shoe inserts, oral anti-inflammatories, topical anti-inflammatories to start, but none of these things will actually get rid of the bunion. They may just help with simply alleviating the pain that the patient is experiencing. The most definitive way to treat them is by surgically correcting them. But one thing I will add is that, at least my philosophy when it comes to bunions, is that I will try not to operate on a patient who’s telling me that the bunion’s not painful. So, we try to typically stay away from cosmetic foot surgery. That’s something that I will not do. If it’s not bothering you and it doesn’t hurt, my recommendation is to leave it alone.

Host: Is there any long-lasting ramifications for leaving a bunion untreated?

Dr. Rahnama: The biggest thing with that is that not having a symptomatic bunion fixed or repaired can do two things - the pain can become worse with time and the bunion can become worse with time. So, those are the two big things that I would caution patients when it comes to their bunion. The third thing is that, over time, the great toe joint can actually become arthritic. And so, if they wait too long, instead of having bunion corrective surgery, that they would have to have fusion of that great toe joint. And, while most patients do well with that, it would be great to avoid that with a lesser procedure, if possible.

Host: During or after treatment, what activity restrictions should patients expect?

Dr. Rahnama: Well, after surgery, depending on the type of bunion procedure that they’ve needed to have, some patients would be able to start weight-bearing, in a surgical boot, as soon as the day after surgery. In patients who have to undergo a slightly larger procedure because of how bad their bunion may be, they need to stay non-weight-bearing on the operative extremity, or foot, for a period of time, typically no more than 3 or 4 weeks.

Host: Is treatment typically “one and done,” or do bunions often return?

Dr. Rahnama: It depends on the type of treatment that they had. Bunions can certainly return after surgery but there are surgical procedures that we can choose so that it gives the patient the best chance at not having a recurrence of the deformity. Those procedure sometimes may take a little longer for the healing of the patient and they may require them to remain non-weight-bearing, or staying off of the foot, for maybe a few more weeks. But, in the long run, particularly if they’re younger, those juvenile hallux valgus patients, as an example that we talked about a little earlier, if we DO do the slightly larger procedure, it can avoid a recurrence as they get older, into their 40s, 50s.

Host: Could you describe a general bunion removal or a bunion treatment procedure?

Dr. Rahnama: So, if you look at a textbook on foot and ankle surgery, you can find over a hundred ways to surgically correct a bunion. The most common two procedures, I would say, are head procedures, is what we call them. It’s when we physically shave the bump down with the saw in the operating room and then we make small cuts in the bone and shift the bone over, and we typically fixate it with one or two screws. That is a smaller procedure. Patients are typically able to weight-bear almost immediately after surgery. But again, that is the smaller of the two procedures. But, if a patient has that done and they have a really severe bunion or if they’re very young, they’re always susceptible to having a recurrence. The slightly larger procedure is where we fuse the joint that is distoproximal, or towards the midfoot. Patients are a lot of times surprised to see that we want to go after an area of the foot that doesn’t appear to be symptomatic for them. But that joint is really where the root of the bunion is. And so, if we can correct the bunion at that level and fuse the joint end close to the midfoot, then straighten out the bone, then we avoid a recurrence.

Host: Can you recall a patient who had particularly bad bunions but was able to return to an active lifestyle?

Dr. Rahnama: I would say that, luckily, most of our patients who undergo bunion surgery are able to get back to not only the things they want to do, but also wearing the type of shoes that they want to wear without discomfort. Really, the aim of the surgery is to be able to help them have a better quality of life to begin with so that’s why we decide to proceed with it to begin with.

Host: Why should someone with bunions consult with the foot and ankle surgeons at MedStar Washington Hospital Center?

Dr. Rahnama: I think it’s really important for patients to be able to consult with a specialist who can help the patient choose the best procedure that’s right for them. And, I would say that we have a very highly skilled team of surgeons here, more than equipped to deal with patients and their foot and ankle needs.

Host: Thanks for joining us today, Dr. Rahnama.

Dr. Rahnama: Thank you so much for having me.

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Transoral thyroid surgery is a procedure we use to remove thyroid nodules by going through the mouth, as opposed to making incisions in the neck. Dr. Erin Felger discusses who’s a candidate and what recovery is like.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Erin Felger, an endocrine surgeon at MedStar Washington Hospital Center. Thank you for joining us today, Dr. Felger.

Dr. Felger: Thank you for having me.

Host: Today we’re discussing transoral thyroid procedures, or thyroid surgeries done through the mouth instead of through open incisions in the neck. Dr. Felger, why would a doctor recommend a transoral thyroid procedure instead of a traditional approach?

Dr. Felger: The main reason that someone would offer a transoral procedure to their patient or an endocrinologist would offer to have a patient seen for transoral procedures is because of scar issues. These can be scar issues related to a medical problem like hypertrophy or keloid, which a number of people in our population have, or scar issues that are psychological, in that nobody wants to have a scar on their neck.

Host: What symptoms do patients share with their doctors that ultimately lead to a diagnosis of thyroid issues?

Dr. Felger: It depends on the type of thyroid issue. The main symptoms that people usually discuss are symptoms of fatigue, constipation, hair loss, skin changes - which are all associated with hypothyroidism, or anxiety, racing heart, heat intolerance - which are due to hyperthyroidism. With respect to surgical issues, the most common symptoms are symptoms related to compression of the thyroid because of its size and they include voice changes, swallowing difficulties or inability to lay flat at night.

Host: What are some of the most common conditions for which the transoral approach is most effective?

Dr. Felger: For most patients, the best reason to have a transoral thyroid approach is, again, for the scar issues. But in terms of actual disease processis, almost any disease process could be taken care of through a transoral approach. The best options are a solitary nodule or a small thyroid cancer, on occasion parathyroids and, very rarely, a large multinodular goiter.

Host: How does the conversation go when you start talking about surgical approaches for your patients?

Dr. Felger: Basically, I start the conversation with explaining why they would be a good candidate for the operation. I also tell them that there is a standard operation so that they hear that there’s another way to do it. And then I go into the details about how many we’ve done, what the procedure is and how it differs in terms of pain control and postoperative care afterwards. And honestly, there isn’t that much that’s different between the two procedures when I’m talking to patients, except for the oral care with the transoral approach. Everything else is very similar.

Host: What does a patient have to do to prepare for surgery?

Dr. Felger: The patient needs to have been seen by the surgeon for their initial consult. And at that time, the surgeon will be giving the patient a list of items that need to be completed prior to the day of surgery. Those usually include labs, EKG, and a preoperative physical at a minimum. The surgeon may require other testing to be done, which might include imaging or a biopsy.

Host: How long is the recovery time after a transoral thyroid procedure?

Dr. Felger: In general, I tell everyone it’s a week, but most patients feel really good after a couple days. But, I also want them to understand that it’s not going to be perfect for a period of time, which is usually around a week, so that’s why I give that as my standard approach. After surgery, patients can expect to have some swallowing difficulty, secondary to the breathing tube. They can expect to have numbness around the mouth where the incisions are placed, as well as on the chin. The chin numbness can last for several months but it does resolve after a period of time which is different for each patient.

Host: What additional treatment or care do patients need after surgery?

Dr. Felger: For transoral patients, they do have to do an oral care regimen until they come back for their first postoperative visit, which just includes a salt water swish and spit after each meal and at bedtime.

Host: Could you share a story of a patient who had a successful outcome?

Dr. Felger: I had a wonderful lady who I saw in my clinic who has terrible hypertrophy with her other scars from other surgeries. She was very concerned about having a scar on her neck that would be visible with this medical problem. She had a nodule that was quite large that needed to be removed. And she and I talked about doing the transoral approach and she was very interested in it. She was hesitant at first to sign up for surgery but ultimately, after discussing with her family, she decided to have the transoral approach. Her surgery went wonderfully and she came back to see me the week after the operation for her first postoperative visit and she was thrilled. She said, “I know that my chin is numb, my mouth doesn’t feel quite right yet. If I had it to do over again, I’d do it this way again. I have no scar on my neck.”

Host: Why is MedStar Washington Hospital Center the best place to seek care for thyroid conditions?

Dr. Felger: We have the best multidisciplinary group in the region. We work with our endocrinologists, our nuclear medicine doctors and our radiologists to provide the most comprehensive care available for any thyroid condition. From the standpoint of doing transoral thyroid surgery, we’re the only hospital in the DC and Maryland area that is doing this procedure. And, again, we have a comprehensive team that we work with so that the transoral procedure can be done as successfully as possible.

Host: Thanks for joining us today, Dr. Felger.

Dr. Felger: Thank you.

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Many adults are caregivers for elderly relatives. Dr. Cesar Torres discusses common problems these caregivers face and his best tips to keep elderly loved ones safe.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Cesar Torres, a geriatric and house-call doctor at MedStar Washington Hospital Center. Thank you for joining us, Dr. Torres.

Dr. Torres: My pleasure.

Host: Today we’re discussing advice for adults caring for older relatives. Dr. Torres, in terms of safety, what are some of the key areas of concern that caregivers often worry about?

Dr. Torres: I think the number one area would be falling. Falls can lead to very life altering fractures, specifically fractures of the hip. And, study after study has shown that a hip fracture will have significant effect on mortality rates. Your odds of dying within the first year of a hip fracture are, unfortunately, quite high. Falls, household accidents - the ability to communicate with loved ones in case of a household accident is something that a lot of caregivers worry about. But if I had to rank it, I would put the risk of a fall as the number one thing that really keeps up everybody at night.

Host: Is this concern just for seniors with medical conditions such as dementia or heart disease?

Dr. Torres: No. All seniors are at risk for it. There are a lot of different reasons for this. There are sensory inputs into increasing the fall risk, such as loss of vision or impaired vision. There’s a loss of proprioception - by that I mean balance. There’s a loss of muscle strengths, so the elder will literally not be able to lift their feet high enough to clear very simple obstacles in their path and so they end up falling or tripping. There’s also the problem with improper medication or over-medication, which we, unfortunately, as physicians, sometimes contribute to and then we have to be mindful of, to try to avoid and mitigate the risk.

Host: What would be the risks involved with over-medication?

Dr. Torres: Well, some medications, and there are over-the-counter medications also that are guilty of this, predispose elderly patients to sedation, dizziness, and these increase the fall risk. By that, medications like over-the-counter sleep aids, Benadryl, antihistamines - they can impair the elderly patient’s ability to manage their household environment.

Host: What can seniors and their caregivers do to reduce the risk of falls at home?

Dr. Torres: I think the biggest thing I see, in doing house calls, is reducing the amount of clutter in the house - throw rugs, items just left on the floor. All of these are potential obstacles and they can lead to a very bad fall that can result in a fracture. Lighting - improving the lighting for seniors is also a great help. Making sure that they’re wearing their glasses. Some folks really do not like wearing glasses. Having handrails. Trying to minimize the need for an elder to go up and down stairs - moving them onto a single floor may also prevent a fall.

Host: They seem like really common sense type things that anybody should follow.

Dr. Torres: But, they get overlooked because they are so common. Sometimes you need that person who comes in to your home and is taking care of your mother or father and she has to point it out and that little bit of added emphasis leads to a change.

Host: How do the geriatrics and house-call experts at MedStar Washington Hospital Center help patients and families care for their aging loved ones at home?

Dr. Torres: Well, since we travel to the home, we have a good sense of what are the environmental obstacles in the home. As part of our program, we’ll do environmental assessment and we’ll make specific recommendations, making sure that all the sensory inputs are optimized for the senior also go a long way. And we can make referrals to eye doctors, ophthalmologists, otolaryngologists, and they can help with making sure the senior’s sight and hearing are improved to the maximal point that they can.

Host: Are there any additional general tips that you would give to families who are caring for aging loved ones at home?

Dr. Torres: I would foster open communication as to what your loved one needs help with, okay? Don’t just assume that they’re doing OK because they’re not calling you for help. A lot of times what we see is that the elder will do everything they can NOT to bother their family members. And, the more open the communication, the more likely you are to know when there is a problem. And I think that goes a long way. Another safety issue that seniors and their families face is the issue of driving. The ability to drive does change with age, but just because a person is of a certain age, that does not necessarily mean that they can’t drive. But the issue is one that needs to be explored as the person ages. Don’t just assume because the person just renews their license automatically that they can actually drive. There are laws - they vary from state to state - that can help but the family should periodically check in. Reaction time diminishes as the person ages. There are the visual changes. There are the hearing changes. There can be significant osteoarthritis of the cervical spine that prevents the elder from turning their head. Driving safety is something that really needs to be a top priority - not just for the patient themselves but for the society at large. The District of Columbia, fortunately after a certain age, there are requirements that the driver undergo vision testing as well as getting the authorization to drive from their primary care physician. So, that’s something I am in favor of.

Host: What are some of the more common conditions you’re seeing in these older adults as you’re going out on house calls?

Dr. Torres: Chronic pain from degenerative joint disease such as arthritis. Hypertension. Diabetes. Obesity. Mood disorders. Sleep apnea. Chronic kidney disease. Heart attack and stroke.

Host: So, when you’re making your house calls and seeing your aging parents, are you seeing issues with medication adherence?

Dr. Torres: Unfortunately, we can. We try to reduce that as much as possible by physically, visually looking at each one of their pill bottles. And, that’s something that, I’m happy to say, that’s becoming much more of a common practice. When the elderly patient comes in to see their primary care physician, they should be instructed to bring all their medicines in their favorite paper bag. We call it the brown bag. The major problem with adherence is the difficulty with remembering complicated medication regimens. Medications that have to be taken three times a day, generally, are extremely difficult. So, yes, adherence is an issue. The more that the physician can simplify the regimen, the better the outcome will be. Some of the tips I can offer: pill boxes can be a help. Any form of reminder, be it visual or even auditory - I mean, there are lots of apps out there that can be programmed to give reminders to take medications. But generally, just being aware that the loved one is on some type of medication regimen. Generally, that’ll spin off into the appropriate technique to make sure that they are getting their medications.

Host: Could you share the story of a family that maybe had a particularly stressful time at home that you were able to help through your program?

Dr. Torres: A patient who was living by herself. The apartment was less than optimal. She had no handicap accommodations. And, I basically, through a series of letters, we were able to help her move into a handicap accessible apartment with more than reasonable accommodations. And, she had been experiencing some mild depression that was starting to impact her adherence to the medication regimens. But that improved dramatically once she was able to move and that was just on the basis of the move itself, into a much safer environment, a much more friendly environment.

Host: Thanks for joining us today, Dr. Torres.

Dr. Torres: My pleasure.

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Adult circumcisions are common in the Mid-Atlantic for men who never received a circumcision as a baby boy. The reasoning? Some men feel self-conscious about the way they look, while others develop skin conditions. Dr. Krishnan Venkatesan discusses the procedure and what men can expect during recovery.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. Krishnan Venkatesan, Director of Urologic Reconstruction at MedStar Washington Hospital Center. Welcome, Dr. Venkatesan.

Dr. Krishnan Venkatesan: Hi. Thank you for having me.

Host: Today we’re discussing adult circumcision, a reconstructive procedure that, while not widely discussed, is growing in popularity among men in the Mid-Atlantic region. Dr. Venkatesan, could you start by explaining what circumcision is for listeners who might not know?

Dr. Venkatesan: Of course. Circumcision is basically removal of excess foreskin from the shaft of the penis. It can be done for many different reasons, which I think we’ll delve into later in this conversation.

Host: So, in the U.S., circumcision is typically performed on baby boys, so why are more men requesting the procedure, as adults, when they’ve been uncircumcised all their lives?

Dr. Venkatesan: There could be many reasons to undergo circumcision as an adult. Sometimes there are specific medical conditions. One is called phimosis, where the foreskin is actually tight and can trap urine underneath the skin and cause inflammation or infection of the head of the penis or the skin or even in the urinary tract. Sometimes, if they have warts or genital warts, men may want circumcision to have those removed. There are also other skin conditions. Lichen sclerosus is an immune mediated skin condition. We actually don’t know exactly what causes it, but basically, it can cause some scarring of the foreskin so the skin gets very tight around the shaft of the penis and onto the head of the penis and some patients may even feel that the head of the penis itself, the skin has lost its elasticity and instead of having a lot of small folds, it’s very flat and shiny, and some patients even will experience itching of the head of the penis, especially after sex, or even some fissures, like cracks in the skin, that can get very irritated after sex or even if the area is manipulated too much. In about twenty percent of those patients, they can also involve the opening of the penis where men urinate from and this can have other implications along the urinary tract, as well. All in all, circumcision is popular here in the U.S. and it’s not practiced that widely in the rest of the world. So, there are otherwise some social reasons that men tend to request circumcision, mainly because they’re self-conscious about being in a locker room or in a team shower or something, if they play sports, where some men may be circumcised, and some are not and they don’t really want to stick out.

Host: Do you ever have men come in who are concerned what their partners might think or their sexual partners might think? Could you address that?

Dr. Venkatesan: Yeah, absolutely. And that kind of goes along that social line that because, overwhelmingly, large number of men are circumcised in the U.S., men may worry that female partners may find it unusual or abnormal and because of that, they may feel more self-conscious about it. And they may also find that it’s less pleasing in intercourse or, in some cases, they may find that it’s uncomfortable for intercourse because the skin is getting irritated or something.

Host: If a man grows up this way his whole life, he’s uncircumcised his whole life, if he chooses to remain uncircumcised, are there any health implications to be concerned about there?

Dr. Venkatesan: No. There is evidence that suggests that circumcision at a young age, before puberty, can have some protective effect as far as decreasing the risk of penile cancer. But, in adult men who have already undergone puberty, there’s no significant benefit to circumcision at that point. The cancer of the penis is very rare, regardless, so as long as they maintain good hygiene and examine themselves reasonably frequently, then they should be able to avoid any serious problems from something like cancer of the penis. I would also like to say that, in other parts of the world, not the U.S., that circumcision sometimes is used as a means of HIV prevention or prevention of transmitting any other sexually transmitted diseases. That has been shown to have a benefit in places where HIV is endemic, like in Africa, but from a medical standpoint, otherwise, there’s no reason that it has to be done in childhood.

Host: Approximately how many adult circumcisions are performed at MedStar Washington Hospital Center each year?

Dr. Venkatesan: I’d say we probably do somewhere between fifty and a hundred a year, between myself and all of my colleagues. Like I said, there’s a wide number of reasons that we do them. Some are more for social reasons and others are for specific medical problems.

Host: Could you describe your patient population for adult circumcision? Are these men young adults, middle-aged, teenagers?

Dr. Venkatesan: Yeah. There’s a wide range of men who come in seeking circumcision. Quite often, there are young men in their late teens or early twenties who were not circumcised as children but, as they are moving out of home or becoming sexually active and exploring that realm, so to speak, they recognize that they’re different from their friends or colleagues and they want to have less inhibitions or less to be self-conscious about it, and they come in seeking it. And, similarly, there are men with medical conditions that can occur at any age, including tightness of the foreskin, or other skin conditions like lichen sclerosus, that need circumcision for actual medical treatment. And there’s no specific age range where it’s right or wrong for them to come in to seek that treatment.

Host: What questions do patients or their partners ask about adult circumcision?

Dr. Venkatesan: The main question they ask, of course, is whether it will be painful. And, like any surgery, there will be some discomfort initially, but typically the healing period is relatively short and within a month after surgery most men are back in normal function and form. I think the main other questions are whether it will cause any effect on sexual function or urination. And, typically, it shouldn’t have any effect of either of those things.

Host: What are some of the risks that are involved with adult circumcision?

Dr. Venkatesan: The risks involved with circumcision include general risks of any surgery, like infection and bleeding, and then, of course, risks associated with the specific area we’re operating on. So, there’s always a risk of needing further surgery if the patient is not happy with the cosmetic outcome. And also, risks of the stitches coming apart or having some scarring requiring further surgery. There’s a pretty low chance of any deeper structures in the penis being affected, like the urinary tract, or any nerves that would provide some function for sexual function or anything like that or sensation. Of course, there are risks with any anesthesia, as well.

Host: What does a patient have to do to prepare for this procedure?

Dr. Venkatesan: I would think that the main preparation really ought to be consulting with their urologist beforehand and understanding the risks of the procedure, the indications for the procedure, and the expected recovery. But other than that, there’s nothing they need to do at home as far as physical preparation or diet or anything like that.

Host: Could you describe how the procedure’s performed?

Dr. Venkatesan: Yeah, absolutely. We basically make two parallel incisions around the circumference of the penis - one upstream from the skin we want to remove and one downstream from the skin we want to remove. And, then we basically unwrap that part of the skin off of the shaft of the penis. And, then the two edges that are remaining, we sew them back together.

Host: What does recovery entail? For example, are there restrictions for having sex, using the bathroom, or exercising?

Dr. Venkatesan: The recovery usually does entail some activity restrictions. We don’t typically leave a catheter or anything like that, so the patient should be able to urinate on their own immediately after surgery and use the restroom, otherwise, without difficulty. I do typically ask my patients to refrain from any sexual activities for about four weeks while the stitches and the incision are healing up. And similarly, for that first couple of weeks, I’d like them to avoid any heavy exercise mainly to avoid any sweating or strain or stress on the incision that might affect it’s healing. We typically do send patients home with some pain medication and some antibiotics. The expectation, for the most part, is that patients generally will not need any narcotic pain medication beyond one week after surgery. By that point, they’re usually up and around doing most of their normal activities, aside from the other activity restrictions that I had described. And, usually by that point, aside from specific, unique jobs that may require further activity restrictions, most patients will usually be able to go back to work within that one week.

Host: Could you share a story from your practice? Perhaps you had a man come in requesting this procedure and was incredibly happy with the results?

Dr. Venkatesan: Yeah. I can recall specifically one man who was in his 50s and diabetic and, as I had described earlier, he had a very tight foreskin so he was getting frequent infections with urine getting trapped between the skin and the head of the penis. And, once we did a circumcision, he was basically infection-free and symptom-free and he was able to maintain much better hygiene there and, overall, was quite happy with the results within a month after surgery.

Host: Like anybody, men would have a specific hygiene regimen prior to being circumcised. Is there anything in that regimen that would have to change or that they would do differently after they were circumcised?

Dr. Venkatesan: No. So, I suspect and expect that hygiene maintenance after circumcision should actually be easier than before circumcision basically because, before circumcision, men would have to pull back the foreskin and really ensure that every crevice and fold of skin is properly cleaned and scrubbed. After circumcision, there’s no excess skin, so the skin covering the shaft of the penis basically has a very smooth transition and should be very easy to clean. Everything’s that there, visible to the eye, can be cleaned easily and there’s... much easier not to miss anything.

Host: Why is MedStar Washington Hospital Center uniquely positioned to take care of men who want to have circumcision as an adult?

Dr. Venkatesan: I think we’re in a strong, unique position to take care of adult men requiring circumcision because we are a tertiary care referral center in our Dept. of Urology. We see patients with very complex problems including complicated skin conditions that require circumcision and reconstruction of the penile shaft and skin. And we see a wide range of men, even ranging to men with no significant problems but who have straightforward circumcisions. But, based on our skill set and the complexity of things that we do and the volume that we do, I think that we are positioned well to offer patients good preoperative counseling and good postoperative outcomes.

Host: Thanks for joining us today, Dr. Venkatesan.

Dr. Venkatesan: My pleasure.

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Sleep apnea, or when patients temporarily stop breathing during sleep, can be cured with corrective jaw surgery. Dr. Ravi Agarwal explains how it works and what to expect during recovery.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. Ravi Agarwal, an oral and maxillofacial surgeon and the residency program director for the Department of Oral and Maxillofacial Surgery at MedStar Washington Hospital Center. Welcome, Dr. Agarwal.

Dr. Ravi Agarwal: Thanks for having me here today.

Host: Today we’re discussing corrective jaw surgery for obstructive sleep apnea and breathing issues. Dr. Agarwal, how is the jaw related to breathing conditions such as obstructive sleep apnea?

Dr. Agarwal: Great question! Most people do not realize that the top jaw and the bottom jaw do more than just allow us to eat and chew. These bones also serve as attachments to a lot of muscles around the face and neck, which support both the tongue and the airway. For example, patients who have an obstructed upper jaw may also have a narrowed nose, making breathing through their nose more difficult. Or, patients with small lower jaws will have a smaller area for their tongue to sit in and have more tongue obstruction while they’re sleeping, leading to obstructive sleep apnea.

Host: Could you describe your patient population for this type of corrective jaw surgery?

Dr. Agarwal: There are two different populations that we see for corrective jaw surgery. The first population are those patients who have jaw deformities, like underbites, deep bites, jaw asymmetries, or usually working with an orthodontist for braces and ultimately would need jaw surgery to correct the alignment of their jaws. These patients often have issues like difficulty with chewing, breathing problems, speech problems, jaw pain, and even concerns about their appearance. All of these complaints we are able to adjust with corrective jaw surgery. As you can imagine, a significant portion of these patients are teenagers, young adults - but we are starting to see a lot of adults who wish to undergo the same procedures. The second population that we see are patients with obstructive sleep apnea or breathing issues related to sleeping. They have a diagnosis of sleep apnea and they acknowledge that they stop breathing at night and have a lot of associated problems with that, such as excessive daytime fatigue, sleepiness, unable to perform their jobs, have fallen asleep while driving. Most of these patients are working with a medical provider. They maybe have tried CPAP, the mask that they wear at nighttime to help them breath. But many of them find this problematic and look for a surgical solution. As I mentioned, the relationship of the jaws to the airway, corrective jaw surgery - those same procedures can be used to advance the jaws, which would help open up the airway.

Host: When we’re thinking about these two different patient populations, how do you decide whether jaw surgery is appropriate for them?

Dr. Agarwal: There’s a lot of factors that we look at when we evaluate a patient. Most often, if there’s an anatomic abnormality that we can detect, they may be a good candidate for jaw surgery. We determine that by 1) a clinical examination - looking at their mouth, looking at their teeth, looking at the shape of their face, the shapes of the bones. We also utilize x-rays, 3 dimensional x-rays, to look at the size of their airways, the dimensions of the airways, and the dimensions of their jaws. Based on their problems, and what we see clinically, we can discuss with the patient if they’re a candidate for corrective jaw surgery.

Host: Could you describe how these types of surgeries are performed?

Dr. Agarwal: Corrective jaw surgery is a surgery that’s done all from inside the mouth. A significant number of patients will probably be working with an orthodontist, so they may have braces - which we actually use during the surgery. What we do is we make incisions in the gums around the jaws, we access the bones, and we use specialized instruments to make cuts in the bone. Once these bones are split, we’re able to reposition them in a new predicted position using splints that we had made before the surgery. The bones are then stabilized with small plates and screws, which you won’t feel or know they’re there and we then use dissolvable stitches to close the gums. The surgery is done under general anesthesia in the operating room and most patients will have an overnight stay in the hospital.

Host: Is there anything that patients have to do to prepare for surgery, perhaps the day of or getting any tests beforehand?

Dr. Agarwal: In general, patients who are getting corrective jaw surgery are undergoing a preoperative medical clearance, very similar to other major surgeries that are happening. Preparation is different, depending on what the patient’s desires are. Someone who wants to straighten their teeth and straighten their bite with the corrective jaw surgery to help their breathing, may be in braces and have undergone orthodontics for one to two years prior to even having the surgery. When they’re in that situation, we work closely with the orthodontist to make sure everything is done correctly prior to taking them to the operating room for the surgery.

Host: How long does recovery typically take and are there any restrictions for eating, talking or exercising afterward?

Dr. Agarwal: The recovery for corrective jaw surgery starts immediately after surgery. Usually there’s an overnight stay in the hospital, where we’re monitoring them to make sure they’re recovering well. But once they get home, there are a few restrictions. Most patients will need about two weeks at home due to the amount of swelling they’ll have. During those two weeks, we ask that they do not do any heavy lifting or exercises. But they can do daily activities such as washing the dishes, cleaning, and housework. After two weeks, most patients can start doing light exercise. But generally, we wait to six weeks before they can perform full physical activities. In terms of their diet, obviously we’re doing a lot of work inside the mouth and the bones of the jaws, and so patients will need to be on a full liquid diet for six weeks.

Host: What about teenagers who are playing sports? How long do they have to sit out?

Dr. Agarwal: For most sports we ask them to sit out for about six weeks. But, after two to three weeks, they definitely will be able to do light physical activities such as jogging and light weights. After six weeks they can return to full sports. The only caveat to that is patients or teenagers who play sports where facial injuries are common. In those situations, I may ask that they refrain from those sports for three months, because at that point the bones have really matured and there’s no further risk to them.

Host: Are these patients sitting with their jaws wired shut?

Dr. Agarwal: Nope. Patients jaws are not generally wired shut after this type of procedure. Using the techniques we utilize today and the plates and screws that we use, we’re able to not have to wire a patient’s jaw shut.

Host: Obviously there are some things that you can’t control - so, the way your jaw is built, your anatomy. But for something like obstructive sleep apnea, is there anything that patients can do to reduce their risk for needing surgery or that they can do to improve their condition otherwise?

Dr. Agarwal: You know, obstructive sleep apnea is definitely a multifactorial medical disease. A vast majority of patients, it may be related to weight, size - so exercise, weight loss would be some of the biggest things that could help reduce their chance of developing or having obstructive sleep apnea. There are non-surgical treatments for obstructive sleep apnea. The biggest one is CPAP. But for patients who don’t tolerate CPAP, there are options for oral appliances. These are devices that are generally made by dental or dental providers that would fit into their mouth and, essentially, shift their bottom jaw forward while they’re sleeping at night. By shifting the bottom jaw forward, it opens up the airway and reduces the obstructive sleep apnea.

Host: Could you describe some of the benefits of this type of surgery?

Dr. Agarwal: There are a lot of benefits to corrective jaw surgery. Obviously, getting the teeth and the jaws in a better position, patients are able to chew better, chew more efficiently, some of their speech problems may be improved. If they have concerns about pain, having the jaws in a better position can reduce their pain. And obviously, like we discussed, breathing. There are other nice results that come from jaw surgery such as an improved smile and an improved facial appearance. One of the things we keep in mind when we’re doing jaw surgeries - how to improve their facial harmony. So, patients often have more confidence about themselves and appreciate the way they appear. However, with all the benefits, there are side effects to every surgery that we perform. Outside of the recovery that we discussed earlier, one of the side effects of corrective jaw surgery is that patients may have some numbness of their lips, teeth and gums, as when we are working in these bones, the sensory nerves are in that region. After one year though, a vast majority of patients have no issues related to the numbness.

Host: Could you share a treatment success story from your practice?

Dr. Agarwal: As you can imagine, there are a lot of treatment successes when you do corrective jaw surgery to help someone breath. One that comes to my mind was a gentleman we took care of who came to his consultation with his family and his kids. And, the patient was trying to explain to me about how he struggled with sleeping and snoring. And then his young child just drops everything and says, “Daddy snores really loud!” And the dad just looks at me and says, “See? I really have a problem with sleeping.” And, you know, a few weeks after surgery, I see him for his post-op and I said, “How are those kids doing with the sleeping?” He says, “It’s peaceful in the house. Everybody’s so happy that I can breathe and I’m not snoring anymore.” And these are the things that really, really...why we enjoy doing this procedure because it really can be life changing, both from a functional standpoint but even from a family standpoint.

Host: What are some of those other issues that you can help correct when you do these types of surgeries, either for the patient or their quality of life at home?

Dr. Agarwal: In the teenage years, if there’s a jaw deformity, there are a lot of psychosocial components - that a patient may have trouble at school with their appearance or may have lack of self-confidence. And, corrective jaw surgery, I’ve seen, has changed the way a patient will present themselves afterwards. They’re excited, they have a lot more confidence, they’re doing better at school. As well as those who are concerned about being able to chew and chew efficiently and get a lot of jaw fatigue. By getting the teeth and jaws in a better alignment, those problems will go away.

Host: Why is MedStar Washington Hospital Center the best place to receive corrective jaw surgery?

Dr. Agarwal: Our hospital is one of the rare institutions in the region that have a dedicated oral and maxillofacial surgeon working. We are one of the busiest centers in the region when it comes to corrective jaw surgery. You will not find a center in the state of Virginia or Maryland that does more jaw surgery than we do. With that comes experience. We’ve seen a lot of different types of deformities, we’ve really advanced our skills in specializing in corrective jaw surgery. One of the technologies we use is taking 3D CT scans and performing virtual planning, working with a third party provider, for us to virtually plan your surgery before you’re in the operating room so that we can pick up on, ‘are there are going to be any issues and are we going to be happy with the outcome that we’re providing.’ The other reason to consider choosing our team is that we’re in a large hospital that has access to every specialty and we take care of some of the most complex patients in the region. So, having a team approach to all surgeries is really beneficial to outcomes.

Host: Thanks for joining us today, Dr. Agarwal.

Dr. Agarwal: Thank you for having me.

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Colorectal cancer is expected to affect about 146,000 Americans in 2019. Dr. Jennifer Ayscue discusses the advanced techniques we use to diagnose and treat this disease.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Jennifer Ayscue, section director of colorectal surgery at MedStar Washington Hospital Center. Thank you for joining us today, Dr. Asycue.

Dr. Ayscue: Thank you so much for having me.

Host: We’re discussing colorectal cancer and the minimally invasive techniques now used for the procedure. Dr. Asycue, could you start by discussing what colorectal cancer is?

Dr. Ayscue: So, colorectal cancer is a cancer of the large bowel or large intestine, which includes the colon, whose job is mainly to absorb water, among other things, and the rectum, which holds stool until it’s ready to be expelled. Cancer occurs when the inner lining of the colon or rectum develops abnormal cells which have the ability to then invade through the bowel wall and even spread to other parts of the body, like the lungs or the liver.

Host: Recent studies have suggested that colorectal cancer has increased in young adults. Could you explain why this is, plus other groups of people who are most susceptible?

Dr. Ayscue: Yeah, we’ve been patting ourselves on the back because for a number of years we’ve been noticing that the rates of colorectal cancer have been decreasing and this is, we think, in large part due to widespread colorectal cancer screening. However, unfortunately, as we’ve taken a closer look, we’ve found that the number of cancers diagnosed in young people, even in their 20s or 30s or 40s, has actually been rising and now they actually have a higher risk of colorectal cancer, in some cases, than people over the age of 50. We’re not really sure the reason of this but it may have something to do with increasing rates of obesity, sedentary lifestyle, drinking more alcohol - especially in men, smoking, eating processed food or red meats, and all of these really increase our risk for getting colorectal cancer. Or it could just be some other environmental factor that we have yet to figure out.

Host: Are there symptoms people can experience with colorectal cancer?

Dr. Ayscue: The most common signs or symptoms that I see are people who have rectal bleeding or urgency, meaning they need to get to the bathroom quickly but even after they use the restroom, they still feel this urgency. They may also have some mucous, maybe even mixed with the blood that we talked about before. They may have a persistent change in their bowel habits, which usually lasts for more than a few days or weeks. They may have abdominal pain or rectal pain. So, these are pretty non-specific and don’t always result in a diagnosis of colorectal cancer but should raise suspicion.

Host: In what ways do you typically diagnose colorectal cancer?

Dr. Ayscue: So, we offer many options. And some of the less invasive options for colorectal cancer screening include tests that may just test for blood in our home tests. Unfortunately, these do require some dietary restrictions and multiple stool samples, but it’s a cheap test and it’s only performed on a yearly basis. The ability for that to detect polyps and some cancers using that method are just limited. Another more sensitive test is called the fecal immunochemical test, or the FIT test, as it’s more widely known. This test tests for blood products as well, but it’s more sensitive and detects blood that definitely comes from the rectum and colon. It’s not great for smaller polyps but it’s a little more expensive than the guaiac test but not overly expensive so that it’s able to be used by a pretty large population. It’s offered for free, actually, through our community program for patients who qualify in certain wards in DC. And it’s usually covered by insurance for those who do have insurance. The last fecal test is fecal DNA test which may also test for blood but like the FIT test, and it’s very good, but it also tests for the fecal DNA which makes it more sensitive and is able to find over 90% of colorectal cancer and more polyps than the FIT test can. It’s only required every 3 years instead of yearly like the other two. However, it is more expensive and can be a limitation if someone is uninsured or if the insurance doesn’t cover it.

Another option is to perform a CT colonography or what’s known as a virtual colonoscopy. This is recommended every 5 years and up to 94% of larger polyps and cancers can be found with this. But it generally requires a bowel prep, similar to colonoscopy, and no biopsy can be formed at the same time. Also, other findings on CT may prompt further workup on those findings - sometimes, unnecessarily. So, I should also mention that if any of these minimally invasive tests are positive, then that person has to proceed on to colonoscopy, where the colon can be evaluated and either lesions biopsied or even removed, if anything’s found. Unfortunately, sometimes these tests can be positive and then no lesion is found on colonoscopy, and this is pretty stressful and frustrating for the patient.

Host: Could you discuss some of the minimally invasive techniques your team uses to treat colorectal cancer?

Dr. Ayscue: We offer a range of colorectal cancer treatments that are minimally invasive, but probably the most common would be the laparoscopic route. And, that would be when a colon cancer or a rectal cancer has to be removed. This is usually in conjunction with, sometimes, radiation or chemotherapy. So then, we can remove it either laparoscopically where we place instruments through very small incisions into the abdomen and then remove the colon through a relatively small incision as well. We can also use robotic techniques where the small incisions are also used but these instruments are connected to robotic arms which are controlled by the surgeon who is in the room at the same time but also allows us to have more fine control of the instruments and get in to spaces that we might not otherwise be able to get in to so that we can remove cancers more efficiently and with less post-operative pain and sometimes better outcomes overall.

Host: Can you discuss the importance of why getting screened early can help your treatment?

Dr. Ayscue: So, the newer recommendations are actually to get screened at 45, whereas it used to be 50 years old, because of patients having a higher risk of colorectal cancer in younger ages. If we’re able to get to people early and get them screened, meaning that they don’t really have any symptoms of colorectal cancer and we’re just looking to see if they have anything like a polyp or an early cancer, then we think by treating the polyp and removing the polyp that we can help prevent that polyp from becoming a cancer, which will hopefully decrease the risk of them ever getting a cancer. If we do find a cancer and it’s in an early stage, it’s much more curable.

Host: What does recovery typically consist of after surgery?

Dr. Ayscue: Well, most patients are in the hospital for anywhere from 1 to 4 days after surgery and most patients are treated with a very specialized program to help avoid narcotic usage and uses a lot of non-narcotic medications. And, with the combination of the minimally invasive surgery and this protocol, we’re able to get patients on their feet very quickly, eating diets within a day of surgery and home, usually, within the 1-4 days with minimal pain medications when they go home.

Host: How do the minimally invasive treatment and diagnostic techniques today compared to techniques used 10, 20, 30 years ago?

Dr. Ayscue: Well, the diagnostic techniques are getting better and better with each year and are able to diagnose now smaller lesions at earlier stages than they have in the past. And I suspect that they’ll become the primary tests of the future with colonoscopy reserved only for positive results in all patients, even high-risk patients. As for the treatment techniques, some of these didn’t even exist or were in the very early research stages 30 years ago, and have become better and better each year and...I suspect that laparoscopic and robotic techniques will merge and we will basically have robotic techniques that allow us to do almost anything in the abdomen without the need for an open incision.

Host: Could you share a story of a patient who had a successful outcome with minimally invasive surgery at MedStar Washington Hospital Center?

Dr. Ayscue: I had a mid-50s female who hadn’t been screened yet and she decided to get a FIT test and it came back positive. She saw me, and we did a colonoscopy at that time. And, I found a large polyp which I couldn’t remove using the colonoscope and I found several other polyps that actually could be removed. She then needed to have a robotic-assisted colon and rectal resection. And, I’m happy to say her pathology revealed a benign polyp which had some pre-cancerous cells. She was cured by that surgery and will just get regular surveillance to avoid needing any surgery in the future. But, if she’d waited another year or two, she might have had a cancer that would have required more treatment. So, we were very happy with this outcome.

Host: Why is MedStar Washington Hospital Center the best place to seek care for colorectal cancer?

Dr. Ayscue: So, our hospital has a significant focus on colorectal cancer, and this starts with the robust screening program that we have, with a nurse navigator who can help patients get the right screening for them and assist with any concerns. We also have a really strong team of gastroenterologists, surgeons, radiologists, and, if needed, cancer treatment doctors who are all very dedicated to the prevention and treatment of colorectal cancer. We definitely have the newest technology and we’re in the process of getting accreditation as one of the first hospitals in the nation for a multidisciplinary treatment of cancer.

Host: Thanks for joining us today, Dr. Ayscue.

Dr. Ayscue: Thank you for having me.

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From 2017 to 2018, vaping increased by nearly 80 percent among high schoolers and 50 percent among middle schoolers. Dr. Jonathan Giurintano discusses the short-term effects vaping can have on dental health and the lungs.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Jonathan Giurintano, a head and neck cancer surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Giurintano.

Dr. Giurintano: Thank you so much for having me.

Host: Today we’re discussing how vaping affects oral health. Typically, when doctors talk about the effects of vaping, the concern is for patients’ lungs. Dr. Giurintano, what are some of the more common oral health side effects of vaping?

Dr. Giurintano: So, of the more common health side effects, simple general irritation of the oral mucosa is probably the most common side effect that we see. However, there have been recently published studies that show that there are higher rates of colonization of the oral cavity mucosa with a fungal organism called Candida albicans in patients who vape or who use e-cigarettes regularly compared to patients who do not use vape devices. The importance of this fungal organism is that if there is an overgrowth of the fungal organism in the mouth, patients can experience what is called oral candidiasis or more commonly known as oral thrush. This can be an inflammatory and very uncomfortable situation to have when it is located on the tongue or on the inner cheeks and can require the use of an antifungal medication in order to resolve the infection.

Host: What concerns you the most about vaping?

Dr. Giurintano: The thing that concerns me the most about vaping or e-cigarette use is that many people see this as a healthy alternative to smoking cigarettes. Among a lot of vape users a common phrase that you’ll hear is, “Oh, it’s just water vapor. It’s safe” which we’re finding to be untrue. There was a big article that was published on CNN as the FDA released the results of an initial study showing that, just over the past year, that the use of vaping among high schoolers has increased nearly 80 percent and among middle schoolers, the use of vaping has increased almost 50 percent. One in five high schoolers has vaped and this is just a really, really shocking number. The reason this is so concerning to head and neck cancer surgeons, such as myself, is that we know that most patients who vape do not only limit their use of nicotine products to vaping itself. Many of these patients often go on to use traditional tobacco cigarettes or other tobacco products in order to fulfill the desire for nicotine, which is the addictive substance that’s often present in the vape liquid. And, any potential benefit that one might have seen from vaping rather than smoking quickly disappears whenever you’re both vaping and smoking cigarettes in order to get the nicotine effect.

Host: How do you address the health hazards of vaping with your patients?

Dr. Giurintano: So, one of the things I like to do is I actually like to explain to the patient how a vape pen or an electronic cigarette works. So, located within that vape pen or that e-cigarette, there’s one or two lithium ion batteries that powers separate heating wires that are composed of a heavy metal that then evaporate a flavored liquid which most oftentimes contains nicotine. And, the carrier substance for this nicotine typically consists of the chemicals glycerin or propylene glycol. We know that these are not inherently dangerous substances themselves. However, whenever you are evaporating these substances such as nicotine, glycerin or propylene glycol, we do know that more harmful or possible carcinogenic side molecules can be released. One of the most concerning things about the vape usage is that the FDA only began to regulate the vape industry in 2016. And today, there’s over 7000 different types of flavorings which have been described in the liquids. The majority of these flavorings are used in the food industry. However, they were only truly developed for oral consumption, not for vaporization. So, the long-term effects of taking these substances that are typically meant for oral consumption and converting them into a vaporized form that’s then inhaled into the oral cavity and into the lungs, is largely unknown at this point. A few of these substances have been studied in the past and have been shown to cause severe inflammation of the bronchi and of the lungs. And, it is assumed that these chemicals that are irritating to the bronchi and the lungs, could also have an irritant effect to the mucosa of the upper aerodigestive tract as well. The American Head and Neck Society, so this is the society of head and neck cancer surgeons across the United States, recently issued a statement stating that ‘given the lack of clear scientific evidence regarding the safety and effectiveness of e-cigarettes for the sensation of, as well as the bystander risk of e-cigarette emission, the American Head and Neck Society does not endorse the use of, e-cigarettes as a safer alternative to traditional tobacco cigarettes.’ The H & S agreed that e-cigarette emissions are not simply harmless water vapor, as they are often promoted and advertised. And this organization further expressed the concern that e-cigarettes represent a viable potential for harm to both individual health and environmental pollution. We’re still in the process scientifically investigating these vape and e-cigarette devices to help provide a clearer understanding of what the risks and/or benefits are of using vape or e-cigarettes and the indications for or against their use.

Host: What are the long-term oral health implications for patients who vape?

Dr. Giurintano: Well, we’re not 100 percent sure at this point what the 20- or 30-year health implications will be for patients who vape. We do know that there are substances within the vapor that’s inhaled that harbor carcinogenic potential. We know that studies have shown that these typically are in much lower quantities than the chemicals produced in traditional cigarette smoking. However, we have yet to see what the long-term effects of regular application of these chemicals to the lining of the upper air digestive tract might cause. The biggest thing we do know is that most e-cigarette or vape users do not exclusively use vape devices in order to obtain nicotine and that many of them will also smoke traditional cigarettes, as well. And for these patients, they are at risk for the typical long-term complications seen in most cigarette smokers, including periodontal disease and increased rates of cavity of the oral cancer, voice box, and lungs.

Host: Thanks for joining us today, Dr. Giurintano.

Dr. Giurintano: Thank you so much for having me.

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Multiple ankle sprains can lead to chronic ankle pain for some patients. Dr. Ali Rahnama explains how minimally invasive surgery can help these patients avoid much larger procedures in the future.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Ali Rahnama, a foot and ankle surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Rahnama.

Dr. Rahnama: Thank you for having me.

Host: Today we’re discussing chronic ankle pain after a sprain and what could be going on inside the foot and ankle. Dr. Rahnama, many of us have experienced an ankle sprain. How many would you say you treat in a year?

Dr. Rahnama: I would say it really depends on the time of year, especially as we get closer to the winter months. Sometimes I may see as many as 4 to 5 of these a week, sometimes even more.

Host: Student athletes and leisure athletes are at risk of sprains. Are there other groups of people who are susceptible?

Dr. Rahnama: While it’s true that typically we do see a lot of athletes with sprains because of the increased level of activity that they engage in on a day to day, we do see them in various patient populations and even non-athletes, particularly as we get closer in to the winter months. Slip and falls, especially in cities like Washington where people use a lot of mass transit and are walking outside on the sidewalk. We, a lot of times, see people slip on little patches of ice and things like that, and injure themselves and get sprains and even sometimes fractures.

Host: How do you determine whether an ankle sprain is mild, moderate, or severe?

Dr. Rahnama: I typically look at three things. I want to see how much tenderness there is, swelling, bruising, that kind of thing, the patient’s ability to bear weight or not be able to bear weight. Those are typically how I determine how bad the injury is.

Host: How long should a patient expect to fully recover from a mild or moderate ankle sprain?

Dr. Rahnama: Typically, a mild to moderate ankle sprain, I would expect to clear up in the ballpark of about 2 to 4 weeks, depending on how bad the injury is and exactly what part of the ankle they’ve injured. Typically, the lateral ankle ligaments are the ones that are affected more commonly. Those would be the ankle ligaments on the outside, as opposed to the inside ligaments.

Host: How long should a patient expect to recover from a severe ankle sprain?

Dr. Rahnama: Severe ankle sprains can take anywhere from up to 6 weeks to even up to 12 weeks to heal, depending on the injury.

Host: Is there anything special that an individual would have to do when they’re taking care of a severe ankle sprain?

Dr. Rahnama: Typically, with a severe ankle sprain, I would say it’s important for them to initially have a period of immobilization, rest, where they can ice it and elevate it and stay off it. And then, it’s really important for them to get with a physical therapy colleague of ours that I’ll very often send my patients to, who will work with them on proprioceptive exercises and strengthening exercises, to help get them to strengthen the tendons and muscles in and around the foot and ankle to help the patient avoid having a similar injury again in the future.

Host: Of course, spraining an ankle is painful, but how long does the pain typically last before it’s considered “chronic?”

Dr. Rahnama: The chronicity of the sprain isn’t just based on how long it takes for them to heal. It really has to do with how many spraining incidents they’ve had total. So, if I have a patient who comes to me for an acute sprain, meaning that they recently had one and so they’ve decided to present for care, or somebody sent them to me for evaluation, the first thing I want to make sure and ask them is that have they had similar incidences in the past that maybe they didn’t see somebody for and that maybe healed on their own and that now they’re noticing a pattern, where they had an initial sprain, sometimes even up to years ago, and as time has gone on, they, every so often depending on what they’re doing, particularly if they’re active, if they continue to have more and more of these incidences - and, so then, that’s when I start to think that it’s something chronic because there’s multiple episodes of it.

Host: So, it’s just being more and more susceptible to sprains?

Dr. Rahnama: Exactly right.

Host: What’s the standard first-line treatment for a sprain?

Dr. Rahnama: So, I would divide it into three things. One, I would say resting and protecting the ankle with a brace or boot, sometimes even a splint. And then second, I would follow that with resting range of motion, strength and stability exercises. And finally, maintenance exercises that would slowly get them back to more intense physical activity and for them to be able to engage in sports that would need sharp cutting, like tennis or basketball, for example.

Host: At what point do you typically recommend surgery for an individual with chronic sprains?

Dr. Rahnama: Well, first I’d like to emphasize that, even as a foot and ankle surgeon, the vast majority of sprains are treated nonoperatively. Only in the setting where a patient has not healed for more than 6 or 8 to 12 weeks and they’ve oftentimes had multiple incidences of sprains, will I start to think of surgery for correction of it. The surgical procedure is actually quite simple for a straight-forward, isolated, chronic lateral ankle tear, or laxity. We make a small incision, and oftentimes we’ll try minimally invasive techniques where we can make small, few-millimeter stab incisions and enter the joint and evaluate for any type of synovitic or pre-arthritic tissue, debride that. Debridement is when we use a shaver and the guidance of the camera, once we’ve gotten into the joint, to essentially just clean up and take out any of that arthritic or inflammatory tissue that doesn’t belong into the joint. And then we can even do our lateral ankle repair through those same incisions so that we don’t have to make any large incisions and open the patient up. It’s fairly straight-forward surgery. So, they actually did studies where they split two groups of surgeons up who had never done minimally invasive surgery before. And, in the first group, they had the surgeons do video games. And then, they had the other group not do anything at all. And, then they trained all...both groups at the same time in minimally invasive surgery and arthroscopic or laparoscopic surgery. And the group that had had the video game training before the surgical training actually got it a lot faster and did much better. So, if you’ve got a kid at home who’s good with video games, he may be good with minimally invasive techniques someday.

Host: When it comes to foot and ankle surgery, why is minimally invasive surgery a good approach?

Dr. Rahnama: Minimally invasive surgery is good for patients for a number of reasons. But, probably the most important things are many times patients undergoing minimally invasive surgery get back to doing what they want to do a lot sooner. There are much smaller incisions that need the body to heal them. And so, overall, they tend to have better outcomes, is what we found.

Host: Have you ever had a patient come in thinking they had sprained their ankle, but it was actually something else?

Dr. Rahnama: So, that’s a great question. We actually see this quite often where somebody will come in with the complaint of a sprain, or what they think to be a sprain, that’s not getting any better and it doesn’t really fit the description of what we would like to see for classifying it as chronic ankle sprainers. And, that’s really when we start to think about, ‘what else could this be, masking itself as an ankle sprain?’ Things like osteochondral defects of the talus, meaning an injury to the cartilaginous surface of one of the bones in the ankle, can cause pain, especially if there’s loose pieces of cartilage from that injury that are now in the joint. Those oftentimes can mask themselves with the same symptoms or similar symptoms as an ankle sprain. Also, tendon injuries can also mask themselves as sprains, where it may really be a tendon tear or even a rupture and the patient comes to us with an ankle sprain that’s just not healing. And so, those would definitely be a couple of things that we see fairly often that patients think are ankle sprains but they’re not. And, obviously, the last thing would be fractures, particularly if the patient was seen in an environment...because a lot of times, primary care offices don’t have X-ray available and so the patient is sent to us with a sprain. And, one of the first things that I’ll do, if the patient doesn’t already have one, is obtain an X-ray to make sure they don’t have any fractures anywhere.

Host: What can people do to reduce the risk of ankle sprains?

Dr. Rahnama: I would say it’s really important for people to keep in to consideration the type of shoes that they wear and particularly be mindful of the type of activity they’re trying to engage in. Runners, a lot of times here in the city particularly, it’s best for them to try to avoid, especially in the colder months, the wet months, avoid trying to go out for a run right after a snow or the rain. And, in the summer months, when we’re out on trails and things like that, really make sure you know the terrain that you are about to go out for a run in, for example, or embark on any type of physical activity, so that you don’t find yourself with any surprises.

So, what I would say is that, particularly in the winter months, if you’re a runner, make sure you have the appropriate shoe gear. Make sure your laces are tied nice and snug. And, maybe avoid the day right after a snow storm. Make sure you know the environment that you’re going to be running in so that you can avoid little slicks of ice and the really wet, deep puddles. Those are really where we see the biggest problems or people will say, “I slipped on a patch of ice,” or “I went off the curb and it was just too wet, and I slipped and I sprained my ankle,” or sometimes even worse. And in the spring and the summer months trail runners - I know that’s very popular these days - familiarize yourself with the terrain that you are about to go on a nice run for. Make sure you understand where there might be a ditch or a hole that you might want to avoid. So, before we go full speed ahead it’s nice to pause and try to really familiarize yourself with our environment.

Host: How do you recommend that patients prepare for foot or ankle surgery?

Dr. Rahnama: I strongly believe an informed patient can help the surgeon help them by developing protocols that are specific for them and their needs. If they feel they don’t have the upper body strength, for example, to stay on crutches and remain non-weight-bearing, they should share that with their doctor - and so that we can work with our physical therapy colleagues to help them gain the upper body strength, for example, to then get them ready for lower extremity surgery so that they can stay off of it. It’s not just about doing our portion of the procedure and then having patients go out and be on their own. We want to avoid that as much as possible. So, certainly in my exam, I try to assess the patient’s whole body to make sure that they have that ability, if they’re overweight, or have other things that impede them to remain non-weight-bearing, I definitely try to address that. But, we definitely want to encourage our patients to be forthcoming with any reservations or any concerns that they might have so that they can help us help them.

Host: What does recovery after surgery entail?

Dr. Rahnama: Typically, a period of non-weight-bearing for 2 to 3 weeks. And I will say that these protocols vary sometimes between surgeons. But there is research now that shows that the quality of new collagen that your body puts down when repairing ligaments depends on the stress being put on them. This is very similar to what we’ve known for a very long time about bone healing and bone turnover in your body. The stress of gravity and the stress of weight bearing actually helps your body heal it the way that it should be healed. And so, after a short period of non-weight-bearing, and making sure that our incisions are healed, I get my patients to therapy as soon as I can right after that to make sure that they engage them with a week to two of fairly aggressive, non-weight-bearing exercises. And then, in under a month typically, I will try to get my patients weight bearing again, again with the help of our physical therapy colleagues, to get them back on their feet and to make sure they have the best outcomes possible.

Host: What are some of those exercises that your patients are participating in during that initial couple of weeks and then the following month?

Dr. Rahnama: So, a lot of them might be resistance exercises, proprioceptive exercises, exercises that really strengthen the muscles, the tissues around the foot and the ankle and to really be able to support the repair that we’ve done. So, collagen are the little building blocks of ligaments and connective tissues in our body. And so, anytime you have an injury to the soft tissues and ligaments included in that, collagen is what your body uses to help repair things.

Host: Could you tell us about a patient who had foot or ankle surgery after a bad sprain and was able to return to an active lifestyle?

Dr. Rahnama: I had a college athlete in her twenties last year who had been spraining since she could remember and now it was getting to the point that, even with the best wrapping by her trainers, she couldn’t do what she wanted to do. So, she came and saw us. Obviously, being an athlete, she had some great trainers and therapists trying to rehab her with no good results. So, we proceeded to surgically fix the ankle ligaments, utilizing a minimally invasive technique and arthroscopy, where we make small incisions, just millimeters wide, and place a small camera into the joint and use that to help guide our repair. Surgery went as planned and we proceeded to use her training team again to help us get her back. And, she was back training in under two months, without restrictions. Now, she’s an extreme case of very aggressive rehab, but the point is that it can be done and there’s no reason to think that even the most physically demanding athletes can’t get back on their feet and get back to doing what they love.

Host: I know a lot of folks can be kind of stubborn when it comes to thinking about surgery. What are some of the reasons that you would give patients if they’re hesitant to come have surgery because they don’t want to take time off their activities?

Dr. Rahnama: That’s a great question. The one thing that I would emphasize is that a small problem, if not addressed by the right specialist, can a lot of times turn in to a much larger problem down the road that the patient then can’t avoid having taken care of. If a patient doesn’t see somebody for a chronic ankle sprain and thinks that this is something that they don’t want to have addressed, the reality is if they DO have it addressed and they have a small procedure now, that may help them avoid a much larger procedure, such as the need for a total joint replacement or joint fusion even, later on in the future as they get older.

Host: Why should someone with chronic ankle pain or a bad sprain speak to a surgeon at MedStar Washington Hospital Center?

Dr. Rahnama: We’re here to help and make sure our patients and individuals suffering from foot and ankle conditions can get back to life and do the things they love and be active. And so, that’s what we do every day, and we just want to make sure the local public knows we’re here, and if they need us, we’re happy to help.

Host: Thanks for joining us today, Dr. Rahnama.

Dr. Rahnama: Thank you so much for having me.

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One way to protect your heart is to choose the right diet. Discover why Dr. Allen J. Taylor believes the Mediterranean Diet—which relies on foods such as fruits, vegetables and white meat—is the best for preventing heart disease.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. Allen J. Taylor, Chair of Cardiology at MedStar Heart and Vascular Institute. Welcome, Dr. Taylor.

Dr. Allen J. Taylor: Thank you.

Host: Today we’re discussing diet choices for heart health, specifically the Mediterranean Diet. With so many ideas online and from well-meaning friends and family, it can be tough to make the best food and beverage choices for on-going heart health. Dr. Taylor, patients hear the recommendation to eat a healthy diet all the time. What does that really mean?

Dr. Taylor: Yeah, everyone’s an expert on their own diet, aren’t they? We’ve long known that (quote) “healthy diets” - and those are typically defined, from a heart perspective, as diets that are low in fat, high in fruits and vegetables - tend to be seen more frequently in patients who don’t suffer from heart disease. On the converse, people that eat poor diets are more likely to have heart disease. And that is true. The question is, where is diet science going? And in 2018, what’s the best diet to prevent heart disease? And that’s where there’ve been changes.

Host: What questions do your patients often ask about how their diets relate to their heart health?

Dr. Taylor: When you talk to patients about diet, there’s usually two things. The first is controlling body weight. And then the second is about controlling specific health problems, such as their blood pressure or their diabetes or their cholesterol. And as you tailor diets to different patients, it often has to be highly customized to the health problems that they have. But overall, it’s about reducing heart risk. And, it can get very confusing to think, “Oh, I have to avoid salt and I have to avoid fat and I can’t eat sugar because of my diabetes.” And the question is, “What can I eat?” And patients get confused. And they get so confused, they can’t make good food choices and they give up. And they eat things which aren’t good for their health. So, how do you bring it all together? There’s so many diets - there’s fad diets, the keto diets, the low carb diets, Atkins diets, South Beach - it’s all over the place these days. And today...tomorrow there’ll be another one. The optimal diet from a heart perspective is one, if you were going to design it, is one that makes good metabolic sense and has been tested. Tested and proven to reduce heart disease risk. Now, when it comes to weight loss, that’s a simple thing. It’s about calorie balance. It’s calories in and calories out. One reason people gain weight as they age is because, they don’t realize it, with every decade they age their daily calorie requirements go down about a hundred kilocalories. Now, the average 20-year-old can probably eat 2,000 or 2,200 calories a day. The average 60-year-old has to eat 400 calories less a day just to stay in balance, 1,700 or 1,800 calories. If you’re eating like you did when you were 20 or 22, you’re gaining weight. So, calorie balance is the most important thing from a weight perspective. But then it’s about what goes in to those calories; what’s making up those calories - how much is fat, how much is sugar, how much is protein? It’s hard to eat like that. It’s hard to eat...how much protein am I going to eat today? How much sugar should I eat today? And, some people can do that. What I try to do with my patients is to make it as simple as possible and to use the best evidence-based diet as possible because we’re trying to reduce the risk for heart disease. And today, that diet is the Mediterranean Diet.

Host: What about the Mediterranean Diet makes it so heart healthy and so, quote/unquote, “easy to follow?”

Dr. Taylor: Well, the first thing about a Mediterranean Diet, and it’s just simply a name for it, but it’s really a style of eating, it’s food choices. And, it has been rigorously studied, both in people with known heart disease and without known heart disease. Very important study, published about five years ago now, was a study called the PREDIMED study. And, it was a study of about 7,500 individuals who were either asked to eat a Mediterranean Diet or an otherwise really high-quality American diet. The American diet was things like using low fat dairy products, saying that things like pasta and rice were ok, and fruits and vegetables are encouraged, and lean fish and seafood are also okay. That sounds pretty good, doesn’t it? It’s pretty much what a lot of us eat. What was interesting is that the Mediterranean Diet is different than that. It’s a diet that’s, again, rich in fruits and vegetables but includes fish. It includes beans. White meats, such as chicken. Wine is okay with meals and that’s often a good selling point for the diet. And then it can include nuts and supplementation with olive oil - olive oil to cook or even olive oil to simply add to your food, like put it on top of salads. When those two diets - this really good quality American diet and the Mediterranean Diet - were compared, Mediterranean Diet won, hands down. There was nearly a 20 percent lower risk for heart events in people who ate the Mediterranean Diet. There was a 30 percent reduction in heart disease risk in the patients that ate the Mediterranean Diet. So, that’s a large reduction - 30 percent risk - that’s the same risk reduction seen with taking cholesterol pills, for example. So, very impactful. The thing about the Mediterranean Diet that I like in particular - while those are the things you should eat, and again, to repeat them, fresh fruits and vegetables, fish, white meat, beans, nuts are okay, wine is okay, and olive oil supplementation - it discourages certain things like soda drinks, commercial baked goods and sweets, spread fats and red meats. And what I like about it in particular is it doesn’t say you can never have those things. It’s about how frequently. For instance, most of those things should be fewer than one serving per day. And commercial baked goods, less than three servings per week. And so, when you stand in the line at your favorite coffee shop, what you’re tempted with while you’re waiting is nothing but commercial baked goods and sweets. And it’s okay to have one once in a while. Not every day, if you’re going to eat the Mediterranean Diet. And, I ask my patients, is that worth a 30 percent reduction in your risk for heart disease? And most become very interested in this type of diet because it’s about the food choices you make. And it’s not like you can never do certain things because look, eating’s supposed to be fun and eating is a part of life many times a day. It’s a social function; it’s what we enjoy. And so, the Mediterranean Diet, I think, can be compatible with a very healthy diet, a very heart healthy diet, but also one you can sustain. The problem with many of the fad diets is they’re great for a week or a month and people will often lose weight and that entices them into it, but frankly, we don’t know the safety of those diets. We don’t know if they’re heart safe. We don’t know what it does to their cholesterol and their blood pressures. In the end, that’s the most important thing. So, if you really want to follow an evidence-based diet, a diet that’s been proven to work, to reduce heart risk, it’s the Mediterranean Diet.

Host: When you give that example, what do you say to those patients who say, “Well, if it’s similar to taking a pill, I’ll just take a pill and still enjoy my cheeseburgers.”

Dr. Taylor: That’s great. Well, I say, “You know what? This was in addition to people taking pills.” So, this doesn’t replace pills and lowering cholesterol is not the goal of this diet. It’s about lowering heart risk. So, if you have a cholesterol problem, you probably will need a pill. If you have a blood pressure problem, you probably will need a pill. But this diet reduces heart risk. And it’s the types of food you’re eating and the types of foods you’re not eating that is driving it. So, it’s the diet that, from my viewpoint, we should be following for heart risk in this country. To come back to the diet that it was compared to, it was the previously recommended diet by the American Heart Association. So, those recommendations - and if you grew up through the ‘80s and the ‘90s, you were told, “avoid fat, avoid red meat, and the rest is gonna be fine.” Now, I’m summarizing, but that was what people were trying to avoid. And what do they substitute? They substituted sweets and baked goods and pasta, which are great, but small amounts. And, the Mediterranean Diet is by far a better diet from a heart risk perspective.

Host: What about those trendy diets like Atkins or like keto. What do you say when folks are wanting to try those types of diets?

Dr. Taylor: The goal of those diets is usually weight loss, and they do work in the short term. You can eat a ketogenic diet, and that’s a fancy term for a diet that is simply carbohydrate poor. So, it takes rice and breads and sweets out of the diet and focuses on vegetables and meats. And so, it’s a high protein diet. And in the short term, people will lose some water weight and they’ll lose water weight very quickly. Then it tails off. And, what the evidence is, is that, in the end, if you eat simply a calorie-restricted diet versus a ketogenic diet, the weight loss is the same. So, there’s no specific advantage of eating a ketogenic diet, when you look at 6 and 12 months out. What we’re talking about with things like the Mediterranean Diet is a diet that is more about prevention of heart disease. It’s not about weight. So, if you want to lose weight, it’s really about ins and outs - how many calories you’re taking in; how many calories you’re burning. Oftentimes patients aren’t quite aware. They’ve got a certain pattern of eating and often there’s some overeating. And, you’ve got to measure it. There’s some great health apps like MyFitnessPal. It’s a free app and you put in all your foods. It tells you exactly what you’re eating and how many calories. And there’s other ones as well. That’s important - to measure where you are and how much you’re eating. And it’ll tell you how much protein and fat and sugars you’re eating. And again, if you want to lose weight, you’ve got to measure your ins and monitor your outs. More exercise, less eating. It’s the only way to lose weight in a stable, long-term way. But from a heart risk perspective, it’s about the types of foods you’re eating. And, the best diet now is the Mediterranean Diet. That diet is better than the best American diet, 30 percent better for heart risk. It’s an easy sell.

Host: So, when you’re thinking about all these diets - you have paleo and you have keto and you have Atkins and they have all these flashy names - well, Mediterranean Diet just sounds very fancy and complicated. How do you break that down for people so it’s something relevant to them that they can really do?

Dr. Taylor: Yeah, it can sound exotic and it isn’t and that shouldn’t scare anybody away. It’s actually just a diet that changes the quantities of things you eat to one, things that are healthier and away from things we’re probably eating too much of. And nothing in this diet is not freely available to people on a daily basis. So, it’s about the quantities. And the thing I love about this diet is that it’s...you don’t have to go to the Mediterranean to eat it. And you don’t have to eat foods you don’t like. It’s about the choices you make. So it’s about eating lean meats, fruits and vegetables. It’s about eliminating sodas and baked goods and sweets. And the occasional red meat is okay. And people that like red meat will find that really comforting and think that they can really sustain this.

Host: What questions should patients ask their doctor if they’re considering trying one of these newer, trendier diets or going on to the Mediterranean Diet?

Dr. Taylor: I think it’s important to talk about the goals of the diet and what the risks are or unknown risks are. If the goal of the diet is weight loss, the answer is simple. You’ve really just got to do it a calorie restriction and more activity. It’s hard work. It’s slow going. The fad diets - you’ll lose a little more weight quickly, but it’s a fake-out—it’s usually water. If the goals are other things like you want to improve your blood pressure, well, there are blood pressure improvement diets, such as the DASH diet. It restricts sodium, it supplements potassium, magnesium. It’ll lower your blood pressure. So, if you’re worried about your blood pressure, you’d like to avoid meds, there’s a diet out there for you. Similarly, for cholesterol. You can lower your cholesterol with a diet - somewhat. Restrict fats, eat lean meats. But by and large, cholesterol is pretty unresponsive to diet. And so, we usually use medicines for cholesterol. So as you talk about what diet to eat and fad diets, define your goals. Is it weight loss? Then the answer is ins and outs. And, if it’s a specific health problem, that is a little bit more of an in-depth discussion because there are some diets that are proven to work - the DASH diet is the best example. But I choose, typically, to focus on the global risk for heart disease because, no doubt, the most effective diet is this Mediterranean Diet. We’ll treat the blood pressure and cholesterol with other ways, but reducing heart risk is so important and the Mediterranean Diet is very effective.

Host: Could you share a success story from your practice about changing their eating habits and reducing their heart attack risk?

Dr. Taylor: Yeah, I can share a few. One is simply weight loss and have had many patients and I’ll describe one that, you know, everyone walks in with their smart phone and they think they’re all app’ed up. And, many patients have turned on to these apps like MyFitnessPal. And I’ve had patients come in and they’ve shown me exactly what they’ve eaten and how they’ve changed what they eat. They found foods that they thought they liked but really are quite unhealthy for them - they have a lot of sodium or a lot of calories. And, have changed their diet and have lost weight. And that’s really gratifying. And they’ve done that simply by more monitoring - and these apps, these health aids can really help. The Mediterranean Diet is a different story. And, a week doesn’t go by where I’m in the hospital talking to some patient, and it’s usually the wife that’s asking the diet question, about how to change a diet to reduce the risk of a future heart event. And, I try to be very optimistic in talking about the Mediterranean Diet - that it is a lifestyle diet. There’s nothing you can’t do, but it’s about food selections and these days, you know, we’re fortunate that the access to fresh foods and to healthy foods can be made without a lot of sacrifice. And so, it’s about shifting the types of foods you eat and usually the wine’s a big seller. People don’t mind a glass of wine with dinner, and that’s in this diet as well. So, people want to know what they can do that’s active to improve their health and eating is such an important part of life. You want to know that you’re eating a diet that’s not just you enjoy but that is healthy for you. So, I think the Mediterranean Diet is really worth a look. You can find simple information online. And even, you know, you can find the study I referenced - the PREDIMED studies - free online. You can go and look that up. And, it’s got the diet simply laid out. So, you can really start to look at the foods you’re eating and choose the right ones. I think diet is an important discussion to have with your doctor, and it’s not a quick discussion. You’ve really got to define the goals and then make a commitment toward changing diet that you can sustain. And, if you can outline a way forward. And I’ll even give patients a copy of the study and a page that summarizes the diet so they can ... somebody can look and say, “I can do that. I like that food. Ah, I’ll just have that once a week. I’ll skip it three times a week.” They sound like they can be successful, and they are. And it’s nice to see that people can make sustainable changes that you know reduce their heart risk.

Host: Thanks for joining us today, Dr. Taylor.

Dr. Taylor: Thank you very much.

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In the past, the only way to treat aortic stenosis was to perform open-heart surgery—a very invasive procedure. Discover how TAVR, a new minimally invasive surgery, can replace a heart valve without surgery, allowing patients to recover faster.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Toby Rogers, an interventional cardiologist at MedStar Washington Hospital Center. Thanks for joining us, Dr. Rogers.

Dr. Rogers: It’s great to be here.

Host: Today we’re discussing high, medium and low risk transcatheter aortic valve replacement, or TAVR. Dr. Rogers, could you start by discussing what TAVR is?

Dr. Rogers: That’s a great question, and a lot of patients are quite confused by this terminology. So, aortic stenosis is a condition that is very common, particularly in older patients. And, it’s caused by a narrowing or blockage of the main heart valve through which blood flows from the heart to the rest of the body. And, as that gets progressively tighter with time and with age, patients can start to get very symptomatic, particularly when they’re trying to be active. So, they get very short of breath, they can get dizzy, they can even get chest pain when they’re trying to be active, even just walking across the room. And, historically, the only way to fix this problem was to do open-heart surgery and literally stop the heart from beating, cut out the old valve, and surgically sew in a new valve. But you can imagine, open-heart surgery is a big deal and it’s very stressful on the body and, the older you are, the more stressful a big surgery is. And so, TAVR is an amazing new technology that over the last decade has revolutionized cardiac surgery, in that we can now replace that heart valve through a little tiny catheter in the groin, with the heart still beating - in fact, with the patient awake. We don’t even have to put the patient asleep. And, we can replace the heart valve and improve the blood flow to the rest of the body.

Host: What do you mean when you say high, medium and low risk TAVR?

Dr. Rogers: So, again, this is a concept that we use very freely in medicine, but patients often get confused by that. And, what we’re actually saying is, ‘What would the risk be for that patient to undergo the old fashioned open-heart surgery?” Meaning, if they were to have open-heart surgery tomorrow, would that be a low risk procedure, an intermediate risk procedure or would it be a very high-risk procedure. And that’s not really determined by the heart at all. It’s often determined by other medical problems they have. And obviously, older patients are more likely to have more than one medical problem. So, if you have trouble with the kidneys, if you have trouble with your lungs, if you have trouble with your liver - then all of those things will make a big procedure, or a big surgery, more high risk. And so, for every patient that comes along with aortic stenosis, we make an assessment based on a whole barrage of tests, looking at all the different organs in the body, as well as the heart, to say, “What would your risk of surgery be?” And that, then, helps us judge whether the open-heart surgery is the best treatment for them or if, in fact, they’d be better to have a procedure like TAVR, which is less invasive.

Host: Who would you consider to be an optimal candidate for TAVR?

Dr. Rogers: Well, certainly anyone who is very high risk for surgery. So, if undergoing open-heart surgery would be very high risk, and there would be a risk of not making it through the procedure, then clearly those are patients who should have less invasive procedure. And certainly, that’s the way TAVR started. It was really only available to patients who were so high risk that they just couldn’t have surgery. But then, as we’ve gotten more comfortable with the technology, and we’ve gotten more data for the technology and as we’ve run clinical trials - very rigorous clinical trials - across the US and across the world, we’ve actually demonstrated that TAVR’s actually a very good option for anyone with aortic stenosis. And, I think within the next 12 months, we’ll expect that the FDA will approve TAVR so that we can offer it to anyone with aortic stenosis. So, for sure if you’re high risk, but the truth is, moving forwards and in years to come, I suspect that TAVR will be the first line treatment for anyone with this condition.

Host: You mentioned inserting the catheter through their groin and replacing the artery that way. Could you describe how TAVR is performed?

Dr. Rogers: Yes. So, of course, each procedure is slightly different for different patients. But, a typical TAVR is performed with a patient under conscious sedation. By that we mean we give you some medication to make you relaxed, make you a little bit sleepy, but you’re breathing for yourself, you’re not on a ventilator and, in fact, some of these patients even sort of, you know, are able to talk to us and are fairly awake during the procedure. And that has a lot of advantages because putting a patient on a ventilator and breathing for them with a mechanical ventilator under general anesthetic increases the risk of the procedure. There’s more risk of picking up a chest infection, needing to be in hospital longer after their procedure, whereas if it’s all done under conscious sedation and with local anesthetic, then patients bounce back much faster and are able to get up and about much faster and that speeds up the recovery. So that’s the first step - it’s done under conscious sedation. And then, what we actually do, is we take the heart valve, the new heart valve, and we crimp it down or we’ll crush it down onto a catheter. So, we squeeze it down so it’s small enough to now go through the artery and the groin. We all have big arteries that go from the heart all the way down through the belly, down the legs, and so, we actually access one of those arteries and thread the catheter, with the new valve on it, all the way from the artery in the groin, all the way up to the heart and then position it inside the heart using x-rays and ultrasound so that we know we’re in the right place. And then, we open up the new heart valve inside the old one and “Hey, Presto” - you have a new heart valve.

Host: What does a patient have to do then to prepare for the procedure?

Dr. Rogers: So, I think we have a great team here that really guide the patients through the whole process, right from the very first contact, through all the testing to work out whether TAVR is the right treatment for them, all the way through the procedure. So, there are a lot of steps to this. This is not just a sort of come in and have the procedure and go home the next day. We always see patients beforehand. We usually bring patients in for a day or two several weeks in advance of the procedure to do all the tests we need to do to make sure that we know everything we need to know about this patient before we embark on the procedure. And then if we’re talking specifically on the (sort of the) day of the procedure, we usually ask people to come in the night before or very early in the morning. There’s a whole series of tests that we do - blood tests, to make sure that there’s...nothing’s cropped up in the meantime. And then, the procedure itself takes 3, 4 hours. And then, the patients typically go to either the cardiac ICU overnight or increasingly, actually, just go back to the normal ward, just to be monitored by the nurses there. And then we try and get people up and about the next day, and the average hospital stay for this procedure now is 2 or 3 days. So, actually, we’ve gone from a process where open-heart surgery patients would be in hospital for a week or more to a process where people are having heart valve replacement and they’re out, sometimes the day after the procedure, which, I think, is a revolution in this treatment.

Host: What are the benefits of TAVR compared to traditional open-heart surgery?

Dr. Rogers: Ok, so the first benefit is that some patients simply can’t have open-heart surgery. They’re too sick. They have too many other medical problems that would make the procedure too high-risk. And therefore, surgery just isn’t an option for them. Whereas, we’re able to perform TAVR safely in those patients because it’s less invasive. For the more general population, TAVR has the clear advantage that recovery is faster. Patients, after surgery, often have longer hospital stays. They end up staying in hospital for a week or so after the procedure. The complications are more common after surgery because it is just a bigger procedure and a bigger stress on the body. TAVR patients, in contrast, tend to go home within 2 or 3 days of the procedure and the recovery after they get home is much faster because they don’t have to deal with the surgical wound, the incision, and all of the problems you can get related to having just had a much bigger procedure. And so, in terms of getting back to normal daily activities, getting back to work, TAVR allows for much faster recovery.

Host: And the recovery process - how does that look for patients?

Dr. Rogers: So, the great advantage - and I think I’ve highlighted it a little bit already - the great advantage to this procedure is it’s not surgery and it doesn’t require cutting the chest open, it doesn’t require general anesthesia. And so, the great advantage of TAVR is the recovery. Patient’s bounce back and recover from this procedure must faster because it’s just less stressful on the body. Now, that being said, it’s still heart surgery, we’re still replacing a heart valve, and so I always try and temper patient’s expectations and say that, “You’re gonna have to take it a little bit slow here at first.” But, it depends. Someone who is in their 60s is going to recover from a big procedure like this much faster than someone who is in their 90s. And so, every patient is a little different. But certainly, the whole goal of doing this procedure is to get someone back to their normal activities, not just what they were like before they had the procedure but what they were like before they had symptoms from the aortic stenosis. So, back to being active, back to playing sports, whatever they want to do.

Host: Could you share the story of a patient who had a particularly successful outcome with TAVR?

Dr. Rogers: Sure. So, one patient, he’d had open-heart surgery to replace the same valve about 10 years or so ago. And, that had been a great success. He felt wonderful afterwards. But, the truth is, prosthetic heart valves don’t last a lifetime. And so, his “new” heart valve started to get tight and he a started to get those same symptoms again. And he was very, very worried about the prospect of having to have open-heart surgery again. He felt like he had done it once; he did not want to go there again. So, when he found out that there was an alternative to avoid having to have open-heart surgery again, he jumped at it. And, he came in the hospital, we did the procedure the same day, we got a great result with the new valve, and he actually went home, I think, the day after the procedure. Now, not everyone goes home so soon but, for him, the difference experienced from the first surgery, where he was in hospital for a week, to going home, literally, 24 hours after his procedure, I think, that’s really remarkable. And certainly, he was overjoyed by the result he got.

Host: Why is MedStar Washington Hospital Center the best place for patients to come for TAVR?

Dr. Rogers: I think that one of the strengths we have is that we’ve been part of the whole TAVR program since it very first took off. The very first procedure was done in France in 2002, and TAVR came to the US in around 2007, and MedStar was part of the first wave of hospitals to perform this procedure. And, we have performed almost 2,000 of these procedures now. We have a great deal of experience with all the different types of technologies which are out there to treat this. It’s not just one valve available. Now we have a whole series of different types of valves, which are...different patients need different valves. And, we’re also very active in research. So, not only do we have access to all of our past experience in research, but we also have access to all of the new technologies. So, when a new valve is made available, we’re one of the first hospitals to get access to it to offer that to our patients.

Host: Thanks for joining us today, Dr. Rogers.

Dr. Rogers: Thank you for your time.

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Relaxing is important an important part of life—especially for the heart. In fact, when the heart has difficulty relaxing between beats, people can develop diastolic heart failure, a serious functional condition. Discover which treatment options can help.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. Valeriani Bead, a board-certified cardiologist at the MedStar Heart and Vascular Institute, with extensive experience in nuclear cardiology and echocardiography. Welcome, Dr. Bead.

Dr. Valeriani Bead: Thank you for having me. I’m really happy to be here.

Host: Today we’re discussing diastolic heart failure which occurs when the left ventricle or the lower left chamber of the heart can’t properly fill with blood. Dr. Bead, is diastolic heart failure a common heart condition?

Dr. Bead: Yes. But first we need to understand what diastolic heart failure is. In simple terms, it’s defined as an abnormality of the diastolic filling, or what we call the relaxation, of the left side of the heart, despite the fact that the heart pumping function is normal. And usually it occurs when the ability of the left side of the heart...when it can’t really accept blood or it’s impaired. And this can lead to a higher pressure inside the heart. Then, that can lead to fluid build-up in the lungs and also to the rest of the body. Now, to answer your question, diastolic heart failure is quite common, and it’s thought to be as prevalent as 20 to 70 percent in some patient populations and is thought to be responsible for about two-thirds of the incidence of congestive heart failure that we see in general.

Host: What are some of the main symptoms of diastolic heart failure?

Dr. Bead: Some of the most common symptoms that we experience with diastolic heart failure are shortness of breath, fatigue, lightheadedness or fainting, and sometimes even an irregular or abnormal heartbeat.

Host: How is this condition diagnosed?

Dr. Bead: Typically, we diagnose diastolic heart failure by good, comprehensive history and physical exam. And then, based on that, we may order some imaging tests called an echocardiogram, which is a sonogram of the heart. This is often combined with the stress tests to show how blood is flowing in the heart during exercise. Finally, we may do additional blood tests or even an invasive procedure called a cardiac catheterization, which is when a thin tube is inserted into the heart in order to see how the heart is functioning and to determine whether or not there are any blockages in the arteries.

Host: Could you tell us a little bit about your patient population for diastolic heart failure?

Dr. Bead: So, the most common individuals we see, those at highest risk for diastolic heart failure, is the older population, so typically individuals over 65 years old and those who have high blood pressure. Sometimes those who have problems with their heart valves, particularly the aortic valve, and typically when that valve is narrowed or doesn’t open well. We also see the diabetics and people who have clogged arteries, and, for unclear reasons, you see it more common in women.

Host: Once you’ve diagnosed an individual with diastolic heart failure, what treatment options are available for them?

Dr. Bead: We always start off with lifestyle modifications, which include smoking cessation, increasing physical activity, and dietary changes. Next, we offer treatment to address the stiffening of the heart and that typically includes controlling the blood pressure, controlling the diabetes, and also, if they have high cholesterol, we also treat that. And some of the medications we use may include a class of medication called beta blockers, which are used to slow the heart rate in order to allow it to function better. We also use medications called calcium channel blockers, which help reduce the stiffness of the heart. Other medications include diuretics that help reduce the fluid accumulation. And, if those are not sufficient, sometimes we offer an invasive procedure called a cardiac catheterization or even surgery to fix any blockages or narrowings in the blood vessels.

Host: What are some of the risks if a patient doesn’t receive treatment for diastolic heart failure?

Dr. Bead: Now that’s a great question because, the main risk we worry about, if a patient doesn’t receive treatment for diastolic heart failure, is death. The other risk we worry about is congestive heart failure, which is when an individual has a sensation that they can’t breathe, and they have evidence of fluid overload. Other things we may see are abnormal heart rhythms called atrial fibrillation. Other things that we may see are passing out, also called syncope.

Host: Is there anything that patients can do to reduce their risk of diastolic heart failure?

Dr. Bead: Yes. The most important thing patients can do to reduce their risk of diastolic heart failure is to keep their blood pressure under control, to control their diabetes or their blood sugars, and to control their cholesterol. And, of course, I mentioned lifestyle changes. So, meaning making sure they don’t smoke, they stay active, and they eat a heart healthy diet.

Host: Could you explain how diabetes is related to diastolic heart failure?

Dr. Bead: Diabetes affects every organ in the body. And in fact, in cardiology, we consider diabetes ‘heart disease’ until proven otherwise. Although the ideology is unclear, diabetes is thought to lead to direct stiffening of the heart, either by having too much glucose in the system or by causing premature stiffening of the blood vessels surrounding the heart and, thereby, stiffening the heart itself.

Host: When you said that, it made me think of a ‘starch,’ like you would put in your clothing to make it stiffer.

Dr. Bead: You know what!? That’s an amazing analogy! Yeah! Cause that’s basically what it does. When you have all this excess glucose in the circulation. It’s basically, because it can literally surround cells and kind of ‘coat’ them so they don’t function so well, and they can become stiff like a starch. Yeah, like starch.

Host: Could you share a treatment success story from your practice?

Dr. Bead: This is always my favorite part! I love talking about my patients because they’re so amazing. There was one middle-aged lady who came to me as a consult from her primary care physician. Initially, it was a semi-urgent consult because the EKG, the electrocardiogram, was abnormal and showed, an abnormal rhythm that was initially concerning for atrial fibrillation when, in fact, she had a lot of skipped beats. When I saw the patient, she was complaining mostly of shortness of breath and the inability to do her Zumba exercises. Oh, she loved to exercise about three days a week. But then she started noticing that her legs were more swollen. She got tired easier. She had a ‘flooded’ sensation in her heart and she really couldn’t do her usual activity of daily living. And, I did a good exam. Her lungs were clear. Her heart actually sounded pretty good, with the exception of some skipped beats. But she did have some swelling in her legs and her blood pressure was quite elevated. And so, based on that, we talked, we adjusted her medication in order to get her blood pressure under better control. I prescribed a diuretic in order to reduce the fluid on her legs. And then we discussed her lifestyle changes such as reducing the sodium from her diet. When we saw her back within a couple of weeks, I had her get an echocardiogram or a sonogram of her heart which showed that her heart was strong but, using certain diagnostic techniques, we could tell that her heart was a bit stiff and it was also thickened from long-standing high blood pressure. So, we were very vigilant in terms of getting her blood pressure under good control. We were able to keep the fluid off. She was...did her part by making the lifestyle changes that she wanted to. And then, within about 6-8 weeks, she was back to doing her Zumba classes with no restrictions. And then, when I see her back every 6 months, she’s actually to the point that she’s helping teach the Zumba classes, which is always awesome.

Host: Why is MedStar Heart and Vascular Institute the best place for patients to seek care for diastolic heart failure?

Dr. Bead: The MedStar Heart and Vascular Institute, really is the best place for general cardiology patients, but, in particular, for patients who have specific diagnoses, such as diastolic heart failure, because it offers comprehensive, state-of-the-art care in a compassionate environment that is patient-centered and evidence based.

Host: Well, thanks for joining us today, Dr. Bead.

Dr. Bead: Thank you for having me.

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Artery buildups serve as silent danger signs of a heart attack. Discover how a coronary calcium score calculates patients’ risk by measuring the amount of calcium in their arteries through the use of a computed tomography (CT) scan.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. Allen J. Taylor, Chair of Cardiology at MedStar Heart and Vascular Institute. Welcome, Dr. Taylor.

Dr. Allen J. Taylor: Thank you.

Host: Today we’re discussing coronary calcium scoring, which is a non-invasive heart scan that a cardiologist can use to help calculate a patient’s risk for coronary artery disease or atherosclerosis. Dr. Taylor, what are you looking for in a patient’s heart when you perform coronary calcium scoring?

Dr. Taylor: Great question. This is a very simple test that very accurately and easily detects the beginnings of atherosclerosis or what otherwise people call (quote) “hardening of the arteries.” It’s that development of plaque, cholesterol buildups and other things that are filling up the arteries as we age. And so, when we’re doing coronary calcium scoring, we’re looking for little pieces of calcium, like in your bones, but that are in the arteries and it shouldn’t be there. And it’s a marker for these buildups that we can easily detect and measure and through that, evaluate a patient's risk for heart disease.

Host: How does the calcium end up there when it’s not supposed to be there?

Dr. Taylor: The calcium comes because the arteries are becoming damaged from the buildups and as they heal, the body naturally lays down some calcium. So, it’s part of these plaques or buildups and it’s the one that we can detect with x-rays because x-rays detect bone, and this is basically bone in your arteries—little pieces of calcium. So, it’s easily detected with a simple scan, a CT scan, that we call a coronary calcium scan.

Host: Are there certain populations of patients who are at increased risk for high levels of coronary calcium?

Dr. Taylor: It’s interesting because simply by aging, that’s your major risk. Now, some people with high cholesterol or high blood pressure or diabetes or smokers - they may develop calcium in their heart arteries at a faster rate. But, just because you don’t have those things, doesn’t mean you’re not developing buildups; it doesn’t mean you don’t have coronary calcium. And the challenge is that by measuring those risk factors, we can detect somewhat of a patient’s risk for heart disease, but it’s only part of the story. And, the important thing about calcium scoring is that it tells us more of the story. It adds to what we already know about a patient and helps us to determine who really is at risk for heart disease.

Host: Is there anything that a patient has to do to prepare for this type of scoring test?

Dr. Taylor: The beautiful thing about this is it’s a very simple test. It’s done using a CAT scanner or CT scanner, but it uses very low doses of radiation. There’s no needle. There’s no medicines. All the patient does is lay down, get hooked up to a few electrocardiogram electrodes, and hold their breath for about 15 seconds. Within 5 minutes, they’re done, and the scan is complete.

Host: Now why does the patient have to hold their breath while they’re getting this test?

Dr. Taylor: The reason that you have to hold your breath is because if the heart is moving when you breathe, it’ll blur the images. So, it’s done during a breath hold. But, the breath hold is very short. The scans are very fast. And, virtually all patients can tolerate the scan. The scanners are very wide profile, there’s not a lot of claustrophobia or that feeling of being closed in by the scanner tube. And the radiation levels, which is previously or often a concern, are very, very low. They’re really like a couple of mammograms worth of radiation exposure. So, it’s a very simple test and actually they’re also very inexpensive. Most health systems will do these tests for under a hundred dollars, if insurance doesn’t cover it. And many insurance payers will actually cover the test.

Host: What happens next if a patient’s scan shows high levels of coronary calcium?

Dr. Taylor: Right. If you find calcium, what does it mean? It means you’re at increased risk for heart disease. By the converse, if you don’t find calcium, it means you’re at low risk for heart disease. So, it really puts a lot of clarity on who is and who’s not at risk. So, when you detect coronary calcium, there’s certain things you’re going to do. The most obvious things are live a better lifestyle since lifestyle changes are so important to heart disease risk. Eat a better diet, exercise more, get good rest, avoid stress, for example. And then, other health habits, like don’t smoke, make sure your cholesterol is well controlled, make sure your blood pressure is well controlled. Maybe you’ll need a cholesterol medicine to control your risk. Maybe you’ll need aspirin to control your risk. With this information, you can make the right lifestyle changes. And also make sure you’re on the right treatments to optimize reducing the risk for heart disease. Because, remember - heart disease is still the number one killer in this country.

Host: If those lifestyle changes don’t work, what treatment options are available to take care of that coronary calcium buildup?

Dr. Taylor: A common question we get is “Can you remove the calcium?” And, you can’t. But remember, if there’s calcium there, there’s plaque or other buildups. And it’s that other parts of the buildups we’re trying to treat by treating cholesterol, for example. Mostly we can show that we can stabilize the plaques, for instance, by lowering cholesterol a lot using very simple cholesterol medications that are very safe and very effective. But, some other choices might be there for patients, like do they or don’t they take an aspirin a day, for example, or what blood pressure targets should they be looking for? Or, maybe they’ve been avoiding diabetes treatments and they should get on treatments. Or, what types of diabetes treatments? So, with your doctor, there’s many healthcare choices that can be made to reduce the risk for heart disease. But, that’s the connection. You get the test, you clarify your risk, and then you treat the risk using those other interventions - lifestyle and then targeted treatments for certain heart risk factors.

Host: You’ve given us a lot of really good reasons to get this test and then to seek treatment after. But what if a patient doesn’t seek treatment? What are some of the risks to their health?

Dr. Taylor: Well, one thing we know is that many patients fear heart disease but may not have to fear it at all because, if you have no calcium in your arteries, the evidence shows the risk for heart disease over the next 10 years is extremely low, like .1 percent per year, one in a thousand. Very low. Now, if a patient does have coronary calcium and doesn’t seek treatment, that would not be the outcome we would want because anytime you do a test, you want to use that test to make better health choices. And, the evidence shows that, in fact, that is what happens. So, when people get this test, they’re more likely to get appropriate cholesterol medication, for example. They’re more likely to take appropriate measures, like taking aspirin. And, they’re also more likely to make other healthy lifestyle choices. So, I think the test has some great utility to help both patients and doctors more carefully identify risk and then respond in the right way. And, the evidence suggests that that’s actually what happens.

Host: Could you tell us about a patient who came in for a coronary calcium scoring test - maybe found that they had some calcium and made some changes to their life or were able to reduce their heart disease risk?

Dr. Taylor: Oh sure. I can tell you stories on both sides of the story. A friend of mine, he’s in is early 50s and has a family history of heart disease, has always worried that something inside of him is not...won’t be right, that genetics have led to him to have risk for heart disease. But he lives a healthy lifestyle, doesn’t have any risk factors. He got a scan - there was no calcium. So, he has been reassured that, in fact, whatever it was that led his loved one - it was one of his parents - to have heart disease, he, at least at this point in his life, doesn’t appear to have it. And it’s a pretty good time to screen, as people turn middle-aged, 50 to 60. That’s when heart disease risk really goes up and we can detect calcium, if it’s present, and how much. On the other side of the story, many, many successful stories that show how this test can be well utilized. For example, a woman who was also middle-aged, in her 50s, and she had been worried about her heart health and didn’t have a lot of risk factors. Not a smoker, good cholesterol. And, in fact, she has very high levels of coronary calcium. And, she’s way above average for age and that says that her risk is much higher than it should be. So, what did we do? Well, she’s now on a cholesterol medicine - her cholesterol wasn’t bad, now it’s perfect. And, not all healthy people should take aspirin, but her risk is high enough with this that we have, in fact, placed her on aspirin - carefully, because aspirin can cause bleeding, so you only want to use aspirin when patients have risk for heart disease. So, her treatments have been changed. Now, she’s still active and she’s still eating well. She was always doing those things. But now we’ve gone from the normal lifestyle changes to, in fact, a very proactive approach to reduce her risk and hopefully that risk is being optimized.

Host: What would you say to a patient who feels like maybe this isn’t for them or they don’t need this type of test?

Dr. Taylor: The interesting thing about calcium testing is that we can only predict, with heart risk factors, about a third, meaning a minority, of actually how much buildup is actually there. You only know by looking. You know, they’ve said ‘a picture says a thousand words?’ That’s the case with this. By doing this very simple test, you can get a complete view of heart risk within 5 minutes, and it’s something that no other test can provide.

Host: What makes the program here at MedStar Heart and Vascular Institute so unique for patients who have coronary artery calcium buildup?

Dr. Taylor: In the mid-Atlantic, MedStar Heart and Vascular Institute has been doing calcium scanning longer than anybody. And, many of our doctors, myself included, have conducted some of the seminal research, the important research, that’s shown the value of this test. And we provide this as a low-cost health service. So, even if patients’ insurance won’t provide it, we so strongly believe that this is the best test that a patient, age 50 and above, could take to really know their heart risk, that we provide this at very low cost. So, we believe in the test. We think it’s very important. And we provide that care so that no patient shouldn’t have the benefit of a coronary calcium scan.

Host: Thanks for joining us today, Dr. Taylor.

Dr. Taylor: Thank you so much.

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People who are concerned about their thyroid health may turn to supplements. But thyroid supplements can cause the very problems they’re supposed to correct.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. In today’s episode, we talk to Dr. Kenneth Burman, Director of Endocrinology at MedStar Washington Hospital Center about thyroid supplements. The thyroid is a tiny organ that’s involved in regulating several major bodily functions including breathing, heart rate and body temperature. Over-the-counter thyroid supplements may seem like a good idea to someone who believes they may have a thyroid condition. But thyroid supplements actually can cause problems with the thyroid and we may not know exactly what’s in them.

Host: Dr. Burman, thanks for joining us.

Dr. Kenneth Burman: Sure. Thank you for the invitation.

Host: You bet. So, over-the-counter thyroid supplements—helpful or dangerous? Tell us about that topic.

Dr. Burman: Sure, be glad to. Over-the-counter supplements for the thyroid come into various categories. So, one type of supplement would be iodine or iodine containing substances. Another type would be substances that contain one type of thyroid hormone, or thyroid hormone analog. There are other ones that are much less well characterized, and we’ll focus on the iodine and the thyroid containing supplements. So, iodine is an interesting substance. It is required for the synthesis of thyroid hormone synthesis and also required for secretion of thyroid hormone. And, thyroid hormones, which are abbreviated T-4 and T-3, contain about 68 percent iodine. So normal iodine in a diet, minimum daily requirement is about 150 micrograms per day and some substances that we use in medicine such as IVP dyes or cat scans contain thousands of micrograms of iodine per day. Supplements can vary over-the-counter and are not necessarily regulated as to how much iodine they contain. So, if a supplement contains something close to the minimum daily requirement (about 150 micrograms) that should be fine and maybe even beneficial. But many of the supplements are not quantitated in terms of iodine, but also contain iodine that is very high in thousands of micrograms in a tablet. And if you take one a day, that would be thousands of micrograms a day.

So, what are the effects of iodine on the thyroid gland? They’re multiple. For a short period of time iodine in these concentrations will lower thyroid hormone secretion so we actually use supplements to very hyperthyroid people under very controlled circumstances. But that control of thyroid synthesis only occurs for 10-14 days approximately, and after that time, they escape from that effect and the iodine fuels worsening hyperthyroidism. Normal people may or may not have those reactions but those are possible, especially in the large percentage of patients in the population that have autoimmune thyroid disease and may not even know it. So, in summary, with regard to iodine, large amounts of iodine should be avoided by normal people and anyone with thyroid disease, a normal amount of iodine, a minimum daily requirement, is reasonable; and everyone, but especially people with a family history or known history of thyroid disease should avoid large amounts of iodine. With regard to thyroid hormone analogs, one of my former fellows and now colleague, Vick Burnett who is the head of endocrinology at Mayo Clinic, Jacksonville, did a nice study that he published of looking at supplements and measuring thyroid hormone in them. And it turned out, that of the 10 or 20 supplements that he looked at, almost all of them had a significant amount of thyroid hormone in them, even if they didn’t put that on the label. So, thyroid hormone itself, given to a normal person, can cause hyperthyroidism, which may be associated with a fast heart rate, palpitation, bone loss, and even more severe problems such as atrial fibrillation and should be avoided. And that these thyroid hormone analogs are difficult to identify in these supplements unless you specifically look for them. And it’s not just the standard hormones of T-4 and T-3 but there are various analogs of thyroid hormone that can cause similar problems that are not necessarily quantitated in these supplements.

Host: When we talk about over-the-counter supplements, are these people who self-diagnose themselves and then they just go out and they get the supplements?

Dr. Burman: Either because they are self-diagnosing themselves but perhaps, more commonly, they’re using it as health food or health additives to try to make them feel better or have more vigor. Of course, regular vitamins are key, and everyone should have adequate amounts of regular vitamins but iodine in excess, or thyroid hormone in excess, in any of these supplements should be avoided. And, of course, the FDA does not regulate supplements like they regulate medications.

Host: So, we don’t even know what’s in them necessarily.

Dr. Burman: Correct. So, this study by Dr. Burnett, it was unknown or unidentified exactly what the contents were and he was very surprised that it turned out to be significant amounts of thyroid hormone in many cases.

Host: So, for the most part, would you recommend people do not take them then or do consider them?

Dr. Burman: We would recommend that, in general, patients with any known thyroid disease not take supplements, and even normal individuals should ask their physicians to examine whether those particular supplements may contain thyroid hormone.

Host: What can happen if you take supplements and you don’t have a problem?

Dr. Burman: If you take supplements and you don’t have an endogenous thyroid problem, there could be enough thyroid hormone in them to cause overactive thyroid activity, just as if you had bona fide hypothyroidism. That can result in atrial fibrillation, heart irregularities, bone loss, and other significant problems.

Host: What other tips do we have on this topic? Anything else we need to share that people need to be aware of?

Dr. Burman: Yeah, it’s always of interest that people wonder where iodine comes from and in food, etc. in our normal American diet. So, I frequently ask the medical students “What’s the most common source of iodine in the American diet?” and they always, unanimously say, “salt.” But it turns out salt doesn’t contain that much iodine. That rather, it’s processed foods that contain iodine as a preservative—bread and pastries, to name one large source of iodine. And then another source of iodine that relates to health food is kelp. Kelp is seaweed which, of course, no matter how it’s prepared, has a large amount of iodine in it that can cause the problems of over or under activity.

Host: Great. Well, thank you for joining us on the show today and I appreciate everybody listening and hopefully you found this information helpful. Thanks again.

Dr. Burman: Thank you.

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Why are more people younger than 50 developing colorectal cancer? Dr. Brian Bello discusses the disturbing trend.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thank you for joining us today. We’re talking with Dr. Brian Bello, a colorectal surgeon at MedStar Washington Hospital Center. Welcome, Dr. Bello.

Dr Bello: Thank you.

Host: Today we’re talking about why more younger patients are dying of colorectal cancer. Once considered an older person’s disease, patients in their 30s and even 20s are being diagnosed with colorectal cancer, which is baffling the medical community. A 2017 study found that, after years of decreasing mortality rates, colorectal cancer deaths in adults age 20 to 55 increased 1 percent per year from 2004 to 2014. Dr. Bello, what do you think caused this seemingly sudden spike in colorectal cancer deaths?

Dr Bello: That’s a tough question to answer. Many people have been looking at this. The answer is really unclear. We think it’s probably a combination of factors. I think if we look at the population now compared to 15 years ago - the population is more obese, that’s probably the driving factor. Patients diets are different than they were 15 years ago. People may not be exercising as much. And then there’s maybe genetic factors that we quite don’t understand. But we are looking at this very closely, but I think the number one issue is probably diet and weight.

Host: Is this something that you’re seeing in patients locally in the Washington DC area?

Dr Bello: Well, certainly people now are asking about it. Many patients come in and have read about this New York Times study and ask do they need a colonoscopy or they have friends that have recently been diagnosed with colon cancer and they are asking if they need one. So, certainly more people are asking about it. I think the key take-home lessons are people need to be educated about what signs and symptoms to look out for. So, if young people are experiencing abdominal pain that’s chronic, that doesn’t go away, or if they have rectal bleeding or unexplained anemia or weight loss, providers should be more willing to provide or give education about a colonoscopy.

Host: What do you mean by unexplained anemia?

Dr Bello: Yeah, usually this blood work is done by a primary care physician and it’s usually a yearly blood work laboratory value that can be checked. If a patient’s blood count is lower than normal and there’s not a good reason for it, then we need to investigate other causes of the blood loss.

Host: How has the increase in colon cancer changed the screening recommendation?

Dr Bello: Currently we’re not changing our screening recommendations. Usually the screening for Americans is everybody over the age of 50 needs a colonoscopy, which is the gold standard for colon cancer screening. For younger patients, as I mentioned earlier, we look for signs and symptoms. If they have concerning things that are chronic, then we recommend a colonoscopy. If we started screening earlier, that would probably mean more unnecessary tests - tests that are very costly and these tests that we do aren’t without risk. We do the CT scans for many reasons, and sometimes we’ll pick up things that are of benign cause, meaning that there’s nothing really to worry about but that usually prompts more tests which mean that patients are paying maybe more money, and these things are clinically relevant, meaning that you could find like a cyst in your liver and then we do additional tests and you really didn’t need to look at that at all. So, we try to avoid unnecessary tests just because they’re costly and could provide risk to the patient. In today’s field of medicine, we’re trying to be more cost efficient, cost effective. So, right now we haven’t changed our screening recommendation - we’re just looking for signs and symptoms - if these younger patients have those, then we recommend a colonoscopy.

Host: How can a young adult patient determine whether they’re at risk for developing colorectal cancer early in life?

Dr Bello: So, one thing that we always look for in these patients are a good family history. So if a patient has any family history of colon cancer in their family, especially relatives that were diagnosed at age 50 or younger, we’re more likely to recommend a colonoscopy. And again, those signs and symptoms that I had mentioned already - bleeding, abdominal pain, weight loss - those are the things we look out for.

Host: What can patients can to reduce their risk of developing colorectal cancer?

Dr Bello: Yeah, we always recommend a healthy lifestyle. Number one is definitely watch what you eat. So, we try to encourage people to eat a high-fiber diet, try to avoid fatty food, avoid fried food. In addition, we recommend that people exercise. Also, we recommend no smoking and try to avoid a lot of alcohol use.

Host: How does smoking and alcohol use affect the colon?

Dr Bello: So, that’s a good question. It’s unclear but we know that people that smoke more are at significantly increased risk of many different things - heart problems, stroke - but specifically for colon cancer we find that there’s an increased risk. It’s an unclear connection. It might have to do with some weird effect that smoking has with the bacteria in the colon or the lining of the colon. It’s unclear. But we just know that from studies there’s an association with it.

Host: What makes MedStar Washington Hospital Center the best place to seek screening and treatment for colorectal cancer?

Dr Bello: Well, here at MedStar Washington Hospital Center, we have a multidisciplinary team. That means we have experts in different fields - like surgeons, gastroenterologists, medical oncologists, pathologists, radiologists - that all see a lot of colon cancer and rectal cancer. So, we just do a lot of high volume. We do this day in and day out and we’re just specifically looking at colon cancer. Because of that I think we see better results and better outcomes for patients. Another thing we do at MedStar Washington Hospital Center is we promote the use of laparoscopic surgery. So that is surgery that we use very small incisions to do major, complex abdominal surgeries in. So we can do, for example, a colon resection with 3 or 4 very small incisions, and when we do this, patients tend to do a lot better. They have less wound complications, we can feed those patients earlier, and they tend to get out of the hospital much faster. So that is another thing we do at Hospital Center that makes it a great place to go for your colon cancer surgery.

Host: What is a colon resection?

Dr Bello: So, a colon resection is a surgery where we remove part of the colon and the fatty tissue surrounding the colon. Usually treatments for colon cancer or other colon problems. So, the old fashioned incisions usually were anywhere from your sternum to your pubic bone. But usually now we can do them with some stab incisions, which are about a centimeter and maybe one other incision that’s maybe 4 or 5 centimeters, where we pull out that part of the colon.

Host: Are you currently doing any research on colorectal cancer that you’d like people in the community to know about?

Dr Bello: Yes, I have research interests in colon cancer, specifically about screening, which we’re talking about today. Specifically, we’ve been looking at why people aren’t getting their colon cancer screening. So, again, everybody over age 50 should have some sort of colon cancer screening, whether that be the gold standard with the colonoscopy or some sort of stool test. It should be done. But for some reason people aren’t getting them done. Approximately 40% of patients across the U.S. and in DC don’t get the appropriate colon cancer screening. So, we’ve done some surveys to find out why. The number one reason why people don’t get colon cancer screening is that they felt that they weren’t educated about it, they didn’t know about it, their primary care physician didn’t tell them about it. Those are the driving factors, but we’ve also found things like people were worried about the bowel preparation they have to do before a colonoscopy or they were worried about procedural risks or they just didn’t like talking about their GI system.

Host: How do all of the surgeons and physicians work together to provide a team approach to care for colorectal cancer?

Dr Bello: So, usually when somebody is diagnosed with colon cancer, we present each of these cases at a multidisciplinary tumor board. We review the CT scan images, the biopsies, and we come up with an individualized treatment plan for the patient. And that’s when everybody can chime in and give their recommendations and we come up with one plan for each individual patient.

Host: Could you share some screening or treatment success stories from your young adult patient population?

Dr Bello: I was involved in the treatment team of a young 20 something year old gentleman. He had some routine blood work done, which showed anemia. His primary care physician recommended that he get a colonoscopy. Unfortunately, that colonoscopy showed multiple large polyps throughout his colon and many of the biopsies showed that these polyps had pre-cancerous cells in them. So then he was referred to me and then I recommended that he undergo a colon resection and we did that. We did that with small incisions called laparoscopic surgery. He did great post-op and now he’s on a very good surveillance plan where we’re doing routine colonoscopies. He did great. If he doesn’t get that blood work or if he doesn’t get a colonoscopy, these polyps would have likely have turned in to cancer by now and then a lot more difficult to treat. Thankfully, we caught them early, and we did his surgery early, and now he’s doing great.

Host: In those younger patients, where they have unusual lab testing, is surgery usually the best option to treat them?

Dr Bello: Oh, hopefully, if the lesions are small, like if they’re just polyps, we can remove those with a colonoscopy. Only if these polyps grow very large or they are cancerous do we recommend surgery. The goal of the colonoscopy is to find these polyps and to remove them at the same time.

Host: So the colonoscopy can serve both as a screening tool and as a preventive measure?

Dr Bello: Yeah, what’s really good about colon cancer screening is, if you get a colonoscopy, we’re able to find these polyps before they turn into cancer - that’s the key.

Host: Thanks for joining us today, Dr. Bello.

Dr Bello: Thank you very much.

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Thoracic surgery has come a long way in the last century. Dr. John Lazar discusses how patients in Washington, D.C., can benefit from safer, more precise surgeries with faster recovery through minimally invasive robotic technology.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. John Lazar, Director of Thoracic Robotics at MedStar Washington Hospital Center. We’re discussing robotic surgery, a minimally invasive technique, which increasingly is being used for esophageal, lung, and other thoracic conditions. Dr. Lazar, what do you mean when you say robotic thoracic surgery?

Dr. John Lazar: So, basically, we mean we’re doing minimally invasive surgery and it’s robotically assisted, meaning the surgeon is in total control of the robot. Nothing is automated, and yet we’re taking advantage of robotic technology, which would be 3-D visualization, uh, removal of any tremor, and basically being able to manipulate the robot in small, hard to reach areas.

Host: When you say removal of tremor, is that from the physician’s hand?

Dr. Lazar: not necessarily the way you would think about a tremor, but for every three motions I make, the robot will make one. So, it sort of stabilizes the hand - there’s no big lunging motions - so we call it stabilization.

Host: What are some of the more common thoracic procedures that are performed with robotic surgery?

Dr. Lazar: So, when we think about robotic surgery, we think about three main areas, one of which is the lung. Uh, the other one is called the mediastinum, which is the central part of the chest - the soft tissue’s there, which includes the thymus. And the other part is the esophagus as well as the stomach.

Host: Are you treating conditions that are just cancer or what sort of conditions are you looking for?

Dr. Lazar: So, we treat conditions that are both cancerous or malignant as well as benign, meaning non-cancerous. Um, non-cancerous conditions are especially prominent in the esophagus - such things as paraesophageal hernias, where the stomach actually over time goes up into the chest. Uh, we also treat things like lung cancer. There are some benign diseases of the mediastinum which we also treat, but they have to be treated with excision. And, that’s pretty much it when it comes to the robot.

Host: So, what are some of the patient benefits that people can expect when they get a robotic surgery as opposed to a traditional surgery?

Dr. Lazar: So, traditional surgery we’re talking about usually a large incision, something anywhere from six inches to twelve inches. Uh, when we talk about robotic surgery, we call it port-based surgery. It’s minimally invasive and instead of the instruments kind of grinding back and forth, they go through a port and so there’s only one small area where the port is touching the skin, and so generally we find that there’s less pain afterwards. People are able to get back to their daily lives quicker. So, in terms of comparison in after-care for robotic surgery versus open surgery, uh, most people who have open surgery are in the ICU anywhere from one to three days, maybe sometimes five days, whereas most patients who get robotic surgery do not need to go to the ICU and therefore, they’re up and out of bed and walking around the floors much quicker and the tubes - there’s usually a tube after surgery - that can come out. And I tell most of my patients that they’re in the hospital three to five days. Everybody’s a little bit different, but that’s about it. Um, most people are walking - they’re walking up the stairs - they’re eating, they’re drinking. Uh, they’re usually...their biggest complaint is they’re a little bit sore, but nothing compared to open surgery. There’s less narcotic use, uh, for minimally invasive and robotic surgery and they’re usually 90 percent better by ten to fourteen days after surgery. That’s not out of the hospital - that’s after surgery itself.

Host: How do patient outcomes with robotic surgery compare to those of traditional surgery?

Dr. Lazar: So, robotic patients are minimally invasive patients. So, generally speaking, if you’re able to get a minimally invasive procedure, meaning smaller incisions, patients usually do better quicker. Over the long term, they do just about the same. But the idea that robotic surgery is just another type of minimally invasive surgery, the advantages being more for the surgeon and less from the patient when we talk about things like VATs or laparoscopic surgery which are other types of minimally invasive surgery. For the surgeon, we’re able to get into smaller places, we’re able to visualize things in 3-D as opposed to just on a flat screen TV, which is the way we do it in traditional minimally invasive. And this allows us to do more highly technical procedures in a smaller space. So, in comparison to open surgery, I think where robotics has really helped the patient is getting them a better...technically a better operation, whether it’s cancer operation or whether it’s for something like paraesophageal hernia, and I think that’s because the surgeons can see better. They are not constrained by stiff instruments like you have in VATs and laparoscopic surgery. In robotic surgery there’s...the wrists are able to flex just like your own wrists and we’re able to see things that we normally couldn’t see and therefore we’re able to do better operations. You’re better to see the margins, and I think that that plays a big role in the post-operative care.

Host: Why is MedStar Washington Hospital Center the best place to seek thoracic surgery from a robotic or a minimally invasive standpoint?

Dr. Lazar: I would say that the group of surgeons across multiple disciplines are outstanding here - and that’s one of the major reasons why I came to join the thoracic team. They have a great deal of experience. They’ve been doing this for many years. They have gone through their learning curves already, and they’re able to offer patients an advanced level of robotic care at the cutting edge. Robotics is being employed by a lot of different specialties, not just thoracic. So, ENT is doing some cancer operations, uh, for tonsils and tongue-based cancers. Gynecology, urology are using it a lot as well for both malignant and non-cancerous procedures.

Host: Thinking about those patients as you were talking, have you had any outstanding or really interesting patients that you could talk about in generalities?

Dr. Lazar: There was an example of a young man who was, uh, working at home, felt his, uh, back sort of twinge, didn’t think anything of it. And then a week later went to his primary care physician who got a chest x-ray and saw that there was a mass along the left side of his chest. It led to a cat scan and showed a mass. His other surgeon was gonna do a large open procedure. Uh, luckily for him, they didn’t accept his insurance and so he came to me as a second referral. And, uh, we were able to do it minimally invasively. It turned out to be a benign cyst that was growing along his major artery called the aorta. We were able to do the surgery safely and he went home the next day and so far has not had any other issues and went back to work within two weeks.

Host: You mentioned that your patient had had back problems, and that’s what prompted him to see his doctor. What are some of the other symptoms that patients often notice before they get to you?

Dr. Lazar: I would say that pain is usually the number one, um, issue that patients have when it comes to the esophagus or the stomach. There’s usually things like nausea, bloating, indigestion, reflux - those types of things. Also, weight loss can be a big part of it. Fatigue.

Host: Tell me a little bit about your patient population. Are you seeing mostly older folks or what does that look like?

Dr. Lazar: So, I think, you know, being in the D.C. area, you see a lot of different people that you normally wouldn’t see. It’s a...it’s a much different population, probably because so many people move here from different parts of the country. So, we see people from 16-years-old to, you know, people in their 90s. And they have a variety of different issues. Um, some are cancerous and some are not. Um, so there’s... it’s really hard to pinpoint it on one thing, which is one of the nice things about practicing here at the...the hospital center is...is you do see a large variety of people.

Host: Who’s at risk for these types of conditions?

Dr. Lazar: So, I would say that the youngest people that we usually see are in their 30s but it goes all the way up in to the 90s, especially for the benign esophageal. This can happen to anybody at any age because it’s just a weakening of the muscle lining.

Host: Is surgery the first line of defense, or the first treatment for these types of conditions or do you typically try another therapy first?

Dr. Lazar: So, when you’re talking about non-cancerous things, obviously people try to avoid surgery at all costs. But usually once the symptoms become impinging on their quality of life, they generally seek surgical opinion. They’re not necessarily sold on surgery at that point but they at least want to keep their options open, especially if medical therapy tends to get more and more expensive, such as anti-acid medications and things like that.

Host: Do your patients typically have to see their primary care doctor first or can they refer right to you?

Dr. Lazar: It depends. Some people come right in to the emergency room, and if that happens, then it kind of bypasses the primary care but I think if they have a primary care, they should see their primary care first and get properly worked up. Most conditions are not surgical.

Host: Are you or your colleagues participating or conducting any research right now on thoracic surgery field that you’d want people to know about?

Dr. Lazar: Um, we are looking to become one of the first centers to robotically repair something called tracheobronchial malacia, which is a weakening of the trachea which is the windpipe that connects your mouth to your lungs. And basically, if it loses its integrity and it just starts to collapse, it can be very difficult and easily winded. In the old days we didn’t really have a lot for this, but now we can buttress it and sort of reinforce that integrity of the trachea and allows them to have a much better quality of life and not feel continuously short of breath.

Host: Thanks for joining us today, Dr. Lazar.

Dr. Lazar: Thank you.

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Due to advances in imaging scans, kidney cancer often is detected by chance and early in the disease process. Dr. Ross Krasnow discusses minimally invasive robotic surgery and other treatment options for localized kidney cancer.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re talking to Dr. Ross Krasnow, a urologist who specializes in urologic oncology at MedStar Washington Hospital Center. Welcome, Dr. Krasnow.

Dr. Krasnow: It’s great to be here.

Host: Today we’re talking about management options for localized kidney cancer and, in particular, the minimally invasive surgery options available to some patients. Dr. Krasnow, what do you mean when you say localized kidney cancer?

Dr. Krasnow: So, localized kidney cancer is cancer that originates from the kidney but is confined to within the kidney or the fat surrounding the kidney or adjacent structures surrounding the kidney. It can also be in some of the lymph nodes, but it has not yet spread to far away lymph nodes and other organs that are not directly touching the kidney.

Host: How common is kidney cancer, in general, and then how common is localized kidney cancer?

Dr. Krasnow: So, kidney cancer is the seventh most common cancer generally, in men and in women. When it presents, most of the time it is localized at the time of presentation. And that’s really because of a stage migration that’s occurred over the years. The kidney lies in the back of the body, and as you can imagine, before we had advanced imaging, it was only picked up when it became symptomatic and at that point it was very large, it would cause pain, it would cause blood in the urine, and it had often already spread at the time of presentation. Now there’s been a stage migration and what that means is often it is picked up incidentally. A patient has imaging such as an ultrasound or a cat scan for another purpose. They have gallstones, they have vague pain, they have indigestion. And they end up getting some sort of imaging and that imaging just happens to show a small renal mass. More and more we’re picking this up when it’s asymptomatic and confined to the kidney, and it’s easier to treat.

Host: So, an individual could come in thinking that maybe they’re just having some back pain and they get an MRI for example, and it turns out that it’s cancer. What is somebody’s reaction to something like that?

Dr. Krasnow: Just to be clear, often when they get that MRI for back pain, the pain is not even related to the cancer; it’s completely unrelated. I think most patients, when they learn that they have a renal mass, are very nervous. And I hope that when I see them and talk to them I can reassure them that they’re going to be fine, most all of the time. Especially when these tumors are small. They’re very easy to manage and very rarely life-threatening until they get to a certain size or demonstrate evidence of spread.

Host: So, does kidney cancer tend to strike certain individuals or certain demographics of people more often than others?

Dr. Krasnow: It’s actually quite sporadic. There’s a slightly increased risk in patients who are smokers, patients who are obese and have diabetes. Certainly, there’s an increased risk in more unusual patient populations such as those with certain genetic predispositions or those on dialysis. But I would say, for the most part, the vast majority of patients I see it in, it‘s completely sporadic.

Host: So, if an individual is diagnosed with a localized kidney cancer - so that fairly contained cancer - what types of treatment might a doctor recommend? Um, you know, traditionally they talk about active surveillance, they talk about radiofrequency. Can you talk about those common types a little bit, and then some of those minimally invasive options?

Dr. Krasnow: When I first see a patient that comes to me with a renal mass, I’m actually reluctant to call it a cancer right away. And that’s because one third, one out of three patients with a small renal mass less than, say, three or four cm, don’t actually have cancer. They just have a growth on the kidney. The other two thirds of those patients do have a cancer, but it actually tends to not be very aggressive, and these cancers are not very aggressive until they’re over, say, three or four centimeters. Once I frame it like that, patients are immediately reassured. And then I talk about some of the management options. Active surveillance is a great option for certain patients. Even renal masses less than three cm have almost no metastatic potential. And that ultimately is what we worry about, not actually having a tumor on the kidney but having a tumor on the kidney that has the potential to spread. Knowing that allows us to offer active surveillance for patients. That means that we watch the mass every, say, three to six months for some time, maybe extend that out to every year, and if the tumor doesn’t seem to be growing, we may not need to treat them at all. This is a really great option for patients who are older, have a lot of other medical problems, or, for whatever reason, are reluctant to have surgery. Maybe they have just one kidney, and were very concerned about preserving their kidney function. When the tumors are over three or four cm, I do tend to recommend some form of treatment, although that’s not always the case. And, of course, it’s not realistic to watch tumors in patients who are very young. You’re not going to watch a tumor in a thirty-year-old for forty years.

So, when we talk about the treatment options, again, there are many. One is often we don’t even have to biopsy these masses but sometimes we do biopsy them to confirm that they’re a cancer. The treatment options from the least invasive to the most invasive, would be having our colleagues in radiology simply put a needle in it, and through that needle they can burn or freeze the mass. That is called radiofrequency ablation when you burn it or cryoablation when you freeze it. Again, that’s a great option for patients who are older, have some other medical problems. It’s also a great option for tumors that are small and in a location where the damage from freezing it or burning it would be confined to just the cancer and not damage other structures that are nearby. The long-term results of cryoablation and radiofrequency ablation are not as clear. The short-term results show very good efficacy, maybe just a little bit less than radical surgery—but not by much. There are certainly situations where ablative techniques are not appropriate. If the tumor is large, is in the middle of the kidney close to blood vessels, close to adjacent organs such as the pancreas, the duodenum, the liver, if it’s close to where the urine collects in the kidney - those techniques aren’t controlled enough. So, at that point, we do recommend radical surgery. Also, patients who want the most effective treatment, the gold standard, we recommend radical surgery. Most often for a small renal mass that is a partial nephrectomy. So, that’s removing the part of the kidney that has the cancer in it while leaving the rest of the healthy kidney behind. In the past, we did too many radical nephrectomies. That’s when we remove the whole kidney for small renal masses. It was really unnecessary. While effective as a cancer therapy, it hurt patients in terms of their renal function, and we really concentrate on maximizing and preserving renal function now.

Host: When you have those treatments such as radiofrequency or cryoablation, those very focused and targeted type therapies, do you also have to undergo chemo or radiation, or any other subsequent treatment?

Dr. Krasnow: It actually is one of the few cancers that doesn’t respond well to chemotherapy at all. And agents for the management of kidney cancer tend to work on the immune system. They also tend to be reserved for patients with metastatic disease or disease that’s already spread. Radiotherapy is ok for kidney cancer. The problem is that it damages the rest of the kidney. So, for localized kidney cancer, chemotherapy and radiotherapy are not…are not needed and they’re not great options.

Host: So, what about something like immunotherapy? That’s…that’s becoming more and more common for so many types of cancers. Could you talk about that a little?

Dr. Krasnow: Yes. So, immunotherapy for kidney cancer has made a lot of waves lately as second line therapy for patients with metastatic disease who have failed first line therapy. There are investigational studies looking at it for localized kidney cancer. Those would be patients who have a very large mass that may not be able to be treated surgically, and you may consider giving them some sort of therapy before surgery to see if you can shrink it to the point where surgery is a viable option. The other space that it’s being looked at is in patients with high-risk localized cancer, so they had surgery but the tumor appeared very aggressive, and the risk of recurrence is high. In that…those are patients you may consider giving an agent such as an immunotherapy agent right after surgery, even if they don’t have evidence of metastatic disease. Those two settings are completely investigational right now and are not the standard of care.

Host: Let’s go back and talk about those surgical options. So, could you elaborate a little bit further on partial nephrectomy?

Dr. Krasnow: So, partial nephrectomy is when we remove the part of the kidney that just has the cancer in it, leaving the rest of the healthy kidney behind. This is in order to preserve renal function and also to maximize cancer control, arguably better than the ablative techniques, such as cryoablation and radiofrequency ablation. The great progress that we’ve made in partial nephrectomy is that we’re now able to do it in a minimally invasive fashion, specifically using robotic laparoscopy. This allows us to make small keyhole incisions, get to the kidney, remove the part of the kidney that has the cancer in it using excellent visualization that the robotic optics provides for us, and then reconstruct the kidney afterwards, to close up all the vessels, and to close up where the urine drains out, in order to achieve a good outcome for the patient. And we can now approach the kidney from the front or from the back, which is helpful for patients who have a tumor in the back of the kidney or for patients who have had prior abdominal surgery where the abdominal cavity may be very scarred and adhesed. Both of these techniques are also extremely good for patients with obesity, because otherwise an open incision would be very large, painful, and lead to a longer recovery.

Host: So, when you’re talking keyhole incisions, about what size is that? Could you give a visual?

Dr. Krasnow: The incisions are between half and one centimeter.

Host: And how does that work when you’re going in through such a small incision - how are you able to remove part of an organ?

Dr. Krasnow: So, we have a camera that has 3-dimensional vision. When we’re doing the surgery, we can actually get depth perception. And, the instruments we place are wristed, so we get more dexterity than we would otherwise through what we would call straight laparoscopy. The last option for localized cancer, when we can’t spare the kidney, we do have to often remove the whole kidney, and maybe remove some of the lymph nodes around the kidney, and we’ve also made advances in minimally invasive techniques for more advanced localized kidney cancer. When kidney cancer that’s localized is very advanced, it can even extend into big vessels within the body, and traditionally that type of surgery would be approached open in order to perform a vascular operation where you’re not only removing the kidney, but you’re removing tumor that’s within blood vessels. This can now be done oftentimes using the robotic platform as well. So, whereas patients would be staying in the hospital for a week or two after surgery with a prolonged convalescence, they can go home in a day or two with very little blood loss.

Host: So, when you approach a patient who you’ve determined needs surgery for their kidney cancer and you say, “We’re gonna offer you this robotic treatment method,” what’s their reaction, or what questions do they usually have?

Dr. Krasnow: Most patients are just interested in how long they’re going to be in the hospital for and how long it’s going to take them to recover. And also, they want a treatment option that’s going to offer the best chance at cure. And I tell them that the robotic partial nephrectomy or a minimally invasive radical nephrectomy is the best way to achieve cure but also provides them to have a fairly rapid recovery.

Host: What does that recovery time look like in comparison to that traditional open surgery?

Dr. Krasnow: So, the traditional open surgery, in order to get to the kidney, we would have to make a very large incision in the front or the side of the patient, have to go through many layers of muscle, and sew that back together. Patients after were extremely sore, they would have difficulty walking and breathing afterwards because of the soreness. Also, during the surgery there was an increased risk for blood loss and other complications. Because we’re making small keyhole incisions, the patients have very controllable pain after surgery. They can restart their diet much earlier, the next day really. Most patients can go home one or two days after surgery compared to staying in the hospital for a week or longer, and they can get back to work much quicker.

Host: What sort of, uh, restrictions at home or restrictions at work would an individual have after that minimally invasive surgery?

Dr. Krasnow: So, after surgery, actually the day after surgery, we want them up walking, moving around, sitting, eating, trying to get back to as much normal functioning as possible. The only thing I ask the patients not to do for a few weeks after surgery is to avoid really heavy straining, heavy lifting, running, strenuous exercise, swimming - things like that, but for the most part they can go about their day when they get home.

Host: What are some of those other benefits for the patients or for their caregivers to minimally invasive surgery?

Dr. Krasnow: For some people, cosmesis matters. And the small incisions are much more cosmetically pleasing than the large incisions we made in the past. So, for certain patients who are looking to go swimming that summer and want to wear a swimsuit, you can hardly ever tell that they had surgery. I think that technology is even going to get better.

Host: Thanks for joining us today, Dr. Krasnow.

Dr. Krasnow: Thank you so much for having me.

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Birth control can come in many forms—but men’s options can be more limited. Dr. Krishnan Venkatesan discusses how a vasectomy can be a solution for men who want effective birth control while maintaining sexual function and the ability to orgasm.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. Krishnan Venkatesan, Director of Urologic Reconstruction at MedStar Washington Hospital Center. Welcome, Dr. Venkatesan.

Dr. Krishnan Venkatesan: Hi. Thank you for having me.

Host: Today we’re discussing vasectomy, a birth control procedure for men that prevents their partners from becoming pregnant without affecting natural sexual function. Dr. Venkatesan, is vasectomy a popular birth control option for men and their partners?

Dr. Venkatesan: Yeah, I would say so. Vasectomy is effective for birth control because it really allows a non-invasive way to cut off the sperm from being delivered into a partner that could cause conception, but it doesn’t interfere with erectile function, sensation, orgasm or ejaculation. So, essentially sex should still feel and be the same but without the concerns for pregnancy.

Host: Approximately how many vasectomies are performed at MedStar Washington Hospital Center each year?

Dr. Venkatesan: I’d say probably between fifty to a hundred vasectomies, at least, per year between myself and my colleagues.

Host: Why do you feel that so many couples or so many men chose to undergo vasectomy?

Dr. Venkatesan: I think vasectomy is a popular option and a good option because it’s relatively non-invasive, it’s an outpatient procedure and has a quick recovery. And, it allows patients to stop using other forms of birth control, whether it’s oral contraceptive pills or condoms, and it’s certainly easier for men to undergo this than for women to have a tubal ligation. And so, it basically allows for natural sexual function without the risks of conception.

Host: Could you describe your patient population for vasectomy - are they older, younger or who is a good candidate?

Dr. Venkatesan: Any man, really, is a good candidate but typically our patients are those who are in their 30s or 40s, sometimes in their early 50s, who have children, who have had some time to give this some thought and, for the most part, these are men who are in stable relationships and have had a shared discussion and a shared decision making with their partner before they come in to discuss or commit to vasectomy. Occasionally, we do have men who are not in a relationship but are fathers of children or who have decided they do not want to have any children and, after giving it a lot of thought, they come in for counseling about vasectomy and may decide to proceed with that.

Host: Are there any factors that might make a man ineligible for vasectomy?

Dr. Venkatesan: Patients that may not be good candidates for vasectomy are generally those who may have had prior surgery on their testicles, either to bring an undescended testicle down during childhood or maybe some surgery on their spermatic cord or even prior hernia surgery, where it may be just more difficult to identify the vas deferens and may make them more prone to having the procedure fail or have a complication.

Host: So, just like any reproductive issue or reproductive procedure, there is an abundance of incorrect information online about vasectomy. Do your patients or their partners express any fear or anxiety about the procedure?

Dr. Venkatesan: Yeah, and I think that’s natural and completely reasonable to have those anxieties. The biggest concerns men have, of course, are that this may affect their other sexual function, including erectile function and the ability to orgasm or to enjoy sex the same way and whether they will still be able to ejaculate after vasectomy. And, generally we’re able to assuage all those fears by explaining that this really should not affect erectile function and men will still ejaculate because most of the fluid that comes out with orgasm or with ejaculation is actually made downstream in the prostate. The only difference is that the semen won’t contain any actual sperm that can cause conception.

Host: This sounds like a very safe procedure. Are there any risks involved with vasectomy?

Dr. Venkatesan: Yes, there are. And, of course, any procedure has its risks. The main risks here would include general risks of any surgery, like infection and bleeding and injuring other structures that are nearby the vas deferens, including the artery to the testicle and the vein coming from the testicle, as well as some nerves that travel along the spermatic cord, which could result in chronic pain in the testicle, although that risk is very low. And the main other risk really would be the risk of remaining fertile if the two ends of the vas deferens somehow remain connected or find their way back to each other and get reconnected.

Host: Could you describe how the vasectomy procedure is performed?

Dr. Venkatesan: Yeah, absolutely. Basically, each testicle, after it makes a sperm, delivers that through a tube called the vas deferens. That travels up the scrotum on each side into the groin and then makes kind of a hairpin turn and goes back behind the bladder to join the urethra, which is how men are able to urinate and ejaculate through the same pipe. What we do in vasectomy is basically find the vas deferens at the top of the scrotum on each side, bring it out through a small nick in the skin or through a small spread incision to open the skin, and cut out a small segment, burn each side of the tube on the inside, and then tie off each end and fold them away from each other and, basically, put them back into the scrotum but in different tissue layers, all to help minimize the risk of the tubes reconnecting.

Host: With all of the steps of this procedure, is vasectomy permanent?

Dr. Venkatesan: Yes, and that’s an important point. I’m glad you brought it up. I always counsel all my patients that, for all intents and purposes, vasectomy is intended to be permanent. Now, technically, it can be reversed. And, there are specific surgeons who have microsurgical training who can do the vasectomy reversal but it’s also important for patients to know that the success rates for that reversal are variable and, from a practical matter, it’s usually not covered by insurance.

Host: How long does recovery take and are there any restrictions for having sex or using the bathroom?

Dr. Venkatesan: Yes. So, because there’s constant sperm production, there’s already gonna be sperm downstream from where we cut the vas deferens. So, men need to be counseled that they are not immediately sterile when they go home that day. So, typically, immediately after the procedure, I will ask my patients to refrain from sexual intercourse or any ejaculation for two weeks. And, after that, they need to continue using contraception, in any other form, whether it’s condoms or with the oral contraceptives with their partner but continue to have sexual intercourse. After 8 weeks, we’ll see the patient back in the office to ensure they’ve healed up okay and, at that time, we’ll have them give a semen sample to make sure that the sperm count is zero. Once the sperm count is zero, then they’re okay to stop using other forms of contraception. The recovery from the procedure itself is pretty easy. Usually, we’ll do it later in the week so that guys can recover over the weekend. We don’t have them take any significant activity restrictions, but they may be a little bit sore for a few days. But usually by one to two weeks after the procedure, they’re able to resume all their normal activities.

Host: When you hear about people having vasectomies, like on sitcoms or in books, you always have this mental image of a man sitting there with frozen vegetable on his private area. What do you typically give for men for pain management or inflammation management afterward?

Dr. Venkatesan: We usually do send patients home with some pain medications. It really depends on, subjectively, what the patient thinks they may need. Quite often, even some extra strength Tylenol or Ibuprofen may be sufficient, but if the patient requires more pain medication, we’re certainly not averse to giving them a prescription for a narcotic pain medication. And aside from taking it easy for the first few days, we also do recommend that they can put some ice packs or frozen vegetable packs on their incisions until everything is starting to feel more comfortable.

Host: Now, on the flip side, is there anything a patient has to do to prepare to have a vasectomy?

Dr. Venkatesan: Not really. Similar to any other surgery, they should make sure they talk to their urologist beforehand in the office and get all their questions answered. I often will encourage patients to bring their partner along because it’s always good to have a second set of ears, and partners tend to have different insights than men, and collectively, you may remember more from the conversation than one person alone. But, physically speaking, there’s no specific preparation that is required.

Host: Can you think of any standout patients who particularly benefited from having a vasectomy?

Dr. Venkatesan: All of them. And, it really depends on their goal but, for the most part, because there’s a very specific goal with regards to achieving sterility, most of our patients have been very happy with the results. I will say that probably the better example cases are the cases where the female partner may have a difficult time taking oral contraceptives or may have some other medical conditions that prevent tubal ligation. And, in those cases, then this really allows them to enjoy a full quality of life and takes some strain off the partner, in addition to the patient themselves.

Host: Why should a patient choose to come to MedStar Washington Hospital Center for vasectomy when they could really go to any hospital?

Dr. Venkatesan: So, I think Washington Hospital Center is a great place to choose to have vasectomy, mainly because of the surgeons we have here who are very experienced in doing it and because, I think, we all do a good job at counseling our patients and answering their questions beforehand, and meeting their expectations with regards to the procedure and everything before and afterwards. And, I will say that traditionally vasectomy is usually done in the office but here we do, quite often, offer our patients to have it done under anesthesia, depending on their comfort level. And, quite often the patients will select to have that done just so they can be more comfortable during and after the surgery.

Host: Thanks for joining us today, Dr. Venkatesan.

Dr. Venkatesan: My pleasure.

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New technology and guidelines allow us to use PET-CT scans to locate cancer earlier than ever before, with faster scans and less radiation. Dr. Carlos Garcia explains what this means for patients and how we continue to stay ahead of the curve in this area of testing.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re talking to Dr. Carlos Garcia, Medical Director of Nuclear Medicine at MedStar Washington Hospital Center. Welcome, Dr. Garcia.

Dr. Carlos Garcia: Hi. Thank you for having me.

Host: Today we’re talking about advances in PET CT technology. Dr. Garcia, what is PET CT technology and when is it used?

Dr. Garcia: So, PET CT technology is a combination of anatomic and functional imaging. We use the anatomy from the CT portion of the exam and the self-function or the live cell portion of the exam from the PET CT exam. We use it mainly for oncologic imaging. It can be used for other purposes as well, but right now the mainstay, the gold standard, for cancer imaging is PET CT imaging.

Host: How has PET CT scanning technology improved in the last 10-15 years?

Dr. Garcia: It’s improved by leaps and bounds, actually. So, in 2006, the new kid on the block was time-of-flight PET CT imaging, which was the most advanced cancer imaging tool at that point in time. Now that’s evolved as technology does into digital imaging. So, analog vs digital imaging.

Host: So, why should a patient come to MedStar Washington Hospital Center for a PET CT scan?

Dr. Garcia: We’ve been very fortunate in the past to, in 2006, to have the first, the most advanced machines in the region. It was called the Time of Flight PET scan, which was the upgrade from, you know, analog imaging from way before 2006, and for many years we were the only ones that had that type of imaging. And now, as of August this year, we have a digital PET scanner, so it’s the step up from the Time of Flight. It’s the most advanced PET CT unit available in the world right now and we are very fortunate to, once again, be one of the first in the region to actually have this kind of technology. When you compare it to the Time of Flight PET scan that we had prior to the one we have right now, it’s basically comparing a flat screen TV to a State-of-the-Art 4K curved screen. You’re talking about night and day when it comes to resolution. Images are 10 times, you know, as crisp as compared to what they were before, that everybody, you know, joked around they were a little fuzzy. Now, the lesion detection has increased. The size of the lesion can be much smaller and still be detected. The amount of time it takes to acquire the images has been cut back almost by 50 percent and the dose that we give the patient in order to obtain these higher-quality images can also, in some cases, be cut back as far as 50 percent as well. So, from a patient point of view, they get a much more reliable scan and half the amount of time with half the radiation exposure, and these are all valid concerns to the patient, you know, because coming to the hospital, you know, you can have a PET scan anywhere. You can have any kind of exam anywhere - it’s the experience you get from, you know, the center, the staff, the amount of time, the comfortability you experience. All those things put together makes it a much better experience to have a higher quality machine in the hands of somebody with much more experience. The result of that has been increase in detectability, increase in being able to see lesions that were too small to be seen before. And, that leads to early detection, early treatment application and, you know, being able to catch a disease when it’s still a time when something can be done about it.

Host: What sort of research are you working on right now for PET CT scanning, and what do you see coming down the road, either at MedStar Washington Hospital Center or nationally?

Dr. Garcia: So, there’s a ton of research being done at all levels with PET CT imaging and cancer applications. There’s many novel tracers, or let’s say substances, that the body produces that are getting linked to radiation and injected into the body and seeing exactly where it will go, known places that you know or known organs that you know it will go to, places that it would take up normally and now it takes up abnormally, and that gives us information. Here at the hospital, we are considered a thyroid/cancer center of excellence, so a lot of the research that we do will be related to imaging with radioactive iodine. There’s many different types; used some for therapy, some for imaging and in our case, we use it to be able to see lesions that are not taken up by the normal exams we do, the normal iodine scans that we do, and sometimes these tumors, in thyroid cancer specifically, may stop working the way they do and they don’t take up iodine. So, we do PET imaging in those particular cases, and that’s actually a proved indication, a reimbursed indication, for patients that are iodine-negative and that still have blood markers that show that there is still cancer and in those cases that’s an indication.

Host: When you’re talking about radioactive iodine, how is that being introduced into a patient’s body and what does that look like for thyroid cancer?

Dr. Garcia: So, in thyroid cancer patients we rely on the fact that the body does essentially one thing with iodine. When you eat it in your normal diet, the iodine gets absorbed, it goes straight to your thyroid gland, and your thyroid gland uses iodine to make thyroid hormone. The body can’t tell the difference between radioactive iodine or normal iodine or between different types of radioactive iodine. So, nine out of 10 times it is introduced as a pill. The body thinks it’s just normal iodine and it’ll take it to wherever there is thyroid tissue. If there’s a little bit of thyroid tissue left behind after the surgery, which happens 99 percent of the time, it will absorb the iodine because it still, you know, retains its function. So, the same thing will happen if the cancer has spread to other parts of the body and wherever the cancer cells have gone and attached themselves to, it is still thyroid cells now growing on, for example, a lung, a bone, you know, or in your brain. It’s still thyroid cells so they retain that function of taking up iodine. So, the body absorbs the pill it took and it’ll circulate through the blood and it’ll find the thyroid cells. And the thyroid cells will latch onto it, look at the iodine, try to make thyroid hormone out of it, but we’ve altered it chemically to get essentially stuck inside the cell and not be able to be metabolized further. All of this translates to being able to see it on images. Wherever the iodine has been absorbed it will show up on the images and that gives us an idea of the degree of spread throughout the body.

Host: Interesting. So, the difference between the PET CT and the regular CT scan is that ability to really track that cancer throughout the entire body. How does that benefit patients, especially in the situation of thyroid cancer, and then how is that helpful for the physician team to treat them?

Dr. Garcia: Not only does it track where it has gone throughout the body because CT exams can show you, as well, irregularities in anatomy, differences in what, you know, patterns are supposed to look like in every part of the body. It will show you where there are cells that are still alive. Sometimes it takes longer for a change to happen on a CT scan, based on the therapy that was applied, then it will take with the level of metabolic function of a cell. Sometimes you can have a tumor that’ll shrink a little bit on the scan when you compare one scan before and after the therapy and when you look at the PET scan it’ll show that there was a very active lesion and then it’s completely inactive. It’s essentially gone, although there’s only been a small shrinkage of the tumor on the CT scan. So, it’s very complimentary to the anatomy that would be shown on a CT scan. This helps physicians to monitor a treatment response. And many, many - even research studies - will take into account the degree of metabolic activity and the change before and after the therapy to see if the treatment is working and should continue or if the treatment is not working and they should switch gears altogether and try something different. It’s called the metabolic response to therapy. In thyroid cancer, we use it in those cases in which we know there’s thyroid tissue still in the body because it’s producing a protein that shows up in the blood, that’s only made by thyroid cells. Sometimes these thyroid cells lose their function to capture the iodine and makes a iodine scan basically not the right study to be able to monitor the response. So, you have to migrate over to the basics of the cell function, which is to take up glucose, for example. So, it will still, it still might be able to take up glucose even though it won’t take up iodine and that is still very, very helpful to know whether or not this patient would benefit from being treated with radioactive iodine or if they need to be treated with another form of therapy, based on the examination - the PET CT exam.

Host: So, a very technical and very advanced way to get back to the basics of what the cancer does.

Dr. Garcia: That’s nuclear medicine, in essence. We rely 100 percent on physiology, which is the normal function of the body. The kidney has a normal function, the brain has a normal function - and when they deviate from that normal function, they stop using the materials or the substances in your blood that they normally would. If you can attach radiation to that substance and then you see that it doesn’t go into the liver when it should, that gives us information - we know what that means. So, you’re basically relying on the body doing what it’s supposed to do, and variations of that function will translate into disease entities, into diagnosis that we can establish. So, we trick the body into doing what it would normally do - it doesn’t know it’s doing it - and we can see it all on images.

Host: What sort research are you and your and your colleagues working on right now in the field of PET CT?

Dr. Garcia: Right now, we are working mostly in thyroid cancer research. We are looking into how much iodine is absorbed in individual tumors. In the past the fact that it showed up on the scan at all was very productive, but what we need to see is how much radiation is being delivered to each individual lesion. And that will make a difference. So, it’s very important to figure out - this is the ongoing research for us - to figure out how much radiation actually gets delivered in a particular lesion. And that will sometimes answer the question of how come we gave the same radiation level to two different patients and it didn’t quite work the same way. And we need to figure out how much is absorbed in each piece of tissue, if you will, that is malignant, and that way, if we know that, then we can start tailoring lesion radiation delivery more so than patient radiation delivery. We will go, I mean, we treat the patient as a whole, of course, you know…but we will go after targeting specific lesions and making sure that that lesion receives as much radiation as possible. We’re very happy to not have repeat customers, you know, and that’s kind of our goal, I mean, like we’ll try to get it all on the first try and if not, leave as little behind as possible if we have to do it again.

Host: Thank you for joining us today.

Dr. Garcia: Ah, it was a pleasure. Thank you for having me.

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Missing teeth is never easy. It can cause some people to feel uncomfortable smiling for pictures, while others experience difficulty eating. Discover why Dr. Ravi Agarwal says dental implants can be the perfect solution.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Dr. Ravi Agarwal: Thanks for having me here today.

Host: Today we’re discussing dental implants which help support dental prosthetics such as bridges, crowns and dentures. Dr. Agarwal, could you explain what a dental implant is?

Dr. Agarwal: Sure. The dental implant is essentially an artificial tooth root in the shape of a metal screw. These screws are surgically anchored to the bone and, once anchored, the body will grow bone on to them and stabilize them. Once that fusion happens, these posts then can be used by your dentist to make supporting teeth such as crowns, bridges and dentures. This is currently the best long-term solution that we have today for tooth replacement. Overall, our success rates are 95 percent, especially when a patient sees a surgical specialist for placement.

Host: So, this sounds like something a patient might see a dentist for instead of coming to the hospital center. Could you explain why that’s a better idea for people who need dental implants?

Dr. Agarwal: Correct. Most of the patients who come to see us start with their dentist because it is a team effort for a patient to have a tooth replacement. However, most commonly a dental implant is a surgical procedure, so you want to see a surgeon who’s specialized in training to take care of all the surgical aspects of placements of dental implants. However, it is a team effort and once the surgery’s done and healed, the patient would then return to their dentist to have the prosthetic made.

Host: What are some of the most common dental implants that your patients need?

Dr. Agarwal: The need for dental implant varies amongst the population. In general, any patient who wishes to replace a tooth can be a candidate for a dental implant. Generally, the most common patients that we see are those requesting a single tooth replacement. This can be a patient who’s missing a front tooth affecting their smile. This could be a patient who’s missing a back tooth affecting the way they eat. However, as the baby boomer generation continues to grow, we’re starting to see a larger population requiring replacement of all their teeth. Most of these patients may have already been in dentures or they have a failing dentition. So, failing dentition is patients who have had a long history of dental work. They’ve had a lot of work done to their teeth. Their fillings or crowns are starting to fail, and it really becomes more and more expensive to repair all these things and it gets to a point where they may be better off considering replacing all of those teeth. So, our team has an excellent reputation in this area to help patients with solutions to replace either one of their teeth or all of their teeth. In the end, we work with all of our patients and their dentists to help come up with surgical solutions.

Host: So, you mentioned the baby boomers. Could you describe your patient population for dental implants?

Dr. Agarwal: Yeah. As I mentioned, we see a variety of different needs that come through our department and our clinic. I have maturing teenagers who are naturally missing some of their front teeth that we’ll replace implants for them. And I also have a 75-year-old patient who’s had a denture for 15 years and says, “Hey, I really want to taste my food better. I want to eat better. I want to chew better. I want to smile better.” So, our dental implant team can help manage all of them with some of the best experience in the region.

Host: What does a patient have to do to prepare for getting a dental implant?

Dr. Agarwal: There’s not a lot to prepare. Most of the patients - we generally request that they have a dental provider. As I mentioned earlier, this is a team effort. You can consider a dental implant like a foundation. I need an architect to tell me how they want the tooth designed so that I can lay the foundation in the correct place. So, most of our patients, we’ll require that they’re working with a dental provider. Otherwise, if they’re missing a tooth or a tooth is failing, the best thing to do is have a consultation with us because there’s not much more preparation before that.

Host: The day of an appointment, do they have to do anything differently - maybe change their eating or medication?

Dr. Agarwal: Well, the day of the procedure...usually we’ll see the patient prior for consultation to determine what their medical conditions are, what medication is taken - any of that can affect the surgery. So, if someone’s on blood thinners, we may require them to stop or discontinue it for a few days during the surgery. And occasionally we start patients on antibiotics or mouth rinses. Usually we’ll work these things out during a consultation appointment.

Host: Could you describe the process of creating and then placing that dental implant?

Dr. Agarwal: So, very simply, placing a dental implant is a short office procedure. An incision is made in the gums to access the bone. We use specialized equipment to create space in the bone for us to anchor the screw that we put in. We then will suture the gums with dissolvable stitches. And most of these procedures, for example a single tooth implant, can be as short as 30 minutes in the office.

Host: It sounds like a very painful procedure. How do you keep your patients comfortable getting them in there, making sure that they’re nice and calm when they go in? And then how do you keep them comfortable and pain free during?

Dr. Agarwal: You know, surprisingly, this is a very common concern amongst the patients who come to see us. Dentistry, in general, has always been thought as a painful...but nowadays our techniques and local anesthesia have really improved, the office environment has really improved. For most patients, we see them first for consultation. At that time, you really get to develop a relationship with a patient - explain to them what the expectations are. However, anxiety is still a concern and, since we are oral and maxillofacial surgery specialists, we have the ability to offer pain, anxiety reducing techniques, such as office anesthesia. Most dental providers cannot provide this same service, so this is another reason that a patient may want to come see our team, is that we can also provide office sedation for these surgical procedures.

Host: What is the recovery period after receiving a dental implant?

Dr. Agarwal: Very similar to having a tooth removed. Most patients will be uncomfortable for a few days, most often requiring over-the-counter pain medications. Depending on the procedure, they may have a little bit of swelling, which mostly resolves after 3 to 5 days. We ask them to modify their diet, avoiding hard, crunchy foods. And, we also put an emphasis on oral hygiene, that brushing their teeth and we prescribe oftentimes antibiotics and antibiotic mouth rinses. So, for the most part, you know, for procedures done at the end of the week, most patients can return to doing most of their daily activities through the weekend.

Host: One thing I would be concerned with is would I be able to drink coffee or hot beverages or eat right away after I got my implant.

Dr. Agarwal: Sure. The day of the procedure we generally ask everyone to take it easy, possibly more of a soft, mushier diet, considerations to avoid extremes of temperature, but there would be no harm in someone having a warm tea or warm coffee.

Host: Why should a patient choose a dental implant instead of another treatment option?

Dr. Agarwal: Over the years, there have been a lot of methods to provide tooth replacement, but the dental implant is the one that is...generally has a high success rate. It’s a treatment that, if done well and done properly, can be there for a lifetime. The other number one reason to have a dental implant is that as you lose teeth, you start to lose the supporting bone. It’s just a natural process that the body has. By placing a dental implant, it stimulates the bone and the patient will lose a lot less bone.

Host: Do you have any treatment success stories regarding dental implants from your practice?

Dr. Agarwal: Well, every patient who comes to us and gets a tooth replaced is a success story for us. However, there is one gentleman that comes to my mind. There was a patient we treated who had sustained a fall while he was on vacation and he suffered a significant amount of trauma to his face, breaking some of his bones in the face, but also losing some of his front teeth. He was initially treated outside, at the hospital where he was on vacation, but once he came back to the D.C. area, he came to see our team to help reconstruct his jaw and his teeth. When I first started seeing him, I could tell he was a little dejected and had a little bit less motivation about his smile and his mouth, and you could tell, even when he was with his wife, that he was just sensitive about the topic. We worked with him. We got him in touch with a dental provider to help him restore the teeth. And our team ended up doing it first - a reconstructive procedure for his jaw bone. But once that was done, we replaced all his top teeth that he had lost, and the ones that were failing, with dental implants. Once we did that surgery and anchored that teeth that same day for him, I remember seeing him the following week and thought this was a completely different person. I’d never seen anyone talk so much. He was chatting with all our team members. He was just so excited. He was telling us how he was looking forward to seeing his grandkids. And it really, at that point, gave him a new lease on life with something sometimes we think as such a simple procedure.

Host: Why is MedStar Washington Hospital Center the best place to receive a dental implant?

Dr. Agarwal: So, our dental implant program is one of the earliest centers in the country that dedicates one and a half days a week to dental implant related procedures. One of the unique aspects of our program is that every patient gets both a surgical and prosthetic consultation. As an oral maxillofacial surgeon, we concentrate on doing the surgical procedures. However, having a prosthodontist, who is an individual who specializes in complex dental prosthetics, as a consultant has only enhanced our ability to provide the best care to our patients. For example, our program has key opinion leaders in the field of dental implants who actually go out and train and teach other practitioners around the country, who then use our protocols developed at MedStar Washington Hospital Center. We’re on the cutting edge of digital technology, having virtual implant planning, in-house 3D printing for surgical guides and even an implant navigation equipment. All of these technologies have allowed us to reduce treatment time, minimize errors and provide temporary teeth on the same day as the dental implant surgery. Even with all of this technology, I think the biggest reason to choose our team is the ability to provide all this advanced care at a reduced cost.

Host: Thanks for joining us today, Dr. Agarwal.

Dr. Agarwal: Thank you for having me.

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From pelvic pain to fertility problems, endometriosis can affect women’s quality of life and relationships. Discover which treatment options Dr. Vadim Morozov says can reduce symptoms, and what to expect during recovery.

TRANSCRIPT

Host: Thanks for joining us today. We’re speaking with Dr. Vadim Morozov, a gynecologic surgeon at MedStar Washington Hospital Center. Today we’re discussing endometriosis, a gynecologic condition that affects more than 11 percent of women between 15 and 44 in the U.S. Welcome, Dr. Morozov.

Dr. Vadim Morozov: Thank you for having me.

Host: Could you start by telling us what is endometriosis?

Dr. Morozov: Endometriosis is a disease where endometrium, which is normally growing on the wall of the uterus and inside the uterus, starts growing outside of the uterus on the surface of your intestines and the surface of your bladder, all around the pelvic organs in the areas. And, as a result of that problematic growth, you start having pain and symptoms associated with it.

Host: What are the most common symptoms of endometriosis?

Dr. Morozov: Most common ones would be very difficult menstrual periods, cramping, severe pain with that. Pain with sexual intercourse. Pain when you go to the bathroom, having the bowel movements or when you’re urinating. Those are the top four that comes to mind when we’re talking about endometriosis. Pain perception is individualized, obviously, right? So, as you know, one person hits the finger and barely notices, and the other person hits the finger with the same strength and like, you know, ‘I’m dying, that’s it, call the ambulance.’ So, having said that, it obviously depends on the patient, her perception of the pain, support structure that she has, and her goals in life.

Host: How is endometriosis diagnosed?

Dr. Morozov: Unfortunately, the only way to diagnose endometriosis nowadays is by laparoscopy. We can make a presumptive diagnosis that the patient might have an endometriosis just by symptoms of what she’s describing and the physical examination. But to be 100 percent sure, usually we have to look and see the lesions of endometriosis and even better to biopsy those lesions and send them to pathology to tell us that, ‘yes, it is exactly endometriosis.’

Host: Are there any genetic or environmental components associated with the risk factors for endometriosis?

Dr. Morozov: There are some. We know, for example, that if you have a mother or a sister or an aunt with endometriosis, you as a patient are at higher risk of developing endometriosis. There are some studies also saying that the environmental factors such as organic pollutants that we have in the atmosphere also affect the development of endometriosis. Um, but there are no conclusive results yet that can pinpoint us with 100 percent accuracy.

Host: Can endometriosis go away on its own?

Dr. Morozov: That’s a very interesting question. The short answer is probably no. Um, you might be asymptomatic, meaning you don’t as a patient don’t have much of the symptoms related to endometriosis. But if you have them, highly unlikely that the disease will resolve and go away on its own.

Host: What are the treatments for endometriosis?

Dr. Morozov: Normally if we diagnose somebody with endometriosis, it’s not unreasonable to start some sort of a medical treatment, such as non-steroidal anti-inflammatory, birth control pills. There are some other medications that are a little ‘heavy drugs’ as we call them - anything that controls hormonal fluctuations in your body - usually is the first line of treatment. In my experience, most patients don’t do too well on those, um, medications. And inevitably ends up with a surgery. Um, so the gold standard would be something like minimally invasive surgery by laparoscopy, with small, tiny, less than an inch incisions that made in the belly, and then the endometriosis diagnosed and removed at the same time.

Host: Are there any risks for a woman’s health long term if she doesn’t get her endometriosis treated?

Dr. Morozov: There are. Endometriosis, to a certain extent, is almost like cancer. Obviously, it doesn’t kill you but it tends to spread in the abdomen and in the pelvis in a similar way. It can actually involve and invade your bowels, it can invade your bladder, it can invade other structures and organs that are in the pelvis. So, technically, if you leave severe endometriosis untreated, you are at risk of developing complications related to it.

Host: Can endometriosis affect fertility?

Dr. Morozov: Yes. Technically we’re saying that endometriosis does not cause infertility, but rather it causes what we call a subfertility, meaning if you’re a woman with endometriosis, for you it is going to be much harder to get pregnant than for a woman who doesn’t have it. The reason being is because endometriosis creates the inflammatory environment in the abdomen and pelvis. Your pelvic organ is constantly in the state on inflammation that lowers the chances of becoming pregnant.

Host: Does all of that inflammation and all of that scar tissue and so forth that happens with endometriosis increase cancer risk or anything like that for women?

Dr. Morozov: There’s been some association between endometriosis and endometrioid type ovarian cancer. There is no direct correlation, but some researchers are looking that they, some particular endometriomas, which is a chocolate-filled cyst of the ovary, can lead potentially to endometrioid-type cancer.

Host: Have you seen any exciting research that has you excited for women’s health in the future?

Dr. Morozov: There are a couple of good areas of research in endometriosis. One of them is to develop markers of endometriosis that allows us diagnosis without doing the surgery. So, the markers are done from drawing the blood from the patient or even the saliva test that goes to the laboratory and tells you as a patient and me as a physician that there’s a good chance that you might have a disease. It’s in the research phase right now but the results, at least preliminary results, are looking very promising. The other field of interesting research is to develop better laparoscopic visualization tools. Very often we go into laparoscopy with a small camera is placed in the abdomen and pelvis and we don’t see anything or maybe we miss a lesion because our eyes are not trained to recognize highly specific lesions in the pelvis. So, some companies are working on the, what’s called filters, that allow a better visualization of endometriotic implants during laparoscopic surgery.

Host: Are there any questions that a woman should ask when she goes to her doctor? What does she need to know to take care of herself going forward after she’s received treatment?

Dr. Morozov: Well, one thing is, what’s the long-term prognosis? What kind of endometriosis I have. Is it the mild disease that’s easily treated or versus a severe disease that involves surrounding organs such as rectum, bowel or bladder or anything else? The next question the woman should ask, depending on her fertility age, will it affect my fertility? Can I get pregnant? Can I get pregnant on my own or do I need to go to see an infertility specialist for this? The next question would be, in 10 or 15 years when I’m done with my childbearing, what are the options for me as far as having a definitive surgical management of this condition? So those are something that every woman diagnosed with endometriosis should keep in mind.

Host: What is recovery like for women after undergoing surgery for endometriosis?

Dr. Morozov: Usually it takes about 6 months to feel better. So, within the couple first months, you’re sore with the surgery itself. After that time the surgical pain starts going away and you’re feeling great. But it still lingers for some time. So, within the 6 months period we expect to see a result of the pain improvement and the symptoms related to endometriosis improvement. How long does it last as recovery depends. I’ve seen patients that are very good and for years don’t have any symptoms and then sort of slowly starts coming back. And I’ve seen the patients who recur within 3 to 6 months after surgery. Unfortunately, it’s unpredictable.

Host: Can a woman expect to become pain-free eventually, after she has treatment for endometriosis?

Dr. Morozov: Very tricky question. The answer is, depends on the conditions and the extent of the disease. Very often, by the time we see those women, the disease is severe enough that it’s near impossible to make them completely pain-free. And I try to have a very honest discussion with my patients in anticipation of whatever treatment options we choose, saying the goal of, whether we do surgery or anything else, the goal is not to make you 100 percent pain-free. The goal of everything we do is to bring it to the point where you can function normally every day. You’re probably going to have pain here and there, but that pain shouldn’t be debilitating. You shouldn’t be missing school or work because of the pain. In my experience, it’s near impossible to make a woman diagnosed with endometriosis 100 percent pain-free.

Host: Why should a woman come to MedStar Washington Hospital Center for endometriosis care?

Dr. Morozov: Well, we are the largest and probably the best equipped group on the east coast, mid-Atlantic. We have multiple fellowship trained specialists that deal with nothing else but endometriosis and pelvic pain. Our group at the National Center for Advanced Pelvic Surgery have multiple urogynecologists and the specifically trained female urologists that deal with the conditions of the pelvic pain and of the reproductive disorders.

Host: Thanks for joining us today, Dr. Morozov.

Dr. Morozov: My pleasure. Thank you for having me.

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Chronic obstructive pulmonary disease, or COPD, has skyrocketed over the past 35 years. Dr. Matthew Schreiber discusses what it means for D.C., and how you can be as healthy as possible if you have the disease.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re talking to Dr. Matthew Schreiber, associate director of the Medical ICU and an attending physician in Pulmonary Disease/Critical Care Medicine at MedStar Washington Hospital Center. Welcome, Dr. Schreiber.

Dr. Schreiber: Well, thank you for having me.

Host: Today we’re talking about a September 2017 report that showed that the number of Americans who died from chronic respiratory diseases, particularly chronic obstructive pulmonary disease known as COPD, skyrocketed over the past 35 years. In 2014, 53 people out of every 100,000 died of a chronic respiratory illness, up from 41 in 1980, a 31% spike. 85% of those deaths were from COPD, which is now the third leading cause of death in the U.S. Dr. Schreiber, how does Washington, DC compare to the national rates of chronic respiratory diseases and COPD?

Dr. Schreiber: Well, Washington DC, if you were to just look at it as a city, it’s doing great. The CDC and the NIH did a report starting in 2011 that talks about state by state, how much COPD is there, and I think when you’re talking about chronic respiratory diseases, COPD is really kinda the marker for what you’re talking about. There are a ton of different things that are chronic diseases in the lung, but the biggest bulk of them is going to be COPD, and even if someone had asthma their whole life, they can later have COPD, because of the chronic nature of that destructive disease. Coming back to what you asked, DC is ranking in with only 4.6% of its residents having COPD and that’s actually pretty darned good, if you look at our neighboring states. It’s 5.9% in MD; 6.1% in VA; and 8.9% in WV. If you dive into the data a little bit deeper though, DC is a tale of two cities. There are a number of things that the CDC and the NIH found had associations with being diagnosed with COPD, and what they found was that in Washington, you had 2.1% of white respondents saying they had COPD, but up to 6.7% in the African American population, and they didn’t report on other ethnic backgrounds. So, 4.6 sounds awfully nice, it’s at the low end of the national levels, but then when you start breaking that down, there are definitely some groups in our district who are suffering from this condition, uh, at higher than average levels for the nation. If you look at people who are unable to work, and this might be because of their lung disease, but, of course, being unemployed can have any number of reasons—19.9% of folks that were unable to work reported being diagnosed with COPD. If you had less than a high school education, 9.6%. Nearly 1 out of 10 people with less than a high school education had been diagnosed with COPD, and age was a big factor. If you looked at folks 18-44, it’s down to 2.2%, but once you’re over 75, almost 10. So, even though you could say we’re doing great, being at the low end of the national level, we’ve got some work to do.

Host: Why would there be such disparity between the education and the types of work that people are doing? Is there some kind of a cause environmentally?

Dr. Schreiber: COPD is a condition that no one can say they know absolutely what causes it. There’s a number of theories behind it. What I can tell you is COPD is exactly what the name says. It’s chronic, so once you have it, you have it. It doesn’t get cured, it doesn’t go away, it might not progress very fast, but you have it, and it’s all about obstruction. The ‘O’ in the name says the whole thing. People with COPD have trouble moving the air in and out of their chest. And so, if you can’t move the air out, and you’re trying to do some activity or exercise, the faster you’re breathing, the more air that you’re breathing in that you can’t then get out, and you get short of breath. And it’s pulmonary disease, lung disease. So, if you look at it as a pure aspect like that, this could be caused by inhaling something that can damage your lungs over and over again. Cigarettes are the model example for that, and in truth, this seems like common knowledge to a lot of people now, it’s new. We didn’t have studies that showed cigarettes caused things like lung cancer until the 1950s. And we didn’t have a surgeon general’s warning about the damages of smoking until the 1960s and 70s, so progress has been made. But you’ve got a lot of history in the United States with tobacco use and tobacco exposure, and a lot of science going into cigarettes since the early 1900s, that have done its job, so to speak, on getting people to use cigarettes, and the consequences of that use, that we’re only now seeing. When you think about other types of inhaled irritants, different jobs can cause different problems. I ask in my clinic all the time, ‘What kind of work have you done through your whole life?’ And people will focus on the things they might have enjoyed or liked and then I always come back, ‘Did you ever do anything that was around smoke, around fires, around a lot of chemicals, around inhaled irritants where you had to wear a mask, or maybe wish you had worn a mask?’ And people will think about what they did earlier in their life. And the lungs are remarkable things. We have “extra,” so to speak, that when you look at the lifelong duration of how much lung function you have and when it would have to get low enough to cause symptoms, we’re all, for the most part, born with enough lung and develop enough into our late teens early twenties that we can all fortunately die of something else before our lungs become an issue. But when you have these exposures or even some people who just have genetics that predisposes their lungs to dropping off function faster than the average person, when you get to later in life, you start to have this obstruction and then these symptoms, and that’s where people come in and we make this diagnosis.

Host: What can a person do to reduce their risk for COPD?

Dr. Schreiber: Quit smoking. That’s clearly from a research based standpoint, the thing that can have the greatest impact on reducing your risk. If you have a strong family history, you know, ‘both my parents and one of my brothers has been diagnosed with COPD.’ If that’s your story, you can talk to your professionals in your clinics and your primary care, uh, centers to say, ‘Is there anything that I should be tested for because it seems like everyone in my family is getting COPD or getting it at a young age,’ or ‘I have a non-smoker in my family who’s been told they have COPD.’ They’re a deficiency; something called alpha-1 antitrypsin. Incredibly rare disease, but important enough because of how it gets passed along in families that it’s something you can consider having testing for if it seems like there’s a higher than average risk for COPD in your family. Um, if you are in a career path or a job that gives you a lot of, what we call occupational lung exposure - you’re around something where you’re just breathing in things that seem to irritate you all the time, or, you know, in the back of your head, you’re just saying ‘Gosh, I’m breathing a lot of this stuff,’ it’s…it’s worth it to come talk to your primary care physician or if you have a pulmonologist you can see otherwise, to talk about your risks and being tested. The American Academy of Family Practitioners recommends that anyone who has ever smoked, meaning 100 cigarettes in their life, so the, ‘Well, I only have a cigarette or two if I’m out on the weekends at the bar,’ well that only takes two years of weekends before you’ve had a hundred cigarettes.

Host: That’s five packs.

Dr. Schreiber: There ya go! And a cough should be tested because we want to catch people early in COPD so we can both manage their symptoms and encourage them to make lifestyle changes that will hopefully not let the disease progress.

Host: So, you talked about some disparities in education and across the work force. Who’s most at risk for developing chronic respiratory diseases and COPD?

Dr. Schreiber: The research shows that far and away the most at risk are still going to be the smokers. Now the question is, who becomes the smokers? There are a number of scholars that have looked into the impacts of tobacco on public health. So, they point out that there’s a disproportionate, meaning a lot more than you’d expect, of advertising for tobacco products in poor neighborhoods. Their arguments that things like menthol cigarettes are targeted at particular socioeconomic or racial backgrounds and advertising has been done in a way to actually target different groups. Now, these are all theories. I…I can’t overtly say there’s proof, but, I think if you walk around a neighborhood that may be lower on the socioeconomic scale, and walk around a very affluent neighborhood, you will notice there are more billboards in some than others, that there are more advertisements on your corner store for cigarettes than in others, and in fact, this has gotten to the point where laws had to be passed about advertising cigarettes in certain proximities to schools and daycares, because of how it seems that there’s not only this risk of socioeconomics and education having to do with developing COPD and as a proxy of that, maybe using tobacco products, but also the way that marketing is being applied because of how those populations are vulnerable when more people may have this condition and smoking and you add fuel to the fire. So, it is a bigger question of social structure than I think I could ever answer, but there are a lot of people very interested in why these disparities are there.

Host: If a person has smoked in the past and they quit, maybe they quit ten years ago, or they used to work in a chemical plant or a place where they’re exposed to smoke, is there anything particular that they can do to either be screened or to reduce the effects of that damage?

Dr. Schreiber: Being screened, absolutely. The only way to diagnose COPD is with something called spirometry. It’s a breathing test. It’s looking for that obstruction. We have someone basically blow into a tube connected to a small computer, and we see how much air came out and how much came out in the very first second. Because someone with COPD, they can get all the air out, they just can’t do it quickly, and if I asked you to blow out for the six seconds it takes for that test and you have normal lungs, it’s hard. Like at the end you’re really trying to push out that last bit. People that have obstructions, I’ve read results from these tests and they’re still breathing out at 13, 14, 15 seconds because that’s how long it takes to get the air out because of the slowness of it. You can’t diagnose COPD with a cat scan, an x-ray, a stethoscope, a physical exam, a history – unfortunately, that still happens all the time. In the NIH/CDC data talking about COPD in all these different states, DC for example - three out of ten people reported never having had spirometry, yet were given a diagnosis of COPD. I would bet they probably have it based on the symptoms they had, but there are other things that could be going on and getting tested with spirometry, which can be done in the clinic, you don’t necessarily have to get what we call full pulmonary function tests which are done in the hospital, um, not as an admitted patient, but just in…in our hospital facilities, to get some of that answered. And a number of primary care clinics can do spirometry in the office. Um, we can do it in our pulmonary clinic, if that’s all the information we need. Or we can send people for additional testing with full pulmonary function tests. What can somebody do to slow the effects? That’s the tough part. There was a…a landmark study that gets talked about all the time in healthcare where a group of researchers developed a diagram showing the natural history of what happens to lungs. It’s called the Fletcher Peto Curve. And, what they showed is that for a person with no lung disease, we have our best lungs at about 20-25 years old. And then it’s literally all downhill from there. For somebody who has vulnerable lungs and has that bit of damage happening from smoking or whatever their particular cause is, if they can get away from that or quit smoking or get rid of that damaging effect, their lungs never grow back. The lungs aren’t like skin and muscle and bones. You kinda have what you have after the age of 25, but the rate of decline slows down. And so, you ask…started off this conversation saying, ‘Where is this large uptick in COPD coming from?’ It’s coming from us finally recognizing what’s been going in a lot of people for probably the last twenty or thirty years. If you look at that Fletcher Peto graph and you say, ‘Well ok, if a 50-yr. old quits smoking at age 50, they might not get bad enough lungs to have symptoms until they’re 75.’ It doesn’t mean they didn’t have COPD at 50, just wasn’t causing them disability where they actually might have gone in and gotten tested for it. If you have someone who’s 73 and maybe has no symptoms because they’re one of those people that you’ve met that smoked their whole lives and did fine, then in 2 years later they start having lung problems, they had COPD all along. It’s just they got so close to that symptom marker that now, you know, a year after they quit, they’re on oxygen or can’t go up the three steps to go in their house, and in truth, that’s the scary thing. I don’t understand the response sometimes from patients but they’ll say something like, ‘Well, I’m not worried because this family member, uh, did well with this or did well with that, and so I’m not worried about smoking.’ But it’s not about necessarily the death with COPD, it’s the disability. Losing your independence and…and I’ve met people in my clinic who literally get short of breath eating. Taking a shower leaves them winded, and that’s the kind of life changing event that is so horrible about COPD, that it takes away your freedom. And, people surveyed in DC talking about how COPD has affected them, almost 2/3 said they have some kind of exercise limitation because of breathing, and that’s why we need people to get checked early, to hopefully get them to either start medication to prevent flare-ups and exacerbations or maintain their symptoms under control, or to make lifestyle changes that might slow the progression.

Host: How do you go about addressing that risk with your patients?

Dr. Schreiber: I spend a lot of the time counseling smoking cessation, and encouraging activity, referring people to something called Pulmonary Rehabilitation, which is different from just physical therapy because they’ll have respiratory therapists and people that are trained on ways you can manage your breathing a little bit better and how to push your limits but not get exhausted, to still make progress. We talk about nutrition, and keeping people physically fit and being preventative, like getting vaccinations where they’re appropriate. Um, so there’s a lot of things when someone has COPD that we can offer them or counsel them to try to keep them as healthy as possible. Medications have been shown to help when you have COPD. And, it’s an interesting split to me and…and I say this to my patients in the clinic all the time - you wouldn’t wait until you’re having a heart attack or a stroke to start taking your blood pressure medicine, even though you feel fine. For some reason with inhalers people say, ‘Well, I’m breathing ok so why am I taking this inhaler every day?’ But these are preventive medicines, and if I can stop you from having a flare-up this year, which then will affect your lung function next year, that’s a win. And so, the things that we prescribe in the pulmonary clinic are not always just to make you feel better, they’re also to prevent you from falling apart in some way, because nature is still going to cause those lungs to decline a bit, but if I can NOT have you in an urgent care or hospital with something that’s gonna make it decline even faster, to then keep you independent and doing things, even though you quote ‘feel like you’re breathing ok,’ then I’m doing my job. Taking a pill for folks just seems to be simpler than using an inhaler, and granted, there’s a lot more coordination going on with using an inhaler, and a lot of people use them wrong, and there’s no point in medicating the back of your throat when we need it to get it down into your lungs. But, it’s another task in the day that takes a few more seconds than just swallowing something with water and, you know, it’s something that I think when you look at a patient and they’re using an inhaler, there might be social or, you know, other biases where you look at them and say, ‘Oh, you’re doing that, as compared to just discretely swallowing a pill with a glass of water.’ And so, I think a lot goes into it. Um, it also comes back to that idea of ‘well why am I taking this medicine if it’s not making me feel better?’ And, with the way that our society, uh, has a healthy and appropriate fear of heart disease and strokes and diabetes and hypertension, um, medications for those, I think, are something people buy into and I don’t think we’re there yet with breathing disorders to say, ‘This is something that you really should do and here are the risks and here are the dangers and here’s why.’ I think, in some ways, that’s a…a blessing, that this is a new enough common disease, so to speak, that we’ve only been dealing with this for forty or fifty years, um, that people don’t have a hundred years of being afraid of heart attacks and strokes the way that, uh, they don’t necessarily have that fear with COPD, but it means we’ve got a lot of catching up to do really quickly.

Host: Thank you for joining us today, Dr. Schreiber.

Dr. Schreiber: No, it’s been my pleasure. Thank you.

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ICU delirium is a state of agitation or confusion that can affect as many as 80 percent of patients who are admitted to the intensive care unit. Dr. Matthew Schreiber explains this condition and how we reduce the risk for our patients.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Dr. Matthew Schreiber: Thank you for having me.

Host: Today we’re talking about ICU delirium, a sudden and intense confusion that can include hallucinations, delusions, and paranoia. So, Dr. Schreiber, what can cause ICU delirium?

Dr. Schreiber: What can cause it is really the focus of a lot of research right now and the list of things is very, very long. We know that medications have an association with delirium. Some of the things that historically have been used in the ICU to help treat a patient also have risks that are now being identified, like delirium. Additionally, the ICU as an environment itself can lend to having delirium because imagine in your normal job, or your normal life, with a newborn child or something else, if you become sleep deprived, the next day you’re a little bit foggy and a little bit less focused, and imagine dealing with night after night of a twenty-four-hour lights on, beeping environment where things are happening because they need to happen to treat somebody. After days of that, it also impacts a patient’s mental status and can lead to delirium. On top of that, delirium is really a very specific disease. It’s not dementia, it’s not pain, it’s not agitation -- those things might look really similar, but what delirium is, is it’s an end organ failure, meaning the brain, in response to other things going on. And we don’t have a model to say A causes B, but we know delirium happens based on a diagnostic criteria—a series of questions and kind of a test, if you will, to say if someone’s delirious or not. But we can’t necessarily chalk it up to ‘if we could just do this one thing we’d be able to get rid of it.’ It’s a…it’s a sign of a disease, but it is its own condition and its own disease and its own thing on its own.

Host: That’s fascinating. So, the brain can actually die from overstimulation?

Dr. Schreiber: It’s interesting that you put it that way, ‘cause that’s somewhat of what’s being shown in some research. If you parallel this to something like sepsis. Sepsis is the whole body responding to an infection in one place. So, lots of people get urinary tract infections, but some people, their body’s inflammation and that’s the body’s response to it, they end up septic from that same urinary tract infection. The brain sees all the same blood as everywhere else in the body, so even though somebody might have low blood pressure or troubles breathing because of an infection down in their lower extremities or again, that urine, the lungs were an innocent victim. Here the brain is an innocent victim to whatever the illness is because of all the things circulating around in the body causing end organ damage. To come back to what you said about the brain dying, there actually are some studies coming out of Vanderbilt where they’ve done MRIs on people who were diagnosed as having delirium during an ICU stay. Six months later the brain actually looks different when compared to people who were just as sick but for whatever reason their body didn’t end up having delirium, so something physical is happening there.

Host: So, we’re talking visual, and auditory and physiological symptoms. What would be some of the indications that a person has delirium as opposed to another condition?

Dr. Schreiber: So, it’s important to point out that those kinds of things you brought up are what a lot of people think of when they think of delirium, but delirium really is more nuanced than that. It’s got a couple of clinical tests that can be done at the bed side to help make the diagnosis, but they’re all consistent in what they are. Delirium is a condition that waxes and wanes, meaning it comes and goes. Dementia is something that comes on and gradually happens over years and doesn’t necessarily just get better. Delirium is something that can be there at 6 AM, and gone at noon and back again at 7 PM and gone at 2 AM and so the ongoing fluctuations like that are a key component. The second part is inattention. The patient just can’t maintain focus. And so, we test that by seeing if they can just do something that we’re asking them to do, uh, ten times. You know, some of them being in the affirmative, meaning do it, and some of them not, meaning we say something and they’re not supposed to do it, but if they can’t maintain focus for those, that’s inattention, and that’s the second component. And the last part is disorganized thinking. You might just call it confusion. But the way that we test for this when it comes to disorganized thinking is we ask questions to a patient that really should have no question of what’s right and wrong. Things like, is ice cream cold? Is a mouse bigger than a giraffe? Can you hit a nail with a hammer? And when somebody has delirium, questions like that still become difficult for them to answer even though they sound like something anyone should be able to get right. Really, it’s hard to tell without actually doing the test. There are people who can be completely oriented, can tell you the date, where they are, their name and be delirious. And there are people who can be disoriented or have dementia or have changes in their ability to respond because of a stroke and not be delirious. So, it really does come back to those key things of waxing and waning mental status, so it’s changing throughout the day, inattention, and disorganized thinking.

Host: So, it sounds like different populations of people, different conditions for which they’re hospitalized in the ICU, can cause varying levels of delirium symptoms. Is there a particular risk factor an individual might have that would make, say me as opposed to you, more susceptible?

Dr. Schreiber: That has been shown. So, the older a person gets, the more likely they are to have delirium. The more ill the person is when they first come into the hospital, the more likely they are to have delirium. People that have a history of dependencies on different chemical substances, whether it’s things like alcohol or illicit drugs or even prescription medications, are more likely to have delirium. Whether if any one of those things is the absolute risk or not, hard to say. But it’s something we really should be looking for in every patient. It’s also important to say this is not just an ICU thing. It’s where a lot of it happens, in fact eight out of 10 people who end up on a breathing machine will have delirium at some point in their hospital stay. But half the people who never end up on a breathing machine can still be that way, and even just regular admissions to the hospital, what we call the medical/surgical floors or wards—up to a quarter of those people will have delirium during their stay, at some point.

Host: So, this is a fairly common thing. How many cases would you estimate that you see at MedStar Washington Hospital Center in a year?

Dr. Schreiber: Hundreds. I think the better way to put it is how many people every day do we see having delirium? We…we make it part of our rounds. It’s something that the nurses do every single shift, is do a test - we call it a Cam ICU, confusion and agitation method in the ICU, to look at that series of questions. Has their mental status changed? We ask people, to basically squeeze my hand or blink your eyes or stick out your tongue. Whatever they can do when I say the letter A, and then I spell out ‘save a heart,’ and heart is spelled wrong, it’s s a v e a h a a r t, and if they get more than two of those wrong, then we move on to disorganized thinking and ask them those simple yes, no questions, and can they follow a command. And if they can’t follow two separate commands and answer questions without more than two errors altogether, that’s delirium. We check every patient in the ICU every single day, and when we find it, then that can actually change our plan of care. Do we need to be more aggressive getting rid of a sedative? Do we need to change that to something else, even if it, you know, we’re not sure it’s going to be as effective to help maintain a level of comfort. Or, is it a sign that something’s going wrong? You know, when a patient’s in the hospital and has a fever, everyone says “oh, we need to figure out why that patient has a fever.” If someone was normal yesterday and delirious today, that’s another sign that the brain is raising a red flag maybe something’s going on and that might be the first sign of an infection or a complication.

Host: Is this something that patients have ever brought up in themselves and say, you know, “doctor, I just don’t feel right?” Or is this something that family members can also watch out for? Or caregivers? What’s their role?

Dr. Schreiber: The patient’s usually not aware because it’s affecting their brain and so that level of noticing ‘hey, I’m different’ is one of the risk factors of the condition. Family see it, they just not necessarily know what to call it. Why is my loved one not themselves? Why did they act like they didn’t know who I was? And the worry is, is this dementia? Is this permanent? Is—have they had a stroke? Is there something going on? Is it any number of things? They don’t necessarily come up and say, ‘I think my loved one’s delirious.’ But when we get those kind of questions, like ‘she was talking out of her mind this morning’ or ‘she couldn’t remember something I said to her fifteen minutes ago’ or something like that, those are red flags to that disorganized thinking.

Host: Is there anything that a patient or a family member can do to decrease the risk for delirium?

Dr. Schreiber: Absolutely. Being a familiar face, being able to redirect, being able to anchor that patient in what’s going on and help them stay focused, has been shown to help. Having things like the whiteboards in our rooms that have today’s date and today’s nurse and today’s information, help reorient the patient. Having things on the television in the room that have current, redirecting kind of issues. Not necessarily dramatic things you might see on the news, but things that let people know of what’s going on now have been shown to help. And also, letting people get the rest they need. You know, we do have an open ICU that allows visiting hours around the clock. But our goal is to let patients sleep at night and stay awake during the day. During the day, we try to be aggressive with pushing things forward as much as the patient can do and so family members can help by being encouraging for that. Helping keep the patient’s spirits up and when the patient’s saying things like “I just don’t know if I can do physical therapy today,” to ask them, “Are you sure? How about a little, but can we help you? Can we cheer you on?” You know, this is really gonna help you out by staying purposeful and active and moving forward because early mobilization and activity’s also been shown to reduce delirium.

Host: Interesting. So, walking or getting up and participating in PT?

Dr. Schreiber: Absolutely, and not just with the physical therapist. One of the things that we’ve been doing here for almost two years now in the medical ICUs is rolling out a bundle of things to help control, manage, and prevent delirium. This is called the ABCDEF bundle. It stands for assessing and addressing pain, because that’s important. When a patient is ‘quote un quote’ agitated, maybe it’s because they’re hurting, and if we can control that pain syndrome instead of just using something like a sedative, or an antipsychotic or something to calm them down, you might actually get two birds with that one stone, and reduce their risk, and help that issue. The B is for both the spontaneous awakening and breathing trial. So, people that are on a vent—mechanical ventilation, a breathing machine for life support - to every single day see, can they breathe on their own? And, if they’re really sick, they’re going to declare that they can’t because they’ll breathe fast, and you can tell within a minute. But maybe they can, because if they can breathe on their own on that machine with some settings being changed, maybe they’re ready for that to come off and you get rid of another risk factor for delirium. The awakening trial is not just saying, let’s turn down any pain or sedative medications to see where we can get the patient awake and comfortable, but literally every single day to push stop on those machines and see if the patient needs it.

That’s been studied, and by always trying to adjust to just enough for the patient what they need was considered standard of care. By doing that but also once a day pushing pause on the machines, cut the number of days of continuous medications like that, cut the number of days on the vent, shortened the ICU stay, and did nothing to raise mortality or patient harm, and so the fear of ‘Well, I can’t push stop on this medicines that going through this IV pump, the patient will hurt themselves,’ never has actually been shown. In fact, continuing it longer seems to be what hurts people. The C is the choice in those medications. Things called benzodiazepines. At home, people might know this as Xanax, is one of those examples. Ativan is another example. That family of medicines has the most research behind it to lead to delirium than anything else we know. In fact, one study showed a direct relationship of the dose that you get of medicines in this family to having delirium within a day, and it doesn’t seem like much but relatively low doses ended up having a hundred percent of people having delirium that day, so we try to avoid those whenever we can. Sometimes they’re needed. We use benzodiazepines when someone is seizing. We use them when someone’s in alcohol withdrawal. But, a lot of times you can find something else. The D is for delirium. To check it, because if you don’t look for it, you’re not going to find it. And that’s that test we call a Cam ICU. The E is early mobilization activity, which might be physical therapy, but our nurses are fantastic. You know, we can sit somebody on the edge of the bed, let them use those core muscles to dangle their feet. We can move people to a chair because the sitting position uses different muscles than laying in bed, and we walk people. And we walk people. You know, we get a physical therapist, a nurse, another nurse to help, if needed, and even if someone is still on a ventilator, still on a breathing machine, still on life support, we can walk them in the unit if they’re able, but we won’t know if we don’t check to see what they can do. And the F is family engagement and involvement. Because it is important for family members to help us help that patient in a way that we can’t. As much as I might like my patients, I will never be that familiar face that they’ve known for years and years and years, at least I hope that I’m never that face. And that’s something we can’t reproduce. And so, we do try to invite families to rounds every day. If they can’t be there, we try to call them every day, and we really do try to encourage that engagement with the patient to help them move along.

Host: Is there a risk for untreated delirium, or if somebody has it, can it resolve on its own?

Dr. Schreiber: Most of the time patients, as they get better clinically, as whatever got them sick in the first place gets better, they’ll start to improve. There are long term risks here though. Being delirious on its own, even when you, what we call, adjust for other things, meaning you’re doing statistics to say how much does this cause that or associate with that, and you say ‘well, I’m going to take two people who are just as sick and one’s delirious and one’s not, how does, how does this outcome change,’ delirium’s been shown to increase mortality at six months. If it’s its own process being on its own, it’s more likely to kill you, which is why it’s so important to try to prevent it with those other things like getting out of bed, and less days on the vent and less sedation. I mentioned the MRI studies a little bit earlier, that there’s something physically different happening in the brain and so, long term, patients that have had delirium tend to have more cognitive issues and functional issues and it can be something simple like more often saying ‘I was going to tell you something. I just can’t remember what that was’, but it can be life changing if now they can’t go back to work. And icudelirium.org is a fantastic website for both patients and practicing clinicians and family members and everyone else to see testimonials from patients and caregivers and hospital professionals all talking about the long-term outcomes of this condition. It can be life altering and the worst part is, if no one was ever able to say ‘hey, you had this while you’re in the hospital’ because there are plenty of places that don’t check for it every day. Even in our institution, I can’t tell you that every single unit, every single nurse, every single day, checks for this. Then they go home and wonder ‘why am I different?’ And we have a long way to go to help support people at the back end of their illness, at the back end of the ICU after they’ve left, to try to give them every opportunity to get back to being themselves.

Host: That’s really a lovely statement, I think, because yeah, I mean it’s traumatic enough being in the hospital, let alone being in the ICU after a traumatic event. Is there a certain subset, say accident victims or surgery, you know, people that had complications with surgery, that you see delirium in more often or a certain age group?

Dr. Schreiber: The older you are, the more likely you are to become delirious. As far as the disease itself, I think the literature is just not there yet from the research. It has been shown in burn ICUs, cardiac ICUs, surgical ICUs, medical ICUs, it doesn’t discriminate. What we do know is it happens far more often if you are on a breathing machine, and that’s probably a mix of both - that means you’re sicker because if you’re on a form of life support to help you breathe, that’s pretty bad. But also, what does oxygen do to you and your brain? If you’ve ever been unfortunate enough to have a family member in a neonatal ICU or if you’ve ever worked near one of those, you know that they, as…as early and aggressively as possible, try to have that baby off of oxygen because of how it can affect your eyes and other things. We always try to use it as little as possible but it has things that cause inflammation, it’s one of the effects, so could the vent itself do some of this? We don’t know. The research isn’t there yet. People who are septic - there’s some studies that say there might be more delirium in that because of the way the whole body can become inflamed, including the brain, when the body is dealing with an infection and becoming septic. But if there is one disease to do it, I don’t think we have that answer yet.

Host: Have you ever seen a very severe case of delirium turn around and what was that process like?

Dr. Schreiber: I have. I, I can distinctly remember a patient who, you’d walk past the room and looked like a normal guy. Sitting in the chair awake, watching tv, and then you’d talk to him, and you’d hear from the nurse, ‘Well, overnight we had to, you know, give him something because he was agitated, or we had to calm him down,’ you know, even if it wasn’t with the medicines. So, right there you have waxing and waning mental status. And then you’d ask questions and he would give answers that just seemed a little off, and so you’d take the next step and ask him to squeeze your fingers when you say the letter a for all those letters, and get that wrong, and then ask him these disorganized think questions and get that wrong. And then something would come out and he, he was scared because that’s what he saw and that’s what he believed was going on, and you would never know this if you didn’t ask the right questions because he would talk to you like everything’s fine, until you got into what he was perceiving and seeing. And, you know, he acted like he was actually handling it ok, and it’s not a big deal but then you realize he’s delirious and that visual hallucination was one of the things his delirium was manifesting. He ended up doing well. He left the hospital. I saw him in the clinic months later and he was trying to go back to work. He ran his own business and said he was having some trouble doing the books, so to speak, but for as close as he came to death with what brought him in, it was a remarkable improvement, just not all the way to as good as you wish you could get if you survived a life-threatening illness.

Host: Thank you for joining us today, Dr. Schreiber.

Dr. Schreiber: Oh, it’s been my pleasure! Thank you.

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Some pituitary tumors need immediate treatment, while others may benefit from a wait-and-see approach. Dr. Susmeeta Sharma discusses the different types of pituitary tumors and how we care for them.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thank you for joining us today. We’re talking with Dr. Susmeeta T. Sharma, director of pituitary endocrinology at MedStar Washington Hospital Center. Welcome, Dr. Sharma.

Dr. Susmeeta T. Sharma: Thank you for having me.

Host: Pituitary tumors often cause no symptoms, but when they do, the symptoms typically are vague and easily can be mistaken for other less serious conditions. Pituitary tumors may be functional, which means they secrete excess hormones, or non-functional, which means they do not secrete excess hormones. Dr. Sharma, when symptoms occur, what do patients typically experience?

Dr. Sharma: The symptoms of pituitary tumor kind of depend on the size of the tumor and whether it’s a functional tumor, what hormone it’s making, is it causing any hormone deficiency. So, I always think that in order to understand what symptoms a pituitary tumor can cause you have to understand the basic physiology and anatomy of a pituitary gland. So, the pituitary gland is a pea-sized gland located at the base of the brain. And I think of it as a conductor of an orchestra. It basically makes a bunch of different hormones, which then regulate other endocrine glands in the body to make other hormones. So, for example, it makes TSH (thyroid stimulating hormone) which then acts on the thyroid gland to make thyroid hormones. It makes ACTH (adrenocorticotropic hormone) which then acts on the adrenal glands to make...regulate cortisone production. It makes prolactin which acts at the level of the breast for development of the mammary glands and milk production. It makes FSH and LH which are gonadotropins which act on the gonads, ovaries, and testes to make female and male gonadal hormones, testosterone and estrogen. And then it also makes growth hormone which really acts on the entire bodies involved in growth, especially in children during puberty, achieving, uh, their full height potential.

So, it’s a really important gland and any small, uh, dysfunction, whether it’s related to an inflammatory disorder or a tumor that’s causing compression - any of that can lead to either hypofunction of one of these hormones or increased function of one of these hormones. A pituitary tumor has the potential to make any of these hormones. So, it’s...if it’s a functional pituitary tumor, it can cause symptoms related to excess prolactin, which will then be breast milk production or irregular menstrual cycles or infertility in a female. In a male it may be even harder to detect because of the lack of the menstrual irregularity as a symptom so while they may present with is decreased libido. And later on, as the tumor grows, it may cause symptoms related to the size of the tumor, so headaches and vision problems. So, it all depends on the kind of hormone that the pituitary tumor is making. Another example would be if it’s making ACTH which is then leading to excess cortisone production that can lead to a patient gaining a lot of weight, muscle weakness, fractures, diabetes, high blood pressure, developing purple stretch marks on their body. So, a variety of symptoms that could be related to excess production of a particular hormone in the body. Uh, so that would come from hormonal excess. But then you could have symptoms related to hormonal deficiencies. So, if the tumor is large enough that it’s compressing normal pituitary cells, you could have a low cortisol state, a low growth hormone state, a low thyroid hormone state, which can then lead to other symptoms of their own. And lastly, like I mentioned earlier, from the size of the tumor. Even if it’s not producing any hormone, as the tumor grows, by the size of the tumor, it can cause headaches to the patient and also, in the space where the pituitary gland is located, it’s a very tight space and it’s very close to the optic nerve or the optic chiasm, and those are fibers that control our vision, especially our peripheral vision, and so, as the tumor grows, it can compress on these nerve fibers, leading to vision problems - double vision, loss of peripheral vision - it may manifest as that. Many times though it may be the patient may not have any symptom at all and it may get detected on an MRI done for other reasons - for example, for headaches, for...which are...may or may not be related to the pituitary tumor. So, the presentation can really be varied and depends on how big the tumor is and if it’s making any particular hormone.

Host: When symptoms arise, is treatment urgent, or do the tumors grow slowly?

Dr. Sharma: The majority of these tumors are slow growing tumors. These are benign tumors, not cancers. Often, patients may hear a diagnosis of brain tumor but this is very different from other tumors that arise in the brain and that have a much higher malignant or a cancerous potential. So, pituitary cancer is very rare and so these are mostly benign tumors. Benign in the sense of them being cancerous but not benign in some of the effects that they can cause if they go undetected. But most of the time, yes, given the fact that these are slow growing tumors, the symptoms often develop gradually. Uh, many times these symptoms can be non-specific so a patient may just have some fatigue and some inability to lose some weight and that could even be a symptom for a hormonal disorder. So, um, sometimes the presentation may be very obvious, very florid, and we may even walk into a room and see a clinical appearance of a patient and think that, “Oh, this patient has to have a pituitary hormonal disorder” while other times it may need a much more lengthy interview in the clinic and exam and for the blood test before a diagnosis can be made.

Host: What are some of those immediate symptoms that would cause you to think a patient you’re visiting with has a pituitary issue?

Dr. Sharma: Um, so, in particular in women, if they have irregular menstrual cycles and there is breast milk production and they have not had a baby and so that would be a situation where there has to be a prolactin elevation in the majority of the cases. Uh, that may or may not be related to a pituitary tumor; that there are other disorders that can cause a prolactin elevation. But that definitely means that they need to be evaluated by an endocrinologist and need to be tested to see if there is a pituitary disorder there. So that would be one example. Other times, especially in conditions where the pituitary tumor makes growth hormone or the hormone ACTH (adrenocorticotropic hormone) which then leads to cortisol excess—those two particular hormonal disorders can often present very floridly, where the clinical appearance can be very dramatic and easy to detect if it has gone undetected for quite a period of time. So, for example, a growth hormone secreting tumor or excess growth hormone leads to enlarged, fleshy hands and feet. The patient would complain of change in ring size, change in shoe size. They would have changing facial features, coarsening facial features over time that one can detect on...while examining or looking at the patient. Another example would be Cushing’s Syndrome, or excess cortisol in the body. In that, also you have a change in facial features, rounding of face, a reddening of face which we call plethora, excess fat positioned on the upper back of the body in the base of the neck area where...near the clavicles. And so all of that can make us at least suspect that this patient could have Cushing’s, and then those patients would need to be screened for that disorder.

Host: What are some of the common diagnostic tests when a doctor suspects a pituitary disorder?

Dr. Sharma: If we suspect that a patient has pituitary disorder, sometimes the clinical presentation is so florid that we may want to test for a particular hormone and other times we may need to test for all of the pituitary hormones. And again, anytime I am thinking of a pituitary tumor, I need to make sure both that A) the tumor is not making any excess hormones, so those would be blood and urine tests to start off with for these particular various hormones and then I also need to make sure that it is not deficient. Many times, the blood and urine tests may not itself be sufficient for the diagnosis - that would be the initial screen, followed by some more dynamic testing that may need to be done to confirm that their patient has a particular hormonal deficiency or hormonal excess. And then again, we need to have sophisticated MRI to be able to detect the full location of the tumor, and then you need to collaborate with the neuropthamologist to make sure we are looking at any possible visual deficits related to the pituitary tumor. So definitely a team work - you need the endocrinologist to be able to assess for these hormonal deficiencies and hormonal excess disorders, you need the neuropthamologist and the neuroradiologist to look at...um, visualize the tumor on the MRI and assess if there are any visual field deficits related to the tumor, and then we need, of course, the neurosurgeon if surgical treatment is indicated.

Host: What is the approximate size of the pituitary gland?

Dr. Sharma: In a three-dimensional structure, the height of a normal pituitary gland is around 6 millimeters in size so, overall again, yeah, the pituitary gland is about the size of a pea. And then, any time there’s a tumor within it—so just a few millimeters above is the optic chiasm and so any time the tumor is growing there is a potential of that gland with the tumor encroaching onto the eye nerves, especially if the tumor is greater than a centimeter, which is what we call a macroadenoma while in the centimeter. When the pituitary tumor is less than a centimeter it’s called a microadenoma.

Host: How big are the tumors that you’re taking care of in these patients?

Dr. Sharma: So, very variable. So microadenomas, may come to our attention two ways. It might just be that in this era of MRIs, an MRI is done for other reasons and we find a small tumor now. Once the tumor is found, you do want to make sure that it’s not making any hormones and then you have to follow it once a year, at least, to make sure that it’s not growing significantly in size that it needs surgical attention, just based on the size of the tumor. Otherwise, it may be that it’s a small tumor but it’s making a particular hormone so mostly functional tumors can get detected at a smaller stage just because of...they’re causing much more symptoms to the patient from the hormonal excess related to them. And so functional tumors may get detected at a size when they’re less than a centimeter. Non-functional tumors though, most of the time if they’ve not been incidentally detected on an MRI, would be greater than a centimeter. So, we have had tumors that are 5 to 6 centimeters, especially many times in patients who have not sought medical attention or have not been seeing physicians regularly. Um, other times the tumor could be very large but it’s just that the patient has not paid attention to the visual field deficit that it may be causing. So, they just get used to not being able to see peripherally and that can be very dangerous, especially if they’re out there driving with the visual defect. So, as an example, we had a young male with a prolactin secreting tumor. And so, this tumor was about 5 centimeters in size. And, these are slow growing tumors so it was probably present for several years but a prolactin secreting tumor in the male, all it was doing in his case was lowering his testosterone levels and thereby probably causing decreased libido but it had to grow to that big a size and to finally, during a testing for a DMV related driver’s license, he failed his vision exam and that’s how his visual field loss initially came to attention.

Host: Is a functional or a non-functional tumor more dangerous?

Dr. Sharma: A non-functional tumor, whether or not it needs immediate attention, would depend on the size of the tumor and what mass effects it’s causing. But definitely a functional tumor always needs attention. So, I’m not sure if one is more serious than the other but definitely a functional tumor always needs attention immediately. And so, uh, most functional tumors, actually the first line of treatment would be surgery. The only functional tumor that can be purely treated medically in the majority of the cases is a prolactin secreting tumor. So, although there are medications available for treating various different functional tumors, in prolactin secreting tumors using medications that are available are so effective that we can actually shrink the pituitary tumor and normalize the prolactin levels with medications alone and they don’t need surgery. And, in fact, outcomes from medical treatment can even supersede what we can achieve surgically and so that is why an endocrinological evaluation is really important for pituitary tumors because we want to make sure that we assess whether or not surgery is indicated and also make sure we’re not missing these, this particular kind of tumor—the prolactin secreting tumor—where we can make a difference medically instead of the patient having to undergo any unnecessary surgery.

Host: When a patient requires surgery, is there a minimally invasive option?

Dr. Sharma: Surgical techniques for pituitary tumors have really advanced. And the majority of the pituitary tumors can be safely resected through the transsphenoidal route. So, we have an endoscopic or a microscopic approach and it depends on the size and location of the tumor when the pituitary surgeon decides which approach to take, but they’re all being done minimally invasively now. And so, this would be a route either under the lips sublingually or trans nasal so through the nasal passage, through the sphenoid sinus and then through the base of the sella, which is what we call where a pituitary gland is located. So, that would be a minimally invasive approach. Patients are usually in the hospital for 2 to 3 days after surgery and are able to leave so compared to the earlier times where you would actually have to cut open the skull and then approach a large pituitary tumor. So even tumors of the size of 5 to 6 centimeters can be safely removed through this route these days.

Host: Is there any scarring related to the surgery?

Dr. Sharma: So, no actual visible scarring. Many times, in the path that the surgeons take, you may have some superficial nerve fibers that are affected and so people may have temporary, um, either altered or loss of taste or smell sensation. They’re definitely going through the sinus so sometime you can have sinus-related issues but those are usually temporary and there’s, uh, no visible scarring. You can’t really tell that the patient has had surgery, in fact.

Host: Why is MedStar Washington Hospital Center the place for people to seek care?

Dr. Sharma: Oh, I think what we provide is a multidisciplinary team approach. It’s really important to see a patient and treat them as an individual and see what would be the best treatment option for them. So, any time I think of a pituitary tumor, I think what it needs is a team and not just a single physician operating in isolation. So, you need an endocrinologist to evaluate the hormonal excess or deficiency related to the pituitary tumor. You need a neuroradiologist to properly evaluate the tumor and make sure they’re using up to the mark MRI techniques and developing newer localization techniques for that. A majority of the tumors do need to be surgically removed so we definitely need an experienced neurosurgeon. Not every neurosurgeon is doing the number of transsphenoidal surgeries I feel that are necessary to develop the expertise, so it’s really important to have an experienced neurosurgeon who does a lot of these. And we are lucky to have Dr. Edward Aulisi as one of our neurosurgeons here. And so, an experienced neurosurgeon and then an experienced neuro-opthamologist to look at visual field deficits related to it. And then as an adjunct treatment, other than surgery and medical therapy, you may also need radiation therapy for the pituitary tumor. So, we have focused stereotactic radius surgery options available at MedStar Washington Hospital Center as well. So, having it all under one roof helps because we all are communicating and trying to develop a treatment plan that is best for the patient...that’s optimal for the patient.

Host: Are you currently doing any research on pituitary tumors that you’d like to share with people in the community?

Dr. Sharma: So, we are starting the research process. We do have Dr. Joseph Verbalis, who’s at our counterpart institute which is Georgetown University Hospital, where he’s already doing a lot of research on posterior pituitary and sodium disorders. And then Washington Hospital Center - we are developing other research programs to look at the path of physiology of tumors so what leads...for different patient populations to develop various kinds of pituitary tumors. We are working with our pathology department to try and see what molecular markers we can identify to better, um, identify what treatment option would be better for a particular patient based on those molecular markers. And then, of course, devising better, more refined surgical techniques for making these surgeries possible in a minimally invasive manner.

Host: Thank you for joining us today, Dr. Sharma.

Dr. Sharma: Thank you for having me.

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Lifestyle modifications are key to treating hypertension, especially for people at high risk. Dr. Valeriani Bead discusses who is at risk and which treatments are most effective.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. Valeriani Bead, a board-certified cardiologist at the MedStar Heart and Vascular Institute, with extensive expertise in nuclear cardiology and echocardiography. Welcome, Dr. Bead.

Dr. Valeriani Bead: Thank you for having me.

Host: Today we’re discussing how the 2018 hypertension or high blood pressure guidelines apply to African Americans, the elderly and other at-risk populations. The guidelines lower the target rate of a healthy blood pressure for average risk individuals, thereby increasing the number of U.S. adults who are considered to have hypertension. Dr. Bead, what is the optimal blood pressure target for a person at average risk for hypertension under the new guidelines?

Dr. Bead: Well, you mentioned that the new guidelines that were just released in November 2017 - well, these were the most recent guidelines in almost fourteen years that were published - and they were treating high blood pressure in adults and they’re really the first guidelines that we’ve had that’s based on extensive research, using the highest quality clinical research and drug trials. And, based on these new guidelines, really the goal blood pressure is anything less than 120/80 millimeters of mercury. And really where the controversy started is now stage 1 hypertension is considered in individuals who present to their healthcare provider’s office with a blood pressure of 130/80 millimeters of mercury. Well, what that means is that more American adults will be told they have high blood pressure because of these newest thresholds. And those who are already being treated will need to really talk with their healthcare providers about whether or not their target blood pressure readings need to be adjusted. And, in some cases, whether or not lifestyle changes and their medication will need to be intensified.

Host: What are some of the symptoms of hypertension?

Dr. Bead: The most common symptoms we experience, which is scary, are none. Some people don’t even know it. They don’t feel it. Which is just fascinating. Outside of that, the most common symptom is headache, fatigue, dizziness, lethargy and at times, but not quite often, they can get chest pain and shortness of breath.

Host: When it comes to hypertension, African Americans are at greater risk, in general, than other nationalities. Why is that?

Dr. Bead: Well, in the United States, in any decade of life, African Americans have a higher prevalence of hypertension than that of Hispanic Americans, whites, Native Americans and really any other subgroup defined by race and ethnicity. And the ideology remains obscure and we really don’t know. But, we do know that hypertension control rates are lower for blacks. That also hypertension, when it’s diagnosed, is more severe and that sometimes the medicines we use to treat high blood pressure are less effective at controlling blood pressure. And with all this, the morbidity and mortality attributed to hypertension is more common in blacks than it is in white Americans and any other ethnic group - which is why identifying and treating hypertension can have such a significant impact on health and morbidity in the African American community, which is why it should be identified much earlier.

Host: When we’re thinking about high blood pressure, regardless of nationality, the risk increases as we age. Could you explain why older adults are at a greater risk than younger adults?

Dr. Bead: That’s a very good question because there really is an extremely high prevalence of hypertension in older adults. And, hypertension is not only a leading cause of preventable morbidity and mortality, but, more importantly, it’s under-recognized and it’s considered a major contributing factor to premature disability and why many elderly adults get institutionalized, such as nursing homes. And, it is worthy to note that after the age of 69, the prevalence of hypertension rises to greater than 50 percent. And so, it’s linear with age. Now, the exact cause is unknown, but we have postulated that as we get older our blood vessels do get stiffer and then that can lead to elevated blood pressure. But, I’ve got to tell you that that’s not entirely elucidated and a lot more research is warranted to help figure that out.

Host: So, we’ve talked about African Americans. We’ve talked about older adults. Are there other patient populations who are at increased risk for hypertension?

Dr. Bead: More often times than not, in my clinic practice, I see pregnant women who come in with elevated blood pressure and that is certainly a population that cardiologists, in general, need to be aware of. Because, blood pressure, while it usually declines during the first trimester of pregnancy, it can slowly rise in either the second or third trimester of pregnancy. And we usually need to be aware of those mothers who have newly diagnosed hypertension, or whether or not they have incident hypertension during clinical conditions such as something called preeclampsia, which is a dangerous form of hypertension, that leads to increased protein and other consequences with the mother’s health. And the reason that this really is important for us to identify earlier is because we have found out through research studies that mothers who are diagnosed with high blood pressure during pregnancy eventually have high blood pressure later on in life. And so, it’s important to identify it earlier so that we can treat it and have it under control.

Host: These women who are diagnosed during pregnancy with high blood pressure, what are some of the risks for them and for, perhaps, their babies if they don’t get that treated?

Dr. Bead: The most important risk we always worry about is the health of the mother and the baby. With high blood pressure, that can put the baby at risk. With high blood pressure, that can put the mother at risk and lead to bad consequences such as congestive heart failure. And so, there are actually very serious consequences to worry about if blood pressure is not controlled during pregnancy.

Host: And, if we take a step back and think about all these other individuals - African Americans, older adults, adults of any age, really, who don’t take care of their hypertension - what are some of the risks for them if they don’t seek treatment?

Dr. Bead: Not to be too grim, the risks for uncontrolled high blood pressure are significant. Meaning, with uncontrolled high blood pressure, it can lead to strokes, heart attacks, abnormal heart rhythms, congestive heart failure, kidney problems, and death. This is typically something that happens over time, which is why you may sometimes hear hypertension referred to as “the silent killer.” Meaning, hypertension can be prevented. And usually, when you have consequences related to hypertension such as the ones I just mentioned, it’s something that could have been identified much sooner and treated earlier, without the bad consequences.

Host: The 2018 guidelines lower that target rate of a healthy blood pressure for average risk individuals. What does that mean for lowering the blood pressure targets for high risk individuals?

Dr. Bead: The implications are essentially the same. To identify high blood pressure individuals, whether they have it average or high risk, it really helps us treat it earlier and potentially reduce future cardiovascular events.

Host: How can high risk patients proactively manage their blood pressure?

Dr. Bead: The lifestyle measures can be effective in treating hypertension. So, there is something called the DASH lifestyle eating plan and the DASH diet stands for Dietary Approaches to Stopping Hypertension. and that has been a long term, randomized clinical trial that actually shows that following this eating program, which reduces the amount of salt in our diet, can reduce the blood pressure by an average of 10 to 15 points. And, using that, in combination with restricting dietary sodium and increasing dietary potassium, can really result in a good effect on the blood pressure. So, in addition to that, weight reduction, regular aerobic activity, not smoking, and limiting alcohol really also go a long way in terms of managing blood pressure.

Host: When those lifestyle methods aren’t enough, what treatment options are available for patients with high blood pressure?

Dr. Bead: So, first line treatment will always be lifestyle changes, such as the ones I’ve mentioned. And then we can go on to second line treatment which usually includes prescribed medications, and sometimes it may require starting two medications at the same time in order to achieve that goal blood pressure of less than 120/80 millimeters of mercury. Also, ruling out any other potential causes such as obstructive sleep apnea, which is when someone doesn’t get enough oxygen when they sleep, can really go a long way in terms of keeping the blood pressure under control and treating that. And, in extreme cases, for patients who have something called resistant high blood pressure, which is basically blood pressure that is difficult to control, we have invasive procedures that are available but that’s something for another discussion.

Host: Could you share a treatment success story from your practice?

Dr. Bead: This is my favorite part! I love my practice and, I’ve only been doing this for about 8 years. And, I’ll never forget one of my first patients, who I met about 7-½ years ago. She was a middle-aged woman who I initially met during a normal EKG. And, at the time, she was dealing with high blood pressure, requiring at least 3 or 4 different medications. She was morbidly obese, and she had problems with arthritis. And, we did a comprehensive cardiovascular workup. And, it turned out that her heart status was actually pretty good. And so, we adjusted some of her medications and, with time, nothing really changed. And at one of her follow-up visits, I sat down with her and looked her in the eye and basically, with as much encouragement as I could, I asked her...that she just has to start moving. Literally, to start doing 2 minutes a day and then, after that, doing 5 minutes a day and then, after that, getting up to about 30 minutes a day. And, I kid you not, when I saw her back in a 6-month follow-up visit, she had lost 50 pounds just by walking. And, she was motivated enough to start changing her lifestyle in terms of what she ate. She followed the DASH eating program and joined a gym and lost another 50 pounds, to the point that her blood pressure was actually too low, and we actually stopped the majority of her medications to the point that she was on one low dose medication to keep her blood pressure under control. And also, she didn’t have any more knee problems. So, she was able to share that success story with me and she spread it to her family, and she’s also been able to do some exercise programs at the local YMCA. And, she’s happy and she’s here to tell the story and she actually had a poster that she shared with me. And it’s something that I share with my other patients as well.

Host: What was the poster that she shared with you, if you don’t mind sharing with us?

Dr. Bead: It was a before and after of herself and basically, it showed pictures of her when she was at her highest weight. It showed pictures of her when she started walking. And it showed current pictures of her at her current weight. Because she had lost over a hundred pounds just by moving and watching her salt intake. So, all of the poster of her - really a before and after. I mean, the picture was worth a thousand words just to see how she transformed by making literally small steps.

Host: That was really amazing and I’m sure that’s really inspirational for a lot of your other patients and maybe even for you every day to remind yourself to get in there and do your exercise and just keep going forward. Why is MedStar Heart and Vascular Institute the best place for people at high risk for hypertension to seek care?

Dr. Bead: Because the MedStar Heart and Vascular Institute really offers comprehensive, state-of-the-art care. And the compassionate environment that is patient centered and really evidence based. And what I really like about MedStar Heart and Vascular Institute is there really is a physician for every type of patient and for every type of medical illness that hits our door. So, there is something for everyone.

Host: Thanks for joining us today, Dr. Bead.

Dr. Bead: Thank you for having me.

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The effects of traumatic injury can linger long after initial recovery. Dr. Jack Sava explains why trauma is a disease and should be treated as such.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

In today’s episode we talk to Dr. Jack Sava, chief of trauma at Medstar Washington Hospital Center about visualizing trauma as a disease in itself.

Host: Thanks for joining us. We’re talking to Dr. Jack Sava, chief of trauma at Medstar Washington Hospital Center. Welcome, Dr. Sava.

Dr. Jack Sava: Well thank you, I’m happy to be here.

Host: Thinking about trauma as a disease in itself, could you explain what you mean by that?

Dr. Sava: Well, it’s interesting to think about injury and how is injury similar or different to something like a heart attack or cancer or stroke or asthma and so forth, and many people today I had somebody tell me a week ago that injury is not a disease really, it’s something that happens. And i think that’s the general perception, and you might ask well why does it matter? Why are we talking about the words? And the reason it matters is because it turns out that looking at injury or trauma as a disease is very helpful and makes a lot of sense and leads us to a lot of sensible policies and a lot of sensible practices. So why is it a disease? Well, trauma, like heart disease has risk factors. It’s related to poverty, substance abuse, mental illness and many, many other things in the same way that hardening of the arteries is related to smoking and diabetes, etc. so really even though you might think because it’s behavioral, it’s different, the idea of risk factors leading to illness is really the same. It also has an acute phase where there’s an event kind of like a heart attack, and that requires some time in the hospital. And then it also has this long tail end, just like other diseases where you have to recover, the recovery is slow, the recovery may not be complete, it may impact your quality of life forever, it may impact your family, and then even more so you’re going to be at risk for recurrence, so if you have a tumor removed from your stomach, you’re always going to have to worry about recurrence of that, and we’ve found that in many of our patients who’ve had an injury, they’re at higher risk for having another injury than other people are, especially whatever led them to that injury, whether it’s their driving habits or their substance abuse problem, or their tendency toward bad luck. If none of those things have been fixed, then they’re at risk for having it happen again.

Host: It’s sort of an umbrella term too, so like mental health would cover a huge spectrum of diseases, is the same true for trauma?

Dr. Sava: Yea, trauma is an unfortunate term in some ways, because it’s been borrowed by so many people in so many ways, so a lot of people use the term to refer to an emotional trauma, like a bad divorce. And a bad divorce is a very bad thing, but it’s not the sense in which I use the word trauma, that’s why I sometimes use the word injury instead. That one’s also tricky but, it’s really not that complicated in principle, I think most of us know what a physical injury is. It’s when an external force causes damage to the tissues of your body, that’s the sort of theoretical definition. What does it mean practically? It means violent injury, like shootings and stabbings, it means vehicular injury like car crashes and motorcycle crashes and bicycle crashes. One of the most important things it means is falls. That could be a fall from three stories or it can mean an elderly person tipping over out of their wheelchair. That is a huge cause of injury in America. It can include intentional self-harm, a suicide and suicide attempts, and it can include workplace injury, and that’s a big problem also.

Host: So why the shift in mindset from trauma is the thing that happens to you to trauma is a disease? When did that occur and how is that impacting your practice now?

Dr. Sava: Well, it’s interesting. Maybe 30 years ago, people started looking at trauma through that lens and immediately a bunch of really profound things became apparent. If you look at injury or trauma and you put it side by side with other diseases, you see some very interesting things. The most obvious way that you might think to grade the importance of a disease would be is it a common cause of death? And so that’s why something like heart disease usually comes out on the top of that list. Because you think about it that everybody whose heart eventually stops beating has a heart problem, so a lot of people in their 90s who eventually their heart gives out, they get put in that category, and so a lot of people have a quote cause of death that’s heart disease. But the center for disease control started asking the question what actually kills young people? Or what kills people at different ages. And when you look at that data it’s fascinating because it turns out it’s all trauma. What kills people in their first second, third, fourth, fifth decades of life is injury, and if you look in your own family, and ask well what took a young person away from my family, you know, most of the time those answers are that somebody got hit by a car, somebody dove into a swimming pool, they’re traumatic incidents. So, the CDC developed a new term, a new metric, to describe the importance of diseases, rather than what’s the number one cause of death, they started asking, or in addition to that, they started asking what are the important causing of lost life years in America? And that was a radical change when they started asking that question, because again the answer is trauma. So, if you want to know what takes away American life years, whether it’s the tragic car crashes or the falls, or the people who die in war time, whether it’s America or worldwide, injury and trauma are the most important cause, and they really eclipse everything else.

Host: So, given the impetus of trauma and traumatic events on our health as a nation what’s next in research and what’s next in treatment?

Dr. Sava: When we started thinking about trauma as a disease and started thinking about how can we impact that like we impact other diseases, we realized a couple of things about trauma and about death from injury, and one of them is that people who die from injury, one of the ways they die is instantly at the moment of their injury. So, if somebody has a horrific car crash, they’d probably die in milliseconds or seconds. So, we have to think about how do we prevent that death? And that’s led to a whole growing field of inquiry about injury prevention, and that takes a lot of forms as well, making cars safer making drivers safer, preventing distracted driving. Workplace safety, helmet use, traffic safety all these things can be very effective in preventing the initial injury in the first place, which you can imagine is the best way to prevent death from it. The most important next time of death for an injured patient is in the initial period, what we typically call the golden hour. And what happens during that period is people might be unable to breathe because they’re injured so badly, and more commonly they’re bleeding to death. So, a lot of stopping trauma deaths has to do with creating systems that can prevent people from bleeding to death, and that starts with people on scene whether they’re professionals or just civilian bystanders, knowing how to stop bleeding there, and then it continues through having protocols with the paramedics and the EMTs for stopping bleeding. Protocols that get patients to the hospital really quickly, and then having dedicated trauma centers where there are whole teams of people who are in the hospital 24/7 with expertise and experience in stopping bleeding, both immediately with the right type of pressure, and also with complicated operations. So, for us, that means in many cases on the average Saturday night people come to us and they come through the door of our trauma center, and they might have major surgery on their chest and abdomen to control catastrophic bleeding within 90 seconds of arrival. So how do you do that? Well, obviously, that doesn’t happen by rolling into a local, local sleepy hospital and starting to get on the phone to call people to leave the dinner table to come in, that’s not going to work. You have to have all these resources, all this readiness, that means surgeons, emergency room physicians, trauma room nurses, blood bank, operating room personnel, anesthesiologists, and on and on. All these people have to be there and have to be either at the door when the patient comes in or ready to be there in a few seconds.

Host: How do you work with the EMS teams so that they’re aware they should bring those trauma patients to Medstar Washington Hospital Center and perhaps not another facility without a trauma center?

Dr. Sava: Well, fortunately over the last couple decades, emergency medical services in most metropolitan areas have developed protocols that they know in advance what kind of injury is going to go where. And what that means is that most cities in America, since trauma was identified as an important disease and in most cities in America if you stub your toe, you’re going to go to a local ER, if you’re shot in the chest, you’re going to go to a trauma center. So in other words, there’s field triage where the paramedics, EMTs can look at a patient and either by the story of what happened (hundred mile an hour car crash) or by the patient's vital signs, or by their judgement, they can pick the right patients and bring them to a trauma center, and it works out much better when critical patients go straight to a trauma center. And that was a bit of a hurdle you can imagine getting people to understand that the sickest patient doesn’t necessarily go to the closest emergency room, that it might actually be better to bypass them and go to the right emergency room rather than the closest one.

You know, we talk a lot in talking about diseases about death and mortality rates and causes of death. It’s important with trauma and injury to recognize that for every patient who dies with injury there are many, many lives irrevocably changed. There’s a whole ocean of suffering that exists for every patient that actually dies. This can take the form of physical disability, but also post-traumatic stress disorder, and depression, and many other consequences of injury. People often after serious injury, have to develop a completely different conception of their body integrity, they can have lost limbs, they can have lost functions, and these things can obviously snowball, especially if not given the proper care, into a patient losing their job, becoming depressed, their relationships falling apart, or they quit school, that makes the depression worse. And even the emotional problems can in turn make the physical problems like pain worse, so it’s very easy to enter into a downward spiral. So even patients who aren’t in the data set of patients who died are often the ones who are suffering their whole life and so we need to have systems in place and resources for those people, because it’s easier to simply talk about mortality rates, often that’s where we focus

Host: How do you triage those individuals who are going to need that extra care even that emotional support after they leave the trauma center?

Dr. Sava: well we screen people in the hospital and we screen people on subsequent visits for post-traumatic stress disorder. I think that there’s still a long way to go in American trauma care to help people, especially people without resources, with the emotional fallout of injury. I think that the care of mental illness for people with no resources, generally speaking, with or without injury, is an opportunity in America and a place where we can make a lot of progress.

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Bladder cancer is the 4th-most common cancer among men, but when detected early, it can be managed and often cured. Dr. Lambros Stamatakis discusses how we find and treat this disease, and what we do if it comes back.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents medical intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. In today’s episode, we talk to Dr. Lambros Stamatakis, Director of Urologic Oncology at MedStar Washington Hospital Center about bladder cancer. Dr. Stamatakis discusses bladder cancer symptoms, how treatment has advanced over the years, including techniques unique to MedStar Washington Hospital Center and what patients can expect during treatment and recovery.

Host: Thanks for joining us today.

Dr. Stamatakis: Thanks for having me.

Host: So, let’s get started on bladder cancer. How common is it, what do people need to know?

Dr. Stamatakis: So, bladder cancer is often considered a bit of an orphan cancer because it doesn’t get as much press as some of the other cancers out there. But it’s actually the fourth most common cancer in men. So if we compare this to prostate cancer, there’s about 160,000 new cases estimated to occur in 2017, bladder cancer we’re estimating around 60,000 to 65,000 in men. So, it’s a relatively common cancer in men, overall about 78,000 cases a year. So, it’s less common in women and the reason for that is a bit unclear, but it is something that we predominantly see in men.

Host: And how common is it in the D.C. area? How many cases do you see in a month or year?

Dr. Stamatakis: Estimates from the National Cancer Institute suggest that there are around 3,000 total new cases in the D.C. metropolitan area, so I’m including Maryland and Virginia in those numbers. I usually, because I am a referral center for bladder cancer, I often see around 10 to 20 cases a month. We do more bladder cancer than any other institution in the District of Columbia. So, being a high-volume center, we’re very experienced in the nuances of the surgical treatment of this disease, which is paramount for how you manage bladder cancer. Because of that, we also have higher expertise in knowing how to stage the disease and also how to manage it moving forward. We also have a multidisciplinary clinic where surgical folks like myself work with medical oncologists and our partners from Lombardi Cancer Institute over at Georgetown to provide systemic therapy in patients that need it or require that. Also, again, clinical trials are another option for some of our patients who are interested, and that can provide therapies that are not otherwise available as standard-of-care yet.

Host: And, what are the most common symptoms?

Dr. Stamatakis: So, blood in the urine is the number one symptom that typically prompts referral to a urologist. Blood in the urine can also be caused by other benign conditions. For example, somebody having a kidney stone or an enlarged prostate. But for the urologists, we need to make sure that we rule out bladder cancer or other malignant causes of blood in the urine. So that’s certainly something that most of our patients won’t present with, but not all. Other patients can have irritating voiding symptoms, meaning they’re going to the bathroom more frequently or they’re having a sense of extreme urgency and that’s not getting better with the traditional therapies that we give for those types of symptoms. Every once in a while now, with modern day imaging, we’re also able to pick these things up incidentally. So, a patient gets a cat scan for another reason and the radiologist sees a little tumor in the bladder that then prompts the referral to us.

Host: So typically, when somebody comes in and they had blood in their urine, is that a sign that it’s usually already advanced a little ways?

Dr. Stamatakis: Not necessarily. Not necessarily. But what it will signal to the urologist is that a specific workup needs to be completed. So, that includes getting imaging of the kidneys and upper urinary tract, so that includes the tubes that connect the kidneys to the bladder, called the ureters. And that’s most typically done using a CT scan and specifically something called a CT urogram. In addition, a cystoscopy will often be offered to the patient and that’s a procedure where we stick a small camera inside the patient’s bladder to directly visualize the surface of the bladder; make sure that they don’t see anything that’s abnormal.

Host: And, most bladder cancers are diagnosed relatively late though, correct? Or …

Dr. Stamatakis: Not necessarily. About 75 percent of them actually are present in the quote non-muscle invasive state. So, that’s a big differentiator when we talk about bladder cancer staging is whether the disease is muscle invasive or non-muscle invasive. And, to go back a little bit, the bladder is essentially a muscular sac that just stores urine. The bladder itself has multiple layers and these cancers derive from the inner layer of the bladder, known as the urothelium. So as these tumors grow, they tend to grow from the urothelium towards the outside of the bladder. And right sandwiched in between is the quote muscle or detrusor muscle of the bladder. So, when we see a bladder tumor on a cystoscopy on somebody who’s been worked up for blood in the urine, the next step will be to take them to the operating room to resect that tumor. That procedure will accomplish two goals. Number one, it’s diagnostic, so we get it out, the pathologist does their exam under the microscope, tells us what it is and how deep it’s invading into the bladder. And then the second thing is that it’s potentially therapeutic. So if it’s non-muscle invasive, often we can then watch those patients very closely and may offer select patients intravascular therapy, which basically means different types of drugs inside the bladder to prevent further recurrence or treat any remaining microscopic disease that’s left behind. If it’s muscle invasive, then we’re a little bit more aggressive.

Host: And how has bladder cancer treatment, how has it advanced over the years?

Dr. Stamatakis: In many different ways. Initially, the treatment of bladder cancer, or traditionally, has, for muscle invasive disease, has been removal of the entire bladder with a urinary diversion. And a urinary diversion basically means being able to figure out a way to somehow get the urine out, for that particular patient. The most common thing that’s done in the United States is something called an ileal conduit urinary diversion, or otherwise known as a urostomy, where, essentially, we plug the kidney tubes into a small piece of intestine which then gets tunnelled through the abdominal wall and creates a small stoma, and the urine will then basically drain into a bag. But as time has gone on, we’ve now developed other methods for urinary diversions. We can even create what’s called a neobladder, using a much longer piece of intestine but being able to connect that pouch that we create to the patient’s native urethra, so then they can basically void through their natural orifice. So, that does help to prevent the need for an external appliance and is more cosmetically pleasing for select patients. In addition, another thing that’s really changed is the kind of something that I eluded to before, was a multidisciplinary approach to treating these cancers, and that is no better highlighted than in the use of chemotherapy up front before radical surgery for these conditions. In a big randomized control trial done by the Southwest Oncology Group in the early 2000s, getting upfront chemotherapy actually was shown to confer an overall survival advantage compared to patients who went to cystectomy directly or bladder removal directly. So, that is something that we do offer all of our patients, upfront chemotherapy, and ultimately, hopefully, be able to confer that survival advantage for them. One thing that we do differently is something called blue light cystoscopy. Blue light cystoscopy is an enhanced cystoscopic technique and essentially what it involves is the administration of a dye into the bladder about an hour prior to going back to the operating room for a bladder biopsy. And what will happen is that this dye essentially gets preferentially retained within the cancer cells as opposed to the normal bladder tissue.

So, when we shine a specific wavelength of light, which looks blue, the areas of abnormality will appear to fluoresce. It almost looks like a fluorescent pink little spot on the screen. So, the benefit is that—is several. First off, we are able to identify tumors that otherwise you may miss on traditional cystoscopy. And it’s not that you have a bad urologist that misses it, it’s just the fact that some of these lesions can be so small that they’re really hard to perceive with the naked eye. In addition, when you have a tumor in place, we have a theory that when you end up excising that tumor through that procedure that perhaps you may be leaving some tumor behind. So, using this technique, we can actually evaluate the edges of the tumor resection site and make sure that we got everything out. And, if we need to, we resect a little bit more to make sure that we have a negative margin, meaning that we got all the tumor out as we possibly can. So, this doesn’t really add that much to the patient experience, other than the fact that they have to have this dye put inside their bladder about an hour before, and we really feel that it adds an additional piece of information to us when we’re making the diagnosis and performing these procedures for these bladder tumors.

Host: When a patient comes in, what should they expect?

Dr. Stamatakis: So, again, I’ll kind of break this up into sort of the non-muscle invasive and the muscle invasive group. So, in patients with non-muscle invasive, otherwise known as superficial, bladder cancer, the one thing that patients need to understand is that recurrence is unfortunately the rule with bladder cancer. These tumors, depending on the stage and the grade, which is something that’s determined by the pathologist, the recurrence rates can be quite high. So, in order to identify those recurrences, we have to routinely perform cystoscopies, again looking inside their bladder, to be able to identify those recurrences early. So, a patient that is being treated for non-muscle invasive bladder cancer needs to realize that they’re going to be getting occasional procedures to look inside their bladder. And often that can be just done in the office as an outpatient procedure with relatively little discomfort to the patient, if any at all. In addition, there are multiple therapies that we use inside the bladder to, again, in certain patients, to help prevent these tumors from coming back. In patients with muscle invasive disease, again, that’s when we get our multidisciplinary folks involved and we’ll have them work together with our medical oncologists to select a therapy that’s personalized to their particular disease state and also for their preferences. And often we will offer radical surgery, and, when it’s appropriate, do it through a minimally invasive approach. I typically use the DaVinci robot for bladder removal, and that’s something that will be offered to many of our patients in our practice. So, those are the sort of, the things that we, that we end up offering to our patients.

Host: What can a survivor expect during recovery and beyond?

Dr. Stamatakis: So, after radical surgery for bladder cancer, again for muscle invasive or locally advanced disease, the surgery itself is a big surgery. I mean, usually, typically, four to five days in the hospital and often it can be several months before they feel really back to normal. And after that, we will be very vigilant about performing imaging studies to make sure that their bladder cancer doesn’t come back. If they have not received chemotherapy up front, we may offer it to them after the surgery, depending on the results from pathology from the bladder removal. And that’s something, again, that we’ll get our medical oncologists involved with. For non-muscle invasive bladder cancer, again, it’s really just being vigilant about seeing each other over and over again and making sure that they get the surveillance that they need with periodic cystoscopies.

Host: As a final thought, maybe, with bladder cancer being so prevalent, why do you think it’s not top-of-mind as much as other cancers?

Dr. Stamatakis: Yeah. Well, again, it hasn’t gotten as much press and also, I think, because the symptoms that we discussed that are associated with bladder cancer are the same symptoms that patients often get with many benign urologic diseases. Again, if somebody has blood in the urine, the first thought to a primary care provider isn’t bladder cancer. It’s “Is the patient having a kidney stone? Do they have a urinary tract infection?” And often, I think our primary care providers don’t like to jump to conclusions because you don’t want to create fear within your patients. We see this a lot in women. Women are more prone to urinary tract infections. They’ll come to their doctor and have blood in the urine and they’ll treat them for a urinary tract infection almost reflexively. And the blood keeps coming back, and they keep throwing different antibiotics at them. It’s often part of the reason why, despite the fact that bladder cancer occurs less frequently in women, it actually presents at a more advanced stage in women compared to men. And that’s because, we think, that primary care providers often will be misdiagnosing them.

So, it is something that I think, from our perspective as educators, to be able to educate the future generations of primary care physicians to understand the appropriate workup for blood in the urine and I think that will help to increase awareness. The other thing that’s also changed is that there’s more advocacy groups out there now, particularly something called the Bladder Cancer Advocacy Network, that actually started in the D.C. metropolitan area. They are now doing a lot to increase awareness of bladder cancer and become advocates for patients and their families. And that’s something that never really existed before and we’ve really been following suit and the folks that have created these sorts of organizations for prostate cancer and breast cancer, which are really the more popular, or more well-known, cancers out there. So, we’re hoping that bladder cancer is going to become something that, really, people know more about as time goes on.

Host: Great. Thank you so much for joining us.

Dr. Stamatakis: Yeah, no problem. Thank you so much.

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Surgery is the gold-standard breast cancer treatment, but some techniques leave women flat-chested or with lopsided breasts. Dr. Patricia Wehner discusses how many women can benefit from oncoplastic surgery, which offers a more natural breast shape so women can look and feel more confident after surgery.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Patricia Wehner, a surgeon with fellowship training in breast surgical oncology and MedStar Washington Hospital Center. Today we’re discussing breast oncoplasty. Welcome Dr. Wehner.

Dr. Wehner: Thanks for having me today.

Host: What is breast oncoplasty?

Dr. Wehner: Oncoplasty in and of itself, what that actually means is it just means removing the area of cancer with attention to cosmesis. So, it’s really removing the area of cancer by doing a partial mastectomy and figuring out a way to cosmetically and acceptably close the defect that you’ve created and making certain that you leave the patient with a very reasonable size and shape breast. So, the goal is always to make it so patients don’t necessarily need to ever remember that they’ve had surgery because you’re trying to make them look how they looked before or at least minimize the disruption that you’ve caused. So, , I trained at USC, so University of California, and it is a huge oncoplastic program there. So, there I learned a lot of various plastic surgery techniques to employ in my daily operative time. So, because of that, I don’t need to have a plastic surgeon come in for most cases. Unless, again, we’re doing sort of a larger reduction or larger reconstructive surgery. Every single patient who undergoes a partial mastectomy, really is a candidate for breast oncoplasty. And again, the point of breast oncoplasty really is to just pay attention to cosmetics. So, what I tell patients is cancer surgery first, because obviously we’re all here to get rid of their cancer and to treat their cancer, but cosmetics is still really important for women undergoing breast surgery because anybody who has to deal with the loss of breast tissue or even the loss of the breast, while they’re going through it they obviously feel it. If they’re undergoing chemo, if they’re undergoing radiation, then obviously it’s something that’s very much on their mind. But five years later, when they’ve completed all of their treatment, and they've completed the chemo and they’ve completed the immediate surgery and they’ve completed everything that needed to be completed right around the time of their diagnosis, I want them to not have to look at their body and also be forced to remember day in and day out. I want them to get back to where they were beforehand, meaning, I feel good, I look good and I don’t want to stare at something that’s going to remind me on a daily basis of what I went through. So, any type of breast surgery, breasts are not twins, they’re sisters, so no matter what they're going to look a little bit different and the goal is just to minimize that difference. So, you’re never gonna reconstruct or recreate what you had prior to surgery. There’s just no way around that. But we want to at least keep it as close to that as possible and to minimize those differences.

Host: If a woman has this procedure and then they have oncoplasty at a younger age, say in her 30s, so the breasts change as we age--how does that compare as their other breast that might be healthy?

Dr. Wehner: With oncoplasty, really you’re taking the patients natural tissue and just sort of rearranging it to fill in the defect. So, I’m not adding anything, meaning I’m not placing an implant in there or I’m not placing something foreign within the breast. So, it’s still the exact same tissue you had before, just maybe a little bit less of it. But, with that, the density of that tissue can change as you get older. You’re breast, as you get older, if you gain weight or lose weight, your breast can gain weight or lose weight and so the same thing with that area of reconstruction can gain weight or lose weight. So, it’s really still retaining everything that you had before it’s just kind of moving it around in a different location. Now, there’s a lot of discussion about skin and nipple sparing mastectomy. So, a mastectomy is different than a partial mastectomy because the goal of a mastectomy is to remove all of the breast tissue. Previously when we did a mastectomy, we would make an incision, we’d remove the nipple, we’d remove the areola complex, we’d remove a good majority of the skin and try to close it as flat as we could. Then we kinda sort of started saving some skin and placing an implant in there and so creating a decent or reasonable breast. And now for certain patients that are fairly well selected, we can actually preserve the entire breast envelope, meaning the nipple, the areola complex, and the skin and still remove all of the breast tissue that’s living underneath of that and then reconstruct it with an implant or even an autologous tissue, so tissue from someplace else. It’s a very technical surgery because it’s a large amount of real estate, I guess for lack of a better term, of what you need to get to in order to remove it.

So, we go through an inframammary fold incision, meaning the incision is at the very bottom of the breast. And through that incision we reach the very top of the breast and remove all of the breast tissue. So, anything that lives above the pectoralis muscle and underneath the skin gets removed. Overall outcomes, so what a patient look like afterwards then tends to be very favorable because you still retain the nipple and you still retain the areola complex. Now they don’t function like they did before surgery, but they still look good because they're there. So, I kind of liken it to the earrings that you would put in an ear. So, while it maybe loses its function, it still looks good, so we leave it there for cosmetics and we know that there’s no increased risk of cancer recurring at that location. This doesn’t hold true for each and every patient because some of this depends on size of the natural breast, shape of the natural breast before reconstruction and just overall body habitus. But for certain patients it really is a great option.

Host: Is there a general criteria that you have for women who would quality for nipple sparing surgery?

Dr. Wehner: So for skin and nipple sparing surgery, most of these women do tend to be a little bit thinner and that’s just because patients who do best with an implant reconstruction tend to be a little bit thinner so they don’t have a very wide chest and they’re beasts have to be a little bit smaller, so generally we say A through C cup. Now we have started doing a two-stage approach for patients who have a large breast, so those who have Ds, DDs, even maybe a little larger than that. Or we actually do a surgery where we reduce the size of the breast first, so we reduce it down to a B or a C cup, let that heal and then after that’s healed then we go back and then do the skin and nipple sparing mastectomy. So, we do have options, it’s just again not a one size fits all type of option and it really kind of depends on the patient and what the patient looks like and even the type of cancer the patient has.

Host: Why is it that how the woman feels afterwards and how she feels about her self-image has become so important?

Dr. Wehner: So, losing a breast is the same as losing an appendage. Even though it doesn’t function like an arm, it’s still an appendage, it’s still an organ and for most women it has a lot to do with who they are as a women, it has a lot to do with their sensually, it has a lot to do with their body image, it has a lot to do with just how they feel about themselves. So, when they put a shirt on, do they feel normal? Do they look normal to the outside world? And that is what the goal of some of this reconstruction is. Is when a patient gets dressed and they go out, how can they give and portray sort of their best self-confidence to the world and nobody’s gonna want to do that if they don’t feel self-confident. So if they feel very anxious about how they look, if they feel very worried or afraid or if they’ve lost a breast and now it’s flat and not reconstructed and so it’s really obvious because they’re other breast is very large and now the other side clearly have tissue loss--does that make them feel sort of uncomfortable and not want to go out in public. So there’s lot to do with just body image that goes along with this type of surgery and there’s a lot to do with sensuality that has to do with this surgery and that’s why it’s really important that when you have a breast cancer diagnosis that you find a provider that you trust and a provider that really can understand that. All cosmetic follow-up procedures are not cosmetic because they are done under the purview of reconstruction operations in the setting of a cancer diagnosis. So, they are considered oncoplastic. And that’s onco meaning oncologic or cancer and plastic meaning cosmesis. So, everything covered by insurance. This is a not a paid out of pocket. We’re not trying to augment you or place implants just because you want them. We’re doing it because this is a legitimate cancer diagnosis and so you should be able to undergo treatment and surgery and come out on the other side feeling good.

Host: What is the oncoplastic surgery recovery like compared to say if they hadn’t had a reconstruction?

Dr. Wehner: So oncoplastic surgery in a partial mastectomy is the same recovery time as a regular partial mastectomy. There's not really any difference. Now if we do oncoplasty in a setting of a reduction surgery, meaning a patient has really, really large breast and they’re heavy and they cause strap indentations on their surgery or they cause them back pain and we chose to reduce the size of their breast all while removing the cancer, that recovery is a little bit different because it’s a more extensive surgery. But even those patients go home the exact same day.

Host: Why is MedStar Washington Hospital Center the best place to seek oncoplastic surgery?

Dr. Wehner: Each and every breast cancer patient that is treated at MedSTar Washington Hospital Center will have oncoplasty employed in their surgery. And whether that’s done by the main surgeon, which I do most oncoplasty myself, or whether that’s done with the aid of a plastic surgery, which is done by my partner here always employs the help of a plastic surgeon. Every patient still will have oncoplasty and still will have the opportunity to have some of these types of procedures brought into their regular partial mastectomy procedure. Historically anybody who underwent a partial mastectomy came out looking essentially like a shark bit off part of their breast. I mean, part of their breast was removed, the skin was closed and that was just it. So, a lot of patients who were treated many years ago have a lot of indentation, a lot of asymmetry and they don’t feel good about it. They really don’t want anybody to see. Whereas now, there’s plenty of patients who come and again are just like oh right, I don’t remember where that scar is.

Host: Is there anything that can be done for those women now that had surgeries maybe ten, fifteen years ago when techniques weren’t so good?

Dr. Wehner: So, there is some plastic surgery options. Some involve reconstruction. Some involve something that’s called fat grafting which is done by our plastic surgeons where they can actually suck fat from one part of the body and inject it within the breast to fill in some of that area. So, there’s options, but it really just depends on what surgery they had, what treatments they had and kind of what they look like now.

Host: Thanks for joining us Dr. Wehner.

Dr. Wehner: Absolutely.

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Breast cancer is one of the most daunting diseases in women’s health, as it affects about one in eight U.S. women at some point during their lives. Dr. Ami Chitalia discusses four lifestyle changes women can make to reduce their risk of developing breast cancer.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. Ami A. Chitalia, a breast medical oncologist at MedStar Washington Hospital Center. Welcome, Dr. Chitalia.

Dr. Ami A. Chitalia: Thank you for having me.

Host: Today we’re discussing general best practices to reduce breast cancer risk. While breast cancer can have a genetic component, there are things that women can do to prevent the disease altogether or improve the chances that, if breast cancer develops, it’ll be detected at an earlier, more treatable stage. Dr. Chitalia, is there a number one thing women can do to reduce their risk for developing breast cancer?

Dr. Chitalia: Well, I think there are a few things that women can do to decrease their risk of breast cancer. There are lifestyle modifications, such as having a healthy diet, exercising and maintaining a normal weight. Also, limiting alcohol intake has been shown to decrease risk of breast cancers. And, of course, screening mammograms will not reduce a woman’s risk of developing a breast cancer, but they may help to find a cancer at an earlier stage, where treatment may be easier to go through. And when there’s a better chance of curing the cancer.

Host: So many cancers have been linked to healthy eating, exercise and weight management. How do these factors affect a woman’s breast cancer risk?

Dr. Chitalia: Yes, these have certainly all been linked to breast cancer risk. I counsel my patients with breast cancer on maintaining a healthy and balanced diet. So, this includes a focus on whole grains, fruits, vegetables and lean meats. However, all foods are okay in moderation. So far there’s no clear link between breast cancer and red meat intake or sugar intake. In terms of exercise, I recommend 30 minutes, at least, of any exercise that will make you sweat or breath faster, so aerobic exercise, 4 to 5 times per week. By maintaining a healthy diet and exercising, a woman can maintain a healthy weight, and this has certainly been shown to decrease their risk of breast cancer.

Host: How are unhealthy habits, such as tobacco use and alcohol consumption, associated with an increased risk of breast cancer?

Dr. Chitalia: So, tobacco use is an interesting question. There has been a study that shows an increased risk of breast cancer with smoking, but in premenopausal women only - so, in younger women. Other studies have not shown this to be true. So, we don’t really have a clear answer for how tobacco use is linked to breast cancer but, either way, tobacco use clearly does increase risk of many other cancers and diseases and can certainly impact healing after breast surgery. Excess alcohol intake - which, for women, is more than four drinks per week - has been associated with an increased risk of certain types of breast cancer as well.

Host: What should women, who are at increased risk because of family history or genetics, do differently to reduce their risk of breast cancer?

Dr. Chitalia: So, women with a family history of breast cancer should seek guidance from their primary care physician on when to begin screening mammograms, as depending on their family history, or the genetics, screening may be recommended at an earlier age than an average woman. Women who carry a genetic mutation with an increased risk of breast cancer should be under the care, ideally, of a breast surgeon or medical oncologist to determine the best screening strategy for them, as well as for monitoring. In addition, these women should be counselled on the risks and benefits of risk-reducing surgeries, such as mastectomies or oophorectomies.

Host: Should all women perform breast self-exams?

Dr. Chitalia: Although self-breast exams have not been shown to have a clear benefit in finding a breast cancer earlier, I think it is important that women maintain a breast awareness so that they’re aware of any changes to their breasts, either in feeling or in appearance.

Host: If women chose to do self-exams, how often should they do them?

Dr. Chitalia: If women chose to perform self-breast exams, I think a monthly basis is a good idea. Typically, at the time when their breasts are the least tender is also a good idea, and when there are less changes such as from a menstrual cycle, if that’s applicable to a woman.

Host: Do you have any stories you could share about patients who successfully found a lump on their own and came in?

Dr. Chitalia: Sure. So, we do have a number of women that come in, usually at first to their primary care doctor or their OB-GYN, saying that they felt a lump. And this, you know, was either while they were showering or while they were performing their monthly self-breast exam. Typically, then, their doctor has referred them to a diagnostic mammogram, an ultrasound, and skipped the screening mammogram in order to expedite their work up. And then they usually get referred to one of us in the practice. So, that has definitely happened a number of times.

Host: If a woman finds a lump, why is MedStar Washington Hospital Center the best place to seek breast care?

Dr. Chitalia: So, I think, for a number of reasons, MedStar Washington Hospital Center is the best place for women to seek breast cancer screening. We offer state-of-the-art equipment and imaging techniques, including MRI-guided biopsies, which are sometimes needed and are only offered at selected imaging centers. In addition, we offer comprehensive care so that in case something is found, such as a breast cancer, we have a large multidisciplinary team, including nurse navigators, radiologists, surgeons, radiation doctors and medical oncologists who focus on breast cancers, such as myself. We also have dedicated breast radiologists who have expertise in reading breast imaging, such as mammograms and ultrasounds. And, above all, I think our nurses, technicians, and staff are kind and caring and really aim to make sure that a patient’s experience is as smooth and comfortable as possible.

Host: Thanks for joining us today, Dr. Chitalia.

Dr. Chitalia: Sure! Thanks again for having me.

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Human papillomavirus (HPV) is the most common sexually transmitted infection in the U.S., and this virus is behind a surge in head and neck cancers among young people. Dr. Matthew Pierce discusses who is at risk, warning signs and how we treat these cancers.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thank you for joining us today. We’re talking with Dr. Matthew Pierce, an otolaryngologist and head and neck surgeon at MedStar Washington Hospital Center. Welcome, Dr. Pierce.

Dr. Pierce: Thank you. Thanks for having me.

Host: The human papillomavirus, or HPV, is one of the most common sexually transmitted infections. In most people, the virus courses through the body and leaves without causing any health problems, though HPV is known to cause cervical cancer in women. However, men and women in their 30s and 40s are developing head and neck cancers at an alarming rate as a result of HPV infection. In the U.S., HPV is thought to cause 70% of cancers in the oropharynx, which is the back of the throat, the base of the tongue, and the tonsils. Dr. Pierce, why is this virus that was once associated solely with cervical cancer now so strongly associated with head and neck cancer?

Dr. Pierce: We don’t really know the answer to that at this point. Uh, it’s only recently, and I say recently in the past 20-25 years, been associated with cancers of the oropharynx, or the back of the throat. These cancers may have always been associated with HPV, and we’re just now realizing it and newly diagnosing these types of cancers. The majority of people have been exposed to HPV at some point in their life. And the vast majority, 90% of the people, clear this without any effects whatsoever. There’s a small population that, for whatever reason, harbors the HPV virus, either in their tonsils, cervix or elsewhere. And there are over 100 types of HPV, but there’s only a very small few percentage of those different strains that actually cause or are related to cancer. And that small percentage, and even smaller percentage who are infected with what we call those high-risk types of HPV, actually develop cancer. And again, we don’t really know why some people develop cancer and why some people don’t, but there’s a lot of good research going into that now. But, uh, there are those high-risk type of HPV infections.

Host: Nearly everyone who has had at least one sexual partner has been exposed to HPV. How do you discuss that with patients?

Dr. Pierce: HPV is a sexually transmitted disease. I don’t really have that conversation with them once they’re diagnosed. You know, it’s a big deal being diagnosed with head and neck cancer, and they really want to know kind of what to do about it. And so, I think it’s good to discuss treatment options and where we go from here. With, uh, head and neck cancer, it’s a very morbid type of cancer to get, and it can really affect patients’ appearance as well as their swallowing and speech, and so it really affects a lot of different parts of their day to day lives. Uh, and so, getting the correct diagnosis and getting a good treatment plan is essential. The interesting thing about HPV head and neck cancers is that they actually respond better to treatment and they have a better prognosis than most other cancers of the head and neck. It’s kind of the silver lining of this new...new wave of cancers.

Host: Why do HPV-related head and neck cancers respond a little bit better to treatment than other head and neck cancers?

Dr. Pierce: Uh, we actually don’t know why these patients respond better to treatment as of yet. There’s a lot of studies going into that, and there’s actually a lot of studies that are looking at what we call a de-escalation or actually trying to reduce the amount of treatment that we actually have to give these patients while maintaining the same results and the same outcomes.

Host: So, on the one hand you have a cancer that’s quote/unquote “relatively easy to treat”, but it can also can be quite destructive. Can you talk about the effects or the symptoms of HPV-related head and neck cancer?

Dr. Pierce: So, HPV head and neck-related cancer is--I wouldn’t say it’s necessarily easy to treat but I would say that it responds better to treatment. Whether that is radiation or chemotherapy, or even surgery, these patients tend to do better after treatment, and they have a better prognosis. Cancers of the head and neck can very frequently affect the patient’s swallowing function and speech, as well as the outward appearance, and so, depending on what type of treatment and where the cancer is located. You can have some scarring from... if the patient has surgery or radiation. Uh, the side effects of treatment can often cause issues with swallowing, or speech, or other aspects of day to day life. I think with head and neck cancer, the best outcomes are when we catch these cancers early on. And the reason that they are very morbid is because of one, their aggressiveness, and two, because of the location. And, you know, anytime you have a tumor that requires treatment in the mouth, in the neck or the throat, it can affect multiple organ systems, including swallowing, speech, uh, and as you can imagine, appearance as well. And so, it is something that we recommend, if you are suspicious, just come in and be seen, and see a specialist if you’re concerned about anything in the head and neck area.

Host: What symptoms might a person experience if they have head and neck cancer that might cause them to go see their doctor?

Dr. Pierce: The symptoms can…can be very subtle, but it’s very important that patients go, if they have any concern at all, to go and see a specialist and get checked out. And some of the major symptoms that most people present with are a mass in the neck or a lesion in the oral cavity that does not heal or an ulcer that persists and doesn’t go away. Other more subtle symptoms can be difficulty swallowing or pain with swallowing. It can be changes in your voice, hoarseness, ear pain, or coughing up blood or blood from the nose. Usually if a symptom lasts for more than 2 or 3 weeks, and it’s not getting better, it’s good to go see a specialist and…and get it checked out.

Host: Do you recommend that any of your young adult patients receive the HPV vaccine, or is that reserved for younger folks?

Dr. Pierce: Absolutely. I think that the HPV vaccine is very important for young teenagers, and the current recommendation is for, uh, children who are 11 to 12 years old, both male and female, to get the HPV vaccine. Children as young as 9 years old, as well as adults up to the age of 26 for women and…and 21 for men, uh, are currently recommended to get the HPV vaccine. Currently, there’s no recommendation above that age, uh, and the reason for that is the majority of people have already been exposed to HPV at that time, and so it’s not gonna have any benefit to the patient once they’ve already been exposed, but for younger patients, it is something that is invaluable. And even though we don’t know the benefit at this time, we do know that it can prevent from an infection, and the prediction is that it will decrease the amount of cancers that we see in the future.

Host: Because HPV is so common, is there anything aside from the vaccine that parents can teach kids to do, or that young adults can do, to reduce their risk?

Dr. Pierce: The only sure way to completely avoid any risk is for complete abstinence, which is not a realistic expectation. Even for people who are in a monogamous relationship still have the risk of being exposed, um, either from their partner’s past partners or even from open-mouth kissing can even potentially spread HPV. And so, there is currently no recommendation specifically for reducing the risk of HPV transmission, uh, other than the standard safe sexual practices that are already recommended for decreasing the chance of STD transmission. The interesting thing about HPV-related cancers are that they typically involve a younger and healthier population. We typically see these in males more than females, about 3 to 1, and there’s usually males in their 50s to 60s, whereas tobacco-related cancers of the head and neck usually present about 10 to 15 years after that, so that is one of the differences that we have seen in the epidemiology of head and neck cancers and HPV cancers is they’re typically in a younger, uh, population.

Host: Could you talk about your team approach to head and neck cancer care at MedStar Washington Hospital Center?

Dr. Pierce: Absolutely. So here at MedStar Washington Hospital Center we have a multidisciplinary approach to cancer care, including HPV-related cancers. We talk about and present all of our new patients as well as our follow-up patients in a team approach, discussing with multiple ENT and head and neck cancer surgeons as well as chemotherapy doctors and radiation doctors. And we approach every patient in this multidisciplinary style of cancer care, uh, which has been shown and proven to be the best form of developing plans for cancer patients. We have a state of the art approach, both surgically and using other modes of treatment for head and neck cancer patients.

Host: Typically, are you having to do surgery on all of these patients, or is it rare that you’d have to do surgery?

Dr. Pierce: These patients respond well to all types of treatment. And depending on each individual patient, if it’s an early stage and a small cancer, these patients can undergo surgery. And one of the benefits that we have here at Washington Hospital Center is we offer a minimally invasive type of surgery to resect these cancers. And that’s in the form of either robotic surgery or transoral laser surgery. And these surgeries offer a minimally invasive way to cure and treat these patients. Fortunately, not everybody needs to have surgery and a lot of these patients respond very well to chemotherapy and radiation. And this… it’s usually, a discussion that has to be made with the patient as well as the tumor board.

Host: Thanks for joining us today.

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Typical symptoms of the flu, which affects up to 20 percent of Americans annually, can take a toll on one’s health in their own right. However, there’s an even more serious concern to consider. Dr. Allen J. Taylor explains how the flu can increase heart attack risk.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. Allen J. Taylor, Chair of Cardiology at MedStar Heart & Vascular Institute. Welcome, Dr. Taylor.

Dr. Allen J. Taylor: Thank you.

Host: Today we’re discussing how the flu can affect a person’s risk of heart issues, particularly heart attack. It’s widely known that the flu can be dangerous, and it kills thousands of otherwise healthy people each year in the U.S. Increasing the concern, a 2018 study published in the British Medical Journal suggests that a patient’s risk of heart attack might be six times higher within the first week of a lab-confirmed diagnosis of influenza. Dr. Taylor, is this another scary media story or is the flu a real concern for patients when it comes to heart attack risk?

Dr. Taylor: This really is not a scary media story. This is the impact of the flu on health in total. People think the flu is a self-limited illness. They’ll feel bad for a few days. And while that’s true, each year the flu causes over 130,000 hospitalizations; 62,000 deaths. And those deaths include deaths from heart attacks - six times more likely after the flu. It’s a real issue.

Host: How can the flu, which many people consider a sinus or respiratory illness, affect heart attack risk?

Dr. Taylor: Yeah, it might seem hard to connect. But, in fact, the flu triggers a host of inflammatory reactions that activate problems throughout the body and activate chronic conditions and inflammation is an important part of heart risk. And, we believe that that’s the mechanism, that through the inflammation triggered by the flu, heart attack risk is six time higher in the week after the flu.

Host: Why is the flu such a concern when vaccinations are available for infants through seniors?

Dr. Taylor: Right. The CDC recommends that all healthy adults receive the flu shot. And the problem we’re having is that folks aren’t getting vaccinated. Fewer than half of individuals get vaccinated, for a variety of reasons and concerns and it’s unfortunately too little. And so, many of those adults that are not getting vaccinated, in fact, are subjecting themselves to the risk of not just the flu but of many conditions, including heart attack. My recommendations at this point would be to first, get a flu shot and have your family members and other loved ones get flu shots. Even if you think you’re healthy, the flu is a risk for you. If you have a chronic condition, even high blood pressure, you particularly need to get a flu shot. And they’re simply easy to get. Every drug store now provides flu shots and they’re inexpensive and typically covered by insurance companies. So, DO vaccinate yourself. And then, stay as healthy as you can. And if you are unlucky enough to contract the flu, look for these other symptoms, and if you experience them, get prompt medical attention.

Host: So, when we think of the flu as a risk, we tend to think of older adults. Could you discuss why this population’s also at increased risk for heart attack?

Dr. Taylor: Well, problems from the flu can affect any otherwise healthy person. There is a group that’s at increased risk and that’s a middle-aged and older group of individuals who have at least one chronic health condition, which could include simply high blood pressure. So, there’s many middle-aged and older adults with chronic health conditions and they’re the ones at most increased risk. So, with the low rates of vaccination and this heightened risk, we really need to do a better job of getting the word out of “get vaccinated, protect yourself and protect others by protecting yourself.” This idea of more immunizations reducing the transmission of flu during flu season is an important one. By your getting a flu shot, you could help somebody else.

Host: Aside from older adults, are other patient populations at increased risk for heart attack after catching the flu?

Dr. Taylor: The increased risk of heart attack seems to affect all people, so it’s not just older individuals but it’s the older individuals with chronic health conditions that are at the greatest risk. But, again, the CDC recommends that ALL adults receive the flu shot.

Host: When an individual has the flu, what sort of symptoms might they watch out for if their heart is becoming damaged?

Dr. Taylor: We commonly think of things like joint aches and muscle aches and fevers and respiratory symptoms. But if you have the flu and you’re experiencing chest discomforts or unusual breathing problems is when I would become particularly concerned. The flu can increase risk for pneumonia, can inflame the lungs, and then, chest pains, either from inflammation around the heart or heart attack. Any worsening symptoms or new symptoms, besides what you’d otherwise expect from the flu, that you’d experience, I’d seek prompt attention for.

Host: Is this a year-around concern or is it just during flu season?

Dr. Taylor: That’s an interesting question. Obviously, there’s flu season, and the flu season for us runs from the fall into the late spring. We do see individuals, though, that travel to other parts of the world and, realizing there’s a South American group, we’ve seen patients that have gone to vacation in the summer, say in the Bahamas, and folks that winter in the Southern Hemisphere will also go to those locations, and bring the flu with them. So, we’ve, in fact, had several recent cases of people contracting the flu and serious problems from it in the summer.

Host: What can patients do, aside from getting the flu vaccine, to reduce the risk?

Dr. Taylor: Well, the first thing is, in the flu season, being very attentive to things like hand washing. And if they’re around sick contacts, to make sure that they’re being particularly attentive. Folks with the flu should be careful about transmission—you know, the way they sneeze, touching objects, also washing their hands. And then, staying as healthy as possible. The more vulnerable populations are folks that are stressed, fatigued, chronic illnesses. So, as always, proper diet, proper rest, good exercise. It could be all part of a healthy lifestyle that could protect one from problems from the flu. But, that said, vaccination is the most important thing. And, right now, we’re simply not vaccinating enough of Americans.

Host: Why is MedStar Heart and Vascular Institute the best place for people who want to reduce their risk of heart-related issues because of the flu?

Dr. Taylor: The heart consequences of the flu can be many, not just heart attack. We see cases of serious heart inflammation, for example, that can be very life threatening. And, we’ve successfully cared for those patients - identifying the flu, treating it, and supporting them through the illness. Properly supported patients usually do well, but prompt identification, aggressive treatment, is essential. So, we really serve as a regional resource for this and patients in our entire region, if they become very, very sick from the flu, we take excellent care of them. We’ve really had some great patient outcomes - folks that, for instance, travelled into the Bahamas and got sick, or in the flu season, and really have been fortunate that they’ve been able to survive.

Host: Could you share a treatment success story from your practice?

Dr. Taylor: I can think of several, but one that was particularly dramatic, was a perfectly healthy middle-aged woman who had gone out of the area to vacation. It was flu season and came back and started feeling poorly and started experiencing chest pains. And, what she had was serious inflammation of the heart muscle and a rapidly failing heart muscle. And in the course of just 12 hours, basically her heart could no longer support her body. So, she actually went on to artificial circulation, outside of her body, for a period of days while her heart recovered. Eventually that was removed and she’s back to full-functioning. And, we had literally hours to act, to identify the problem and to put her on artificial circulation. But today she’s alive and well and really is a great success story.

Host: Thanks for joining us today, Dr. Taylor.

Dr. Taylor: Thank you very much.

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Lymphedema can cause painful, uncomfortable arm swelling for people who have been treated for breast cancer. Dr. David Song discusses how we can reduce or eliminate these symptoms with advanced surgery.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. In today’s episode, we talk to Dr. David Song, Regional Chief for MedStar Plastic Surgery and a nationally recognized specialist in treating people who have lymphedema. Lymphedema is a condition in which fluid accumulates in the body causing pain and swelling in the areas where the fluid builds up. About 20 percent of patients diagnosed with breast cancer will develop lymphedema. Compression garments, physical therapy and massage techniques used to be the only treatment options for lymphedema symptoms. Now we can treat the root cause with surgery, and Dr. Song is one of the only doctors in Washington D.C. and the east coast who offers these advanced surgeries.

Host: Thanks for joining us.

Dr. David Song: Thanks for having me.

Host: So today we’re talking about lymphedema surgery. Lymphedema surgery is actually fairly new.

Dr. Song: That’s right.

Host: And what does that mean—fairly new?

Dr. Song: So probably within the last decade it’s become more of an explosive sub-arena of plastic surgery and microsurgery, where we’re able to see long term results now—five, ten year results and the impact that we’re having on patients with lymphedema can be very profound in a positive way, and it can really change their lives around. So, it’s something that’s very exciting. I’ve been doing it for several years now.

Host: And how many hospitals in the D.C. area perform this?

Dr. Song: So, as of now, my understanding is I’m the only one in the greater D.C. area that does this. There’s not many people that do this in the country, so it’s a new field, it’s in its infancy and there’s just not a lot of people that do this.

Host: And who are some of the patients that do get lymphedema surgery?

Dr. Song: So primarily they’re patients after breast cancer surgery. So, a mastectomy, radiation or lumpectomy with lymph node biopsy and radiation—those are the patients that can develop lymphedema. Approximately 20 percent of all patients with breast cancer that get mastectomy and radiation and lymph node biopsies can develop lymphedema, so it’s a disease that’s not uncommon and it can be rather debilitating. It can limit one’s function, motion, quality of life. So, if you think about, you know, the tens of thousands of women that get breast cancer a year, that get mastectomy and radiation, and 20 percent of those every year can develop lymphedema, you’re talking about, again, tens of thousands of women that are walking around with lymphedema.

Host: How do you help patients understand if the surgery is a good option for them?

Dr. Song: Yeah, so surgery, a surgery, one of these options is good for virtually everybody. Uh, so it’s a matter of consultation, it’s a matter of having frank discussions about what patients are willing to undergo, optimizing their nutritional status, their body weight status prior to surgery, stopping smoking—all the things that can help our success rate. So, it’s a lengthy discussion with a patient, and so that’s the way to find the best individualized treatment plan for each and every patient that we see.

Host: So what types of lymphedema surgery do you offer and how do they work?

Dr. Song: So, the whole gamut, starting from lymphovenous bypasses, which are actually rerouting the lymphatic channels to the veins in the extremities. And that requires a technique called super-microsurgery. These vessels are beyond paper-thin and they’re, on average, less than .8 millimeters in diameter, down to as small as .3 millimeters in diameter. So, the suture that we use is exceptionally small and thin. It’s a specialty ordered suture. So, rerouting the lymphatics into the veins helps to drain the entire arm and it bypasses the blocked pathways that patients with lymphedema have. So that’s one. The other option is to transplant lymph nodes from an area in the body that there’s a redundancy of lymph nodes, like your back or the inguinal region where you pick the right lymph nodes, sparing the important ones—and there’s a technique to do that—then transplant them into the arm or leg that’s affected by lymphedema. That acts as a natural pump. So, combining those two techniques, lymph node transplantation with lymphaticovenous or lymphovenous bypass, seems to be the preferred method of choice with the longest outcomes of success. There are other aspects of lymphedema surgery that we can go into, as well. For those that are severely affected - years and decades they get more like an elephantiasis-type of outcome, where the skin is thickened and changed. Those patients are more amenable to what’s called the Charles’ Procedure - it’s an old procedure where we’re actually removing all the subcutaneous tissue, the fat around the affected leg or arm and then regrafting it with skin grafts. It’s a pretty radical procedure, but that’s really reserved for the very advanced patient with lymphedema.

Host: And how long will it take to actually see results?

Dr. Song: So, we can see results right away because of the scar release that we get. And the lymphaticovenous bypass works right away. But, the lymph node transplantation, it takes a while for the lymph nodes to grow and to start pumping again, and so that sometimes takes upwards of six to nine months to see some results from a lymph node transplantation. But you can see immediate results from the lymphaticovenous bypass and liposuction and the methods can be tailored to each and every patient.

Host: And recovery time is how long?

Dr. Song: Typically, for a lymphaticovenous bypass, it’s sometimes an outpatient procedure. When you add a lymph node transplantation, we usually like to keep patients for 2 days, sometimes 3, depending on their pain level. So, it’s a one to two-day, possibly three-day admission, and the recovery time back to work is, you know, maybe a week or so thereafter. So, it’s a very short period of recovery.

Host: And, once they leave, they have to wear a compression garment?

Dr. Song: That’s right. So, this is not a panacea for all lymphedema. It is an adjunct. Occasionally we get complete resolution, but most of our patients see improvement, sometimes dramatic, but they still have to keep up with their lymphedema therapy, their manual lymphatic drainage and their sleeves, especially when they fly.

Host: What else can we share about it? Is there anything else we didn’t discuss already that people should be aware of?

Dr. Song: I just think the answer for patients with lymphedema, that’s present now, is something that I hope everyone at least hears about and knows that there’s an option for them. You know, ten years ago this was rather new—it was a concept—and I’m hoping that with efforts like this to get the word out with patient advocacy efforts, insurance companies will start to recognize this as something that’s proven and that’s, not, no longer experimental, because it clearly isn’t.

Host: Well, thank you so much for joining us.

Dr. Song: Absolutely. Thank you for having me.

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DCIS is sometimes called “stage zero breast cancer.” It’s contained to the milk ducts, and the primary concern is whether it comes back after treatment. Dr. Patricia Wehner discusses how we diagnose and treat this disease.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. Patricia Wehner, a breast surgeon with fellowship training in surgical oncology for the MedStar Regional Breast Health Program. Today we’re discussing ductal carcinoma in situ, or DCIS, breast cancer. Welcome, Dr. Wehner.

Dr. Patricia Wehner: Thank you!

Host: What is ductal carcinoma in situ, or DCIS, breast cancer?

Dr. Wehner: So, ductal carcinoma in situ, which is referred to DCIS for short, is a stage 0 type of non-invasive breast cancer. And what that means is DCIS really is a type of breast cancer that’s confined to just the milk ducts of the breast. So, if you think of the composition of a breast, a breast is composed of multiple milk carrying pipes or tubes of the breast that come through the breast and join up at the nipple. DCIS is a cancer that’s contained just within those milk ducts.

Host: Is DCIS life-threatening, if it doesn’t spread?

Dr. Wehner: So, ductal carcinoma in situ, or DCIS, in and of itself is a non-invasive cancer. And that’s why we call it a Stage 0 cancer. Stage 0, again, meaning just confined to the milk ducts of the breast. If treated, then DCIS is not necessarily life-threatening. The concern for DCIS is in the recurrent form of DCIS, meaning after it’s treated, will it come back? And the concern there is if it comes back, will it come back as an invasive cancer? The difference is invasive cancers have the potential to spread. So, they have the potential to go to other places of the body and that could be anywhere – the lungs, the liver, the brain. DCIS, in and of itself, does not have that ability but when it morphs into an invasive cancer, that’s when it has the ability to spread to these other locations.

Host: How is DCIS detected if it’s just in the milk ducts?

Dr. Wehner: DCIS is generally just detected with screening mammography. So, within the United States, there’s about 55 million annual screening mammograms that are performed on a yearly basis. And, of those mammograms, about 1 in 1300 will show ductal carcinoma in situ. For the majority of patients, when we look at a screening mammogram, what we’re looking for is are there any new lumps or what we consider to be nodules or asymmetries that have shown up on mammograms. Or, are there new areas of calcium or calcifications that have showed up on mammograms. DCIS, in the majority of times, shows up as new calcium or calcifications. So, essentially, when we look at a mammogram, there are new little white dots that show up on the mammogram. White dots on a mammogram don’t necessarily equate to a cancer and that’s why, when we see them, we kind of ask a couple questions. And that is, “Are they new? Are they increasing in size or number? Are they fine and tiny or are they big and chunky?” If they’re big and chunky, then generally we don’t have to worry about them. But if they’re small and fine and kind of clustered or grouped together, that’s when we get concerned and will recommend to have a minimally invasive needle biopsy done to determine - is this DCIS or is this something that maybe we don’t need to worry about and it’s just representative of normal changes that we can see on the breast? Whenever we recommend a core needle biopsy, what is involved is coming into an imaging center. We take pictures, with the help of a mammogram machine. And then we place some local or some numbing medicine within the breast. Then a small needle’s placed within the breast, around the area where the calcium or calcifications is located, and a little bit of tissue is removed. That tissue is then looked at by the pathologist, under the microscope, and that’s what can give us our diagnosis of cancer or not cancer. So, going back to the number of annual screenings, about 1 in 1300 patients that get screened with a mammogram throughout the year will actually end up positive for DCIS. So, there’s about 51,000 new diagnosis of DCIS, or stage 0 breast cancer, each year.

Host: Do all women with DCIS require treatment, if they’re at average risk?

Dr. Wehner: So, when DCIS is found, so when you have a new diagnosis of ductal carcinoma in situ, the standard recommendation does require or recommend to have a multidisciplinary approach to the treatment of this. This may include surgery, it may include radiation therapy, and it may include a pill that’s considered essentially an anti-hormone pill, or an endocrine therapy. Chemotherapy is not something that we will ever use for ductal carcinoma in situ. And chemotherapy is what everybody thinks of when they think of cancer treatment, because chemotherapy is the stuff that can make you feel kind of sick and make your hair fall out, make you kind of sick to your stomach. We don’t use that for DCIS. Standard, if it’s small – so the area of calcifications or the area of known cancer is small - then we can generally remove it by doing something that’s called a partial mastectomy. Now, a partial mastectomy – there’s a lot of terms that mean the same thing, and so you may hear it called as a lumpectomy or as removal of just the cancer or as breast conservation therapy. All of those terms mean the exact same thing. And, that just means the goal is to remove where the cancer cells are living and to get a little bit of healthy, non-cancerous tissue around them. Whenever we remove just part of the breast and we leave the rest of the breast behind, then generally we do recommend radiation therapy to be followed. Radiation generally doesn’t start ‘til a month or so after the completion of surgery and after healing, and then that can be anywhere from 3 weeks to 6 weeks, on a daily basis. That’s not standard for each and every patient but that’s the general guideline we use. Now currently, we do have a clinical trial that has just opened that’s actually looking at observation alone for certain ductal carcinoma in situs, rather than moving forward with surgery. And that particular trial is called the COMET trial. And so, for certain patients that have fairly favorable DCIS, and favorable just refers to various things that we see under the microscope, for some of those patients now rather than moving to a surgery first, those patients can be observed with mammograms every 6 months. And, as long as nothing is changing on the imaging, then we can continue to observe them.

Host: Why is radiation therapy preferred over chemotherapy for DCIS?

Dr. Wehner: So, radiation therapy and chemotherapy treat cancer in very different ways. When we talk about cancer treatments, we talk about treatments that are local/regional treatments or we talk about treatments that are systemic treatments. And what that means is certain treatments are given just to the breast and the surrounding breast tissue and other treatments are given to the entire body. The point of both of those treatments is the same, which means the point of both of those treatments is to treat the breast cancer. They just go about it in a different way. So, for stage 0 ductal carcinoma in situ, to give a systemic treatment or a whole-body treatment through chemotherapy we know doesn’t work. It doesn’t affect the recurrence of this stage 0 cancer and it doesn’t affect the overall lifetime survival of this type of breast cancer. That’s not true for other invasive cancers, but for DCIS, chemotherapy just has no real added benefit, which is why we don’t use it. Radiation therapy, however, is a treatment that’s directed just to the breast and the surrounding breast tissue. And the point of radiation is to reduce the risk of recurrence. So, what we want to do is reduce the risk of DCIS coming back because we know when it comes back, about half of the time it comes back as that invasive form. And, it’s the invasive form that we worry about the most because that’s the form that can spread to other parts of the body.

Host: There’ve been discussions for several years about the over or under treatment of DCIS. What is your opinion about whether it should be treated and how do you help women make that choice?

Dr. Wehner: So, breast cancer is no longer a ‘one size fits all’ approach. So, historically, when we treated breast cancer, way back when, we used to treat it with a modified radical mastectomy. So, everybody lost their breast, most patients got chemotherapy, and most patients got radiation therapy, regardless of the type of breast cancer they had. In today’s era, we are much more specific about the types of treatments that we recommend and that’s because it’s not a ‘one size fits all’ criteria any longer. DCIS, we know, is a non-invasive type of breast cancer that has a chance of turning into an invasive type of breast cancer. And so, historically, we have always treated DCIS with at least a minimum of surgery. Current trials do show us that treating it with surgery and then adding radiation will decrease the risk of recurrence but doesn’t necessarily change the overall survival. And so, with that type of data, is where people start to say, ‘well maybe we’re overtreating this.’ So maybe we don’t need radiation therapy. Or maybe we don’t even need surgery. Radiation, for certain patients with DCIS, is no longer a standard recommendation. So, if patients are a little bit older, if patients have a really low-grade type of breast cancer that seems favorable, for those patients we are potentially not recommending radiation therapy. There’s also a new genetic test that has recently come on the market that’s given us sort of a discussion point as to what somebody’s risk of recurrence of the DCIS is. And, that may help us decide adjuvant treatments. But again, this also goes back to the current clinical trial that we have open, which is the COMET trial, and that’s really trying to answer that question of - are there certain patients that we don’t need to treat with radiation and don’t even need to treat with surgery? And are these patients that we choose to just follow with imaging, such as mammography, do they do okay overall? And there’s no real way for us to answer that question without enrolling patients on this trial. And so, we have a lot of high hopes that we can get patients to enroll in this trial and then we can really have a good answer to that question.

Host: Could you tell us a little bit about your patient population – what are the ages of women that you’re seeing with DCIS?

Dr. Wehner: So, women with DCIS can be any age. So, they can be as young as in their 30s and we can see them up to the age of 103, I think is the oldest patient I’ve treated. So, it’s not that it is necessarily an age criterion that we see for patients. We do know that the number one risk factor for developing breast cancer is age. So, the older we get, the more likelihood we have, or we become, to develop a breast cancer. And, there’s nothing you’re going to do about that because nobody can magically become younger. So, we do see it throughout a wide variety of patients.

Host: Have you ever had a patient who was maybe on the fence or had a cancer that you felt needed to be treated and she just wasn’t sure? Could you tell us about that experience with her and how you helped?

Dr. Wehner: So, we have a lot of women who come in that are very anxious about their diagnosis of cancer, and rightfully so. However, what I try to explain to patients is breast cancer is a very different cancer compared to something like a brain cancer or a pancreatic cancer. And that just is because breast cancer is very, very treatable. So, most patients with a DCIS treatment, are alive and well five years, ten years later. And that’s just partially the nature of the disease and partially because our treatment options have gotten so good at treating this, that while nobody wants to say that they have a cancer and they have to undergo therapy for a cancer, it really has become very streamlined and fairly minimal. For most patients that have a lumpectomy or a partial mastectomy - the two mean the same thing - it’s actually an outpatient procedure. It only takes us really about one to two hours in the OR to perform this procedure. For most patients, we don’t even have to put them fully to sleep for this procedure, meaning – we give them anesthesia but not so much anesthesia where we have to put a breathing tube down. And then, patients go home the same day. So, patients really do incredibly well from this sort of surgery and they recover very, very quickly. And so, I find a lot of anxiety and fear of treatment is because they just don’t understand what’s really involved with the treatment of it.

Host: Is there anything that women need to know about selfcare and recovery? What does the recovery look like for DCIS, if you have a procedure?

Dr. Wehner: So, for a partial mastectomy, I send everybody home essentially with just a small band aid that covers the incision and then we send them home in a tight, supportive bra. The key that I tell everybody is they should wear this supportive bra at least for a week after surgery – that includes sleeping in the bra – and that’s just because we do use some deeper sutures within the breast. And so, it’s just more comfortable to provide support to your breasts via this compression bra. And that can be the one we send you home in, that can be one that you have at home – it’s just something that provides compression and support. Patients are allowed to shower the day after surgery. It’s completely fine to get it wet with warm soapy water and then just kind of pat it dry and put your bra back on. There’s not a lot of restrictions. Patients can use their arms. They can brush their hair. They can cook meals. They’re not allowed to drive if they’re taking narcotic pain medicine or if they cannot sit comfortably in a car with the seatbelt on. But, the recovery time actually is pretty minimal. And that’s what most patients end up coming back in to the hospital saying, “You know, I only really needed a pain medicine for maybe one evening and then extra strength Tylenol worked just fine for me.” And patients are pretty surprised at how well they feel afterwards. So, to do a mastectomy is a very different procedure than a partial mastectomy and that’s because a mastectomy, the goal of that is to remove all of the breast tissue, whereas the goal of a partial mastectomy is just to remove part of the breast instead of the entire breast. When we remove an entire breast, then things become a little bit more complicated when we start talking reconstruction, meaning rebuilding another breast. And that can come in the form of an implant-based reconstruction or autologous reconstruction, which really just means we’re taking tissue from someplace else on your body and moving it to where your former breast used to be. Those surgeries are very different and much more complex and much more involved. Those surgeries, some of them, means a hospital stay of four or five days. It really just kind of depends on what type of reconstruction is going on. To do a very simple mastectomy, where the goal is to make it flat and not reconstruct, those patients stay in the hospital one night and go home the next day.

Host: Why is MedStar Washington Hospital Center the best place to seek DCIS expertise?

Dr. Wehner: So, all breast cancer needs to be treated in a very multidisciplinary approach. And, as I alluded a little bit earlier, we have a lot of different treatment options for the way we treat breast cancer. Here, at MedStar Washington Hospital Center, we have a very active and very robust multidisciplinary team. And part of that is because our patient population here just isn’t always the healthiest. And they have a lot of comorbidities and social factors, things that inhibit them from being able to come to the hospital to get treatments. And so, when you come here to have your breast cancer treated, you really come here to have everything treated and everything looked at. When we meet on a weekly basis, which we do as a multidisciplinary team every Wednesday morning, we have about thirty practitioners that come to our meeting. And that includes breast surgeons, breast medical oncologists, breast radiation oncologists, breast imagers, physical therapists, nutritionists, social workers, nurse navigators. We have a lot of just additional people that really take part in your care that you don’t even realize are working behind the scenes. And that really is just to make certain that you, as a person, is taken care of and not just you as a breast cancer patient.

Host: Thanks for joining us today, Dr. Wehner.

Dr. Wehner: Absolutely.

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Every year in the U.S., 20 per 100,000 people experience sudden hearing loss, a medical emergency commonly caused by upper respiratory tract infection. Dr. Selena Briggs discusses how early, specialized treatment can help restore hearing.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today, we’re talking to Dr. Selena Briggs, a neurotologist skull base surgeon within the Department of Otolaryngology at MedStar Washington Hospital Center. Welcome Dr. Briggs.

Dr. Selena Briggs: Thank you, thanks for having me.

Host: Tell us a little about yourself, why did you go into medicine, and how did you come to practice at MedStar Washington Hospital Center?

Dr. Briggs: I’ve had an interest in going into medicine, I think, from my youth. It actually stemmed from my pediatrician, Dr. Frank Newburger who practiced here in Silver Spring, and he was a great mentor, and a great pediatrician and that spurred my interest, and then later I developed an interest in music and dance, I was a ballerina, and I loved ballet. And while I was younger, there was a miss America who was deaf and a ballerina, and that sparked my interest in understanding more about deaf culture and hearing loss. So, throughout my career it’s just kind of moved in that direction of hearing health and this direction.

Host: Today we’re talking about upper respiratory infections that can lead to hearing loss. Dr. Briggs, how can an upper respiratory infection cause hearing loss?

Dr. Briggs: That is an excellent question. Most people are unaware of the association between upper respiratory tract infections and hearing loss. It’s not uncommon for an individual to wake up in the morning after experiencing an upper respiratory tract infection and state that they can’t hear out of one ear. They’ll commonly call their primary care provider and try to get an appointment to be seen, and nothing gets seen on examination. That is the main concern. That is of pinnacle concern, in fact. Those individuals may be suffering from something called sudden idiopathic sensorineural hearing loss or simply sudden hearing loss. That’s most commonly associated with upper respiratory tract infections or the common cold.

Host: So, I know when I have colds or even allergy problems and anything really affecting my sinuses I get that kind of clogged feeling in your ear—what are some symptoms patients tell you about when they get this hearing loss going on?

Dr. Briggs: The clogged sensation in the ear and the sudden sensory no hearing loss actually are two separate entities. Both cause hearing loss and both have similar symptoms of presentation, but the source of it is very different and the treatment for it is very different as well. So, when you have an ear infection or even pressure in your ear from a sinus infection, that’s usually caused by something called your Eustachian tube. I don’t know if you’ve ever been on a plane and your ears popped and you feel that sensation? It’s your Eustachian tube opening and closing that allows you to equalize your pressure while you’re on a plane. But when you have a sinus infection, oftentimes that Eustachian tube becomes plugged, and doesn’t open and close normally. That causes pressure, muffled sensation, and sometimes can even cause fluid to develop in your ear. That typically is a short-lived, self-limited process. The sudden sensorineural hearing loss or sudden hearing loss is a completely different process, where it doesn’t cause a pressure problem, but it actually causes injury to your nerve. It may cause permanent damage to your ear. It’s not something that you should take lightly. It can be a long term even permanent issue for individuals. So, if one wakes up with sudden hearing loss, from the sudden sensorineural hearing loss, the nerve type of damage, about one out of three people it will resolve on its own, one out of three people it’ll improve but not go back to its normal, and one out of three people it won’t change at all. There are interventions that we can do to make your likelihood of returning back to normal greater, but the key thing is that you have to get in and be seen within three days to three weeks. Outside of that window, the likelihood of it becoming permanent loss is significantly greater.

Host: How many people experience this?

Dr. Briggs: So, on an annual basis, so every year within the United States, it’s speculated that approximately five to twenty out of 100,000 individuals experience sudden sensorineural hearing loss.

Host: So, since this is suspected to be caused by viral problems or a virus, what can the doctor do either that primary care doctor, and then at what point do you need to be transitioned over to a specialist?

Dr. Briggs: The key thing first is being evaluated by your primary care provider or even urgent care and having an ear examination. Making sure your ear drum looks normal, there’s not wax that’s occluding or plugging up the ear canal, and make sure there’s not fluid behind the ear drum, as we talked about before associated with allergies or sinus problems. It sounds strange, but a normal ear exam is an emergency. So, if you have a normal ear exam, and hearing loss, you need to be seen and have a hearing test right away

Host: What about those individuals who do put it off? Is it damaged to the point where they can never get that back then if they wait too long?

Dr. Briggs: There is a time window, and there is a time urgency. A few days, ot so much out of the window of treatment. Typically, we state 21 days is when medical therapy is most effective, and those therapies tend to be steroids either taken orally or via an injection through the eardrum into the middle ear space.

Host: Once the patient has had this hearing test, how quickly do they receive that treatment, and how long does that treatment take?

Dr. Briggs: So once an individual has a hearing test that documents sudden sensorineural hearing loss, they should be seen by an otolaryngologist or a neurotologist within 24-48 hours. The treatment is started rather urgently, because it gives them the best opportunity for the best outcome. So the treatment, depending on the patient’s associated comorbidities such as diabetes or hypertension, may include oral steroids vs injection steroids in the middle ear space vs a combination of the two, and that’s started immediately. There are other therapies that are recommended within the literature or can be used, such as hyperbaric oxygen therapy for restoration therapy as well.

Host: What’s the hyperbaric oxygen therapy?

Dr. Briggs: Essentially it simulates diving, scuba diving. So, it puts you in a chamber where you have increased oxygenation or oxygen levels, to increase the oxygen to your nerve, in a hope that increasing its oxygenation it’ll help it to heal faster.

Host: And what do the steroids do to help mend the hearing loss?

Dr. Briggs: It decreases inflammation on the nerve similarly, helping to increase blood flow and hopefully improving the hearing

Host: So, the more blood that’s flowing through the ear in a healthy way of course the better you’re able to hear.

Dr. Briggs: Right, exactly.

Host: So aside from that sudden sensation of not being able to hear, are there any other symptoms that an individual should be aware of or talk to their doctor about?

Dr. Briggs: Oftentimes individuals who have this sudden hearing loss may experience other symptoms that can prompt them to know it is the sudden nerve type of loss vs the conductive type of hearing loss with the fluid and the sinuses. Some of those symptoms include ringing in the ears, so if you have a high-pitched sound or even a sound of white noise like when you turn the radio between stations, that’s another indicator that you may have a nerve type of damage in your ear. Vertigo or dizziness in association with the hearing loss is another indicator that it may be a nervous type of loss.

Host: Are there other conditions aside from respiratory infections that might cause that sudden hearing loss? I know you think about construction workers and the loud noises and things, is that the same, or is that different?

Dr. Briggs: That’s a different entity, that’s noise induced hearing loss, and that can cause a sudden we call it a sudden threshold shift, so sudden changes in your hearing. For example, if you’re exposed to a loud sound or a blast, that too can cause a sudden hearing loss. It’s similarly treated, interestingly, however. There is a host of disease processes that can cause hearing loss in addition to the viral ideology, and that’s why it’s even more important for you to come in and be seen and evaluated. Individuals with diabetes can have it associated with neuropathy, it can be an early sign of strokes, it can be a sign of tumors of the skull base, thyroid disorders, autoimmune disorders, there’s a whole list.

Host: So really since upper respiratory, obviously, probably one of the more common causes of hearing loss but since there are so many things that could cause it, it’s really about getting to the root of that issue. Could you talk a little bit about how you do that and how your team works together to do that?

Dr. Briggs: Yeah, definitely. So, the patients will come in and be evaluated with a physical examination and a history, and that largely directs which direction we’ll go in terms of diagnosis and treatment. It’s very common for individuals who have a sudden hearing loss to have an MRI of their brain and their inner ear to evaluate for any changes of the hearing and balance nerve, or any lesions that might be compressing the hearing and balance nerve. And then based upon the patient’s other history and family history and comorbidities, they may undergo various laboratory testing to assess for diabetes or other autoimmune disorders that might be contributing as well as Lyme disease and other infectious processes.

Host: Could you talk about a compelling story that you’ve had come in with that upper respiratory problem and how that treatment looked for that patient

Dr. Briggs: There is one individual who is a clinician as well, who presented with bilateral involvement so most often individuals come in and it’s involving one ear. In exceptionally rare cases it involves both ears. This individual needed their hearing in order to perform their work, and so we were able—he got in almost immediately after onset of symptoms, started oral steroids, and inter-tympanic steroids, and hyperbaric oxygen therapy and remarkably had restoration of his hearing. At his initial visit we had to communicate via typing on his computer and him speaking back, because he couldn’t hear at all.

Host: He couldn’t hear at all? It wasn’t just a decrease?

Dr. Briggs: No, and that’s the other thing to understand with a sudden hearing loss, it’s not always just a sudden decline in hearing, some people actually wake up and be deaf in one ear.

Host: What’s the emotional or the mental state of people when they come into the office?

Dr. Briggs: Completely scared, definitely. It’s life changing and life altering. I think we often take for granted our hearing, and then once we lose it, or lose some aspect of it, we realize how important it can be to your life. It can be jarring, and it can be life altering and scary for patients to experience, but as long as an individual’s gotten in early, the opportunity for treatment is significant. Without treatment, yes, one third may have no change, one third will have some change, and one third will improve somewhat. But with treatment that can dramatically improve the odds of improving the hearing back to their baseline.

Host: Is there anything an individual maybe that’s prone to those upper respiratory infections can do to reduce their risk?

Dr. Briggs: Unfortunately, not. There’s no treatment, there’s no preventative therapy that’s been identified in the literature to reduce your risk of developing sudden sensorineural hearing loss from these upper respiratory tract infections.

Host: Could you talk a little about the importance of an individual coming to an otolaryngologist

Dr. Briggs: It’s critical for patients to come in and be seen by otolaryngologists or a neurotologist because of the specialized care and therapy that can be provided. We work as a team with primary care providers, with urgent care providers and with emergency department providers to get the patients in early and provide them with the treatment that’s necessary, but it is important that they are ultimately referred to an otolaryngologist who could provide them with that inter-tympanic steroid therapy injection which is a very specialized procedure, only performed mostly by neuro-otologists, but also by some otolaryngologists. In addition, it’s important that they be evaluated for those other disease processes that might be mimicking the sensorineural hearing loss, the idiopathic type.

Host: Thank you for joining us today Dr. Briggs.

Dr. Briggs: Thank you for having me

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Mammogram screening guidelines can be hard to follow, as organizations tend to change them every few years. To keep women up-to-date on best practices, Dr. Ami Chitalia says it’s important that doctors reiterate the guidelines and personalize them to patients.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. Ami A. Chitalia, a breast medical oncologist at MedStar Washington Hospital Center. Welcome, Dr. Chitalia.

Dr. Ami Chitalia: Thank you for having me.

Host: Today we’re discussing the current recommendations for mammography, which is a recommended screening test for breast cancer. The 2018 guidelines from the American Cancer Society suggest that women at average risk for breast cancer have yearly mammograms starting at age 45, and they can switch to every other year at age 55. But, the ACS also notes that women should have a choice to start screening as early as age 40. Dr. Chitalia, with guidelines that seem to change every few years, do you find that women have trouble keeping their screening schedule straight?

Dr. Chitalia: Yes. So, they definitely do have trouble and I don’t blame them. I think it’s important that physicians reiterate the guidelines to their patients often so that they are aware of any important updates or changes to them.

Host: What’s your opinion on when women at average risk for breast cancer should start having annual mammograms?

Dr. Chitalia: So, there are a lot of different answers to this question. Depending on which society’s guidelines you follow, such as the USPSTF, which is the United States Preventive Services Task Force, or the ACS, which is the American Cancer Society, and a few others as well. The answers range from starting at age 40 to starting at age 50. Above all, I think it’s important to use shared decision making with a physician helping the patient to weigh pros and cons and come to an informed, value-based, individualized decision. That is the model that is recommended by most guidelines, especially between ages 40 and 45. ACS recommends annual screening beginning at age 45 and then, either annually or every other year after age 55. So, shared decision making is again recommended after age 75, as well.

Host: When you have a woman come in, what sort of questions do you ask her or what kind of discussions do you have to help her decide what’s best for her?

Dr. Chitalia: Sure. So, that’s a great question. So, one of the biggest things is family history, so really getting a good family history of not only breast cancers but maybe also ovarian cancers and other cancers as well. Also, just asking the patient herself if she’s ever had any abnormal mammograms in the past, if she’s ever had any breast biopsies in the past. That may change your recommendation and make it more specific to her.

Host: What do the 2018 guidelines mean for women at increased risk, such as those with a family history of breast cancer or genetic factors?

Dr. Chitalia: So, if a woman carries a family history of breast cancer, that may mean she is recommended to undergo screening at an earlier age than an average woman. An example of genetic factors may be a BRCA 1 or 2 mutation, which are the most common mutations associated with hereditary breast cancers. So, for the majority of these women, the recommendation is to have their first screening mammogram at the age of 30.

Host: Do women need to do anything special to prepare for a mammogram?

Dr. Chitalia: So, it’s suggested that women schedule their mammogram at the time when their breasts are the least tender, which usually tends to be the week after their menstrual cycle, but this can be somewhat different for each woman. If they’ve had mammograms at another facility is the past, it’s usually a good idea to bring those images and reports in with them so that the radiologist reading their current mammogram can use them as a comparison. They should also let the technician know if they have had previous biopsies or if they have breast implants. And also, it’s recommended that deodorants, perfumes, and lotions be avoided under the arms or on the breast area during the morning of the mammogram.

Host: Could you describe what a woman should expect at her mammography visit?

Dr. Chitalia: Sure. So, she’ll be asked to remove clothing from the waist up as well as a necklace, if she’s wearing one. She will be standing, and she’ll be asked to place each breast, one at a time, on a platform on the machine and the technician will help to place her arms and head so that they don’t block the breast and so that they can take the best images possible. The machine will then compress the breast in order to take pictures. So, the reason that that’s done, it’s important for breast tissue to be spread out, as much as possible, so that the x-ray can go through all of the tissue and the most complete and detailed set of pictures can be taken. The whole process should take no more than 20 to 30 minutes. So, I know a lot of women do have some anxiety related to their mammogram - fear of sort of discomfort or pain, and so, you know, I always tell patients that it is okay to take a mild pain medication, such as Tylenol or an Ibuprofen product, as long as it’s approved by their physician, maybe an hour before the mammogram to alleviate some of that discomfort, if they’ve experienced that before.

Host: What sort of questions do women ask about getting their mammogram?

Dr. Chitalia: So, typically, by the time they’ve come to see me, they’ve already had their mammogram so, of course, they are somewhat anxious to hear their results, especially if they’ve had some abnormality in the past. It depends on what type of mammogram is ordered. There are screening mammograms and there are diagnostic mammograms. The screening mammograms - they do not get results right away. It usually takes about a week or so, depending on the institution. So, for those, I think they tend to be a little bit more nervous because, if all is normal, usually it’s a letter in the mail and, if not, they get a phone call to come back. For the diagnostic ones, they’re actually told of their results there and then, that same day, before they leave from their mammogram. So, I think for those, they’ve already been told and that’s ok. And a lot of my patients are getting diagnostic mammograms since they’re coming to me, usually for some sort of a breast abnormality.

Host: So, the guidelines that we’ve been talking about are regarding screening mammograms where you’re getting checked for a potential breast cancer. What happens if something is found that’s perhaps abnormal during that screening mammogram?

Dr. Chitalia: So, it depends on the abnormality. And, that can range from repeating the mammogram in 6 months, which is earlier than the usual annual repeat. It could also mean getting additional views, so if it’s a screening mammogram that caught something that needs additional views, that should be done right away, within, you know, days to a couple of weeks. And THAT would be a diagnostic mammogram. In addition, usually a targeted ultrasound to that region is done. Sometimes, depending on the woman and her history, it could mean an MRI of the breast. So, it sort of depends on what the abnormality is. If it’s clear that it’s a benign abnormality, such as a cyst seen on the ultrasound, then usually that’s just followed in a bi-annual or annual basis. And sometimes, depending on the woman, they can have a biopsy if it’s something benign like a fibroadenoma and usually that’s it and then they resume their usual screening. So, the answer is it really depends on the abnormality that is found, the grade or the score that it’s given by the radiologist, and then the recommendation that’s given following that.

Host: Why is MedStar Washington Hospital Center the best place for women to seek breast cancer screening?

Dr. Chitalia: MedStar Washington Hospital Center does a great job in a lot of different areas, you know, so we do offer state-of-the-art equipment and imaging techniques, including MRI guided biopsies, which are only actually offered at certain selected imaging centers. And we do offer comprehensive care so if there is an abnormality, they can see a large multidisciplinary team, including nurses, radiologists, surgeons, radiation doctors and medical oncologists, such as myself, all, you know, in the same building, which is nice for them. We also have dedicated breast radiologists who have sort of expertise in reading mammograms. And, you know, I think also our nurses, our technicians, the staff are really kind and caring and just kind of aim to make sure that their experience is smooth and comfortable. So, I really feel that MedStar Washington Hospital Center is a great place to go for a woman to have their mammogram.

Host: Could you share a screening success story from your practice?

Dr. Chitalia: So, I’ve had a few patients recently who were found to have a pre-invasive cancer, which is sort of a pre-cancer before it takes its next step to becoming a true invasive breast cancer. This was actually found on their very first screening mammogram in their forties. So, both patients felt lucky to find it at this stage where it was actually a stage 0 cancer and the treatments, at that point, are much easier to take.

Host: If you could summarize the screening guidelines and how those are followed at MedStar Washington Hospital Center, what would you recommend to a woman at average risk for breast cancer about the importance of getting her mammograms every year?

Dr. Chitalia: Yeah, so, I think, you know, once we’ve had the discussion and they’ve reviewed their medical history, their family history, any personal breast history with their primary care physicians and a decision has been made to proceed with mammogram, I think it’s important that they do so because if an abnormality is caught, it can be treated promptly and followed promptly. So, I think that sticking to, you know, that annual screening is important because it can catch something early and it can be taken care of in an expedited manner.

Host: Thanks for joining us today, Dr. Chitalia.

Dr. Chitalia: Sure! Thanks again for having me.

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Nearly 25 percent of all heart attacks might be silent myocardial infarctions, or silent MI. These heart attacks can cause serious, long-term damage without any noticeable symptoms. Dr. Allen Taylor discusses who is at risk for this condition and how to prevent it.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thank you for joining us today. We’re talking with Dr. Allen J. Taylor, Chief of Cardiology at MedStar Heart and Vascular Institute at MedStar Washington Hospital Center. Today we’re talking about silent myocardial infarction, or silent MI, which is a heart attack that goes unnoticed by the person who has it. Silent MI might have no symptoms, or the symptoms might be so mild that they’re mistaken for muscle pain or heartburn. But the lack of symptoms is deceiving. Research has found that Silent MI, without a history of traditional heart attack, increases a patient’s risk of heart failure, heart attack, and death in general. Dr. Taylor, how can a condition that feels and seems harmless be so dangerous?

Dr. Taylor: Silent MI is an unrecognized problem. It’s the same as a recognized heart attack, in terms of its risk. Seems surprising, how can something silent be so dangerous. And it’s not just the recognition that’s the problem, in terms of risk, but it’s the fact that when not recognized, we don’t have an opportunity to apply the right treatments that improve outcomes. So, silent MIs are risky and they’re just as risky as MIs that patients recognize. So, it’s important that we find them and get patients on the right treatment.

Host: Are silent MIs common?

Dr. Taylor: So, about a quarter of heart attacks are thought to be silent. And I think that when we use the word silent, we have to explain a little bit. Cause some MIs are truly silent - the patient never even has a symptom. Some MIs are unrecognized and so, silent to the patient, although there was a symptom that the patient didn’t recognize as being typical for a heart attack. Patients may mistake their symptoms - for instance, they may say “Oh, that’s just heartburn”, or they may experience heart pain as back pain. Or, in older patients in particular, they may simply have no symptoms at all or simply be feeling down or fatigued or just “off” a particular day. We hear all these stories and, whether it’s truly silent or unrecognized, it’s about 1 in 4 heart attacks that occur in the community.

Host: How are silent MIs detected if they cause no symptoms?

Dr. Taylor: Detection of unrecognized or silent MI can be a problem because it takes a test to detect it since the patient didn’t experience warning symptoms. Some ways we’ll identify them are using a simple test such as an electrocardiogram, that if it shows the changes of a heart attack, that we would then do further investigations to confirm if the electrocardiogram was true or not. Electrocardiograms can be very useful tests in detecting heart attacks that have been unrecognized, although it’s important to note that there’s both false positive test as well as negative tests. So, the electrocardiogram is not perfect, but it’s our primary tool to detect them. Another test that is very common in use is a heart function test called an echocardiogram. It’s a test using sound waves that looks at the heart function and if an area of the heart was shown to be not functioning properly, we might suspect that it had been impaired by an unrecognized heart attack. And that might lead to further investigations to determine if that was true or not. But the detection is difficult. And so, it takes going to your doctor and having one or two of these tests to see if your heart’s in really good shape.

Host: What happens after you discover that a patient has experienced a silent MI?

Dr. Taylor: Well, the first thing I say is “Don’t panic.” Let’s dive a little deeper into this. But, what happens then is we’ll just basically use the same evaluation as someone that had a known heart attack and run them through generally simple tests to see. For example, if the EKG or ECG electrocardiogram was abnormal, we’d perhaps get an echocardiogram to see if the heart function was ok. And then maybe a stress test - having somebody walk and then lightly jog on a treadmill while placed on an electrocardiogram to see if that shows any signs of heart stress when being active. And, if that’s not enough, we have very sophisticated tests that we can really dive very deep into heart function and to make sure the arteries are in good shape or, if not, what the depth of the problem is. So, it’s really the same evaluation as someone who has a known heart attack. And if we find there’s truly an abnormality, what then begins, after it’s assessed, is pick the right treatments. Does someone need an artery treatment right up front, and clearly then we’ll move them on to the right preventative treatments to prevent anything further from happening.

Host: Who’s at risk for silent MI and should patients worry?

Dr. Taylor: It really can be anyone because if it’s truly silent or unrecognized, any of us could mistake, say back pain, for back pain when it was really truly a heart attack. But there’s a few patient populations we’ve really focused on. One would be patients with diabetes. The patients with diabetes often don’t feel pain in the same way. And, they truly can be silent, or they may even experience a heart attack in a day when they simply don’t feel well and maybe their blood sugar control gets worse all of a sudden and they can’t figure out why. In an older patient, particularly in older females, the heart attacks can also be truly silent or unrecognized because they present in odd ways like back pain or a day in which they feel tired or just simply off. But it’s important to know that if anyone is feeling any symptoms that are unexplained - heartburn that’s just a little different than the usual heartburn they’ve experienced and longer lasting - they shouldn’t assume it’s heartburn, but get seen promptly to make sure that, nothing’s going wrong with their heart.

Host: What can patients do to reduce their risk of silent MI?

Dr. Taylor: In terms of reducing the risk for it, well it comes down to the core risk factors for heart disease. That is, high blood pressure, high cholesterol, diabetes, tobacco use, and then leading an optimal lifestyle, regular exercise 30 to 60 minutes most days of the week, avoiding tobacco, eating a diet that’s low in fat and low in sugars. So, it’s a lifestyle approach. Really, knowing your numbers and leading a healthy lifestyle to prevent it. But then not taking symptoms that you think are a little funny for granted.

Host: Why is MedStar Washington Hospital Center the best place to seek heart care?

Dr. Taylor: Well, I’m very proud of what we do at MedStar Washington Hospital Center and MedStar Heart and Vascular Institute because we simply can take care of anything from the most simple to the most incredibly complex. And we have every possible diagnostic tool to help uncover heart disease and every possible tool then to treat it. No matter the severity, we have a team that can help and that’s another unique aspect of MedStar Heart and Vascular Institute is that when you see one person, you’re really seeing an entire team. An entire team of experts that work together for making your care optimal.

Host: Could you share some success stories from your patient population?

Dr. Taylor: I have an interesting case - a young man, he’s very overweight but he had come in the hospital in terrible shape and things weren’t quite right. And in fact, in looking at his electrocardiogram, we noticed that there were signs of an old heart attack. And, in fact, what we indeed found in investigating it, was in fact he had an artery that was totally blocked, and it really had helped contribute to this whole illness that started with just a little breathing difficulty and retaining fluid. And by diagnosing the artery blockage, now we’re on a completely different course of care and now we’re seeking some really novel ways to restore blood flow past the total artery blockage. And while it’s unusual for a 30-year-old to have a blocked artery, it was the EKG that tipped us off and it’s really changed the way we’re caring for him. And, while I don’t want to alarm every 30-year-old person out there to say, “Oh my goodness, I could have a totally, artery totally blocked”, it raises the point of leading an optimal lifestyle. Good diet, exercise, maintaining good body weight, avoiding tobacco are the real ways to preserve your artery health.

Host: Thank you for joining us today, Dr. Taylor.

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PET-CT scans provide detailed information on where cancer is located, whether it’s spreading and if treatments are working. Dr. Carlos Garcia explains how this test works, what to expect if you’re having one and how your doctor uses the results.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re talking to Dr. Carlos Garcia, Medical Director of Nuclear Medicine at MedStar Washington Hospital Center. Today, we’re talking about the benefits of PET CT scanner. Dr. Garcia, what is a PET CT scanner and when is it used?

Dr. Garcia: So, a PET CT scanner is kind of a gold standard for cancer imaging. Just like in the past it was called a CAT scan, now they’re called CT scans, are for anatomic imaging of multiple causes, whether they’re cancer or not. PET CT is 99.9 percent dedicated to cancer imaging. The difference between a PET scanner and a CT scanner is that a PET scanner will rely on the cells being alive and consuming a specific type of substance that makes them show up on the scan. This substance is normally either produced or it circulates in your body. And we add radiation to it and that’s why we can see it on the images. So, it’s a combination now of anatomic imaging from the CT portion of the exam and functional or metabolic imaging from the PET portion of the exam. PET stands for positron emission tomography. Positrons are just basically an energy source that will, you know, produce an amount of radiation that we can translate into images, and the more active a cell is--especially the cancer cells tend to be more active than normal cells--the more they’re going to emit this type of energy, the more they’re going to take up this type of radioactive substance that they would normally not, and that’s how they show up in a more avid, or they light up on the scan, if you will.

Host: So, how is the substance introduced to this other substance that you mentioned in order for it to show up on the PET scan?

Dr. Garcia: So, what we do is we make the patient the source of the radiation. We inject the patient with a modified version of glucose, which is the most common one; that’s why I am going to use that as an example. It’s called fludeoxyglucose, or FDG for short. You’ll see that many of our exams have acronyms for that same reason. It’s kind of a hard, long word. So, we inject the patient with this glucose substance, and all the cells in the body normally will use glucose as energy. Cells that replicate faster or grow out of control, as cancer cells do, will use more glucose because they require more energy to sustain this growth pattern. So, the cells that take up more glucose will take up more of the radioactive glucose that we have injected into the patient, and that’s why they will shine in comparison to the background of normal cells. These cells will look bigger, darker and brighter because they just take up more of the radioactive substance that we tricked the body into taking because it doesn’t know it’s radioactive; it just thinks it’s glucose.

Host: So, what are the advantages of combining a PET scan with a CT scan for cancer?

Dr. Garcia: For many, many years, when we did not have PET images available, we only used CT imaging, which could provide us only with an anatomic version of whatever is going on inside the body. The problem with this is sometimes you can see a tumor—we’ll just use that as an example, and only the inner portion of the tumor might be where all the cancer is, and the rest of it might be just inflammation resulting from the presence of that cancer or tumor. The PET scan can differentiate that sometimes. It can show you what is the actual size of the live tumor inside of a structure that might be, let’s say for example, 5 cm larger, but it’s not all tumor. This helps in many ways to guide the therapy. One of the main applications of knowing this difference between what is functional or what is metabolically alive versus just the anatomy, is that when you apply this to radiation purposes for treatment, for example, the radiation field that will be attached, I’m sorry, that will be used for that particular tumor will only be the size of the part of the tumor, or the part of the mass, that is actually alive, so you can actually make it a little more circumscribed and more directed. So that’s one of the applications when you talk about it. Now it’s called all hybrid imaging--that is the gold standard nowadays of all cancer or oncologic imaging. And now the new hybrid imaging scanners like the ones that we have here, will overlap these images, and they’re called fused activity, and you can definitely see the background and over the background of anatomy overlap with the cells that are actively replicating that turn out to be cancer cells.

Host: So, having the fused images really provides a deeper layer and a deeper perspective for both the imaging team and the physician. Does the patient also get the chance to see those images?

Dr. Garcia: When we have the opportunity to show the images to the patients, by all means. Nine out of 10 times, the physicians that have ordered the tests are comfortable with the patients knowing the results. We always want to extend the courtesy of the referring physician to be directly involved with the patient and them communicate the results, but we have had scenarios in which the patients are very comfortable knowing and they are very, very well versed in their own disease process, as it should be nowadays, and we are happy to show them the images. The overlapping of the anatomic portion of it and the live cell, the metabolic portion of it, it completely takes away from having to even point at the screen. Everything becomes very, very obvious and you can use different color schemes to bring out certain cell types, so it makes a picture worth a million words instead of a thousand words. And all the physicians within the hospital, they have the opportunity to be able to see these images on Enterprise-wide imaging viewer that they have access to as well. So, that makes our job very easy. Even though they’re always welcome to come to the reading room and have us show them the images directly, we can have phone conversations, them looking at the exact same images that we are looking at, and we can tell them slice number and position, and target everything they need to know.

Host: Are there certain cancer types for which PET CT scan is most applicable or certain body parts that are easier to do?

Dr. Garcia: That’s an excellent question because, for a long time, PET CT imaging was considered to be the, you know, savior for all types of cancer, and that unfortunately is not true. It has limitations and then it has indications that make it much more favorable. So, off the top of my head, I can tell you the top three indications that we use it here at the hospital are for breast cancer, lung cancer and lymphoma. So, these tend to be tumors that are very metabolically active. When I say metabolically active, it means that they have a tendency to take up more glucose than normal cells would, than other types of cancer would, so as long as they take up this increased amount of glucose, they will be brighter on the images and they will really stand out from the background, making the ability to detect them much, much easier.

Host: It really makes the cancer sound like a living thing and like a living disease, if you will, as opposed to just this abstract.

Dr. Garcia: I’m going to actually start using that way of explaining it because that actually sounds exactly right. That is, it’s a live being that has a mind of its own sometimes, and our job is to be able to detect it early, be able to apply what we see to a treatment program, and then, after the treatment program, be able to monitor the response to the therapy by seeing whether that activity that translates into a lot of glucose uptake, seeing if it went down, meaning the number of cells is going down based on the therapy. If you have less amount of cells, it’ll be less glucose that will be taken up and the shine on the exam, if you will, will decrease over time. So, we measure, we have units to measure the intensity of this activity and we use them very specifically, you know, to monitor the response to therapy because those units should go down as the number of cells within the cancer start dying as a result of the therapy.

Host: If my doctor tells me that I would need a PET CT scan, what should I expect from that appointment? What will that process look like?

Dr. Garcia: So, the first thing that you’re going to do is you’ll be contacted by one of our staff members from the PET CT Center, and they’re going to ask you to prepare your body to be able to absorb the glucose better, and that’s going to require for you to be fasting for at least six hours prior to the examination. So, the first glucose that you will receive, meaning the first source of energy that your body that has now been without food or drink for six hours, it will be starving. So, you prepare the body to eat something, and then the first thing that it sees is the glucose. And like I said before, it doesn’t know that it’s radioactive. It just thinks it’s glucose, so it’ll latch onto it immediately, and that way you won’t have any competition with glucose from your diet, I mean, which are carbs basically from your diet, competing for a space to latch onto certain cells. So, everything that you will have will be radioactive glucose it’ll latch on. And you arrive to the center. We give you the injection. It’s going to an intravenous injection in your arm. You’ll sit in a quiet room for anywhere between 40 or 60 minutes, and the reason why you want the quiet room is because you don’t want any stimulus to any organ in your body, so we’ll get you in a nice warm-temperature room, you’ll relax, and then about after 60 minutes from that, we will place you in the PET CT camera, and with the new cameras, the amount of time that you will spend under the camera is a lot less, so you’re looking at anywhere between a 20 to 30-minute scan from the level of your eyes down to your mid thighs. And once you conclude that portion of the exam, then the images get sent over to the radiology reading room, to the nuclear medicine reading room, for interpretation.

Host: How does that doctor then use the imaging to suggest treatment for me?

Dr. Garcia: So, we use a staging system, and I’m going to just use cancer, you know, as an example, which is the majority of the reasons why you do a PET CT scan. There’s a staging system to know how far or how advanced, your cancer is. And depending on how advanced your cancer is, the treatment modalities will change. Let’s use, for example, if we have a patient with lung cancer and they have a small lesion in a very circumscribed area and nothing anywhere else because the PET scan did not show that there was spread to any other organ in the body, then, in these particular cases, one of the treatment modalities might be surgery, for example. You know, I’m not a surgeon, but this is, you know like, this is, you know, one of the treatment modalities, one of the treatment options would be surgery. If, for example, the same patient has that same spot in the lung, but also has spots in his liver, also has spots in his bones, surgery may no longer be an option and a more systemic approach is necessary, meaning something, a form of therapy that will apply to your entire body since there has been spread. So, it can guide the clinician to knowing what the treatment options are for the patient, and that opens the discussion, you know, with the patient that these are now your options and this is your staging, you know, this is what we consider it to be. Because nowadays patients will do a lot of research on their own, and they come in asking you, you know, like, what is my stage? Am I stage I or stage II? What are my options based on these stages? So, that’s really, really what helps to kind of tell the patient where they are and what their options are.

Host: So, really mapping the progress of that tumor through the body and then the patient’s progress, thereafter, is mapped by the images.

Dr. Garcia: Correct. Mapping is a good word to use specifically for this because you will do a PET scan in various clinical phases. One of them is going to be for initial diagnosis. If a patient comes in and has an x-ray and they see a small spot on his lung, that could qualify him for having a PET scan, and they’ll isolate a nodule. Then, after that, they will apply whatever treatment option is available to the patient based on the images, and then you will have another PET scan after the therapy has been installed to monitor treatment response. So, there’s an initial treatment strategy and then a subsequent treatment strategy. That’s how PET scan is divided nowadays. So, it’s early, it’s a very important early on in the initial staging and diagnosis, and also in the monitoring treatment response phase to see if it all cleared up, if it’s spread more, or if it’s actually regressed completely. And we see patients that sometimes showed up in their doctor’s office with a small tickle in their throat. And it turned out, then they went over to their ear, nose and throat doctor, and they saw a little growth--you know, a little something, a little bulging inside their throat. And when they ordered a PET scan for this, it turned out that it was not just in that little spot, but it was in many other areas within their neck or within their chest. And, like I said, you know, once you know that, it’ll change the treatment options, but I can say definitely, this is something that I share with my colleagues, is that you sometimes, you know, you get, your day brightens up, when you compare it to a study before that showed a tremendous amount of disease, and after chemotherapy or radiation, it’s all gone. So, it’s always nice to have that dramatic effect when you see live cancer cells everywhere and all these cells are dormant--you know, they disappeared basically. We call them night and day scans.

Host: For many imaging tests, patients have asked questions about or have been concerned about the level of radiation to which they’re exposed. How does the PET CT radiation dose compare to MRI or another imaging?

Dr. Garcia: That’s an excellent question because that is the one thing that people will worry about a lot is radiation exposure. Yes, PET scanning alone will produce much higher radiation exposure than a chest X-ray, but you have to think about the amount of information that comes as a result of that, you know, slightly over, you know, the normal degree of exposure. People sometimes don’t understand that you just by standing around, you know, are getting a little bit of radiation from nature. And living in Denver for a year, you actually get more radiation than by having a PET scan. So, it all depends, you know, like on what kind of information you get out of it. When you do CT imaging of certain parts of your body, depending on what part of your body you’re going to image, that part of your body gets an amount of radiation. PET scanning is the injected dose that will distribute throughout your body, so the dose that you receive will be spread out through your entire body, and that is, in essence, less of a dose to each organ in your body than if you only imaged one particular area at a time. So, it is a little bit more than CT alone if you only did CT imaging, but again the risk, benefit, and the amount of information you get for only a small amount of extra radiation, which is very, very below what the maximum amount of radiation you can receive in a year is, you know, is a wealth of knowledge.

Host: Are there any patients for whom PET CT scan just is not an option because of either the radiation dose or another complication?

Dr. Garcia: Actually, I can’t think off the top of my head of a case in which you could not use a PET scan. We more, we more will see it in cancers that either don’t take up glucose, radioactive glucose, so it’s not the appropriate test for that particular type of cancer. Other limitations, of course, are that it has been proven through many, many studies that it is not the best examination for that particular type of cancer. There are some types of diseases that we wish we could use them on there, for those, but it’s not approved to be used for those cases.

Host: Thank you so much for joining us today.

Dr. Garcia: Oh, it’s my pleasure. Thank you for having me.

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Most thyroid cancer is small and slow-growing. Dr. Kenneth Burman shares why it's best to remove the cancer surgically before it has a chance to spread.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents medical intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Today I am joined by Dr. Kenneth Burman. Thanks for joining us today.

Dr. Burman: Thank you very much for the invitation. I’ve been here about 20 years. It’s really been a great experience. I’ve enjoyed it. We’ve had great support and we see a large number of thyroid patients and we have a big group so that gives us a lot of insight and experience regarding various thyroid issues.

Host: And you’ve probably seen a lot of change in 20 years, I would think.

Dr. Burman: Yes. Our ability in all of medicine to diagnose and treat diseases, especially cancer, has changed dramatically, and that applies to thyroid cancer as well.

Host: For, especially, low-risk thyroid cancer, what shall we do? Should we have surgery, or should we do active surveillance? What, what do we mean by active surveillance, to begin with?

Dr. Burman: You, you happen to hit a very controversial area. So, until about 5 or 10 years ago, we would treat most thyroid cancers the same and specifically I am talking about papillary thyroid cancer and not talking about other types of thyroid cancer such as medullary cancer and anaplastic cancer, which are totally different diseases. So, focusing on papillary thyroid cancer which accounts for about 90 percent of all thyroid cancers, in general, it’s an indolent disease that’s picked up by identifying a nodule in a patient’s thyroid, biopsying it, showing that it’s likely cancer or is cancer, and then recommending surgery. The surgery could be either removing the whole thyroid gland or a portion of the thyroid gland and then, in some cases, administering radioactive iodine therapy. And those have been the time-honored treatments and assessments for papillary thyroid cancer. But what’s happened in the last five to 10 years is that it’s recognized that the vast majority of patients with papillary thyroid cancer do well, the mortality rate is low, probably less than 3 to 5 percent over 10 to 20 years, and it’s especially low in most younger individuals.

So, we don’t want to expose people to unnecessary diagnosis and treatment modalities that they may not need. So, the issue is, or isn’t, that there are a group of patients with slow-growing indolent thyroid cancers that we could just watch? The answer to that question is unknown at the present time. There are various clinical trials around the country, especially in New York, where they’re taking the patients with small papillary thyroid cancers, doing a biopsy and not operating and just monitoring those patients. But the outcome of those results will take many years, maybe decades, to determine whether that’s the appropriate course. In summary, the answer to your question is if we can identify a young, healthy patient with no other risk factors for thyroid cancer that would make it grow, and the thyroid cancer is small, meaning less than one centimeter, and the patient is willing to be monitored, there are some physicians, especially in a clinical trial, that would just monitor that patient with sonograms every 3 to 6 months for an indefinite period of time and follow it and if the nodule increased in size by about 20 percent or 30 percent or more they would then re-biopsy and then consider surgery. The standard of care, however, in the United States at the present time is to identify a thyroid cancer and to perform surgery. If it’s a small papillary cancer that appears to be indolent, it’s perfectly appropriate to do a lobectomy alone and leave the other lobe intact. If it’s more aggressive cancer you might want to (or larger cancer) you might want to do a total thyroidectomy.

Host: So, what would be the advantages to not do surgery?

Dr. Burman: Well, first of all, with regard to surgery, surgery must be performed by an experienced thyroid surgeon. And it’s an interesting observation that approximately 90 to 95 percent of thyroid surgeries in the United States are performed by surgeons who do 5 or less a year. So, you certainly want to go to an established institution with experienced thyroid surgeons. The risk of complications of thyroid surgery, even of taking out one lobe, include permanent or temporary low calcium and permanent or temporary hoarseness as the two most common complications that are still relatively uncommon. In experienced hands, they occur in less than 5 percent of patients, but in less experienced hands, the risk is much higher. So, for the population of the United States as a whole, if you find a small papillary thyroid cancer, and you don’t have access to an experienced surgeon, the question is, is it safer to just monitor those patients and if the nodule grows and may cause more impingement of surrounding tissue, to then operate. That isn’t the standard of care in the United States at the present time, but some physicians are doing that and there are active monitoring clinical trials.

Host: And what’s your stand? Do you typically recommend surgery since it’s the standard of care, or do you ever recommend monitoring?

Dr. Burman: In the vast majority of cases, our approach is to note that the mortality rate from thyroid cancer under present treatment and diagnosis regimens is really good. The prognosis is really good. The mortality is very low. The morbidity is relatively low as well of recurrent disease, so it makes most sense to us to, once you diagnose thyroid cancer, to recommend a lobectomy, but especially in patients who are otherwise relatively healthy and have a nodule that is more than 5-10 millimeters. Of course, there are exceptions. If a patient is 80 years old and has metastatic cancer from another cause, or heart problems, you’re going to temper your advice appropriately.

Host: So, just to clarify, you do recommend, typically, the more surgical approach, correct?

Dr. Burman: Correct.

Host: Yup. And how do you talk about this with patients? Do you give them the options?

Dr. Burman: Well, first off, you have to have a great relationship with your surgeons. We have 3 excellent endocrine surgeons who do approximately 700 to 800 thyroid cases a year in total. So, they’re very, very experienced and very interactive, and we present most of our complicated patients in a conference where there’s a multidisciplinary approach. So that is optimal in this circumstance helping to make a decision about the appropriate course of therapy. It’s the surgeon themselves and the patient that make the final decision whether it should be lobectomy or total thyroidectomy, but it’s the whole team, including endocrinologists, that decide whether the patient should be sent for surgery in the first place.

Host: What other things should people consider?

Dr. Burman: I think the most important thing is the experience of the surgeon and interaction with the endocrinologists and surgeon with a full discussion of the advantages and disadvantages of each approach of monitoring versus lobectomy.

Host: Thank you so much for coming on the show today and sharing your knowledge on low-risk thyroid cancer options.

Dr. Burman: Thank you for the invitation.

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Can talcum powder cause ovarian cancer? Dr. Louis Dainty discusses why he recommends women not use the product on their genital area.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re talking to Dr. Louis Dainty, Regional Director of Gynecologic Oncology at MedStar Washington Hospital Center. Welcome, Dr. Dainty.

Dr. Dainty: Thank you. It’s great to be here.

Host: Why don’t we begin by telling us a little bit about yourself. Why did you go into medicine, and how did you come to be at MedStar Washington Hospital Center?

Dr. Dainty: My interest in medicine began as a, as a kid. I knew I wanted to be a doctor and going the long way to get there, I went in the military, went to medical school after spending some time in infantry and just retired from the military a physician after 26 years just last year.

Host: What led you into women’s health and women’s oncology?

Dr. Dainty: I fell in love with women’s health as soon as I rotated on my OBGYN rotation as a medical student. Initially I thought I was going to be interested in orthopedics but then it was much easier working with women—they were a lot tougher than men.

Host: Today we are talking about ovarian cancer and talcum powder, or baby powder. So, a jury in August 2017 awarded a woman $417 million in a case against Johnson and Johnson. The woman claimed that her terminal ovarian cancer was caused by the company’s baby powder, which she said she’d used for decades. And this isn’t the first time that talcum powder has been blamed for causing ovarian cancer. So, Dr. Dainty, what does science say about whether baby powder can cause ovarian cancer?

Dr. Dainty: The first concern about the possible link between the use of talcum powder and ovarian cancer dates back to 1960s, and that sprung from the initial contamination of talcum powder with asbestos. For some time now, there hasn’t been any asbestos in talcum powder, but still the question remained whether or not there was an association between the use of talcum powder on a female perineum and risk of developing ovarian cancer. The data has been studied, mostly not in a prospective manner but in an observation manner, and the data is mixed—most studies showing that there is no association between the use of talcum powder and ovarian cancer, and others showing that there is a small increased risk of ovarian cancer with the use of talcum powder. When scientists have gone back and looked at the data in total, it seems that statistically there is a very small increased risk of ovarian cancer with the use of talcum powder on the perineum, with specifically a single type of ovarian cancer, and that’s the most common type which is papillary serous carcinoma of the ovary.

Host: What do the studies suggest about a woman’s risk for developing ovarian cancer if she’s used talcum powder?

Dr. Dainty: Your lifetime risk of developing ovarian cancer is about 1.6 percent of all women, so slightly less than two women out of 100 will get ovarian cancer during their life. And the majority of women die from that cancer because it usually doesn’t present until it’s very advanced. Some of the studies suggest slight increase of a risk of ovarian cancer where, if the baseline risk was 1.6 percent, some studies have shown that it might be as high as 1.8 percent. Now that doesn’t sound like it’s a lot, but instead of 14 women out of a thousand, 16 women out of a thousand would develop ovarian cancer. So those two additional women would certainly not feel that that’s not a significant increased risk from talcum powder. So, while statistically it seems like a very small increase, anything we can try to do to try to decrease your risk of developing ovarian cancer, especially something as simple as not applying talcum powder to your bottom, is worth the effort.

Host: So, would it be fair to say that you do recommend that women who use talcum powder stop doing so, or use it less frequently?

Dr. Dainty: Yeah, I would recommend that they don’t apply it directly to their perineum because the vagina is interesting in that there is a communication, obviously, physiologic communication, between the outside world and the inside of your body by means of the vagina and the cervix. And so, in theory, talcum powder could be transported from outside of your body into your vagina and up through your cervix because that’s where sperm travel. Talcum powder certainly also could be transported that way, physiologically. So, yes, I’m recommending that if you’re going to use talcum powder that you use it sparingly around your bottom and not apply it directly to your perineum or your vagina. Cornstarch, without any other additives, seems to do some of the same functions as talcum powder without, the, any obvious risks or any clear association between risk and, so if you have to use something, maybe a more natural subject like cornstarch would do. But again, so just avoid using talcum powder.

Host: Why do women use talc in these areas, and are there certain groups of women who use it more often?

Dr. Dainty: Historically, generations past, I think that a lot of women were taught to put a sanitary pad on, and prior to application of the sanitary pad on their vaginas, they would put talcum powder just to absorb moisture and to also combat bad smell. I think a lot of women, especially older women, grew up doing that. I think younger women, there’s very few women that do that anymore. And so, that’s why people started using talcum powder in the first place.

Host: And when you say that it affects the perineum of the woman, could you explain what that body part is, for individuals who might not know.

Dr. Dainty: So, the perineum is anything, the vagina, the labia, external genitalia basically, between your thighs, from your pubic bone down to your anus.

Host: Are there other products a woman may use, internally or externally, such as petroleum jelly, that may raise her risk for ovarian cancer?

Dr. Dainty: Yeah, that’s an interesting question and the bottom line is there is no evidence to date that there is any increased risk with those, at least not that I am aware of, but you bring up a good point—any petroleum-based product that’s applied to your perineum could have, theoretically have, a risk. The bottom line is what I tell most of my patients is when people ask me, you know, “should I use douching or anything like that,” I say “no” and basically that God designed the vagina just the way it’s supposed to be and you shouldn’t mess with that—mess with it as little as possible. So, I don’t recommend using any foreign products, that are artificial products, that you don’t have to. Obviously, people that need artificial lubricant in order have comfortable intercourse, the products with the least number of additives, either color or perfumes or anything like that, are, are, going to be the safest.

Host: Is it safe to use baby powder on a baby’s bottom?

Dr. Dainty: We don’t know what that risk is, but certainly the use of baby powder for babies is pretty common, and we don’t know whether or not that increases risk. It’d be hard—it’s hard to design a study where you take a hundred babies and expose half of them to talcum powder and the other half you hold back, so all you’re left with is recollection of whether or not a mother said that she used talcum powder on her baby’s bottom or not. So, it’s difficult to get at those kind of exposures through scientific investigation. If I had babies again, I would probably not use talcum powder on their bottoms.

Host: If you have a woman who’s used talcum powder for years or for decades, should she be concerned, or should she see her doctor more frequently?

Dr. Dainty: No. There is no—there’s no call for alarm and there’s no call for increased testing or surveillance. There is no current routine screening that is recommended for the prevention or diagnosis of ovarian cancer in people that are at baseline risk. That means a lifetime risk of 1.6 percent, perhaps, in the United States. So, no, I wouldn’t say that anybody who has used talcum powder in the past should do anything different except maybe stop using talcum powder.

Host: When you’re talking about screening for ovarian cancer, there is really no great test, like mammography for breast cancer or pap smears for cervical cancer. What does screening look like, then, for ovarian cancer?

Dr. Dainty: There is no routine screening. As you just said, there is no routine screening for baseline risk, women at baseline risk for ovarian cancer. There are some screenings that we recommend for women who fall into the category of familial or hereditary ovarian cancer, which is a different topic altogether. But for the baseline-risk, general population, there is no routine screening. The only thing that, as an individual and/or a provider, that you may ask a patient to look for are symptoms. So, early satiety, bloating, increased abdominal girth, abdominal pain that occur more days than not—if that’s a new finding, that’s something you need to bring up to your OB GYN. And so that’s really the only screening that I would recommend for all folks.

Host: So, you alluded to this a little bit before. What are those main risk factors for ovarian cancer?

Dr. Dainty: Probably the biggest is age. So, the average age for ovarian cancer is about 63. So, the older you get, the higher risk you are of developing ovarian cancer. Obesity is the number one modifiable risk factor. If you are 25 pounds overweight, which we all are, you are at 400 percent risk of having endometrial cancer. So, we talk about talcum powder because it increases your risk by 20 percent, and being overweight by 25 pounds, you increase your risk by 400 percent. If you are 50 pounds or more overweight, the risk goes up to 10 times the baseline risk. Certainly—and let’s not even talk about smoking, right? So, yes, talcum powder is real, but it’s not, the data is not so strong. Certainly, the most common talked about risk of ovarian cancer is familial risk. Now, right now, familial risk accounts for maybe 15 or 20 percent of all ovarian cancers. So, most are sporadic or just happen spontaneously. Family history is certainly, though, very important. So, if you have other family members who have breast or ovarian cancers, especially those that have had those cancers prior to age 50, those are folks that may need to be referred to a geneticist for testing.

Host: Does that include both sides of your family—so my mother’s side of the family or my father’s—or does that run more prevalently in one or the other?

Dr. Dainty: No, it includes both sides. That’s an excellent point. It’s all first-degree relatives. So, if your father’s sister had ovarian cancer early or your father had breast cancer, that would be something that would be very concerning and something that would possibly warrant referral to see a geneticist.

Host: This has been very insightful and eye-opening so thank you again, Dr. Dainty, for joining us to discuss this very delicate but also very important women's health topic.

Dr. Dainty: I appreciate the invitation. Thank you.

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An adult can bleed to death in less than five minutes from a severe wound. Bystander intervention is critical to survival, but many people are afraid to help in the moment. On this anniversary of the 9/11 attacks, Dr. Jack Sava discusses the Stop the Bleed campaign, a national movement to teach people simple steps to save lives.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re talking to Dr. Jack Sava, Chief of Trauma at MedStar Washington Hospital Center. Welcome, Dr. Sava.

Dr. Sava: Well, thank you.

Host: So, today we’re talking about the Stop The Bleed campaign, a national effort to encourage bystanders to become trained and empowered to help in a bleeding emergency before professional help arrives. Dr. Sava, why is it so important that bystanders know what to do if they see someone bleeding?

Dr. Sava: Well, I think that the Stop The Bleed campaign has become important in a couple different ways. This campaign grew out of a tragedy, a mass shooting, and so the original idea of the Stop The Bleed campaign is that first responders, specifically police officers, should be able to stop bleeding with direct pressure and a few other means. But, quickly everybody realized that this doesn’t just apply to a police officer in a mass shooting. It applies to all of our lives. We’ve all become accustomed to the idea that if we’re on a subway platform and somebody has a cardiac arrest, that it would be great if we knew how to do CPR and save their life. So, the fact that everybody now is getting on board with doing CPR, but many people don’t understand the very basics of how to stop bleeding, is a bit of a mismatch. And I think that’s part of the impetus for the Stop The Bleed campaign is to bring the care of bleeding patients up to what we’re trying to achieve with the care of patients who have had a cardiac event.

Host: What’s the danger if somebody is bleeding--how fast can that person die from blood loss?

Dr. Sava: Well, people can die in seconds or they can die in hours, and some of the people who die in seconds are not going to be saved by pressure on the subway platform, and maybe, you know, some of the other people have time to get to the hospital, but what we’re after is this big middle ground of people who have severe bleeding and what happens in the first hour is going to make a difference between them living and dying. I’ve seen over the years footage, as we all do nowadays, of people who have been bleeding from an arm or a leg, and have been in a crowd of people who didn’t know what to do, and you can watch these people bleed to death. And it’s a very moving experience for anybody, but for a trauma surgeon it’s torture to watch people who are well intentioned, but don’t understand that if they did one or two simple things, they could save that person. It’s very hard to watch, and we see this play out in people who come in who probably had an opportunity to have somebody stop the bleeding before arrival in the hospital.

Host: I think as a population people are just almost trained to panic when they see blood, you know, worrying about their own safety. What are the precautions that an individual might be thinking about or what’s going through their mind when they’re watching this individual bleeding?

Dr. Sava: Well, I think that’s a great point. I think we’ve all gotten messages about what matters over the years, and people, even at their best, might have a hard time balancing those different things about priorities, about what matters, and when they’re under a lot of stress, they’re not going to be thinking that clearly. So, what do I mean by what matters? Well, first of all, infection matters. In a very general sense, I think we all think that wounds have to be treated with sterile stuff, with certain types of gauze and medical equipment, other than that there’s going to be an infection. So, first of all, one of the important things that we need to train people is if you’re about to bleed to death, infection doesn’t matter at all. It literally should be the furthest thing from your mind. Another thing that matters is pain. So, if I tell you, and we don’t often talk about this, but if you see, uh, somebody with a big wound on their arm, the last thing, as an empathetic human being, that you’re going to be inclined to do is to press on it. We’re trying to say that as if it’s common sense, but it’s actually very counterintuitive to press on a wound. It seems cruel, but that requires, some, uh, some discipline, some, you know, some training, maybe some mental preparation because it can be hard to do. I think that’s something that we in the medical profession get good at. We’re used to thinking of pressing on a wound as a nice thing to do for somebody, even if it’s uncomfortable for them. We, you know, we feel good about that, but I think to the bystander, that connection might not have been made, and so now you picture somebody--well, what if it’s your child? Many of us have been through situations like giving a child medicine where you have to hold them down, and you all know that sometimes in a marriage there is one partner who can do that because they feel like they’re doing something good, even though it’s unpleasant, but some people just can’t torture their own child that way, so that’s something that is not so much a fact that they need to learn, but something they need to mentally rehearse, and they need to really embrace the idea that this has to happen, despite the fact that it could lead to an infection weeks later that could easily be treated with antibiotics, but also despite the fact that it might be very painful. Now, in the military, you know, they have protocols. In many cases, if somebody has a gunshot wound to the leg, the medic might be kneeling on it or standing on it. I mean, those are things again that are not in our normal course of activities.

Host: I can only imagine what that would feel like - you come up on somebody and they’re already in pain, and putting additional pain on them - it’s the right thing to do. So, if I were walking through a subway, for example, and I see an individual bleeding out of their arm or leg, walk me through what I should do for that individual.

Dr. Sava: Well, the first thing to do, the immediate response, should be to press on it hard and to press on it with whatever you can find. One of the things that I see is that people like to use a lot of cloth, for lack of a better word--a lot of gauze, a lot of, you know, giant shirts and so forth, and what that can tend to do is spread out the force well beyond where it’s needed and diminish the actual pressure at the right, at the point where it’s needed, so you need to, uh, get an idea of where the actual cut is, and obviously, if somebody had a whole pant leg soaked in blood, it’s very easy to be very wrong about that, so in some cases it means cutting off a piece of clothing or removing clothing, or if other people have sort of layered on dressings and cloth all over the place, you’ve got to kind of figure out where the actual wound is if you’re going to successfully manage it with pressure. So, first step is to apply pressure. Now, in many cases that stops the bleeding. Now, I think that usually a person pushing on a wound does a better job than a dressing. My advice would be, if you’re pressing on something and it stops the bleeding, don’t be in a hurry to try to turn that into a bandage that’s wrapped. Just take a moment and be happy with your success, and keep your hand on there until help arrives.

Host: Dr. Sava, what should a person do if that direct pressure doesn’t stop a person’s bleeding?

Dr. Sava: If the direct pressure doesn’t stop the bleeding, another alternative that you may have available to you is to use what we call a hemostatic dressing. That means a dressing that’s built to stop bleeding. So, nowadays over the last 10 years we’ve developed gauze dressings that are coated with special substances that stop bleeding, and so if you have those, those can be very effective to put on or into the wound, and then reapply the direct pressure. Now, if those things don’t work, on an arm or a leg, the next step is a tourniquet. Tourniquets have been around for a long time. There are commercially available tourniquets, and one of the missions of the Stop The Bleed campaign is to try to make these very readily available. Just like there’s defibrillators now everywhere, we want there to be tourniquets, you know, in glass cases at every school and everybody’s glove compartment, and so forth. The key thing about a tourniquet is it has to be above or upstream of where the wound is, so if you have a wound on your thigh and you put a tourniquet on your knee or on your calf, then that’s obviously not going to help. So, tourniquets are very effective when there’s room to get them between the wound and the torso.

Host: So, the goal of the tourniquet--could you explain a little bit about that?

Dr. Sava: What the tourniquet does is it stops all blood flow to the arm or to the leg. And you might think, oh, that sounds bad to not have any blood flow to your arm or your leg, and actually, yeah, if you had no blood flow to your arm or to your leg for 8 or 10 hours, that would be a problem for that arm or leg. And that gets us back to the question of pain because putting a tourniquet on effectively is not comfortable, so you have to kind of push through that. And basically, you have to tighten that tourniquet until it stops the blood flow, so there’s a good kind of feedback about whether or not your tourniquet is working because the wound should stop bleeding. It’s very simple and satisfying physics. We see patients very frequently now who have probably had their lives saved by tourniquets. And it’s interesting because tourniquets were not as commonly used 15 years ago, so really one of the major lessons of the war and the conflicts recently has been that tourniquets really are lifesaving and it really is OK to have them on for a reasonable period of time. So, thankfully, we’re now, over the last 5 or 10 years, seeing the emergency medical services providers putting on tourniquets in the field, and it’s even trickling down to citizens, so we’re seeing workplace accidents where somebody at the job site has applied a tourniquet, and people are coming in awake and alert and surviving, whereas before that they would have come in soaked in blood and perhaps dying.

Host: It seems so antiquated to, you know, to be a newer technology, you know, like people have done this for centuries. And how did it fall out of practice?

Dr. Sava: Yeah, it’s interesting. There’s a lot of things that are cyclical like that, but the reason it fell out of practice was the concern for having no blood flow to a limb for a period of time, so, you know, there were a number of cases where there were consequences because they were left on too long. And the fact is also sometimes you might put a tourniquet on and it might turn out not to be necessary, and so between some of them not being necessary and some of them being left on too long, there was a period of time where people became anti-tourniquet, but the war changed all that.

Host: How are you and your team here at MedStar Washington Hospital Center working to promote the Stop The Bleed campaign or these initiatives, globally or nationally?

Dr. Sava: Well, the Stop The Bleed campaign is great because it’s organized into some very simple messages, um, what we’re trying to teach. And so now there’s a course of materials, there’s a simulation mannequin leg that we use to teach the skills, and there’s ... it’s all been put together into a product or course that we can teach very quickly, in an hour or two of time, so we are now going out into the community, um, to teach this course to all types of people. I’m teaching it to my kids’ school this fall, which has raised the interesting discussion of how young can you be to learn these skills. Now, my kids were … I was yelling at my kids about bleeding management probably from the age of 4 maybe? I mean, they ... I used to get a cut on my finger, and I am not, of course, very freaked out by minor cuts, so I would just let it bleed and call my kids and then say ‘this is going to bleed until you stop it,’ and then my wife would tell me that’s inappropriate. So, but anyway, for the school kids, I think the country is trying to decide what age is appropriate. Now, first aid skills and CPR go down into middle school and beyond sometimes, but this is, you know, a little more scary, and so everyone’s trying to decide that.

Host: So, if I want this training for myself, how would I contact you or what are the resources available?

Dr. Sava: You can google Stop The Bleed and you can find courses through the website. You can also contact any local trauma center will likely be teaching the course. This has become a big push on the part of the trauma surgeons of the country, so most trauma folks either are putting on courses or know about them.

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Health organizations’ guidelines about PSA screening for prostate cancer can be confusing. Dr. Ross Krasnow discusses how he advises men about the test.

TRANSCRIPT

Introduction: MedStar Washington Hospital Center presents Medical Intel, where our healthcare team shares health and wellness insights, and gives you the inside story on advances in medicine.

Host: Welcome, everybody, and thanks for joining us today. We’re talking to Dr. Ross Krasnow. He is a urologic oncologist at MedStar Washington Hospital Center. Welcome, Dr. Krasnow.

Dr. Krasnow: Thank you for having me.

Host: So, we’re going to talk about PSA testing for prostate cancer. In 2016, Ben Stiller, the actor, made waves with a blog post titled, “The Prostate Cancer Test That Saved My Life,” in which he encouraged men to learn more about PSA testing, and it was something that he had gone through personally. And, the article also renewed a debate between medical professionals and organizations about the effectiveness of this test. Please explain to us a little bit more about what PSA testing is. Why is there so much debate surrounding this test?

Dr. Krasnow: PSA stands for prostate specific antigen. It is a substance that the prostate actually secretes into the ejaculate. The prostate is a sexual organ. It’s not really supposed to be in the bloodstream, but it does leak into the bloodstream in small amounts. When a patient has prostate cancer, PSA will be secreted into the bloodstream at a higher level. Because of how PSA can be elevated in the bloodstream, it can be used as a screening test for prostate cancer, and it has been used successfully as a screening test for prostate cancer. Unfortunately, some of the data that demonstrates the efficacy, or lack thereof, of PSA testing for prostate cancer, is controversial. Specifically, in 2012 the US Preventative Task Force gave PSA testing a grade D recommendation. What that means is that they thought that the benefits of testing did not outweigh the harm, and they did not recommend PSA testing in men. In May of 2017, the US PTF, the US Preventative Task Force, revised their recommendation, and upgraded the recommendation to a grade C recommendation in men between the ages of 55 and 69.

What this grade C recommendation means is that the test should be offered based on the professional judgment of the clinician and patient preference. Prostate cancer screening works when used properly, but there are harms. That’s why the Preventative Task Force came out with their recommendation in 2012. And those harms are a false positive rate of 15 percent. That means that 15 percent of men with an elevated PSA may not have prostate cancer at all and undergo unnecessary testing. When I say unnecessary testing, that primarily means a prostate biopsy, and a prostate biopsy can have complications. Also, there is a real risk of overtreatment. Most of the prostate cancer that’s diagnosed with the prostate biopsy ends up being low-grade prostate cancer, also what we call indolent prostate cancer. Yes, under the microscope, the cells are abnormal, and it’s technically called prostate cancer, but it’s unlikely to negatively impact that man’s life in any way. Also, there’s a risk of over-detection of prostate cancer in men who are older with a lower life expectancy. Prostate cancer is a very slow-growing cancer, and it takes 10 to 15 years for it to progress, and maybe even longer for it to cause death. So there’s not a lot of utility in screening and treating older gentlemen.

Host: So, what do current screening guidelines say about PSA tests then? So, for example, like the US Preventative Services Task Force or American Cancer Society?

Dr. Krasnow: As I mentioned, the updated recommendations from the US Preventative Task Force give it a grade C recommendation for men between the ages of 55 and 69. This means that a conversation needs to take place between the physician or advanced practice provider ordering the PSA test and the patient to understand the risks and benefits associated with PSA screening. And really, the American Cancer Society and American Urological Association guidelines have a similar emphasis on shared decision-making. The American Cancer Society updated their recommendations in 2016. They recommended that screening should start at the age of 50 after a conversation using shared decision-making takes place. They also recommend screening, specifically African-American men, starting at the age of 45, and they recommend screening patients with a family history of prostate cancer at the age of 40. The American Urologic Association has similar recommendations. They recommend starting screening a little bit later at the age of 55, but again they emphasize the importance of the patient understanding the benefits and harms of screening before undergoing PSA testing. The American Association of Family Physicians hasn’t revised their recommendations in some time, but they do not recommend screening at this time.

Host: As a younger male, how is a man supposed to know which guidelines to follow?

Dr. Krasnow: There really is no right or wrong guideline to follow. The key is that the patient themselves has to engage in the decision-making process with their provider to decide whether they should undergo PSA testing or not. They need to understand the benefits of PSA testing, that PSA testing can lead to a decrease in the risk of a prostate cancer mortality, but they also need to understand that you have to screen a lot of patients before you save even one person, and the treatment for prostate cancer has its own risks associated with it. One person may feel that they don’t want to undergo that type of test for what they find to be minimal benefit. Another person may say, “You know what? I want to know if I have cancer, and if I have it, I want to treat it, because I don’t want to face the long-term consequences of having a cancer down the line.” The other thing to mention is that the detection of prostate cancer with PSA testing may not impact survival as much as we would expect, but there is a lot of benefit to preventing patients from having progressive prostate cancer that either invades into local structures or becomes metastatic. I’ve certainly seen patients in my practice who have advanced prostate cancer that spreads to other organs and they feel that, had they had testing at an earlier stage, an intervention could have been offered sooner.

Host: That makes me wonder, you know, have you seen patients like Ben Stiller, who is a younger male than I guess what is presented in those guidelines to follow, in which this test found the cancer really at the really early stage of their lives, or have you seen patients who went through a biopsy and it turned out that the test was false positive?

Dr. Krasnow: I’ve definitely seen both of these types of scenarios. I have a specific patient in mind that I treated. He was a very young gentleman. He was less than 50 years old, who ended up getting a PSA test because he had some urinary symptoms. In reality, based on the strict screening guidelines, he may not have needed a PSA test at all because he was less than 50, but it was warranted because he had some urinary symptoms. His PSA was very, very high. At that point, we did a prostate biopsy on him and it showed only a very small focus of low-risk cancer, but something didn’t make sense. His PSA should not have been that high for having such a low, small focus of cancer on the biopsy. So we had a long discussion about what the next step should be. Should we continue PSA testing? Should we treat? Should we do an MRI? We ended up doing an MRI, which showed an area that was of concern for a higher-risk cancer. We then discussed the potential treatment options, and he elected to undergo a radical prostatectomy using the robotic platform. And at the end of the day, his final pathology was a very high-grade cancer that left unchecked would likely have led to a lethal prostate cancer, so I was very relieved that he had had that PSA test and that we had intervened. On the other side of the spectrum, I’m often referred patients in their 70s, mid-70s or patients who have a lot of medical, what we call comorbidities. That means they have a lot of other medical problems—heart problems, lung problems, vascular problems, and they end up being referred to me for elevated PSA and for a biopsy. And when I meet with them, I say, “You know what? We should not biopsy you because we’re likely to find prostate cancer or likely to find an indolent prostate cancer, but it’s unlikely to ever affect you in your lifetime. So, I feel that I have avoided overtreatment in many patients as well. I think the key is to be smarter about testing, being more selective.

Host: How do you advise men regarding prostate cancer screening and do you find the test valuable, or do you think more men are harmed than helped because of false positives?

Dr. Krasnow: Let’s not forget that prostate cancer is by far the most common cancer in men. Over 160,000 men are diagnosed with prostate cancer each year, and it’s the number 2 cause of cancer death in men with 26,000 men dying of prostate cancer each year. This number is really comparable to breast cancer in women. Since the inception of PSA testing, there has been a sharp decrease in prostate cancer mortality. Approximately 1 out of 7 men in the US will be diagnosed with prostate cancer during their lifetime, and nearly 2.8 percent of men will die from the disease. We’ve discussed how PSA testing can decrease prostate cancer mortality and that treatment is associated with better survival over just watching it, so yes, I think that we definitely can help patients through PSA testing, but we can cause harm if we test the wrong patients. So, we really need to engage in smarter PSA screening.

I think an important key is the shared decision-making so that patients really understand the benefits and risks associated with testing. I think we need to be smarter about screening patients who are at an increased risk of prostate cancer, such as African-American and those who have had a close family member with prostate cancer. I think that it’s reasonable to start screening even at an earlier age, such as 50 or below, and I think that there is now data that suggests that a low PSA at the age of 50 may suggest that you don’t need any further testing, and so I think that is something that’s coming down the line. It’s important that we don’t test patients who have a life expectancy of less than 10 years because they’re really unlikely to derive any benefit from the testing and any further workup or treatment could definitely result in harm. I really advocate for stopping screening at the age of 70, except in only rare situations where someone is extremely healthy for their age, has a long life expectancy and, for whatever reason, is extremely burdened about the health of their prostate. I think it’s important that we check PSA in men with urinary symptoms, especially before procedures or treatment of benign prostatic hyperplasia, like the young gentleman I told you about earlier.

Host: Dr. Krasnow, are there certain men who are at risk for prostate cancer and should be screened earlier or more frequently?

Dr. Krasnow: Absolutely. There are populations of men who are at increased risk of prostate cancer. Race is strongly correlated with prostate cancer mortality. African-Americans have at least double the incidence of prostate cancer compared to white men. And it’s not only that the incidence is higher. They have an increased risk of high-risk prostate cancer and they have a 2 to 3 times increased risk of dying from prostate cancer, so not only is this a population that’s underrepresented in the medical literature, but they’re at increased risk of having an adverse outcome from prostate cancer, so it’s more important that we screen in that population. Another important population that I talked about earlier is men with a family history of prostate cancer, and when I say family history I specifically mean those who have a father or a brother with prostate cancer. They have a much higher risk of developing prostate cancer, and again, more importantly, a higher risk of dying from prostate cancer. And studies suggest that screening in those patients with a family history may decrease prostate cancer death by 50 percent. We are also developing a better understanding of those who may have an increased genetic predisposition to prostate cancer. For example, one of the most common causes of breast cancer is a gene mutation called the BRCA gene, associated with breast and ovarian cancer in women. And what we’re learning now is that men who have this mutation also have an increased risk of prostate cancer and an increase in lethal prostate cancer. Now we know that men who have a family history of breast cancer in the women in their family should also be more aggressively screened for prostate cancer.

Host: So, to me it sounds like the PSA test and the screening, it’s effective. What’s the future for prostate cancer screening? Are there better methods coming down the pipe?

Dr. Krasnow: I definitely think that PSA testing is effective when used in a smart fashion in patients who are younger and in patients who are more likely to die from prostate cancer. But the test could definitely be improved. Also, we’re understanding that just because a man has a diagnosis of prostate cancer doesn’t mean that we have to treat them for prostate cancer. We can effectively prevent prostate cancer death by watching the cancer closely. But, there are better methods coming down the pipeline. There’s a lot of interest in earlier screening for prostate cancer, but not yearly screening. There was recently a publication by my colleague, Mark Preston, in the Journal of Clinical Oncology that showed that by essentially screening with a single PSA test at a younger age, if your PSA value is below a certain cutoff, you may never need PSA screening again for the rest of your life, and I think that’s a very exciting proposition to say, OK, at the age of 45 we are going to do one PSA test. If it looks OK, we never have to do it again. That would certainly prevent screening in a large amount of patients, but we’re not there yet. Also, we’re better integrating advanced imaging into the diagnosis of prostate cancer. Specifically, I mean MRI for prostate cancer—magnetic resonance imaging. This type of imaging has increasingly been used in men who had an elevated PSA and have had a negative biopsy, but a scary high-level PSA, and it can be used to see prostate cancer that you can’t see on the ultrasound and detect by routine biopsy. Now there is data that suggests that we may be able to push the MRI into an earlier phase and use it in the screening process, so instead of the process being an elevated PSA leading to a negative biopsy, leading to an MRI, leading to another biopsy, maybe a smarter way to do it is an elevated PSA, leads to an MRI, and then if there is something suspicious on the MRI, then we do the biopsy. This is new because up until recently the MRIs haven’t had a high enough resolution to really see prostate cancer. There’s also better biomarkers for prostate cancer. One is called the 4K score. It uses not just PSA, but PSA that’s found in the blood and PSA that’s further broken down by the body, and it may also be useful in screening patients who have an elevated PSA prior to biopsy to better detect those who may just have a lethal prostate cancer. And, in fact, MRI and these new biomarkers, like the 4K score, have recently been integrated into the NCCN guidelines. So, we’ve made a lot of progress in how to intelligently use PSA testing for the screening of prostate cancer. I think that we have more work to do, but it’s looking even more promising, and I’m hopeful that we can further reduce the burden of screening and the harms of screening through these new technologies.

Host: That is really great news. I especially liked the part where you were telling us about how we can do it just one time at the age of 45 or so, and then never have to do it again. Hopefully, that time will come soon.

Dr. Krasnow: I hope so. It’s early data now, but it’s looking like that may be promising.

Host: Thank you very much for joining us today.

Dr. Krasnow: It was my pleasure.

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Digital rectal exams for prostate cancer can be a little uncomfortable, but they’re vital for early cancer detection as part of regular screening. Dr. Ross Krasnow explains why a digital rectal exam is important and what to expect.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re talking to Dr. Ross Krasnow, a urologist who specializes in urologic oncology at MedStar Washington Hospital Center. Welcome, Dr. Krasnow.

Dr. Krasnow: It’s great to be here. Thanks for having me.

Host: Today we’re talking about the digital rectal examination used to check for abnormalities of the lower rectum, particularly prostate cancer. Doctor Krasnow, what can a man expect when he gets a digital rectal examination?

Dr. Krasnow: So, I think that most people, when I tell them they need a digital rectal examination, get pretty nervous about it. And they also don’t always understand why they need it. So, the first thing I do is try to explain, “Why are we doing it? Why do I need to put my finger in your rectum?” And typically, I’ll…I’ll grab a mannequin and I’ll show them where the prostate is. And we do the digital rectal exam because the prostate sits right next to the rectum, right in front of it actually, and the best way to access the prostate through an examination is through the rectum. You can’t feel it on the outside of the body.

Host: When might a man get this test - at what age should they start and how often?

Dr. Krasnow: So, there is a lot of controversy surrounding prostate cancer screening. But for the most part, men who choose to undergo prostate cancer screening, which should occur around the age of fifty, should have both a PSA test along with a digital rectal exam. There is some controversy as to whether the digital rectal exam adds anything to the blood test called the PSA that we use to screen for prostate cancer, but I think it’s an important part of screening.

Host: So, in both of those tests, what exactly are you looking for?

Dr. Krasnow: So, when we talk about screening for prostate cancer there are really two components. One is a blood based test called the PSA. PSA is a substance that’s secreted into the ejaculate by the prostate, but a small amount of it leaks into the bloodstream. When a prostate has prostate cancer in it, more of that substance can leak into the bloodstream, and that number becomes elevated and can be a signal of prostate cancer. That’s why we use that as a screening test. The digital rectal exam is pretty crude, really. We’re just feeling for any nodules, lumps on the prostate and any evidence of a prostate cancer extending into nearby organs like the rectum.

Host: So, you mentioned around age fifty - are there any other recommendations for men, perhaps men that are at higher risk for prostate cancer because of family history of the disease?

Dr. Krasnow: Absolutely. So, there are different guidelines as to when prostate cancer screening should start. The American Cancer Association recommends screening for prostate cancer starting at age 50. And in men with a family history of prostate cancer, specifically in men with a first relative who had prostate cancer - that would be a brother or a father with prostate cancer, screening should start earlier. Also, men of African American descent should start screening earlier because not only are those men at an increased risk of prostate cancer, specifically they’re…they are at an increased risk of lethal prostate cancer. I believe that African Americans with a history of prostate cancer are supposed to be screened at age forty-five and men with a first relative who had prostate cancer should be screened at age forty.

Host: So, with the advent of PSA tests and those becoming more and more popular, what do you recommend for patients? Do you still continue to recommend different tests depending on their specific risk, their family history and so forth? Should all men have both the digital rectal exam and the PSA?

Dr. Krasnow: So, the problem with the digital rectal exam is that it’s not a really good test for prostate cancer at the end of the day. In men who have an abnormal digital rectal exam, only about three maybe four percent of those patients will actually have prostate cancer. In men who have an abnormal PSA, it’s about six to seven percent of those men will have prostate cancer. Really, I view a digital rectal exam as an adjunct to PSA testing to learn more about the size of the prostate and the anatomy of the prostate to understand the interpretation of either their PSA or…or biopsy.

Host: What are a couple of the…the most common concerns that men will ask you about this test, or the most common fears?

Dr. Krasnow: I think for the most part, most men are concerned about it being painful. I think men also wonder if it’s even necessary. So, when I talk to them about it, I try to reassure them that it’s certainly awkward but it’s not painful, and I also tell them the rationale for why I’m doing it. Often when I see men for prostate cancer screening, very rarely am I only seeing them for prostate cancer screening. More often than not, men who are coming to me regarding prostate cancer screening are in their 50s, 60s and 70s, and they have associated urinary symptoms. They are getting up to go to the bathroom at night, they feel like they are not emptying their bladder completely, so when I am talking to these men, I’m not just focused on prostate cancer and prostate cancer screening. I’m focused on other aspects of a man’s health - sexual function and urination - and so the digital rectal exam helps me treat those aspects of their life as well.

Host: Do you feel like there’s still work to be done to educate men about the importance of prostate cancer screening and what do you think the future of that looks like in DC?

Dr. Krasnow: So, Washington, DC is very interesting in terms of prostate cancer. It has some of the highest incidents of prostate cancer compared to the rest of the United States. And the risk of prostate cancer mortality is higher in the DC area than in the rest of the United States. So…so certainly prostate cancer screening seems to be important in this area. That being said, there has been a lot of controversy regarding the efficacy of prostate cancer screening. So, recently the US preventative task force upgraded their recommendation for prostate cancer screening from a grade D recommendation to a grade C recommendation. The grade D recommendation essentially recommended against prostate cancer screening but newer and more robust data has shown that prostate cancer screening can be effective in lowering prostate cancer mortality. So, the grade C recommendation means that the patient and the clinician should have a discussion regarding prostate cancer screening and after weighing the risks and benefits of the screening, they can be offered PSA testing. Urologists are to blame for over-diagnosis and over-treatment of low-risk prostate cancer that would otherwise not affect a man in their lifetime, leading to toxicity – treatment-related toxicity, such as urinary problems and sexual problems. I think that now we’re doing a much better job of screening more intelligently. Selecting who is at risk for prostate cancer and screening just men in the right age category or the right risk category that would benefit from screening, and often, even if we make a diagnosis of prostate cancer, we may not treat it if that cancer is low-volume and low-grade cancer, and this is a paradigm shift compared to what we used to do, which was treat everyone indiscriminately.

Host: Thanks for joining us today, Dr. Krasnow.

Dr. Krasnow: Thank you so much for having me.

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Lost time = lost brain function when it comes to patients who have had a stroke. Dr. Rocco Armonda discusses mechanical thrombectomy, a minimally invasive procedure that can provide lifesaving treatment for strokes caused by large blood clots.

TRANSCRIPT

Introduction: MedStar Washington Hospital Center presents Medical Intel, where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Today, we’re talking about mechanical thrombectomy with Dr. Rocco Armonda, Director of Neuroendovascular Surgery and Surgical Co-Director of the Neuro Intensive Care Unit, MedStar Washington Hospital Center. Mechanical thrombectomy is a breakthrough procedure to quickly and effectively remove blood clots from the brains of stroke patients using a stent retriever device. The procedure often is used when the patient is suffering a large-vessel occlusion.

Host: Dr. Armonda, what is a large-vessel occlusion?

Dr. Armonda: Right, so what this refers to is basically the major conductance vessels of the brain, the major vessels that basically bring blood into the brain, so we’re talking about mainly the carotid artery, the middle cerebral artery and the posterior circulation—it’s primarily the vertebral artery and the basilar artery. These are the major conducting vessels that we’re looking at, and what studies have shown of recent is that mechanical intervention with the use of catheters, a combination of mechanical devices called stent retrievers and aspiration techniques, have actually dramatically changed outcomes to the point where we basically are seeing a success rate of on the order of 70 to 90 percent if we can get to patients early enough. And, we’re talking about huge life savings in terms of preventing paralysis, preventing them from death, preventing them from being bedridden, maintaining their independence, their ability to speak, communicate, relate to their families. An individual who is typically in the prime of their life or just post-retirement, and they go from being paralyzed on one side of their body and unable to speak, to basically speaking and moving and walking and back to their normal baseline, and that’s pretty dramatic. But it takes a well-organized system to do this. And, it really took a number of studies that basically showed at the highest level of evidence dramatic changes in terms of outcome. With those vessels who have large-vessel occlusion, you can get to them in a very rapid fashion, and in fact, the core of the infarct was smaller than the tissue at risk.

Host: One of the better-known stroke treatments is tPA, which is a medication given through an IV to help dissolve blood clots. Is mechanical thrombectomy a replacement for tPA?

Dr. Armonda: You know, when IV tPA first came out, the clot-busting medication was given through the IV. That was the only FDA-approved intervention. And now, you know, the paradigm has shifted, so it’s not that mechanical thrombectomy replaces IV tPA; we actually do both in a lot of cases. There’s three different scenarios. There is one scenario in a patient where we’ll start the IV tPA and you might shift them to a place that does mechanical thrombectomy. There’s another scenario where you start the IV tPA while you’re ongoing doing the mechanical thrombectomy. And, then there’s a third scenario which is a patient who can’t qualify for IV tPA. Let’s say they have had recent surgery. Let’s say because of other time-window reasons you can’t exactly place the onset of the stroke. So, it’s beyond perhaps the 4.5-hour period, so those patients will go straight to mechanical thrombectomy. So, the idea is that mechanical thrombectomy is not competitive with IV tPA; it is complemented. You know, there’s some cases where, honestly, we started the IV tPA, we do the mechanical thrombectomy, and given the fact that they started the IV tPA, the clot suctions up much quicker, and/or we’ll do an angiogram and the clot’s now gone, in rare cases. But, you know there’s situations where you don’t want to stop and wait and see if the patient gets better because you’re already putting into that situation of 20 percent-plus decline in their outcome. IV tPA is usually given earlier, typically under three hours, but up to 4.5 hours, but if you have a patient who is beyond that 4.5-hour period, but whose imaging shows evidence of a large-vessel occlusion, but still preservation of a large portion of brain, and that the core of the infarct doesn’t exceed a certain volume, those patients may not be able to get tPA, but we can do a thrombectomy. And, then you have another group of patients who may have just woken up from a stroke. Those wake-up strokes beyond the typical 6 hours may also benefit from mechanical thrombectomy.

Host: Is six hours the typical window for a patient to receive mechanical thrombectomy?

Dr. Armonda: The sooner, the better. The way it works, basically, is that the best outcomes are those patients treated under three hours. Time is brain here. Each 30-minute period of time lost is 10 percent loss of good outcome. So, if you compare outcomes in patients who are treated within a three-hour period versus patients within a five-hour period, the difference could be as much as 70 percent good outcome versus 50/50 percent good outcome, and maybe even lower. So that means that you start at 50 percent and then it decreases from there at the five-hour mark. Beyond five hours, it may actually get lower and lower, so five hours is usually, you know, the optimal time period that we really shoot for. But, the idea here is that you want to be able to get to patients as quickly as possible. And, you know, there’s a couple areas of delay. You know, one of the areas of delay is in patients and families just recognizing signs of a stroke. Does the patient have problems with their speech? Does the patient have a problem with a paralysis? Does the patient have asymmetry in terms of their face? Is it arm weakness? Is it leg weakness? Is this something new compared to before?

Sometimes, it could be a level of consciousness problem, and if they have problems speaking, they may not necessarily be able to communicate this, especially for elderly patients who may live alone. The other problem is that we’re also seeing an increase in stroke in the young. There’s been some reports on this just recently. And, the problem with stroke in the young is that, two things. One is that the individual is young and he may actually deny or she may deny that they are actually having a stroke. They may attribute it to, you know, a muscle spasm or problem with overexertion. The other problem is that because they are in the younger ages, when they present to the emergency room, they may not get as rapidly triaged because an ER physician may not be thinking of a stroke in a young person. But again, sudden-onset symptoms involving a paralysis, you know, the evidence of eye preference where they may be looking to one side, paralysis of their arm, leg, and/or face asymmetry should make, you know, ER physicians, family members, EMS think of a large-vessel occlusion. And it’s different. You know, there’s not many hospitals in this area that have the ability to do emergency thrombectomy. You know, emergency thrombectomy is a very specialized procedure that is best done by practicing neurointerventionalists, people who are using the tools, the devices in that circulation, day in and day out. It’s not appropriate for a peripheral interventionalist or cardiologist, or someone who dabbles in peripheral vascular to now be trying to attempt mechanical thrombectomy in the delicate vessels of the brain. They’re at much more risk for causing damage. So, it demands a lot from a hospital system.

Host: How do the specialist teams work together to treat people who need mechanical thrombectomy?

Dr. Armonda: So, it’s a—it’s a critical balance of multiple different team members. We’re a comprehensive stroke center, the first one in DC. We’ve had this ability to sort of bring the expertise and scientists from NIH Stroke Team together with the neurointerventionalists and with our capacity to do this emergency work, and it transfers from emergency work from trauma to emergency work to stroke care, and it goes hand-in-hand. It means that the hospital system has to be very well streamlined in terms of the efficiency of receiving patients, rapidly imaging patients and being able to have a whole team of individuals to treat this individual. So, it’s not just the neurointerventionalist. It’s also, you know, the stroke team, neurologists who are screening these patients. It’s the imaging team in terms of CT or MR personnel from radiology who are screening them. It’s the anesthesia team who is supporting the anesthetic during that patient’s neurointerventional procedure. And, then the follow-on care in terms of management in the ICU is absolutely critical. You know, you can win the battle in the angio suite and open up the vessel, but if you can’t control the blood pressure, you know, you’re at risk for that patient converting this dry stroke into a hemorrhagic stroke, and that could be fatal. You know, a lot of patients don’t know the difference between a primary stroke center and a comprehensive stroke center. And, they see a sign that says “stroke center,” so they bring their loved one to the closest hospital, and that might be a block away, a mile away, but they realize that that patient can’t get – their loved one can’t get an emergency thrombectomy at that hospital, and then they have to be transferred. So when they look at studies where patients had to be transferred, it was a minimum of 1 hour in the best of scenarios for that patient to then make it to another hospital, so that’s already at least a minimum of a 20 percent decline in outcome. So that’s why it’s so important in terms of, you know, getting the message out there to EMS, getting the message out there to other clinicians to ensure that, you know, rapid transfer is made and rapid evaluation is made, patients are brought to the right place.

Host: So, it’s really a combination of fast action and the hospital team working together?

Dr. Armonda: The idea is, once you see the patient in terms of early warning systems throughout your network, you want to start mobilizing the neuro-rescue. You want to start mobilizing the thrombectomy team. That means, you know, a team of nurses, technologists, anesthesia and the neurointerventionalist. And the unique thing about what we have here is that we have radiologists, neurologists, neurosurgeons all working together in the same procedure. So, there might be a patient who presents with a stroke and it might be a neurosurgeon doing the thrombectomy because he’s on call that night. Or it might be a radiologist doing it, or it might be a stroke neurologist who is neurointerventional-trained because all of us, from different specialties, work together in the same arena, and we work together day in and day out, so we have a very comprehensive team approach.

Every single step of the treatment care has to be the most efficient workflow. It’s like a car pulling in for a pit stop. You know, you have to work in parallel. You can’t work in series. Everybody has to have a job and they have to sort of approach at the same time. So, in trauma, we do the same thing. We have to be able to rapidly get the patient from the door to imaging, and then from imaging, if they’re a candidate, to the interventional suite. You know, and our interventional suites here are state-of-the-art. We have two biplane machines. What biplane means is that you’re imaging both from the frontal plane and the lateral plane. You know, these are basically endovascular operating rooms. And, both are set up for anesthesia, so we could literally run two thrombectomy cases at the same time. There’s very, very few institutions around the country that could do that, and we have the personnel to do that. So, it’s not just, you know, have the rooms because an x-ray machine can’t run itself. It’s having the nurses, it’s having the technologists, it’s having the anesthesiologists. And, the beauty of our anesthesiologists, they are very adept to patients with multiple comorbidities. They are very adept of emergency airway, you know, from all their experience with cardiac patients, all their experience with trauma patients. Anesthesia is one of the most solid services that we have here. And you have to have that because while you’re busy trying to get access into their arterial system and get your catheters up there, you want someone who is maintaining the patient’s blood pressure, who’s securing the patient’s airway, who’s ensuring that the patient remains immobile so that you’re not dealing with a moving target. You know, and that’s a difficult situation because these patients are not intrinsically healthy patients. These patients usually have problems with their lungs, usually cardiac problems as well, variations of all kinds of blood pressure problems, kidney problems, and so forth. So, it takes a real level of sophistication and team approach.

Whenever I see a patient come back in a clinic or a patient who, and family, comes in my office and thanks me, I try to redirect those patients back up to the ICU so they could visit with the nurses who took care of them. They could thank the PAs who were part of their care, and the nurse practitioners, because we never do anything here as a single individual. Everything that we do is as part of the team. And, the best things we do are with the best teams, and I think we really have one of the best teams here.

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No one knows why stones and tumors sometimes form in salivary glands. Most are not cancerous, but if they aren’t treated promptly, they can be big trouble. Dr. Matthew Pierce discusses the risk factors and how advances in technology make treatment easier than ever.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thank you for joining us today. We’re talking with Dr. Matthew Pierce, an otolaryngologist and head and neck surgeon at MedStar Washington Hospital Center. Welcome, Dr. Pierce.

Dr. Pierce: Thank you.

Host: Today, we’re talking about salivary gland disease, which is a grouping of conditions that affect oral health. The salivary glands produce saliva, which helps digest food and protect the teeth from decay. Salivary gland diseases can cause discomfort and can lead to serious health concerns that affect the mouth and lips. Dr. Pierce, what are some of the more common salivary gland diseases you treat?

Dr. Pierce: So, I treat a multiple array of salivary gland diseases, everywhere from benign diseases to cancers of the salivary glands. Um, some common ones that I treat are stones of the salivary gland using a multiple array of techniques, including sialoendoscopy, which is small scopes in the salivary glands. In addition to stones, I also treat patients who have had chronic infections or inflammation of the salivary glands, as well as tumors of the salivary glands, including the parotid gland and the submandibular gland. And those can both be cancerous or benign tumors of the salivary glands.

Host: How many salivary glands does the average person have?

Dr. Pierce: So, everybody has four major salivary glands. They have the parotid glands on either side of the cheek as well as submandibular glands below the mandible, below the jawbone, as well as multiple minor salivary glands throughout the mouth - in the palate, underneath the tongue, and in the cheek mucosa itself.

Host: So, you have scopes that are small enough to fit within those glands?

Dr. Pierce: We have scopes that can fit into the major salivary glands, in the ducts that drain the major salivary glands. The scopes are very small and they can go in through those glands and we can look for strictures, or narrowing, of the ducts as well as...we can look for stones and potentially even remove some small stones from those ducts.

Host: What would cause a stone to form in the salivary glands?

Dr. Pierce: So, we don’t really know the exact way that these stones are formed. We do know that patients that are dehydrated, that don’t drink enough fluids, are more prone to it, as well as patients that have an increased amount of exogenous calcium or taking calcium for other reasons sometimes can lead to stones, but not for everybody. So, the shorter answer is that we don’t really know what causes these in certain people.

Host: So, if someone has a salivary gland disease, what symptoms would prompt them to come to the doctor?

Dr. Pierce: The major symptom that most people notice is swelling in the area. So, swelling in the cheek or swelling just beneath the jawbone, and that could be in the form of a lump, it could be in the form of an infection, or it could also be associated with pain. Stones often present with recurring swelling and pain that then resolves and then comes back. This can be diagnosed through physical exam as well as certain x-rays and imaging techniques.

Host: So, you mentioned a couple of reasons why doctors think somebody might develop a salivary gland disease. What are some of the things that patients can do to perhaps reduce their risk for this happening to them?

Dr. Pierce: Well, as I mentioned, uh, one of the best things that you can do is staying well hydrated. But, other than that, there’s not much that one can do to prevent stone formation, or tumor formation, either. There are some rare tumors of the salivary glands that can be associated with smoking, but in general, most of the tumors of the salivary glands are not associated with smoking or any other…other type of lifestyle changes or anything like that.

Host: So, we’re talking about a very small gland. How large...how large are the tumors that you find within the salivary glands?

Dr. Pierce: The average size of tumors that I take out of the salivary glands are usually about the size of a marble. Sometimes, they can be as large as a golf ball size, but they’re not usually very big. Sometimes, they can get very large and cause discomfort, but the majority of tumors of the salivary glands actually don’t cause many symptoms. Um, and they’re actually quite small and often they’re found incidentally when getting imaging for other illnesses or other issues.

Host: So, compared to the size of a normal or a healthy salivary gland, how big would the marble-sized tumor be compared to that regular gland?

Dr. Pierce: So, the average-sized gland--obviously, it varies from person to person, but it could be as much as double in size. Or, you know, you may just feel a small little nodule in your cheek or just underneath your jawbone. They typically don’t increase the size of the gland itself. Again, as I mentioned, maybe you might feel a little nodule inside your cheek or your neck there.

Host: What are some of the risks to an individual if they don’t get this treated or if it goes undetected?

Dr. Pierce: Uh, the vast majority of tumors in the salivary glands are benign, meaning they are not cancer. However, there are certain ones that if you don’t treat, they continue to enlarge and even can turn into cancer if you don’t treat them and…and take care of them in a timely fashion. So, there are risks to not doing anything. There’s also the risk of, uh, stones or other tumors causing obstruction, causing recurrent infections and inflammation, and causing swelling of the actual gland.

Host: So, all of that would affect, you know, what…what body functions?

Dr. Pierce: So, it doesn’t really obstruct blood flow. It doesn’t really...it wouldn’t really affect any body functions. Even if you do have an obstruction of one gland, usually it does not cause enough decrease in flow. You have enough accessory glands to where it’s not gonna really cause dry mouth unless you have some other type of disease causing decreased salivary flow in your other glands as well.

Host: Could you talk a little bit about your patient population? Are you usually seeing this in younger folks, older folks?

Dr. Pierce: The majority of salivary gland diseases are...are seen in older people in their 40s, 50s, 60s, and above. And the reason for that is it takes a while for these tumors to grow as well as the stones to form. This is something that happens over the course of many years, um, for salivary gland stones. And, uh, certain tumors are seen mostly in the elderly. However, it varies depending on what type of tumor it actually is. But we usually see these in the adult population.

Host: How do you work with other members of your team or other colleagues are MedStar Washington Hospital Center to care for patients with these diseases?

Dr. Pierce: So, we work very closely together, especially with the endocrinology team. A lot of patients who have received radioactive iodine may be more prone to developing strictures and salivary gland diseases. And so, we work very closely with them to find these patients that may be suffering from post-radiation salivary dysfunction. We also work closely with the radiation oncologists in finding these patients and help treating these patients. Uh, certain patients that have cancers of the salivary glands often require further treatments in addition to surgery, and this may be radiation and/or chemotherapy, and so we work closely with our colleagues there as well.

Host: If a person undergoes radiation for any type of cancer, you know, in the chest or the neck or the head area, is the dry mouth or are those salivary issues pretty common?

Dr. Pierce: So, patients that receive radiation to the head and neck area often do have problems producing saliva and they often have dry mouth afterwards. It’s a common side effect of radiation treatment. Radiation in other areas does not cause that same type of dry mouth. It’s pretty unique to patients who have had neck cancer and receiving radiation to that specific area. And the reason for that is because the radiation dose is actually concentrated in the area that has the cancer, and, unfortunately, the salivary glands are in that area. And so, in order to get rid of the cancer completely, a lot of times the salivary glands are affected. And this does not happen in all patients that undergo radiation, but a good portion of them it does.

Host: Is there any, uh, medication therapy that you would give these patients to control the size of the tumor?

Dr. Pierce: Um, initially, there is not a medication to treat cancers or tumors of the salivary glands. These are typically treated with surgery up front. For patients who have dry mouth, there are certain mouthwashes and medications that we can give to these patients to help saliva production. In patients that have salivary gland stones or strictures, again there’s not really an oral medication that we can prescribe that’s going to help with these conditions. These are typically surgically treated in the right patient population.

Host: Why should a patient choose MedStar Washington Hospital Center over maybe another physician in the community?

Dr. Pierce: MedStar Washington Hospital Center is a tertiary referral center and we have a very unique capacity to collaborate with our colleagues in other specialties. And we treat everything from the most simple to the most complex salivary gland diseases. And, by coming to one center where you get very comprehensive type of care, you avoid delays in care as well as you get the most state of the art treatment for, um, whatever salivary gland disease you may have.

Host: Could you talk about any patient success stories that you might have from your population?

Dr. Pierce: Um, I’ve had quite a few good success stories, uh, both salivary gland stones or patients who have had recurrent inflammation of the salivary glands, uh, using this endoscopic technique. I had a patient that had a tumor of his parotid gland and he elected to undergo surgery to remove this, and he underwent a successful surgery. He was sent home on the first day after surgery. Um, and he is extremely happy with his result and fortunately, it was not a cancer and he is done with treatment.

Host: What is the technique that you use to do these scoping procedures in patients? Are they under anesthesia? How does that work?

Dr. Pierce: The sialoendoscopy, which is the scope for salivary gland diseases such as stones, is typically done with the patient asleep. There are some physicians that will do this with the patient awake. And a lot of times it depends on the patient preference. It’s a relatively straightforward and low-risk procedure, but usually the patient requires some type of sedation for comfort.

Host: And is it typical that they would have that similar result, where they can go home the next day?

Dr. Pierce: The patients that have the scope, uh, for either a salivary gland stricture or salivary gland stone usually go home the same day. Uh, the patients that require excision of a salivary gland usually stay one night in the hospital.

Host: Do they have any recovery time for stitches or anything like that?

Dr. Pierce: For removal of the salivary glands, they require an incision in either the neck or right in front of the ear. The incision is usually well hidden and the scars are kept to a minimum in the patients that require excision of the gland or excision of a tumor. Uh, the patients that have stones or the patients that have the, uh, sialoendoscopy procedure do not require stitches.

Host: Thanks for joining us today.

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Everyday choices affect our colorectal cancer risk – even what we eat and drink. Dr. Brian Bello discusses how eating a high-fiber diet and cutting down on certain beverages can help reduce your risk of developing colorectal cancer.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thank you for joining us today. We’re talking with Dr. Brian Bello, a colorectal surgeon at MedStar Washington Hospital Center. Welcome, Dr. Bello.

Dr. Bello: Thank you very much for having me.

Host: Nutrition and dietary factors have been tied to a wide range of diseases in the past decade, including colorectal cancer. The choices we make every day about what we eat and drink can have a dramatic effect on our current and future health. Dr. Bello, what food and beverage options are most alarming to you as a colorectal surgeon?

Dr. Bello: Well, as a colorectal surgeon, we tell them to try to avoid processed meats, like bacon, sausage, ham and jerky, beef jerky. Unfortunately, the bacon and ham and sausage are the things that people love and like to eat, especially and also red meat, so we just try to tell them to substitute leaner meats or skinless poultry or fish, and that usually can help them.

Host: What is it about the red meat, specifically, is it more harmful as compared to leaner meats?

Dr. Bello: Yeah, scientists don’t know for sure. It’s probably the way that the meat is processed and preserved - maybe some chemicals there, it’s unclear.

Host: So I know we talked about food, are there any drinks that may contribute to a person’s risk?

Dr. Bello: We know that obesity and diabetes are risk factors for colon cancer. So, we know that people that drink a lot of these high sugar beverages may get diabetes. So, we usually tell people when we’re counseling them about their diet, to try to avoid those high sugar drinks, those energy drinks, those fruit drinks, and tell them to drink water, low dairy.

Host: And what about alcohol?

Dr. Bello: Alcohol, if consumed in a mild or moderate fashion’s okay, but we tell people not to drink excessive amounts of alcohol.

Host: Are your patients ever surprised when you mention diet and nutrition as a factor in colorectal cancer risk?

Dr. Bello: Yeah, people seem to be surprised, and many people don’t even realize that their diet is not a healthy one. So, usually we go over their usual daily intake and figure out what they can do better. We try to give them a lot of education about this. We try to give them menus and lists of things that they can do and eat so that they can have a better diet. We also find it helpful that, if they come with a family member, specifically the person that cooks for them, that they’re involved in that discussion.

Host: Now you mentioned some of the things that you recommend that your patients avoid. What would you consider an ideal nutrition plan, say for a lunch or a dinner, for someone at average risk of colon cancer?

Dr. Bello: We always recommend our patients be on a high fiber diet. So, when people come in and they tell me they’re eating a lot of red meats and processed meat, I immediately try to give them some education. I tell them what foods are rich in fiber which include raw fruits, like apples and bananas; vegetables, especially raw vegetables, like lettuce and spinach; legumes, like beans, all have a lot of good dietary fiber which has been associated with less colon cancer risk. So, it’s always good to have a variety of food, specifically a variety of fruits and vegetables, whole grains. I mentioned a high fiber diet - usually about 25 to 30 grams a day. Skinless poultry and fish are good. Nuts and beans. And we try to tell them to limit these things that aren’t good for you, so fatty food, fried food, sweets, foods that are high in sodium - those are the key things to limit.

Host: Should patients who admittedly make poor nutrition choices, or just really enjoy junk food, be screened more often for colon cancer than say an individual with a healthier diet?

Dr. Bello: That’s a good question. I’d say we haven’t had enough data to make that choice yet. I think we still take in account the other risk factors where the patient symptoms, are they having symptoms like bleeding or abdominal pain, change in their bowel movements. I think poor nutrition alone, we don’t recommend that they get screened more often than other people. That would probably lead to unnecessary tests. But I think we take the whole picture and see what their other issues are and what their other risk factors are.

Host: Could you discuss your team approach to care when it comes to balancing nutrition with colon cancer screening and awareness?

Dr. Bello: Yeah, so here at MedStar Washington Hospital Center, we have different experts in different fields. So, not only do we have surgeons and oncologists, we have nutritionists that can help patients find a good balance of what’s healthy and what tastes good. That’s an advantage that we have at Washington Hospital Center.

Host: So, why is MedStar Washington Hospital Center the best place to seek that colon cancer screening and guidance?

Dr. Bello: Yeah, I think we see a lot of colon cancer - we’re a high-volume center. So, a lot of us do primarily colon cancer and rectal cancer - those are our primary patients, such as myself and my colleagues. We do present any new colon cancer at a multidisciplinary tumor board, where there’s a lot of experts from different fields weighing in. With that, we come up with the very individualized treatment plan for each patient. So, because of that, we’ve shown that those patients have better outcomes.

Host: Could you share any success stories from your patient population, perhaps an individual with a very poor diet or a cancer risk that maybe turned their diet around?

Dr. Bello: Yeah, I think I get the most satisfaction when I’m seeing patients for a long time. For example, if I do a colon surgery on them, I usually follow them for several years, up to five years after surgery. And then I see that they’re following my recommendations of leading a good, healthy lifestyle. They’ve stopped smoking. They’re eating better. They’re eating more fiber in their diet. And they’re exercising. Those are the patients I feel that we’ve helped.

Host: Thank you for joining us today, Dr. Bello.

Dr. Bello: Thank you very much. My pleasure.

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An overactive bladder isn’t just part of getting older. Dr. Andrew Sokol, a female pelvic medicine and reconstructive surgeon, discusses the symptoms and causes of overactive bladder, as well as what we can do to treat it.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel, where our healthcare team shares health and wellness insights, and gives you the inside story on advances in medicine. In today’s episode, we talk to Dr. Andrew Sokol, a female pelvic medicine and reconstructive surgeon at MedStar Washington Hospital Center, about overactive bladder. Dr. Sokol discusses why this very common condition is not a normal part of aging and how it can be treated with both lifestyle changes and more advanced treatments. He also talks about why that 8 glasses of water you’ve been told to drink may be doing more harm than good.

Host: Thanks for joining us.

Dr. Sokol: Thanks so much for having me.

Host: Why is this topic top-of-mind today? What’s important to know?

Dr. Sokol: Right, so, overactive bladder is this constellation of symptoms that is incredibly common. The term really refers to the urge, the need to run to the bathroom, urgency, frequency, which is going to the bathroom more than normal, with or without leakage, and it’s the type of leakage where you can’t get your key in the door or get your pants down fast enough. So, the prevalence or the amount of people who have this in the community is incredibly high. Actually, incontinence or leakage of urine is the second most common reason for admissions to nursing home facilities, but a lot of younger people also experience these symptoms.

Host: So, when we say younger people, in this case, how young can this happen?

Dr. Sokol: Yeah, I mean the, the, symptoms can occur even in children, of course, but oftentimes they’re looking for different sources, so I’d say when we’re talking about younger women, it tends to be women ages 18 through menopause, and then women who are after the age of menopause being the older women.

Host: And how many, how many, people have overactive bladder symptoms?

Dr. Sokol: So, I mean the absolute numbers are very high. I think that we can’t come up with an absolute number because it’s underreported. People think it’s a part of, normal part of aging, but I can tell you that by the time a woman turns 80, there is a 20 percent chance that she’ll have surgery for a pelvic floor disorder. So pelvic floor disorders, of which overactive bladder is one, are more prevalent than breast cancer. So, it’s incredibly common and the, the, amount of people who get them increases as age increases, so there’s a prediction that there will be a doubling of these types of issues by 2050 and that surgeries for pelvic floor disorders will double by 2050 as well, so it’s very, very common.

Host: And the increase would be? What’s the reason for the increase?

Dr. Sokol: Mostly due to aging. So, we do, we do, also know that the symptoms of urgency and frequency in overactive bladder are more common in women who are postmenopausal or whose ovaries have stopped producing the female hormone estrogen because the skin that’s around the opening of the urethra, the tube that you urinate through, is estrogen responsive, and so that dryness and irritation and the shift of the flora make women more prone to those symptoms.

Host: Can you share some of the most common causes?

Dr. Sokol: Right, so unfortunately the most common cause is over-consumption of fluid. There’s a broad misconception that one needs to drink a certain amount of water and it is typically quoted at 8 glasses of water, which is based on absolutely no research, but has become almost dogma. And then the second most common would be the over-consumption of bladder irritants and diuretics like coffee, tea and soda. Really, eliminating those things, cutting down on the fluids and having good toileting habits can take care of a lot of the symptoms of urgency and frequency, sometimes decrease leakage or the need to wake up at night, which is called nocturia. And, so I’d say those are the most common causes of overactive bladder. Actually, 90 percent of overactive bladder is called idiopathic, meaning that there’s no underlying anatomical or neurological cause, 10 percent as an underlying cause.

Host: So, in those 90 percent of cases, what are some tips?

Dr. Sokol: So, yeah, so it turns out that there’s a lot of good tips for this area. And so, because so much of this is behavioral, the first step is always behavioral. That’s actually what’s recommended by the guidelines of the groups that treat these disorders. So, the first step, I would always tell someone to cut the fluids down and I really say there is no magic number for the amount you drink, just drink when you are thirsty. I always would advocate for people who are having urgency to run to the bathroom, timed urination, so just go to the bathroom regularly, 6 to 8 times a day. Stopping fluid intake within three hours of going to bed is a very effective way of decreasing the need to wake up to go to the bathroom, and then pelvic floor squeezing exercises, which are called kegels, which have been around forever because they actually work. That’s a great way to defer the urge. In other words, someone who’s trying to get into the door, get the key in the door and is having the overwhelming urge oftentimes can squeeze those pelvic floor muscles and the urge will pass and it’ll give them time to calmly walk to the bathroom. So that’s really – those are the first steps that we always take.

Host: And then, how about the other 10 percent?

Dr. Sokol: Yeah, so 10 percent of women who, who have symptoms may have an underlying problem. The most common is, of course, urinary tract infections or bladder infections. So, as a provider or physician, when someone comes to me, my job is to, of course, rule out the uncommon things that can cause it; they’re generally easy to rule out. The first thing that we’d always make sure is that there is no infection, not only urinary tract infections, but often sometimes making, make sure there are no vaginal infections which can cause these symptoms. Another area that we have to rule out is voiding dysfunction, the inability to empty the bladder completely, which in women is, of course, more uncommon than in men because women don’t have prostates, but it can happen when there’s vaginal relaxation or prolapse, which is something that I treat for a living. It can happen in women who have underlying disk disease, like lower disk disease in their spine. It can happen in women who have had strokes. It can happen in multiple sclerosis. It can happen if there’s something obstructing the urinary system, like prior surgery for urinary leakage. And so these are the less common things that a specialist would rule out in someone who’s got persistent symptoms that didn’t get better with the behavioral stuff and some of the other simpler things we do.

Host: What are the most common ways to treat overactive bladder?

Dr. Sokol: Right, so, the recommendations, the guideline recommendations, start with behavioral therapy. That’s everything that I just said. That’s the fluid management, the toileting and the kegels. The second step is often female pelvic floor physical therapy. We have a whole network, particularly in this greater Washington region, of physical therapists who help defer the urge, train the pelvic floor muscles so that the muscles are strong, and help someone have time to get to the bathroom. And, then the third step is, there is a whole class of medication that’s used to treat the symptoms of urgency, frequency or urgency incontinence. And these medications have been around for a long time, so this class of medications for overactive bladder is called anticholinergics. They’re reasonably effective, but they’re most effective when they’re done with the other treatments. And, then there’s a newer medication that was recently released over the past 5 to 7 years that gets around some of the annoying side effects of some of these medications. The medications used to relax the bladder can also cause dry mouth and dry eyes and constipation, and so that’s sometimes sort of a stumbling block for people using these medications. I’d say most people do not start medications right away. We would always start the conservative things first, and then, if those things fail, then we would institute an evaluation of the urinary tract or other causes. And, if there was nothing found, there’s lots of newer things available as well, so that includes acupuncture of the ankle, which has been shown to work as well as the medicines, and then Botox, which is very effective. It is done right in the office. It’s a medicine that’s put right in the bladder to relax the bladder wall. And, then finally, there’s something called an InterStim. Which is, basically, it’s an outpatient placement of a bladder pacemaker, which can be used for people who have failed other therapies as well. So, lots of things we can do for overactive bladder symptoms nowadays.

Host: So, how do you help women get around some of the emotional issues, right? I mean if you have to run to the restroom all the time, at some point.

Dr. Sokol: Right. So, yeah, women with overactive bladder sometimes feel really socially isolated. They don’t – try not to go out so much because they find themselves being the person that has to get up from dinner three times. So, I mean, I think the most, the best way of sort of allaying their fears is, first of all, just letting them know how common this problem is. I think if people talk to their friends they’ll—It’s unbelievably common. The second is letting them know that there are things that can be done to treat the symptoms—there are effective treatments. And so, one of the, I think, most common things that we battle with, as urogynecologists, is this thought that it’s a normal part of aging, which is completely untrue, not only for overactive bladder, like we’re discussing, but also for leakage of urine with physical activity, which is called stress urinary incontinence. And there are very effective treatments. It’s not a normal part of aging and someone who’s experiencing these symptoms should/can see someone who can help them with their symptoms. That’s really reassuring to people because a lot of people, and even primary care providers, sometimes don’t understand that there are very effective treatments for a lot of these symptoms. I think the, sort of the takeaway point, maybe, would be that, that these symptoms of urgency, frequency and sometimes urgency incontinence, can’t make it to the bathroom, are incredibly common, but simple behavioral things are sometimes effective in treating those symptoms. If those symptoms persist despite moderation, then seeking care can be very fruitful because there are a lot of things that are available nowadays that can treat these symptoms and really decrease suffering, decrease the need to use pads, and really help people with these symptoms.

Host: Thank you for joining us.

Dr. Sokol: Thanks for having me.

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Chronic pelvic pain can cost women productive time at work and lost opportunities with family and friends. Dr. Vadim Morozov discusses which populations are most at risk for chronic pelvic pain and the personalized treatment options that are available.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. Vadim Morozov, a gynecologic surgeon at MedStar Washington Hospital Center. Today we’re discussing chronic pelvic pain which can be a symptom of a variety of gynecologic disorders. Welcome Dr. Morozov.

Dr. Morozov: Thank you. Glad to be here.

Host: What do you mean when you say chronic pelvic pain?

Dr. Morozov: So, chronic pelvic pain, by definition, a pain in your pelvis that’s been there for longer than six months duration. It could be caused by multiple reasons, but most common one in the female population are things like endometriosis, fibroids, scar tissue.

Host: What symptoms might prompt a woman to seek treatment?

Dr. Morozov: So, things like very painful menstruation. Pain with intercourse for, example. Pain with going to the bathroom and just the one that doesn’t go away - the one that’s not getting better with just something like Motrin or Advil. Those are the conditions that I would suspect that she has something else and needs to be addressed.

Host: When we’re talking pain, are you talking a burning sensation or cramping? What are...what are women complaining about?

Dr. Morozov: That’s a very interesting question. So, actually women can complain about any type of pain and in the pelvis, it’s highly non-specific, meaning you could have a certain condition but the pain could range from, as you mentioned, burning, pinching, to doubled over with stabbing—“I can’t even take a breath.”

Host: Is it always in the pelvic area or does it radiate?

Dr. Morozov: It does go to other things and other parts of the body. For example, pain with endometriosis’ very commonly go down toward the back. It can go down the legs. It can shoot down toward out the stomach or in your buttocks. It’s very difficult to pinpoint the location of the pain and the specific cause of the pain in a lot of cases.

Host: Who is most at risk for chronic pelvic pain?

Dr. Morozov: Obviously, uh, women are 95 percent. So, if you look at the all population of chronic pelvic pain, 95 percent of the chronic pelvic pain happens in the female population. We’re still unsure why it happens. Males do too, but very unfrequently, as you can, tell from that statistic. If you had endometriosis in your family—if your mother or your sister was affected by endometriosis, you are much higher chance to have an endometriosis and pelvic pain. If you had fibroids in your family, you are at a higher risk of having a fibroid. If you’re African American, for example—race plays a specific role. African Americans statistically are three times as likely to have fibroids as white women. Asians, for example, almost unheard of having fibroids on the other hand. So, very specific genetic component that plays a role.

Host: Is there any sort of genetic testing or any testing that can help determine a woman’s risk?

Dr. Morozov: Unfortunately not. There are multiple companies that are trying to get commercial testing on the market. So far, we do not have anything that can predict a risk of developing endometriosis. Or even a chronic pelvic pain for the condition. The interesting thing about chronic pelvic pain and endometriosis or fibroids is that you could have endometriosis and not have pelvic pain. And almost the opposite is true. You can have the most severe pelvic pain and then, when we investigate, you will have very minimal or very mild endometriosis. So, there is no direct correlation between the cause and effect.

Host: Once a cause is defined, if a cause can be defined for chronic pelvic pain, what are some of the treatment options that are available?

Dr. Morozov: We usually start with discussing what causes the pain, as you said, right? So, if we can identify that, let’s say, it’s a fibroid, for example, or endometriosis or pelvic scar tissue (adhesive disease), usually we try some medical intervention in the beginning. Maybe some sort of a non-steroid anti-inflammatory, otherwise known as Advil, Motrin, and Ibuprofen. Maybe we try to have some sort of a physical therapy intervention. In my experience, in the majority of cases, that doesn’t work. Very few times it actually will make women asymptomatic, meaning she’s happy with that treatment and done. The next step would be the surgical intervention.

So surgical intervention, nowadays in 21st century, we truly believe it needs to be done minimally invasive, laparoscopic way, meaning small, tiny, less-than-an-inch incisions in the belly with one of them in the belly button. Go home the same day within 2-4 hours. Very quick recovery time. Almost no blood loss. Having said that, the surgery just the first step in the long way to recovery. So, identifying and treating the cause of the pelvic pain, let’s say an endometriosis or whatever, will not make you pain free unfortunately. And that’s a very complicated topic and people wrote books and chapters and actually I wrote some chapters and research and that. You will need to do a lot of other things on top of the surgery, meaning we will have to suppress your hormonal fluctuation one way or the other. The fewer menstrual periods you have as a woman, the shorter they are, the better your chance of not having the recurrence of endometriosis. Pelvic physical therapy would be the next step. There is a highly interesting phenomenon that’s called central sensitization and to explain it in the lay terms, this is where your central nervous system gets used to the pain over many, many years. And technically speaking, no matter what we do in your pelvis, you still feel the pain. So, we’ll have to address that problem. So, it’s a multi-specialty approach before we can get patient to the level where she can function comfortably.

Host: If a woman, say, doesn’t have severe symptoms or has just gotten used to living with them, is there a risk for leaving chronic pelvic pain untreated?

Dr. Morozov: Not the pelvic pain. Now obviously, the chronic pelvic pain is, puts the huge burden on society. The estimate that it costs several billion dollars a year for economy from lost wages, lost time from work, lost...lost time from spending with your family and kids. Endometriosis, for example, left untreated, could become severe enough and could affect other organs next to it—so it could affect your bowel, it could affect a kidney. And I have dealt with cases before where the endometriosis was bad enough that the kidney almost died off because it was obscured in the outflow. So, eventually, it can get you in trouble.

Host: Have you had any women come in with chronic pelvic pain who just had a very severe condition and you were able to help them and get them back to a functional level?

Dr. Morozov: Absolutely. That’s what we do. I mean, the worst endometriosis - although some expert will debate - is called a stage 4 endometriosis - was severe. And we do surgery, we restore the anatomy, we remove the endometriosis that affects the organ. And, they seem to be doing great. They’re fully functional, they still have pain here and there, but at least we can get them to the point where they can function on an everyday basis and have a normal life.

Host: Do you have any one patient that stands out in particular who was maybe very severe and has done really well?

Dr. Morozov: Yeah, we have, just recently - about a month ago - I did a surgery on a patient and she’s great, she feels absolutely phenomenal.

Host: Are there any environmental factors associated with the risk of endometriosis or other chronic pelvic pain?

Dr. Morozov: Absolutely. There’s been a lot of research done on the environmental factors in endometriosis. One of them is well known, organa pollutants or organa phosphorus components that exist everywhere. Actually, very common product on the market is a sunscreen that has them. And I’m not abdicating, I’m not saying don’t use sunscreens, but we have to be cognizant about what we buy and use. There’s been studies saying that the specific components that are used in the industry actually produce both to develop an endometriosis.

Host: Are you conducting any research, you or your colleagues, regarding chronic pelvic pain that women in the community should know about?

Dr. Morozov: Not currently. I mean, I’ve been involved in the research for chronic pelvic pain and endometriosis. The problem with the research in this arena is that it’s hard, as I mentioned before, to correlate the extent of a disease with the sensation of pain. Multiple commercial companies been in the market trying to develop some sort of the either medication or pain control, endometriosis control or fibroid control drugs and some of them are successful, majority are not. So, it’s a tricky area of research.

Host: What innovations in chronic pelvic pain do you hope to see in 10 to 20 years?

Dr. Morozov: So, there is some research right now that I find very fascinating. There’s a company that’s testing the RNA fragments, which is a blood sample, and actually they claim they can get yours out of your saliva, so it’s just a little swab out of the mouth. And they are saying that if you can analyze, sort of fragments of RNA, which is nucleic acid in your blood, they can predict whether you have an endometriosis or not. So that would be very useful diagnostic tool which we don’t have right now at all. As I said, the only way to diagnose endometriosis is to perform the surgery, which, of course, carries the risk of any surgery. Bleeding, infection, you name it, damage to the surrounding organs. If we can have a test, either by blood drawing or by swabbing the mouth and sending it to the lab, tells you as a patient and me as a physician that you have a certain degree of, you know, sensitivity that that will be the endometriosis. What is more important, that test would be absolutely phenomenal to see the progression after the treatment. So, let’s say we do the surgery and then we test that patient six months to a year later and see if that test becomes negative. That would be even better application.

Host: Why is MedStar Washington Hospital Center the best place for a woman to come for chronic pelvic pain care?

Dr. Morozov: Because we have the best interdisciplinary team on the East Coast. I mean, our Center for National Advanced Pelvic Surgery has multiple specialists that deal with nothing else but with chronic pelvic pain, fibroids, endometriosis. We have multiple fellowship-trained urogynecologists. We have a urologist that works with us with interest in woman health. So, this is a place where, if you have a problem, you would expect that they will be detected and solved.

Host: Thank you for joining us today, Dr. Morozov.

Dr. Morozov: Thank you for having me.

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Many people use health and fitness apps to set exercise and dietary goals, but these apps can also help diagnose and manage heart conditions. Dr. Allen Taylor, Chief of Cardiology at the MedStar Heart and Vascular Institute, discusses the evolving role of health and fitness apps in heart care.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thank you for joining us today, we’re talking with Dr. Allen J. Taylor, Chief of Cardiology at MedStar Heart and Vascular Institute and MedStar Washington Hospital Center. Today we’re talking about the future of wearables as they relate to heart health. In 2017, Apple launched the Apple Heart Study App which is intended to pair with the Apple Watch’s heart rate sensor to notify patients of irregular heart rhythm activity. This is a next step in technology that may help patients and cardiologists monitor and manage heart conditions outside the clinical setting as well as an opportunity to develop more personalized treatment plans based on a continuous flow of data. Dr. Taylor, how do the cardiologists at MedStar Washington Hospital Center currently use data from smartphone or device apps to help patients achieve better heart health?

Dr. Taylor: These apps are really the way of the future, aren’t they? Everyone has a smartphone, everyone is tied to their digital life, and so we’re using this in several different ways. The first way is to simply monitor fitness. And the second way is to, in fact, monitor illness. So, for instance for monitoring fitness, you’ve seen people who may have little step monitors or activity monitors that they wear on their wrist as part of a phone or as part of a separate app. And those can be used to set goals or daily targets and really motivate activity. And I think they’re really quite useful. And we can use them to help set fitness goals - how many steps a patient should take or how much activity time they should have.

The second way we’re using these is, in fact, to monitor illness. And this is something, I think, that’s really very exciting. This could include things like monitoring heart rhythms, monitoring patient’s fluid status if they have weak heart muscles, or using it to monitor important numbers like blood pressure through wired applications. And, in terms of the heart rhythm, you know, we have patients that are currently monitoring their abnormal heart rhythms using their iPhones and detecting when they’re in or out of certain abnormal heart rhythms like atrial fibrillation, or monitoring for changes in heart rate that might signify or indicate an abnormal heart rhythm. In today’s pacemakers, they’re all wired with these special apps to monitor fluid status. So, even before patients can feel the effects of rising or fluid retention, they can get a warning from their pacemaker to tell them that they’re retaining fluid.

And with blood pressure being such an important number these days, trying to get everyone to optimal blood pressure below 130 over 80, we’re finding that those home blood pressure monitoring is more important than even the numbers we get in the clinic. We really rely on patients monitoring their blood pressure because their most accurate blood pressure is the one in their home, the one they live with day-to-day. Not the one that when they come to the clinic every 6-months or every 12-months. And now these blood pressure cuffs are connected by Bluetooth to phones, and we get a nice record of what their home blood pressures have been. It’s very helpful to monitoring and tailoring therapy to get the right level of blood pressure control. So, we use these devices not just to monitor and set fitness goals but really to truly monitor illness.

Host: What concerns do you have regarding the use of apps for heart health care?

Dr. Taylor: You know, as we move into this digital age, we are all just aware of having our digital lives out there and exposed, and there’s definitely a balance of risk and benefit. For instance, we’re using remote monitoring for pacemaker devices and it creates convenience and we think better outcomes. But there is risk entailed. And so, we’ve got to acknowledge and identify the risk and do all we can to mitigate it. You know, HIPPA or that privacy act that relates to health information, tells us that privacy is very important. And as our digital lives are increasing, so comes more risk with those opportunities. A few things I would advise, though. The first is to make sure that when patients are communicating with their healthcare providers, they’re using secure portals. There can be a lot of sensitive information which can be sent across public means of communication and so use those secure portals to communicate. People should always be careful with their own devices—update the software, make sure the security patches are in place and be careful with the apps you’re downloading to make sure that they’re truly secure. And then lastly, it’ll be heartening, I think, for folks to know that device manufacturers are aware of this. And they’re learning and are increasingly attentive to the risks of their apps or devices for hacking and data breaches. And so, security there is something which they’re helping with, as well. And in the end, I think, it will be a shared responsibility of all of us individuals to have our devices secure, the devices we’re given to be, have optimal security and the healthcare providers for interacting with to respect that data and to manage it in a secure as possible way. But I think, in the end, we see the tremendous opportunity before us to leverage this digital age for better health and the risks, I think we can understand, and it will all work together to make everything as safe as possible.

Host: What do you think the future holds as far as using medically-centered apps, such as the Apple Heart Study app, to provide ongoing patient care outside the cardiologist’s office?

Dr. Taylor: Yeah, I think the potential is, I won’t say limitless, but I think it’s enormous. Promises for diagnosis, for example, linking this data to portals so we can see what patients are doing, see their activity levels, see what’s happening to their fluid status if they have heart failure, their heart rate status if they have heart rhythm problems, and really, to track their success. Personalized coaching is really out there with these devices. For example, there's devices that will give personalized coaching on diet, if you’re importing your diet, what you’re taking in, or setting exercise targets and encouraging and coaching. And lastly, in heart rhythm problems we’re seeing really great applications, for atrial fibrillation for example, for detecting atrial fibrillation. And when we detect atrial fibrillation, we’re treating patients differently. We’re using blood thinners and proper treatments to prevent problems from occurring. So, I think really the promise is on not just diagnosis of heart problems but the management of heart problems. Because, let’s face it, you go to a doctor twice a year. And there’s a lot of time when other stuff is happening, and it really provides a more complete picture of what’s happening to folks as they live their lives. So, these apps have an important opportunity for us to really give us a full picture of our health lives and also connect it to make better diagnoses and to get the right treatments.

Host: Why is MedStar Washington Hospital Center the best place to find technological innovations in heart health care?

Dr. Taylor: MedStar’s truly committed to innovations. So much so, we have an institute for innovations called MI2, the MedStar Institute for Innovation. And, in fact, they themselves are developing apps to help patients take better care of themselves and to help us take better care of them. Always seeking ways to leverage our modern digital world for, you know, better and more efficient care. So, I think it’s an exciting time. I think all of us, we’re all people too. We have these same devices, use fitness monitors, and it’s exciting to talk to patients about this to encourage them to use these devices or to use them in different ways. Or, to tell them what’s out there, for fitness, for diagnosing heart rhythm problems or for monitoring their care. So, it’s an exciting time of empowerment in healthcare. And these apps, and this new digital world we live in, are helping with that.

Host: Could you share some success stories from your patient population?

Dr. Taylor: Oh, I have so many success stories from this digital world, provide a few ideas. One, I have a patient who really diagnosed his own atrial fibrillation. And he was monitoring when it was occurring and found that it was, he was very accurate in detection and, he then was so proactive, he sought out and found the types of treatments that he wanted. And, once he had those treatments in place, he monitored how successful it was and it turned out to be very successful. So, he really found and treated his atrial fibrillation through a digital app.

I have another patient that I recently saw, and she came to me and she said, “You know, I’m really working on getting more fit. And I think I am. But when I start to exercise I notice all of a sudden my heart rate is 150.” And she said, “Here, let me show you.” And she brought out her phone, and she showed me her heart rate graph while she was exercising. And, lo and behold, at occasional times during her exercise, her heart rate jumped to 150 and stayed there, in a very unusual way. And, in fact, that made the diagnosis of an abnormal heart rhythm, that we were able to successfully treat with a very simple medication and she’s doing much better. And now she’s monitoring if she’s having any recurrences and she is not.

And then, I’ll give a third example of an app that’s called Image Share that let’s doctors use their smartphones to rapidly transmit data in a secure way about heart attack patients to decrease the time to treatment, and that’s an app to increase communication among healthcare professionals in the crisis of taking care of a heart attack. So, some really, really good success stories - really empowered patients, knowledgeable patients, and then apps in a health system to really lead to more efficient and better outcomes.

Host: Thanks for joining us today Dr. Taylor

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A paraesophageal hernia can have symptoms as simple as acid reflux or feeling bloated after a small meal—or no signs at all. Dr. John Lazar, Director of Thoracic Robotics, discusses how we diagnose and treat paraesophageal hernias.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. John Lazar, Director of Thoracic Robotics at MedStar Washington Hospital Center. Today we’re discussing benign esophageal diseases, a group of non-cancerous disorders in the esophagus, which is the tube that connects the throat to the stomach. Dr. Lazar, what are some of the benign esophageal diseases you see most often in your patient population?

Dr. Lazar: I would say that the most common benign disease that we see is something called the paraesophageal hernia. And what that is, is that over time, the diaphragm weakens and the stomach starts to track up into the chest. Um, and it can be quite uncomfortable at certain points which is generally when people start seeing us.

Host: What are some of the common symptoms of paraesophageal hernias?

Dr. Lazar: So, the most common one is reflux, meaning that you have this taste of acid coming up into your mouth or sometimes it causes you to cough. Other ones are after eating a small meal you feel very bloated. Sometimes it even causes you to actually have to vomit in order to feel better. This is something that happens gradually over time, so a lot of times, people don’t realize they even have these problems until someone points it out to them. Other issues with the esophagus which are less common is something called acalasia, which is the inability for the lower part of the esophagus that is connected to the stomach to open up all the way. So, food actually sits there at the end of the esophagus and usually you have to wash it down with a glass of water or unfortunately, even then, sometimes things come back up.

Host: So, they sound like pretty similar symptoms to other disorders. How common are these esophageal diseases?

Dr. Lazar: So, I would say that achalasia is probably very small, in the single digits, if you took the population as a whole. Or I would say that paraesophageal hernias are probably around 10 to 15 percent of the population. And most of the time they’re asymptomatic, meaning no one has any symptoms and they’re only...only found incidentally, meaning you went in for a chest x-ray or something else was bothering you and they did a CT scan and they ended up finding some of these things. I think when you’ve had long standing gastroesophageal reflux, it’s time to talk to your doctor about maybe even getting screened when a...with a EGD by a gastroenterologist, just to make sure that there’s no permanent damage done to the esophagus. I think if you’re in the category of, “Oh, you know, this happens every year, once a year,” you’re probably OK, but if it’s happening more and more often, then you really should talk to your doctor about getting screened.

Host: Are there certain groups of people who are more at risk, say men or women?

Dr. Lazar: So, generally people who have increased abdominal pressure, so that would be people who are overweight, uh, sometimes women who’ve had multiple babies, and over time, the diaphragm weakens. It’s...it’s kind of hard to predict who will or who will not have it.

Host: In terms of treatment, what are some of the most common first-line treatments for these disorders?

Dr. Lazar: Sure. So, basically the only treatment is for the symptoms, unless you fix the problem. So, a lot of times people will take antacids, over-the-counter or prescribed by a gastroenterologist or a primary care physician. But if you want definitive therapy from it, surgery’s the only cure.

Host: Is there an issue with people taking antacids and things like that long-term as opposed to having surgery?

Dr. Lazar: Yeah, so there’s a growing debate as to whether a certain type of drug called proton pump inhibitors, or PPIs, also has long-term damage to other organs and that’s an area in which people are looking into but it’s become very popular in the news and so a lot of patients have been talking to their doctors about whether or not surgery’s right for them.

Host: Could you explain what a PPI is for individuals who might not know?

Dr. Lazar: So, a proton pump inhibitor works on suppressing the acid on a molecular signaling level and so therefore people have less symptoms from reflux because the pills tell the body to make less acid.

Host: When a person does need surgery, what are some of the more common procedures that are done?

Dr. Lazar: So, if we’re talking about a paraesophageal hernia, generally paraesophageal hernia repair involves pre-operative testing with an esophagram, which is drinking of contrast, and then they get x-rays that shows how the contrast goes down. The other common test is a CT scan of the chest, which is about a ten-second test. And then the other test can be something called manometry, which tests how well the esophagus squeezes food down the length of the esophagus.

Host: So they’ve run through all of these tests...and then, once they go in for treatment, what...are you doing a...an open surgery with these folks, if it’s necessary...minimally invasive? What does that look like?

Dr. Lazar: So, almost all surgeons are doing minimally invasive paraesophageal hernia repairs. In the old days we would generally go through the left chest, which was a very painful procedure. Now we’re doing it minimally invasively through the abdomen where there’s less nerve endings and, uh, they’re able to go home much sooner. We do it robotically. Patients are brought to the operating room. They’re put to sleep. They’ll have five ports about the width of my index finger. And then we will use the robot, which is completely controlled by the surgeon, to then bring down the stomach back into the abdomen, take down all the scar tissue that was holding it in there, and then close the opening that’s in the diaphragm that...where the stomach was going in.

Host: Could you talk a little bit about the recovery from that type of procedure?

Dr. Lazar: Sure. So, the great advantage of robotic surgery or any kind of minimally invasive surgery for paraesophageal hernia, is that generally people go home anywhere from one to three days afterwards, uh, depending on the surgeon’s preference. So, generally they have less pain, they’re able to eat and drink much quicker, and so there’s really no reason to keep them in the hospital. Uh, they still take about seven to ten days to really get back on their feet once they’re home.

Host: What is the risk of not seeking treatment for long-term symptoms?

Dr. Lazar: So, I think that there’s a group of people who are very scared of surgery, and rightly so, who have paraesophageal hernias. Unfortunately sometimes the stomach can twist along the esophagus and cut off the blood supply, and therefore, it becomes a surgical emergency to reduce the stomach and get it back down and there’s a risk of the stomach becoming what we call ischemic, or there’s no blood supply to it. Uh, and that...that can be life or death in some cases. In the past we had talked about only treating symptomatic paraesophageal hernias, but there’s growing evidence because of this that maybe we should start taking care of these patients earlier when the hernias are smaller and they’re actually in better health.

Host: What are some of the emerging technologies or procedures that you’re using at MedStar Washington Hospital Center?

Dr. Lazar: So, I would say that the biggest technology that’s really catching on both nationally here and that we brought to the Washington Hospital Center is...is robotic technology. And, in most senses, this is robotic assisted technology, so the surgeon still remains completely in control of what’s going on. The robot is there just to enhance visualization, enhance their ability to operate within a confined space, and to basically make it a smoother operation for the surgeon.

Host: Have you had any patients in the past who have had severe hernias who you were able to help with this type of surgery?

Dr. Lazar: Sure. So, I think, in a lot of senses, because of the enhanced visualization, we’ve been able to do a better operation than we would open in the abdomen, and in some cases, just as good as we would have done through the chest but with much smaller incisions and therefore better recovery because we’re able to take down all the scar tissue that basically keeps it up there. We’re able to reduce, you know, the stomach back in to the abdomen or in to the belly area and then close these large defects. Because we have wristed instruments, we’re able to then suture in a much better way or close the defects in the diaphragm and then make sure that the patients reestablish the normal anatomy.

Host: So, in...in doing so, in reestablishing that anatomy, is there a follow-up procedure that these patients will have to have?

Dr. Lazar: No. Generally, once the surgery is performed, and then they’re able to get out of the hospital in a couple days, uh, we follow them along, at least a couple weeks, and we’ll see them back yearly just to make sure that everything’s OK. But generally speaking, uh, there’s no other procedure that’s usually required afterwards.

Host: Why is MedStar Washington Hospital Center the best place to go for treatment of hernias and other benign esophageal diseases?

Dr. Lazar: Well, we have a team of specialists in thoracic surgery who are very dedicated to understanding esophageal disease. We’ve all been specially trained in the esophagus. A lot of people get training in a lot of different things. Our passion is, uh, esophageal disease, whether it’s cancerous or non-cancerous. And, so therefore, I think that we have a lot of experience and knowledge in identifying esophageal disease and, technically speaking, we’ve dedicated our lives to...to perfecting it.

Host: Thanks for joining us today.

Dr. Lazar: Thank you.

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A new procedure can lead to quicker, more effective recovery after ACL repair. Orthopedic Surgeon Dr. Evan Argintar explains how internal bracing works and who can benefit from the procedure.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

In today’s episode, we talk to Dr. Evan Argintar, assistant director of sports medicine at MedStar Orthopedic Institute at Washington Hospital Center about their exclusive use of internal bracing in ACL repair and reconstruction.

Host: Thanks for joining us today, we’re talking to Dr. Evan Argintar an orthopedic surgeon and assistant director of sports medicine at Medstar Orthopedic Institute at MedStar Washington Hospital Center. Welcome, Dr. Argintar.

Dr. Argintar: Thank you for having me.

Host: Today we’re talking about internal bracing, which can be used to stabilize a joint and accelerate healing time allowing a patient to resume activity faster. When you say ‘internal bracing’, what do you mean, and how does that work?

Dr. Argintar: So, traditionally with ligament reconstruction whether that be in the knee or the elbow, we’ve traditionally used a graft. A graft is another tendon. Sometimes that can be from the person. Sometimes that can be from a cadaver, the most common example in my practice is the ACL. You need to put a new ligament where the old ACL ligament was, and that whole process of maturation can take anywhere from eight to ten months and that requires the body to do this process called ‘sinovialization’ which is a fancy way of saying becoming part of the human body. The issue with that process is at about two or three months the ligament you put in there becomes weak, and what we’ve found is that’s the time when it’s most likely to fail. And so researchers have developed an internal brace which is nothing more than a really strong suture that’s made out of a polyethylene or a plastic that travels with the new ligament, and it gives it stability and allows it to maintain the structural integrity throughout this process of maturation but specifically at the two to three month period when patients are ramping up their rehab but when their ligament might be weakest. So, what we’re finding here at Medstar Washington Hospital Center in our research is that patients seem to be doing better, they’re having better clinical outcomes and they’re more predictable.

Host: When you say it travels with the ligament, what do you mean?

Dr. Argintar: For an ACL, you have to drill tunnels into bone, and so when you create a new ACL, you’re putting that new ACL in tunnels into bone where the old ACL ligament was. And so this new internal brace travels right next to the ligament, so it has the same trajectory, and it has the same biomechanical forces on it. if you think about it as sort of a temporary ACL, while the new ACL is maturing, to me in my mind that’s how I make sense of it.

Host: That makes sense to me too. You mentioned the ACL. What other parts of the body is this useful for?

Dr. Argintar: We’ve been using it in elbow reconstruction. Sometimes people can have lateral or even medial elbow instability, and we’re finding that whenever you’re doing a repair of a ligament, or a reconstruction of a ligament, meaning taking a tendon from somewhere else in the body or taking a cadaver and incorporating it to replace the old one, this gives additional stability, which allows me as an orthopedic surgeon to be potentially more aggressive earlier on with therapy. Which I think helps mobilization, and it allows patients to be more aggressive in their therapy, which I find anecdotally is helping with outcomes.

Host: When you don’t use the internal bracing, when you’re taking that tendon from somewhere else in the body or from a cadaver which is a donor body, where typically would you take it from? Would it be that same area? Would it be a different limb?

Dr. Argintar: It all depends on the surgery. The most common example would be with an anterior cruciate ligament or ACL reconstruction. Now certainly you can take it from a cadaver and that’s the least painful of all options for patients, but traditionally there are two main sources for patients—one is the bone patella bone which is taking a little piece of bone on the knee cap and a little piece of bone on the tibia or the leg bone and the connecting ligament in between. The other option is a hamstring tendon, which can be taken from the front or the back of the knee. Those would be the two most common examples in ACL surgery.

Host: How long has this been available for the ACL, and are people coming and asking you about it?

Dr. Argintar: We’ve been finding that as word gets out that we’re doing more of this internal bracing, people are seeking us out for second and third opinions for ACL reconstructive surgery, and elbow reconstructive surgery, absolutely. We have research pending but not yet published which is demonstrating that this is a safe procedure it’s also allowed us to do ligament repair in a setting where traditionally we were unable to repair ligaments—it’s that strong. (4:27)

Host: What is the preparation process and what should a patient expect before, during, and after the procedure?

Dr. Argintar: Preparation for ACL surgery is all about the pre-rehabilitation. Sometimes we’ll actually send people to physical therapy in order to get their range of motion. What we know for all surgeries is that if you go into a surgery with poor motion you get poor motion afterwards. Most times, I’m able to educate patients on how to get that motion beforehand, so if they’re successful with those exercise programs, they are in very good shape for surgery.

Host: Is this something that can be done under general anesthesia or is it local anesthesia?

Dr. Argintar: This is all done with general anesthesia. It’s done as an additional component to surgical procedures in the operating room. It doesn’t increase the length of the surgery, in fact in some cases it might even make it faster.

Host: You mentioned before that this allows patients to be a bit more aggressive in their therapy and it allows you to get them into that therapy a little bit quicker. Could you talk about that process? What is the traditional trajectory from ACL surgery into therapy as opposed to internal bracing?

Dr. Argintar: So typically with ACL reconstructive surgery, patients will have surgery—for the first ten to fourteen days they worry about nutrition and health hygiene and then about two weeks afterwards they initiate physical therapy. The problem is that therapy can be modified based on how strong you think your repair can be, so as we incorporate these extra elements that improve or increase the strength of a surgical procedure, that will give clinicians more confidence to be more aggressive earlier on. Although me personally I rehab now ACL repairs and ACL reconstructions exactly the same, I think as we collect research moving forward respectively what we’re actively doing. In fact, we’re one of only three centers to my awareness, in the United States that are collecting this research and doing this type of surgery. Traditionally, ACL reconstructive surgery, the whole rehabilitation, is somewhere between eight and 10 months and is very patient specific. We know that for ACL repair, which is for keeping the ligament and putting it back where it came from, that’s a surgery that absolutely requires this internal brace for additional stability. We have found anecdotally that the atrophy of the muscle after surgery is less, and patients get back to sport activities quicker. A perfect example is two firefighters that I recently took care of. I prepared them for the eight to 10 months of rehabilitation, which is a lot of sedentary work for people who very much want and need to be active, need to have rotational stability in their knee, need to put out fires, and everything they need to do that happens in their job every day. I can think of two recent patients who were happy to get back to their job at six months without restriction. And that two months of lack of them doing sedentary work was transforming both to their job and to their mental health, because patients certainly want to get back to normal living, whether it be work or sport.

Host: What sort of research data are you picking up? What does that look like and what is the patient’s role in your collection of that data for your research?

Dr. Argintar: So we’re looking at research on lots of different levels. One is “is this internal bracing safe?” and the answer is unequivocally ‘yes’. Personally, I’ve done several hundred of these procedures, and my partners have had similar experiences, so we have looked at that data, and it has been submitted and will be ideally published in the next year demonstrating the efficacy and safety of this procedure. Two, we’re looking at how this will allow us to repair ACL ligaments in the knee. Again, we have a lot of anecdotal evidence based on over a hundred patients with ACL repair which is a real new aspect of knee sports medicine. Once upon a time people attempted repairs and they were fraught with failure, and for a long time this was sort of ignore as not a possibility. As we learn better about the anatomy of the ACL and we’ve incorporated these new technologies we have revisited the idea of ACL repair and we have found the success rate has been excellent here.

Host: Why were surgeons having a difficult time repairing the ACL?

Dr. Argintar: It has a lot to do with understanding the anatomy, number one. When people attempted these repairs twenty years ago—what we know now, but what we didn’t know then is that the origin where the ACL starts was not as accurate as we understand it now. In fact, the whole way we do ACL reconstructive surgery has really changed over the last five years. It’s not uncommon now for me to see patients who had the old gold standard ACL and we unfortunately have to revise them because they don’t have the rotational stability. So it’s that information all the new research that’s come out over the last decade about simply understanding where the ACL starts and where it goes coupled with the evolution of all these minimally invasive ways to incorporate these new interesting technologies that allow for repair this has all culminated to the ability to repair ligaments in a way that we never had the ability to do.

Host: Part of your research is determining whether this is safe, and you’re saying that yes it is safe, anecdotally at least. What are some of the safety concerns that individuals have had about this procedure?

Dr. Argintar: So, there are no specific safety concerns. Whenever there are new technologies in place in a knee joint for example or outside of a joint, you want to make sure that the benefits of the device aren’t outweighed by the negative aspects of the device. So, as we launch our investigation and this was based on the success of other institutions, even internationally, we have found that this is completely safe. In fact, when I look at my ACLs with and without the internal brace, I need to look at my report to see who has received that brace, because from the outside there’s no easy way to determine—it’s that similar.

Host: That’s a very good sign. What does your patient base or your patient demographic look like for this procedure?

Dr. Argintar: Typically, people who are getting ACL surgery or elbow reconstructive tend to be younger, more active, age to me is not important. Level of activity is. I’ve certainly done ACL surgery in people who numerically, chronologically perhaps are a little bit older but I meet people who are chronologically old who are more youthful than some of my patients. I would say ACL surgery in general is something that is done for people in their young teens up through their forties but there are certainly outliers on both sides of that bell curve.

Host: Is there anybody who this procedure would not be safe or effective for, in your opinion?

Dr. Argintar: No. This would be safe for anyone who needs this type of surgery. So, we’ve had patients traveling across the country for this type of treatment, patients regionally from Philadelphia and new York, or west like Colorado, the good news is that the word is out on the street -- people who are wanting to maintain their anatomy, which makes logical sense, people who want to see if they’re candidates for ACL repair, are seeking out medical centers like MedStar Washington Hospital Center, where doctors are doing cutting-edge surgery that might obviate the knee for reconstructive, larger surgeries.

Host: Is there anything else that you would want to elaborate on or if somebody’s interested in receiving this type of procedure what would be the process for them to get to you?

Dr. Argintar: Certainly, see one of me or my colleagues who specializes in sports medicine here at MedStar Washington Hospital Center. Again, we’re one of few centers in the country this is using and researching these technologies to strengthen ACL reconstruction, as well as even do ACL repair, so we’re excited to be on the forefront of this new cutting edge sports medicine intervention.

Host: Thank you so much for joining us today, Dr. Argintar.

Dr. Argintar: Thank you for the opportunity.

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Partial knee replacements can provide relief from arthritis pain without the long recovery of a total knee replacement. Orthopedic Surgeon Dr. Evan Argintar explains the benefits and who might qualify for the procedure.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re talking to Dr. Evan Argintar an orthopedic surgeon and assistant director of sports medicine at Medstar Orthopedic Institute at Medstar Washington Hospital Center. Today we’re discussing an advancement in joint replacement surgery called bioplasty. These procedures preserve as much of the normal joint anatomy as possible. Dr. Argintar, what’s the goal of this advancement?

Dr. Evan Argintar: So traditionally the treatment of arthritis has been a big issue and as the Baby Boomers age, we’re actually finding that there are not enough orthopedic surgeons to treat the amount of arthritis that is developing in our country. And as people get older the good news is that people want to maintain the quality of their life, the level of activity and the problem traditionally has been that the definitive treatment for arthritis specifically in the knee has been somewhat limited. We used to do knee arthroscopy but appropriately this has come under criticism because it doesn’t give a very sustained relief and then the only thing you can do definitively is some element of a knee replacement. There are three parts of the knee. The inside the outside and underneath the kneecap, and a full total knee replacement or total knee arthroplasty replaces all three types. That is a very good procedure that’s a fantastic procedure if all three portions of your knee are diseased or arthritic. Because sometimes patients have an isolated medial or lateral portion of their knee which is far worse than the rest we have developed as orthopedic surgeons partial knee replacement, and so the indication for that is very specific and not all patients are candidates for it.

The problem arises when patients have one out of the three compartments extremely arthritic, one completely normal, and one kind of average, and this puts people in a bit of a grey area. Do you do a partial knee replacement and accept that some of that cartilage in the remaining portion of the knee is diseased and potentially pain generating? Maybe. Or do you do a full knee replacement, replace all the bad stuff with all the good stuff? Maybe. The problem with doing the full knee replacement is that in 2017 you have to sacrifice the ligaments on the inside of the knee and you usually have to change the joint line and what that translates to is really a bit of an artificial feeling knee, and one that does have some intrinsic limitations for activity. Certainly, you can walk and move and have pain relief, but the ability to have a sport and to be active and to pursue professions where you need to have that level of comfort and that sense of a normal knee can somewhat be limited or altered. What I’ve done here at MedStar Washington Hospital Center is incorporate technologies of both partial knee replacement with some of the treatments I’ve done in isolation in the sports world, cartilage restoration, ligament reconstruction. So once upon a time, for example, if you had medial isolated arthritis on the inside part of your knee without an ACL, you had no option without a knee replacement. Now you can do a partial knee replacement with an ACL reconstruction, and this allows people to maintain their youth and maintain their activity and avoid some of the limitations inherent with a bigger surgery.

Host: What other types of bioplasty surgeries are available?

Dr. Argintar: Another example would be a partial knee replacement on one side of the knee with a transfer of cartilage to the other side of the knee. If you have a pothole in the middle of a normal road, you can do sporty cartilage restoration surgeries to make that pothole complete. Arthritis is the opposite. That’s a street that has no more pavement, and that’s when you have to repave it with the knee replacement. But again, now as we’re fusing the sports medicine with joint reconstruction, we’re coming up with novel solutions for people who don’t want the inherent limitations with full knee replacement. Patients are not all good candidates for this. We’re finding that patients are coming in seeking to see if they are good candidates for this.

Host: Who is a good candidate for a bioplasty surgery?

Dr. Argintar: Candidates are both people who have a combination of the desire to maintain young and youthful coupled with the right type of need. Unfortunately, sometimes I find people who want to maintain their anatomy but at such advanced tricompartment arthritis that my advice to them is let’s consider the full knee replacement. However, a lot of times people come in and we find that they are in fact candidates for this novel approach to joint reconstruction. Knee replacement is a great surgery and it has been done historically successfully, but like in all surgeries, we’re trying to identify patients who might not be as successful as others and so I would incorporate others to be aware that other surgical interventions exist, and although you might not be a great fit for it, it’s worth pursuing and we’re happy to have those consultations and oftentimes we recommend that the first opinion is dead on accurate and other times we are able to give different operative options.

Host: Could you talk a little bit about how the prep and the procedure for that vary from the partial knee replacement and some of these other fusion type surgeries?

Dr. Argintar: Well, it’s interesting. Even in my training you know 10 years ago, we would do knee arthroscopy with a hope that you could quote unquote clean up the arthritic knee. Everyone with arthritis has a meniscal tear, and the meniscal tear is an easy target. And I spend many hours all day long convincing people that a knee scope to treat a degenerative meniscal tear will not solve their problems. And, unfortunately, I see a lot of unhappy customers coming from other areas around us that do that surgery knee scope with the thought they can clean it up and they come out very unhappy with a lot of pain, and those are often patients who I find are good candidates for a potential partial knee reconstruction or replacement in combination with some other cartilage restorative procedure. There has been some good well known, well publicized articles and major publications—The New York Times—showing that knee arthroscopy may be overused in the setting of arthritis and I would agree with that 100 percent. It’s just so very unpredictable, and very often not sustainable, and so although they may have some relief for weeks to months, it doesn’t change the quality of their life for any meaningful period. So, I shy away from knee arthroscopy in the setting of arthritis.

Host: If surgeons have practiced the same way for so long, why was there a need to develop something different?

Dr. Argintar: The evolution of my practice was based on a lack of satisfaction for both me seeing patients coming from other places in the area that had unsuccessful knee arthroscopy outcomes coupled with some of my younger patients who although got pain relief from a full knee replacement, never felt great with it, always had some limitations with it, and so I challenged myself, and this is the challenge that has been brought on the shoulders of some of my other colleagues, you know, regionally and throughout the country, to create a solution that is a middle ground between the minimally invasive knee scope and the maximally invasive full knee replacement and I think that we have found something that is relatively unique and novel here.

Host: Do you have any shining patient success stories you could share?

Dr. Argintar: Sure. So, a perfect example of someone who has done quite well is a lady of mine who is quite young. She had a full knee meniscectomy, removal of the knee the meniscus 15 years earlier. We know that after a course of that is full blown arthritis eventually, and she was a victim to that, only 45 very active, working, running around, young children. She was not excited to sacrifice two-thirds of her knee because she had a degenerative medial joint with an ACL tear. So, in this situation, I was able to do an ACL reconstruction, which allowed me to do a successful partial knee replacement. She’s been beyond happy, back to work, back to activity, back to being a mom, well she never left being a mom, but she’s doing it more comfortably, and she hasn’t looked back. You know doing a full knee replacement sometimes you have to do that in the 30s, the 40s. The problem aside from the artificial feeling of it is that twenty years later you have to do another one. Partial knee replacements also don’t last forever, but it gives people potentially a long window of feeling more normal when they’re younger in their life and wanting to do more activity recreationally, professionally whatever that may be.

Host: How long is recovery for a bioplasty procedure compared to a traditional knee replacement?

Dr. Argintar: I usually tell my patients that a full knee replacement will take about six months whereas a partial knee replacement is more of a four-month recovery. Everyone walks and stands immediately, but because you’re doing less surgery, there’s less inflammation, less pain, easier to move it, so it’s a little bit of an easier recovery

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Pituitary tumors are more common than many people realize, with up to 17 percent of people at risk for developing one in their lifetimes. Dr. Susmeeta T. Sharma, Director of Pituitary Endocrinology, discusses how our team of experts recognizes and treats pituitary tumors.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thank you for joining us today. We’re talking with Dr. Susmeeta T. Sharma, Director of Pituitary Endocrinology at MedStar Washington Hospital Center. Welcome, Dr. Sharma.

Dr. Sharma: Thank you for having me.

Host: Today we’re discussing pituitary tumors, which are much more common than many patients and physicians realize. Dr. Sharma, what types of pituitary tumors do you treat?

Dr. Sharma: So, one of the most common functional pituitary tumors would be a prolactin-secreting pituitary tumor. So, prolactin is a hormone that the normal pituitary gland makes that’s involved in the development of breast mammary glands and milk production in females, and so when a tumor is making prolactin, that excess prolactin in females can lead to irregular menstrual cycles, can lead to breast milk production, feeling of breast engorgement, breast pain. This irregular menstrual cycle and excess prolactin levels can also lead to difficulty or inability to have children, and that’s many times how it comes to attention to a physician. In men, it can cause decreased libido and some signs and symptoms of low testosterone, so low energy levels, decreased libido, erectile dysfunction, inability to have children, um, decreased hair growth, some of the symptoms that you see related to low testosterone levels. Given that we don’t have the menstrual cycle marker in men, many times the prolactin-secreting tumors in men tend to be larger in size, and so many of them can have headaches and vision changes related to just the size of the pituitary tumor, and so that’s how they may manifest to a physician.

Host: How do you determine if the patient’s symptoms are caused by a pituitary tumor or another condition?

Dr. Sharma: Right, so some of the symptoms a patient may present with, for example, low energy levels, decreased libido, can be related to various different hormonal disorders, or it may not be related to a hormonal disorder at all, and so the first time, if the patient is presenting with these symptoms, we need to assess the levels of these hormones to see if there is a hormonal disorder there. So, one would measure testosterone, prolactin levels in a woman, FSH, estrogen levels, get a detailed history and exam, and all of that can help detect whether or not there could be a hormonal dysfunction, which can then lead us to assess for a pituitary tumor. So, they may come to us already with a diagnosis of a pituitary tumor where we are trying to see if it’s making some hormone, or they may come to us with these symptoms where we are trying to see if there could be hormonal dysfunction, which can then lead us to a diagnosis of a pituitary tumor.

Host: After a patient is diagnosed with a pituitary tumor, what is their next step for getting treatment?

Dr. Sharma: So, yeah, once we have...there might be 2 or 3 steps involved in the diagnosis of a hormonal dysfunction. We may do some initial screening tests, followed by some confirmatory testing, but, yes, once the diagnosis has been made that a person has a functional or a nonfunctional pituitary tumor, then we would go on to treatment. The treatment can vary from just simple observation and monitoring, which would be the case in a nonfunctional small tumor that’s not causing any mass effect, to medical treatment, which would be a case in a prolactin-secreting tumor, which we can treat effectively with medication group called dopamine agonist therapy, which are now well-tolerated medications, uh, to surgeries. So, most functional tumors, other than the prolactin-secreting tumor, will require surgery, and any nonfunctioning tumor that’s causing mass effect would require surgery. Many of the pituitary tumors after surgery may require further adjunct therapy, uh, so if there is residual hormonal excess or residual tumor, um, they may require radiation therapy for that or adjunct medications for further hormonal control.

Host: How common are prolactin-secreting pituitary tumors?

Dr. Sharma: So, pituitary tumors in general, I think, they are underrecognized. If you look at the studies done for diagnosing pituitary tumors, the data that comes available comes from either radiological studies, so MRIs that are done in the general population, or autopsy studies, so done after the death of a person, and so, uh, the data coming from there shows that among the population, about anywhere from 10 to 20% of the individuals, depending on the study you look at, can have a pituitary tumor, and in some it may be causing hormonal excess or hormonal dysfunction; in others it may be not. Among those pituitary tumors, about 40 to 50% are actually gonna be a prolactin-secreting pituitary tumor, so I always say, when I’m talking to a group of people, that if we are about 100 people sitting in that room, about 10 to 15 of us could have a pituitary tumor, and out of that about 5 to 6 could have a prolactin-secreting tumor, and that’s how common it can be.

Host: What surgical options are available for individuals with prolactin-secreting pituitary gland tumors?

Dr. Sharma: So, for a prolactin-secreting tumor I would say about 80 to 90% of the time we are able to manage that medically. The time that we need a surgery for a prolactin-secreting tumor would be A) if it has gone undiagnosed for a long period of time and it has become really large, and then it bleeds into itself, so as the tumor grows the blood supply sometimes is not able to keep up with itself and it may bleed suddenly into the tumor, which is what we call pituitary apoplexy and, if that happens, that’s a surgical emergency. The patient can develop sudden-onset hormonal deficiency, sudden-onset vision changes, sudden severe headaches, and so that is definitely a time when they would need pituitary surgery. Other times a prolactin-secreting tumor may need surgery is if the patient is not able to tolerate the medications, so most of the time these medications are well tolerated, but occasionally the patient may develop gastrointestinal side effects, dizziness, or...and is just not able to tolerate the medication. In those cases, one may need surgery. Uh, another scenario would be although the majority of these tumors do respond to this group of medication called dopamine agonists, there are a small percentage which are resistant to the medication, so resistant prolactinomas. If a tumor is growing or the prolactin levels are increasing while being on an optimal dose of the medication, then that would be another case where we would need surgical intervention.

Host: Are there any life-threatening complications associated with prolactin-secreting tumors?

Dr. Sharma: Uh, so, it…from the prolactin itself, the high prolactin levels may not be life threatening, but from the pituitary tumor, as the tumor grows, you can have hormonal deficiencies, so the hormonal deficiency that can be life threatening is a cortisol deficiency, so again, in the scenario where it’s very large, and over time the patient develops, from mass effect of the tumor, loss of pituitary cell function that makes ACTH, which then leads to cortisol production, they can have cortisol deficiency, and cortisol is a life-sustaining hormone. The same way, you can have TSH or thyroid-stimulating hormone deficiency, which then leads to thyroid hormone deficiency. And, again, those are both two life-sustaining hormones, and if that goes undetected, one can have serious consequences.

Host: Is the physiological response to starting therapy gradual, or is it a big shift for patients?

Dr. Sharma: These tumors are very...if they’re going to respond, they’re very responsive to the medications where the prolactin levels start to decreasing within days, and so even in patients where you actually have the tumor compressing on the eye nerve and causing vision changes, you can...and the medication will start making a difference right away, and as long as they are compliant with the medication and we are titrating up the dose to get the prolactin levels normal, uh, the tumor size will also respond in most cases.

Host: What about some of the more rare tumor types you treat?

Dr. Sharma: Other functional tumors that are more rare, it can be a growth hormone-secreting tumor, so that’s called acromegaly or gigantism, so if the growth hormone-secreting tumor occurs in a child who is still growing and their growth plates have not fused, uh, they can become really tall and that’s why the disorder is then called gigantism. On the other hand, if the growth hormone excess happens as an adult, you have a condition called acromegaly, and so these patients have a change in facial features. The facial features become really coarse. They will have change in...increase in ring size, increase in shoe size, they develop these enlarged hands and feet. They can also develop high blood pressure and have an effect on their heart, so the heart gets enlarged, uh, which can then make them prone to developing arrhythmias or irregular heart rhythms. Um, they can have increased chances of polyps in the colon and the intestine, and so although not clearly established, they can be at an increased risk of colon cancer. They can develop sleep apnea, they can develop carpal tunnel syndrome and then they can also develop pre-diabetes and diabetes, so many comorbidities can be associated with a growth hormone-secreting disorder. So, when that presents, the treatment for that functional pituitary tumor is surgery. One does want to make sure that they don’t have other hormonal deficiencies or hormonal excess. Sometimes, these tumors can be co-secretors, so they can secrete more than one pituitary hormone, but after that initial hormonal evaluation the treatment is gonna be surgery. Many times, because these growth hormone-secreting tumors are large, because the presentation can be subtle and the transformation in the clinical features can be gradual, they do often get detected in a larger size, so as a macroadenoma, and so many times they require adjunct treatment after surgery in the form of medical therapies or radiation therapy. So, we actually had a patient, a young male, who presented to his dental surgeon for jaw surgery, and so basically his main complaint was that he’s lost his smile. And so, he ultimately ended up having a growth hormone-secreting disorder, and exposure to these high growth hormone levels had led to protrusion of his jaw such that when he smiled, only his lower teeth were visible and his upper teeth were no longer visible, so that’s why he said he lost his smile. But, an astute dental surgeon at MedStar Washington Hospital Center, while looking at his dental x-rays, saw that the bone where the pituitary gland sits, that sella, that looked enlarged, and so he referred the patient to us for evaluation, and for sure he had a pituitary tumor about a centimeter and a half that was making growth hormone. He’s now status post-surgery for the pituitary tumor and his growth hormone levels are much lower now, but he’s requiring adjunct treatment with a medication that is a once a month injection.

Host: In adults, are the physical changes gradual or sudden?

Dr. Sharma: Yeah, no, these...most of these changes in an adult will be very subtle and so, many times they get overlooked, especially if you are seeing the person every day, the changes in facial features can be very subtle. Many times, the change in ring size or shoe size, um, a patient or a person may attribute it to gaining weight or fluid retention, things like that, or just aging process and it may not get detected. I have had people whose shoe size has changed from an 8 to an 11 before it gets diagnosed so no, it doesn’t happen overnight. It’s a gradual process. Many times, um, we ask people to bring out their driver’s license or other prior photographs to actually compare how they have changed. Many times, it takes for a visit to a relative who has not seen you for a year, and they comment that you look different and sometimes that can lead to an evaluation, but many times it can be because they have developed high blood pressure or a heart issue or a diabetes that then leads to being seen by a physician and that leads to further evaluation, so the presentation can be at various different points.

Host: So, for these patients, is medication management a more likely treatment option than surgery?

Dr. Sharma: For most functional tumors, it will be surgery as first-line treatment. The only medical treatable pituitary tumor is prolactinoma, but many times medical therapy is needed as an adjunct, even after surgery has been done, and so you need to look at various different treatment modalities, with the goal being to optimize hormone levels and make sure that the tumor is either completely gone or, um, the residual tumor is...remains stable over time, and so it would be a mix of different treatment modalities.

Host: Why is MedStar Washington Hospital Center the place to go for pituitary tumor care?

Dr. Sharma: So, I think whenever we think of a pituitary tumors, it’s important to remember that not one physician can treat all pituitary tumors. The pituitary tumors involve hormonal dysfunction, which needs an endocrinologist, who is...has expertise in the evaluation of pituitary disorders. You need an experienced neurosurgeon as most functional tumors and many nonfunctional tumors require surgical treatment. You need a neuro-ophthalmologist who is experienced in recognizing the visual field defects that can go with pituitary tumor disorders. You need improved MRI techniques and a good neuroradiologist to detect these pituitary tumors. And you need state of the art radiation therapy, stereotactic radiosurgery modalities, as another treatment option to be available. And then you need a team that is keeping in mind and discussing the treatment plan with each other and coming up with a treatment plan that’s best optimized for the patient instead of just giving a one-sided recommendation. So, the reason I think a pituitary center is really important, rather than just going to a physician, is because we are looking at the patient as a whole and coming up with a multidisciplinary team approach for these pituitary tumors.

Host: Is there anything patients can do to prevent pituitary tumors?

Dr. Sharma: So, yeah, we don’t completely...there are certain hereditary disorders where you...that are associated with pituitary tumors, and if...those are very rare, um, most commonly multiple endocrine neoplasia, and if that runs in the family, then that could be something that you need screening for, but otherwise it’s not completely understood what causes pituitary tumors. That’s another area of research. We are developing more and more mutations, but those are not specific for a pituitary tumor and not everybody with that mutation is going to have pituitary tumors, so we are still at a learning stage for that and nothing in particular that one can do to decrease their risk of pituitary tumors because primarily we don’t completely understand why they develop. One of the most common questions that patients ask me is that they had a very stressful period where they were leading a very stressful life, and that by increasing their cortisol levels, did that cause Cushing’s or any other form of pituitary tumors, and no, we do not think that, at least as of now we don’t have any current evidence to suggest that. Uh, so the main thing that one can do is to be in tune with your own body, to recognize any new symptoms that one may be developing and make sure you’re following up with your physician as many times they may detect if there is any evidence of any pituitary disorder and then, if needed, refer to an endocrinologist or a pituitary specialist.

Host: Are certain patient populations more at risk than others?

Dr. Sharma: Oh, so yes, uh, age-wise there is. But also, there are certain pituitary tumors which tend to occur in a younger age group or in more in females versus males. For example, Cushing’s disease, which is a tumor, where the tumor makes ACTH, which then causes cortisol excess - that tends to be more common in young females compared to males, so there are certain gender predilections in some of the pituitary tumors, but not always.

Host: Thanks for joining us today Dr. Sharma.

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