Medical Intel, brought to you by MedStar Washington Hospital Center - Physican http://radiomd.com/ Thu, 14 Sep 2017 18:18:55 +0000 FeedCreator 1.8.3 (obRSS 1.9) http://radiomd.com/images/podcast-medstar.png Medical Intel, brought to you by MedStar Washington Hospital Center - Physican http://radiomd.com/ AMPLATZER PFO Occluder Device http://radiomd.com/medstarphy/item/34870-amplatzer-pfo-occluder-device amplatzer-pfo-occluder-deviceLowell Satler, MD, discusses the recently FDA-approved AMPLATZER PFO Occluder, including benefits, risks, and best potential candidates for the device. Dr. Satler also explains the implantation procedure, as well as MedStar Heart & Vascular Institute's unique, patient-based approaches to post-surgical care.

Additional Info

  • Segment Number: 5
  • Audio File: medstar_washington/mwp010.mp3
  • Doctors: Satler, Lowell
  • Featured Speaker: Lowell Satler, MD
  • Specialty: Null
  • Guest Bio: Lowell Satler, MD is the Medical Director of the Catheterization Lab at MedStar Heart & Vascular Institute at MedStar Washington Hospital Center.

    Learn more about Lowell Satler, MD
  • Transcription: Melanie Cole (Host): The US Food and Drug Administration recently approved the AMPLATZER PFO Occluder Device, which can reduce the risk of stroke in patients who have previously had a stroke believed to be caused by a blood clot that passed through a small hole in the heart and then traveled to the brain. My guest today is Dr. Lowell Satler. He’s the Medical Director of the Catheterization Lab at MedStar Heart and Vascular Institute at MedStar Washington Hospital Center. Welcome to the show, Dr. Satler. What had been done in the past to prevent recurrent, cryptogenic strokes in terms of PFO closures?

    Dr. Lowell Satler (Guest): As you know, cryptogenic strokes probably occur in up to 25% of young patients. We don’t know the source of the stroke, and we start to look for different particular abnormalities, one of which is a small hole in the heart known as the patent foramen ovale. When we’ve identified a patient with a cryptogenic stroke and a patent foramen ovale, we thought that it might be best to have the patient on some type of anticoagulant. For many years, anticoagulants were felt to be the treatment of choice even though we had other methods of treating it, such as an AMPLATZER PFO Occlusion Device. Until recently, there was no data to suggest that the AMPLATZER PFO Occluder Device was superior to medical therapy and as a result, the only patients that were treated with a PFO occluder device in the past were patients who could not take medical therapy or who had recurrent strokes on medical therapy. With the recent FDA approval of the PFO occluder device for the treatment of cryptogenic stroke, we now have a different algorithm for treating patients and that we can offer them the PFO occluder device early on in their disease management.

    Melanie: What would be some indication for closure with this device? Give us some clinical indications.

    Dr. Satler: It would be a young patient with a cryptogenic stroke for the first time. They are usually evaluated with a series of studies. They’re often seen by either their Primary Care Doctors, or a Neurologist, or even a Hematologist. They’ve all presented with a stroke. They have documentation by a CT or MRI of the stroke, and then an evaluation for the source of the stroke is pursued. This usually involves an echo, which will show the presence of a PFO in a certain percentage of these patients.

    Once we’ve identified the PFO and it appears anatomically suitable for closure, we can now recommend using this device to close the defect. What the AMPLATZER PFO Occluder does is it closes the PFO and thus blocks blood clots from passing from the right atrium to the left atrium. To place the device, usually, we insert a delivery catheter through a vein in the leg until it reaches the heart. Then we would advance the occluder through the delivery catheter and open the left disk in the left atrium and then the right disk in the right atrium. The position would then separate the PFO Occluder Device from the delivery catheter, and you remove delivery catheter leaving the occluder device permanently implanted in the heart. This is all done with guidance by Echo. We use a special Echo called called Intracardiac Echo to allow placement and delivery of the device. The patient then leaves the cath lab and would recover overnight in the hospital to be discharged the following day.

    Melanie: First of all, you mentioned about providers referring to you, and you mentioned Neurologists and Hematologists, so what would cause them to refer?

    Dr. Satler: They’re both evaluating patients with strokes of undetermined etiology at first and if they cannot find another source – a common source might be carotid disease, it might be an irregular heart rhythm – if those are not identified, somewhere in the evaluation an Echo is usually performed, which may demonstrate a patent foramen ovale.

    Melanie: Let’s compare medical treatment versus this closure device. When you were using medication -- who would not be a candidate for the device?

    Dr. Satler: You have to have certain anatomic requirements so the device would actually fit properly, but the recent trial demonstrated the following important findings. This was known as the RESPECT Trial. It took six and a half years to finally show a positive conclusion, but a better way of looking at this is that if a thousand stroke patients were treated with this device, about six of these patients would have an additional stroke within one year, compared to twelve patients who would have an additional stroke if they were just treated with blood thinning medication alone. Another way of saying this is that there would be a 50% reduction in the incidence of stroke.

    Melanie: Dr. Satler, then when you’re talking about the procedure itself, tell us about using imaging studies for the patient before and during the procedure.

    Dr. Satler: Before, most of the imaging that identifies the defect is either a surface echo, or 2D echo, or a TEE, to better define the septum and the abnormalities in the septum. Once the defect is identified, and if we decide to treat, the device is implanted with a different type of Echo -- it’s called an Intracardiac Echo. This is a small probe that is placed into the right atrium, and it allows us to visualize the entire intracardiac anatomy for the precise placement of the device.

    Melanie: And what might be the complications for the occluder?

    Dr. Satler: They’re small, but they do exist – perforation of the heart, infection, a blood clot during or after the delivery, and then very rarely, erosion of the device through the heart. There are certain types of patients that we would not treat. It should not be used in patients who have a tumor or a blood clot at the device implantation site, or a blood clot in vessels along the path to the heart, blood vessels that are too small to allow performance of the implant procedure, have a body organ such as a heart muscle, heart valve, or blood vessels that do not permit placement of the required device, have other congenital heart defects, or have an active infection or an untreated infection.

    Melanie: Who would be the continuing provider after this procedure?

    Dr. Satler: It’s a team approach. It would be the Cardiologist, the Primary Care Physician, and even the Neurologist to monitor for additional events.

    Melanie: And what are some of the recommendations for medicational intervention after discharge? How long does a patient need to be on them?

    Dr. Satler: We usually have patients on Aspirin and Clopidogrel, or dual antiplatelet therapy for a period of two to three months, after which time, we stop the Clopidogrel. Our main recommendation is that if anyone is going to have any kind of elective procedure, we prefer them to wait for six months. During that first six months, there is healing of the device, and the interlining of the heart covers the fabric of the device. If any type of elective procedure is performed in the early portion of that six months, there is the potential for bacteremia and an infection of the device. We recommend routine SBE prophylaxis for the first six months after the device implant. In general, we try and avoid any kind of dental manipulation for the first six months after the device implant. Certainly in patients who need any kind of dental work we recommend that be performed prior to the device implant.

    Melanie: Have you seen any leakage in the implant post-procedure?

    Dr. Satler: We achieve over 85 to 90% complete closure of the residual defect, and so there is a small percentage of patients that will still leak after the device is implanted. For those patients, we can either continue them on additional anticoagulants or antiplatelet therapy or in some case we can identify the residual leak and place an additional device.

    Melanie: Dr. Satler, do you think other providers are aware of the possibility of referral and the FDA approvals at this point?

    Dr. Satler: We have found at this point in time that the recognition of approval of the PFO Occlusion Device is not known in most of the medical communities, both Cardiology, Neurology, Hematology, and even the Primary Care Physicians. Everyone has been used to the fact that the data, until October of 2016, was not strong enough to support the approval, but after the RESPECT trial with a six-year follow-up, the data was strong enough for the FDA to approve it in October.

    Melanie: So what would you like to tell other physicians about the AMPLATZER PFO Occluder Device for cryptogenic stroke – give your best advice, what you want other physicians to know about recognizing this approval and looking into this device or referral?

    Dr. Satler: Going forward, we now have an effective tool to reduce the likelihood of stroke in patients with cryptogenic strokes that have PFOs. We can effectively reduce the likelihood of recurrent strokes by 50%. It simplifies the patient management as they no longer require lifelong antiplatelet or anticoagulant therapy. Particularly for this young patient population, it allows a less complicated management course.

    Melanie: Thank you, so much, Dr. Satler, for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center, and 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
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David Cole Tue, 28 Feb 2017 00:02:46 +0000 http://radiomd.com/medstarphy/item/34870-amplatzer-pfo-occluder-device
Cervical Disc Replacement http://radiomd.com/medstarphy/item/34624-cervical-disc-replacement cervical-disc-replacementOliver Tannous, MD, discusses the surgical options for treating cervical disc disease and related issues, including the emerging approach of cervical disc replacement. Dr. Tannous also explains the research and FDA approval process surrounding disc replacement, as well as the promising benefits: a more rapid recovery, fewer complications, and a reduced risk of subsequent surgeries to address adjacent segment disease.

Additional Info

  • Segment Number: 1
  • Audio File: medstar_washington/1702mwp4a.mp3
  • Doctors: Tannous, Oliver
  • Featured Speaker: Oliver Tannous, MD
  • Specialty: Null
  • Guest Bio: Oliver Tannous, MD, is an orthopaedic spine surgeon at MedStar Washington Hospital Center.

    Learn more about Oliver Tannous, MD
  • Transcription: Melanie Cole (Host): The standard initial treatment for symptomatic cervical disc disease typically involves physical therapy, medications, and occasional spinal injection procedures. If the symptoms continue and are very bothersome for more than six to twelve weeks, surgical treatment might be considered. My guest today is Dr. Oliver Tannous. He’s an Orthopedic Spine Surgeon and a member of MedStar Orthopedic Institute at MedStar Washington Hospital Center. Welcome to the show, Dr. Tannous. What’s typically been done for cervical disc disease and issues?

    Dr. Oliver Tannous (Guest): Hi Melanie, thanks for having me. For one it’s patients who have already failed conservative care. They’ve failed physical therapy, injections, they’ve given it time, they continue to have symptoms in their disc disease. The standard of care for the past 30 years has been a discectomy and a fusion, meaning what you do is you go in, you take out the disc, you take out whatever’s pinching on the nerve, you relieve the pressure off the nerve, and now, instead of the disc being there, there’s a big space. You put a piece of bone and over time, the patient’s natural bone -- at the level above and the level below -- fuses into the bone graft that you put into the patient. It’s called a fusion or an ACF, which stands for an Anterior Cervical Discectomy and Fusion. That, still today in 2017, is the gold standard for cervical degenerative disc disease, but the caveat to that is that there’s new technology now for cervical disc replacement that are showing some really promising results over the past 10 years. There is a movement now towards trying to treat cervical disc disease in some patients with a disc replacement as opposed to a fusion.

    Melanie: So tell us about the disc replacement. Who might be a good candidate for this?

    Dr. Tannous: People who are the best candidates for a fusion are typically patients who are going to be between the ages of 30 and 60. They can’t have a lot of arthritis -- the problem with arthritis is that it limits motion and it makes things more stiff. If you think about the spine, there are essentially two parts to the spine. There’s the front part, which is in front of the spinal cord. There’s the back part, which are the facet joints, which are behind the spinal cord. When we do a discectomy, it’s the front of the spine -- we’re taking the disc out from the front -- but you have to understand that we’re not going after the facet joints in the back. In patients who have normal looking facet joints, they’re great candidates, in general, for a disc replacement because they’re going to have normal motion in the joints in the back. But if you’re too old, or if you have too much arthritis and the facet joints are too arthritic, typically most surgeons today would do a fusion, as opposed to a disc replacement because you don’t want to increase the range of motion through an arthritic joint, it would cause excess pain.

    Melanie: So then speak in the disc replacement about motion preservation and adjacent segment disease and how this changes that.

    Dr. Tannous: Absolutely. A little bit about adjacent segment disease, in its simplest definition -- if you think about doing a fusion is you have seven levels in the neck that are moving. When you do a fusion -- if you lock up that level by doing a fusion -- now the motion that would have otherwise been absorbed by that level goes to the level above or the level below so you increase the stress that’s being experienced at the level above or the level below. When patients come in, they have degenerative disks, and typically they’ll have it at multiple levels, but we only go after the one level that’s being symptomatic. When you fuse that, now discs above it or below it that already have some level of degeneration – the process accelerates the degeneration of discs above it or the discs below it. It’s called adjacent segment disease and overall, the rate is about 2.5 to 3% per year of increased degeneration, meaning at ten years, 25% of people who have already had a fusion will need a fusion at the level above it or the level below it because of symptomatic disease at those levels. That’s where the concept of the disc replacement came in. The theory is if you put a disc replacement and maintain the range of motion of the spine, you eliminate that increased stress that gets absorbed at the level above it or the level below it. That’s the concept of adjacent segment disease.

    Melanie: And based on this theory, what’s recovery like for patients for cervical disc replacement?

    Dr. Tannous: In my experience, patients who have disc replacements recover a lot faster. I don’t put them in a brace. In fact, you don’t want to put patients in a brace after a disc replacement because you want them moving through the implant, you want them to preserve that range of motion of the neck and you don’t want them to get stiff versus when patients have a fusion, you put them in a brace – and most surgeons will put patients in a brace from anywhere from six to twelve weeks -- because you want to lock up that level, you want the spine to fuse. You don’t want to increase the motion to that segment while things are healing. In my experience, the recovery rate for disc replacement’s much quicker. I’ve had patients go back to work within three to four days. After the surgery, they typically leave the hospital the morning after having had the surgery. I’ve seen incredible results with a disc replacement.

    Melanie: Tell us about the FDA approval process for it.

    Dr. Tannous: So you have to understand, anterior cervical discectomy and fusions -- so ACDF, meaning the anterior fusion -- has been the gold standard for the past 30, 40, 50 years and it still is, today, the gold standard because it is an extremely successful procedure. In spine surgery, it’s arguably the most successful surgery in the spine world. In order for the FDA to approve a disc replacement, you have to at least show that a disc replacement is not inferior to the standard of care, which is cervical discectomies and fusions. In the 2000’s, several companies that started studying this through IDE trials that got approved by the FDA, meaning they allowed them to test these implants for the specific purpose of getting it FDA approved. These were randomized, prospective, multicenter level one studies that were overseen by the FDA. As far as Orthopedics Research is concerned, these are the most meticulous studies in the Orthopedic and the Spine literature because they have to be because they’re being scrutinized by the FDA.

    In the 2000s, they studied one-level disc replacement and overall, what they found, is that there was some trend that the disc replacements were superior to fusions with regards to patient outcomes, with regards to pain improvement, with regards to subsequent surgeries for adjacent segment disease. They didn’t find that most of these were statistically significantly greater, but at least what they found was that they were definitely not inferior to fusions. That prompted the FDA in the mid to late 2000’s to approve one-level disc replacement for multiple companies. Again, they couldn’t find a statistically significant increase in adjacent segment surgery between one or the other for one-level.

    Now, for two-level disc replacement – and now so far two companies have been approved for it – one this past summer, and one back in 2013 for two-level disc replacements. Both of these show, actually pretty impressive results. For two-level fusion versus a two-level disc replacement, the reoperation rate – meaning you have to go back to the OR because either you didn’t fuse, or now you have another disc that’s degenerative, or you have some complications in the surgery – for two-level disc replacement, the reoperation rate is 16% versus 4% and that’s for one company. For the other company, they found a reoperation rate for two-level fusion of 15% versus 4% for two-level disc replacement and these are statistically significant numbers, so some potentially very promising data and these are five- to seven-year results for both of these companies, with both of these implants.

    The rate of adjacent segment disease for one company – sorry from one implant for two-level fusion, the rate of adjacent segment disease was 11% versus only 3% for a disc replacement. And for the other one, it was 12.5% for a fusion, versus 6.5% for a disc replacement. These numbers are very promising. We’re now at the seven-year mark for some of these two-level disc replacement studies and they’re showing very promising results with very low complication rates for these implants. In my opinion, I think for a younger patient who doesn’t have a lot of arthritis in the back or the neck, who doesn’t have a cervical deformity, who doesn’t have any other contraindications, I think a two-level disc replacement might be a better way to go than a two-level fusion.

    Melanie: And what are some indications for referral – you just mentioned a few, but continue along that line and wrap it up for us, with your best advice about cervical disc replacement.

    Dr. Tannous: What I tell my patients -- and I saw every patient just before every surgery -- is that as a spine surgeon, I’m best at treating arm pain, or leg pain. When the nerve is being pinched and now you have disease in the spine that’s causing pain to travel down your arm or your leg there’s a 90 to 95% chance or more that I can make that pain go away as a surgeon. When patients come in and they say that they have predominantly just neck pain, without the arm symptoms, I don’t have a great surgery for that, unfortunately, because there are so many things that can cause neck pain. So really, I think the best candidates for a cervical disc replacement, or cervical spine surgery in general, are ones who are going to have predominantly arm symptoms because the nerve is being pinched, as opposed to the ones who aren’t as good candidates, or the ones who have predominantly neck symptoms without the nerve symptoms. I tell that to every single one of my patients and I really stress that in the clinic, before the surgery, and I emphasize that right before we go back to the operating room because we have to understand what the goals of the surgery are. We’re relieving arm pain, and not neck pain, in general.

    Melanie: And what would you like to tell other physicians, Dr. Tannous, about adopting this procedure and looking at some of those numbers you mentioned?

    Dr. Tannous: Well, first and foremost, I want to really stress that as in everything else in spine surgery, the best approach is a conservative approach. I treat 95 plus percent of my patients with the utmost conservative care, meaning we try everything that we can before we talk about surgery because most patients get better without surgery. Now, once they’re surgical candidates and they’ve failed everything else – and again you have to understand that this isn’t technology that is already been to be proven to be far superior. It’s promising, but the standard care today still is a fusion, but there's some very promising data out there to show that disc replacements are going to be the wave of the future. As with everything else, you don't just jump right into it, it’s a discussion with the patient. The patients have to understand the risks, the benefits, the alternatives and try everything possible before talking about going under general anesthesia and having a procedure done.

    Melanie: Thank you, so much, Dr. Tannous, for being with us today. You’re listening to “Medical Intel” with MedStar Washington Hospital Center and 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
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David Cole Sun, 22 Jan 2017 19:41:45 +0000 http://radiomd.com/medstarphy/item/34624-cervical-disc-replacement
Urologic Reconstruction and Indications For Referral http://radiomd.com/medstarphy/item/34531-urologic-reconstruction-and-indications-for-referral urologic-reconstruction-and-indications-for-referralKrishnan Venkatesan, MD, discusses the specific conditions that may require urologic reconstruction, including erectile dysfunction (ED), Peyronie's disease, urinary fistulas, and urethral stricture. He outlines best practices in speaking to patients about these oftentimes sensitive subjects, as well as how to recognize when they might benefit from an appointment with a specialist.

Additional Info

  • Segment Number: 4
  • Audio File: medstar_washington/1701mwp3d.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): The surgical treatment of complicated urologic disorders in men requires extensive expertise and performing delicate surgeries. My guest today is Dr. Krishnan Venkatesan. He’s the director of Urologic Reconstruction at MedStar Washington Hospital Center. Welcome to the show, Dr. Venkatesan. Let’s just start with what has typically been done in the past for men with various urologic dysfunctions.

    Dr. Krishnan Venkatesan (Guest): Hi, Melanie. Thank you for having me. Urologic dysfunction is a broad term, but for many men it can range from any issue, such as trouble with erection, or a curvature with erection, or trouble with urination. Generally, there has been a culture of machismo where men don’t see a doctor regularly and they don’t really seek out any kind of medical care until it’s too late or until the condition gets quite bad. Urologic conditions fall very much into that category of things that guys may be too shy to bring up with their wife, and even too shy to bring up in the locker room, so to speak. So, generally, what we like to encourage is that when primary care physicians are seeing gentlemen for any condition that they also try to broach the topics of how’s the urination, is their urinary quality of life good, or are there bothersome symptoms that they’re having that were so progressive that they didn’t really occur to them and they were just adjusting. And, similarly, for erectile dysfunction, if they’re having an issue in that department, so to speak, it’s something that we try to make very much a judgment-free zone and without any awkwardness so that men can feel comfortable bringing it up and speaking freely about it.

    Melanie: What are some of the conditions that would indicate further referral or possibly reconstruction?

    Dr. Venkatesan: As far as the indications or the conditions that would need reconstruction, generally they are divided into the anatomic differences in men. So, one condition would be urethral stricture, which is basically a scar tissue or obstruction in the urethra, which is the pipe that passes urine from the bladder to the outside world. So, this stricture can occur from any number of reasons. in fact, in almost half of men there’s no clear explanation, but in many men it could be a result of trauma, like landing hard on the bicycle bar, or on a handlebar, or on a stairwell, or even during horseplay, if there’s some trauma to the genitalia or the perineum, the area behind the scrotum, this could result in some damage to the urethra. It could also be a result of prior procedures, having had a catheter before, or even an infection. Some of the other conditions include urinary tract fistulas. A fistula is basically an abnormal connection between two adjacent structures. So, it could be a hole from the urethra to the skin or a connection from the rectum to the urethra, depending on what treatments the patient had previously or what other pathology the patient might have underlying. These fistulas generally are unlikely to heal with conservative management, so they may need surgery to repair them. There’s also a condition called hypospadias, which is actually congenital. This is when boys are born with the opening of the penis not right at the tip of the penis but rather on the underside somewhere along the shaft. Aside from being a cosmetic issue, in the long run that opening can get tight and cause urinary obstruction, and it can also cause issues with the ability to conceive children because men cannot deposit semen in the right location to be able to impregnate a female. There’s also other anatomy that basically could require reconstruction. Men can sometimes develop a curvature with erection. This is commonly known as Peyronie’s disease, and this may require surgery for correction. Not all men require surgery, but if the curvature is bad enough that they’re not able to penetrate, or if it’s painful to penetrate, or it’s painful for their partner, then it may be something that needs specific interventions. There’s also erectile dysfunction itself which may need either medical or surgical intervention. Then, there are also other traumatic injuries, like we mentioned previously, such as ureteral injury. The ureters are basically the tubes that connect the kidneys to the bladder and deliver urine that the kidneys make down into the bladder. These can be injured generally from other surgeries that are going on in the abdomen. They can be injured by stone surgeries or any manipulation of the ureters themselves and, of course, can be injured by outside trauma, such as blunt or penetrating trauma. That goes really for any other part of the urinary tract. Kidney trauma may require surgery, although that’s not that common that it does. Bladder injuries as well as injuries to the penis and urethra and testicles and anything else in the scrotum may all require some kind of intervention and sometimes, depending on the trauma, that may need to be done emergently.

    Melanie: What are some of the current thinking in treatment approaches, doctor, because certainly, you mentioned at the beginning, getting men in to see the doctor is certainly a thing, so doctors have to be aware of that ability to get men to take action with some of these. So, what do you tell men and what it the current thinking in some of the treatment for urinary tract fistulas, for example?

    Dr. Venkatesan: The general treatment for fistulas and for most conditions, the philosophy is to basically go from least invasive and end with the most invasive treatment option. So, if there’s something that is available that is the least invasive, the least likely to cause additional side effects or risks or compromise from the treatment itself, and has the quickest recovery, that’s obviously the most ideal option. The example I actually like to give is, for example, for erectile dysfunction, treatment starts with pills like Viagra and Cialis, and if those don’t work, moves on to a vacuum erectile device, and beyond that, then injections where the patient actually has to learn to inject themselves directly into the penis with the medication. And then, lastly, the most invasive option would be a penile prosthesis, which is actually a surgically implanted device that can restore erective function. Of course, the treatment options are not the same for different conditions, but the general philosophy is that surgery generally ought to be a last resort. Sometimes, there are not many other options aside from surgery, but if we can be conservative, then we’ll certainly try to be.

    Melanie: What about indications for referral? If somebody has a urethral stricture or even BPH and their first line of defense is not working, give us some indications for other physicians for a referral?

    Dr. Venkatesan: That’s a good point. Any time the patient has a known diagnosis or something like urethral stricture where they may have been treated many years ago and they finally realize that their symptoms have recurred; they’re having a slowing stream, trouble emptying, recurring infections, bladder stones, or a worst case scenario where they’re actually having some retrograde effect and it’s affecting their kidney function, then all of those are good indication or a good reason to refer somebody to a reconstructive urologist. Similarly, if you have a patient who has a known diagnosis of BPH or a presumed diagnosis of BPH, but they’re not responding to the first-line medications such as Tamsulosin, or their symptoms are progressively worsening despite being on medication, then that would be a good indication for the patient to see a urologist or perhaps even a reconstructive urologist to ensure that there’s no other underlying pathology that could be a confounding factor, like a stricture, for example, which will cause many of the same symptoms but won’t really respond to the BPH medication.

    Melanie: And, what does the surgical game plan involve, who do you involve in all of this?

    Dr. Venkatesan: The surgical game plan generally, of course, depends on the surgery that’s necessary. I work closely with my plastic surgery colleagues. So, for patients who have complex fistulas, we may need to recruit one of the muscles from the inner thigh to help sandwich that between the two areas that are having an abnormal connection. So, in that case, I will do part of the surgery to expose that anatomy, and then the plastic surgery team will come in and harvest that muscle that’s called the
    “gracilis muscle”, and then they may interpose that between the bladder and rectum or the urethra and the rectum, and, in that case, of course, it’s a kind of a tag team approach. Otherwise, the surgical game plan, in general, for all patients starts with a good preoperative visit where we discuss all the treatment options. We discuss what is the best option for them and then we discuss the technical aspects of surgery, like how exactly I am going to do it; then, we talk about the risks, and we talk about the recovery; and, of course, we get all the patient’s questions answered. The important thing is that the patient is on the same page as us as far as expectations from surgery and that there are no surprises on the day of or afterwards.

    Melanie: Wrap it for us, Dr. Venkatesan. As reconstructive surgery for men in urologic conditions, what do you tell your patients and what would you like other physicians to know about speaking to their patients about these delicate procedures?

    Dr. Venkatesan: I think the best philosophy is that quality of life is very important, and patients often find it difficult to bring this up. So, sometimes the onus is 50/50. It is just as important for a primary care physician or that frontline of healthcare professionals to help bring this up and to help address those issues and triage them appropriately. The reason I say that is not only because quality of life is important for happy healthy people, but also because sometimes these are conditions that are the sentinel signs of some other underlying dysfunction. To go back to erectile dysfunction, for example, erectile dysfunction may be the first sign of some other cardiovascular disease or arteriosclerotic disease happening systemically. So, often in a patient who believes he’s otherwise healthy or has really never seen or followed up with a doctor, if he presents with complaints of erectile dysfunction, that’s a good conversation starter for a primary care doctor, or for a urologist, for that matter, to say, “Hey, there’s no clear explanation for this problem, we ought to probably have you get checked out and do a comprehensive health evaluation.” So, it’s helpful in both directions.

    Melanie: Thank you so much for being with us today, doctor. You are you 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
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David Cole Tue, 10 Jan 2017 01:21:07 +0000 http://radiomd.com/medstarphy/item/34531-urologic-reconstruction-and-indications-for-referral
Partial Joint Replacements http://radiomd.com/medstarphy/item/34514-partial-joint-replacements partial-joint-replacementsEvan Argintar, MD, discusses the varying types of knee replacement surgeries, including total, partial, and a new hybrid surgical approach that combines arthroplasty with cartilage restoration techniques. Advancements such as this provide the opportunity for faster recovery and maximized function.

Additional Info

  • Segment Number: 3
  • Audio File: medstar_washington/1701mwp3c.mp3
  • Doctors: Argintar, Evan H.
  • Featured Speaker: Evan H. 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.

    Learn more about Evan Argintar, MD
  • Transcription: Melanie Cole (Host): Uni-compartmental knee arthroplasty has had varying degrees of acceptance since its introduction approximately thirty years ago. However, with the introduction of more minimally invasive technologies this procedure has seen an increased interest. 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. For people who've had knee pain and require surgery, what's typically been done in terms of joint replacement?

    Dr. Evan Argintar (Guest): I always like to start off by saying that joint replacement is the last option, but the unfortunate reality of arthritis is that it's a condition that's not curable. Cartilage doesn't have blood flow and for that reason, it can't heal. So, when non-operative management fails and that's traditionally activity modification, anti-inflammatory medication, bracing, physical therapy. When that fails, in general, the only predictable outcome that improves clinical measures would be joint replacement. Traditionally, people favor doing a total joint replacement or total knee replacement. However, that's a big surgery and that replaces all three compartments of the knee, the medial, the lateral, and the anterior or the patellofemoral joint. Because some individuals have worse disease in one or two out of the three compartments of their joint, this created the need for another alternative which is also known as “partial knee replacement”. Today in 2017, partial and total knee arthroplasty are the mainstays of surgical treatment for the arthritic knee.

    Melanie: Dr. Argintar, what are some of the radical advantages of the procedure as it stands now?

    Dr. Argintar: Whenever I'm discussing the pros and cons of partial and total knee replacement, the first thing I make clear to them is that both are good operations for the right person. The problem with total knee replacement is that unlike a hip, which is a true joint replacement, meaning everything that is removed surgically is replaced, knee placement is a little bit different. I say that for two reasons, one, in general, when you do a knee replacement you have to sacrifice ACL and usually you sacrifice the PCL. These are two ligaments that provide the knee with rotational stability on the inside of the knee and they also have proprioceptive fibers which allow your brain to, in a sense, know where your knee is. It helps with the kinematics normal function of the knee. Additionally, with a total knee replacement you change the orientation of the joint line and this, in general, creates a new knee, what I usually call a replaced knee but not exactly what you are starting with. So, patients with a total knee return a little bit slower and have some restriction that perhaps someone with a partial knee does not have. That would be one difference. Now, again, if all three of your compartments are bad, then a total knee replacement is a great option but if you're someone who has horrible medial knee arthritis and your other two compartments aren't quite as bad, then sometimes the partial knee is a better option. Conversely, with a partial knee, you keep most of your stuff. By stuff, I mean the compartments that aren't diseased or are not advanced diseased. This means that you have more normal function, faster recovery, and you maintain the ligaments on the inside of your knee.

    Melanie: Dr. Argintar, what is the current thinking for you? What are you doing that's a little bit unique and combined with a partial knee replacement?

    Dr. Argintar: That's a great question. People who don't subscribe to the partial knee replacement would say, well, if you have one bad compartment and you have another one that is where the writing is on the wall, you might as well just bite the bullet, call a spade a spade and replace the whole thing because really that is the downside of partial knee replacement. The very upside to it, which is preservation of the rest of your knee, well, that can get worse. So, in five years, in ten years, in twenty years or forty years, you might find that you have to convert that over to a full knee replacement. Really, the million dollar question is how much time of activity preservation with a partial knee would make that surgery a surgical value to someone if even they knew it had to be converted to a full knee replacement. Most experts believe that that number is somewhere around a decade and that's been my results. The interesting thing that I'm doing is combining elements of the sports world, sports orthopedic surgery, specifically cartilage restoration with arthroplasty. I believe this has giving me a hybrid surgical option that is somewhere in between partial knee replacement and full knee replacement. What I've been doing is in very unique situations when people have advanced arthritic disease in one portion of their knee and perhaps some mild disease in the other of the three compartments, is that I do the partial knee replacement. Then, I do some element of cartilage restoration. Cartilage restoration means doing something to stimulate the knee to heal and create a fiber cartilage which is better than nothing. Not quite as good as what you're born with and this can be accomplished in lots of different ways. You can transfer plugs of cartilage from part of the knee to the arthritic knee and, in fact, when you're doing a partial knee replacement you resect the arthritic component of the knee and oftentimes there are little pockets of cartilage that you remove that are actually quite normal and before I remove these I take them and just simply transfer them over to the other side of the knee where it needs some help. There are other options called “micro-fracture”. That's a traditional surgery where you poke holes in arthritic areas that are deficient of cartilage and you can help to stimulate a fiber cartilage growth, which is something in 2017 we have ways of making this better. Now I use a proprietary substance called bio-cartilage which is minced up juvenile cartilage which we think has the ability to help stimulate the production of even better cartilage, something similar to a fiber cartilage. The long and short of it is that not all knees can be treated the same. It's not just a partial, it's not just the total. There might be this whole area in between which maximizes function and minimizes the restrictions inherent with the full knee replacement.

    Melanie: Are there certain indications for patient eligibility? Younger patients might be candidates for this. Are older patients exempt from this type of cross procedure?

    Dr. Argintar: That's a very interesting question. The original literature that guided orthopedic surgeons for partial knee replacement was actually found in the geriatric population. The population that was a little bit more sedentary but had more focal arthritic injury because the results of knee replacement are a little bit unpredictable, a uni-arthroplasty was then applied to a younger active population. For me, when I'm doing a partial knee replacement, a total knee replacement, or this hybrid what I call a bio-plasty, I don't really allow age to factor into the discussion. Really,, I look at people more based on what is the condition of their knee and also, more importantly, what are their goals, what are their activities, what will they be happy with, what restrictions they can deal with. That being said, I think my most successful clinical outcomes with this type of bio-plasty hybrid surgical approach are in the younger patients who have come to me for second or third opinions, are not excited about a full knee replacement and are excited about doing something else which preserves functions, preserves their youth, and preserves their level of activity.

    Melanie: After surgery while the joint surface is protected while that cartilage heals, what do you tell patients about living with this new knee the way that it is now? Are there any limitations for them?

    Dr. Argintar: The answer is not really. A true statement is that the more you work, or run, or jump on these arthroplasties, the quicker they do run out. That being said, the person that I'm offering those bio-plasty to is someone who I want to be active, who I want to not modify their activities, so they can maintain their youth and their active lifestyle. So, I don't give them any restrictions. I do find that the recovery is faster and so far I have been very happy with the subset of patients who have been a good candidate for this surgery.

    Melanie: Wrap it up for us, Dr. Argintar, with what you want other physicians to know about using that world of sports medicine and combining it with orthopedic surgery, why that's so unique and what you want them to know about it.

    Dr. Argintar: It's a unique approach and I think in 2017, we have to be open to new things but we have to approach new things guarded. There are many excellent examples of exciting innovations in orthopedic surgery that simply didn't work out. What I find so attractive about this type of hybrid surgical approach is that each of these surgical options, that being arthroplasty and cartilage restoration, have independently been validated within the spectrum of their own specialty. What's unique about my approach is that I do a lot of arthroplasty and a lot of sports medicine and I've fused these two well-established, evidence-based medicine approaches together in the hope of finding a solution that is not, shall I say, the norm or currently offered. I would ask clinicians as they have their youthful, young, active patients who are perhaps slowly getting arthritic disease to be aware that there are other options available for their patients and they should seek out providers who are comfortable in describing and implementing these types of approaches.

    Melanie: It's great information. 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 Cole. Thanks so much for listening.
  • Internal Notes: Null
  • Hosts: Melanie Cole, MS
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David Cole Sun, 08 Jan 2017 21:06:58 +0000 http://radiomd.com/medstarphy/item/34514-partial-joint-replacements
The New “Pathway” For MedStar Physicians http://radiomd.com/medstarphy/item/34501-the-new-pathway-for-medstar-physicians the-new-pathway-for-medstar-physiciansMichelle Magee, MD, explains how an intensive diabetes "boot camp," combined with a new blood glucose monitoring system, is making dramatic strides in reducing patients' A1C levels. This new technology provides real-time results, allowing diabetes educators to contact patients and uncover why blood sugar spikes are occurring.

Additional Info

  • Segment Number: 2
  • Audio File: medstar_washington/1701mwp3b.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): A 12-week diabetes boot camp intervention offers learned centered survival skills education and algorithm driven DM medication titration by endocrinologists who provide certified diabetes educators. My guest today is Dr. Michelle Magee. She’s an endocrinologist and the director of the MedStar Diabetes Institute a MedStar Washington Hospital Center. Welcome to the show, Dr. Magee. Tell us about this 12-week diabetes boot camp intervention.

    Dr. Michelle Magee (Guest): Well, we have noticed that there are many patients who are living with diabetes who have a hard time getting their arms around how to optimally control their blood sugar so they can live well with their diabetes. So, what our boot camp program is, is it’s a 12-week intensive program where they come in to see us two times on site; we give them an exciting new technology device that’s a blood glucose meter that sends us all of the sugars that they do. Then, they graduate to our virtual visit center where, for another 8-10 weeks, we speak with them frequently and make sure they’ve received what we call “survival skills education” and have had frequent adjustments to their diabetes medications so that by the time they’re done, their sugars are much improved from when they came into the program.

    Melanie: Is there an issue with them taking their blood glucose and this monitor? Tell us about the monitoring system and how it works and the adherence issues you might run into.

    Dr. Magee: Yes. So, the system we’re using is the Telcare blood glucose monitoring system. It’s a cellular enabled blood glucose meter which is exciting. It sends the sugars, not by Bluetooth with an expensive data plan, but by a cellular network so there’s no charge to the patient for data. Every sugar that they do, as long as they’re within the cellular network, is sent to us and appears on a dashboard that our diabetes educators look at. In the pilot study, we gave it to the patient and gave them enough strips to do two sugars a day and so that’s what we’re doing in the ongoing clinical study. It is covered by most insurance plans and we help the patient to do the paperwork that’s necessary to get supplies into their hands of the strips that they need for this meter.

    Melanie: So, tell us about the review by the certified diabetes educators to review these blood glucose levels and what happens next.

    Dr. Magee: So, each day, they go to their dashboard and each of the patients who is participating in the program appears there and they quickly scan through to see who’s having high sugars; who’s maybe having low sugars and even who is not checking any sugars and then we reach out to each individual based on what we’re seeing and talk to them about either their highs or their lows or encourage them to do the checking so that we can watch their sugars. We frequently find that this has really been a game changer both for the patients and the educators. It is quite a transformation to be able to see the sugars, to call the patient at a moment in time when they’re having a high or a low so that we can ask them why they might be high or low. One of my favorite stories is a patient has been doing quite well since he came into the program. His sugars were all down under 200 having come in with a high of 400. One day, we see a 400, the educator calls him. Turns out he’s in McDonald’s having a sweet tea. So, that was the big Eureka moment for him. He realized that he cannot do that and live well. So, the educators get the sugars. They don’t have to deal with sugars written in a log book, they can look at them when the patent’s here, when the patient’s not here. So, the patient, in a way, feels like someone’s looking over their shoulder and helping them along.

    Melanie: And then, what do the patient’s do with that report? Do they return to their primary care practices with this progress report? What happens then?

    Dr. Magee: Well, this is being done in full collaboration with MedStar’s internal medicine providers. They actually order the past pathways for the patient and at points along the way, if we need to make major changes, we let the primary care provider know what we have done medication-wise. At the end, we send them a report with what the patient’s values were when they came in, what they are at the end and any further ongoing recommendations for diabetes management or education.

    Melanie: Did the majority of your patients use the smart meters successfully and report increased adherence with their blood glucose testing and do you think, in your opinion, that this was because they knew they were being monitored?

    Dr. Magee: All of the patients could use to learn the meter. We were really pleased by that. We were worrying about some of the elderly patients—whether they could do it. But, really, it works just like any other blood glucose meter and if you spend a little time with a patient, they can use it. Then, yes, I think certainly told us that having them watched was a good motivator for doing the values so that we wouldn’t be calling them to ask them where they were.

    Melanie: Makes a lot of sense. So, tell us about 6 months down the line.

    Dr. Magee: So, six months down the line, of course, is the billion dollar question in terms of health economics and it’s one thing to get the A1C down and another to keep it down. I don’t yet have six months data for the patients who were in the pilot in an on-going fashion but what I do have is information on how they’re having less frequent visits to the emergency room and to the hospital. So, we were very pleased to see that at 30 days, we had a 27% reduction in risk for hospital visits and emergency room visits and at 3 months, that reduction was 63%. Then, to answer your 6 months question, a small tweak upwards in the tail at 6 months to about 45%. So, we do need and we’re just beginning to address support strategies for ongoing maintenance of glycemic control and we’re looking at such things as the dashboard being taken back in by the internal medicine providers and residents as devices that actually look at blood sugars and insulin doses and generate recommendations for adjustments and for web-based coaching programs that can assist the patient in an ongoing fashion and track along with their sugars and reach out to them when they appear to be falling off the rails again.

    Melanie: Dr. McGee, tell us about the evidence and what it demonstrates and then wrap it up for us as where you see this particular pathway taking patients down the line.

    Dr. Magee: I think this shows us clearly that patients need a certain amount of core survival skills education in order to manage their diabetes medications and the multiple variables that impact their blood sugars on a daily basis; that if we can assist the primary care provider in making frequent adjustments to medication rather than having them done every quarter when they come in for their standard diabetes care visit, then we can get patients to their goal blood glucose levels. We’re very excited about this and we are now working on rolling it out and spread throughout the system to other hospitals and to other primary care practices so the providers can avail of the boot camp and offer it to their patients with uncontrolled diabetes.

    Melanie: Thank you so much, Dr. McGee, 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
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David Cole Wed, 04 Jan 2017 00:56:38 +0000 http://radiomd.com/medstarphy/item/34501-the-new-pathway-for-medstar-physicians
Minimally Invasive Vascular Surgery http://radiomd.com/medstarphy/item/34492-minimally-invasive-vascular-surgery minimally-invasive-vascular-surgeryListen as Edward Woo, MD, director of the MedStar Vascular Program, and Misaki Kiguchi, MD, vascular surgeon with MedStar Heart & Vascular Institute, discuss the latest advances in treatments of vascular disease and how minimally invasive technologies can provide better patient outcomes.

Additional Info

  • Segment Number: 1
  • Audio File: medstar_washington/1701mwp3a.mp3
  • Doctors: Edward Woo and Misaki Kiguchi
  • Featured Speaker: Edward Woo, MD and Misaki Kiguchi, MD
  • Specialty: Null
  • Guest Bio: Edward Woo, MD, is director of the MedStar Regional Vascular Program. In this role, Dr. Woo oversees vascular surgery for MedStar Health. He is also chairman of the Department of Vascular Surgery at the MedStar Washington Hospital Center and a professor of surgery at Georgetown University. Dr. Woo performs all types of vascular surgery and has a keen interest in aortic disease, specifically aortic aneurysms. He has a large practice in peripheral vascular disease and carotid disease as well as all aspects of vascular surgery. Dr. Woo has published more than 100 papers, and he has led numerous clinical trials. He is known and respected throughout the world and is asked to lecture internationally for his expertise in vascular surgery.

    Learn more about Edward Woo, MD

    Misaki Kiguchi, MD, is a vascular surgeon with the MedStar Heart and Vascular Institute (MHVI) with office hours in Washington, DC and Chevy Chase, MD.

    Learn more about Misaki Kiguchi, MD
  • Transcription: Melanie Cole (Host):  Technologic advances over the past decade have had a major impact on the treatment of vascular disease and created a new and exciting work environment for vascular surgeons. My guests today are Dr. Edward Woo, he's the Director of the MedStar Vascular program; and Dr. Masaki Kiguchi. She's a vascular surgeon with the MedStar Heart and Vascular Institute. Welcome to the show, doctors. So, Dr. Woo, I'd like to start with you. What types of treatments have traditionally been done for patients with vascular disease?

    Dr. Edward Woo (Guest):  Well, thanks for having us, Melanie. Traditionally, with vascular disease, we would perform a lot of open surgical procedures that required larger incisions, would really push the patients back in terms of their ability to recover for longer periods. Now we've come about with multiple new technologies that really create more minimally-invasive techniques that sometimes, they're just a little poke in the skin, and we can have patients back on their feet the same day and back to normal.

    Melanie:  Dr. Kiguchi, have open bypasses been associated typically with significant morbidity, mortality, and had an impact on the quality of life for the patient?

    Dr. Masaki Kiguchi (Guest):   Melanie, I think it definitely has. The minimally-invasive techniques puts people back on their feet, most of them are actually outpatient procedures, and so the patients can go home that same day, and oftentimes without the use of large incisions. The patients tolerate these procedures much more, and so not only do they stay in the hospital a shorter amount of time, they are able to actually get back to their quality of life much faster.

    Melanie: Dr. Woo, have percutaneous interventions such as balloon angioplasty with or without stenting and other revascularization techniques, have they required more re-intervention than open bypass? What have you seen?

    Dr. Woo:  I think it kind of depends upon the patient and the disease process. The reality of everybody's different, every pathology's different, and sometimes, when we intervene, whether it be with an open bypass or a percutaneous procedure, it can require re-intervention to keep it going. However, a lot of situations, these patients can have one intervention or one procedure and go on for the rest of their life with success.

    Melanie:  Dr. Kiguchi, what are some indications for peripheral vascular angioplasty? What are you using?

    Dr. Kiguchi:  Well, I think that we can put these back into two categories: peripheral vascular disease involves either the arteries or the veins. With arteries, the most common is just doing a percutaneous transluminal angioplasty with and without stent. As Dr. Woo had mentioned, it really depends on the patient, the patient's comorbidities, the lesion, and the characteristics of the lesion whether you use the stent or not. That is most common, percutaneous, the angioplasty that we use but there are other methods of treating blockages, especially in the artery that involves stents, atherectomy, and other devices.

    Melanie:  Speak about a few of those, if you would, Dr. Kiguchi?

    Dr. Kiguchi:  As we just mentioned, the transluminal angioplasty involves a balloon that makes a lumen so that the blood can flow through the blockage. Sometimes, if the blockage is resistant to the ballooning, we place a transluminal stent within that lesion to keep that area open. In addition, we can use atherectomy devices. That is to break up the blockage itself and to create a lumen so that the blood can flow distally. 

    Melanie:  Dr. Woo, have you seen a resulting decrease in complication rates that might have helped angioplasty develop into an independent therapeutic procedure with its own indications and contraindications instead of being used as an alternative to surgery?

    Dr. Woo:  I think the answer to the question is really kind of both. There definitely is a decrease of complications just because it's a percutaneous procedure. It's more minimally-invasive, and patients get back on their feet quicker, so even if you think about just the long-term complications of being in a hospital for a period of time; people get pneumonias, or urinary tract infections. Things like that are all avoided because the patients are out of the hospital the same day. Those things have led to percutaneous procedures being an alternative to bypass, but because of the results we've seen with these percutaneous procedures and the minimal complications, I think that we've become more willing to treat patients earlier and give them therapeutic options that we otherwise probably would not have subjected them to in order to perform a bypass, just because it was such a bigger procedure. So, I think patients nowadays with more mild to moderate claudications, so pain when they walk, we will treat on an earlier basis with angioplasty just because it's so minimally-invasive and we know the risks are so low.

    Melanie:  Dr. Woo, as public enthusiasm continues to increase with regards to minimally-invasive vascular techniques, where do stents fit into this picture? They're hearing about absorbable stents, so speak about that.

    Dr. Woo:   So, as you can imagine, the field continues to move with improving and new technology. The field has evolved significantly in the last 20-30 years and one of the new things that everybody's hearing are these bio-resorbable stents and really what this is is basically, when there's a narrowing in the blood vessel, we treat it initially with a balloon angioplasty, which opens up the blood vessel, and then we may or may not place a stent, which is a lattice structure to help prevent recoil of that lesion or that narrowing. Now, the problem with these stents is long-term, it can act as a nidus for what we define as entemohyperplasia. So the body, in a way, is kind of rejecting that stent, and having cellular deposition around that stent that can lead to narrowing in the medium- to long-term. So, the stents work really well in the short term to prevent immediate recoil, but long-term may actually be a problem in terms of forming new stenoses. So, where the bio-resorbable stents come in, they allow for an immediate support or lattice structure to prevent that short-term recoil, and then over time, they dissolve to prevent that more medium- or long-term potential for restenosis.

    Melanie:  Dr. Kiguchi, do you feel that advances in technologies such as Dr. Woo's discussing allow surgeons to perform even more anatomically challenging procedures than before? Are you seeing that?

    Dr. Kiguchi:  Absolutely. I think we are continuing to challenge ourselves with pushing the percutaneous techniques so that we can treat safely and effectively tougher lesions, not just anatomically, but also in the severity of disease as well.

    Melanie: Dr. Woo, in addition to some of these new devices, how have developments in gene therapy and brachy therapy brought several new minimally-invasive options to the treatment of peripheral vascular diseases?

    Dr. Woo:  I think we're still really early there. There's a lot of excitement and enthusiasm about gene therapy, but really, we're just not quite there yet. I think, you know, in another 5-10 years, we're going to actually see some real therapeutic options in terms of that field, but right now, it's really just not mature yet.

    Melanie:  Dr. Kiguchi, to wrap up your portion, tell the listeners what you would like them to know about minimally-invasive vascular surgeries and where you see it going on the horizon. What's exciting to you?

    Dr. Kiguchi:  I think the treatment of peripheral vascular disease today is vastly different from the traditional invasive open treatments that were performed in the past. Breakthroughs that happen every day in minimally-invasive treatment has pushed sort of outpatient procedures to the forefront and so that patient can really get back on their feet as quickly as possible. So, we definitely can continue to sort of push these procedures as long as they are safe and effective for the appropriate patients and so that they can actually get back to their daily life.

    Melanie:  And, Dr. Woo, from a patient's perspective, they hear “vascular disease”, right away they go thinking about surgery, and you mentioned claudication, but sometimes, exercise can be a limiting factor if they do suffer from claudication. What do you tell patients and what do you want other doctors to tell patients about living with and managing their peripheral vascular diseases?

    Dr. Woo:  I think the most important thing, first and foremost, is to see a vascular specialist to have this discussion. And, really, a lot of treatments need to be tailored and be very patient-specific and patient-oriented. Symptoms in one patient that may require treatment, may not necessitate treatment in another patient. And so, you really have to tailor the treatment options and decisions for every single patient individually. For instance, there may be one patient that is, where their life is significantly inhibited by the fact that they can't walk three or four blocks and want to exercise and be more active and that claudication prevents that and if it's a straightforward intervention that can be done percutaneously, it probably makes sense to do it; whereas, in another patient that is really not very active, doesn't walk that much, never is going to walk three to four blocks, and is not limited to that, I think in those patients, going ahead and trying to treat those lesions may not make as much sense.

    Melanie:  Thank you both 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
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David Cole Tue, 03 Jan 2017 01:10:38 +0000 http://radiomd.com/medstarphy/item/34492-minimally-invasive-vascular-surgery
Managing Med/Psych Patients in Aging Population http://radiomd.com/medstarphy/item/34064-managing-med-psych-patients-in-aging-population managing-med-psych-patients-in-aging-populationIt's not uncommon to encounter complex hospitalized medical/psychiatric patients who are also part of an aging population. The elderly can present with cognitive impairments that become a challenge to manage in a patient care unit. In an effort to address behavioral issues that can arise in a medical setting, MedStar Washington Hospital Center developed multi-disciplinary teams and protocols to better care for these patients.

Listen as Lourdes Desi Griffin, PhD, assistant vice president for medicine and psychiatry, shares best practices and lessons learned.

Additional Info

  • Segment Number: 3
  • Audio File: medstar_washington/1642mwp3a.mp3
  • Doctors: Griffin, Lourdes
  • Featured Speaker: Lourdes “Desi” Griffin, PhD
  • Specialty: Null
  • Guest Bio: Lourdes “Desi” Griffin, PhD is an assistant vice president for medicine and psychiatry at Medstar Washington Hospital Center.

    Learn more about Lourdes “Desi” Griffin, PhD
  • Transcription: Melanie Cole (Host): Demographic trends globally point in the direction of increasing numbers of older people with serious and chronic mental disorders. My guest today, is Dr. Lourdes Griffin. She’s Assistant Vice President for Medicine and Psychiatry at MedStar Washington Hospital Center. Welcome to the show, Dr. Griffin. What are some of the most common mental health disorders you’re seeing in the aging population?

    Dr. Lourdes Griffin (Guest): Good morning, Melanie. I am seeing an increase in the elderly population of depression, anxiety, confusion that may be linked to medication, or Alzheimer’s. As our population ages, these are becoming more prevalent in the patients that we see in our medicine locations as well as in our inpatient units.

    Melanie: Some of the difficulties or complexities of managing med-psych patients in this aging population might have to do with comorbidities, Dr. Griffin. What are some of those that you see – and you mentioned medications, so blood pressure, diabetes – what are you seeing that makes it a little bit more difficult to diagnose what’s going on?

    Dr. Griffin: We have to look at all aspects of the patient’s life. It may be that their medication needs to be calibrated differently for their age and span of their life. It also may be that their comorbid medical condition or their preexisting psychiatric and behavioral health issues that they may have had earlier in life continue to manifest and maybe change in their presentation, as they get older.

    Our elderly patients are often times confused, they’re disoriented, and these are factors that we need to take a good look at in a healthcare setting to provide a safe environment for them to get the care that they need.

    Melanie: While we’re speaking about bipolar disorder, and depression, and mental health issues in the aging population such as these, we’ve seen a growing sophistication in the treatment approaches. What are you doing with these people that will help them to manage these conditions?

    Dr. Griffin: We’re beginning to look at integrated care more carefully, and the coordination of care between the behavioral health providers as well as their primary care providers in order to make sure that we’re treating the entire person. When it comes to the administration of medication and management, you need to look at their environment, their setting, what are the risks of their living situation? Are they alone? Do they have enough supervision, oversight, and assistance that they need? And also, one area that we’ve begun to pay attention to a little bit more is their substance use. A lot of the elderly population may have had substance use issues earlier in life, and these could continue to persist as they age and present a different and complicating set of factors.

    Melanie: Are you seeing that some of these people had one of these mental issues as a younger person and then developed them more fully as they aged?

    Dr. Griffin: More that they’ve continued, yes. Some of these are lifelong behavioral health issues that persist throughout their lifespan.

    Melanie: And to help you with assessment and management, are you using neuroimaging? What are you doing to help assess the situation and the severity of it?

    Dr. Griffin: Well, at the MedStar Washington Hospital Center, we have teams of trained clinicians, very good psychiatrists that are skilled in working with the elderly population, and looking at the effects of their medical treatments – their comorbidities, their medications, and how it might affect their mental status and the way that they function.

    Melanie: So when we note that link between medical comorbidities and outcomes, what are you seeing as you look to assess these?

    Dr. Griffin: We’re involving the support systems in the community, and looking for increased independence in the least restrictive environment as possible for these individuals.

    Melanie: Does this depend on the type and number of conditions that are considered in this definition of comorbidities?

    Dr. Griffin: Yes, it does, absolutely. The more conditions, the more complicated the case.

    Melanie: And when medication intervention is involved, what are you looking to do when you’re trying to balance out these medications?

    Dr. Griffin: I think that you need to work very closely with your specialist, whether it is that you’re working with their rheumatologist, their pulmonary specialist, whatever physicians are treating the medication condition, to make sure that the behavioral health treatment complements, does not interfere, or complicate the situation.

    Melanie: Dr. Griffin, tells us about your Behavioral Emergency Response Team.

    Dr. Griffin: Yes, a large number of the patients that are admitted to inpatient units in our facility, as well as in most facilities throughout the country, have a preexisting behavioral health issue or may be victims of dementia, Alzheimer’s, or some type of delirium due to their medical condition. What this does is the individuals tend to be often confused, agitated, and may not understand the reasons for being hospitalized and their care.

    What we’ve set up is a behavioral response team that will work with the nurses, and the physicians and the treatment providers on the acute care units to help explain was to de-escalate, manage, and help the patient who is having a behavioral health issue. It could be the demented patient who is confused and trying to leave to walk home who gets agitated. It could be patients that are withdrawing from substances or patients with pre-existing behavioral health conditions that need extra management. Most acute care nurses have had brief treatment in behavioral health or psychiatry, but not maybe the extent of treatment that would be required.

    The goal is to provide integrated, comprehensive care for the patient, both inside, as well as outside our facility, so that they are able to stabilize and live a lift that is healthy and productive for them at whatever stage of life they’re in.

    Melanie: And Dr. Griffin, tell us about some of the non-pharmacological approaches that may help individuals with serious mental illness, and comorbid conditions to better self-manage – or their loved ones – their complex comorbidity, as being relevant to improving both their symptomatic and functional outcomes.

    Dr. Griffin: Understanding the root of the problem is the most important one. Finding out why the patient is upset. If there’s a patient who is having an acute episode and is either agitated or confused – understanding the source of that, working with the clinical team to see what that is. And then, there are very well-trained clinicians how are able to speak with the patient, calm the patient down. There are psychiatrists that are able to work with the attending if it is not a psychiatric provider, but a provider of another medicine -- some specialty, or some surgical specialty -- to prescribe the appropriate medication for that individual.

    And then, caregivers are a very important piece. These patients will be discharged from an inpatient setting and the comprehensive approach to care in an outpatient setting involving the supports that they would need, counseling for the individual, as well as for the caregivers. Caregivers need to know how to identify when a patient is becoming agitated, and to try to address the situation before it becomes an issue. The same thing on the inpatient units, we’re working with the nurses to help them begin to identify when a patient is beginning to get agitated or experience difficulties. One of the goals of working with patients who have behavioral health concerns is learning to identify when there may be an issue that is arising. We are working with the nursing staff on the units -- and also, many outpatient providers work with caregivers to begin to identify situations that might trigger a problem – that might escalate a patient’s behavior. If you can address the situation before it develops into a behavioral health crisis, it would be much easier to manage.

    Again, the goals are the treatment of the entire person, integrating the medical care with the behavioral health care both on inpatient settings and outpatient settings, and working with providers, whether we’re talking about nurses on an acute care unit, or family members who take care of a patient after discharge, increased awareness that behavioral health is a part of our society. Most individuals may have a behavioral health crisis at one point in their life or another, and addressing it and treating the entire patient in a caring, and compassionate way is our goal here at the MedStar Washington Hospital Center.

    Melanie: Thank you, so much, Dr. Griffin, for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center, and 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
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Melanie Cole, MS Wed, 26 Oct 2016 22:29:25 +0000 http://radiomd.com/medstarphy/item/34064-managing-med-psych-patients-in-aging-population
Advanced Heart Failure http://radiomd.com/medstarphy/item/33706-advanced-heart-failure advanced-heart-failureSamer Najjar, MD, director of the Advanced Heart Failure Program at MedStar Heart & Vascular Institute at MedStar Washington Hospital Center, discusses the epidemic of heart failure in the United States.

He shares best practices for determining the classifications of heart failure, including how to assess patient history, and the threshold at which they cross over into advanced heart failure. He discusses a range of therapies including inotropes, implantable devices, transplant, and end-of-life care.


Additional Info

  • Segment Number: 1
  • Audio File: medstar_washington/1633mwp5b.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): Heart failure is a very common condition affecting more than five million Americans. With more serious cases of heart failure, and when it progresses to an advanced stage, difficult decisions must be made between the doctor and their patient. My guest today is Sameer Najjar. He is the Director of the heart failure program at Med Star Washington Hospital Center. He specializes in advance therapies for heart failure, including the medical management of heart transplantation and ventricular assist devices. Welcome to the show, Dr. Najjar. Tell us a little bit about heart failure and the classification of it.

    Dr. Sameer Najjar (Guest): Thank you very much for having me. As you mentioned heart failure is very prevalent. In fact, I now say we're having an epidemic of heart failure at the country because of the millions of people who have it. Not only is it very prevalent, it is also very expensive. It's one of the largest expenses for Medicare. It has a higher morbidity and a high mortality, a lot of hospitalizations, a lot of people who get readmitted or re-hospitalizations, and about 300,000 people die every year of heart failure. Now the classification of heart failure is based in large part on symptoms. We classify people as a Class 1, 2, 3 or 4. A Class 1 person is somebody who has absolutely no symptoms. So, they may have a weak heart but they could be up, outside running and doing all sorts of activities that they want. A Class 4 person, at the other extreme, is somebody who could barely do anything. They are having shortness of breath or fatigue, tiredness--just sitting down and not doing much. In between, the Class 2 and Class 3, the Class 2 people are those who can do activities but maybe not as much as somebody who is a Class 1. The Class 3 is somebody who's struggling, who can do stuff but they're struggling. For example, they can maybe not even walk two blocks. They can walk a block, so they're not housebound or bed bound, but they're certainly very symptomatic. For most patients with heart failure, the standard treatment involves medication. There's a whole set of medications that have been proven to help patients with heart failures and they're prescribed quite well for patients who have the heart failure condition and they're supplemented by devices, so things like defibrillators and pacemakers, which have also been shown to help patients with heart failure. Like I said, most patients with heart failure do well with these, but over time, the heart failure oftentimes progresses, it becomes more severe and these medications become less and less efficacious. The person who is initially Class 1, for example, may find themselves going on to Class 3 and get close to a Class 4. Now you have somebody who is really very limited, and by limited, I mean they're not able to do much. They're not able to live a good life, their quality of life is not good, they are not able to do activities that are meaningful to them or to their families and caregivers, and so things are looking pretty bleak. At that point, we do have additional things to offer them, and so these therapies are, what we call “advanced heart failure therapies”, meaning that they are geared towards patients who have the advance stages of heart failure. The key question is, when does somebody cross that threshold of going to say, “Well, I just have heart failure,” to somebody who says, “Well, I have an advanced heart failure”? Unfortunately, we do not have a single blood test that we can do that says, “Ah! I measured this level, and therefore, I'm going to call you this, that you now have advance heart failure” but there are many clinical signs that can sort of give it away. So, if you have somebody who's trying to do their best, they are taking all their medications. They're doing what they're supposed to do. They're limiting the amount of fluid that they're taking, but, in spite of that, they keep retaining fluid. They keep ending up back in the hospital. Something that tells us that there's something that's changed in this person, and now this person is maybe sicker than we thought what they were six months or a year ago, to the point that those medications are not holding them anymore. Also, in some people, you start seeing while the blood pressure is going down and down, and the medications that we give standardly for heart failure, now we have to back down on the doses of these medications. That is another trigger that tells us, “Well, something is progressing.” There are multiple different things that can happen. The third thing is, some people start developing kidney injury or liver injury. In other words, there's an organ damage and so these are all triggers or markers that a person is progressing towards advanced towards advance heart failure. In a given individual, they don't have one specific pattern of how things progress, it varies from person to person. Some people don't have to be hospitalized. They're able to stay at home, but they tell you that they can't get out of bed. Some people don't retain fluids, but their kidneys and their liver are showing evidence of damage. Other people just keep retaining fluid, but their kidneys and liver are working fine. And so, there's not one simple thing that gives it away but there's a multitude of things that could happen, and one has to stay vigilant and watch for these things and when they happen, be able to act on them. I want to emphasize on one really important thing and that is that the most important thing are symptoms. Oftentimes what patients with heart failure do is they adapt their lifestyle to what their body allows them to do. You ask somebody, "How are you doing now?" They'll say, "I'm doing fine." Then you ask them, "Well, what are you doing now?" And they say, "I don't do anything, I watch TV all day." You ask them, “What you were doing a year ago?" They say, "A year ago I could take the dog out, I'd walk them, take a stroll on the beach, and all that." You ask them, "Why aren't you doing that anymore?" They reply, "Oh! I think I must be older age, or the weather's not good." So, they find excuses why they're not doing them and the reality is they just sense internally that they're not able to do activities, and, therefore, they stop doing them or slowly ramp them down. I think being very careful about taking a very good history and asking people about, number one, what is their activity level, and perhaps, even more importantly, how is that activity level different than what it was before? That is often the first marker that the heart failure is progressing. There is one test I should mention called the “cardiopulmonary stress test” that measures something called “peak oxygen consumption”, which over, over and over again in clinical trials have shown that the peak oxygen consumption is the best prognostic marker in patients with heart failure. But, unfortunately I have to admit that test is not widely available and is not widely used, so we can't rely on it. I think the clinical markers, particularly the history, in terms of what are the exercise tolerance and performance of a person, as well as thing such as re-hospitalization, and organ damage are markers that clinicians need to be aware of to try and distinguish who's progressing towards the advance heart failure. Now, when somebody is progressing towards advanced heart failure, what are the therapies that are available? We have therapies across the spectrum. For some people, it's really the end of the road, and the right thing for them to do is to help them, and their caregivers, and their families, discuss end of life issues and palliation and, eventually, hospice. That is the right thing to do for them. For other people, we have things to help them and those things can include either specific medications called “inotropes” or surgical therapies which includes LVAD and transplant. The LVAD, or left ventricular assist devices, are a relatively new therapy and really just took off within the past five or six years. We've had these therapies for two decades but earlier the technology was not that good. So, back in the ‘90's and in the early 2000, we had these devices that worked well for only a few months up to a year, and then they would be degraded after that, and so they're not a good long-term option. But, nowadays we have the second, even the third generation of left ventricular assist devices which are smaller than the first generation, the surgeries are easier, and both the surgeon and the cardiologist are better at the management of both peri-operatively and post-operatively of patients with left ventricular assist devices. So, we're able to get much better outcomes in patients who have these LVADs. The LVAD can be implanted in one of three configurations, either as a bridge for transplant, meaning somebody is eligible for transplantation but we are not able to hold them with standard medical therapy to get to the transplant, therefore, we need to do something in between to keep them alive and give them a good quality of life until they got the transplant, so we put in an LVAD. Now, some people do not qualify for transplantation, and in those patients they can get an LVAD as destination therapy, meaning we put in the LVAD and they are going to go home and spend the rest of their life on the LVAD, with the understanding of the reason that to do the LVAD is to get them better quality of life as well as more longevity. In some people, we're not yet sure whether or not they're candidates for transplantation, and, therefore, the LVAD is implemented as a bridge to, what we call “decision”, meaning we'll put the LVAD in now and then, down the line, in weeks or month afterwards we will decide whether a person is a candidate for heart transplant patient or not. Heart transplant is a time honored therapy for people with end stage heart failure. Heart transplant is an excellent therapy, and the average survival, the medial survival, is approximately 13 years. The Achilles Heel of heart transplantation has been, and will be, at least for the foreseeable future, the availability of donor hearts. There are far more people who need heart transplantation than there are hearts available to donate. That's why the LVAD has come into play because not everybody can wait on medication until they get a heart transplant.

    Melanie: Dr. Najjar, are you seeing compliance issues when they start advancing towards advance heart failure with medications? Is that one of the reasons?

    Dr. Najjar: Compliance issues can be a problem in the community and it sort of varies depending on multiple different factors. The people who have compliance issues when somebody has regular heart failure are going to be the same compliance issues when they progress towards to advanced heart failure. In general, people who are compliant when they have regular heart failure are probably going to stay compliant with advance heart failure. So, I don't necessarily view that compliance is what triggers somebody to progress, per se, although it may be accelerated, meaning if somebody is not taking their medication, their heart is not able to benefit from those medications so they may progress at a faster rate. But, it's not the compliance, per se, that is going to trigger them or tip them over. But, compliance is an issue. One of the things we didn't talk about is when we're evaluating people for these LVAD transplant, we do a very comprehensive assessment, and that assessment includes both the medical side of things, we need to understand how each organ system is functioning, but there's also a very important psychosocial assessment that's a component, that's part of it. We need to understand is the person compliant, is the person caring about their health, are they trying to do the right thing to help themselves? All these things come into play, particularly when you talk about something like heart transplantation where the resources are very scarce. So, you really have to be very careful about allocating those resources because you don't want to give it to the wrong person.

    Melanie: Wrap it up for us, please, Dr. Najjar. Tell physicians what you want them to know about advanced heart failure.

    Dr. Najjar: I think the most important point is to recognize that heart failure, which all physicians are seeing quite frequently, can progress to advanced stages, and, if it's not caught early, if we let it go, then the person can get go to the point where we don't have anything to offer them. But, if it's caught early, in this day and time, we do have good therapies to offer patients and, therefore, the critical part is to recognize it before it’s too late, because we could do things to help these patients.

    Melanie: Thank you so much for being with us today, Dr. Najjar. It's a very informative segment. 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 Cole. Thanks for listening.
  • Internal Notes: Null
  • Hosts: Melanie Cole, MS
]]>
David Cole Sun, 28 Aug 2016 13:27:57 +0000 http://radiomd.com/medstarphy/item/33706-advanced-heart-failure
Hyperthermic Intraperitoneal Chemotherapy http://radiomd.com/medstarphy/item/33627-hyperthermic-intraperitoneal-chemotherapy hyperthermic-intraperitoneal-chemotherapyHIPEC, or hyperthermic intraperitoneal chemotherapy, is given immediately after a peritonectomy or cytoreductive surgery, while the patient is still in the operating room.

The chemotherapy drugs are heated to make them more potent, then used to directly bathe the surgical site in the abdomen. This method kills any remaining cancer cells and provides higher, more effective doses of medication, without significantly affecting the rest of the body.

Listen in as Chukwuemeka U. Ihemelandu, MD, discusses which patients are the best candidates, when to make referrals and how outcomes advance this procedure.

Additional Info

  • Segment Number: 1
  • Audio File: medstar_washington/1633mwp5a.mp3
  • Doctors: Ihemelandu, Chukwuemeka U.
  • Featured Speaker: Chukwuemeka U. Ihemelandu, MD
  • Specialty: Null
  • Guest Bio: Chukwuemeka Ihemelandu, MD, is a board-certified surgical oncologist at MedStar Washington Hospital Center. He is Assistant Professor of Surgical Oncology at Georgetown University Medical School and is a member of the Society of Surgical Oncology (SSO) as well as the Society of Surgery for the Alimentary Tract (SSAT). Dr. Ihemelandu specializes in the treatment of peritoneal carcinomatosis, or cancer of the abdomen, through the use of cytoreductive surgery and intraoperative chemotherapy. He also specializes in the treatment of gastric cancer, sarcoma and pancreatic cancer. His clinical interests include advanced abdominal cancers. His research interests include analyzing the use of near-infrared fluorescent technology to look for microscopic cancer during surgery to aid in the complete removal of a disease. He is also analyzing the molecular profile of unique tumors in the abdomen to understand how treatment can be personalized for each patient.

    Learn more about Chukwuemeka Ihemelandu, MD
  • Transcription: Melanie Cole (Guest): Hyperthermic intraperitoneal chemotherapy is one of the most innovative treatments available today for complex abdominal cancers. My guest today is Dr. Chukwuemeka Ihemelandu. He’s a board certified surgical oncologist at MedStar Washington Hospital Center. Welcome to the show, Doctor. Tell us about HIPEC, what exactly this procedure is and who are the best candidates for it?

    Dr. Chukwuemeka Ihemelandu (Host): HIPEC, as you mentioned, stands for Hyperthermic, which is also called “heated”, Intraperitoneal means the chemotherapy is placed into the abdominal cavity, chemotherapy. And the whole idea behind it is for patients who have metastatic disease from either appendix cancer, colon cancer, gastric cancer and ovarian cancer. So, these patients, a couple of years ago, would have been told that there was no other option for them. We have an option for them including cytoreductive surgery, which basically involves going in there and taking out all the tumor cells that we can see with the naked eye and then treating the microscopic cells, those are the cells we can’t see with the naked eye, that are left behind with the intraperitoneal chemotherapy, the HIPEC. And so, this innovative approach is best for patients with peritoneal metastasis whether from appendix cancer, or colon cancer, gastric cancer or ovarian cancer.

    Melanie: So, with this process your heating the chemotherapy drugs, and are you doing this right after surgery into the abdomen?

    Dr. Ihemelandu: The process is actually done in between the procedure. So the cases would take anywhere from 10 to 12 hours and we would start off by the resection, meaning taking out of the disease that we see, and then we run the chemotherapy. It’s usually run for 90 minutes during the case, and after we’ve completed the chemotherapy, we then do our putting together of the anastomosis and any other repair that we have to do. And so, in answer to your question, yes, the chemotherapy is done at the time of surgery.

    Melanie: Is this injected into an IV line or is this added to the drugs or added to a heated saline? How do you use it?

    Dr. Ihemelandu: The drugs for the heated intraperitoneal chemotherapy are given through a device, it’s a machine that heats the chemotherapy and then it’s circulated through a circuit into the abdominal cavity. So, the chemotherapy is not going through the vein, it doesn’t go into the artery, it goes into the abdominal cavity and is circuited by the machine through the circuit for 90 minutes after which we then drain the chemotherapy from the abdominal cavity.

    Melanie: What are some of the benefits to the patient and what is their after like?

    Dr. Ihemelandu: The benefits include, one, we’re able to give the patient a much higher dose of the chemotherapy than the patients could possibly receive IV, intravenously. Also, we are able to place the chemotherapy directly on the site of the disease. When patients are given systemic chemotherapy, literature tells us that only about 15-20% of the systemic chemotherapy actually gets absorbed into the abdominal cavity. So, very little of the internal abdominal cavity is exposed to that systemic chemotherapy. And so, part of the advantage for the patient is that we’re able to expose the intra-abdominal cavity with the peritoneal metastasis to this chemotherapy. So, there is direct contact. And the other benefit is that there are very little, minimal side effects to the patient. They usually don’t lose their hair. A couple of them might have bone marrow suppression, but it’s very transient. It happens 4 to 5 days after administration of the chemotherapy, but they bounce back pretty quickly.

    Melanie: Tell us about some of the outcomes you’ve had using this and maybe some of the challenges regarding the establishment of this as a standard of care.

    Dr. Ihemelandu: I will start by talking about the challenges. I guess one of the biggest challenges that for anything to be accepted in the medical community we’re always looking for a randomized trial. Unfortunately, there’s been only one randomized trial looking at the benefits of this high-tech cytoreductive surgery and that was carried out in Europe. Attempts have been made to that in the United States but it’s very hard to get a patient to agree to get randomized into the cytoreductive surgery versus just surgery along with palliative care. And so, that study hasn’t been done, probably will never be done, and so we’re left with case studies--individual institutions reporting their outcomes. We’ve had very good outcomes for our patients, most especially patients will present with appendix cancer, currently patients who present with low-grade appendix cancer. We don’t talk about 5 year survivals. In fact, we’re talking about 10 year survivals, and that’s the range of 80-85%, which is actually outstanding, when you think back to about ten or twenty years ago this was not the case. We’ve also had very good outcomes with patients with colon cancer, with peritoneal metastasis. I actually have a very great story about a young man who was told there was no other option for him because he had liver metastases and he had peritoneal metastasis, and he came to us and we took him about 3 years ago he underwent the cytoreductive surgery with intraop chemotherapy, and he is disease-free three years out now. So, these are a few of the outstanding results we’ve had. We’ve also had great results with patients who present with ovarian cancer and we treat them with intraop chemotherapy.

    Melanie: So, where there is a pharmacokinetic benefit and that tumor penetration is very specific, what is it like after the fact for the patient? Do they feel that heat going in?

    Dr. Ihemelandu: The patients actually do not feel the heat. At the time of surgery, they actually are asleep as expected because they’re intubated. If you think about it, they lose of a lot of heat when they are undergoing surgery. So, if anything, our heated chemotherapy actually is beneficial to them because it heats up their core temperature. So, there’s no downside, at least we’ve not seen any downside to the heated chemotherapy. And, the highest temperature we usually go to is about 42 degrees Fahrenheit and it’s very tolerated by the patients with no overt side effects that we’ve seen. We’ve reported extensively on the morbidity of this procedure, which is always a concern for the acceptance of such an aggressive approach to cancer. But our morbidity rates have decreased as we’ve gotten better at the technical aspects of doing the case.

    Melanie: So, doctor, in just these last few minutes wrap it up for us, for physicians, in what you have found in this innovative and complex approach to advanced intra-abdominal malignancies. Tell us what you want them to know.

    Dr. Ihemelandu: What I would like my colleagues to know out there is that for patients who are diagnosed with what we typically would call a Stage 4 disease, and these are patients who have disease confined to their abdomen, what we also call “peritoneal metastasis,” that there is an option for them that actually offers them survival benefits. We’re so much better at this procedure and we have very minimal or acceptable morbidity rates. And, most importantly, we have very outstanding survivor benefits to the patients. So, I will encourage them that, if they do have a patient who meets this criteria having been diagnosed with recurrent colon cancer with metastasis, appendix cancer with peritoneal metastasis, ovarian cancer with peritoneal metastasis, or gastric cancer with peritoneal metastasis, to send the patient to us. We’re a center of excellence for peritoneal metastasis malignancy. Our center was actually the first in the United States and we actually have the largest data set and the most extensive experience with this procedure. And, we’ve documented this in multiple publications that we’ve got great outcomes for these patients. So, I encourage my colleagues to offer these patients these benefits and send them over to our center.

    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 for listening.
  • Internal Notes: Null
  • Hosts: Melanie Cole, MS
]]>
David Cole Wed, 17 Aug 2016 22:19:46 +0000 http://radiomd.com/medstarphy/item/33627-hyperthermic-intraperitoneal-chemotherapy
Removals of Soft-Tissue Sarcomas: When to Make a Referral to a Specialist http://radiomd.com/medstarphy/item/33581-removals-of-soft-tissue-sarcomas-when-to-make-a-referral-to-a-specialist removals-of-soft-tissue-sarcomas-when-to-make-a-referral-to-a-specialistStatistically speaking, a soft tissue mass in the extremities is likely to be a lipoma and is appropriately managed by general surgeons. However, there are occasions when it is actually a mischaracterized soft tissue sarcoma. These are best dealt with by specialized orthopaedic oncologists in order to avoid spreading the cancer to surrounding areas.

Robert Henshaw, MD, a board-certified orthopaedic oncology surgeon at Medstar Washington Hospital Center, discusses how to recognize when a mass is not a lipoma and when additional imaging and referrals should be made.

Additional Info

  • Segment Number: 2
  • Audio File: medstar_washington/1631mwp3a.mp3
  • Doctors: Henshaw, Robert
  • Featured Speaker: Robert Henshaw, MD
  • Specialty: Null
  • Guest Bio: Robert Henshaw, MD, is a board-certified orthopedic surgeon specializing in oncologic oncology, a field dedicated to the treatment of musculoskeletal tumors. Such tumors are rare and include a wide variety of benign and malignant diseases such as bone sarcomas (such as osteosarcoma, chondrosarcoma, Ewing's sarcoma), soft tissue sarcomas (such as synovial sarcoma, liposarcoma, malignant fibrous histiocytoma), as well as metastatic cancers affecting the extremities. As these diseases can occur at any age, Dr Henshaw routinely treats pediatric and adult patients, having operated on over 2700 tumor patients in his first 18 years of practice in Washington, D.C. Dr. Henshaw sees and treats patients from the entire mid-Atlantic region, along with referred patients from around the country and the world.

    Learn more about Robert Henshaw, MD
  • Transcription: Melanie Cole (Host): Removal of soft tissue sarcomas by general surgeons can often fail and end up spreading the cancer to surrounding areas. When should a general surgeon make a referral to a specialist rather than performing the procedure themselves? My guest today is Dr. Robert Henshaw. He’s a Professor in Clinical Orthopedic Surgery and Orthopedic Oncology and the Vice Chairman of Orthopedic Surgery at MedStar Washington Hospital Center. Welcome to the show, Dr. Henshaw. Tell us typically how are soft tissue sarcomas treated and by whom?

    Dr. Robert Henshaw (Guest): First of all thanks for having me on. This is a subject that’s dear to our heart because in my practice of over 20 years treating soft tissue sarcomas, we see a lot of patients that have had an unplanned procedure thinking that the mass that they had was in fact a lipoma. It was only after the fact that it was identified as a sarcoma. In general, the treatment of a soft tissue sarcoma is going to consist of a wide to radical resection, in other words a margin of a good normal tissue around the tumor itself, in order to minimize the risk of local recurrence.

    Melanie: So, you are doing the wide local excision. Who is doing this typically and is there a reason a general surgeon should or should not be doing this procedure?

    Dr. Henshaw: We do these wide local resections routinely for these tumors. The problem that we see time and time again is that tumor is misidentified from the get-go. The reason for this is because soft tissue sarcomas oftentimes present as a mass that’s painless in one of the extremities and can frequently be mischaracterized as a simple lipoma. So, the key to the proper treatment is knowing what you’re dealing with before you commit to any type of surgery.

    Melanie: What is a good situation for the general surgeon?

    Dr. Henshaw: General surgeons have always taken care of the majority of simple lipomas that patients present. From a statistical perspective, a soft tissue mass in the extremity is most likely going to be a lipoma. Our job is to try to help doctors recognize when a mass is not a lipoma and if there’s any question about it, that’s when additional imaging and referrals should always be made.

    Melanie: And to whom? Are we looking at oncologists, orthopedic oncologists? Who is it you would like them to refer to?

    Dr. Henshaw: The field of orthopedic oncology, which really has been present now for well over forty years, is devoted to dealing with sarcomas of the extremities but there are surgical oncologists that also deal with these type of tumors. I think the key to the proper treatment of any cancer patient is that the doctor taking care of the patient be familiar with the disease, know how to surgically remove it, and, most importantly, provide any additional aftercare.

    Melanie: Why is that even more important when you’re talking about limb-sparing sarcoma surgery?

    Dr. Henshaw: MSTS, which is the Musculoskeletal Tumor Society, has done several studies over the decades looking at causes for amputation and one of the identified risk factors is an inappropriately placed biopsy or surgical procedure prior to proper referral of the patient. So, in order to ensure that patients get the optimal care, we want to identify the tumor and make an appropriate referral.

    Melanie: And, are grafts, or muscles, tendons replacing bones and joints, done at the same time as the tumor removal?

    Dr. Henshaw: Many times, a complex resection will require some form of reconstruction and we often times will do that at the time of the primary resection. But these, of course, are for very large deep-seated tumors. The ones where the general surgeon may run into problems is the patient presenting with a superficial or seemingly superficial mass that he mistakes for a lipoma when, in fact, it’s a sarcoma, and these are the cases that often times can result in litigation.

    Melanie: What about some adjunct therapies to go along with this type of surgery, the intra-arterial chemotherapy or radiation? Are you doing some of these at the same time?

    Dr. Henshaw: Depending upon the size and the stage and the aggressiveness of the tumor, some form of preoperative or adjuvant treatment, whether it is chemotherapy or radiation or a combination of both, many times we will offer to the patient. But, for relatively small lesions, especially if they’re low grade, often times a good surgical procedure in and of itself can be curative.

    Melanie: For the patient, is this laparoscopic when you do the wide local incision?

    Dr. Henshaw: No, laparoscopic techniques are useful for looking inside of cavities, such as the abdominal cavity, or arthroscopic techniques for looking inside the chest. What we’re dealing with are tumors that are actually arising within muscle bone and soft tissues. There’s no cavity to put a scope into.

    Melanie: In just the last few minutes, would you like to cite some case studies that give evidence to the fact of a general surgeon and to submitting this to another surgeon that might be more qualified in this area?

    Dr. Henshaw: We actually just published a paper in the Journal of the American Academy of Orthopedic Surgeons looking at the risk factors leading to an inappropriate surgery or biopsy for patients presenting with soft tissue masses. In there, we present numerous case examples of what can happen if a patient is not appropriately imaged and worked up prior to surgery. It turns out that patients that have had an inappropriate or unplanned surgical resection are at higher risk of complications, they require more extensive surgery, are more likely to require flap reconstruction, radiation and other adjuvant techniques, and there is a significant increase in the risk of litigation regarding the original surgery that was done for that patient.

    Melanie: Dr. Henshaw, would you like to just speak very quickly about the pathology and the stage in the clinical presentation so that other surgeons listening can know what to look for?

    Dr. Henshaw: Again, it comes down to the appropriate identification of a soft tissue mass. If you have a very typical subcutaneous, rubbery, non-tender mobile mass, statistically that’s going to be a lipoma. It’s those cases where something is a little bit different: the tumor feels different, there’s skin involvement, the tumor’s not mobile, it might extend deeper than a standard lipoma. Those are the cases that should raise a red flag that this is something that should be imaged and evaluated before attempting any type of surgical procedure. And for soft tissue tumors, MRI is by far the easiest and best study to evaluate the tumor. If it is, in fact, a benign lipoma, the scan will suggest that and the simple excision can then be performed. But, if there’s anything abnormal or worrisome on the MRI, that then is a perfect segway into a referral to somebody who has an oncologic background.

    Melanie: Thank you so much for being with us today, doctor, it’s really 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
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David Cole Sun, 14 Aug 2016 00:43:39 +0000 http://radiomd.com/medstarphy/item/33581-removals-of-soft-tissue-sarcomas-when-to-make-a-referral-to-a-specialist