Medical Intel, brought to you by MedStar Washington Hospital Center

When Should You See a Podiatric Surgeon?

David Cole — Thu, 27 Jul 2017 05:00:01 +0000

Persistent foot or ankle pain may seem like just an annoyance. But without proper treatment, the pain and discomfort can get worse, potentially damaging mobility and quality of life.

In this segment, Dr. Caitlin Zarick, Podiatric Surgeon with MedStar Washington Hospital Center, joins the show to discuss when you should see a podiatric surgeon and how a comprehensive, patient-focused approach offers the latest innovations in podiatric surgery, health and treatment.

Additional Info

Segment Number: Null
Audio File: medstar_washington/mwc024.mp3
Doctors: Zarick, Caitlin
Featured Speaker: Caitlin Zarick, DPM
Specialty: Null
Guest Bio: Caitlin Zarick, DPM, is a board-qualified reconstructive foot and ankle surgeon and associate professor in the Department of Plastic Surgery at Georgetown University.

Learn more about Caitlin Zarick, DPM
Transcription: Melanie Cole (Host): Persistent foot and ankle pain may seem just like an annoyance, but without proper treatment, the pain and discomfort can get worse potentially damaging mobility and quality of life. My guest today, is Dr. Caitlin Zarick. She’s a Podiatric Surgeon with MedStar Washington Hospital Center. Welcome to the show, Dr. Zarick. What are some of the common sports injuries that a podiatric surgeon would see? What are some of the most common things that happen to our feet?

Dr. Caitlin Zarick (Guest): Yeah, one of the most common things – especially around the summertime when everyone is a little bit more active – are common ankle sprains. Ankle sprains are usually treated conservatively and will usually get better in a month, maybe a couple of months depending on how severe it is. Sometimes it’s either just with an ankle brace, or if it’s a severe ankle sprain, patients need to be offloaded sometimes in a boot. There’s only very few patients who over a period of time had done significant damage to their ligaments, and those are the types of patients that might require some more advanced care.

Melanie: People are tempted to walk it off – you have a pain in your ankle, you rest it a few days, maybe you put a wrap around it – what do you tell people about those types of home treatments – wrapping, icing, keeping it up, that sort of thing?

Dr. Zarick: They are definitely good treatments for sure, but occasionally they need to be more aggressively treated with something that’s called a CAM boot, which basically acts as a big cast that you’re able to walk in. If you’re doing these home remedies, it might not be enough, which can actually lead to chronic issues or issues that are persistent in the future that sometimes will occasionally need surgical intervention.

Melanie: While we’re talking about that – so if people do injure themselves, do you see a lot of – they used to call them turned ankles because of heels and things like that – and are those the type of things we can do home treatment? Or, do you have to hear something to go see a surgeon? People say, “Oh, I didn’t hear my ankle pop, so I don’t have to go see anyone?”

Dr. Zarick: You don’t necessarily have to hear something, but if you have – things you want to look for would be significant swelling in your ankle or bruising. Those are not things you would typically see if it’s just a simple turned ankle from wearing a high heel, and that’s when you would want to seek the more advanced help.

Melanie: Let’s talk – before we talk about surgical intervention, people try all sorts of things to level out their gait and to make that base of support as strong as it can be. What do you think about inserts and the ones you can even buy at the store – Spenco’s and these other ones – do we use these? Do we want to make sure our arch is nice and supported? Speak about that a little bit.

Dr. Zarick: Yeah, so there’s definitely – some people have a perfectly normal foot, and they don’t necessarily need any kind of arch support. But there’s other people that have – you’re born with a bunion, you’re born with a flat foot or a really high arch foot, and these foot types can put extra strain on different tendons and ligaments, which over a period of time can cause arthritis in the joint as well as just pain and degeneration of your tendons. Those are the type of people – whether you’re having pain or not – but if you have this abnormal foot type, that’s the kind of person that should seek some type of arch support, whether it’s a custom arch support or orthotic.

I typically recommend people try the over the counter ones first because they’re typically less expensive. The ones that you want to avoid are any of the inserts that you can bend in half with your hand. Those are really just giving you a cushion as opposed to giving you support in your foot. The better ones -- you mentioned the Spenco and the Super Feet -- are ones that have a more rigid sole to them and it actually is more like a piece of plastic that will give you some support inside of your shoe.

Melanie: Dr. Zarick, how important are shoes? Because people think they should be wearing walking shoes if they’re walking or running shoes only if they’re running, but the technology has changed so much. Tell us a little bit about shoes we should be wearing.

Dr. Zarick: Yeah, shoes are very important, and it’s hard to tell every single patient that you should be wearing this one specific type of shoe. I can speak from my own experience that different sneakers feel more comfortable on my feet, and other sneakers that I recommend to my patients all the time do not feel comfortable on my particular feet at all. I have wide feet with high arches, so something that can accommodate my wider foot in the front is going to be more comfortable for me than a more rigid sneaker that doesn’t help accommodate that, and actually presses on my toes and causes them to go numb. While it is very important to be wearing more supportive shoes, it can also take some time for you to find that particular shoe or that particular brand that is going to be the best fit for your particular type of foot.

Melanie: That is so important, and when might surgical intervention be necessary? What types of conditions do you see where you say, “You know what? This is something that I’m going to have to really fix.”

Dr. Zarick: Yeah, so there is a multitude of surgical things that need to be done for the foot. Going back to the ankle sprains, if it’s been several months and you’re really inhibited in your daily activities where you’re still getting pain and swelling in the area – we’ve done further testing, you’ve done physical therapy and you’ve exhausted all of that, that’s when you become a good surgical candidate and where surgery – you would really benefit from that.

Other things, obviously bunions and hammertoes, are very common things that the podiatric surgeon will do surgery for if it’s inhibiting your activities or inhibiting the kinds of shoes that you can wear and really causing you pain on a daily basis. Other common things would also be arthritis – whether it’s arthritis of your big toe joint, arthritis in the back of your foot near your heel, and then another common area is arthritis across the mid portion of your foot. That is also a common area to need surgical intervention for as well.

Other things – potentially a lot of patients that have diabetes they can get wounds and different things. There are multiple surgical interventions that we can do to prevent wounds and infections from happening in this type of patient. One of the most complex surgeries that we perform is what’s called a Charcot reconstruction surgery. A Charcot's foot is something that happens in our diabetic patient population. It can happen to people that also just have neuropathy on their feet. Their bones start breaking down, and it morphs into an irregular shaped foot. We actually can reconstruct the arch and fuse a bunch of joints together in the foot to give them a more stable foot that they can ambulate on.

Melanie: So with the exception of things like diabetes, Dr. Zarick, if somebody has just a chronic type situation then they can see a podiatric surgeon when it affects the quality of their life. Whereas, an acute situation, you might have to actually go to the Emergency Room and have it fixed?

Dr. Zarick: Correct, they can – if it’s an acute situation where you can’t get an appointment right away, then you should definitely go to the Emergency Room. If it’s an ankle sprain and you can wait a couple of days for an appointment, that’s fine to come and see is in a couple of days. The more chronic situations, those patients we are typically seeing more frequently and evaluating when the appropriate time for surgery would be.

Some other acute situations we do see fractures in the foot, like a fifth metatarsal fracture. Some people are familiar with the term a Jones’ Fracture, and other midfoot fractures are other common things that we see as well.

Melanie: What about plantar fasciitis? It’s something that especially the weekend warriors -- and in the summer, people running – besides shin splints, plantar fasciitis seems to be so common and yet so painful, and it can be debilitating. What do you tell people about it?

Dr. Zarick: It is definitely one of the most common things that we see. In 95 to 99% of people, it goes away with simple, conservative treatment, which includes a bunch of stretching and those over the counter inserts, as well as some other things that I usually recommend. There’s a very small percentage of the population that doesn’t get better with these simple, conservative things, and physical therapy, and such. I’ve done, a couple of times, on patients something called PRP or platelet-rich plasma injections, which seems to be pretty effective. It’s done on other parts of the body as well. These patients typically aren’t needing any kind of major reconstructive surgery for their plantar fasciitis, although, on occasion, it is done.

Melanie: Wrap it up for us, Dr. Zarick, with your best advice about when to see a podiatric surgeon and some prevention of common sports injuries that you might be seeing to protect our feet and ankles?

Dr. Zarick: Yeah, so really, the best time to come and see us is any time you’re having foot or ankle related pain – whether it’s been present for months or you’ve just had an injury, and you need to be evaluated, those are really the best times to come and see us.

Things to prevent it is obviously good shoes, which we had touched based upon. If you know you have a weak ankle, wearing an ankle brace when you’re doing heavier sports activities and really just being cautious about who’s around you and the amount of activity that you’re doing. Patients really need to be sensitive towards, “I had pain over here when I was on vacation,” and taking it easy for a couple of days instead of being that weekend warrior who has been going out and doing more activities.

Melanie: That’s great information. Thank you, so much, for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to MedStarWashington.org, that’s MedStarWashington.org. This is Melanie Cole. Thanks, so much for listening.
Internal Notes: Null
Hosts: Melanie Cole, MS

Treating Cancer With The Edge System

David Cole — Tue, 25 Jul 2017 05:00:01 +0000
About half of all cancer patients receive some type of radiation therapy during the course of their treatment. Radiation therapy is a type of cancer treatment that uses beams of intense energy to kill cancer cells.

In this segment, Dr. Pamela Randolph-Jackson, Chair of the Department of Radiation at MedStar Washington Hospital Center, discusses advances in radiation oncology treatments
and the types of cancer treated with the Edge system.
Additional Info
Segment Number: Null
Audio File: medstar_washington/mwc026.mp3
Doctors: Randolph-Jackson, Pamela D.
Featured Speaker: Pamela D. Randolph-Jackson, MD
Specialty: Null
Guest Bio: Pamela D. Randolph-Jackson, MD, is chair of the Department of Radiation, MedStar Washington Hospital Center. Her research focuses on radiation oncology, especially for use in treating breast, lung and gastrointestinal malignancies. She specifically is interested in treatments using positron emission tomography/computed tomography (PET/CT); magnetic resonance imaging (MRI)/CT fusion; three-dimensional conformal radiation therapy; and intensity-modulated radiation therapy (IMRT) for breast, rectal, uterine, prostate and lung cancer.

Learn more about Pamela D. Randolph-Jackson, MD
Transcription: Melanie Cole (Host): About half of all cancer patients receive some type of radiation therapy during the course of their treatment. Radiation therapy is a type of cancer treatment that uses beams of intense energy to kill cancer cells. My guest today, is Dr. Pamela Randolph-Jackson. She’s the Chair of the Department of Radiation at MedStar Washington Hospital Center. Welcome to the show, Dr. Randolph-Jackson. Tell us about some of the latest advances in Radiation Oncology treatments going on today.

Dr. Pamela Randolph-Jackson (Guest): Well, thank you for having me. I’m glad to be here. I would say that the latest and the greatest is Stereotactic Radiation Therapy. We call it either Stereotactic Radio Surgery or Stereotactic Body Radiation Therapy. The reason why it’s such a great modality is that it’s a quick source of treatment. Usually, patients are here for six to seven weeks with conventional radiation therapy when you use IMRT or 3D Conformal Therapy, but with the Stereotactic Radio Surgery, you can be in the radiation oncology department anywhere from one to five days.

Melanie: And what about minimizing dose exposure to the surrounding healthy tissue? Is this something that’s taken care of very well with Stereotactic Radiation?

Dr. Randolph-Jackson: That is definitely one of the pluses of this form of treatment. It’s a fast treatment; it’s accurate. The precision is within millimeters – we call it submillimeter accuracy. You do minimize any radiation dose to normal tissue.

Melanie: Is this a little bit more intense than past radiation? Are there less treatments administered?

Dr. Randolph-Jackson: There are less treatments, but the great thing about the Edge, which is the modality that we use here, is that – when you think about radiation therapy, we call it a biological dose. Although you’re giving fewer treatments, the dose per treatment is higher than you would be giving if you were treating the person over the six to seven weeks’ time period. Biologically, it’s equivalent to the same dose.

Melanie: And what are some of the types of cancers that can be treated with the Edge?

Dr. Randolph-Jackson: Almost anything. Mainly, if you’re going to treat Stereotactic Radiosurgery, that pertains the head or the brain. We can treat all benign entities like acoustic neuromas. You can treat metastatic lesions involving the brain. You can treat prostate cancers, pancreatic cancers, liver metastasis from any cancer – spine metastasis from pretty much any cancer.

Melanie: What about some of the advantages of treating tumors with the Edge versus some other radiation treatments? Is it more comfortable for the patient, real-time imaging? Explain some of the advantages.

Dr. Randolph-Jackson: The main advantages, I would say, are just as you pointed out. We have the accuracy and precision, also the speed. This machine has the highest dose rate of any machine that is in the industry. It’s 2,400 MUs per minute. Just the dose rate by itself means that the radiation dose is given quickly, which means the patient is in a position for less of a time period, and the probability of that patient moving is less as well. The main advantage is the time spent on the machine and the time spent in the Radiation Oncology Department. The patient can get on with other things – if it’s chemo or other things such as that, it just makes it a lot easier.

Melanie: How long, approximately, generally, is a patient under this type of radiation?

Dr. Randolph-Jackson: Ten to fifteen minutes. You can actually fit it within a regular treatment timeslot.

Melanie: What about the cost-effectiveness of the Edge and the Stereotactic Radiation? Is this better than what we’ve seen in the past?

Dr. Randolph-Jackson: It’s actually cheaper because radiation therapy is billed by the number of treatments delivered. Because you’re delivering fewer treatments, it’s actually a cheaper treatment than say a 30 to 40-session course of radiation therapy.

Melanie: And speak about motion management capabilities. For example, if you’re treating a tumor for lung cancer, and the lung is a moving organ – constantly moving. Does this help with that?

Dr. Randolph-Jackson: It does. We do something called respiratory gating, which gates where the lung is. That, with the administration of fiducial, when needed, which is a marker that the Radiology Department puts in the tumor itself. It’s easy enough to track the tumor, and because of the speed of which the radiation is delivered, you really can’t breathe as fast as the radiation is being delivered. The fact that the machine tracks your movement, your respiratory movement, and the speed of the machine, it adds to the accuracy and decreases the time on the machine.

Melanie: Dr. Randolph-Jackson, people have heard Gamma Knife and Cyber Knife treatments. What’s the difference between the Edge, Gamma, and Cyber?

Dr. Randolph-Jackson: Well, the difference in terms of Gamma Knife, is that Gamma Knife can only treat any malignancy in the head or benign entity in the head. You can’t treat the body – anything in the body -- nothing in the liver, the lung, or the pancreas with the Gamma Knife. That’s one thing.

The difference in Cyber Knife is that the Edge treats it quicker. In other words, we don’t have to place fiducials in everybody part that we want to treat. The planning is quicker, and the treatment course is quicker. Cyber Knife takes longer treatment times and usually, it’s based on fiducial placement.

Melanie: Going back to the Edge, how is the procedure performed? What can the patient expect from their day?

Dr. Randolph-Jackson: It’s very easy for a patient. They come in for simulation, which is how we plan a patient for any type of radiation therapy. We use immobilization devices because, as you know, it adds to our accuracy if the person is not moving. If we’re treating a head and neck tumor, then a mask is made just for that patient, which keeps them from moving from side to side. The planning space is CT-based. We plan on our CT scan that we get that day. If we need more information, then we will fuse other studies like an MRI. The planning is done, the patient comes back, and they receive their treatment.

Melanie: And is there any reason to look back to SBRT or Gamma at this point, now? Not Gamma necessarily, but Cyber, as well, is there any reason to look back to those for some people who may not be candidates for the Edge system?

Dr. Randolph-Jackson: I think that when you look at all three modalities if you think about head – anything in the head like acoustic neuromas, trigeminal neuralgia, brain metastases -- I think that all three treats with the same accuracy and outcome. When you look at body treatments, so Stereotactic Body Radiation Therapy, Cyber Knife and the Edge treat with the same outcomes. However, the Edge is faster in the delivery of the treatment and more comfortable for the patient than Cyber Knife would be.

Melanie: Is there any difference after these treatments have been administered?

Dr. Randolph-Jackson: No.

Melanie: So radiation is radiation?

Dr. Randolph-Jackson: Radiation is radiation.

Melanie: What might they feel as side-effects?

Dr. Randolph-Jackson: They really shouldn’t feel anything at all. If you’re treating anything in the head, you can have swelling from radiation. That’s one of the side-effects from any form of radiation. Usually, we put these patients on steroids, which stops that from happening or prevents that from happening. They won’t have headaches or blurred vision or anything of that sort. You can have a flair from the treatment of the spine after radiation therapy – a flair in your pain. Steroids have a tendency from preventing that from happening as well. Everything can be pre-medicated, such that the side-effects are very inconsequential.

Melanie: Wrap it up for us, with your best advice and what questions you would like patients to ask about these forms of radiation therapy and what you tell them every day?

Dr. Randolph-Jackson: What I would say is that radiation therapy may not be for your particular cancer. It’s very specific, and there are specific size criteria needed to be treated using radiosurgery. However, I think that if you go to a Radiation Oncologist or you’re seen in an office of a Radiation Oncologist, you should ask the question whether or not you may be a candidate for radiosurgery versus traditional radiation therapy.

Melanie: Thank you, so much, for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to MedStarWashington.org, that’s MedStarWashington.org. This is Melanie Cole. Thanks, so much for listening.

Internal Notes: Null
Hosts: Melanie Cole, MS

Diet and Nutrition’s Effect on Wellbeing

David Cole — Thu, 20 Jul 2017 05:00:01 +0000
The nutrients in the foods that we eat enable the cells in our bodies to perform their necessary functions. What you eat can greatly affect your health and well-being. Scientific studies have shown many times that choosing healthy foods can reduce the risk of heart disease, cancer, and other diseases.

Listen as Andrea Goergen, Clinical Dietitian, discusses diet and nutrition's effect on wellbeing, and how you can enjoy a variety of foods, eat healthy and have more energy.
Additional Info
Segment Number: Null
Audio File: medstar_washington/mwc027.mp3
Doctors: Goergen, Andrea
Featured Speaker: Andrea Goergen, RDN
Specialty: Null
Guest Bio: Andrea is a registered dietitian nutritionist (RDN) at MedStar Washington Hospital Center’s bariatric clinic. She is also the owner of Cultivate Healthy, a nutrition and wellness company in Washington DC. Using an “all foods fit” approach, Andrea works with patients and clients to help them lose weight, prevent and manage health conditions like diabetes and hypertension, and improve their overall health. Andrea has been working in the field of health research, health education, and nutrition for over 15 years. She graduated from the University of Maryland at College Park in 2002 with a degree in dietetics, after which she joined the Peace Corps as a health extension volunteer in rural Guatemala. Andrea returned to the US to pursue a master’s degree in International Health with a focus on social and behavioral interventions at Johns Hopkins School of Public Health. Andrea’s work has been featured on Good Morning Washington, in multiple scientific journals like Public Health Genomics and the American Journal of Preventive Medicine, and online on Reader’s Digest, WTOP, Women’s Health, and her own blog at www.cultivatehelathy.com.
Transcription: Melanie Cole (Host): The nutrients in the food that we eat enable the cells in our bodies to perform their necessary functions. What you eat can greatly affect your health and well-being. Scientific studies have shown, time and again, that choosing healthy foods can reduce the risk of heart disease, cancer, and other diseases. My guest today, Andrea Goergen. She’s a Registered Dietician/Nutritionist at MedStar Washington Hospital Center’s Bariatric Clinic. Welcome to the show, Andrea. Tell us about healthy eating and how it can help us -- because people hear about supplements in case they’re not getting all of the healthy foods that they should be getting. Give us a summary of healthy eating and really what it does for us.

Andrea Goergen (Guest): Sure, thank you, for having me. What happens with diet and exercise is it’s all working together to help optimize every function in your body. Having the right nutrition -- like vitamins, and minerals, and protein, and carbohydrates, and fat, and all of the good things like that in a reasonable balance helps everything work just a little bit better. You’re looking at energy production, support of the cardiovascular system, healthy bones, and teeth, all of that works together. You can usually get it from a balanced diet, but sometimes you have a little bit more trouble with that, so it’s easier to supplement to make sure you’re getting what you need.

Melanie: Let’s talk about getting what you need, and people don’t always know – they hear about these diets, and fad diets, and no carbohydrates, and carbohydrates are bad, and too much fat – so clear up a little bit about portion sizes and what we should see on our plate. Also, Andrea, please reiterate the importance of carbohydrates because even a tomato and a carrot are carbohydrates. People need these in our diets, so tell us what our plate looks like.

Andrea: Absolutely. I think it really depends on what your goals are. If you’re trying to lose weight, it might be slightly different than if you’re just trying to maintain your weight and optimize your energy levels and things like that. In general, what I do recommend is half your plate being vegetables and a quarter of your plate being starch – carbohydrates as we sometimes call them – and then a quarter of your plate being protein. Those vegetables are definitely carbohydrates, as you said. They’re considered complex carbohydrates, so they’re loaded with fiber, lots of vitamins, and minerals. They’re not going to be the starchy kind that people assume make up the section of carbs.

Carbs are important for energy production. A lot of research studies out there have shown that they’re good for reducing inflammation in the body and supporting a healthy cardiovascular system. Really, there are a lot of fad diets out there and a lot of misconceptions, really. For the most part, unless you have some sort of major allergy or intolerance, you really don’t need to be cutting out healthy ingredients in your diets like bread and pasta, rice, all the fruits, and vegetables. Potatoes are okay; they get a bad rap too.

It’s really about the portion sizes and making sure that you’re balancing what’s on your plate. I use a small plate. I actually use side plates, and I recommend that my clients and my patients do, as well. Use a side plate or salad plate, fill it half with vegetables, a quarter with starch, and a quarter with a nice, lean protein. That can give you a lot of the energy that you need -- a lot of the fiber, and vitamins, and minerals without leaving room for things that are not going to be your best friend in the weight loss process or the healthy eating process.

Melanie: If you wanted to use food as an energy source, which it is automatically, are there certain foods that you like people to – you’ve mentioned vegetables – and if we want to stay alert and really be as sharp as we can and have focus, what foods do you like us to eat?

Andrea: For alert and focus – you want proper brain function and nerve function for being alert and focusing, so a lot of the things you would be looking for would be your minerals. Magnesium is good for nerve transmission and things like that. You want to make sure that your central nervous system is at its peak, basically. Lots of vitamins and minerals are going to be very important for that. I don’t recommend targeting the vitamins and minerals unless you’re doing supplements because you’re missing things, but making sure that you have a good balance.

Lots and lots of fluid – water is your best choice there – can help boost the function of your vitamins and minerals and make sure they’re doing what they’re supposed to be doing. You can feel sluggish or fatigued with a little bit of a brain fog if you’re missing some fluid and are dehydrated. A lot of people are more dehydrated than they really think they are. It isn’t until you get thirsty that you think, “Oh, I should drink something,” but usually, you’re experiencing dehydration long before thirst comes in. That is a huge problem for energy.

Other things that are helpful, B vitamins are wonderful for keeping the energy going and making sure that you’re functioning at your best.

Melanie: How do we know how much we’re getting as far as Magnesium, and Calcium, especially for women and older women, and the B vitamins – B12, we hear about that for alertness and focus. How do we know, and if we are not getting what we should be getting from our food, what do you recommend as far as multivitamins or extra D or any of those kinds of things?

Andrea: That’s a good question. I think, for the most part, if you’re eating a balanced diet, and you really are getting in a good combination of things – that can be leafy green vegetables, some citrus fruits, you’re getting in lean protein sources including beans and eggs. Those are great options, as well, that are very packed with vitamins and minerals. When you’re getting all of those things – whole grain bread and fortified cereals and things like that have a lot of the things that we’re looking for. Most of the time, you’re not going to be deficient in these vitamins and minerals. It’s not very common to be deficient in these if you’re having a balanced diet.

One of the best things you can do if you’re feeling fatigued or you’re feeling sluggish -- there are other things that can happen, too, like muscle cramping or weakness. Other things could be strange things like tingling or numbness in your hands and feet, nausea, and vomiting, and things like that – some of that can come from lacking in vitamins and minerals.

I do recommend you go to your doctor, get tested, have your blood tested for nutrient deficiencies. They’re the best source for figuring out what levels your body requires – what you’re missing. Basically, they’ll send you to the right place to get the supplements you might need. Sometimes, you just need a little bit of Vitamin D. For instance, I am Vitamin D deficient on a regular basis, so I do have to supplement. I found that out at my doctor’s office.

Not everybody needs a multivitamin. Most of the time they won’t do you any harm. I would go for a complete multi vitamin unless you’re over 50 or so, you might need as much iron at that age. In general, for most adults, just a regular, complete multi vitamin can really give you everything that you need if you’re lacking. In general, I would go for specific vitamins and minerals that you’re missing so that you’re not overdoing it and you can really focus on your food.

Melanie: Well, I found that I am Vitamin D deficient, as well. Like you, I do supplement that because it is an important nutrient that many people – so it is a good idea to check with your physician to see if you are Vitamin D deficient – or any of those nutrients, as Andrea said.

Now, what about weight loss because eating for health to stay alert, relaxed, have more energy, that is different than necessarily losing weight, which is a whole different ballgame and quite hard to do. What do you recommend as your best advice about weight loss, and making sure that we’re still getting those adequate nutrients that we need, and what do you think about journaling?

Andrea: Sure. I think you have a really good point there. There are differences. The nice thing about an all foods fit approach, which is the approach that I take, is making sure that you have a generally healthy lifestyle, so when you are quote-unquote dieting, that you’re actually implementing strategies that you’re going to use for the rest of your life. You’re not creating some sort of unsustainable approach that once you finish, the weight comes back on. Really, they do go hand in hand – healthy eating and trying to lose weight.

My big suggestions for people are to make sure that you’re not skipping meals. I think people are under the assumption that if I don’t eat much, I’ll lose weight. That works for some people, but for the most part, it’s very tough. If your body isn’t getting what it needs, it starts to panic, and it goes into this starvation mode. It’s really going to be very hard to lose weight because your body thinks that it’s protecting you from starvation, basically.

Making sure that you’re eating three meals a day – you can make some small meals, and that’s fine – but making sure you’re getting three meals a day and making sure that you have some protein in each of those meals. When you cut your calories, you want to make sure that you have plenty of protein in your body. Otherwise, your body thinks that it’s starving and it’s going to look for – the amino acids that it would get from proteins, it’s going to find it in your muscle stores. Instead of burning off your fat stores, it’s going to burn off your muscle stores. That’s something you really don’t want because muscles help you really burn more calories. Making sure you have three meals a day, and that you have lots of healthy, lean proteins, that’s going to keep your body relaxed and allowing you to use the fat stores to burn off for energy.

Journaling, it’s tough to maintain. I think a lot of people struggle daily making sure that you get it in. I do think in the weight loss process you can come up with some really interesting information. I think information is incredibly valuable in the weight loss process in figuring out what you’re doing on a regular basis that might be helping you or that might be hurting you. I do recommend at least writing it down on a piece of paper. Any Dietician/Nutritionist can take a look at it and see what’s working for you and what’s not working for you.

Also using apps or a website that allow you to track your food and then automatically provides you with information, you might start seeing where there are some red flags. Maybe a food that you love is just too high in calories, or maybe you’re not getting enough protein, and you thought you were. A lot of those can also track your vitamin and mineral intake. That’ something you can look at to see if something needs to be shifted there, as well. Making sure that you’re getting plenty of vitamins and minerals, making sure that you’re getting your protein in and that you’re eating on a consistent basis, can really help you with the weight loss process.

My one last tip for losing weight is to make sure you’re not drinking your calories. If you’re bringing in calories from sodas, and juices, and Frappuccinos, and the sports drinks, and things like that, it’s so easy to overdo your calories that way. You’re not getting a whole lot out of that. A lot of times you're missing fiber and a lot of the vitamins and minerals that you could be getting from whole foods. Make sure that when you’re drinking that you're not drinking extra calories.

Melanie: That’s great information. Wrap it up for us with your best advice, Andrea, on really healthy eating and what we should be thinking about when we really want to see that good, healthy plate, to stay alert, to relax, to have more energy, and just really for our optimal well-being.

Andrea: I think a combination of things – I had a friend actually tell me something pretty interesting, which was nutrition is kind of boring. We know what we should be doing, but sometimes it’s hard to actually put it into place. Every once in a while, just doing a double check and making sure am I eating regularly? Am I filling my plate with fruits and vegetables, and a variety of foods – protein and even some starch – and making sure that you’re getting all of those things and that you’re satisfied and enjoying your meals. If you’re not, it’s easy to give up. It’s easy to throw your hands in the air and saying, “I’m not doing this.”

Look for a balanced variety on your plate. Do you have gorgeous, green, leafy vegetables and ripe fruits – which are amazing right now, locally – and some lean protein. The grill is a great place to get your lean protein right now. Make sure you’re getting that on your plate. It’s all about balance and making sure that it’s livable, it’s something you can adopt as a long-term lifestyle, and that you’ve got a good variety. If you ever are doubting what’s going on, seek professionals. We’ve got all of the information that you need, and we can really help you focus in on what’s going right and what’s going wrong.

Melanie: Thank you for being with us today, Andrea. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to MedStarWashington.org, that’s MedStarWashington.org. This is Melanie Cole. Thanks, so much for listening.
Internal Notes: Null
Hosts: Melanie Cole, MS

Treatment for Hernia

David Cole — Tue, 18 Jul 2017 05:00:01 +0000
Hernias occur when a weak abdominal wall allows a piece of the intestine or other tissue to slip through, often creating a noticeable lump. They either develop slowly over months or years or develop very suddenly.

Hernia surgery is critical for repairing the opening or weakness in the abdominal wall. If the opening is not repaired, tissues can become entrapped, weakening blood supply to those areas.

In this segment, Dr. Ivanesa Pardo, discusses treatment for hernias to help determine the most effective repair surgery for you.
Additional Info
Segment Number: Null
Audio File: medstar_washington/mwc020.mp3
Doctors: Pardo, Ivanesa
Featured Speaker: Ivanesa Pardo, MD
Specialty: Null
Guest Bio: Ivanesa Pardo, MD, FACS, is a board-certified general and bariatric surgeon at Medstar Washington Hospital Center.

Learn more about Ivanesa Pardo, MD
Transcription: Melanie Cole (Host): Hernias can occur when a weak abdominal wall allows a piece of intestine or other tissue to slip through often creating a noticeable lump that can either develop slowly over months or years or they can develop very suddenly. My guest today is Dr. Ivanesa Pardo. She’s a general and bariatric surgeon at MedStar Washington Hospital Center. Welcome to the show Dr. Pardo. So what is a hernia? How does it even occur?

Dr. Ivanesa Pardo (Guest): Well thank you so much for having me on your show. So a hernia is a defect, that’s what we call it, in the muscle layers of the abdominal wall. In simple terms it’s a hole within the muscle layers of the abdominal wall and there are common places where hernias can occur. For instance, at the umbilicus or belly button and the groin area, those are the most common places for hernias. They can also occur at the site of previous surgical incisions and depending on where they are and if they are original hernia or after surgical incision then they can different names. These places that are most common for hernias are we call them weak spots on the muscle layers. For instance, the umbilicus or belly button that’s w here we have our umbilical cord when we were inside our mothers as babies and that is a hole that eventually will close but for some people they have a persistent opening and that opening then later in life can enlarge to become a hernia.

Melanie: If left untreated are hernias dangerous?

Dr. Pardo: They can be. If a hernia is symptomatic, meaning if they person has pain or any other symptoms related to the hernia, that’s when we talk about repairing them. Depending on what can go through that defect and it can be fatty tissue or it can be segments of intestine then that would tell us a little bit about the urgency of which we would want to repair these hernias. Because there is something called an incarceration, which is when what is going through the hernia gets stuck like it cannot be pushed back in, be that it be the intestine or the piece of fatty tissue. And then there is something even worse called strangulation, which means that organ or piece of fatty tissue that’s stuck is losing its blood supply so it’s starting to die and that would be a surgical emergency.

Melanie: So if somebody notices this little bump Dr. Pardo because sometimes you just notice it and you go “Oh what is that?” then is that the time to go see a physician? Do you wait to see if it goes away, do you try and push it back down through? What do you do if you notice it?

Dr. Pardo: So if you notice a lump and it’s not tender and there are no changes on the skin you can always just push it to assess yourself if you’re dealing with something that is kind of going in and out. Hernias for the most part when you do certain movements that are called Valsalva maneuvers for instance coughing, sneezing, straining, you can feel that that lump may become larger or push out or even become a little bit tender. If you find these characteristics it would be cautious to go to the doctor to get the diagnosis confirmed. That does not necessarily mean that you’re going to get surgery offer, in fact you can go to your primary care doctor to have this evaluated. And they’re going to be able to asses if it is a hernia. If they’re in doubt they can order some testing or they can send you to a surgeon to better confirm the diagnosis.

Melanie: Are there some common activities that cause them? We used to hear oh if you lift that improperly you might get a hernia or something that’s too heavy for you, are there some things that you’d like to let the listeners know that they can do to reduce their risk of hernia?

Dr. Pardo: So there’s definitely horror stories of a person that exercises a lot and does a lot of heavy lifting and then they can feel a pop and those are hernias that occur all of a sudden. And there’s no limitation that I would put on a person to not do an activity in order to avoid a hernia, but somebody that does have a hernia may want to be careful when doing such activates, like lifting, because then the hernia can become symptomatic, can become incarcerated, and enlarge overtime so you can definitely become problematic. If you don’t have a hernia, I would say definitely don’t pass beyond your own limits and every person knows for the most part what their own limits are.

Melanie: So when does it require surgery Dr. Pardo and what’s involved in hernia surgery?

Dr. Pardo: So I recommend surgery when the defect is large enough that even if it’s reducible, which means even if the defect going through, if it’s large enough where a segment of intestine could get stuck where we talked about incarceration and strangulation, I would recommend to electively repair it before that were to happen. Of course if it does happen then you know that’s more of an emergency surgery. In surgery terms, elective is always a better way of repairing because everything is more under control. The way that we repair hernias, there are many ways. We could say there’s old fashion which is called open repairs which equals larger incision. And then there’s the more modern repairs which we call minimally invasive. And that can be laparoscopic or robotic. And that would depend on the availability of the facility where you have that and of course the skills of the surgeon. Most hernias that need repair will most likely require a mesh implantation. And a mesh is a screen, it’s a synthetic material and what it does is it reinforces the muscle layers where the defect, where the hernia, is. So we reduce the chances of the hernia coming back after it’s been repaired so with the advent of mesh what we’ve created is a hernia that would have had almost a 50% chance of coming back, now we’ve reduced it to 3-5% chance of coming back. So I would say that it is a conversation that you would have with your surgeon if you do need repair and if you do need mesh.

Melanie: And you mentioned that the chances of it coming back. So depending on the type of repair that you have, the chances of it coming back or coming in a different spot, what do you tell people about those?

Dr. Pardo: It’s very important when healing from the surgery that we limit those activities that cause increased pressure of the abdomen like lifting, straining, for usually about a time of 6 weeks. And that is to let the tissues heal and the mesh incorporates and be as strong as it can be in order to procedure with those activates. Those would reduce the chances of the hernia coming back. Now we try to optimize the patients prior to surgery so people with diabetes. People who are obsess, people who are smokers, we try to improve all those things before surgery because that would give you the best result possible.

Melanie: So wrap it up for us Dr. Pardo with your best advice about people who might notice that they have a hernia or who want to avoid one if they possibly can, and what do you tell people every day about hernia, hernia repair, and possible prevention?

Dr. Pardo: So definitely if you have surgery before because you can get hernias at incisions sites, avoid heavy lifting especially know your own limits so you don’t pass those limits because that’s when your risk of creating hernia is. If you ever notice a lump and you’re unsure go to your primary care doctor and they will be able to identify if it is indeed a hernia and if they’re unsure they will send you to see a surgeon. Of course you can always see a surgeon directly to assist in the diagnosis. And depending on what is found, then we would have the conversation as far as does it need to be repair and if so what is the best approach for the specific person.

Melanie: Thank you so much for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to MedStarWashington.org. This is Melanie Cole, thanks so much for listening.
Internal Notes: Null
Hosts: Melanie Cole, MS

Bariatrics and Weight Management at Medstar Washington Hospital Center

David Cole — Thu, 13 Jul 2017 14:00:00 +0000
Obesity comes with health risks. Diabetes. High-blood pressure. Joint pain. Sleep apnea and more. That's why so many people have turned to us for help. MedStar Washington Hospital Center's Bariatric Surgery Program is one of the area's most experienced and comprehensive.

Join Dr. Timothy Shope, Director of Bariatric Surgery, to begin your journey to better health and if this is your first step in the bariatric surgical process, to think of this as a tool to aid in the long term weight loss that could improve the quality of the rest of your life.
Additional Info
Segment Number: Null
Audio File: medstar_washington/mwc021.mp3
Doctors: Shope, Timothy R.
Featured Speaker: Timothy R. Shope, MD
Specialty: Null
Guest Bio: Timothy Shope, MD, is a bariatric surgeon and Chief of the Section of Advanced Laparoscopic and Bariatric Surgery at MedStar Washington Hospital Center. He is a fellow of the American College of Surgeons and a member of the American Society for Metabolic and Bariatric Surgery (ASMBS) as well as the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).

Learn more about Timothy R. Shope, MD
Transcription: Melanie Cole (Host): More than 12.5 million Americans are severely overweight according to the US Department of Health and Human Services. Obesity comes with health risks – diabetes, high blood pressure, joint pains, sleep apnea, and so much more. Many people who are seriously overweight have tried different diets and medications and professional weight loss services for years without long-term success. My guest today is Dr. Timothy Shope. He’s the Director of Bariatric Surgery at MedStar Washington Hospital Center. Welcome to the show, Dr. Shope. Who should consider bariatric surgery? Are there certain parameters to considering bariatrics, and who can qualify?

Dr. Timothy Shope (Guest): There are parameters, Melanie, and thanks for having me along. The patient that would be a good candidate for surgical weight loss or bariatric surgery would include anyone who has a body mass index or BMI greater than 40, or more than 35 with certain medical conditions such as – you already mentioned diabetes and sleep apnea. There are some carve-outs, which would include patients that have an excess weight of approximately 100 pounds over their ideal body weight, as well.

Melanie: If people have that, and they’ve determined by BMI that they are a candidate, what is the first step? What do they do, and how long does it take between deciding that this is something you’d like to pursue and actually having the surgery?

Dr. Shope: No patient comes through our doors until they’re definitely ready to proceed. Oftentimes patients will tell us that they’ve been thinking about this for five, seven years. Once they’ve made the decision, and they have their initial consultation with the surgeon to determine candidacy, they’re then put into a pretty well-defined program. This includes not only psychological evaluation and potentially counseling, but also, one of the most important components, which is nutritional counseling, which involves our registered dietician. Those patients will have monthly visits with the dietician. Mostly, that’s based on insurance needs, and it’s either three or usually six months of preoperative counseling with the dietician.

Once they’ve completed that program if they met the other program requirements – and that will vary minimally from program to program -- they would then come back to see the surgeon. If everything is in line, we will proceed with surgery.

Melanie: Based on insurance requirements, are there certain things like psychological counseling, and you mentioned the nutrition consulting – what else does insurance sometimes require that they do?

Dr. Shope: Some insurance programs – I’m sorry, some insurance companies will require visits with, for example, a cardiologist or, perhaps a pulmonologist. That’s pretty rare. More and more insurance companies are requiring an evaluation by an exercise physiologist, or some meaningful time spent with the physical side of things. The insurance company’s main requirements are dietician visits and that psychological or psychiatric evaluation.

Melanie: Tell us about the types, Dr. Shope, of bariatric surgery that you’re doing there at MedStar Washington Hospital Center.

Dr. Shope: Sure. We perform the gastric bypass surgery, which is still considered to be the gold standard in the United States. We perform the sleeve gastrectomy. All of those procedures, for the most part, are done laparoscopically these days. On occasion, we do some open procedures when it’s appropriate, and we also have the opportunity to use the robotic equipment as well.

Melanie: Let’s start with bypass. What’s involved, and explain whether this is a malabsorption type of procedure? What is it like for the patient?

Dr. Shope: The gastric bypass is actually a combination procedure where we provide pretty substantial restriction, which basically limits the amount of calories the patient can take in at any one time, as well as the malabsorption that you mentioned. The malabsorption makes it so that of the amount of calories that a patient takes in, only a certain percentage of them would then be actually absorbed appropriately and available by literal consumption by the patient.

As far as what it’s like to live with the operation, patients will have pretty substantially reduced plate sizes. Their portion sizes will be much smaller, and they’ll be eating less at any one time. It’s important that we make it possible for them to get enough calories in in a day, and that dietician counseling makes it certain that of those calories that they take in, a certain proportion of that should be proteins first, perhaps some fats and some carbohydrates, as well. There’s a very significant stress that we place on fluid intake. It’s very easy to become dehydrated after these procedures, and if patients aren’t aware of that, and constantly practicing their fluid intake, it can be a little bit of trouble for them.

Melanie: What’s the difference with the gastric sleeve?

Dr. Shope: The gastric sleeve is a truly restrictive operation. With it, we only reduce the amount of fluid or food that the patient can take in at any one time. The sleeve – with that operation, we create essentially a long, narrow tube of stomach. That long, narrow tube is what provides that rather substantial restriction and limits the amount that they can get in at any one time.

Melanie: Can either of these be reversed?

Dr. Shope: The sleeve gastrectomy cannot be reversed. We actually remove a fair portion of the stomach – somewhere around three-quarters or 80% of the stomach is actually, physically taken out of the patient and cannot be replaced. Reversing the gastric bypass is technically possible, but there has to be a very, very good reason for anyone even to consider it. If it’s considered and subsequently performed, some of the risks that the patient accepted at the initial procedure may even be more so with the reversal of the procedure. The patient may well then regain their weight and their medical troubles that they had.

Melanie: What is life like afterward – after having – whether they’ve had the sleeve or the bypass – as far as nutrition, going to restaurants, supplementation, and exercise? Tell us about some of those things.

Dr. Shope: Sure. Life after the surgery, my patients tell me it’s a little bit to get used to in the early going. They do have to understand that they can only take in a certain amount at a time. There will be times, not only early on, but throughout the rest of their life where – perhaps, they eat a little bit too fast, maybe they haven’t chewed their food, as well as they thought they did, or maybe they’re at a meal with their family, and they’re not consciously aware of what they’re doing where they may actually have some trouble with food feeling like it’s stuck, or perhaps even – needing to excuse themselves to run to the bathroom. This is something that they learn to accommodate with over time, and after months or certainly, after years, they can go out to dinner with the family. They can go to social events. They can live their lives like they otherwise would be able to. They just have to pay a bit more attention to the pace of eating and the types of food they’re eating, and the quantity, certainly.

With regard to lifestyle choices afterward, they can and certainly should be physically active. As far as the nutritional supplements that these patients should be on – all patients should be on a standard multivitamin. Many of our patients should also be on calcium supplementation. That’s particularly important if the patient is an early- or middle-aged woman, for example, for bone health. Any time where there is an identified nutritional deficiency, which is a bit more common in the gastric bypass, but certainly, possible in the other procedures, those patients should then be then supplemented for that then identified the nutritional deficiency.

Our program, we monitor nutritional labs – vitamin levels, calcium levels, copper levels, zinc levels, some micronutrients that we know that they can become deficient in on at least a yearly basis. Anytime that we evaluate the patient and consider that they might have a nutritional deficiency, we’re going to look for that. If it’s present, then it should be supplemented.

Melanie: And what about medications for things such as high blood pressure and diabetes? Have you seen, Dr. Shope, these things maybe not go away, but at least get a little bit better as far as comorbidities with obesity are concerned?

Dr. Shope: That’s certainly the goal of the surgery. I always tell my patients that I care what the scale says, but I case so much more what’s happening with their overall health. These operations should not be done just for weight loss purposes. The patients have, in many cases, resolved or improved some of those medical troubles we discussed earlier – diabetes, high blood pressure, sleep apnea, for example. Some of those medical troubles can go away rather quickly. For example, I’ve seen with as little as 20 to 30 pounds of weight loss patients that have sleep apnea will tell me that they find that they’re lowering the settings on the machine or they’re actually waking up fighting the machine. Some will even admit that they’d forgotten to use the machine and not had a headache the next morning, the slept well, their partner didn’t tell them that they snored that night, for example.

Equally important with diabetes, for example, and particularly with a gastric bypass operation, patients that are diabetic that have had a gastric bypass can see their diabetes improve in some cases even before they leave the hospital, which is only a few days after surgery. And then, in the following weeks and months, those medications are being lessened, their blood sugars are being much more well-maintained. They are essentially resolving or improving substantially, their diabetes.

Blood pressure is a little bit different. Blood pressure can be simply because your parents had high blood pressure – your age, your gender, your race. It’s not just about the weight, but certainly, we have seen blood pressure improve substantially simply with weight loss. The truth is, there are some downright skinny people who have high blood pressure, so we may not be able to resolve that for all patients completely, but it should be much better managed, and in some cases, the patients will come off of one or maybe more of their medications, as well.

Melanie: Wrap it up for us, Dr. Shope, with your best advice for people that are considering bariatric surgery, what you would like them to know about this tool to aid in lifelong weight loss?

Dr. Shope: I think that these operations should be thought of as a tool and nothing else. There’s no operation that’s going to make them achieve their goals in life. The operation can be used to help them get to those goals, but in and of itself, it’s not going to make them do anything. If they combine the tool that they’re provided with with their new lifestyle of healthy eating, more appropriate choices, exercise, they ought to see a rapid improvement in their medical troubles, certainly weight loss and just a better life in general.

I would also suggest that they should only consider this if they’ve truly exhausted other means. This is not the first thing that they should think, and they should be fully committed to it before they even come through the door.

Melanie: Tell us about your team at MedStar Washington Hospital Center.

Dr. Shope: I could not ask for a better team. Our front office staff is wonderful with the patients. Many times, they get to know their personal lives more than I do. We have a nurse; we have a nurse practitioner that is dedicated to bariatric surgery. We’ve got two full-time dieticians. We’ve got four surgeons now. We’ve got a GI doctor that’s part of our team. We have a psychologist and a psychiatrist that will see patients in our offices. We have a fully comprehensive surgical weight loss program here, and again, the people are really what drives it. The surgeons always get the accolades, but the reality is if I didn’t have the rest of this team in place, there’s no chance I could do what I do.

Melanie: Thank you, so much, Doctor, for such great information. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to MedStarWashington.org, that’s MedStarWashington.org. This is Melanie Cole. Thanks, so much for listening.

Internal Notes: Null
Hosts: Melanie Cole, MS

The Latest Advances in Spine Surgery

David Cole — Tue, 13 Jun 2017 22:52:29 +0000
Spine surgery has traditionally been done as an open surgery. However, in recent years, there have been technological advances have allowed more back and neck conditions to be treated with minimally invasive surgical techniques.

The orthopaedic surgeons at MedStar Orthopaedic Institute have extensive training in the most advanced and innovative surgical procedures to treat back pain, including minimally invasive back surgery and motion sparing surgery.

In this segment, Dr. Oliver Tannous discusses the latest advances in spine surgery at Medstar Washington Hospital Center.
Additional Info
Segment Number: Null
Audio File: medstar_washington/mwc025.mp3
Doctors: Tannous, Oliver O.
Featured Speaker: Oliver O. Tannous, MD
Specialty: Null
Guest Bio: Oliver Tannous, MD, is an orthopaedic spine surgeon at MedStar Washington Hospital Center. As a spine specialist, he utilizes state-of-the-art, minimally invasive and motion preservation techniques to treat conditions of the bones, discs, and nerves of the neck and back.

Learn more about Oliver O. Tannous, MD
Transcription: Melanie Cole (Host): Spine surgery has traditionally been done as open surgery, but in recent years, however, technological advances have allowed more back and neck conditions to be treated with minimally invasive surgical techniques. My guest today is Dr. Oliver Tannous. He’s an Orthopedic Spine Surgeon with MedStar Orthopedic Institute at MedStar Washington Hospital Center. Welcome to the show, Dr. Tannous. What are some of the most common causes of back pain, and when you see a patient, when does it then become surgical?

Dr. Oliver Tannous (Guest): Hi Melanie, thanks for having me back. It’s good to be here. Great question. Back pain is, I think, the second most common reason to go to a medical office or Emergency Room after respiratory causes. It’s something that we see very commonly – not just me as a spine surgeon, but I think any primary care physician sees, as well. The vast majority of back pain, thankfully, is not at all serious. It tends to be muscle strains or some inflammation that happens around the spine from just good old-fashioned arthritis. It’s very rare that back pain then becomes a surgical problem.

Unfortunately, in 2017, as spine surgeons, we are terrible, and we have abysmal results, for the most part, when we try to treat back pain, and back pain only with surgery. What I explain to all of my patients is that when they have arthritis that causes back pain, but where the bone spurs have also grown and now are pinching on the nerves and causing nerve pain to travel down the legs -- as spine surgeons, we are very good at treating nerve pain that’s secondary to arthritis in the back.

When I have my patients come to see me, I really try figure out how much of their pain is really in their back, and how much of their pain is the nerve symptoms – the neurologic symptoms that are traveling down their legs. If it’s predominantly leg pain, well, I tell them I have a really good surgery to treat that, but if it’s predominantly back pain, I tell them that I probably am not going to make their back pain better, and then at that point, we really try to focus on non-surgical treatments and try to give them some pain relief.

Melanie: When we talk about – people hear the words minimally-invasive – and what does that mean, and what are some of the benefits of a minimally invasive procedure versus the traditional, more invasive procedures that you might have done in the past?

Dr. Tannous: Very good question. Everybody comes into the clinic, and everybody wants to know what this whole minimally invasive spine surgery is all about. Everyone wants the three-millimeter incision, and they want to avoid the bigger procedures. A lot has advanced in spine surgery over the past ten or fifteen years, but really over the past five years, as well. For some people – and I stress that – for some people, they are great candidates for a minimally invasive procedure. All that means is that we disrupt less muscle; we disrupt and take out less bone to accomplish the same goals.

The goals of spine surgery, first and foremost, when people have a neurologic deficit, you have to decompress the nerve. If you don’t decompress the nerve, you don’t alleviate the neurologic symptoms, and people don’t get relief of their leg pain or their quote-unquote – what people call sciatica.

Number two, if there’s any instability, you have to stabilize the spine. Traditionally, to do a spinal fusion to stabilize the spine, it used to be a big, open incision down the back and you spread all the muscles open to get down to the spine and do the work that you have to do. For some people, when the disease is so advanced, this is still the golden standard. This is still the way it needs to be done. There’s a significant subset of patients where we can accomplish the same goals, but instead of making a four or five-inch incision, we can potentially use a one-inch incision. But then again, it’s not really the size of the incision that matters; it’s how much muscle has been dissected off of the spine, and how much of the structures surrounding the spine have been disrupted in order to do the surgery. That’s really what the concept of minimally invasive spine surgery is. It’s not necessarily the size of the incision, but it’s how much of the dissection has taken place in order to accomplish that goal.

A really nice technology that has developed over the past ten years is doing spine fusions from the size as opposed to from the back. Coming from the side, there’s really very minimal muscle, you’re moving the bowel contents out of the way, and you pretty much have direct access to the spine without having to take down any muscle insertions. Versus having to do it from the back, you have to take down all of the big, robust, thick, paraspinal muscles that need to be dissected out of the way in order to access the spine.

And the same goes for decompressions. Traditionally, to do a decompression, you would go from the back and make a much bigger incision and then dissect all of the muscles out of the way. Today, we can do a lot of our decompressions through little tubes. The nice thing about these tubes is that instead of dissecting the muscles out of the way, you’re spreading them out of the way. You’re not damaging muscle fibers. You’re not ending up with high amounts of blood loss, so our techniques have become a lot more refined and a lot more targeted depending on which nerve is being pinched and where the pathology is in the spine – where the arthritis is in the spine.

Melanie: Dr. Tannous, you mentioned the word fusion, and right away, patients think, “Okay, now I’m not going to have any range of motion in my spine,” whether we’re talking about the neck, or cervical disk replacement, or in spine surgery. Are these motion preservation techniques? What can you tell them about what they can expect afterward?

Dr. Tannous: Excellent question. That’s another one of the major advances in spine surgery over the past ten years or so. Especially in the next -- not so much in the lumbar spine, yet. I don’t think we’re quite there yet with the technology -- but especially in the neck, the advent of cervical disk replacements has really changed, I think, the playing field for a lot of patients.

Traditionally, if patients came in and they had pinching of the nerves in the neck, the gold standard for relieving that pinched nerve and stabilizing the cervical spine – which is the neck – was to do what we called an anterior cervical diskectomy and fusion or an ACDF. What this is, is you go through the front of the neck, you move all of the vital structures out of the way, you take the disk out, you decompress the nerves in the spinal cord. You put a piece of bone in that spot, and then you stabilize it with screws and plates, and what happens over time is that bone will then grow into the bones in the spine.

For the most part, it still is the gold standard in 2017, but what’s nice now is that we have the option to do cervical disk replacements. For the right patient – and I won’t go into the details of who that right patient is – but in general, it tends to be younger patients who don’t have a lot of deformities, who don’t have a lot of arthritis, who have a pinched nerve. You can do the same thing. You can go to the front of the spine; you take the disk, you decompress the nerves. But now, instead of putting a piece of bone in there, you’re putting a mobile implant in there that essentially reproduces the natural motion of the neck.

The nice thing about that is that the one thing we know about spine surgery is that it isn’t just one joint. For example, in the neck, you have seven joints, right? There are seven levels. When people come in in their 30s, 40s, and 50s, to have one level addressed, there’s about a 3% chance per year that they’ll have to have another level addressed down the road. We think that cervical disk replacements are preserving the natural motion of the spine, transferring less stress to the other levels above or below, and potentially minimizing the risk of having to have another surgery down the road above or below the level where the disk replacement took place. It’s a very promising technology. It’s been FDA approved now for both One and Two-level disk replacements. In my experience, I’ve had patients have tremendous results.

Melanie: What do you see the future of spine surgery? What’s coming down the path?

Dr. Tannous: That’s a really good question. I think the future of spine surgery, as for medicine in general, is going to be an evolution and emerging of medicine and technology, especially with the technology. Robotics are advancing; navigation is advancing. Our ability to accomplish the same goals of surgery with smaller incisions, less invasive techniques, I think over the course of the next five or ten years, we’re really going to see technology and technique merge together.

At the end of the day, technology will never replace a good clinician. It will never replace someone sitting down and listening to the patient, and really understanding the story and coming up with the right diagnosis. It will never replace technical ability, but it will allow surgeons who have all of these abilities to really take it to the next level and minimize the treatment side effects and optimize patient outcomes. I think we’re at a very exciting time in the evolution of medicine, and I think we have a lot to look forward to in the next five or ten years. Especially in spine surgery where we’re just at the beginning of motion preservation techniques, and of minimally invasive techniques.

Melanie: Thank you, so much. It’s really great information, Dr. Tannous. Thank you for being with us, today. This is Medical Intel with MedStar Washington Hospital Center. For more information, you can go to MedStarWashington.org, that’s MedStarWashington.org. This is Melanie Cole, thanks so much, for listening.

Internal Notes: Null
Hosts: Melanie Cole, MS

How to Prevent Summer Burns

David Cole — Sun, 11 Jun 2017 18:17:12 +0000
According to the NIH, in the United States, approximately 1.25 million people with burns present to the emergency department each year. People do not realize that summer fun carries with it an increased risk of many types of burns.

In this segment, Dr. Jeffrey Shupp, director of the Burn Center at MedStar Washington Hospital Center, joins the show to discuss how to prevent those summer burns and how the Burn Center is the only adult burn treatment facility in the Washington region, serving the District, southern Maryland, northern Virginia and eastern West Virginia.
Additional Info
Segment Number: Null
Audio File: medstar_washington/mwc023.mp3
Doctors: Shupp, Jeffrey Wilson
Featured Speaker: Jeffrey Wilson Shupp, MD
Specialty: Null
Guest Bio: Jeffrey Shupp, MD, is the Director of the Burn Center at MedStar Washington Hospital Center and an attending surgeon in the Burns/Trauma section of surgery.

Learn more about Jeffrey Shupp, MD
Transcription: Melanie Cole (Host): Several summertime activities can lead to burns. The most common type of summer burns come from overexposure to the sun and injuries from fireworks and grilling. According to the American Burn Association, approximately 450,000 individuals may seek treatment for burn injuries this year. My guest today, is Dr. Jeffrey Shupp. He’s the Director of the Burn Center at MedStar Washington Hospital Center. Welcome to the show, Dr. Shupp. What should we be aware of in the summer as far as burns? People tend to think of sunburns, but that’s not the only type of burn that you’re seeing in the summertime.

Dr. Jeffrey Shupp (Guest): That’s correct. A lot of times people associate burn injuries that would need to be treated at a burn center in the Winter months or when it’s very cold outside, but we do see a significant amount of patients that have been injured doing things that normally occur in the Summer, such as grilling on a barbecue grill, or having recreation activities that are near a campfire. Things like that are more common for us in the summer, and oftentimes we don’t see them as soon as we would like to see them as far as identifying patients that might need further care.

Melanie: What should people identify – and let’s start with the burns that come from maybe grills or campfires. Sometimes someone’s grilling, and they just burn themselves or burn their hand, or feel the heat come up on their face. When is it something that they should seek medical treatment about?

Dr. Shupp: The first thing we want everyone to know is that we don’t mind seeing everyone. If you’re concerned enough about an injury that occurred, don’t feel as though you are wasting our time or utilizing resources that you shouldn’t be. We would much rather see people that are concerned enough about their injury and then not need to see them again versus waiting too long.

As far as actual things about the wound that would make it more likely that you would do better with care at a burn center would be blistering of the skin, any burns to the face, or any burns to functional areas – over joints, in areas that are difficult for you to get a dressing on, for example. Those are all reasons to be seen and evaluated at a burn center. Like I said if you don’t need continued treatment or the burns aren’t as severe as you would have thought then you can always go back to your regular life and see your primary care doctor or what have you. I think one of the things during the summer is the delay in evaluation by the burn center that sometimes makes treatment a little more complicated.

Melanie: What should we do for ourselves, Dr. Shupp, in terms of burns even if it’s a minor – and explain a little bit about the grading of burns and how you are identifying different types of burns – what we should be doing based on whatever happens.

Dr. Shupp: Okay, so most people are familiar with first, second, and third-degree burns. A first-degree burn is basically a sunburn. The outer layer of the skin is red, but it doesn’t usually blister in real time. As we all know, sunburns can eventually peel and things like that, but it’s not a wet, fluid-filled blister like you would see with the next class of burns, which would be second-degree burns. This is an injury to the skin that involves both layers of the skin. The skin has two layers, and the second-degree burn is when the second layer of the skin is a little injured, but it usually heals, but it’s kind of hard to know that at the very beginning. Those second-degree burns can be at risk for infection and can be a source for the need for further care.

Third-degree burns is when both of the layers of the skin are, in fact, injured to the point where they are not able to heal. Most third-degree burns need some sort of surgical intervention so that the wounds can close in an appropriate amount of time. We talk about this timing because the other thing that people worry about with burns is scarring. The only thing we really know is the longer the wound stays open and doesn’t close, the more risk you are at developing scars. That’s really the battle we’re trying to fight in getting the burn wounds closed.

Melanie: What about burn wound treatment at home? What is it we should do right away? People think they should put creams on them, or Vaseline, or ice, or water, or what should we do if we burn ourselves?

Dr. Shupp: It goes back and forth as far recommendations with cold water. We recommend temped water, which is Luke-warm to room-temperature water. That helps with alleviating the pain and allow you to clean off whatever debris might be there at the time. The secret is, a lot of our burn wound care that we do in the hospital is very simple, which is soap and water and ointments that moisturize the skin. We don’t use a lot of topical creams or ointments that have a lot of antibiotics to them. If you are being prescribed those types of ointments, then you should be being treated by a provider or physician.

There are a lot of home remedies out there. Oftentimes the home remedies make it more difficult for us, once we evaluate a patient, to determine the depth of the burn because a lot of things that we’re looking at are very subtle changes in the skin. If something’s been put onto the skin that masks that, then it makes it more difficult for us to evaluate it and worst case, sometimes we have to remove whatever it might be, and that adds more irritation and pain to the area.

Aloe-containing products for very superficial burns are probably okay. Again, the skin does better when it’s in a moist environment, so things we can do to keep it from drying out would be good. If there is a lot of exposed dermis – that pink part of the skin after that upper part of the skin has blistered away, exposed. Those are the types of wounds we really want to be seeing early to help guide and make recommendations for care.

Melanie: Do you keep a burn covered or open?

Dr. Shupp: We keep burns covered unless they are on the face area.

Melanie: What about sunburns because this is very common, and people don’t even realize they’re getting them when they are getting them. When does a sunburn become something you really need to seek professional help about and give us your best advice for preventing sunburns.

Dr. Shupp: My best advice for preventing sunburns are to limit your exposure, which I’m sure everyone would be laughing at that because it’s hard to do when you’re having fun, and you’re participating in recreational activities outside. The next rule of thumb is to apply sunscreen regularly. We get caught up in the SPF level and the amount of time that the sunscreen is active for, but in all reality, if you’re in and out of the water, you’re washing a lot of the product off. The most frequent application as possible would help to prevent -- and then, taking breaks throughout the day to see how much irritation is on the skin. Oftentimes if you come in for just 30 minutes all of a sudden, your skin feels different because you’re not in the sun anymore, and you’re like, “Oh, my goodness, I have had a lot of sun exposure.” Take those checkpoints throughout the day. Don’t just wait until the end of the day and have a worse sunburn.

As far as seeking treatment, if you’re able to stay hydrated and your pain control is adequate, most patients do fine at home. If you get to the point where a lot of your skin has been injured, and it’s difficult to move, and it’s difficult to stay hydrated, then that’s the type of patient that sometimes finds themselves at the hospital. Those things are what are making it difficult. The skin itself usually is fine unless there are areas of injury or the patient had had a previous burn, then we can see where the sun actually causes blistering and deeper burns. That’s very rare.

Melanie: And for burn wounds – you mentioned infection earlier in the segment. What should someone be looking for to keep these free from infection or prevent their risk of getting an infection?

Dr. Shupp: The easiest thing is to keep them clean and keep them covered. If they are in difficult to dress areas – for example, like the armpit, or the back of the knee – then those are all good reasons to come to the burn center. A lot of the care that we provide is very nuanced and the amount of experience that a nurse or a technician who has been putting dressings on patients with burns for decades can be underappreciated.

A lot of times I’ll see patients who have a perfectly reasonable care plan for a burn injury, but the whole thing just comes undone because the dressing didn’t stay in place or the tape wasn’t sticky enough, or they couldn’t get enough of the ointment that was prescribed to them. These are all common things that lead someone coming in a delayed manner that maybe we could have addressed from the get-go and had a much better experience and kept the wounds in better shape for healing.

Melanie: And tell us about the burn center at MedStar Washington Hospital Center.

Dr. Shupp: Here is the only regional adult burn care center in the Greater Metropolitan area. We treat the entire spectrum of thermal and thermal-like injuries from very thick, large, total body surface area patients to ambulatory injuries. We have a dedicated staff of surgeons, therapists, nurses, and an entire dedicated unit and team where all we do is focus on patients who have burn injuries.

A lot of the things that go into some of the recoveries from burns isn’t the wound, it isn’t the ointment that someone picked -- because even in the burn center community, everyone always debates about the type of topical ointment -- but the one thing that is consistent is that multidisciplinary care leads to better outcomes and better functional recovery. Being able to have dedicated staff to help the patient and support the patient through recovery -- whether it’s a hand therapist or a nutritionist to improve the patient’s nutrition to optimize it for wound healing, or whether it’s the psychologist or the psychiatrist who helps the patients through – those resources are literally at the patient’s fingertips the moment they walk through the door at any regional burn center.

It’s sometimes something that people don’t think about until they put themselves in that position where they hit the ignitor button on their grill, and a big ball of flames comes out. They back away in time and they’re like, “Wait a minute. What if that went a totally different way? Where would I have ended up?” [COUGHS] Excuse me. It’s something that we like to brag about, but it’s also an integral part of our care delivered here.

Melanie: And in just the last few minutes, Dr. Shupp, wrap it up with your best advice about preventing burns in the first place in the summertime and what you want people to know about burns and their risk of getting burned in the summer.

Dr. Shupp: I think the most important thing is to realize that it’s the common things that we do that go awry that leads to injury. Most of the time, when I talk to a patient about something that has happened that caused the burn – well, I’ve done it that way 500 times, or I always start the grill that way, or we have bonfires every weekend, and nothing like this has ever happened. As we go through these months in the summer where we’re spending more time outdoors, we’re doing more entertaining with fuel sources and fire, that you just always take a pause before being around that type of exposure because it can happen at any time to anyone. That amount of awareness is something that I would just like everyone to have as they’re doing these types of activities. And it’s not just burns; it’s dehydration, it’s exposure to lightning, it’s these things that happen all the time that we don’t become injured from is usually when something happens. That type of awareness is something I think everyone should just keep in their mind when they’re doing these activities.

Melanie: Thank you, so much, for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to MedStarWashington.org, that’s MedStarWashington.org. This is Melanie Cole. Thanks, so much for listening.
Internal Notes: Null
Hosts: Melanie Cole, MS

Treatment for Kidney Stones

David Cole — Mon, 05 Jun 2017 22:25:00 +0000
Kidney stones are solid deposits of minerals and acid salts that build up inside the kidneys. Kidney stones are relatively common, hospitalizing more than one million Americans each year. Approximately 10 percent of people in the United States will have a kidney stone at some point in their life.

In this segment, Dr.Daniel Marchalik joins the show to discuss kidney stones and how MedStar's urology specialists focus on the medical management of kidney stones for patients that require metabolic evaluations for recurring kidney stones.

Additional Info
Segment Number: Null
Audio File: medstar_washington/mwc022.mp3
Doctors: Marchalik, Daniel
Featured Speaker: Daniel Marchalik, MD
Specialty: Null
Guest Bio: Daniel Marchalik, MD, is Director of Ambulatory Urologic Surgery and Director of Medical Education at MedStar Washington Hospital Center. He is also an instructor at MedStar Georgetown University Hospital. As a urology specialist, he uses noninvasive, minimally invasive, and endoscopic methods to treat some of the most common conditions in urology, such as stone disease, voiding difficulty caused by prostate enlargement, and elevated PSA.

Learn more about Daniel Marchalik, MD
Transcription: Melanie Cole (Host): Kidney stones are relatively common, hospitalizing more than 1 million Americans each year. Approximately 10% of people in the United States will have a kidney stone at some point in their life. My guest today is Dr. Daniel Marchalik. He’s the Director of Ambulatory Urologic Surgery at MedStar Washington Hospital Center. Welcome to the show, Dr. Marchalik. What is a kidney stone and how do they form?

Dr. Daniel Marchalik (Guest): Hi, thank you for having me. A kidney stone is basically a collection of some type of mineral – usually, it’s composed of calcium, but it could be other things as well. It’s something that forms in the urinary tract, in the kidney normally and then travels down and can either be found in the kidney, the ureter or ultimately, inside the bladder.

There are different reasons for formation. Some of it is inborn. Some people are genetically predisposed to forming kidney stones. Some of it is environmental -- things that we do with our diet and exposure that we have to different things that can lead to it.

Melanie: Is one gender more likely to get kidney stones over another?

Dr. Marchalik: Yes, men are more likely than women to get kidney stones. That being said, it’s extremely common in both genders. The lifetime risk for a man to have a kidney stone is about 13%, and the lifetime risk for a woman is about 7%. Even though the risk is much higher in men, it’s still very high for both genders.

Melanie: And Doctor, what are some symptoms – somebody really wouldn’t know one is forming necessarily would they? Would they get any red flags? Would there be any symptoms?

Dr. Marchalik: Yeah, and that’s one of the realities of kidney stones is that a lot of times you don’t know that you’re forming a kidney stone. Or, if a kidney stone has formed, you don’t know that it’s growing inside your kidney until that stone becomes quite large or until that stone drops down into the ureter. The ureter is the tube that connects the kidney to the bladder that the urine passes through. If the kidney stone drops down and blocks the flow of urine in the ureter, then you can develop really severe pain from the kidney becoming distended from all of that urine backing up.

Melanie: What would you notice, then? Would you feel intense pain like appendicitis when something’s really just blazing pain, or does it come on a little bit gradually?

Dr. Marchalik: No, most of the time the way that people realize that they’re having a kidney stone is with very severe, very sharp pain in their back. That pain has been evaluated, and they compare it in severity to pain from having labor. It’s very, very intense, very severe. Normally, that pain is in the back. For some people, it can also radiate to the groin, and it usually stays on one side, either the right side or the left side.

Melanie: If somebody gets that pain and they are not sure – is this an emergent situation? Do you call 9-1-1, or can you take yourself to your doctor, physician, or the Emergency Room?

Dr. Marchalik: Almost always, this is something that you can take yourself to the hospital, and it doesn’t usually require an ambulance, but this is something that the pain can be so debilitating that you want to be seen right away. Now, the time that it does become an emergency where you really want to get to the hospital as soon as possible is when you start to develop that pain, but then you also have fevers, and chills, and burning with urination. Those can be symptoms of an infection, and if an infection happens in the face of a kidney stone, that can be very, very troublesome and could be very dangerous.

Melanie: Doctor, what are some available treatments for kidney stones?

Dr. Marchalik: That depends entirely on the location and the size of the kidney stone. Some stones, which don’t cause symptoms and which are small or in certain areas of the kidney, can just be watched. Some stones are pretty small, and they might cause symptoms, but we can observe them hoping that they will pass on their own because depending on the size of the kidney stones, many will pass on their own. Some stones are large enough so that they really don’t have a good chance of passing on their own. If that’s the case, they would require some type of surgical intervention. There are different types of surgical interventions that we can take to take care of a kidney stone.

Melanie: Before we talk about a few of those, what’s it like to pass a kidney stone? What happens?

Dr. Marchalik: It’s very painful. Patients describe this as this nagging pain that comes in waves, and usually, it starts out in the back, and as the kidney stone makes its way down the ureter, the pain tends to migrate along with it. Initially would be a back pain, then it might become a stomach pain and a groin pain. The pain would come in waves, so it gets worse, then it gets better, then it gets worse, then it gets better.

The reality of passing a kidney stone is that kidney stones can take up to four weeks to pass. Even though you’re making progress – even though the stone is on its way out, it’s just taking a long time, and that can be a difficult thing for a lot of patients understandably.

Melanie: Speak about some of the treatments that you might do, and based on the location of the stone itself, are these treatments that you do right then and there? Or, are they scheduled -- something that can wait a day or two? Just speak about some of these procedures.

Dr. Marchalik: Of course, that depends entirely on the clinical scenario. If someone has a kidney stone and they have an infection, that’s an emergency. In that case, what we normally do is we don’t treat the stone as much as we treat the blockage that the stone is causing. In those cases, we put a stent – which is a tiny little plastic tube that can go from the kidney to the bladder inside the ureter. That little tube allows for the urine to flow through it. And then we treat the patient with antibiotics and wait for him to recover. That’s the only kidney stone surgery that we have to do truly emergently. For everything else, those stones are normally something that we can watch for a few days, or even a few weeks depending on what the likelihood of passage is, and to schedule this as an outpatient surgery at a time that’s convenient for everyone.

Melanie: What about prevention? Is there any way to prevent a kidney stone? And Doctor, is there a certain time of year that you’re seeing more of these that they might be more common?

Dr. Marchalik: Absolutely. Those two are very much connected. Kidney stones are more common in the summer for an understandable reason. The number one risk factor for forming a kidney stone is dehydration. I think a lot of us are guilty of not drinking enough water, and we’re especially guilty of that in the summer when it’s hot out. People start to exercise a lot more, but then they don’t increase their water intake to account for the amount of sweating that they are doing and the amount of exercise that they are doing.
One of the big things that people can do to prevent themselves from getting a kidney stone is making sure that they hydrate well. For the most part, that means not only are you having water when you’re having your meals, but then you’re also having a bottle of water between meals. You’re making sure that you are staying hydrated the entire time.

The other thing which we are also guilty of for the most part is we eat too much salt. The amount of salt that you have in your diet is probably one of the other big risk factors for forming stones. Between those two things, I think a lot could be done to prevent kidney stones.

Melanie: Wrap it up for us, with your best advice, if somebody maybe has a family history of this, or if they’re just – this is something that they are concerned about – what would you like them to know about preventing kidney stones, and what to know if they’re recognizing that there might possibly be one?

Dr. Marchalik: My advice would be this: Kidney stones are incredibly common. If 10% of the population is going to end up getting a kidney stone and you have a family history, you’re probably even more likely. If you're one of those patients for whom kidney stones are a real risk, you need to be very vigilant. You need to make sure that you hydrate very well. You need to make sure that you limit the amount of salt that you have in your diet, the amount of protein that you have in your diet. You need to make sure that you hydrate especially well during times where you’re likely to be dehydrated, like the summer, or times when you do intense exercising.

And then, if you do end up having these symptoms, like a severe, sudden pain in the back, or severe, sudden pain that’s coming in waves that’s radiating down to your groin, then come to the Emergency Room and make sure that you get seen right away. This is especially true if you develop fevers, chills, or symptoms of a urinary tract infection because that could be a truly dangerous situation.

Melanie: Thank you, so much, for being with us today. This is Medical Intel with MedStar Washington Hospital Center. For more information, you can go to MedStarWashington.org, that’s MedStarWashington.org. This is Melanie Cole. Thanks, so much, for listening.

Internal Notes: Null
Hosts: Melanie Cole, MS

Cardiogenetics: The Importance of Genetic Testing and Counseling

David Cole — Tue, 31 Jan 2017 00:18:43 +0000
Susan O'Donoghue, MD, discusses the burgeoning field of cardiogenetics, which can help identify various certain inherited cardiovascular disorders, particularly those that are based in the heart's electrical system. Potential candidates include individuals who have fainted due to physical exertion or who have a family history of unexpected cardiac arrest and/or death at young ages.

Dr. O'Donoghue also explains the importance of genetic counseling pre- and post-screening and guidance on when a molecular autopsy might be in order.
Additional Info
Segment Number: 3
Audio File: medstar_washington/1702mwc4c.mp3
Doctors: O’Donoghue, Susan
Featured Speaker: Susan O’Donoghue, MD
Specialty: Null
Guest Bio: Susan O'Donoghue, MD, is a board-certified cardiac electrophysiologist at MedStar Heart & Vascular Institute at MedStar Washington Hospital Center. She previously served as Associate Director of the Cardiac Arrhythmia Center and Director of the Combined Cardiac Electrophysiology Fellowship Program at MedStar Georgetown University Hospital/MedStar Washington Hospital Center. She is presently Director of Cardiogenetic Services at MedStar Washington Hospital Center, a new program for the diagnosis and treatment of inherited cardiac disorders, which she developed. Dr. O'Donoghue has been providing care for more than 25 years.

Learn more about Susan O'Donoghue, MD
Transcription: Melanie Cole (Host): Imagine a world where genes not only tell the story of a person's future health but allow physicians to intervene early and prevent future health problems. The fast-growing field of Cardiogenetics allows for improved screening and early treatment of certain inherited cardiovascular disorders. My guest today is Dr. Susan O'Donoghue. She is a Cardiac Electrophysiologist with MedStar Heart and Vascular Institute at MedStar Washington Hospital Center. Welcome to the show, Dr. O'Donoghue. First, let's -- explain what this growing field of Cardiogenetics is.

Dr. Susan O'Donoghue (Guest): Certainly. Cardiogenetics is the study of a patient's inherited tendencies for heart problems. We're all aware that some families have an elevated cholesterol and they have a likelihood of developing coronary artery disease and that's a general tendency, but in addition to that, there are very specific genetic disorders which can be inherited as -- what's called an autosomal dominant -- meaning the individual has a 50% chance of carrying the disorder. Some of them are associated with very specific heart rhythm problems or problems with the heart muscle, and there's much more that can be done nowadays to both screen for and treat these disorders.

Melanie: So tell us about some of the inherited disorders that are associated with heart rhythm problems. What are some of the conditions?

Dr. O’Donoghue: Well, some of the conditions include what's called the Long QT Syndrome. The QT interval is an EKG measurement that's a reflection of the heart's electrical recovery after each heartbeat. Probably at least one in 2000 people carry a gene mutation that affects how the heart electrically recovers, and these individuals can be at risk for unexpected serious, even life-threatening heart rhythm problems. There are many others including disorders such as Hypertrophic Cardiomyopathy, which is probably at least everyone in 500 people and in this disorder, the heart muscle is anatomically abnormal. It is abnormally thickened. In addition, the heart's electrical system can be affected, so again these individuals can have a variety of heart rhythm problems, some of them potentially quite serious. And there are quite a number of other disorders that affect, specifically, the heart's electrical system.

Melanie: So then when would this take place -- when would you want to find out, and with who -- about whether somebody is at risk for these?

Dr. O’Donoghue: The red flag for recognizing an individual who might carry one of these inherited disorders include things such as fainting during exercise, or of course, anyone who has experienced a cardiac arrest and been successfully resuscitated, particularly below age 40, when the more common things such as coronary disease are much less common. In addition, if an individual has a family history of multiple relatives having died unexpectedly at a young age unexpectedly, again that would be a situation where we would want to evaluate that individual and that family and see if we can identify the problem and prevent future catastrophic illnesses or sudden deaths.

Melanie: We have been hearing in the media, and there's even some legislation put forth about testing kids in sports for sudden cardiac death, which can occur at any age, but specifically had been seen in athletes and the American College of Sports Medicine has been on this case. What do you say about this particular condition? What do you think about it?

Dr. O’Donoghue: That topic, as to whether children should be screened for participation in sports and how they should be screened, is actually very controversial. It's a very complex subject, and there are cardiology associations in both Europe and the United States, who have weighed in on this topic and there are some differences between the recommendations in Europe and here in the United States. On the plus side, of course, if you can identify an individual who may be at risk, that's extremely important and can be life-saving. On the downside, is mass screening and EKGs for everyone indiscriminately also ends up identifying patients -- individuals who don't really have a problem, but their EKG is just a little bit outside the norm. The concern is that a lot of individuals can be precluded from participating even though there's nothing really wrong. And then of course, as with everything, there's the cost-benefit ratio. How much does it cost to identify one individual and is this the way our resources should be spent? It's actually a very interesting and controversial topic. I wouldn’t say it's totally settled at this point. Clearly, anyone who's going to participate in sports should be examined by their doctor. The doctor should be asking questions about family history and about symptoms. That, I think, there's universal agreement on.

Melanie: So tell us about some of the Cardiogenetics services at Medstar Washington Hospital Center that you provide including genetic testing and counseling after the testing.

Dr. O’Donoghue: Absolutely. The field of genetic testing is really in its early stages, but will clearly become much more important as the years go by. It's possible now with a sample of blood or saliva to test for these specific genetic disorders. Part of that testing -- part of our responsibility when we do that testing -- is to order the tests responsibly and properly to know what questions to ask and what abnormalities to look for. Very importantly, a part of any Cardiogenetics service has to be genetic counseling before the test to know what the implications are, and also to help the patient and their family interpret the results because the results can be quite complex and not necessarily a simple "yes, or no." One of the services we offer is genetic counseling, which as they say should be mandated anytime genetic testing is going to be carried out. In addition, of course, if we identify a disorder, we have all modes of treatment available from medications, to device implantation, to surgery, whatever might be required.

Melanie: So if somebody is on the fence as it were about genetic testing -- and we've all heard about it with the BRCA gene and all of this -- but this is relatively new for listeners to hear about. When would you suggest that people really consider getting this genetic test, or even coming in for counseling for it?

Dr. O’Donoghue: Individuals who have had either been identified with one of those disorders, or individuals whose family members have been identified, or who have a family history of sudden death, or congestive heart failure in young family members. Those individuals would benefit from coming in, giving us their history, letting us review the available records, and then, of course discussing whether this is a situation where genetic testing might be helpful. Genetic testing is not something that we do just to see if someone might develop coronary disease because they have an elevated cholesterol. That's an entirely different evaluation. Genetic testing is not part of that evaluation. It's really for patients with suspicion or known family history of sudden death, or heart failure at a young age, of fainting spells at a young age.

Melanie: So wrap it up for us, Dr. O'Donoghue, with your best advice about what you want people to know about this burgeoning field of Cardiogenetics?

Dr. O’Donoghue: What I would like people to know is that we can empower them, that knowledge is power, and that if there is a family history that is suspicious, or in fact, if an individual in their family dies suddenly and unexpectedly, they should request a molecular autopsy in addition to a traditional autopsy. Blood should be saved to allow for genetic testing so that other individuals don't need to fear and don't need to be at risk. It's possible after an unexpected sudden death to identify the problem and give very specific treatment and to give some reassurance to the rest of the family. The concept of molecular autopsy is something people are not familiar with, and people need to be familiar with.

Melanie: And tell us about your team at MedStar Washington Hospital Center.

Dr. O’Donoghue: Well, MedStar Washington Hospital Center, of course, has been the leader in Cardiology in the region for many, many years. I've been here for 25 years as a Cardiac Electrophysiologist and have long wanted to develop a Cardiogenetics program, which we have now got in place and, of course, when patients come in, and we can identify their problem, we can hook them up with experts in every aspect of cardiac care, be it valve problems, be it heart rhythm problems, the cardiac imaging here, whatever they might need, we take a team approach. I have a wonderful genetic counselor, and we have all my colleges and all of their various subspecialties of cardiology so we can treat the entire family. For the youngest members of the family, we also work closely with colleagues at Children's Hospital, which is of course right next door to us. The aim is to take care of the entire family.

Melanie: Thank you, so much for being with us today. It's really great information. You're listening to Medical Intel with MedStar Washington Hospital Center. And for more information you can go to MedstarHeartInstitute.org, that's MedstarHeartInstitute.org. This is Melanie Cole, thanks so much for listening.
Internal Notes: Null
Hosts: Melanie Cole, MS

Surgical Treatment Options For Sleep Apnea

David Cole — Wed, 11 Jan 2017 23:43:02 +0000
Stan Chia, MD, discusses the curative options for sleep apnea patients who are not good candidates for CPAP. Options include removal of the tonsils, reducing excess tissue of the tongue, advancing the upper and lower jaw to open up the airway, and even bariatric surgery to eliminate obesity-induced apnea. Dr. Chia also provides information on the newest therapy, upper airway stimulation, which is a pacemaker-like device implanted in the chest.
Additional Info
Segment Number: 2
Audio File: medstar_washington/1702mwc4b.mp3
Doctors: Chia, Stanley Hung-Hsuan
Featured Speaker: Stanley Hung-Hsuan Chia, MD
Specialty: Null
Guest Bio:
Stanley Chia, MD, FACS, is the chairman of the Department of Otolaryngology, and is associate professor of Otolaryngology at MedStar Georgetown University Hospital. He is also a highly skilled otolaryngologist at the MedStar Pituitary Center.

Learn more about Stanley Chia, MD
Transcription: Melanie Cole (Host): While positive airway pressure therapy is generally one of the first lines of treatment for moderate to severe sleep apnea, patient compliance and adherence represents a clear problem. For those people who may have an issue adhering to their CPAP, surgery for sleep apnea may be a feasible alternative. My guest today is Dr. Stan Chia. He’s the Chair in the Department of Otolaryngology at MedStar Washington Hospital Center. Welcome to the show, Dr. Chia. First, what is sleep apnea and what are some of the adherence issues with CPAP that we keep hearing about in the media?

Dr. Stan Chia (Guest): Thank you very much for having me on the show. The continuous positive airway pressure currently is the gold standard for treating obstructive sleep apnea. However, a lot of people have difficulty keeping the mask on at night or using it consistently. The reasons why can include things like discomfort with the mask; they might feel claustrophobia with the mask; they might have trouble keeping the mask on at night because they might move around and it gets displaced; there’s also quite a bit of a pressure that’s created so that they can sometimes feel like they’re breathing in a wind tunnel; sometime the noise from the machine. So, there’s really a varied number of reasons why people have difficulty with the mask.

Melanie: So, then, if you’ve diagnosed them with sleep apnea and they’re using or not using the mask and then you say, “Well, we need to look at other options,” what do you tell them about procedural interventions for sleep apnea?

Dr. Chia: There are some surgical options that are available and the most commonly known ones include the palate procedures and removal of tonsils, but that is not a great option for just about everybody. So, if you have large tonsils or if you have an elongated soft palate, then that may be a great option to treat it but if you look at the overall success rate for that procedure, it’s actually about 40-41 percent. So, it’s not something that is applicable for every single patient that walks through the door. There’s also something that we can do to reduce some of the tissue in the back of the tongue. If people have what’s called “lingual tonsil hypertrophy” and that’s when there’s excess tissue located in the back of the tongue, you can actually use a transoral robotic approach to remove some of that tissue. So, there’s additional procedures that we can do to advance the upper and lower jaw and open up the airway at all different levels. That can sound a little bit scary to people at times because it can sometimes change the way that the face looks but it has the highest success rate of any surgery that’s available out there. Also, most people that end up undergoing this procedure end up finding that the appearance of their face either is the same or even sometimes improved because people might have a weak jaw to begin with. So, that’s definitely a surgical consideration to offer people as an alternative to the CPAP. There’s also a new therapy that’s available that’s called the “hypoglossal nerve stimulator” what this is is a pacemaker-like device that is implanted within the right chest; so just on top of the pectoralis muscle on the chest. There are three separate incisions, one of which is just over that right chest wall, another one in the right neck, and then, a third one in the side of the chest. So, it’s not a minimally invasive operation. However, it does not involve a lot of pain or discomfort. So, the way that it works is that there’s a wire that is tunneled into the chest and senses when you breathe at night and a second wire that’s tunneled underneath the skin and goes up into the neck just below the chin and wraps around the nerve that moves the tongue. Once the device is activated, it senses every time you take a breath in and causes the tongue to move forward to open up the airway. So, this is a very novel technology that’s only been available for about two years now. I was actually on the FDA approval board for this device and found that it was a very promising new technology. At this point, there’ve been hundred of patients that have undergone this procedure with a very high success rate. Personally, I’ve done about 14-15 of these procedures. The patients that have undergone the activation and are currently using the device have had a success rate of around 85%...

Melanie: Wow.

Dr. Chia: …in terms of controlling their symptoms and severely improving their sleep apnea. So, it’s really been quite successful recently.

Melanie: Do you see that this might be a permanent solution? Is it something that will stay with them for life?

Dr. Chia: It is something that is implanted just like a pacemaker, so it is something that stays in your body unless there’s a problem that we have to remove it. So, there is a battery that lasts about ten years and so the battery does need to be changed in ten years. So, that is something that has to be considered but that is essentially a lifelong procedure. One does have to keep in mind that not everybody is a candidate for this procedure, so we are fairly selective at who can actually undergo this procedure. So, you have to have a severity score of sleep apnea between 20-65. That’s determined on a sleep study that’s done before the procedure is considered. We also have to have a body mass index of less than 32. That can actually rule out quite a number of people that have sleep apnea. There are a number of people that develop sleep apnea because of obesity and when you use that as a criteria, it ends up ruling a lot of people out for being a candidate for this procedure. There’s also a minor procedure that has to be done called a “drug-induced sleep endoscopy” to determine the site of obstruction of the airway. Once you see that the pattern of collapse is favorable, then we can go ahead with the approval process to undergo this procedure.

Melanie: If you’re doing a procedure that involves some kind of tissue reduction or ablation or any of these things, is there then scar tissue that’s created, Dr. Chia? Or, are these permanent solutions? Do they have to be redone at some point?

Dr. Chia: There always is scar tissue whenever you make an incision in the body. We don’t typically see it as a problem if you’re making incisions inside the throat where the scar tissue becomes problematic or becomes uncomfortable. It’s generally a procedure that you don’t want to try to repeat but, on occasion, there are issues where you have to do revision surgeries but it’s the exception rather than the rule. So, it’s uncommon to have to do something again.

Melanie: Now, one surgery which is much more major that has been recommended for sleep apnea is bariatric surgery. What do you tell your patients if they are somebody who is obese and their sleep apnea is a result of their obesity?

Dr. Chia: That’s actually a terrific question. I refer people to bariatric surgery pretty frequently. If you have a body mass index of greater than 35, there’s quite a body of literature that shows that any surgical option is not going to be as successful. So, some of these procedures are quite involved or even painful so I tend to not like to put people through these procedures if there’s not a high likelihood that they’re going to succeed. So, if you have extremely severe sleep apnea and particularly if you have a body mass index of greater than 35, I frequently refer people to have a consultation for bariatric surgery.

Melanie: Then, wrap it up for us, Dr. Chia, in the last few minutes here and your most recommended surgical interventions and your best advice for people who suffer from sleep apnea.

Dr. Chia: So, in terms of recommendations for surgical procedures, it’s very important to have a careful evaluation of your prior history, do a careful physical examination which will include an endoscopy of the airway and possibly a drug-induced endoscopy, and then a careful discussion about what the different options are. The surgical options can include upper airway surgeries such as soft tissue surgery to reduce the soft palate or the base of the tongue, structural surgery such as upper and lower jaw advancement, or stimulation surgery such as the hypoglossal nerve stimulator. These different options are a nice complement to each other in terms of what we see anatomically and what a patient needs. So, not everybody is looking for the same thing when they look at surgical options. Once we have a discussion with the patient, we try to do what’s best for the patient in terms of what they’re looking for and what surgical expectations are expected or are made of them.

Melanie: Thank you so much. You're listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks so much for listening.

Internal Notes: Null
Hosts: Melanie Cole, MS

Treatments for Erectile Dysfunction

David Cole — Tue, 10 Jan 2017 01:29:11 +0000
Krishnan Venkatesan, MD, discusses the common causes of erectile dysfunction (ED), including high blood pressure, high cholesterol, diabetes, side effects from certain medications, prior surgeries, trauma to the pelvic and/or genital region, and mental/emotional hindarances. Dr. Venkatesan also explains the various ways to address ED, such as medication, vacuum devices, injections and penile prostheses.
Additional Info
Segment Number: 1
Audio File: medstar_washington/1702mwc4a.mp3
Doctors: Venkatesan, Krishnan
Featured Speaker: Krishnan Venkatesan, MD
Specialty: Null
Guest Bio: Krishnan Venkatesan, MD, is the Director of Urologic Reconstruction at Medstar Washington Hospital Center.

Learn more about Krishnan Venkatesan, MD
Transcription: Melanie Cole (Host): Erectile dysfunction is a common problem affecting many men of all ages. Currently in the US, up to thirty three million men are affected by ED. My guest today is Dr. Krishnan Venkatesan. He’s the Director of Urologic Reconstruction at MedStar Washington Hospital Center. Welcome to the show, doctor. So, what are the most common causes of erectile dysfunction?

Dr. Krishnan Venkatesan (Guest): Hi, Melanie, thanks for having me. Erectile dysfunction is something that’s hard to pin down on one cause often. Usually, it’s a combination of things and very much so will depend on each particular patient. Often it’s a combination of other medical conditions like high blood pressure, diabetes, high cholesterol--all those conditions that are known to also cause atherosclerosis in the heart and other blood vessels anywhere else in the body. It could also be a result of other medications. Sometimes it could be a result of specific surgery or other trauma that’s happened in the pelvis or that’s happened externally to the genitalia. There’s also a strong component of mental health or emotional well-being to sexual health that can also manifest as trouble with erection.

Melanie: So, are there certain risk factors? Are there men that are more at risk for this than others?

Dr. Venkatesan: Yes, generally, erectile dysfunction is something that gets progressively more common with age. So, age itself may be a risk factor although somebody who’s older and who’s perfectly healthy shouldn’t have any increased chance of erectile dysfunction compared to somebody who’s half their age who has a lot of medical problems. But, generally speaking, as you age you also accumulate all these other medical issues so all those risk factors I mentioned in your first question like high blood pressure, high cholesterol, diabetes, especially if those things are not well controlled or if they have some peripheral artery disease or, like I said, any history of trauma to the pelvis or genitals or external genitalia or any previous surgeries like surgery for colon cancer, surgery for prostate or bladder cancer--all of those things can be risk factors that can make men more prone to erectile dysfunction.

Melanie: Dr. Venkatesan, I think before men can get treatment for this, they first have to come to see you and women, they’re the ones getting their men in to see a urologist in the first place. What do you want women to know and men about coming in for something like this and why they should not be embarrassed because it is a medical condition?

Dr. Venkatesan: Yes. That’s absolutely a good question and I agree that we do rely on women or partners of either gender to get their loved ones in to get this issue addressed. What I’d like them to know is that this is important for multiple reasons. Number one, because quality of life is a major issue and if this is weighing in on you, you know weighing on somebody very heavily, it can cause relationship stress. It can cause depression. All those things can cause other medical problems or difficulty in functioning on a day-to-day basis. The other issue is erectile dysfunction may be a sentinel sign of other issues going on in the body. Often it can be the first presenting sign for peripheral arterial disease or atherosclerotic disease or some other cardiovascular disease elsewhere in the body. Like you mentioned, men are not very prone to going in to the doctor for regular healthcare visits and for checkups. So, they many not believe that they have any health problems or any conditions that need to be addressed until they realize that they’re having trouble with erection. As it turns out, this may be actually reflecting some other underlying medical problem that also needs to be investigated and addressed.

Melanie: What’s the first line of defense? Of course, in the media and all the commercials, doctors talk about Levitra, Viagra, and Cialis, and you see very famous men coming on to these commercials to promote these medications. What are the medications really intended to do? Explain to the patients what you want them to know about seeing all these ads.

Dr. Venkatesan: Sure. The medications are not intended to be an on-and-off switch. They’re basically meant to act like a signal amplifier. The signal still needs to be traveling from the brain to the penis to be able to elicit an erection. The signal in the brain starts with the appropriate mood, the stimulation, all of the external factors that help to bring on an erection naturally. Now, what the medications do is basically amplify that signal from the brain so that the penis can get harder. You can get more blood flowing into the penis and the erection can last a little bit longer. Those are usually two out of the three complaints that men have is that they have trouble achieving an erection or it’s taking longer to get or it doesn’t last as long or it’s not as hard as it used to be. Now, as far as what to know about those commercials, obviously, everybody’s got some skin in the game as far as these pharmaceutical companies. All of the medications work generally in a similar fashion. They all work in the same mechanism. Each one may have a slightly different chemical compounding so that one has a longer half-life than the other. Because of this, also, I found that some patients respond better to one medication preferably over another.

Melanie: If the medication, as you say, this is not an on-again-off-again switch, you have to commit to these medications, correct?

Dr. Venkatesan: Right.

Melanie: So, if somebody is finding that the medications do not work for them, first of all, are there lifestyle behaviors, things, alcohol, smoking that will make it so these medications don’t work the way that they should?

Dr. Venkatesan: Yes, absolutely. So, all of those underlying conditions that we talked about earlier, if those are not addressed and well controlled, then the medications may have little to no effect. The primary step is really to get the underlying problem addressed and either well-controlled or if possible, even reversed. Once you do that, it may not reverse all the damage that’s been done over time but it can certainly prevent further progression of the damage that’s causing the erectile dysfunction. Then, if the medications still don’t work, generally, we have a broad algorithm, at least here in my practice, where I tell patients that they should get up to the maximum dose of one medication and if that hasn’t worked, then they should try another medication in the same class. If the maximum dose of that also doesn’t work, then it’s probably not a reflection of the medication being ineffective themselves but of the reflection of the severity of their erectile dysfunction and a sign that we may need to move on to the next step on that ladder.

Melanie: So, let’s talk about the next step on that ladder, some procedural interventions, external devices, vacuum devices. What would be the next line?

Dr. Venkatesan: Good question. Our treatments basically travel the spectrum going from least invasive to most invasive. So, the first step, like we said, was pills like all the different brand names you mentioned. If the pills don’t work, then the next step is actually considered or the next least invasive step is considered the vacuum erectile device. This is basically a plastic cylinder that’s placed on the outside of the penis and with a pump that’s either battery operated or manually operated, this pumps all the air other of the cylinder which creates a negative pressure that basically pulls blood into the penis. Once the penis has enough blood in it to give an erection that’s efficient for penetration, then the patient has to slide on a rubber band or a ring of sorts to help keep the blood in the penis. If that doesn’t work or if it doesn’t work well for a specific patient because of their anatomy or the nature of the device, then the next step would be injections directly into the penis. This is something where we initially have to do the first injection in the office so we can show the patient how to assemble it, where to inject, and to figure out what the right dose is for them. Then, whenever the patient wants to have an erection, they can inject this medication directly into the side of the penis and this should give a fairly predictable response within five to ten minutes where it gives them an erection that should last about 30-45 minutes. This same medication that we inject also comes in a small tablet form that’s called a “suppository” that can actually be inserted into the tip of the penis, into the urethra that men urinate through. So, that’s one alternate option that’s in the same class.

Melanie: And, Dr. V, how do you get men here to either of these, whether you’re using the injection or the suppository type treatment? Men’s eyes must roll back when you discuss this type of treatment.

Dr. Venkatesan: Yes, obviously, some of these options are cringe inducing initially when you hear about them but a lot of it just takes reassurance. I have to tell men that I have plenty of patients who use these regularly and that they, too, had the same reaction when they first heard about it but they get over that initial mental block or that anxiety about having to do it. Once they do, they’ve been able to get predictable results. Basically, if the man is motivated enough to come see us about erectile dysfunction, then it’s likely that they’ll be motivated enough to try the different options available to them to restore that quality of life.

Melanie: So, then, go to one last bit of procedure and what you would go to next. And, then, I’d like you to really give your best advice for men about what they can do about their situation.

Dr. Venkatesan: Yes, sure. So, the end of the spectrum, as far as treatment options go, is what we call a penile prosthesis. This is also often called the pump so sometimes men may confuse it with the vacuum device. But, this is a silicone device that’s surgically implanted into the penis. There are essentially two cylinders that go inside the penis and there are a few different models. Sometimes they’re just cylinders that the men can bend upwards or downwards depending on what position they want the penis to be in. There are a little bit more sophisticated models as well that also are attached to a reservoir and a pump, all of which will be internal. The pump sits in the scrotum and when the men want to have an erection, they pump up the pump. It gives them an instantaneous erection and there’s no lag time which is one advantage. The other nice thing is they can use it as frequently as they want and they can use it for any given time. They can keep the erection for as long as they want. There’s no limits on that. It also maintains the same sensation; ejaculation and orgasm are also maintained without any dampening. So, despite it being a surgery and being considered one of the later options, it’s certainly not a last resort because it’s the least effective. It probably has the highest patient satisfaction rates and the highest patient partner satisfaction rate of all the treatment options other than the pills.

Melanie: So, then, wrap it up for us and what do you tell men and their loved ones about the importance of seeking treatment for erectile dysfunction and the reasons, really, to go see somebody about it.

Dr. Venkatesan: Well, good question. Just like I said before, I think this is something that’s worth addressing because it can really put a strain on a relationship. It can have a personal strain that can cause depression and inability to function normally throughout the day and it can have effects even though this is something that obviously comes up mainly in the bedroom; it can have effects outside the bedroom and that quality of life is certainly something worth addressing and worth restoring. Additionally, like I said before, this erectile dysfunction may be a sentinel sign or a signal that there’s other problems going on that may not be evident themselves or may not have been diagnosed before and it’s important to get those addressed and investigated accordingly.

Melanie: Thank you so much for being with us today. It’s really great information. You're listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks so much for listening.

Internal Notes: Null
Hosts: Melanie Cole, MS

Minimally Invasive Gynecologic Surgery

David Cole — Sun, 08 Jan 2017 23:17:57 +0000
James Robinson, MD, discusses new advances in minimally invasive, non-invasive and robotic-assisted gynecologic surgeries. These new approaches address issues such as endometriosis, uterine fibroids, chronic pelvic pain, and abnormal bleeding. Benefits include shorter hospital stays, less pain, a more rapid return to work and daily activities, preserved fertility, and a reduced risk of post-operative infection or other complications.
Additional Info
Segment Number: 2
Audio File: medstar_washington/1701mwc3b.mp3
Doctors: Robinson, James Kane
Featured Speaker: James Kane Robinson, MD
Specialty: Null
Guest Bio: James K. Robinson, MD, FACOG, is board certified in obstetrics and gynecology and fellowship trained in minimally invasive gynecologic surgery (MIGS).

Learn more about James K. Robinson, MD
Transcription: Melanie Cole (Host): The landscape of gynecologic surgery has evolved rapidly in the past few years. New surgical and non-surgical options are emerging for a variety of gynecologic conditions with a major emphasis on minimally invasive and noninvasive options. My guest today is Dr. Jim Robinson. He’s a board-certified Obstetrician and Gynecologist and Fellowship-trained in Minimally Invasive Gynecologic Surgery at MedStar Washington Hospital Center. Welcome to the show. Dr. Robinson, what has typically been done for women in the department of gynecologic surgery?

Dr. Jim Robinson (Guest): Well thank you, for having me. In general, women historically -- with gynecologic problems including things like uterine fibroids, and chronic pelvic pain, endometriosis -- have required invasive abdominal surgeries that require prolonged hospital stays and often times have led to the loss of fertility.

Melanie: And what are we seeing now in terms of endometriosis or uterine bleeding, fibroids and the like.

Dr. Robinson: Advancements in minimally invasive surgery have allowed us to do almost every surgery that we historically did through open incisions, through small keyhole incisions called laparoscopy. In terms of uterine fibroids, historically women with large, symptomatic uterine fibroids would require a hysterectomy. And while this is still an option for some women, women who desire future fertility often require uterine preservation and, therefore we’re looking at removing the fibroids and repairing the uterus in a procedure called myomectomy. We’re now doing almost all of our myomectomies in minimally invasive ways using laparoscopic, hysteroscopic, and sometimes robotic-assisted laparoscopic ways to remove these fibroids.

Melanie: And in terms of fibroid procedures, let’s start with those. What are some of the benefits to the patient? What’s that procedure like if you’re using robotics or minimally invasive?

Dr. Robinson: In general, most people recognize the benefits of minimally invasive surgery as being shorter hospital stays, less pain, quicker return to work and better return to activities of normal living. But other benefits also exist and those benefits include the potential for decreased bleeding, the potential for decreased risk of postoperative infections like deep venous thrombosis, which is a blood clot in your leg that occurs from immobility that can travel to your lungs in a pulmonary embolism. Those postoperative risks are lower after laparoscopy since those patients are up and moving around faster. In fact, our patients are generally up the day of surgery. We make sure they get up and are going to the bathroom the day of surgery. Many of our patients are able to go home on the day of surgery and instead of spending two to three days in the hospital are typically out the day of surgery or maybe spending one observational day in the hospital and then going home and beginning their recovery and returning to normal activity.

Melanie: In terms of endometriosis, Dr. Robinson, what are you doing for women that also helps to preserve their fertility?

Dr. Robinson: Again with endometriosis, endometriosis is a condition that has the potential to wreak havoc on a woman’s reproductive organs. Endometrial tissue, which typically grows within the uterine cavity, or the womb, is growing outside of the uterus, proliferating, and shedding on a monthly basis. This can lead to both chronic pelvic pain, which typically worsens and progress and also can lead to a lot of pelvic scarring. That scarring can both affect fertility because it can block fallopian tubes and cause the pelvic organs to become matted together. But it can also affect those surrounding organs, like the bladder, the rectum, and the ureter. We often see endometriosis that is affecting all of the pelvic structures, and sometimes structures outside of the pelvis. When we do surgery for endometriosis in women who desire preservation of fertility it is imperative that we restore anatomy back to normal and we actually remove, or excise, all of the endometriosis that exists. That procedure sometimes requires a high level of expertise because the endometriosis can be on the bowel or the bladder, and it can require a more advanced level of surgery so that you can repair those structures. That’s something that we can do now laparoscopically and sometimes with the assistance of robotics.

Melanie: Dr. Robinson, many women experience abnormal bleeding whether they’re in perimenopause, or just prior to that. What do you tell them about abnormal bleeding or ultra-heavy bleeding? What do you tell them about procedures for that?

Dr. Robinson: The first thing we always have to do when somebody comes in with abnormal bleeding is we have to try to figure out what’s causing the abnormal bleeding. There are two classic types of abnormal bleeding, bleeding that happens cyclically, during the cycle, so it’s really no change in the hormonal status of the patient, but now when they have a period, their periods are much heavier, they’re lasting longer, potentially they’re more painful and the patient’s becoming anemic and symptomatic. The problems that cause that type of heavy menstrual bleeding -- or abnormal bleeding -- typically are from things like fibroids that enter the endometrial cavity, or a condition called adenomyosis, which is similar to endometriosis in that it’s endometrial tissue that is now growing within the muscle of the uterus. In those patients, we want to address the disease.

In women who come in with abnormal uterine bleeding that’s not cyclic -- that happens randomly -- that is typically of hormonal origin and in those cases, we want to really identify what’s going on. Is there something in their endocrine system – their thyroid, their prolactin -- or from perimenopause, that’s causing them not to ovulate regularly, giving them the abnormal bleeding? It’s important for us first to diagnose what’s going on so we can tailor our treatment to the patient.

With respect to treatment, many of our treatments -- once we diagnosis the patient -- can be performed either in an office setting or in a very strict outpatient surgical setting where we actually operate hysteroscopically up within the cavity of the uterus. Our procedures range from hormonal management with either birth control pills or intrauterine devices, all the way through minimally invasive hysteroscopic surgeries where we either remove the fibroids that are entering the cavity -- or the polyps that are entering the cavity -- or we can even, in women that do not desire to preserve fertility, do things like endometrial ablation, where we destroy the endometrial cavity so that no further bleeding occurs. That’s something that we can do in patients that don’t want to get pregnant in the future but would like to avoid a bigger surgery that’s going to cause them to miss more work, or that’s going to cause them to be in a little bit more pain postoperatively.

Melanie: Dr. Robinson, when women hear about hysterectomies, we’ve been hearing about them for many, many years and then you hear somebody say, “Oh, they’re not doing those very often anymore.” Tell us about hysterectomies. What’s going on in the world today?

Dr. Robinson: Well, I like to tell my patients that it’s not your mother’s hysterectomy. We’ve really come a long way with respect to hysterectomies. While some women want to preserve their uterus either for fertility or not, many women who are past childbearing would benefit from a hysterectomy, so the disease that’s causing their problem is definitively treated. The beauty of the current era is that we can do close to 100% of hysterectomies in a minimally invasive way at this point. It should be very uncommon for a woman to have to undergo an abdominal hysterectomy even with very large, symptomatic fibroids, or a uterus that is large and is involved with adhesions and other problems. You can almost always remove even those larger uterusus in a minimally invasive way, generally as an outpatient.

The other thing that’s really important is that we’ve learned that the benefits ovaries and woman’s hormonal status lasts well past menopause. Even after women have stopped ovulating and making the estrogen that they typically make, they’re still making testosterone. Their ovaries are still functioning and the benefits of the ovaries extend to sexual function, heart health, bone health, skin health, memory, and probably even years of life. We’ve become much more ovarian conservationists in the modern era and even women who are menopausal and postmenopausal are often discussing ovarian preservation at the time of hysterectomy.

One of the other things that we’ve started doing is we’ve started to routinely remove the fallopian tubes when we do a hysterectomy, even when we leave the ovaries. And we’re doing this because we now know that approximately 20% of ovarian cancers probably start in the fallopian tube. By removing the fallopian tube, it can actually decrease a woman’s lifetime risk of ovarian cancer by about 20%. The last thing that laparoscopic, vaginal approach to a hysterectomy offer women is we don’t shorten the vagina at all. Because we’re not shortening the vagina, we’re not affecting sexual function, which historically were the problems. We’re also not severing the supportive ligaments of the uterus, so we’re not increasing a women’s risk of prolapse, or urinary incontinence.

Melanie: That’s absolutely fascinating, Dr. Robinson. Wrap it up for us with your best advice. If a woman is sitting across from you at your desk and asking you about the future of minimally invasive surgeries and gynecologic surgeries, and what they can expect, what do you tell them every day?

Dr. Robinson: I have this con—[laughs] I’m glad you asked. I have this conversation every day with a patient and unfortunately, we still live in an era where many people are using older techniques. They’re still using these open approaches. They’re still removing ovaries as a matter of routine. I think it’s important for women to research what they’re having done. I think it’s very interesting that many women will spend a lot of time researching their plastic surgeons, about maybe a cosmetic procedure, or something else that they were considering having, but they trust their OB/GYN because their OB/GYN is the person that delivered their baby. That person may or may not be skilled in the less invasive approaches to care for them as they’re getting older or having more problems.

I think it’s imperative for women to take control of their healthcare and to research the options that exist. I think it’s important for all of us as physicians to really lay out the options because surgery is not the only option. I spend a lot of time talking people out of surgery who I don’t think need it. I certainly don’t want to be taking somebody to the operating room when we can expect the same benefit in a less invasive way. When surgery is an option, I want my patients to know that with very few exceptions, we can approach their problem in a much less invasive way than they’re probably aware of and maybe even a less invasive approach than their regular OB/GYN is aware of.

Part of the education that we need to do is we need to educate not only our patients and our Primary Care physicians so that they know what kind of options are available for them. I think it’s an exciting time for women and I think that as we train more people in minimally invasive gynecologic surgical techniques, we’re going to see the landscape of surgery for women’s healthcare continue to change rapidly.

Melanie: Thank you, so much, for being with us today, Dr. Robinson. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to MedStarWashington.org, that’s MedStarWashington.org. This is Melanie Cole. Thanks, so much, for listening.
Internal Notes: Null
Hosts: Melanie Cole, MS

Managing Your Diabetes

David Cole — Wed, 04 Jan 2017 00:42:12 +0000
Michelle Magee, MD, explains why type-2 diabetes is on the rise across all generations, genetic factors surrounding the disease, and lifestyle factors you can shift in order to get control of your blood sugar. Dr. Magee also discusses when you should consider insulin therapy, as well as new medications and advances in insulin delivery methods.
Additional Info
Segment Number: 1
Audio File: medstar_washington/1701mwc3a.mp3
Doctors: Magee, Michelle
Featured Speaker: Michelle Magee, MD
Specialty: Null
Guest Bio: Michelle Magee, MD, MedStar Health Research Institute, is an endocrinologist at MedStar Washington Hospital Center (MWHC) and an associate professor of Medicine at Georgetown University School of Medicine in Washington, DC. She also serves as director of the MedStar Diabetes Institute (MDI). In this capacity she leads and supports diabetes clinical, educational and research programs, including diabetes outpatient and hospital services across MedStar Health and diabetes education programs in the community. Dr. Magee's community work focuses on minority and vulnerable populations.

Learn more about Michelle Magee, MD
Transcription: Melanie Cole (Host): According to the CDC, 29 million people are living with diabetes. That's one out of every eleven people in this country. For diabetics, managing diabetes can be challenging every single day. My guest today is Dr. Michelle Magee. She's the Director of MedStar Diabetes Institute at MedStar Washington Hospital Center. Welcome to the show, Dr. Magee. So, tell us about what's going on. What are you seeing with diabetes and the state of this country today?

Dr. Michelle Magee (Guest): We're seeing a really alarming rise in the incidents of diabetes. It tracks along with the rise in obesity and really is largely in consequence of changes in lifestyle over the last 10 or 20 years. People walk less, they're eating out more often. That tends to give you less healthy eating options, so you know, there are two things that I think about when I think about a patient's risk for diabetes. One is whether they have the lifestyle factors and the second is whether it runs in their family because Type II Diabetes, which is the most common form of diabetes, does run strongly in families.

Melanie: So, how would somebody know? Is this something that they get checked on their annual physicals? How would they know?

Dr. Magee: Yes. It's standard now that you'll be checked for diabetes on your annual physical, usually simply by a blood glucose test that should be fasting, nothing to eat after midnight except drink water if you need it, or your doctor may order an A1-C test. That's what I call the diabetes control number. It looks at what the average of your sugars in the past two to three months before the test is done. It’s sugars that attach to your blood cells and there are normal ranges for those numbers, there are ranges that we call pre-diabetes, meaning that you're at particularly high risk for getting diabetes, and then there are numbers that tell us that you have met parameters for a diagnosis of diabetes. So, very important to ask your doctor when you have your once a year physical, "How did my diabetes test numbers look?"

Melanie: Tell us what those number mean. What are the normal ranges people should look for?

Dr. Magee: So, on fasting blood sugar, so first morning sugar, the normal is less than 100, 100-125 is what we call pre-diabetes, and 126 or higher is diabetes. When we're looking at the A1-C control number, we're looking at a range of less than 5.4 to 5.7 is normal, 5.7 to 6.4 is pre-diabetes, and greater than or equal to 6.5 is consistent with a diagnosis of diabetes.

Melanie: What is the first thing you tell your patients if they do come up with some of those numbers that could signal pre-diabetes, or full-on diabetes?

Dr. Magee: So, we have a lot of evidence about how to treat patients in either of those categories. There have been large, national studies that show us that an intensive lifestyle intervention can cut your risk for going from pre-diabetes to diabetes by up to 60% and that's simple things like exercise five days a week for thirty minutes a day, and losing about 7% of your body weight, which, you know, for a 200-pound person would only be 14 pounds, so it's not a lot. That does significantly cut your risk if you have pre-diabetes for it turning into diabetes. And then, once you're in the diabetes range, then, again, lifestyle is important, you can't get away from that and if you want to stay healthy and you don't have diabetes or you have pre-diabetes, or you have diabetes, you have to eat well and you need to exercise. And then, we have multiple medications that we can add to the regimen to help control blood sugars for the patient who actually has diabetes and that is started by your primary care doctor and, if necessary, then you could see an endocrinologist if you don't get to your goals within a three- to six-month period.

Melanie: Dr. Magee, you mentioned that it does run in families and when you're dealing in this age of childhood obesity and you must be seeing children now coming up with this type of diabetes, it used to be called adult onset, but now it's Type II, what do you tell families when you see that this is a possibility for the whole family?

Dr. Magee: I always want to emphasize is what we teach is the patient that has pre-diabetes or diabetes, is a healthy lifestyle for their whole family. It's much easier to do these things if you all jump on the bandwagon together and, yes, one in three children born in the US now is going to develop diabetes in their lifetime. This is a preventable illness by largely, largely by lifestyle factors. So, it's really important for families to embrace being healthy together.

Melanie: That's so important. And as far as treatment goes, and you talked about lifestyle, then you mentioned medication. People think about insulin injections, that's mostly Type I, but could be Type II, so speak about the medicational intervention required if somebody can't control their diabetes with lifestyle.

Dr. Magee: Yes. So, if you can't --and I'm really…Type I always has to take insulin, so I'm not really going to speak to that. Type II diabetes, which is 90% of patients with diabetes, so almost everybody, typically patients will do well with a pill or two for many years, but over time, many patients will need insulin. It's important to start it when you need it, not to wait until you've already developed problems from diabetes. The complications that we think of with eyes and kidneys and nerves, heart disease and stroke. It's very important to treat early on and keep the sugars well-controlled, because we know it decreases the risk of complications over time. The other thing that's really important that I think we need to mention is that you do need some education so that you can learn how to live well with diabetes. We know that over almost half of the people in the US never get any education when they have diabetes and this is really critical. You have to know, not only how to eat and to exercise, but also how to take your medications, what the side effects are, what to do if your sugar is too high or too low. You really need education to be able to get that information.

Melanie: Where do you see diabetes research going in the future? What's on the horizon?

Dr. Magee: Oh, there's always exciting things on the horizon. They're always working on new classes of medications. We had another new class come out this year. We now have 12 classes of pills and insulins that you can take for diabetes and then there are exciting things in the insulin delivery arena. Some, an insulin patch, some implantable depots of insulin, things in the technology arena that help patients track their lifestyle, track their medications, track their sugars. There's a huge amount going on in that arena and you just really need to stay tuned to see what comes through the FDA that are the exciting developments that we can get to the patients.

Melanie: In just the last few minutes, Dr. Magee, wrap it up for us with your best advice for diabetes, for living with and managing the symptoms of diabetes for the listeners.

Dr. Magee: To live well with diabetes, you need to learn enough about it that you can take control of it and so that the diabetes will not take control of you. That's kind of my philosophy and at the root of all the work we do to educate patients and to manage their medication.

Melanie: Thank you so much for being with us today. It's really great information. You're listening to Medical Intel with MedStar Washington Hospital Center and for more information, you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks so much for listening.

Internal Notes: Null
Hosts: Melanie Cole, MS

Prevention and Treatment of Common Sports Injuries

David Cole — Sun, 20 Nov 2016 19:07:56 +0000
Dr. Evan Argintar, an Orthopaedic Surgeon at MedStar Orthopaedic Institute, dives in to the most common injuries associated with exercise and athletics. From acute to chronic injuries, he provides recommendations for nonsurgical therapies and advice on when it's time to consider a surgical approach.
Additional Info
Segment Number: 5
Audio File: medstar_washington/1642mwc3e.mp3
Doctors: Argintar, Evan
Featured Speaker: Evan Argintar, MD
Specialty: Null
Guest Bio: Evan Argintar, MD, is a member of the MedStar Orthopaedic Institute at MedStar Washington Hospital Center, where he performs surgery. Dr. Argintar also serves as the Assistant Director of Sports Medicine at MedStar Washington Hospital Center.

Since September of 2012, Dr. Argintar has served as Director of Sports Medicine Research at MedStar Georgetown University Hospital Residency, Assistant Professor of Clinical Orthopaedic Surgery at Georgetown University Medical Center, and Clinical Instructor of Orthopaedic Surgery at The George Washington University Hospital.

Dr. Argintar specializes in sports injury and upper extremity reconstruction. He sees patients with injuries to the knee, shoulder, elbow and hip. His clinical interests include arthroscopic surgery, ligament reconstruction, joint reconstruction/replacement, cartilage restoration, hip arthroscopy and hip preservation. He is currently involved in research on ACL repair, a new surgical technique that may replace traditional ACL reconstructive surgery.

Learn more about Evan Argintar, MD
Transcription: Melanie Cole (Host): Exercising is good for you but sometimes you can injure yourself when you play sports or you exercise. Accidents, poor training practices, and improper gear can cause many different kinds of injuries. My guest today is Dr. Evan Argintar. He's an orthopedic surgeon with MedStar Orthopedic Institute at MedStar Washington Hospital Center. Welcome to the show, Dr. Argintar. What are some of the most common sports injuries that you see?

Dr. Evan Argintar (Guest): Thanks for having me. There are so many different sports injuries and so sometimes it's perhaps easier to frame it by the region of the body. In terms of shoulders, it's very common to get inflammation of the rotator cuff, rotator cuff tendonitis. For the hip, often athletes will get hip trochanteric bursitis. In the knee, patients get a constellation of symptoms that will lead to patellofemoral syndrome or anterior knee pain. For the ankle, often patients will sprain their ankles or injure the lateral ligament of their ankles.

Melanie: When we're talking about injuries, there are two types: acute and chronic. Explain the difference please.

Dr. Argintar: Well, the chronic injury is the one that is been bothering the athletes for weeks to months, even years. Sometimes there are injuries that are clinically silent so patients may have a chronic injury that doesn't really bother them. They make acutely injure it which means they get acute symptoms, after a throw, after a slide, after a push during the sport, or even something professionally. So, from the perspective of an orthopedic surgeon, it is purely did you have symptoms before that accident or did you not? However, sometimes they can be blurred.

Melanie: Let's talk about knee injuries for a minute. You mentioned patellofemoral syndrome. What is that and how is the knee easily getting common sports injuries?

Dr. Argintar: Patellofemoral syndrome is, by far, the most common clinical problem that I see with athletes and even non-athletic people--even couch potatoes, a lot of people have this problem. It is really a constellation of a whole group of different diagnoses often lumped together appropriately. Some people will call this jumpers knee, patellar tendon, tendonitis anterior knee pain syndrome, but what it all comes down to is pain on the front of the knee. When I try to identify the cause of this commonly occurring issue, again, it all comes down to the flexibility or lack thereof as well as specific weaknesses. A very common collection of symptoms are tight IT band; tight hamstring, which is the muscle behind your leg; and then, people tend to have weak medial quadriceps and weak hip abductors. The hip abductors are really tiny but critically important muscles on the side of the hip. It helps pelvic control but also plays a role in the natural tracking of the kneecap.

Melanie: Are there any ways to keep your knees healthy?

Dr. Argintar: Well, absolutely. First of all, weight bearing is good for all joints as well as the knee. But then, there are people that struggle with these inflexibility weaknesses. I often see people with knee pain. I'm very able to predictably get them better. The bigger challenge is in maintaining that clinical improvement and I do that with the creation of a home exercise program that is instilled in a patient by frequently going to a physical therapist that works on creating a program that focuses on the flexibility of these two really large muscles that can get very stiff. It also works on core strengthening, pelvic girdle strengthening, medial quad strengthening. The patients with pain are able to get better and then they're able to maintain that improvement as they play sports or do whatever else they wanted to do.

Melanie: Some injuries we're seeing a lot of lately are ACL injuries and especially to soccer playing girls. What do you tell parents and the athletes themselves if they feel like they've gotten an injury? What do you tell them to do right after the fact?

Dr. Argintar: Well, the first thing is, it can be dangerous sometimes to give advice to people over the phone or over e-mail. So, the first thing I tell them is that if they have any real concern, there's only so much any doctor can do by just hearing about the problem. The clinical exam is just as important. So, any parent with a child or any athlete who has a problem or a concern, I would say, “Get evaluated.” That being said, the first question I ask them is, especially in respect to the knee, and even more focused with the soccer players, was it a non-contact injury? Oftentimes that smells of an ACL injury. I ask them did their knees swell up. There are a lots of problems that don't create the effusion or the knee swelling in the joint, and so as I'm trying to stratified different diagnoses based on how the parents, or even the athletes, describe their symptoms. Those are two of the things that I try to tease out early.

Melanie: Are you still using or advising RICE for people to do if they just get a short term injury?

Dr. Argintar: The answer is yes. RICE is still a good thing. Five years of orthopedic residency and RICE is the number one thing that works for all injuries. RICE is resting, icing, compression and elevation. All that does is it decreases inflammation. Remember inflammation is a good thing. It brings blood to a site of injury and blood has growth factors and healing factors that help stimulate healing. The problem is that with bleeding, you get swelling and swelling causes stiffness, so it's always a bit of a balancing act. You want to optimize the good stuff coming with the blood and minimizing the bad side effects of that. So, all of the compression, icing and elevation minimizes the consequences of swelling ideally.

Melanie: Dr. Argintar, is there ever a time that heat comes into play?

Dr. Argintar: Yes, heat is good. People often ask me, “Should I ice it? Should I heat it? What should I do?” The reality is that both, in general, are safe, and I tell patients to kind of play around with both and see if and when either gives more of benefit. In general, though, after an acute injury, you twist your knee and it's swollen, so icing tends to be better because it decreases the swelling. Then, for more chronic issues, heat tends to be better because that brings the blood flow, bring some of the healing agents. Both are safe although I will caution the patient icing to make sure to give yourself a break every once in a while. Patients can actually give themselves frostbite from too much ice.

Melanie: Speak about some available treatment options for the longer term if somebody does injure their rotator cuff or their ACL, or they get patellofemoral syndrome. What do you tell them about some treatment options that might be available?

Dr. Argintar: Well, the first thing is you have got to shut it down. Pain is your body's mechanism of telling you that something is not going right and so you have to listen to that. People will get into problems when they try to ignore the knee pain and run, or ignore the shoulder pain and pitch, and then you start creating a more complicated knot that takes a lot longer time to unravel. After you let things calm down, often with the help of the therapist or an orthopedic surgeon, you have to figure out what the cause of that problem is. Sometimes accidents happen and your body can heal them. Oftentimes, though, there is a bad plumbing issue whether that be inflexibility, or a weakness, or a combination thereof. Usually, if you don't identify and actually treat that issue then you're prone to that same injury again. Most athletes and most patients prefer to have an event that they don't repeat.

Melanie: What do you use as a first line of defense? Do you tell people to use NSAIDS or go to physical therapy? Kind of just walk us through a treatment line until you would possibly discuss surgical intervention?

Dr. Argintar: Sure. As an orthopedic surgeon my favorite thing to do is operate. However, fortunately, I operate on a very small minority of my patients and always surgery is the last option. And, so, in general, some of the things that I recommend for a lot of the overuse injuries or traumatic injuries like in shoulders, elbows, hips, knees and ankles, would be some combination of activity modification, a strong anti-inflammatory, often physical therapy and, in some cases, a steroid injection.

Melanie: So, that's a good point. Speak about a steroid injection. If somebody gets one in their shoulder or their elbow, how often can they get those?

Dr. Argintar: That is a great question. There is a big stigma attached to the word “steroid”, and that is appropriately existing from the anabolic steroids that got appropriate negative press with professional athletes. This is not that. A steroids injection or a cortisone injection is a direct injection of a medicine that decreases inflammation. It does it in a different way than the typical NSAID, which is the non-steroidal anti-inflammatory. A Steroid is, of course, a steroidal anti-inflammatory. In terms of frequency, some people are worried by the way it side effects, like weight gain, which does not happen with the injection because it doesn't go into your mouth and go around your body through absorption, through your stomach. It depends on the problem. Everything in moderation is okay, and it depends on the age. So, if you have an arthritic knee, I have patients coming in every two or three months sometimes for an injection. That's how they get by and avoid surgery. For a younger person, I would give them one injection with the goal of never giving it to them again.

Melanie: Then, wrap it up for us with your best advice about possibly preventing some of these common sports injuries--what you really tell patients every single day.

Dr. Argintar: The best way to prevent injury is to have a strong defense and there are specific muscle groups in the hips, in the shoulders, in the knees, and ankles. It is very easy to neglect them and often the neglect leads to a bad plumbing issue which is clinically silent until you injure yourself. So, my advice for the shoulder would be, for the shoulder, periscapular strengthening, rotator cuff strengthening. For the hip, hip abductor strengthening, core strengthening. For the knee, hamstring IT band flexibility, medial quad strengthening. For the ankle, calf flexibility. These are the things that an average person could potentially Google and just learn how to do some simple stretching and strengthening exercises that could either both defend from injury or make an injury less bad and more easily recoverable.

Melanie: Thank you so much for being with us today, Dr. Argintar. That's great information. You're listening to Medical Intel with MedStar Washington Hospital Center, and for more information you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks so much for listening.
Internal Notes: Null
Hosts: Melanie Cole, MS

Neck and Back Pain Basics: What You Need to Know

David Cole — Tue, 08 Nov 2016 02:16:48 +0000
Lower back and neck pain are among the most common reasons that people seek medical care. These issues greatly affect their ability to work and manage daily activities of life. The latest Global Burden of Disease study reveals that back pain has the second highest number of Disability Adjusted Life Years (DALYs) in the United States.

If you suffer from this type of pain, you're likely looking for solutions. As you do, it's wise to consider all of your options – surgical and nonsurgical. Oliver Tannous, MD, says that the first step is to figure out exactly where your pain is coming from.

Listen in as Dr. Tannous describes the variations of back pain, nonsurgical therapies, and which surgical treatments work best for certain patients.
Additional Info
Segment Number: 4
Audio File: medstar_washington/1642mwc3d.mp3
Doctors: Tannous, Oliver O.
Featured Speaker: Oliver O. Tannous, MD
Specialty: Null
Guest Bio: Oliver Tannous, MD, is an orthopaedic spine surgeon at MedStar Washington Hospital Center. As a spine specialist, he utilizes state-of-the-art, minimally invasive and motion preservation techniques to treat conditions of the bones, discs, and nerves of the neck and back.

His clinical focus includes disorders of the cervical, thoracic, and lumbar spine, ranging from isolated disc herniation to complex deformities and failed surgeries. His research interests include optimizing patient outcomes after surgery and improving techniques for eliminating postoperative spinal infections.

Learn more about Oliver Tannous, MD
Transcription: Melanie Cole (Host): According to the American Academy of Orthopedic Surgeons, low back and neck pain are among the most common physical conditions requiring medical care. They also greatly affect the ability to work and manage daily activities of life. The latest Global Burden of Disease study reveals that back pain has the second highest number of disability adjusted life years in the United States. My guest today is Dr. Oliver Tannous. He's an orthopedic spine surgeon with MedStar Orthopedic Institute at MedStar Washington Hospital Center. Welcome to the show, Dr. Tannous. Please explain a little bit about your role in spinal surgery for the listeners.

Dr. Oliver Tannous (Guest): Hi, Melanie. Thanks for having me and thanks for the introduction. So, I'm an orthopedic spine surgeon which means that my area of expertise involves anything regarding the spine--anything from the base of the skull down to the tailbone. So, the three levels of the spine that I engage in clinically are the cervical spine, which is the neck; the thoracic spine, which is the back; as well as the lumbar spine, which is the lower back.

Melanie: Dr. Tannous, unless people have actually suffered back pain themselves, they don't quite understand the debilitating effects that it has. Speak about what you've heard from your patients about the lasting effects it has on their daily quality of life.

Dr. Tannous: Oh, absolutely. I mean, neck and back pain is unbelievably debilitating and I see patients come into my clinic every single day with such changes in their quality of life and they can't do the things that they want to enjoy. They can't pick up their grandchildren, they can't drive to the gym, and it really affects their overall sense of confidence, their sense of happiness, and they typically come to me with sort of that depressed mood and it's up to me to figure out what's going on and how to guide them in the right direction; get them back to healthy living and quality of life.

Melanie: So, when should a person have that initial conversation with you to check if they need or need to consider spinal surgery?

Dr. Tannous: To answer that question, we first have to figure out what's causing that neck pain or that back pain. The good news is that the vast majority of the time, 90+% of the time, when people have acute neck or back pain, meaning new onset of neck or back pain, typically there's nothing surgical to do for the spine. The pain is typically coming from muscle strain, or maybe a sprained ligament within the spine, or maybe some good old-fashioned arthritis that the vast majority of the time gets better with non-operative treatment modalities.

Melanie: So, what do you tell them about what they probably should have already tried before they consider spinal surgery? Some non-surgical approaches?

Dr. Tannous: Absolutely. So, the great news is there are so many things that non-surgical spinal specialists have in their armamentarium. Typically, when someone goes and sees their primary care physician, or maybe the pain management physician, or whoever it may be that sees the patient first, there are so many things that can be done to help alleviate the pain. The first thing that typically most physicians do is they start the patients on anti-inflammatory medications; then, at the same time, they typically start a course of physical therapy to work on strengthening, stretching, ergonomic exercises, posture training; things that a lot of people sort of, in their 20s to 60s, experience as general decline when they maybe aren't as healthy, or aren't fit, or aren't as flexible as they once used to be. If that fails, then, typically, if there's some significant pathology that we see on the MRI, we can send the patients to pain management where they can consider some steroid injections into their spine and that can really have long-lasting, beneficial pain relief for those patients. And, finally, once they've failed all other options is typically when they come to me as the spine surgeon, to look at their spine and talk about surgery as potentially an option to make them better.

Melanie: So, what are some signs they should be aware of that they need to consider surgery if they've tried all those other options?

Dr. Tannous: Let me give you a quick rundown of the types of patients that I see in my clinic. The most common reason that I see people in my spine surgery clinic is arthritis of the spine. When people have arthritis in their neck or in their back, in and of itself, that arthritis doesn't necessarily mean they're going to have symptoms, but when it becomes so severe and it grows, it starts pinching on the nerves within the spinal cord or the nerves coming out of the spinal cord. When that happens, typically people come and they have either arm pain, when that pinching is happening in the neck; or leg pain, when that pinching is happening in the lower back. I also see younger patients who don't have arthritis who may have just a disc herniation. Typically, it happens with squatting or with heavy lifting, and they'll get sort of this sharp, shooting sciatic pain running down their leg, and the good news is, the vast majority of times that gets better without needing surgery. I also see patients with spinal deformities who can't stand up straight and then patients who have maybe tumors in their spine, infections in their spine, or fractures in their spine. So, that's sort of the gamut of the types of patients that I see in my clinic.

Melanie: People hear the words “spine surgery” and they get nervous. What types of spine surgery are you doing today? What's new and innovative in the world of spine surgery?

Dr. Tannous: Well, that's a good question. The easy answer is there are so many new technologies out there in the terms of motion preservation; in terms of it used to be back in the day when someone had to have a spinal fusion, you would take out a disc and put a big piece of bone in there to lock them up. For the most part, we still do that on a routine basis, but there's newer technology now in terms of disc replacements where you can put an implant in where it preserves that motion. Instead of having to fuse someone, you can put a disc replacement that maintains the motion. We're doing it much more in the neck, but the technology is advancing and there are hopes that it will be widely available in the future for the lumbar spine as well. I also do a lot of procedures using tubes, minimally-invasive techniques, so instead of having to make a big, traditional, mid-line incision, I can target the area involved and put a tube down into the spine which is what people think of as laser spine surgery, although no one ever uses a laser in the spine. You place a tube down into that level that you want to target, and you can decompress the nerve and give quite significant pain relief, once you decompress the nerve. And then, we also have other techniques to fusions from a minimally-invasive approach, where traditionally, we used to do fusions with big, open incisions and big muscle dissections, and patients end up with quite a few weeks of post-operative pain and nowadays, what we're finding is that the pain levels are markedly diminished, people are getting out of the hospital earlier, and they're, overall, doing quite better than they did ten or fifteen years ago with some of these new technologies that are out there.

Melanie: As people grow older and they shrink, their body shrinks, they have this compression. So, sometimes, as you stated, there are just pains that go along with aging. Tell us about some of the decompression procedures. What is life like for people after these procedures?

Dr. Tannous: So, you're talking about compression fractures that people get. So, if you think of maybe your grandmother, or maybe your grandfather, and you knew them when they were younger and they were taller, and then, over time, they develop maybe the hunchback and they slowly lost height. For the most part, people who have that, they don't have pain, or maybe they have aches here and there, it's not an issue. There's another subset of patients who maybe they become osteoporotic and now they have a fall, or maybe they went on a bumpy car ride and often they have this acute pain, this worsening pain, that comes on very suddenly. And then, we get x-rays, and we find that one of their vertebral bodies, one of the segments in the spines has collapsed. It's called a “compression fracture”. But, again, the good news is that the vast majority of those patients, they get better with time, the fracture heals with time. When it doesn't, that's when they usually come to me because it's been six to eight weeks, they're still having pain, maybe we get an MRI and we find that that segment is still lighting up on the MRI, meaning there's still motion. It's still active. It's still the source of pain. We have a really nice procedure called a “kyphoplasty”, where we can put a couple of needles right into that fracture site, inject some cement, and it is almost instant pain relief. People wake up from that procedure, they stand up, and they feel quite a significant difference in their pain level, and they can get back to their quality of life.

Melanie: And you mentioned range of motion, because that is something that people are concerned with when they hear the words “back surgery” and specifically in the neck. So, how do you maintain that range of motion so that they can still turn their head and drive after the procedures?

Dr. Tannous: We're getting to some of the more intricate nuances and it's very patient-specific. In younger patients who need a cervical spine procedure to decompress their spinal cord or decompress their nerves, if it involves one or two levels, then the nice thing is we can use disc replacements as an option. So, instead of having to fuse that level and lock up that one or two levels, we can now use disc replacement to preserve the motion that went in those two segments. It does two things. Number one, it preserves motion; number two, if you think about it, when people have a fusion, all that motion and stress that used to happen at those levels now goes to the level above or the level below. It puts increased stress on the other levels of the spine versus when you maintain their motion and you put a disc replacement, what happens is, there's now less stress on the adjacent levels, or there's less stress on the level above or the level below, and we're finding that this may have some very significant, positive, long-term effects on people.

Melanie: In just the last few minutes, Dr. Tannous, what are some things that people should look for before considering spinal surgery? What do you tell them every single day and what do you want them to know?

Dr. Tannous: Yes. I'm a very conservative surgeon. Obviously, I love to operate; it's how I make my living, but I, first and foremost, want to make sure that my patients have a very successful outcome if they ever consider surgery. So, the first thing that I tell patients when they come to me—because, by the time they come to me, everyone has an MRI that shows something significant. Everyone has symptoms that are significant, and maybe they haven't tried everything out there. So, a lot of times, when I see patients for the first time, I end up sending them back to physical therapy, or I send them back to pain management for some more injections. Maybe I tell them to try to lose some weight and see how that goes. I really try to do everything absolutely possible to avoid surgery. If that all fails and they come to me for surgery, then we sort of discuss what the goals of surgery are. Typically, when people have arm pain or when they have leg pain because the nerves are being pinched, as spine surgeons, we are very successful at treating arm pain or leg pain that's coming from a pinched nerve from the neck or in the back. When people have only neck pain or only back pain without arm pain, arm numbness, or arm tingling, our success rates for treating just neck pain or just low back pain aren't quite as good and the reason is because there are so many levels that are involved. So, you're not going to fuse the entire spine just hoping to get the one level that may be causing the most pain. At that point, it's a lot more of a conversation in terms of what to expect from surgery; if surgery is right for the patient. So, I really spend a lot of time talking to my patients, explaining the MRI images, explaining my clinical findings, and really trying to come to a plan, because at the end of the day, when I operate on someone, we're doing it together. Yes, I'm the surgeon, but the patient has to have the very best interest in their health, and their recovery, and the surgical process. I take that very seriously and I spend a lot of time counseling them on what to expect and how to optimize themselves pre-operatively.

Melanie: Thank you so much for being with us today, Dr. Tannous. You're listening to Medical Intel with MedStar Washington Medical Center. For more information, you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks so much for listening.

Internal Notes: Null
Hosts: Melanie Cole, MS

New Device Reduces Risk of Stroke in A-Fib Patients

Melanie Cole, MS — Mon, 07 Nov 2016 17:07:29 +0000
In general, the most dreaded complication associated with atrial fibrillation (A-fib) is the occurrence of stroke. The first line of defense is usually a blood thinner–an oral medication taken to reduce the risk. But for some patients, these are not a safe solution. In these cases, a new implantable device called the Watchman™, may help.

Listen in as Manish Shah, MD, an electrophysiologist at MedStar Heart & Vascular Institute at MedStar Washington Hospital Center, explains the benefits of the Watchman.

MedStar Washington Hospital Center is the first in the region to implant this device.
Additional Info
Segment Number: 3
Audio File: medstar_washington/1642mwc3c.mp3
Doctors: Shah, Manish
Featured Speaker: Manish Shah, MD
Specialty: Null
Guest Bio: Manish Shah, MD, is the Program Director of Cardiac Electrophysiology Training at MedStar Washington Hospital Center and MedStar Georgetown University Hospital, as part of MedStar Heart & Vascular Institute. He is board certified in cardiac electrophysiology, as well as cardiovascular disease, and is a recipient of the general cardiology faculty teaching award at MedStar Georgetown University Hospital.

Learn more about Manish Shah, MD
Transcription: Melanie Cole (Host): Atrial fibrillation, or AFib, affects nearly three million people in the United States. It's often described as feeling like a fish jumping in your chest, although many people feel no symptoms. For people who have atrial fibrillation, blood clots that can cause strokes are a danger. The Watchman Device may be the answer to issues related to AFIB. My guest today is Dr. Manish Shah. He's an electrophysiologist with MedStar Heart and Vascular Institute at MedStar Washington Hospital Center. Welcome to the show, Dr. Shah. Tell the listeners first: what is atrial fibrillation?

Dr. Manish Shah (Guest): Thank you very much. Atrial fibrillation is an irregular heart rhythm problem, and it typically involves the top chamber of the heart. And as you stated earlier, it can certainly be responsible for patients experiencing palpitations or a flip-flopping sensation in their heart, or in their chest, rather. It can also account for symptoms such as fatigue, or shortness of breath, or feeling like you just don't have the same amount of energy as you normally do when you exercise. Those are all good reasons when we begin to suspect atrial fibrillation in our patients.

Melanie: If somebody has it and it's undiagnosed, are there some risks for untreated atrial fibrillation?

Dr. Shah: Absolutely. In general, the most dreaded complication associated with atrial fibrillation is the occurrence of stroke, and we know that patients who have atrial fibrillation and other risk factors, such as being over the age of 65, for example, or having high blood pressure--those are all risk factors that can increase your risk of stroke. And, specifically, we know that if you, for example, carry two such risk factors, your stroke can be at least 3-4% per year or even higher, putting you at very high risk for having a stroke, long-term.

Melanie: So, then, what do you typically do when someone has atrial fibrillation? What's the first line of defense?

Dr. Shah: In general, when we see somebody who has atrial fibrillation and who we believe is at elevated risk of having a stroke, our first line therapy is really going to deal with protecting them from stroke by administering them a blood thinner. Those are oral medications that they can take either once or twice a day to help reduce their risk of stroke. But, some patients do not qualify for that blood thinner or are not good candidates for being on a blood thinner, essentially because they're at an increased risk of bleeding or have had trouble with bleeding issues in the past.

Melanie: So, if people are not a candidate for those first line treatments, what is the Watchman and who would be a candidate for this?

Dr. Shah: So, the Watchman Device is a new device that has recently entered the United States market. It previously has been in Europe for almost ten years, now and has been part of a large investigational trial in the United States about ten years ago. But, fortunately, it has recently gained FDA approval and is part of our armamentarium to really help those patients who are at risk for stroke and atrial fibrillation. We specifically begin to think about the Watchman Device in patients who are either at a high risk of bleeding, or who have had some bleeding problems while on a blood thinner for their treatment of atrial fibrillation.

Melanie: So, then, does it reduce the risk of stroke, as well as those blood thinners? Tell us a little bit about what it actually does.

Dr. Shah: Yes. So, the Watchman Device has been shown through two large, well-constructed, randomized, controlled trials which are best quality trials, that the Watchman Device is as good as taking the blood thinner Warfarin, or Coumadin. We also know that one of its major benefits is that it reduces, by a large amount, the risk of having a bleeding event inside of the brain, which is called a hemorrhagic stroke and long-term, that is really the major benefit of the Watchman Device, is that it, overall, will protect you as well as being on a blood thinner, and it also will protect you from having a bleeding event inside of your brain, if you were, for example, were taking a blood thinner like Coumadin or Warfarin.

Melanie: Tell us about the Watchman procedure, Dr. Shah.

Dr. Shah: So, the Watchman procedure is a very simple procedure. It involves putting a catheter--a catheter is a plastic tube, pretty small; less than the size of your pencil--and we put it into the blood vessel down in the groin area. That catheter passes up to the heart, and the Watchman Device is essentially a self-expanding structure. So, it emerges from the catheter and is placed into the top chamber of the heart on the left hand side. We have a name for that. We call it the “left atrial appendage”. That's where the device is placed and that's where most blood clots form in patients who have atrial fibrillation. And so, by essentially covering that appendage, that pouch which is coming off the top chamber of the heart, it will prevent blood clots from leaving the heart and going to your brain and thereby preventing you from having a stroke long-term.

Melanie: How long is the Watchman left in?

Dr. Shah: It will stay with you for your entire life. So, this is not a device that has to be exchanged or changed. Once it's implanted, your body actually lays its own tissue over top of it, essentially sealing it off from the rest of the heart and it stays with you for the rest of your life.

Melanie: So, what have you learned from the first 100 cases?

Dr. Shah: So, it's really been an amazing experience here at the hospital center. We're proud to say that we've done our 100th Watchman implant and we've had a remarkable track record with it. I think the greatest thing that we've learned about it is that it's a safe and simple procedure to do. Your overall risks are less than about 1 in 50 that we can cause any type of problem in patients and most patients will leave the following day after the procedure. They don't have any discomfort or any pain whatsoever.

Melanie: And, what do you see that the future holds for stroke reduction in AFib patients?

Dr. Shah: I think that the Watchman Device is going to play a large role in managing some of our most difficult patients who have atrial fibrillation. So, certainly now, we see that the Watchman Device is going to be used for patients who are at high risk of bleeding, or those patients who have had some type of bleeding issue when on a blood thinner, but in the future, I anticipate we'll be using it on patients who are at lower risk of bleeding because I think the data behind the Watchman Device is likely to be favorable as we begin to treat patients who have atrial fibrillation earlier in their disease, of course, as opposed to later on. So, you know, if you ask me what's going to happen five to ten years from now, it's possible that when a patient presents to us with atrial fibrillation, they are likely going to have the procedure to treat them for atrial fibrillation, called an “ablation” and, at the same time, we may be thinking about putting in a Watchman Device for those patients. Now, obviously, we need some trials to really demonstrate benefits, but I anticipate that being the future of the device.

Melanie: So, Dr. Shah, in just the last few minutes, give us your best advice for patients who suffer from atrial fibrillation and what you really want them to know.

Dr. Shah: I think that the first thing that they should know is that atrial fibrillation is a disease that can carry symptoms and those symptoms can be debilitating in some patients and require treatment and that treatment is catheter ablation for atrial fibrillation. For those patients who do not have symptoms with their atrial fibrillation and are at a high risk of bleeding, or have had bleeding problems on a blood thinner, those are patients who we should think very strongly about the Watchman Device. I think it's a safe, effective technology for them and one that will likely provide them with lifelong benefits in terms of protection from stroke without taking or carrying the risks of bleeding that occur when you're taking a blood thinner.

Melanie: Thank you so much, Dr. Shah, for being with us today. You're listening to Medical Intel with MedStar Washington Hospital Center and for more information, you can go to www.medstarheartinstitute.org. That's www.medstarheartinstitute.org. This is Melanie Cole. Thanks so much for listening.

Internal Notes: Null
Hosts: Melanie Cole, MS

When Should You Start Considering Surgery To Treat Bunions?

David Cole — Tue, 18 Oct 2016 23:06:20 +0000
Bunions can range from mildly unattractive to a major source of pain. When you notice that bump in the area around the base of your big toe, questions start to pile up.

What caused this? Which shoes best minimize the pain? At what point should I consider surgery?

Katherine Raspovic, DPM, a podiatric surgeon at MedStar Washington Hospital Center, tackles these questions and more.
Additional Info
Segment Number: 2
Audio File: medstar_washington/1642mwc3b.mp3
Doctors: Raspovic, Katherine
Featured Speaker: Katherine Raspovic, DPM
Specialty: Null
Guest Bio: Katherine Raspovic, DPM, is a board-qualified podiatric surgeon at MedStar Washington Hospital Center and MedStar Georgetown University Hospital. She is an assistant professor in the Department of Plastic Surgery at Georgetown University School of Medicine.

Learn more about Katherine Raspovic, DPM
Transcription: Melanie Cole (Host): Whether it’s sandal season or boots season, you may be thinking it’s time to do something about that large bump that juts of the base of your big toe. It can also be quite painful when exercising or wearing certain shoes. My guest today is Dr. Catherine Raspovic. She’s a podiatric surgeon with MedStar Washington Hospital Center. Welcome to the show, Dr. Raspovic. So, what is a bunion?

Dr. Catherine Raspovic (Guest): Sure. So, a bunion is a large prominent area on the forefoot area at the first metatarsophalangeal joint region and, basically, some patients are born with them; some people develop it over time, and it’s a little bit different for everyone. Some people say they have no pain at all, and others complain of a great deal of pain with their bunions. So, it’s something that’s very different when it comes to size and also symptoms for each patient.

Melanie: Is there a genetic component to bunions?

Dr. Raspovic: We do think that there is a genetic component. So, oftentimes, a lot of my patients say, “Yes, my mom or dad has bunions,” grandparents, so a lot of it does depend on the foot structure that you inherited. So, yes, there definitely is the genetic component to developing these.

Melanie: And is it something you’d start to see in your children? Will you start to notice if they’re developing a bunion, and if we notice that, is there anything we can do to stop it from continuing?

Dr. Raspovic: Absolutely. So, there are some cases where children do develop bunions early and in situations like that, I always recommend to children go get evaluated by a foot specialist for advice in terms of treatment and what to look for but, most often, we see these present in older patients. There are patients even in their 20s, 30s, 40s, or even older. And, if anyone has pain or just notices the development of a bunion, I always recommend to go see a foot specialist like a podiatric surgeon who can give you education about what is happening, why it’s happening and what treatment options that there are.

Melanie: Let’s bust up a myth. Do high heels cause bunions?

Dr. Raspovic: That is a myth that is very common. We can't say for sure that they do, but they likely contribute to the development. However, I do have patients who say they wear heels all the time and don’t have bunions, but I would have to say they more than likely do contribute to the development of bunions.

Melanie: So, if someone comes to you, what’s the first line of defense? Do we look at the shoes that they’re wearing? Do orthotics help to lift the weight off that base of the big toe? What do you tell people about the shoes and possible orthotics in first line of defense?

Dr. Raspovic: Absolutely. So, first line of defense, when a patient comes into the office for the first time for their first evaluation for a bunion, I always ask them what they have done already and then give them treatment options based on what they have and haven’t done. So, on the initial visit, we look at the patient shoes. I always advise patients to wear shoes that aren’t causing a lot of pressure over the area. Sometimes an arch support will help, sometimes it won't. So, orthotics may be an option to help patients feel better in the early stages. Sometimes we recommend patients to modify their activities if a certain sport or activity causes pain, we’ll ask them to take a break from it for a period of time. Anti-inflammatories can also be indicated. Some patients rely on these every now and then if they have discomfort and they need just something a little extra to help. But, I think the most helpful thing for a patient is picking out a good shoe that doesn’t put pressure over the area and some people do benefit from an orthotic to take pressure off the area as well.

Melanie: You mentioned good shoe and, as somebody who likes to walk a lot, I’m lucky I get to wear running shoes. They really help my bunions a lot. Now, do you tell people about certain shoes that are better than others?

Dr. Raspovic: I do. So, if patients are active, like to run, in a lot of sporting activity, and I don’t know if I can talk about brand names, but I always point them towards a shoe like the ASICS or New Balance. I’m a fan of ASICS just because of the wide variety that they have that accommodate both wide and narrow foot types. I always advise people to go to a good running store or athletic type store where the people who work there can accurately measure the foot and fit them in the properly sized fitting shoe because, I think, a lot of people have difficulty with the bunion and a shoe fit because oftentimes, the front of the foot can be little bit wider than the middle of the foot or the back. So, going to somebody who can really help pick the proper size with a running shoe is definitely helpful.

Melanie: So, then, if it gets really bad and it becomes so painful that they just really can't stand it and the shoes don’t seem to be helping, anti-inflammatories aren’t helping, what kind of procedures can take care of bunions?

Dr. Raspovic: Yes, so, I only recommend surgery to patients when they start to have pain with their bunion that’s impacting their daily life and their quality of life. If a patient comes to me and says, “I have this bunion but I don’t like how it looks and it doesn’t hurt me,” then I don’t advise surgery. I think, surgery is definitely the most beneficial when you’re in a situation where you are having pain. Now, in terms of surgical intervention, there are different options, and those options depend on how severe or how advanced the bunion is. So, what we typically do in the office if we’re discussing surgery with a patient, is we’ll thoroughly evaluate the foot, the bunion itself, and then, we take full weight-bearing x-rays, and we measure different angles on the x-ray to determine what exact procedure needs to be done to give the patient the best bunion correction possible.

Melanie: And, then, what are the procedures like for the patient? Are you off your feet for a while? Is there a boot? Tell us about the procedure.

Dr. Raspovic: Absolutely. So, in general, we have to keep in mind, when we do these bunion procedures we’re almost always cutting bone, and/or fusing bone, we’re doing some sort of work on the bone and the tissue as well. The bone, in general, takes about six to eight weeks to get nice and strong again after we operate on it. So, in general, usually when we do a type of bunion procedure, we’ll keep patients off of their foot for about six weeks, depending on what was done, and then, we transition them, typically, to walking in a walking type boot. So, for a more aggressive type bunion procedure, the reality is that sometimes it could take up to 10 to 12 weeks for patients to get back into a comfortable shoe and that, a lot of times, is dependent on the swelling that they have afterwards. For something less aggressive, it can be a little shorter than that. But the biggest challenge, I think, in foot and ankle surgery in general, is the swelling after surgery. Some people’s swelling goes down very quickly; for others, it can even take a few months or longer. So that, oftentimes, can be the limiting factor with getting back into a shoe.

Melanie: So, then, what about after the fact? What’s the recovery after that? Can they grow back or is this something that it’s just once it’s done, it’s done, and will they have any limit in their range of motion?

Dr. Raspovic: Now, that’s a great question. So, there certainly is always a chance that we do a bunion type surgery--a bunion reconstruction--that they could grow back, but what we always do is we pick the best procedure based on the patient, the x-ray, the clinical findings, and the patient age and activity level, so that we are minimizing any chance of the bunion returning. So, anytime we operate, there’s always a small chance, but the vast majority, people do very well. The one thing that could happen is definitely some stiffness of the joint after surgery and what I encourage my patients to do once the incision and bone is healed, I oftentimes get patients into physical therapy or show them how to do range of motion type exercises at home because, not only will the big toe joint become stiff after bunion surgery, but if we have the patient immobilized for a while, the ankle joint can also become stiff if it’s not bending. So, definitely, I’m a big fan of physical therapy because I think that is really the key to getting patients back to where they want to be faster.

Melanie: So, give your best advice and wrap it up for us for people that are starting to see that bump, that bunion, and what you tell them every single day about it.

Dr. Raspovic: Yes, so, if you’re starting to see that bump, it never hurts to go be evaluated by a foot doctor like a podiatric surgeon or specialist, just to become educated and discuss all your treatment options. If you’re not having pain and you can wear comfortable shoes and you can be active and participate in whatever sports or activities that you’re currently doing, chances are you do not need surgery, and you’re going to be just fine, but I only recommend surgical intervention if it gets to the point where the pain from the bunion is starting to impact your daily lifestyle.

Melanie: Thank you so much for being with us today. It’s really important information. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to www.medstarwashington.org. That’s www.medstarwashington.org. This is Melanie Cole. Thanks so much for listening.

Internal Notes: Null
Hosts: Melanie Cole, MS

Transradial Cardiac Catheterization: When, Why and for Whom is it an Option?

David Cole — Sun, 16 Oct 2016 23:49:18 +0000
Most young cardiologists are now being trained to perform cardiac catheterizations transradially– or through the wrist. Traditionally, this procedure, which is used to diagnose or treat arterial disease, involved inserting a catheter in the groin.

The transradial approach provides a much more comfortable recovery for the patient and lowers the risk of bleeding, which can significantly impact outcomes, even reducing mortality in certain patients.

Listen in as Robert Lager, MD, explains how this procedure has evolved and the benefits for patients, today.
Additional Info
Segment Number: 1
Audio File: medstar_washington/1642mwc3a.mp3
Doctors: Lager, Robert A.
Featured Speaker: Robert A. Lager, MD
Specialty: Null
Guest Bio: Robert A. Lager, MD specialty is Interventional Cardiology at MedStar Heart & Vascular Institute.

Learn more about Robert A. Lager, MD
Transcription: Melanie (Host): Since the first cardiac catheterization in 1929, the procedure has continually evolved with advances in understanding, capabilities, and ease of operation. My guest today is Dr. Robert Lager. He's an interventional cardiologist with MedStar Heart and Vascular Institute. Welcome to the show, Dr. Lager. Why don't we start by having you give us a little physiology lesson about the heart and how it works?

Dr. Robert Lager (Guest): Thank you for having me today. The heart is, obviously, an important organ within the chest and the heart has several functions but the most important function for the heart is as a pumping organ. The heart has several chambers: two on the left side of the heart, two on the right side of the heart. These chambers are muscular chambers, made of muscle, and they basically propel blood through the chambers either to the lungs themselves to gather oxygen or, once that's been gathered, back to the left side of the heart and over to all the organs: the brain, kidneys and abdominal organs etc. The heart actually has several systems built into it including an electrical system which controls the rhythm of the heart and a plumbing system which basically carries blood to the heart muscle itself via the coronary arteries which run along the surface of the heart muscle and then dive in deeper as it supplies blood flow and oxygen to the heart muscle itself.

Melanie: It's a fascinating organ. How do you doctors get a good look at the heart to tell us what's going on?

Dr. Lager: It really depends how or rather what we'd like to see. There are many different ways to image hearts, many different ways to evaluate heart. Some are electrically using EKGs, and some are imaging techniques such as CAT scans or MRIs to look and characterize the muscle of the heart. Then, some are to look directly at the heart arteries and we use catheters to do that. We usually use thin catheter tube to inject x-ray dye into the heart arteries which allows us to look at the arteries themselves and decide whether any problems such as narrowing or blockages in the heart.

Melanie: If this gives you a good robust picture of the inner workings of the heart and how it's working, who would be a candidate for this? Who would you decide needs this type of catheterization?

Dr. Lager: Catheterizations themselves, cardiac catheterization are done specifically to look at patients who we suspect may have heart artery narrowing or blockages. Those patients often present with either classic symptoms such as chest pain with exertion, shortness of breath, or related symptoms such as shoulder, jaw, or back discomfort. The patients who have symptoms which occur with exertion and a more stable pattern, we often will evaluate with things like stress tests first to see whether there is actually a suspicion of a blockage or narrowing in a heart artery. There are also groups of patients who come in with these types of symptoms suddenly, unexpectedly, at rest, which are more heart attack like symptoms and those patients are most frequently brought to cardiac catheterization immediately without any delay, if possible.

Melanie: Dr. Lager, what is cardiac catheterization?

Dr. Lager: In a catheterization procedure, we bring a hollow tube catheter through an artery either from the groin or the wrist up to the heart. We position the catheter opening right at the opening of the main arteries of the heart which start just above the heart and then run along the surface of the heart. Then, we inject x-ray dye contrast into the heart arteries while we're taking x-ray pictures, fluoroscopy, from outside the chest. Therefore, we see as the x-ray dye courses through the heart arteries, we can see whether or not there are any narrowing or blockages in the arteries themselves. So, the first key to doing this procedure as you alluded to is selecting the right patients, patients who really should be having these procedures. Then, once we've decided that a procedure like this needs to be done, then we decide how to do it. Historically, actually, I think you mentioned that this procedure was first done in 1929. This was actually done by a physician in Germany who actually accessed his artery in his arm, right at the level of the elbow, and brought a catheter up and took measurements with that catheter on himself when he walked from his office to the radiology department to measure the blood pressures in his heart and lungs. So, subsequently, and all through the late 70's and early 80's we started to do these procedures more typically through the groin, and that was because we needed to use larger catheters and as we started to actually develop procedures to fix heart arteries, that is to say angioplasty, we first started with balloons to do that in the ‘80s, and we use fairly large tubes to do that, too big for anything that would accommodate through the arm themselves or at least through the smaller arteries at the wrist. So, we would either do what was called a “cut down” which meant exposing the arm artery right around the level of the elbow or, as we moved to the groin, it was actually easier for us to do it through the groin, and that was called the “transfemoral approach”. So, from the 1980's onward, at least in the United States, well into the 1990's and even in to the 2000’s, the vast majority of procedures we did were from the groin, the transfemoral approach.

Melanie: What is trans-radial catheterization?

Dr. Lager: Many doctors, especially in Europe and in Asia, began to realize that we could start to do these catheters from the wrist. And, this really took off in places outside of the US much earlier. So, that many European hospitals and physicians, and many hospitals in Japan and other Asian countries were doing procedures from the trans-radial approach, that is from the wrist, long before we talked about doing it here in the US. The reason why that was started to consider is, one, the catheters got smaller. So, we didn't need to use such big catheters to get in the arteries. Two, the wrist itself is a very easy place to access the arteries, and that's because it is immediately against the bone so we can see the artery, and can control any problems of bleeding very easily whereas, in the groin, the arteries are very large and it's very deep, and we often can't see exactly what's happening at the artery level either when we're working or after we're working and take the tube out. So, there became a lot of excitement about this procedure because it was clearly safer in relation to bleeding at the access site, whether that was the growing or the wrist. As we gathered more information about trans-radial procedures, we started to learn that it might have benefits in specific groups of patients who are at highest risk for bleeding. Not to mention that from a patient comfort perspective, the trans-radial approach is exceedingly more comfortable for the patient. Whenever we've done studies to look at a patient, when a patient has had a procedure both from the groin and later from the wrist, if you were to ask them, “How would you like the procedure done if you had to do it again?” Ninety percent of them said they'd rather do it trans-radially, through the wrist. It became a growing momentum about reasons to use the wrist, and those include safety reasons and comfort reason. We've seen in the United States, finally, a major push to start using the trans-radial approach over the last five years. Although it is still not the majority procedures done in this country, most young cardiologists are being trained to do the trans-radial approach as their default approach.

Melanie: Dr. Lager, are there some patients for whom this is not an option, maybe the elderly whose skin might be extra thin at that point, sometimes hard to find an artery in their wrist area? Are there some people that are that just can't get this procedure?

Dr. Lager: There are. One of the interesting paradoxes of this area is that the patients sometimes who are the most difficult to do trans-radially are actually the patients who benefit the most. Your example is a great one, let's say a very elderly patient who's very frail and small and thin with low body weight often has much more fragile blood vessels, small wrists, small arteries. They are actually the same patients who have the highest bleeding risks when you go from the groin. They also, as you get older, can develop a lot of twists and turns in the arteries, we call that “tortuosity”” and that can be a very important problem from us as we come from the wrist. It's quite a ways to go up, down, all the way up to the shoulder and then back out of the heart. As we get older, those arteries can develop lots of loops and bend, and sometimes it's just not even technically possible to get a catheter to track around all those loops and bends. So, elderly patients are one group that truly benefit very much from the trans-radial approach but also maybe one of the more difficult groups to perform it in. When you look at big studies to show what are the primary failure rates for trans-radial, probably I'd say the most typical one would be patients who had bypass surgery before, coronary artery bypass surgery, open heart surgery, where the surgeon will sew bypass grafts into the aorta and then bring those down to the native heart arteries. Sometimes it can be difficult to take pictures of those bypass grafts from either the groin or the arm. We often come into more technical issues trying to do that from the arm than we would from the groin. That being said, I still personally do the vast majority of my procedures from the wrist for patients who had bypass surgery, and the vast majority of them are successful. There are groups of patients who may have had the artery actually harvested for bypass surgery. For that, they use the radial artery for a bypass, and, therefore, obviously we can't use the wrist for that procedure. There are patients who are on dialysis and have arteriovenous fistulas--these are manmade connections between the vein and artery in the wrists or arm that are used for dialysis—and, therefore, we really stay away from those because they can be very fragile and we don't want to do anything to jeopardize that longstanding fistula which is used for dialysis. Other than that, occasionally we'll see a patient, where we do check to see if there's good blood flow to the hand from more than one artery in the wrist, although that's somewhat controversial. In other places in the world, that's not even checked anymore, but in the US we tend to check on that. Sometimes if we see that the other artery in the wrist that we're not using, if that's very small, or doesn't really supply much of blood, then we may avoid going in through the wrist altogether. So, we do still check that routinely in the United States. Outside of the US, most people think that's probably unnecessary. Those really are the typical stories of patients who, for whatever reason can't undergo trans-radial. It's a very small percentage of patients who cannot be counted for trans-radial approach.

Melanie: Dr. Lager, in the last few minutes, give your best advice as if I was a patient sitting across from you in your office asking you questions about catheterization in general, why I might need it. Tell them what you tell them every single day about the ease of this procedure and the better outcomes?

Dr. Lager: We know that for many patients once we've made a decision and that's a key part of this, as I mentioned, is the decision to perform a cardiac catheterization. Once you've made that decision and it's clear for clinical reasons that a catheterization is appropriate, our next decision is how to do it. We always have the two options of the artery in the groin, the femoral, or the artery in the wrist, trans-radial. For those of us who do these routinely now, the default position, the routine approach, should be the wrist. The reasons I mentioned were for patient comfort which is clear and incontrovertible, and not only the bleeding risks which seem to be lower at the access site for the wrist but, more recently, in certain groups of patients we've seen, for instance, those patients who come in with heart attacks where we have to give lots of blood thinner, their risk of bleeding is very high and those patients have actually shown a mortality benefit for trans-radial approach versus the femoral approach. Why is that? It’s because bleeding is such a major player in bad outcomes for patients with these procedures. We worry a lot about blood clotting, things that cause heart attacks or catheters causing clots, but, in truth, the bigger risk is bleeding. So, any approach that can lower the risk of bleeding can significantly affect the entire outcome of a patient who might otherwise have had a terrific result from the procedure but if they have a bleeding complication it could be disastrous. When I talk to patients in the office who are more elective, who are not in the throes of a heart attack, we talk a lot about the risks and the benefits of the procedure and clearly one of the major risks of the procedure is bleeding. We give blood thinners during procedures routinely and so using any technique that we can use to lower the risk of bleeding is one we should strongly consider as our default position. Secondly, as I mentioned from the comfort standpoint, there are so many of us that have bad backs, and the notion of having to lie flat after procedure for sometimes between four and eight hours after procedure is pretty daunting. Even when the procedure went great, you end up incredibly uncomfortable. In fact, every now and then, I talk to patients and say, "How was your experience the last time you had this procedure?" They say, "The actual procedure was fine but I was miserable for six hours lying flat after the procedure." Well, in this procedure, the trans-radial procedure, you can literally walk off the table if you wanted to. We tend to keep people at some bed rest for about an hour or two just to watch them after sedation is given but you can sit right up, you can eat right afterwards. You can be in total comfort instead of flat on your back, and that is something I don't think we emphasize enough when we talk about the trans-radial procedure is that comfort element, which can be the number one problem for most patients when they come through this procedure it's so much less of an issue.

Melanie: Thank you so much, Dr. Lager. That's really great information for listeners. You're listening to Medical Intel with MedStar Washington Hospital Center. For more information you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks so much for listening.
Internal Notes: Null
Hosts: Melanie Cole, MS

Myths of Joint Replacement Surgery

David Cole — Thu, 13 Oct 2016 14:41:43 +0000
Joint pain and disability lead to almost one million total joint replacements in the United States each year. However, there are countless people who avoid surgery due to certain myths about the procedure, resulting in unnecessary, chronic suffering.

Listen in as Savyasachi Thakkar, MD, breaks down the myths and truths about joint replacement surgery, and offers answers for those considering the option.
Additional Info
Segment Number: 3
Audio File: medstar_washington/1636mwc4c.mp3
Doctors: Thakkar, Savyasachi C.
Featured Speaker: Savyasachi C. Thakkar, MD
Specialty: Null
Guest Bio: Savyasachi Thakkar, MD, is a board-eligible orthopaedic surgeon at MedStar Orthopaedic Institute. He is a member of the Maryland Orthopaedic Association, the American Academy of Orthopaedic Surgeons, the International Congress for Joint Reconstruction, the AO Foundation, and the American Association of Hip & Knee Surgeons.

Learn more about Savyasachi Thakkar, MD
Transcription: Melanie Cole (Host): If your knees or hips are causing you constant pain, you may have thought about undergoing surgery to have them replaced but are myths about joint replacement holding you back? My guest today is Dr. Salvia Thakkar. He's an orthopedic surgeon and a member of MedStar Orthopedic Institute. Welcome to the show, Dr. Thakkar. Let's debunk some of these myths for the listeners starting with age. Some people think if they're in pain and they've been told they should consider a replacement, that they're too young for that and that that's only for people who are elderly.

Dr. Salvia Thakkar (Guest): Thank you, Melanie. Thanks for having me on the show. So, yes, that's a very frequent myth and frequently patients tell me that "Well, you know, Grandma got this surgery when she was 80 years old and why should I have it done when I'm 60 years old?" Well, we have new literature which shows us that even patients under the age of 55, let's say they undergo a total knee arthroplasty, which is a total knee replacement surgery, 30 years down the line, 60-70% of these patients are still going to have their implants in good shape. Now, I always tell the patients that if they get to be 85, that I will go ahead and do a revision surgery for them and if they get to be 115, then one of my partners will go ahead and revise this for them. So, the procedure can last for a good 25-30 years in most patients with the current activity levels and I think that to improve their quality of life, why wait until that late?

Melanie: So, then if people are waiting, another myth that I've heard quite often, is that you have to be in excruciating pain and you can no longer walk or function before you even consider replacement surgery. Do you agree with that?

Dr. Thakkar: I don't agree with that at all. So, pain is definitely one of the indicators to say that you want to have surgery but how does that pain impact your quality of life? Which matters more? So, let's take an instance. Let's take someone who's in excruciating pain, they haven't been walking around, they're bedridden. What happens to that person? That person becomes overweight, their muscles are not as strong because of disuse and their recovery is just even harder after surgery. What if we have someone who's an avid athlete, who's a golfer, who likes to bike and they're so having some pain and they have terrible arthritis? Well, for that patient, if they're not in excruciating pain, they've been using their joints a little bit, they've been using their muscles, they're stronger, and they can recover faster. So, I think that pain is one of the markers but it's not the end-all, be-all for these procedures.

Melanie: And, what about people who think that they will be bedridden afterward and that the recovery process is so long and severe that it will just take too much out of their quality of life?

Dr. Thakkar: Oh, that's, again, another myth. So, you know, my patients, I try to do the surgeries as early as possible in the morning, so let's say we do it at 7: 30 in the morning, most surgeries last about two hours, so by 9: 30 they're out of surgery. I have a deal with our physical therapists that they are up and walking by noon. So, patients are up out of bed the same day. They may be get to a chair and then the next day after surgery, they're walking in the wards, they're walking up and down steps, and most of the patients who have a hip replacement surgery go home the next day after surgery and most of the knee patients are in the hospital for two days and then go home thereafter. So, that's a total myth. The goal of this procedure is to get them up and walking and not to keep them in bed.

Melanie: People also feel that sometimes they'll have so much restriction after a joint replacement that they won't be able to move as well and they'll lack range of motion and hips especially scare them because we use do much with our hips. So, speak about that and permanent restrictions of range of motion after surgery.

Dr. Thakkar: Absolutely. So, any period immediately after surgery is sensitive in terms of recovery. So, we try to protect the muscles. We're trying to protect the soft tissues that we've used to approach the joint for surgery. Now, let's take the example of hips. There are several ways to approach a hip replacement. You can go in from the front in an anterior approach, or you can go in from the back, a posterior approach. These are the main approaches that we use today. Each of these approaches dissects through specific muscle planes and these muscles are designed to protect the hip against dislocating or popping out. Now, what we want to try and do is that the first six to eight weeks after any hip surgery, we want to try and give patients certain restrictions. So, if I go through the front, I want to make sure that they do not hyperextend their hip and they're careful about rotating their foot externally. If I go through the back, I'm careful about telling them that they should not flex at the waist beyond 90 degrees and they should not be tying their own shoes. Someone should be helping them do that. These are restrictions only for the immediate post-operative period. That's about six to eight weeks. After that, patients can get back to doing whatever they like doing. They can get back to any activity they like doing without any significant restrictions. So, I think that we've come a long way in making sure that they have a balanced, pain-free, and functional joint and I don't restrict them tremendously.

Melanie: And, what about if somebody is alone and they feel that they're going to be going through this alone? What do you tell patients about joint replacement and support needed?

Dr. Thakkar: Right. So, that has been the Holy Grail of joint replacement surgeries--how to find help for these patients, how to make sure that they get to us safely, we treat them safely, and then they go back home. So, for that, we have this unique program at the Washington Hospital Center and also at Georgetown--both MedStar hospitals. These are Patient Acute Care Coordinators, or PAC Coordinators. We have three of these individuals who are specially trained social workers who coordinate everything for the patient from the day they agree to have surgery, on the day of surgery, and then during the rehabilitation process thereafter. So, you have a point person to go to who makes sure that you'll have your doctor's visits, you'll have your surgeon who'll evaluate and treat you during your hospitalization, and who'll also make sure that your physical therapy and nursing needs are taken care of after surgery. So, you don't have to be afraid at all. We have people to take care of you.

Melanie: And Dr. Thakkar, the implant itself, people hear about the different types and whether they're going to set off the alarms at the airport. Speak about what's going on and the latest advances in the implants for replacement surgery.

Dr. Thakkar: Yes, absolutely. So, this is the part that excites me the most, is what bearing surfaces we're using in lieu of the natural cartilage that we have in our joints. So, traditionally, we used a lot of different types of metals, largely either titanium or cobalt-chromium metals. Some patients can be allergic to one metal and we make sure that these are patients are selected pretty carefully, and we don't use that metallic implant in those patients. In such patients, we use ceramic implants, we use polyethylene bearing surfaces, which kind of help reduce that load transfer, help make the motion more smooth, and these patients don't have reactions. I like to try and use implants that have been in the industry for at least 10-15 years. I like to see the outcomes. I don't want to be a trailblazer in putting something very new in a patient that we don't have outcomes associated with. In addition to the implants, what we also use is that we have robotic assistance and computer-guided assistance to make sure that we place these implants in a very narrow range of allowable tolerances because we want to make sure that they last for 20-30 years. The current implants that we use definitely assure that for the patients.

Melanie: So, wrap it up. It's such great information. You've really cleared up so many of the myths that would keep someone from considering replacement surgery for joints. Wrap it up for us. Give your best advice for what you say to patients every single day, Dr. Thakkar, about when they need to consider a replacement.

Dr. Thakkar: Absolutely. So, I tell patients that the minute their joint pain has started affecting their quality of life, which means that they cannot work, they cannot enjoy their life, they cannot live independently, that's the best time to come in. We'll start talking. We'll explore all the options that we have. We have a therapeutic ladder that we climb with the patients from non-operative management all the way to surgery, and then even the recovery process, and we make sure that we care for the patients from day one and we try and make them their best. We try and give them a pain-free, stable, and functional joint.

Melanie: Thank you so much, Dr. Thakkar, for being with us today. You're listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole, thanks so much for listening.
Internal Notes: Null
Hosts: Melanie Cole, MS

Weight-Loss Surgery: Your Questions Answered

David Cole — Tue, 11 Oct 2016 19:22:31 +0000
Considering weight-loss surgery inevitably results in a long list of questions and concerns.

Elizabeth Alexandra Zubowicz, MD, a bariatric surgeon at MedStar Washington Hospital Center, walks us through the patient journey, from initial consultation to recovery, and offers explanations for some critical questions along the way.
Additional Info
Segment Number: 4
Audio File: medstar_washington/1636mwc4d.mp3
Doctors: Zubowicz, Elizabeth A.
Featured Speaker: Elizabeth Alexandra Zubowicz, MD
Specialty: Null
Guest Bio: Elizabeth Alexandra Zubowicz, MD, is a board-certified minimally invasive, general and bariatric surgeon at MedStar Washington Hospital Center. She is a member of the American College of Surgeons, the Society of Laparoendoscopic Surgeons and the American Society for Metabolic and Bariatric Surgery.

Learn more about Elizabeth Alexandra Zubowicz, MD
Transcription: Melanie: (Host): Thinking about weight loss surgery? At the top of your "to do” list is choosing the very best hospital and an experienced medical team. My guest today is Dr. Elizabeth Zubowicz. She's a bariatric surgeon with Med Star Washington Hospital Center. Welcome to the show, Dr. Zubowicz. Who should consider bariatric surgery?

Dr. Elizabeth Zubowicz (Guest): I recommend anyone who's been trying their whole lives to lose weight and have been struggling and failed other attempts at weight loss to consider weight loss surgery. In terms of the specific, insurance requirement require in order to be covered require a BMI of 35 or more with medical problem, or simply a BMI of 40 or greater to be covered for the bariatric procedure.

Melanie: What kind of medical problems are considered?

Dr. Zubowicz: The medical problems include diabetes, high blood pressure, high cholesterol, sleep apnea, osteoarthritis and even if you may not necessarily be diagnosed with those, a lot of time people may have things like latent arthritis or sleep apnea and not even know it. I still recommend people to come in if they're in that 35-40 range. We usually do assess for all of those beforehand to see if they would be approved for surgery.

Melanie: Is there a psychological counseling involved in these parameters?

Dr. Zubowicz: There is a psychological counseling and it's actually something that is required by insurance companies and required by our program as well as any other program that you would attend. It requires at least one visit with the psychologist or psychiatrist. If the patient already has one that they see routinely, we could give them the guidelines that need to be addressed. As far as our Hospital Center goes, we have our own dedicated psychologist that the patients can go and see.

Melanie: What would you like them to do in advance before considering surgery? Should they still be trying to diet? This is a tool for them, yes? So, what do you like them to do in advance?

Dr. Zubowicz: There's a pretty rigorous pre-operative program that patients undergo in advance and the things you really recommend are learning healthy eating habits, learning portion control, making sure that they're medically optimized and safe to undergo surgery, and get them, at least in the beginning, in an exercise program. We actually, at the Hospital Center, have a program at the gym that's nearby to the hospital where they go do an exercise evaluation. There are no strict requirements in terms of whether or not they need to lose a certain about of weight but mostly, we want to see that they are actively trying to make those lifestyle changes because bariatric surgery can be very successful but it's only successful if you do it in conjunction with healthy lifestyle changes.

Melanie: Tell us about the types of bariatric surgery available?

Dr. Zubowicz: There are three primary types of bariatric surgery that is most commonly performed. We use the gastric band, the sleeve gastrectomy, and the gastric bypass. The majority of the time it can be performed laparoscopically which means you make 4-5 small 3mm to 5 mm incisions and that helps decrease hospital stay, recovery time and pain.
Melanie: Are any of these reversible?

Dr. Zubowicz: None of them are truly reversible. The first one, the lap band, this involves placing a band around the stomach as a way to cause restriction and decrease the amount of food you can eat. There is no actual change to the patient's anatomy. So, theoretically that's reversible but I do warn people that it does require another major surgery in order to take the band out and oftentimes the reversal surgery isn't covered by insurance unless there are actually complications from the band. So, even though the anatomy is not being altered you can, in theory, take out the band making it reversible, I caution people not to make that their number one reason why they would choose the band.

Melanie: Tell us about gastric bypass surgery, what's involved in that?

Dr. Zubowicz: The gastric bypass surgery has been performed the longest amount of time for weight loss and so that is the most data regarding effectiveness and complications, etc., are out there for the gastric bypass. The bypass involves both the restriction where we make the stomach smaller as well as bypassing a significant amount of small intestine. So, even what does goes down is not absorbed in the same way that it would in a normal person. It's very effective for weight loss and the weight loss tends to be the fastest with the bypass. It's also probably the best for resolution of diabetes. I will say the third surgery is the sleeve gastrectomy and that is also very effective for weight loss as well as resolution of medical problems like diabetes, high blood pressure, high cholesterol. The sleeve involve actually stapling up the side of the stomach and we take out about 70% of the stomach. It's called a purely restrictive procedure, slightly less involved than the bypass, with a slightly lower complication rate, but the weight loss is just as good as and as well as the resolution of the medical problems.

Melanie: What can the patient expect after these surgeries? Can they still go out and eat at restaurants? What do you tell them about eating in that first couple of weeks?

Dr. Zubowicz: So, obviously, there are going to be huge changes in eating after getting a bariatric procedure. For the first couple days, patients should expect to be nauseous, expect to have some abdominal pain. That's normal. The important thing is making sure you're keeping up liquids to stay hydrated. For the first two to three days, patients should remain on clear liquids, then we transition them to full liquids like yogurt and thicker soup and things like that. Around the two week point is when we transition them to actual solid food. In terms of going out to eat, we actually have cards that we give to patients so when they do go out to eat, they can order from the children's menu just because there's no point in, obviously, getting large portions when you can't eat them all. But, again, it's also important to remember that usually when people go out to eat, you're not able to track just how many calories, how much fat is in what you're eating. It's still important to pick the healthier option.

Melanie: Are there certain foods that they should now stay away from or try to avoid?

Dr. Zubowicz: Nothing specifically. People tend to have a harder time with certain foods like thicker tougher meat and things like that but, over time, people usually end up being able to tolerate pretty much anything. I do hear that a lot of times peoples’ taste buds significantly change, so something they may have really liked beforehand they no longer like after or vice versa, something they didn't like before the surgery and now they do. It's more kind of a trial and error. At the beginning, you'll have to see what your body can tolerate and what your body doesn't.

Melanie: We said near the beginning, Dr. Zubowicz, that this is a tool to help them lose weight. What do you tell them about what they need to change after the surgery in lifestyle modifications that are so important?

Dr. Zubowicz: Just like pre-operatively where we recommend the healthy eating habits, the portion control and the exercises, obviously, need to be continued after the surgery. The surgery itself helps with the initial weight loss and can help magnify the effects of healthy eating and exercise but to consistently keep that weight off for the long term, you've got to keep those healthy eating habits. I recommend, in general, at least three to four times a week of cardio, thirty minutes per session; to try to add in strength training; in addition to always be mindful of portion control and eating three to four small meals as opposed to snacking throughout the day. If people use all these tools together, they could be extremely successful with their weight loss.

Melanie: If they follow all of these guidelines after surgery, how much weight can they expect to lose?

Dr. Zubowicz: On an average, people that receive the lap band lose about 50% of their excess weight, and people who undergo the sleeve gasectromy of the gastric bypass lose about 60-70% of their excess weight which means that, let's say that they're 100 pounds overweight, with the band, they lose about 50 pounds and with the bypass or the sleeve, they lose about 60-70 pounds.

Melanie: In the last few minutes, Dr. Zubowicz, please give us your best advice for people considering bariatric surgery, and what you really want them to know?

Dr. Zubowicz: People considering bariatric surgery, obviously, being able to make your lifestyle changes to lose the weight is the best in being able to avoid a surgery but by the time someone that is considering bariatric surgery, I'm sure they've already tried the dieting, tried the exercise, and it's just not working. It's because, I think, a series of genetic changes and basic changes to your metabolism that really makes it extremely difficult to, even by doing the right things, lose that weight. That's where the bariatric surgery can be extremely successful. It helps fundamentally change the body's metabolism and make the lifestyle changes like exercising and eating healthy more effective.

Melanie: Thank you so much for being with us today. You're listening to Medical Intel with Med Star Washington Hospital Center. For more information you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie, Thanks so much for listening.
Internal Notes: Null
Hosts: Melanie Cole, MS

Thyroid Cancer Surgery: Less Invasive, Less Scarring

David Cole — Wed, 05 Oct 2016 22:35:29 +0000
Approximately 12 million Americans are affected by thyroid disease and some of those cases may be cancerous. When a thyroid nodule is discovered, imaging, biopsies and possibly surgery may be recommended.

Jennifer Rosen, MD, Chief of Endocrine Surgery and Vice Chair of Research at MedStar Washington Hospital Center, provides the full picture of what to expect during the process.
Additional Info
Segment Number: 2
Audio File: medstar_washington/1636mwc4b.mp3
Doctors: Rosen, Jennifer
Featured Speaker: Jennifer Rosen, MD
Specialty: Null
Guest Bio: Jennifer Rosen, MD, FACS is Chief of Endocrine Surgery and Vice Chair for Research of the Department of Surgery at Medstar Washington Hospital Center. She serves on the Collaborative Endocrine Surgery Quality Improvement Program Committee of the American Association of Endocrine Surgeons (AAES) and sits as a representative of the College to the Commission on Cancer (COC), a program of the American College of Surgeons (ACS). She has been active on numerous committees of the American Thyroid Association (ATA) and serves as Endocrine Section Editor for the Journal of Surgical Oncology. For more than five years, Dr. Rosen served as The Laszlo N. Tauber Assistant Professor of Surgery and Molecular Medicine at the Boston University School of Medicine.

Learn more about Jennifer Rosen, MD
Transcription: Melanie Cole (Host): According to the American Cancer Society, approximately 12 million Americans are affected by thyroid disease and some of those affected may become cancerous. My guest today is Dr. Jennifer Rosen. She’s the Chief of Endocrine Surgery and Vice-Chair for Research of the Department of Surgery of MedStar Washington Hospital Center. Welcome to the show, Dr. Rosen. Tell us about the risk factors for thyroid cancer…

Dr. Jennifer Rosen (Guest): So, in fact, there are only a couple of known risk factors for developing thyroid cancer. The first is exposure to radiation and by this I really mean significant levels of radiation such as with radioactive fallout or treatment with radioactive iodine or external beam radiation. The other known risk factor, of course, is a family history of thyroid cancer and this really only explains a very small number of patients with thyroid cancer, in particular, a kind of cancer known as “medullary thyroid cancer”.

Melanie: Is this more common in men or women?

Dr. Rosen: Far more common in women. In fact, I would probably say out of every 10 patients we see, 7 or 8 of them are going to be women.

Melanie: So, how would a woman know? Would she have had to experience thyroid issues earlier on in her life to kind of keep track of her thyroid? How would you know if you had cancer?

Dr. Rosen: So, the answer really is most of my patients who come to see me with thyroid cancer don’t know that they’ve ever had a problem with their thyroid before. Either it’s found through a nodule found by exam by their primary care physician or maybe one of the members of their family was treated for thyroid issues and that’s how they found it o even incidentally where the patient noticed that they were having some changes in their voice or changes in their swallowing. We have a lot of patients who come to see us, in fact, who had a CT scan or an MRI done for an accident or for a neck injury or neck issues and that’s how they find their thyroid nodules. The vast majority of the patients who come to see me with thyroid cancer, in fact, have no symptoms at all and when we check their thyroid function again, the vast majority of patients who come to see me with thyroid cancer, the thyroid is functioning perfectly normally.

Melanie: How is it diagnosed? Can it be caught early?

Dr. Rosen: So, yes. The patient who comes to see me who noticed a thyroid nodule or the thyroid nodule was found, the first thing that we do is we do an ultrasound. This is a non-invasive test. If you’ve ever had it before, it’s very simple. You use an ultrasound probe and rub it on the skin with a little bit of cold jelly and it takes a picture image of the thyroid and the surrounding tissue. That’s the most important diagnostic step for anybody noticed to have a thyroid nodule. The next thing that we do is for patients that meet criteria and we do follow the American Thyroid Association guidelines and recommendations for when we do or do not biopsy thyroid nodules. For the most part, patients who have nodules over 1 cm or with any of the worrisome appearance of these nodules, we’re going to do an ultrasound guided needle biopsy. It’s a very straightforward process and should be done with someone that has a lot of experience in doing those. It’s a day procedure. You come and go during the same procedure. The skin sometimes is numbed up and then a series of small needles is passed into the thyroid nodule using the guidance of the ultrasound probe. Some people tell me that this didn’t cause any pain or discomfort at all. Sometimes patients have a little bit of pressure sensation during this procedure and we collect all of that needle specimen is collected into either a vial, a jar or a slide. Sometimes we put a specimen aside for genetic testing and it really has to be collected at the time of your needle biopsy. Those specimens go off to the pathologist who looks at them under a microscope and then comes back and tells us whether that patient either has a completely benign growth, an obviously cancerous growth or this middle category called “indeterminate”. In twenty percent of needle biopsies, the biopsy results alone are not enough to tell us whether they have cancer of the thyroid gland or not. So, those patients often have surgery for the purpose of diagnosis. So, patients really come to us through those two main ways. Every so often, a patient will come to us because they already have spread of the disease to other parts of their body and that’s how we make the diagnosis for thyroid cancer.

Melanie: So, if you’ve determined that it is cancer, what is the first line of defense as far as treatment goes? And, speak about reducing scarring if they do have to have surgery.

Dr. Rosen: Sure. So, the patients who come to me with a diagnosis of thyroid cancer, very often they’ve already read on the web, maybe they have a family member or somebody who has been through this process before. The first thing and the most important thing is for me to sit down and tell them it’s not a one-size fits all operation. It’s a conversation that we’re going to have about how we’re going to approach this. So, if a patient has a significant thyroid cancer, meaning something that’s over 1 cm, their options really are thyroid surgery and it comes really in two different approaches. The first approach is lobectomy—removal of half of the thyroid that contains that thyroid cancer alone; or a total thyroidectomy—removal of the entire thyroid gland and examination of the lymph nodes in the center of the neck at the time of surgery. Any patient with a diagnosis of thyroid cancer needs to have a neck ultrasound looking at the lateral lymph nodes to see if there are any worrisome lymph nodes. Almost 1 out of 5 patients have spread to the lymph nodes elsewhere in the neck at the time that they come to see me. So, that’s an important thing to find out before surgery because that’s going to change the scope of my operation and, of course, the size of the incision. So, if a patient comes to see me and they have opted for having a total thyroidectomy—removal of all of the thyroid gland—then, I’m going to examine the lymph nodes in the center of the neck at the time of surgery. We often remove the lymph nodes at the center of the neck at the time of surgery. We can do that all through the same small incision. Our incisions typically are low in the neck. They go across the neck. They’re about a fingerbreadth above the collar bone. There are also a couple of other approaches to thyroid surgery but this is our preferred method and my 3 partners and I do quite a fair number of these. The most important first thing that a patient can do to help the operation go well is avoid significant sun exposure just before surgery. Men should not shave and women should not put any makeup or perfume in the area. No special lotions or creams—just cleanse the area as instructed by whatever hospital they’re going to. Then, the things that I do in the operating room are really important for minimizing scarring. The first, of course, is surgeons who do a lot of this operation are more comfortable with managing the operation making for a small incision, delicate handling the skin of the skin in the operation. I use the same closure with every patient every time. It’s a very non-reactive suture. None of the stitches that I put in the incision have to be removed. They all are going to melt away on their own and then we use a little bit of glue on top of that—a special kind of skin glue that is very protective of the skin lining. Then, I tell patients, “Don’t do anything for the incision until I see you in the office 2 weeks after. No creams or lotions. Try to avoid a lot of sun exposure.” You don’t have to go out of your way to cover the incision or do anything special for it and you can shower the day after surgery as long as you don’t rub at the incision or take the glue off. By the time they come back to see me in the office, many patients have either had the glue come off from that incision or the glue is still there and we’ll peel it off at the time that we see them in the office. If the incision is soft and flat and looks as though it’s going to go on the path towards healing without any intervention, that’s exactly what I do. I leave the incision alone. Any patients have a concern for family history of keloid scarring or hypercellular scars or hypertrophic scars, I’ll advise them to either use a small amount of vitamin E cream or sometimes some of the silicone gel strips or lotion that they can apply to it but, really, the less is better. Part of the most important part of managing that incision is going to be careful skin handling in the operating room.

Melanie: What is life like, Dr. Rosen, for those patients after this type of surgery? Do they have, sometimes, temporary loss of voice? Do they have to take daily thyroid pills? How is life changed for them?

Dr. Rosen: So, there are a number of ways this can change. The first, of course, is getting used to the fact that you’re going to have to take a lifelong medication and that medication is Levothyroxine. That’s the generic form of that. We make our best guesstimate about what the dose is going to be for that patient after surgery and then we often adjust it a number of times very gently a couple of times after surgery. In our hands, we find that most patients don’t need more than one or two dose changes to find the right level for them. Now, you have to remember that for patients with thyroid cancer, replacement therapy is, they’re actually going to get thyroid hormone suppressive therapy. They’re not just going to get enough thyroid hormone to replace the thyroid but often they’re going to be given a little extra to keep the brain signal to the thyroid called the “TSH” level a little bit lower than most patients. So, we need to really find the right dose for them. That medication needs to be taken first thing in the morning, separated from food or drink, and so we’ll work on adjusting that and getting patients used to the fact that they can’t just get out of bed and have their cup of coffee or breakfast right away. They need to take their pill and then they can go on with the rest of their day. Most of my patients will not experience the signs and symptoms of low thyroid function. So, when they go on the web and read about this, they’ll hear about loss of energy, loss of hair, gaining weight and so forth. Our patients shouldn’t change their weight more than about 3-5 lbs. after surgery. They ought to feel normal after surgery. Now, there are risks and complications to this operation. The first is that right in the few weeks after surgery, you can have some swelling in the neck. That should go away over time and that can give people a pressure or a discomfort feeling that there is something in their throat when they swallows and that should go away with time. If there is any injury to the nerves that go into the voice box, most commonly the recurrent laryngeal or the external branch of the superior laryngeal, you can either have hoarseness or you can have difficulty in sustaining the upper part of your voice—sort of the issue with yelling at your kids or raising your voice or finding that your voice fatigues by the end of the day. For most patients, that should go away within a few weeks after surgery. If there truly is a nerve injury, we recommend that patients, six weeks after surgery, get evaluated with the video stroboscopy. That’s a special technique where they look in the back of your throat to see if the vocal cords are moving. Less than 1 out 100 patients should have a permanent change in their voice after this operation. The other thing or symptom that patients often experience is a low calcium level from injury to or removal of one of their parathyroid glands. Those are little glands the size of a grain of rice. They’re attached to the thyroid gland and they help regulate the calcium level in your blood. A number of patients—anywhere from 3-6% if you look at the American literature—can have low function of those parathyroid glands after surgery and then they can have numbness and tingling in the fingers, hands or around the mouth and maybe 1 out 100 patients permanently will have low function and will have permanent low calcium levels where they have to take multiple pills during the day. The vast majority of my patients, within 3 months after surgery, tell me that they feel normal and are back to their usual activity level.

Melanie: In just the last few minutes, Dr. Rose, what a fascinating topic and you’re so well spoken. Please wrap it up and tell the listeners what you really want them to know about thyroid cancer, if it can be prevented, and any lifestyle modifications you’d like to tell them about.

Dr. Rosen: So, the first and most important thing is, come to see a doctor and don’t be afraid. Surgeons don’t bite. We’re there to take good care of you. The vast majority of surgeons in the United States do endocrine surgery. A lot of them do a lot of this kind of surgery. Ask questions. Feel comfortable with the person who’s going to take care of you. Thyroid cancer is very treatable. Even patients with metastatic disease, meaning spread of the thyroid cancer to other parts of the body or lymph nodes can be safely treated and live a long, happy, healthy and productive life. So, don’t feel that this is a death sentence or something that’s going to be a significant change in your life. That may be true for some patients but don’t let it keep you from getting your treatment and going forward. The other thing is, you really need to see either your endocrinologist or your endocrine surgeon as a partner in going forward and making sure that you have the best possible outcome. We monitor our patients for life. I would say that the happy, healthy patient I see before surgery should be happy and healthy afterwards, back to their usual level of energy, exercise and activity and I’m very pleased to be able to take care of patients at this important and critical point in time because I know the vast majority of patients are going to go on to lead a productive life and be better, if not improved, after their operation.

Melanie: Thank you so much for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to www.medstarwashington.org. That’s www.medstartwashington.org. This is Melanie Cole. Thanks so much for listening.
Internal Notes: Null
Hosts: Melanie Cole, MS

The Epidemic of Heart Failure

David Cole — Tue, 06 Sep 2016 22:42:30 +0000
Heart failure is a very common condition, affecting more than 5 million Americans. But it is not a death sentence. Through lifestyle changes, new medications, and advances in technology, the condition can be managed and patients can lead longer, fuller lives.

Listen as Samer S. Najjar, MD, the Director of Advanced Heart Failure at MedStar Washington Hospital Center discusses advanced heart failure and the ways that it can be managed for a better quality of life.

Additional Info
Segment Number: 1
Audio File: medstar_washington/1636mwc4a.mp3
Doctors: Najjar, Samer
Featured Speaker: Samer Najjar, MD
Specialty: Null
Guest Bio: Samer S. Najjar, MD, is the Director of Heart Failure at the MedStar Washington Hospital Center. He specializes in advanced therapies for heart failure, including the medical management of heart transplantation and ventricular assist devices. Prior to these positions, Dr. Najjar was an Assistant Professor of Medicine at Johns Hopkins University, and he was the Director of the Heart Failure clinic at the Johns Hopkins Bayview Medical Center. He was also the Head of the Human Cardiovascular Studies Unit at the National Institute on Aging.

Dr. Najjar has more than 60 publications in peer-reviewed journals. His research interests are arterial-ventricular coupling, cardiovascular aging, clinical heart failure.

Learn more about Samer S. Najjar, MD
Transcription: Melanie Cole (Host): Congestive heart failure affects more than five million Americans. Your cardiologist can help you manage the condition with lifestyle changes and medications leading to a longer, fuller life. My guest today is Dr. Samer Najjar. He’s the director of the Heart Failure program at MedStar Washington Hospital Center. Welcome to the show, Dr. Najjar. What is congestive heart failure?

Dr. Samer Najjar (Guest): Well, thanks for having me and thanks for taking the time to discuss heart failure which is a very important disease. It’s probably not talked about as much in public as we talk about some of the other cardiovascular diseases. The American Heart Association has done a really excellent job of educating the public about things like heart attacks and strokes because for those diseases, when you have symptoms, you have to go to the hospital very early because there are things that can be done and the longer you wait, the more injury can happen. Heart failure tends to be a little bit different in that it is also very common. In fact, as you mentioned in the beginning, there’s more than seven million people in the country, or about two and a half percent of the population that has heart failure. And, in fact, when you go to people over the age of 65, the numbers get even higher. So, approximately five percent of people over the age of 65 and ten percent of people over the age of 75 have heart failure. So, it’s a very prevalent disease. I call it now an epidemic of heart failure. It’s all around us. A lot of people have it. Some people know about it but others don’t. So, this is a very important epidemiologic project that we need to educate the public and let people start to know what heart failure is and what can be done about it. Heart failure, the difficult thing about it is that it doesn’t have one way that it presents itself. People have different feelings or symptoms that can tell them or that can tell their doctors, their healthcare providers that they have heart failure. Usually, people think about it when they see swelling of the legs. So, if your legs get swollen everybody thinks, “Aha! My body is retaining fluid, therefore I’m congested, therefore I have congestive heart failure.” But not everybody presents themselves based on swelling of the legs. Some people will pick it up because they’re getting more and more short of breath. For many people, they realize that they can do less and less. So, the amount of walking they can do before they have to stop just gradually and progressively, it gets worse and worse. Some people lose their appetite. Some people will get abdominal pain. So, there’s multiple or a myriad of different types of symptoms that people can have which makes it a little bit harder to distinguish who has heart failure and who does not. To make things even more complex, heart failure is not one disease. So, when people present with heart failure, often heart failure is the last manifestation of a whole different set of things that could have happened, all of which end up with heart failure. Just for the sake of simplicity, I’m going to break it down into two different types. There is one type which we call “heart failure with preserved ejection fraction” and then there’s another one which is “heart failure with reduced ejection fraction”. What that means is in the first type, when you do an ultrasound of the heart, when you look at the heart, the heart squeeze is normal. So, the heart is squeezing normally but in spite of the fact that it’s squeezing normally, it’s having difficulty getting blood to the rest of the body. That’s something that we in the medical field have struggled with for awhile because it’s not immediately obvious to us, why would you be in heart failure if your heart is pumping strongly? This is to be distinguished from the other type of heart failure where the heart muscle is weak. So, the heart is trying to pump but the muscle is weak and there it’s much more intuitive. “Well, if the muscle is weak, it’s having a hard time pumping the blood forward. Therefore, the blood will back up. It will back up into the lungs which is what makes us short of breath and then it backs up into the rest of the body and that’s how we start retaining fluid.”

Melanie: Dr. Najjar, who is at risk for heart failure? Are there certain risk factors that predispose somebody to this?

Dr. Najjar: Yes, there are definite well-known and well-described risk factors for heart failure. So, anything that can cause injury to the heart puts people at risk for having heart failure. So, people who have high blood pressure that is uncontrolled; people who have heart attacks; people who have blockages in vessels in the heart, and then the risk factors for that; people who are smokers; people who have high cholesterol. All of these people are predisposed to have a heart attack and when a heart attack happens, what happens with a heart attack is there’s a blockage in the vessels of the heart and, therefore, that part of the muscle of the heart doesn’t get blood flow and it dies and that leads to a weak heart. And so, this is a big risk factor, which all the risk factors that we think about classically and traditionally from a heart perspective, also high blood pressure alone is a risk factor. But, then, there are maybe thirty to forty percent of patients who develop heart failure who don’t have any of those risk factors and we don’t know why they develop heart failure. So, there are definite risk factors that can predispose people to having heart failure but, then again, some people don’t have any risk factors and it just happens. And, in minorities, it’s actually genetic. So, in some families, heart failure runs in the family that then have a genetic predisposition and they are set up for having it. But, it’s important to emphasize that there are known risk factors which is why these risk factors have to be addressed during the lifetime of a person. So, high blood pressure should be treated. High cholesterol should be addressed. Anybody who has diabetes or high blood sugar that also should be addressed. Smoking, people should be advised against smoking. There are also lifestyle things that are very important. Exercise is a huge risk factor modifier and our population needs to do much more physical activity and exercise than what is common—than what is being done now as well as obesity. So, all of these sort of go together, they go hand in hand in terms of creating risk factors for heart attacks and, as a result, they might lead to heart failure. Now, in the one case that I mentioned about the people that have the heart failure where the heart squeezes normal, there the risk factor tends to be older age, particularly older women who have high blood pressure and African American older women are at a particularly high risk for having that type of heart failure. The difference between these two types of heart failure is the following: in the heart failure where we have a weak heart, we actually have developed quite a bit of therapies for that. So, the first thing to be done when somebody develops this and when we identify it is we have to put the patient or the person on medication. There are a lot of medications that have been studied and there are several medications that have been shown without any doubt that they actually improve survival so people live longer and it makes people feel better. So, it is very important with anybody with heart failure that they are seen by their doctors and followed by their healthcare providers because they have to be put on these medications and the doses of these medications have to be adjusted until we hit the right dose. So, there’s a medication component to it. There’s also, for some people, devices such as pacemakers and defibrillators. Some people would need these devices because these devices can also help save their life and, for some people, it will also make them feel better. That’s what the healthcare team brings to the patient but also there are things that they themselves will need to do. For example, once somebody has heart failure and we call it “congestive heart failure” because the person is retaining fluids, they have to counteract that. So, salt is the big culprit. Salt in the body helps the body retain fluids so people who have heart failure, they need to avoid salt because that will help their body prevent the accumulation of fluid. The other thing is since they’re at risk for retaining this fluid, they have to monitor how much fluid they take in. So, oftentimes, we talk with patients about limiting how much water they drink or how much fluid they drink so as not to have it be retained in the body. So, salt is an important part of it, how much fluid is taken is an important part of it, exercise is absolutely critical, as you mentioned before, and in some people we even tell them that they have to weigh themselves on a regular basis because once the body starts retaining fluid, the first thing they will see, even before they have symptoms, is oftentimes the weight starts going up and that’s the time when we can actually intervene and do something about the weight.

Melanie: Are the medications that you put them on, is this now a lifetime thing? Do they have to be on these for the rest of their lives?

Dr. Najjar: Pretty much so. Some people, a minority of people, sometimes the heart can improve and they can come out of the heart failure and in those people, after they’ve been on the medication for awhile, we may be able to get them off but for the majority of people, when they go on these medications, they will be on these medications for their lifetime, yes.

Melanie: So, do you consider, Dr. Najjar, congestive heart failure now to be a chronic disease as opposed to something that happens that’s acute like a myocardial infarction?

Dr. Najjar: Absolutely. The heart failure is sort of a prototypical disease ,along with diabetes and hypertension, as being chronic conditions. This is not just a condition of, well, something happened and you ended up in the hospital, we treat you and you go home and it’s over with. Not at all. A heart failure is something a person’s going to live with for the rest of their life and they may or may not end up in the hospital for a period of time but what is more important is during the days when they’re at home or the weeks or months or years when they’re at home living with this, what are the lifestyle changes that they have to do for this? Because this does not go away. This is a chronic condition that is staying with them and so the lifestyle changes we talked about, the medications are important, and then the check-ups and the follow-ups with their healthcare team are important. In fact, now when somebody gets hospitalized, when they leave the hospital, we now call it not a “discharge” from the hospital but a “transition of care” because the hospitalization is just one small episode where things get adjusted but then they have to be carried forward after the person leaves the hospital. So, heart failure definitely is the prototypical or the ambassador of what we call, now, “chronic diseases”.

Melanie: So, wrap it up for us, Dr. Najjar, and give us your best advice about people that may be at risk for congestive heart failure, the lifestyle modifications and what you would like them to know.

Dr. Najjar: So, what people have to know is that anybody who has any risk factor for heart diseases, in general, they can’t just ignore them. They have to act on them because even though these things, they don’t hurt, they don’t lend you in the hospital if your blood pressure’s a little high, if your cholesterol’s a little high, you don’t feel it. You don’t know that you’re having a problem. You don’t want to wait until you have a problem, either a heart attack or heart failure. You have to be able to modify those risk factors in middle age, in young age, as soon as you find out that they happen because when you’ve already developed the disease, you’ve already lost the opportunity to prevent them. Once you do have the disease, once you do have symptoms that are such, either your legs are swelling or you’re getting more short of breath or you feel more tired than you felt before, it is important to talk to your doctor or healthcare provider so they can look into it and find out whether or not you have heart failure. If you do have heart failure, there are things that they can treat you with which will number one, make you feel better and number two, get you living longer.

Melanie: Thank you so much for being with us today, Dr. Najjar. It’s such important and great information. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information you can go to www.MedStarWashington.org. That’s www.MedStarWashington.org. This is Melanie Cole. Thanks for listening.

Internal Notes: Null
Hosts: Melanie Cole, MS

Act F.A.S.T.: Quick Diagnosis and Treatment for Stroke

David Cole — Mon, 05 Sep 2016 21:50:30 +0000
Approximately 800,000 people have a stroke each year; about one every 40 seconds. MedStar Washington Hospital Center is the first hospital in the Washington region to be certified as a Comprehensive Stroke Center by The Joint Commission. The Hospital Center joins an elite group of only 73 medical centers nationwide to receive this prestigious certification.

Listen as Amie Hsia, MD, Medical Director of the Comprehensive Stroke Center at MedStar Washington Hospital Center, discusses what exactly happens in your body during a stroke, the ways we can stop it and the importance of receiving diagnosis and treatment quickly.
Additional Info
Segment Number: 2
Audio File: medstar_washington/1633mwc5b.mp3
Doctors: Hsia, Amie W.
Featured Speaker: Amie W. Hsia, MD
Specialty: Null
Guest Bio: Amie Hsia, MD, is a board-certified vascular neurologist and medical director of the MedStar Washington Hospital Center Comprehensive Stroke Center, associate professor of neurology at Georgetown University, principal investigator of the NIH Stroke Program at MWHC, and co-principal investigator of the NIH-funded StrokeNet regional coordinating center - Stroke Capital Area Network for Research (SCANR). Dr. Hsia received her undergraduate degree from Harvard University and her medical degree from Duke University. She completed her neurology residency at Stanford University, where she also served as chief resident. She remained at Stanford for her fellowship training in stroke and neurocritical care. Born and raised in the D.C. metropolitan area, Dr. Hsia returned to Washington for the opportunity to provide advanced stroke care to area residents. Dr. Hsia serves as an advocate of the Greater Washington Region American Heart and Stroke Association to support governmental policies related to stroke care. She is a founding member and was the first physician chair of the D.C. Stroke Collaborative, working to improve the level of stroke care through collaboration among the D.C. hospitals and EMS. With the NIH Stroke Program, she works on developing and evaluating acute stroke treatments with advanced neuroimaging.

Learn more about Amie W. Hsia, MD
Transcription: Melanie Cole (Host): Approximately 800,000 people have a stroke each year, one about every forty seconds. Medstar Washington Hospital Center is the first hospital in the Washington region to be certified as a comprehensive stroke center by the Joint Commission. My guest today is Dr. Amie Hsia. She's the medical director of the Medstar Washington Hospital Center Comprehensive Stroke Center. Welcome to the show Dr. Hsia. What is a stroke?

Dr. Amie Hsia (Guest): A stroke is a disruption of blood flow to the brain either due to blockage or a rupture of a blood vessel, and when this happens, symptoms happen all of a sudden. In the blockage type of stroke, it's been shown that for every minute that passes, two million brain cells actually die during that period of time which is why you've probably heard the saying, time is brain or every minute counts when it comes to stroke.

Melanie: What are the symptoms, being most important red flags?

Dr. Hsia: The symptoms of the stroke, the common element is that they do happen all of a sudden and so it could be sudden onset of difficulty with your speech, understanding what people are saying, or actually expressing yourself, sudden onset of weakness or numbness on one side of the body, sudden onset of unsteadiness or uncoordination, and sudden onset of a vision problem, often on one half of your vision. If any of these things occur, then the important thing is to call 911 to get medical emergently.

Melanie: Dr. Hsia, people may notice a person is slurring their words, or their face is drooping, they think maybe they've had too much to drink, or if they are concerned they say, "I'll drive you to the hospital." Is that recommended?

Dr. Hsia: Certainly not recommended. If someone were to have sudden onset of these type of symptoms, one thing that we have trained the public to do in addition to medical providers and EMS specialists is to use the acronym of FAST which stands for “face, arm, speech and time”. You can look at their face to see if one side of the face is drooping. Have them raise both of their arms, is one arm drifting down? Ask them to speak. Is it unclear? Are they having difficulty? And then, time being, call 911, so that you can get evaluated as quickly as possible. It's been shown that patients to arrive to an emergency department by ambulance are evaluated more quickly than patients who arrive through the door, brought by a family member or a friend.

Melanie: What's the diagnostic process at a local hospital when they get to a stroke center?

Dr. Hsia: The things to expect when you show up in an emergency department are, they'll ask questions including when did the symptoms come on? When was the onset of your symptoms? Or, what time was the last time you were known to be normal? Then, they'll assess you to briefly understand what are the problems that you're having with your function? Other things that you can expect in terms of very quick testing include some blood tests that are drawn and, also, importantly, brain imaging, usually with a CAT scan, to determine if you're having a blockage type or a bleeding type of stroke.

Melanie: What's it like for the patient once you've determined which type of stroke? Does it move quite as quickly as they see on TV?

Dr. Hsia: It moves fast in order to do all of these tests quickly. The goal for treatment these days that is the entire reason why all of this evaluation is done as quickly as possible is to evaluate patients to see if there are potentially treatment candidates for a clot busting medicine called “TPA”. This is a medicine that has been proven to be a benefit for patients. It's delivered through the vein, and it's proven to be a benefit for patients who are having a blockage type of stroke if it can be caught early. Early enough means within that first four and a half hours of the onset of the symptoms, or the time the patient was last known to be normal. Therefore, the goals for treatment time are to treat patients as quickly as possible under sixty minutes from the time that the patient arrived in the emergency department and even now, pushing those times to be even shorter, they're treating patients under 45 minutes, if that's possible.

Melanie: If you've given them the TPA, which is recognized as the gold standard clot busting medication, then what happens afterwards? They get into recovery based on whatever damage was done. Are they then on medication for the rest of their lives? Do they have a risk of a recurring stroke? Speak about after that.

Dr. Hsia: Typically, the patients after the clot busting medication treatment are admitted to hospitals. The other thing that I want to make sure that I do mention is that now, in addition to this intravenous clot busting medication, clot retrieval treatment or it is also referred to as endovascular treatment, is also now the standard of care for patients who, in the civic situations are having a very large stroke with a large vessel in the brain that's blocked. If patients are eligible for this treatment, it may immediately follow that IVTPA treatment that is given. But, once any of these acute treatments are given or that initial acute evaluation is done in the emergency department, whether or not someone is eligible for these treatment, then patients are typically admitted to the hospital for further monitoring and diagnostic testing to try and sort out as best as possible what was the underlying cause of the stroke. Once those tests can be done, then the medication regimen can be determined as to what are the best medications for the patient to be on in order to reduce their risk of having another stroke in the future. This medication is done in conjunction with certainly any lifestyle management or changes that need to be made with a person's diet or exercise in order to reduce their risk of having another stroke in the future.

Melanie: Let's speak about prevention. Are there some things you like to tell people on a regular basis? Lifestyle modifications that they can do to, hopefully, prevent a stroke?

Dr. Hsia: Certainly, if someone smokes, then making a very concerted effort to quit smoking. We can give all of the medications but if someone continues to smoke in addition to taking the medications, then you're kind of fighting against yourself. Blood pressure control is incredibly important and it can be difficult because having high blood pressure is something that typically doesn't cause pain or discomfort on a day to day basis but it does require management and being compliant with medications and following your blood pressure on a day to day basis. Same kind of idea for blood sugar. If you have diabetes or elevated blood sugar, then it's incredibly important to stay on top of maintaining and managing your blood sugar. Cholesterol management, a cholesterol panel and those tests and levels are checked during a hospitalization. If someone is placed on cholesterol lowering medication, then those levels need to be followed as an out-patient in close conjunction with your physician.

Melanie: Dr. Hsia, please give us your best advice for stroke: what you want people to know, what you tell them every day about symptom recognition, and what you want them to know about stroke.

Dr. Hsia: When it comes to stroke, one of the first things is identifying those symptoms as potentially being a stroke because that really starts off the chain reaction and the chain of events of identifying the stroke symptoms. Remember that FAST acronym--face, arm, speech, and time. Call 911 and get to your local emergency department as quickly as possible, so that you can be evaluated. Remember that there are treatments that are available that can change the course of your stroke and, therefore, of your life. We have a clot buster IVTPA. We have clot retrieval treatment to pull out large clots that may be stuck in the brain. Then, there is also the co-ordination of care across the community. It's important to remember while your local hospital may not be able to offer all treatments, they are connected with other hospitals such as comprehensive stroke centers which is what Medstar Washington Hospital Center is. Comprehensive stroke centers can offer higher levels of care, where we have 24x7 coverage of being able to offer endovascular clot retrieval treatment, neurosurgical treatment, Neuro ICU, and even beyond the standard treatment clinical trial opportunities when one may not be able to be eligible for standard treatments, there may be another treatment option that's available that's being studied. The important thing from the beginning is awareness of stroke and the awareness that there are treatments available to treat a stroke and improve your outcome.

Melanie: Thank you so much, Dr. Hsia, for being with us today. Such great and so important information. Thank you so much. You're listening to Medical Intel with Medstar Washington Hospital Center. For more information, you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks so much for listening.
Internal Notes: Null
Hosts: Melanie Cole, MS

What is Palliative Care?

David Cole — Sat, 20 Aug 2016 20:02:24 +0000
Palliative care services at MedStar Washington Hospital Center provide hospitalized patients with serious illnesses ongoing relief from symptoms and stress during and after treatment. Our interdisciplinary palliative care team members are experts in this specialized field of medicine—and deliver an important level of additional support to our patients. The team takes a holistic approach to care aimed at healing mind, body and spirit.

Listen in as James Hunter Groninger, MD, discusses how members of the team work collaboratively with one another, and hand-in-hand with patients' other medical specialists and health care providers to help ease physical pain and other symptoms and promote patients' emotional, psycho-social and spiritual health at any stage of illness.
Additional Info
Segment Number: 1
Audio File: medstar_washington/1633mwc5a.mp3
Doctors: Groninger, James Hunter
Featured Speaker: James Hunter Groninger, MD
Specialty: Null
Guest Bio: James Hunter Groninger, MD is the director, Section of Palliative Care.

Learn more about James Hunter Groninger, MD
Transcription: Melanie Cole (Host): A chronic illness or life-threatening health condition can present an array of tough questions and challenges. Palliative care can relieve symptoms of a disease while maintaining the highest possible quality of life for patients. My guest today is Dr. Hunter Groninger. He’s a palliative care specialist at MedStar Washington Hospital Center. Welcome to the show, Dr. Groninger. What is palliative care?

Dr. Hunger Groninger (Guest): Thank you. Thank you for asking. Palliative care is specialized interdisciplinary care that focuses on prevention or relief of suffering for patients with a serious progressive illness. It focuses on support for their loved ones, families and caregivers as well. It’s a specialty that is relatively new in the United States, but it has really been catching on strong because people who have a serious progressive illness really need a lot of whole person, holistic support that focuses on quality of life.

Melanie: A lot of times people confuse palliative care and hospice care and they think that if they get involved in palliative care that means end of life. Please explain this difference to them.

Dr. Groninger: That’s a great question, and you’re right, there are a lot of people who have that understandable misconception. Palliative care is a supportive care specialty, like I defined, and anybody who has a serious progressive illness, who has pain management needs, who needs expert management of other symptoms, who needs psychosocial, spiritual support or counseling is eligible for palliative care compensation. And so, palliative care really is a service that’s available to people based on their need for it as long as they need it. They deserve to have it. That could be for people who have a disease that is serious or life-threatening but potentially curable. That could be for people who have a chronic serious progressive illness. But, it is importantly different from hospice care. Hospice care is a type of palliative care but it’s really that type of supportive care for people who really are at the end of life to the best of our ability to prognosticate or predict the future. So, hospice care is an insurance benefit in this country that is covered under Medicare and under most other insurances, but it’s a benefit that really is focused on estimating someone’s prognosis. So, people are eligible for hospice care if their physician estimates the time that they have left with the disease that they have to be six months or less if the disease runs its usual course. So, there are important differences between the two. Palliative care is for anybody who needs that type of supportive care. Hospice care is for people who are specifically approaching end of life.

Melanie: Can you have curative treatments together with palliative care?

Dr. Groninger: You certainly can. A good example of a patient that my team is helping to take care of now, this is a gentleman who is relatively young. He’s in his early 40s. He has a new diagnosis of a type of lymphoma. We met him because he was having out of control pain from the disease itself and from complications from the disease. He also has a lot of needs for psychosocial support, for spiritual counseling support. So does his wife. So does his family. But, in the context and the predicted trajectory of this disease, we believe that his disease will respond to treatment; we believe that his disease will go into remission; and we hope that he will live a long, healthy, productive life. So, this is somebody, again, that is in need of these holistic supportive care services, but is someone that we believe will actually do quite well with treatment. We’ve talked with him about the fact that we look forward to the time when he’s feeling so much better that he actually doesn’t continue to need our services.

Melanie: Who else besides the patient? Can their families be involved in palliative care?

Dr. Groninger: That’s a good question. I think when we think about palliative care, we really focus mainly on the patient. I think that is what most providers do. But, we’re very interested in who is part of the illness experience around the patient as well. So, this is really family-focused care. When anybody gets the diagnosis of a serious illness or a life threatening illness, it impacts the community around them. It impacts what their home life is like; it impacts their professional life; it impacts their relationships. And so, part of what we really try to do when we’re thinking about the whole person is really thinking about at least the immediate community and family around the individual. So, when we think about targeting our interdisciplinary support, we think about what are the needs of the patient, but what might a spouse need, or an adult child, or some of their closest friends and family around the individual as well because it’s been well-documented that when an individual is diagnosed with a serious illness, that it seriously impacts the function of the family unit; it can seriously impact the finances of the family; and so, we want to be mindful of what the entire illness experience is like. If we’re really going to support an individual through a difficult time, we have to be thinking about, not only the individual, but sort of the aftershocks of what’s happening around that person as well.

Melanie: And you’ve mentioned interdisciplinary, multidisciplinary, what services actually do you offer in palliative care? What can people expect? Is there nutrition advice, spiritual counseling, mental health and psychological counseling? Speak to the services a bit.

Dr. Groninger: When somebody has — I’ll continue with the example of the patient I was referring to before — when someone has serious physical pain and that’s the physical component of suffering is something that needs attention, but you can imagine that if someone is seriously physically affected by pain other discomfort, that’s going to affect how their emotional state feels. It’s going to affect their relationships. They may not able to do what they would normally do for daily activity. A patient who is in serious pain can’t go to church once a week like he would normally do. So, when we think about suffering we really try to think about a model of total pain or total suffering, meaning that when people suffer they suffer in different modalities together, and that could be physical, emotional, social or relational and spiritual. And, our interdisciplinary team intends to reflect those needs. So, we’re very lucky here at MedStar Washington Hospital Center to have a very deep interdisciplinary team that consists of physicians, nurse practitioners, social workers, spiritual care, clinical pharmacists, and special volunteers. So, we really try to attend to all the different domains of suffering, so to speak, so that we really can help people to improve the quality of life in spite of what’s happened to them.

Melanie: Do they have to give up their own doctor?

Dr. Groninger: Absolutely not. I think we work very, very closely and very collaboratively with their primary doctors, whether that’s their primary care physicians or their a primary specialty doctors. Our model here at MedStar Washington Hospital Center is one of integration. So, we are continuing the process of integrating into the care of people with advanced heart failure, people with new diagnosis of cancer, different types of cancers. We are just embarking on a collaborative model for patients who have advancing kidney disease. So, we believe that patients and their families get the best care when teams are working together. So, this is not a model of you choose one or you choose the other. With us you get both and we will work really closely with your primary medical doctors to make sure that we’re working symbiotically to give you the best care possible.

Melanie: Can patients get palliative care if they are at home?

Dr. Groninger: They can. For the most part, the patients that we see are patients who have been hospitalized and, happily, we have a growing presence in the outpatient setting. Helping patients to receive palliative care at home is an ongoing evolution in medical culture in the United States. Our program here is piloting different ways to do that. An example that I share with you is a pilot program that we have with advanced heart failure patients who we’ve joined in their care during a hospitalization. We’re piloting a tele-health or virtual clinic, so to speak, program, so that we can continue to provide ongoing support needs when they are at home through telecommunication, through video-conferencing in order to maintain that connection, to maintain that support for them without patients having the extra burden of needing to come back to see us for additional clinic appointment. Most patients who are living with a serious illness have a lot of medical appointments. They’re at high risk of coming to the emergency room or being hospitalized, and so we really want to think about, “What can we do to help support you so that you can, hopefully, avoid those complications and those episodes, and how can we also help to maintain support to the best way possible without you having to be further burdened with more visits to a medical care setting?” Those are some examples of pilot programs that we’re working on to see how we can do this best. I think that that will be a really important component of the future of home-based palliative care.

Melanie: In just the last few minutes, Dr. Groninger, best advice for people who are trying to understand palliative care, going through some problems, chronic health issues, with loved ones. Tell them what you tell them every single day.

Dr. Groninger: I think that we do a lot of education with patients and families about palliative care and about what it is that we do and aim to do try to help individuals have a better quality of life. I think that our mission is really focusing on helping patients and family members to think about what is it that we can help with today that would make today a little bit better? And, maybe think about tomorrow as well. What is it that’s important to you? And, I often have a conversation with patients or family members about how can we understand who you are as a person and what your goals are in the context of what’s happening? I know that people don’t come to the hospital just to get medical care. They come to the hospital or they come to an emergency room or they take their medication in order that they can achieve something better; that they can feel better; that they can be more functional. And, even that is to achieve other goals that are important like to be able to work, or to be able to enjoy time with family, or to finish high school. People go through these experiences and it’s hard having a serious illness. In order to achieve life experiences and life goals. And, I think at the end of the day what, we really want to do is understand what are your specific life goals? What are the experiences that you’re looking to be able to do? How can we think about it in the context of what’s happening realistically right now, whatever the medical situation happens to be today or this week, and how can we aim to make that better? How can we help you feel better than before? I think that’s a conversation that, in one way or another, we have with all of our patients.

Melanie: Thank you so much, Dr. Groninger, for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information you can go to MedstarWashington.org. That’s MedstarWashington.org. I’m Melanie Cole. Thanks for listening.
Internal Notes: Null
Hosts: Melanie Cole, MS

Midlife Sex: Myths v Reality

David Cole — Thu, 18 Aug 2016 22:29:40 +0000
When it comes to sex after 40, one of the biggest misconceptions is that age will sour your sex life. But in reality, many women in midlife say the quality of sex is better than ever.

Listen in as Cheryl Iglesia, MD, discusses myth vs. reality about midlife sex.
Additional Info
Segment Number: 4
Audio File: medstar_washington/1631mwc3c.mp3
Doctors: Iglesia, Cheryl
Featured Speaker: Cheryl Iglesia, MD
Specialty: Null
Guest Bio: Cheryl Iglesia, MD, is a leader in the field of female pelvic medicine and reconstructive surgery and is nationally recognized for advancing surgical techniques, clinical research and medical education. She is an expert clinician renowned for her skills in diagnosing and treating pelvic floor disorders. Among many roles, Dr. Iglesia is the current chair of the Advisory Board for the Pelvic Floor Disorders network at the Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD) and is the immediate past chair of the Committee for Gynecologic Practice at the American Congress of Obstetricians and Gynecologists(ACOG). She has served on the board of directors of the American Urogynecologic Society (AUGS) and the AUGS Foundation and was appointed as the inaugural chair of the AUGS Guidelines committee. She currently serves as vice chair on the Patient Education Board at ACOG and is an appointed special governmental employee for the ObGyn Devices Panel at the United States Food and Drug Administration (FDA).

Learn more about Cheryl Iglesia, MD
Transcription: Melanie Cole (Host): When it comes to sex after 40, one of the biggest misconceptions is that age will sour your sex life. Is that a given? Does it have to be that way? My guest today is Dr. Cheryl Iglesia. She is a Urogynecologist with MedStar Washington Hospital Center. Welcome to the show, Dr. Iglesia. What do you see, that women and men ask you, are the biggest myths when it comes to midlife sex?

Dr. Cheryl Iglesia (Guest): I’m so happy to be here, Melanie, and I just love talking about sex. When it comes to midlife, I think that some of the biggest myths are relating to performance anxiety and that things don’t work as well when you get older. Organs can be out of place, blood flow may be less and so people feel less confident and then they just do it less and then it becomes a ho-hum thing. And I think that the biggest miss is that there’s a lot of things that you can do to reverse it and there’s a lot of things you can do to prevent it to maintain your sex drive and your sex life.

Melanie: Let’s start with women, what do you see as some of the biggest challenges because, as women are going through perimenopause and into menopause certain things get drier, our hormones have changed. all kinds of things change with our bodies.

Dr. Iglesia: Yes, I think if you specifically map it out, by three years past menopause 50% of women have dry vaginas. There’s a new term that’s been coined called GSM, it’s like the EG for women, but GSM is “genitourinary syndrome of menopause.” So, we can say on air instead of using “vulva and vagina atrophy,” which sounds terrible. What it refers to is a lack of estrogen and the changes in the hormonal milieu of the vagina that lead to drier tissues that affect not only the vagina and the vulva structures but also the urethra, the bladder and some of the surrounding glands.

Melanie: Do you ever recommend for some of these challenges topicals, some of those testosterone creams, progesterone creams that we see on the market?

Dr. Iglesia: Yes, there’s nothing worse than sandpaper sex. So, if it’s dry, wet it. It’s almost you can’t get it too wet, right? So, the thing about it is generally speaking, obviously, you should be evaluated, making sure that you don’t have any skin conditions or any other infections, yeast infection or otherwise. But you start topically and what most people recommend is you can start with either a lubricant during sex or a moisturizer, both of which are non-hormonal. And there’s differences between lubricants, most of which have silicone or they’re water-based, and there’s lots of the out there. We kind of steer away from some of the ones with mint or menthol or heat because that can burn, particularly a drier vagina. And that’s during sex, but apart from sex you can use a moisturizer, many of which are designed to replace the pH. It’s a little bit more of an acid, mild acid to keep the pH—so, it’s more acid, 4.5, and that keeps the healthy bacteria from staying around and not getting an overgrowth of unhealthy bacteria.

That doesn’t work for everybody, though, and after that we would move to hormonal topical treatment. And the only FDA-approved ones have estrogen, and these are very different from the estrogens that you take by mouth. There is one that’s designed to take by mouth. But the topical estrogens are creams, Estrace, Premarin, and there’s a tablet called Vagifem, and then there’s a ring Estring that stays in for three months and, generally, the partner can’t feel it. That just releases daily estrogen for three months. Now that is all FDA-approved and the doses are so low that there really is not any significant cancer, blood clot or heart disease risk for that. There are no FDA-approved treatment options for testosterone. I know that many people find that helpful and they have to get through compounding pharmacies. We just have to find someone who is monitoring that because if you do absorb too much testosterone, not only can the clitoris grow but then you can get more hair in unwanted places and balding and acne and maybe some heart issues from that, or lipid issues.

Melanie: I think another issue is libido and desire. We seem to go up and down in our lives with that, and men, of course, they have Viagra and they have all these things and, boy, they tout that stuff, but the women they came up with that female Viagra, which is not really that. So, speak about women and desire and libido and how we can ramp that up a little bit.

Dr. Iglesia: There’s a lot of things that go into desire, and the new Flibanserin, which has been touted as the female Viagra, you’re right, Melanie, that isn’t for everybody and doesn’t help, and you can’t drink alcohol, for one, with it. But, it is only FDA approved for women who are premenopausal. It’s not actually not FDA approved for people who are postmenopausal, and we don’t have any FDA approved drugs. And some people feel that testosterone levels, men have Low T, women can suffer from Low T, but there’s a lot of things that go into desire, just in terms of the way women feel about their bodies. I think there’s a lot of concern about body image. I think that some changes that can occur in the architecture of the vagina, particular after you’ve had children. It takes longer to have orgasm, maybe you don’t feel as much, and they’re just feeling very different about their bodies, less confident. And then, there are relationship issues. In addition to that, there’s menopause. I mean, we have the women and we have 30% of them by the time they’re over 50 have dry vaginas. Well, 50% men over 50 have erectile dysfunction, and 60% over 60, and 70% over 70, so there could be some relationship issues and some performance issues on the partner side, and this is assuming heterosexual relationship, obviously.

Melanie: So, what do you tell couples and/or women every single day, Dr. Iglesia, about ways to combat some of these libido issues, body image issues, all of these things? With men it could even be prostate issues.

Dr. Iglesia: Yes, you have to change it up. I mean, I’m not going to say personally, but I have been married to the same guy for now 23 years, and you can’t be doing the same thing. You’ve got to change up. Everybody’s got to change their game. I would say change the location, change the time of day, get some toys in there. There are so many good ones that are out there now. These Lelo vibrators, and then they have these new cock rings, and there’s just a lot of new things that you can experiment with. It may take a little bit longer because blood flow is going there, but now you can use that little Gigi vibrator right on the clitoris. And now, we have special enhancers and arousers just specifically designed to bring more blood flow to that vital area. So, change it up. Read the Kama Sutra, look at different positions, start doing other fun things together to revitalize your relationship. I have to say, at this point in our life, and I have children and they’re grown, you really have to have invested in that relationship with your partner. And, if there are issues, I find that referring out to a sex therapist or couples therapy, making sure that everything is working, just in terms of blood flow and blood pressure and checking on meds that could have a negative impact. Anti-depressants can have a pretty significant impact negatively towards women’s drive and even arousal and some of the blood pressure medicines, in particular, as well. So you need a pretty comprehensive evaluation that can’t be done during your regular routine annual check-up when you’re getting your mammogram, and your breast, and your pap smear, if it happens to be that time. You have to have a separate exam and you’re got to make this priority. It’s nice, I think, when couples come in, whether they be male-female, female-female, whatever, just to talk about some of the issues.

Melanie: What absolutely great advice. Just wrap it up for us, Dr. Iglesia, with your best advice, as couples come to you or women come to you with questions about these myths and misconceptions about sex as it gets into the ages.

Dr. Iglesia: I would say don’t give up. If it’s something that’s really bothering you and really bothering your partner and you really want to make improvements, don’t listen to a gynecologist that says, “Well, what do you expect, Melanie, you’re getting older, and this is what happens.” You don’t have to suck it up. You can divorce your gynecologist. You can see a specialist and someone who’s going to validate these concerns and maybe offer a very thorough evaluation, give you the appropriate referrals, give you the permission to and some advice on other things to try because it’s really a whole new world order and we don’t have to settle for sandpaper sex. We don’t have to settle for lack of arousal. I think you can resume that zest and your drive, and you can maintain it, and it’s totally possible.

Melanie: Thank you so much. What an amazing guest you are, Dr. Iglesia. Thank you so much for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information you can go to medstarwashington.org. That’s medstarwashington.org .This is Melanie Cole. Thanks for listening.

Internal Notes: Null
Hosts: Melanie Cole, MS

Cochlear Implantation and Dementia

David Cole — Tue, 16 Aug 2016 01:48:00 +0000
For older adults, particularly those with dementia, hearing loss can increase isolation and damage their overall quality of life. Cochlear implants are an effective treatment for hearing loss, but the anesthesia used during the procedure may cause risks for this populations.

Listen in as Selena Heman-Ackah, MD, explains how she performs the implantation procedure with only local anesthesia with sedation to improve the overall outcome and decrease the risks of the procedure for patients with dementia.
Additional Info
Segment Number: 3
Audio File: medstar_washington/1631mwc3b.mp3
Doctors: Heman-Ackah, Selena
Featured Speaker: Selena Heman-Ackah, MD, PhD, MBA
Specialty: Null
Guest Bio: Dr. Heman-Ackah completed her medical degree at the University of Cincinnati-College of Medicine, followed by a surgical internship and Otolaryngology-Head and Neck Surgery residency at the University of Minnesota, and a fellowship in neurotology at New York University. Dr. Heman-Ackah holds an MBA from the University of Cincinnati and a PhD in otolaryngology from the University of Minnesota. She previously served as the Director of Otology, Neurotology and Audiology at Beth Israel Deaconess Medical Center, and as instructor and assistant professor of otolaryngology at Harvard Medical School.

Learn more about Dr. Heman-Ackah
Transcription: Melanie Cole (Host): Hearing loss has been found to independently increase the progression and severity of dementia. So, cochlear implants would decrease that progression. However, there is a concern that general anesthesia may contribute to that progression. My guest today is Dr. Selena Heman-Ackah. She is otolaryngologist with MedStar Washington Hospital Center. Welcome to the show, doctor. Tell us a little bit about hearing loss as it relates to dementia and the progression of that.

Dr. Selena Heman-Ackah (Guest): There have been a number of studies just in the past decade that have linked progression of hearing loss with the progression of cognitive decline with aging. A number of these studies have shown a correlation between an increased incidence of dementia of all forms as well as an increase in the progression of dementia in patients as related to the severity of hearing loss. So, the goal is to prevent hearing loss or mitigate the hearing loss in some form, either with hearing aids or with cochlear implantation, depending upon the severity of the hearing loss, to help decrease the progression of dementia or even prevent the onset.

Melanie: Is there any link to that frustration of somebody with hearing loss and their ability to get themselves out in the community?

Dr. Heman-Ackah: Definitely. Because, exactly what you stated, individuals who are communicating with other individuals with hearing loss they tend to get frustrated. It leads to social withdrawal, particularly in the geriatric population or the aging population with hearing loss. And there have been a number of studies that have linked social withdrawal, depression, anxiety and decline in function as well with progressive hearing loss. So, the goal really is to keep individuals having the ability to communicate, and that keeps them in the game. It keeps them active. It keeps them cognitively functional as well.

Melanie: So, along with that social feeling, now cochlear implants could help with that. What has typically been done in the past with those?

Dr. Heman-Ackah: In general, implants are an outpatient procedure that can be performed on anyone from the ages of one to the oldest person that has had an implant on record is over a hundred. And the device is implanted within the cochlea, which is the hearing organ, and then there’s an external device that’s worn outside that picks up the sound from the environment and codes it into a signal that your inner ear and brain can understand. So, those two devices coupled help to improve an individual’s hearing both in terms of the clarity of their hearing as well as the volume of their hearing.

Melanie: So, if that’s what’s typically been done then why are we seeing that there’s a concern that general anesthetic can also contribute to that progression of dementia?

Dr. Heman-Ackah: Typically, with the cochlear implantation, it’s done under general anesthesia and in general anesthesia, there is a risk factor of exposing an individual with dementia to general anesthesia. It’s been reported to increase the progression of dementia. So, the procedure that I’ve been doing, which is somewhat different from the traditional cochlear implant procedure, is performing the implant not under general anesthesia but under local anesthesia with sedation. That decreases the risk of progression of dementia for these individuals while improving their hearing. So, it helps to decrease the progression again. In other words, you’re helping their hearing with a cochlear implant and mitigating that risk of general anesthesia of the traditional approach for cochlear implantation.

Melanie: So, then how does that work, are they in twilight with a local anesthesia, how does that work, and is there a fear?

Dr. Heman-Ackah: The patients that I’ve had that have undergone this procedure have done remarkably. They are in a sedated state, so they tend to be resting during the procedure, but they don’t have a breathing tube. They’re breathing spontaneously and we just use local anesthesia and do the procedure. It’s similar to some of the other procedures that are done for hearing loss, a different type of hearing loss called the stapes procedure, which is traditionally under local sedation. It’s using that same anesthetic model but for a different procedure in the same area.

Melanie: And, are there any other advantages? Time in the recovery room or length of a hospital stay?

Dr. Heman-Ackah: Definitely. For an individual who has dementia, and they may also have other associated comorbidities such as heart disease or lung disease, it decreases the risk of anesthesia for other procedure as well. They do have a decreased time in recovery; whereas, usually if you have a general anesthetic, you have an extended course in recovery. But, with the local and sedation the recovery time in the hospital is decreased almost in half, and the recovery outpatient is decreased as well.

Melanie: And, what’s it like for the patient after the surgery, after this procedure under a local anesthetic, how soon can they go back home? Is there dizziness? What’s it like for them?

Dr. Heman-Ackah: They go home the same day. About a third of patients to half the patients will experience some dizziness for about a day or two. That typically resolves on its own and it’s very short-lived. Two weeks to four weeks after the procedure, the device is activated and that’s when the individual hears. So, it’s important to note that on the day that surgery is done, the hearing is not restored. It takes about two weeks for the device to be activated, but at that time then there is some improvement in hearing. Then, there’s a period of counseling and sessions with an audiologist to optimize the hearing and help the patient to learn how to hear with their new device.

Melanie: That’s got to be a weird feeling for them?

Dr. Heman-Ackah: It is an interesting feeling for them, definitely. But most patients are so excited about having implants and restoring their hearing. It’s more of an exciting experience for people than a weird one.

Melanie: Could you use that same procedure for a young adult with hearing loss?

Dr. Heman-Ackah: You can use the same procedure for anyone with hearing loss. The cochlear implantation itself, in general, is for younger individuals without other comorbidities. It’s performed under general anesthetic, but it could be performed under local with sedation as well. Anyone essentially with severe to profound sensory neural hearing loss could undergo cochlear implantation. And, in fact, in the pediatric population, it’s quite common as well.

Melanie: Doctor, in the last few minutes, please wrap it up for us about the progression of dementia and how cochlear implantation may decrease that progression and how that concern of general anesthesia can be allayed by doing the procedure under local with sedation.

Dr. Heman-Ackah: With age and with time, it’s very common for individuals to experience sensory neural hearing loss or progression of hearing loss. In some individuals that hearing loss progresses faster than others and puts them in a situation where their hearing is severe to profound. They have difficulty communicating with their family, interacting in the grocery store, and participating with their care, with their providers, and they can’t hear or understand descriptions of medications or proposed procedures. Cochlear implantation is a procedure that can be performed and a device that can be used to help mitigate those issues for individuals with severe to profound hearing loss. Additionally, with age and with time, dementia is relatively common within the geriatric population. Studies have shown that hearing loss can accelerate the progression of dementia and increase the incidence of dementia. So, with implantation, the goal is to restore hearing but also decrease the progression of dementia or onset of dementia in this population.

Melanie: Thank you so much for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information you can go to medstarwashington.org. That’s medstarwashington.org. This is Melanie Cole. Thanks so much for listening.
Internal Notes: Null
Hosts: Melanie Cole, MS

Risks of Long-Term Use of Acid-Reducing Medications

Lauren Allen — Wed, 03 Aug 2016 17:05:38 +0000
Roughly 20 percent of Americans suffer from frequent episodes of acid reflux.

Acid blockers are a great way to help ease the symptoms of heartburn. However some of the newer and stronger acid-reducing medicines appear to increase the risks of bone disease, fractures, and intestinal infections.

Listen in as Tim Koch, MD discusses the risks of long-term use of acid-reducing medications, and other options to ease acid reflux symptoms.
Additional Info
Segment Number: 1
Audio File: medstar_washington/1631mwc3a.mp3
Doctors: Koch, Tim
Featured Speaker: Tim Koch, MD
Specialty: Null
Guest Bio: Dr. Tim Koch graduated from the University of Chicago Pritzker School of Medicine in 1980. He works in Washington, DC and specializes in Gastroenterology. Dr. Koch is affiliated with Medstar Washington Hospital Center.

Learn more about Tim Koch, MD
Transcription: Melanie Cole (Host): Although medications for GERD or gastroesophageal reflux disease are very popular and widely prescribed, the safety of some types have been called into question. Are these meds safe for long-term use? Are some more effective and safer than others? My guest today is Dr. Tim Koch. He's a gastroenterologist at Medstar Washington Hospital Center. Welcome to the show, Dr. Koch. First, tell us: what is GERD?

Dr. Tim Koch (Guest): When we're referring to GERD, we're referring to people who have chronic acid reflux or heartburn and because of their chronic reflux or acid heartburn, they will develop problems with the food pipe.

Melanie: So, what's the standard course of treatment, Dr. Koch, that people are doing all over the country? Tell us a little bit about treatment for GERD.

Dr. Koch: Unfortunately, frequent reflux of acid is very common in the United States. Up to 20% of people in the United States have frequent episodes, or they do have acid refluxing up to the esophagus. When they see their physicians, often they're asked about simple measures such as elevating the head of the bed; such as avoiding specific foods that may bother them, such as citrus fruit, tomato-based products. In many individuals, however, this is not enough and they can buy over the counter medications such as cimetidine, such as famotidine, and, in some people, these are helpful but for the majority of people, it's still not effective. When they see their doctors, they'll then speak with them about the possibility of using the newer agents, so-called proton pump inhibitors, and it's the proton pump inhibitors which have more recently given rise to the question of, "Are they safe in the long-term use?"

Melanie: Are there complications to untreated GERD, Dr. Koch?

Dr. Koch: People with untreated GERD can develop damage to the food pipe and that damage can present with trouble swallowing; with vomiting. This is due to scarring of the food pipe. It's been known for quite some time that individuals with chronic GERD may have an increased risk of developing a precancerous type of lesion called Barrett's esophagus, and in studies from around the world, the question has been raised whether chronic GERD is a risk factor for the development of cancer of the food pipe.

Melanie: So then, let's discuss those medications for what can be silent, right? GERD doesn't necessarily mean something that you feel--that heartburn feeling. It's not always like that, is it?

Dr. Koch: People can present with other symptoms and then, we need to be thinking about whether this is due to GERD. Other types of symptoms can include earache, sore throat, nasal congestion, atypical feelings in the chest--chest pain or chest pressure --and some people may just present with a morning cough.

Melanie: So then, if they are taking a proton pump inhibitor, which there are many, what do you tell them when they ask you about the safety of these and long-term use?

Dr. Koch: For just a very brief overview, we've heard about the question of long-term safety for a number of years from studies in which we reviewed the question of whether it increases action in the gut, whether or not it increases the risk of having bone loss. I think most patients now are asking us about long-term use because they've seen recent reports that long-term use might increase the risk of dementia, or might increase the risk of chronic kidney disease. When we see patients on long-term use, the first thing we try to do is find out exactly how much they are using. Are they using it every day? If they're using multiple doses a day, this might be a higher risk. If they're using it for many years, it might be a higher risk. If we're not exactly sure why they're taking the medication, then this is something which also I think is important that may indicate that over time, they may be at higher risk. The first proton pump inhibitor, which was named Prilosec, was developed by Astra Sweden in the late 1970's. Prilosec was approved by the Food and Drug Administration in the United States in 1990 and was initially approved for treating ulcer disease. People then thought about whether or not this would be a good treatment for acid reflux or heartburn and Dr. Walter Hogan at the medical college in Wisconsin, in Milwaukee, started talking with his colleagues about whether or not they could start Prilosec for treatment of chronic acid reflux. When Prilosec was originally approved, it was approved for short-term use of only a few weeks because of concern in laboratory rodents, especially rats, that they might develop a type of tumor in the stomach with long-term use. When these tested tumors were not found in humans, people then started using proton pump inhibitors, such as Prilosec, for more long-term use and that's when it was found that in people with severe chronic heartburn and reflux symptoms, that the use of Prilosec was extremely helpful.

Melanie: So, doctor, people hear about GERD from the media and from commercials. What is the role of hiatal hernia and gastroesophageal reflux?

Dr. Koch: It's been known for quite some time that there's a relationship that a hiatal hernia, in which the stomach moving up into the chest can cause irritation of the esophagus--the food pipe—and this has been known from studies where the surgeon repaired the hiatal hernia and people's problems with GERD disappeared. The most convincing studies have been people with lung problems such as chronic asthma, chronic cough or hoarseness in the morning and with repair of the hiatal hernia, these symptoms have gone away.

Melanie: Would you know someone had a hiatal hernia? Do you have to do endoscopy?

Dr. Koch: There are several ways to take a look at the actual food pipe and endoscopy is one of the ways in which a hiatal hernia can be discovered. Hiatal hernia can also be seen on an x-ray where they swallow some white chalky barium material and take a look at the food pipe.

Melanie: If people want to contribute to their own treatment without necessarily resorting to those PPIs, what do you tell them are some lifestyle modifications - things they can do to help with GERD?

Dr. Koch: This is, of course, something that's been looked at and thought about for many years. We generally don't' think that just elevation at the head of the bed, avoiding eating for three hours before bedtime, avoiding specific foods such as citrus fruits or avoiding tomatoes is sufficient and, in many people, we do try to make sure that if they're smoking, that they stop smoking and if they're overweight, are they able to lose some weight. These things may be helpful for reducing the episodes of GERD.

Melanie: And so then, if you were to tell people your best advice, what would you want them to know about GERD and the possibility of PPIs and even the role of hiatal hernia in possibly helping it?

Dr. Koch: I think the main message here is that if you've been taking these types of medications called
“PPIs” for many years; you've been using more than one dose a day; if you're not really sure why your doctor suggested you use this medication, then you need to ask your doctor about re-evaluating the situation. There are several ways this re-evaluation has been done. One way is by actually looking at the food pipe to see if there's been damage from chronic acid reflux. Another way, which can be helpful, is by performing a specialized study of the swallowing of the food pipe and the strength of contractions of the food pipe. This type of study often suggests that there are other treatments available for the reason that the patient has been taking, or the individual has been taking, one of these PPIs.

Melanie: Thank you so much, Dr. Koch. It's really great information and so important for the public to hear. You're listening to Medical Intel with Medstar Washington Hospital Center. For more information, you can go medstarwashington.org. That's medstarwashington.org. This is Melanie Cole. Thanks so much for listening.

Internal Notes: Null
Hosts: Melanie Cole, MS