Medical Intel

Acne is common in teenagers, but it can become a more persistent problem for adults. Dermatologist Dr. Sanna Ronkainen discusses how we treat adult acne and ways to protect your skin.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Sanna Ronkainen, a general dermatologist at MedStar Washington Hospital Center. Thank you for joining us, Dr. Ronkainen. Dr. Ronkainen: Thank you for having me. Host: Today we’re discussing acne, a common problem that’s often associated with teens but affects many adults, as well. Dr. Ronkainen, could start by discussing the reason adults develop acne? Dr. Ronkainen: Absolutely. So, for some adults that I see, their acne is carried on from their teenage years into their young adulthood. So, I see a lot of patients in their early 20s who are still struggling with acne. However, acne, particularly of the face, chest and back, can also linger or become a more persistent problem in women who are in their late 20s, 30s or 40s or even later than that because of the hormonal component of acne. Patients also come in reporting acne when they have inflammatory bumps or acne-like lesions on the body, which sometimes can be related to folliculitis, which is an infection of the hair follicles, which usually happens on areas of the skin that are covered by clothes, such as the buttocks or the thighs. So, we see a variety of different reasons that adults get acne. Host: Do certain demographics, such as race and gender, make a person more at risk for developing acne? Dr. Ronkainen: I think that gender, particularly females, in the kind of 20s, 40s range, tend to have more of a hormonal component of their acne, so definitely we see that patient population a lot in our dermatology clinics. Host: We know the face is a common area that people get acne, but where else can people get acne? Dr. Ronkainen: Classic acne tends to affect the face, chest and back. However, if it’s severe, it can also affect the shoulders. And, as I discussed earlier, folliculitis can affect the buttocks or other areas such as the thighs. Host: What treatment options are available for adults with acne? Dr. Ronkainen: So, even just starting at the local pharmacy, there are a lot of over the counter options for acne and there are many different ingredients that patients can experiment with. Benzoyl peroxide is a classic treatment for acne that really targets the bacteria that grows on the skin. There’s also salicylic acid, glycolic acid or sulphur washes it; work to more exfoliate the skin, help clear the pores that way. These are available over the counter in various products, however, they can be coupled very nicely with prescription products such as topical antibiotics or topical retinoids. These can also be accompanied by oral medications if the acne is deemed to be more severe. Host: How long does it typically take a patient to treat their acne? Dr. Ronkainen: Acne can be really frustrating to treat and, especially when patients are coming in to see me, they want results pretty quick. And, it’s frustrating to tell them that it takes up to three months to really see if a certain new acne regimen is going to work for them. So, I usually tell people that we should start seeing some improvement by the first month, but really by three months we should know if this treatment regimen is really working for them or if we need to change it up a little bit. Host: What are some tips people can follow to help them prevent or treat acne? Dr. Ronkainen: To prevent or treat acne at home, it’s very important to be mindful of what you’re putting on your skin every day. Number one, you need to make sure that the products that you’re using on your skin are not blocking your pores. And so, the products you would be looking for to be using are labeled non-comedogenic, meaning they don’t cause acne. Also, while at home, you can start out with some gentle cleansers and gentle topical treatments that are available over the counter and incorporate those into your daily regimen. Host: Why is MedStar Washington Hospital Center the best place to seek care for acne? Dr. Ronkainen: 353 Washington Hospital Center dermatologists have a wide breadth of experience in treating acne and all types of skin cancer in patients of all ages. So, we really have the dermatologists who work well with the patient to find a regimen that works for them, whether it is just topicals or if we need to go to more aggressive therapy such as oral antibiotics, anti-hormonal therapies, or Isotretinoin, also known as Accutane. Host: Could you share a story where a patient overcame acne after visiting you at MedStar Washington Hospital Center? Dr. Ronkainen: Absolutely. We see acne patients every day in our clinic and there’s nothing more satisfying than having a patient come back in three months, after you started them on a regimen, and have them just have a visible happiness on how well that they’re doing and the improvements that they’ve seen. Host:  Is there anything in people’s diets that could influence their risk of developing acne? Dr. Ronkainen: You know, this topic comes up a lot in my appointments with my patients. And, the only study that we have that has shown a correlation between a certain dietary component and increased development of acne, is skim milk. I don’t think we know exactly why that is, considering as compared to patients who drank regular or whole fat milk and there was no evidence of increased acne in that patient population. So, that’s the only piece of evidence-based medicine that I can point to, to say maybe switch over to the whole fat milk. Host: Some people can be tempted to pop their pimples when they arise. Is this something that’s safe to do? Dr. Ronkainen: As tempting as it is, I do not recommend that my patients pop their own pimples. Breaking the skin can cause more inflammation and can cause more scarring in the long run. Sometimes, if patients have a really deep, painful acne bump, sometimes they can come in to the clinic and have an injection of an anti-inflammatory medication to help soothe that area. However, usually trying to pop the pimple yourself is more trouble than it’s worth and will lead to long-term scarring which tends to be a more frustrating process for patients I see in the long run.  Host: At what point should a patient go to see a dermatologist to treat their acne? Dr. Ronkainen: I think if a patient is not satisfied with how their skin is looking at home, a visit to a dermatologist is an easy choice. We can always talk you through what you’re using as your home regimen - tweak that as well as add in prescription-strength products. So, if you’re at home wondering whether or not you should be seeing a dermatologist, even a one-off consultation certainly wouldn't hurt. Host: Thanks for joining us today, Dr. Ronkainen. Dr. Ronkainen: Thanks so much for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

For many women, breast reconstruction is an important part of the healing process after breast cancer surgery. Plastic surgeon Dr. Kenneth Fan discusses the three reconstruction methods we use and why treatment often depends on patients’ unique expectations, goals, and needs.    TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Ken Fan, a plastic surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Fan. Dr. Fan: Pleasure to be here. Host: Today we’re discussing how breast reconstruction surgery, one that occurs after cancer surgery, works and what patients can expect from it. Dr. Fan, could you begin by explaining why women undergo breast reconstruction surgery after cancer surgery? Dr. Fan: Well, that’s an interesting question. And I think a important point to point out at this juncture is that breast reconstruction after cancer is not cosmetic surgery. It’s a reconstructive procedure and it’s actually mandated by law as a result of the Women’s Health and Cancer Right Act. Therefore, I think it’s important for patients to know that their access to breast reconstruction surgery is not optional. There’s something about breast reconstruction after cancer surgery that really gives patients hope and an opportunity to feel whole again. And we see this in our research. After breast reconstruction, patients who have had reconstruction have the same quality of life as patients who haven’t even had cancer. And this has been shown in large, large series of data. And therefore, I think it’s important for a team of breast surgeons and plastic surgeons to discuss what the right option for breast reconstruction for that patient is. Host: What is your patient population typically like? Dr. Fan: I see patients for breast reconstruction with all sorts of lifestyles and requirements. And therefore, it’s very important for us to have a group discussion on what the best breast reconstruction modality is. For example, some patients have a very active lifestyle and want to get back to work right away. Therefore, we can do certain types of reconstruction that facilitate that. Other patients want this to be the last surgery they go to and really want that home run, so they don’t have any future operations in the future. And so, we also have surgeries for that breast reconstruction patient as well. Host: How does breast reconstruction surgery work? Dr. Fan: That’s a great question. So, globally speaking, there are three main ways that breast reconstruction can occur. The first one is an oncoplastic approach in which the breast surgeon takes out a small tumor and mere rearrange tissue within the breast. The second approach is after mastectomy. And this is usually with a, what we call, prosthetic-based reconstruction. We use an implant, or a temporary device called an expander, to reconstruct a breast mound. The third option is what we call autologous space reconstruction. And in autologous space reconstruction, we use patients own tissues, either from the abdomen or from the back, to reconstruct a breast. Host: Following breast cancer surgery, how long does it typically take women before they have a breast reconstruction surgery? Dr. Fan: So that’s a great question. Breast reconstruction can generally be done in the same operating room visit as the cancer surgery. However, there’s some rare cases in which patients will need what we call a delayed type of reconstruction. However, it’s important for patients to come see us before surgery and we can explore all the options together. Host: How close can you get to making a breast look the way it did prior to surgery? Dr. Fan: Depending on the cancer characteristics and the cancer excision, we can come pretty close. I think for patients and for us surgeons, our greatest hope is that patients, while clothed, can have the appearance of not having had breast cancer. And that is our ultimate goal. And, I think more often than not, we achieve this goal. However, if the patient were to look in the mirror unclothed, there are certain scars that would give away the fact that they had breast reconstruction. Host: Is there anything women must do prior to breast reconstruction surgery? Dr. Fan: Not necessarily. What’s important is to have a group discussion on what the best modality is for that patient. We practice a patient-centered approach, so we go through all the options and really discuss with the patients what is the best modality to make sure that they are happy with their surgery. Host: Is there any new, exciting research related to breast reconstruction surgery? Dr. Fan: At MedStar, we are constantly looking at how we can do things better. In particular, a lot of our research focuses on complications after breast surgery and improving the patient experience after breast surgery. Our second main point of research is improving the patient experience after surgery. In particularly, we are looking at use of enhanced recovery after surgery, short for ERAS protocol. This protocol, we have found, has decreased the amount of narcotic usage significantly that patients have to take after surgery. Patients find themselves walking post-op day 1 or 2 after a major operation and are leaving the hospital sooner. So much so that they are surprised at even how well they’re doing themselves.   Host: Why is MedStar Washington Hospital Center the best place to seek care for breast reconstruction surgery? Dr. Fan: I think it’s important for patients to know, for perspective patients to know, that at MedStar Washington Hospital Center we’re focused, not just on disease, but on the patients themselves. We focus on the patients’ needs through a multidisciplinary approach and really engage patients to help understand their expectations and desires. This makes us such a special place as providers are constantly collaborating together to come up with the best solution for our patients. Host: Thanks for joining us today, Dr. Fan. Dr. Fan: Thank you. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

About 800,000 Americans have a heart attack each year—and younger women account for nearly one-third of them, according to a recent study. Dr. Patrick Bering discusses what’s causing this rise in heart attacks.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Patrick Bering, a cardiologist at MedStar Washington Hospital Center. Thank you for joining us, Dr. Bering. Dr. Bering: Thank you so much for having me. It’s a pleasure. Host: According to a 2018 study, younger women are having more heart attacks. In fact, they’re accounting for nearly one third of all female heart attacks in recent years. Today we’re going to discuss why this is, and ways women can prevent heart attacks. Dr. Bering, could you begin by explaining why we’re seeing this rise in heart attacks among young women? Dr. Bering: Absolutely. This is definitely an alarming trend that’s seen nationwide. One of the reasons why we think we’re seeing more young women hospitalized with heart attacks is that there has been an increase in the cardiovascular risk factors among young adult women. Among these would be things like high blood pressure, diabetes, obesity, smoking and poor lifestyle, including poor diet and low physical activity levels. Host: And is this something you’re seeing only in young women or young men as well? Dr. Bering: We see premature heart disease both in young men and young women. Unfortunately, we have been seeing a trend for increased hospitalizations for heart attacks in young women more so than young men. There may be some additional risk factors that young women have. And, when I say young women, I mean women and young adults, so between the ages of 35 and 55. And these can include women who have conditions such as polycystic ovarian syndrome, premature menopause or a history of preeclampsia during pregnancy. Host: Are there certain demographics of young women that you’re seeing more than others? Dr. Bering: That’s an interesting question and one that we’re still gathering information about. It seems to be important where you live from a socioeconomic perspective. In that way, your neighborhood may actually be a risk factor, positive or negative, for your development of heart disease. We do see a high amount of premature heart disease in African American women, which is a concern for us and we aim to combat this from many different facets, aiming at preventing the risk factors for heart disease. Or, if they develop, to try to optimize them to prevent any long-term consequences to cardiovascular health. Host: Are there symptoms or warning signs of heart attacks that people should be aware of? Dr. Bering: Definitely. You hear about classic symptoms which include pressure on the chest or some people describe it as an elephant sitting on the chest. These classic symptoms are more common in men. Unfortunately for women, the symptoms may be more atypical. They can include things like heartburn, fatigue, shortness of breath, low energy, acid reflux, nausea. Because women have more atypical symptoms of heart disease, they may be less likely to seek medical attention at the time that they’re experiencing something like a heart attack. Host: Could you expand on some of the symptoms young women may have? Dr. Bering: Certainly. As I said, this can be confusing, even for the healthcare community, at times. Since young women or even women post-menopause are more likely to have atypical symptoms that may be gastrointestinal, it has to be in context with the rest of their symptoms and well-being. If there’s been a change in their ability to do physical activity or exercise, that goes along with symptoms of heartburn or nausea, low energy or fatigue - those combinations are more worrisome than if it’s just heartburn after they’ve had, say, a spicy or acidic meal. Host: Is there any point at which somebody should definitely see a doctor? Dr. Bering: Absolutely. If someone is having significant shortness of breath or decreased energy, intractable nausea, or heartburn that doesn’t get better with usual methods such as an antacid, they should seek medical attention, especially if they have a history of premature heart disease in their family or if they have risk factors for heart disease that we described before - high blood pressure, diabetes, obesity, poor diet, poor physical activity, high cholesterol.  Host: What can young people do to prevent heart disease? Dr. Bering: That’s a great question and one of our most important ones. At an individual level, young people can be aware of their health, in a way that prevents the development of risk factors for heart disease. That generally goes along five different related and intertwined steps to positive health. Those include things like healthy diet, regular physical exercise, control of blood pressure, control of weight and focusing on positive stress and mental health in their life. Even things like getting 7 to 8 hours of sleep per night is a very important step of focusing on your overall health. Host: Could you explain how regular doctor checkups could go a long way in young people preventing heart disease? Dr. Bering: Definitely. For young people, even though many of us feel well or healthy, or we may have a lack of medical problems, some of the risk factors for heart disease may actually be silent. Many people don’t FEEL that they have high blood pressure and instead, they discover it later in life once some of the consequences of high blood pressure have accumulated over time in the body. A regular checkup with your primary care health provider every year is an important way for you to have a dialogue and positive relationship with the health care community. We, in health care, are very excited about seeing patients where we can make positive influences to prevent disease. And, in fact, that seems to be one of our...or actually, our MOST successful strategy, when we are combating disease. Host: Why is MedStar Washington Hospital Center the best place to seek care for heart disease? Dr. Bering: At MedStar, we’re so proud to serve our community and we’re lucky that we have passionate healthcare providers that can focus on a variety of issues related to your cardiovascular health. In one sense, we have great primary care physicians, as well as cardiologists, who are focused on the prevention of heart disease. In another sense, if you are unfortunate enough to develop cardiovascular disease or the risk factors for it, we have a team of experts that are able to provide you with comprehensive, expert care in order to manage your conditions optimally in a strong dialogue with you. We like to make our care patient-centered so that everything is focused on goals that we can achieve with the patient themselves. Host: Could you share a story in which a young patient received optimal care for heart disease at MedStar Washington Hospital Center? Dr. Bering: Absolutely. I’ve recently had the privilege of taking care of a young woman who had initially thought that she had symptoms of acid reflux. As it turned out, this was actually a heart attack in its beginning stages. Since she presented with atypical symptoms, our emergency room physicians were keen enough to look for a cardiac cause and discovered the early signs of the heart attack. When she came under my care, I was able to get her the appropriate procedure that she needed in order to open up a blocked blood vessel supplying blood to her heart muscle. In that sense, we were able to successfully handle her care, both from the moment she hit the door in the emergency room to the point of discharge with minimal heart damage and overall good heart function. Host: Thanks for joining us today, Dr. Bering. Dr. Bering: It’s been a pleasure. Thank you again. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Some of the most unexpected injuries in medicine are due to orthopaedic trauma, which involves problems related to bones, joints, and soft tissues. Discover what some of the most common orthopaedic trauma injuries are and how we treat them.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Robert Golden, Chief of Orthopaedic Trauma Surgery at MedStar Washington Hospital Center. Thanks for joining us, Dr. Golden. Dr. Golden: Thanks a lot for having me. Host: Today we’re discussing common orthopaedic trauma injuries which commonly affect bones, joints, ligaments, tendons and muscles, and how we diagnose and treat them at MedStar Washington Hospital Center. Dr. Golden, could you begin by explaining why orthopaedic trauma injuries generally occur? Dr. Golden: Sure. They can occur from multiple different kinds of mechanisms, the most common being falls and motor vehicle crashes. But we also see a large number of injuries from bicycle related injuries, scooter related injuries. We also, in this area, see a fair number of gunshot wounds.  Host: What are some of the most common orthopaedic injuries that you see? Dr. Golden: A lot of them depend on how the person was injured. We do see a fair amount of injuries from pedestrians being struck by cars. They tend to get injuries to their legs and lower extremities. A lot of people who just fall, and they can hurt anything including ankles and lower extremities, but then they also tend to have a lot of wrist injuries and shoulder injuries from falling and putting their arms out to protect them. Host: And could you explain, giving specifics, some of those injuries? Dr. Golden: Sure. A very common mechanism when you fall and you put your arm out is that you break what’s called your distal radius, which is just the bone at the end of your arm right before your wrist. It’s a very common injury in older people as well as in younger people when they suffer a high energy fall. Some of the injuries from the pedestrians being hit by cars involve what’s called a tibial plateau, which is the top part of your tibia, right below your knee. You can imagine the bumper of the car striking you on the side and that bumper is right about the level of your knee, so a lot of people get injuries that way. Once it gets a little warmer and people go back to motorcycles or riding bicycles, then you start to see a little more high energy injuries, especially from the motorcycles and those can involve injuries to your femur or your thigh bone. And, the higher energy crashes with motorcycles, and with cars, then you can get some of the pelvis injuries that people see. The other thing we’ll see is we’ll get patients referred in who have had complications from fractures that they’ve had in the past. Sometimes the fractures just don’t heal and then that’s called a nonunion. Sometimes they heal but they heal in a crooked position. So, we’ll also treat those patients. And, if they haven’t healed, a lot of times you need to figure out why that is. Sometimes that’s because the bone simply doesn’t have enough blood supply to it. Sometimes it’s because the patient doesn’t have the components necessary to actually heal that, be it enough vitamin D in their system or other reasons that can prevent bone healing. So, oftentimes we’ll have to take them back to the operating room and do other procedures to try to get them to heal, including taking some bone from another part of their body and bringing it into the area where it hasn’t healed. If they’ve healed but it healed crookedly, called a malunion, sometimes we’ll even have to re-break the bone or cut it at the area where it’s crooked - sometimes that can be done as a single procedure. Sometimes we have to put on different kinds of apparatus that go on the outside of the bone and interface with a computer program so that we can control how the bone is manipulated over time and we’ll slowly restore them back to a straight position to get them to heal. The other thing we’ll often see as orthopaedic traumatologists is we also specialize in bone infections, so we’ll get patients referred in who have had bone infections for lots of different reasons, sometimes as a result of trauma but sometimes just as a result of getting an infection, so we’ll treat those as well. Oftentimes, that requires a surgery to open up the bone, get out as much of the infection as possible so that then antibiotics can be used to control the infection for long-term cure. Host: Could you discuss common treatments for these injuries and how they work? Dr. Golden: Sure. A lot of the injuries depend on where in the bone it’s broken. Injuries that occur close to the joints, which are called periarticular injuries, generally require plates and screws to fix them so that you can align the bone, make sure the joint is re-aligned back as perfectly as possible. And then that’s held in place with small metal plates that are held on to the bone with screws. That allows the bone to stay in the proper position and then it heals around it, so the plates are functioned like scaffolding and hold everything in the right spot and then it’s still up to the person to actually heal the bone. If you break some of the long bones, like your tibia or your femur, then sometimes we’ll put rods into them. Those go on the inside of the bone and, like the plates, they form a scaffolding, but these...the bone heals around them, so they’re totally contained within the bone itself. Host: And what kind of recoveries can these patients expect? Dr. Golden: Some of it depends on what’s injured. In general, bones take about 12 weeks or 3 months to heal. Some of the injuries, the hardware that we put in is strong enough to support their weight. If that’s the case, we’ll get them up as soon as possible right after the surgery and get them moving to minimize their stiffness that they might get, minimize the amount of muscle loss that they may have from not being able to move around. Some of the injuries, you just simply can’t do that. Some of the plates and screws that we put in have to get very close to the joints in order to get the joint perfect and those aren’t strong enough sometimes to support the person’s weight. If that’s the case, then they may have to have a period of not putting weight on that limb, using crutches or a walker or sometimes even a wheelchair, until that bone heals strongly enough that then they can start putting weight back on it. Oftentimes, if that’s the case, then we’ll have the physical therapists involved to try to minimize their stiffness and minimize any sort of muscle loss they may have from not using that limb. A lot of times we get other services involved, as well, to try to maximize their recovery, minimize the impact onto their life. Unfortunately, a lot of these people weren’t expecting anything to happen that morning and leave for a normal morning and then they have a huge life interruption from these traumas. So, it’s a little bit different that going in for an elective surgery when you know when it’s going to happen and you can plan for it. So, often we have to have a lot of social work involvement to help them in terms of planning for disability insurance and time off of work until they can be strong enough to get back to their occupations. Host: Do you have any tips to help people prevent these injuries? Dr. Golden: A lot of them, it’s just being careful with what you’re doing, especially with the motorcycles and bicycle crashes, and sort of knowing your limits. Unfortunately, sometimes it is just a random occurrence that happens. You can’t do anything about it if you’re driving down the street and somebody runs through a red light and hits you. You had nothing to do with that but, unfortunately, you still have to deal with the consequences of it. Host: Are there certain patient populations you see the most with orthopaedic trauma injuries? Dr. Golden: Orthopaedic trauma tends to be what’s called a bi-modal distribution most of the time, meaning that we see a lot of younger people in their late teens and twenties, then we see a lot of older people. Those injuries occur for different reasons. The young people tend to be doing the more high energy, risky sort of things - riding motorcycles, riding bicycles, doing things fast with high energy. The older people just lose their balance and have less stability in their bones. So, when they fall, they may break their hip, when, if you fell, you would just get right back up and be fine. Host: Why is MedStar Washington Hospital Center the best place to seek care for orthopaedic trauma injuries? Dr. Golden: Well, we have a full staff of orthopaedic traumatologists here. There’s two of us who specialize...orthopaedic trauma and that’s pretty much exclusively what we treat. But we also are supported by a full orthopaedic department that has specialists in all the other disciplines. So, sometimes if you have a injury to the bone and the ligaments, we’ll take care of some of the bony issues, and then some of the sports medicine people will take care of some of the ligament injuries or the hand people will take care of those specific injuries. We are also plugged in to the MedStar trauma service network here with the trauma team that can provide a multidisciplinary approach to make sure that any other injuries you may have that don’t relate to orthopaedics - injuries to internal organs or other body parts - can be managed, as well. Host: Could you share a story in which a patient received optimal care for orthopaedic trauma injury at MedStar Washington Hospital Center? Dr. Golden: Sure. We’ve had tons of patients come through since I’ve been here and a lot of them have multiple injuries. I just saw a guy who we treated seven years ago now was just coming back essentially to get a checkup. But he had injured both of his limbs, again this was a motorcycle crash, both of his lower legs, both of his feet, some of them were open fractures, meaning the bone had come out through the skin. He also had a bunch of injuries to internal organs. So, he came in, was treated by the general surgery trauma team to stabilize all his internal organ injuries. We then treated his bones. He needed several surgeries to try to minimize any risk of infection and prevent that from happening. We then stabilized his bones with the plates and screws and rods. And then the plastic surgery team provided flap coverage to get that covered as well. One of our more well-known instances of treating patients has been both with the Congressional baseball shooting, prior to that the Navy yard shooting. We had victims of those shootings here, as well, and that was truly an interdisciplinary exercise where there were the general surgery trauma team was involved, vascular surgery teams were involved, we were involved - and all that care came together at the specific times when it was appropriate to make sure that we first saved the lives, then, eventually, got everything fixed and back to function and, you know, getting back in to life. Host: Do you have any advice for what patients can do before EMS arrives? Dr. Golden: Well, a lot of it is just staying calm and keeping the limbs that you think are injured still. Sometimes that involves you just staying still and not moving around. If there’s other things available to help with that - and that can be as simple as finding some cardboard and rolling it up to form sort of a make-shift splint, or sometimes even newspapers are enough, just to help keep everything still - generally that’ll make it feel more comfortable because if the bones aren’t moving around where they're not supposed to, it will hurt less. That could also help prevent some of the associated injuries to the soft tissues around the bones that can be injured if the bone is moving abnormally. So, that may help the person who is hurt, in terms of just pain control, as well as trying to prevent some of the issues to the skin and the soft tissues. Sometimes, if it’s an open fracture and there’s actually bleeding from the wound, you can just put some pressure on the area where it’s bleeding and that will help minimize that as well, until an EMS professional arrives.  Host: Thanks for joining us today, Dr. Golden. Dr. Golden: My pleasure. Thanks for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Deep Vein Thrombosis (DVT), a condition in which blood clots form in the deep veins, affects as many as 900,000 Americans each year and can cause symptoms such as pain while walking and a burning sensation in the legs. Learn who’s most at risk of developing DVT and common treatment options.    TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Steven Abramowitz, a vascular surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Abramowitz. Dr. Abramowitz: Thank you for having me. Host: Today we’re discussing deep vein thrombosis, or DVT, a condition where a blood clot forms in one or more deep veins in your body. Dr. Abramowitz, could you begin by discussing how these blood clots form and where they typically arise? Dr. Abramowitz: Sure. So, in our body, our veins are responsible for bringing blood back into our heart. Arteries take it away, veins bring it back. And, when we think of the veins in our body, there are veins that are superficial, or near the skin, and veins that are deep that run down near our bones or with our arteries. These deep veins - you could think of them, if you’re in the DC area, as our big roads - let’s say the New Hampshire’s or the Pennsylvania Avenues or the Georgia’s. And, some of our superficial veins are more like our side streets - like a T street or a U street. And, everything drains into these deep veins. But, sometimes there can be a traffic jam, and that traffic jam, in the case of our blood vessels, is a blood clot. And that blood clot can occur anywhere these deep veins are - in the arms, in the legs, essentially anywhere that you may name a deep vein. And what we find is that, depending upon where the clot is, it can lead to a variety of different symptoms. And, if that clot breaks free, it can travel back to the heart, where all the blood from our veins goes originally. And that can result in a pulmonary embolism, which can be a fatal condition. Host: And what are some of the common symptoms of DVT? Dr. Abramowitz: Most commonly, people who have DVT in the lower extremities, will experience swelling, pain when walking, a hot burning sensation as their leg gets warm or engorged and full of blood. And those typically are the most common complaints that people have. Host: Who is most at risk of developing DVT? Dr. Abramowitz: Anybody can fall victim to deep vein thrombosis. And really, it depends on what’s going on with someone else’s health. So, for example, there are plenty of patients that we treat here at MedStar Washington Hospital Center who are younger, maybe they’re in their teens, and the first time that they know they have a clotting disorder or a blood disorder that may make them more likely to make blood clots, would be the presentation with a DVT in one of their legs. Other times, patients who have had surgery or other conditions that make them less mobile or engaging in activity in their lives could be victims of DVT, as well. And, it can also be something that we find in hospitalized patients, people who are immobile in a hospital bed for extended periods of time. So really, it’s a condition that can affect anybody of any given age. Host: How is DVT diagnosed? Dr. Abramowitz: For the most part, it’s both a clinical diagnosis and a confirmation with ultrasound. And we use ultrasound as a simple way of diagnosing the presence of clot within the deep veins. And this is done, again, as a very quick test without radiation exposure, or dye, and it’s a simple procedure that we can do, even at the bedside, for someone who’s in the hospital. Host: What treatment options are available for DVT? Dr. Abramowitz: Right now, for patients who have deep vein thrombosis, we currently offer two therapies. First, most patients with deep vein thrombosis, will be treated with something that’s called an anticoagulation agent. In basic terms, it’s a blood thinner. And the reason we put somebody on a blood thinner is not that it actually gets rid of the blood clot, but that it makes it less likely for more blood clot to form because our bodies have the natural ability to break down clot over time. But for some patients who have extensive clot or a lot of clot throughout the vein, let’s say in a leg, we can actually go in with a wire and a small catheter, which is like a plastic tube or a hose, and we can give the medication directly into the clot, to make that clot go away faster for those patients, as well. Host: And, how fast is faster for those blood clots, typically? Dr. Abramowitz: Well, if we’re performing a procedure on a patient, usually we can get that clot away in a single session. For patients who have to have blood thinners, sometimes it can take the body up to 3 to 6 months to dissolve the clot on its own. Host: Is there anything people can do to prevent DVT? Dr. Abramowitz: For patients who are sick or at risk for DVT, meaning they’re not moving around a lot or they already have something else in their body that’s making them feel inflamed or more likely to develop a blood clot, those patients can both get up and walk and move around. If they can’t do that, engage in exercises so that they’re activating those muscles in their legs and circulating blood. For patients who are, let’s say younger, and they have a blood condition making them more likely for DVT, again, moving around is really important. And, a lot of times we talk about blood clots in a setting of travel or prolonged travel. So, if you’re getting on a plane, I always tell patients not to have that 2 or 3 glasses of wine and pass out, make sure you get up and walk every hour or so. And, if you’re in the hospital, or you’re in a sedentary job, or it could be you’re sitting at a desk, make sure you stand up and walk, too. Host: Why is MedStar Washington Hospital Center the best place to receive treatment for DVT? Dr. Abramowitz: Well, one of the great things we have here at MedStar Washington Hospital Center is an interdisciplinary approach to the management of deep vein thrombosis. People who have DVT, not only do they have symptoms now, but they can have symptoms in the future, too, because as the body breaks down that clot, it causes swelling and inflammation in the same way as if you were to get a sprained ankle - you’d have swelling and inflammation. And, that swelling and inflammation can lead to scarring of those veins. So, the deep veins - maybe they’re a four-lane highway before your blood clot, but afterwards they’re a two-lane highway. And that can lead to swelling and that sort of congested traffic for a long period of time. At Washington Hospital Center we offer all of the new therapeutic interventions for deep vein thrombosis management. Anything from sucking out the clot, which is called mechanical thrombectomy, to dissolving the clot rapidly, which we call pharmacomechanical thrombolysis, which is essentially like a little machine that injects that clot busting medication in and sucks the clot out. And, we also put those catheters in and leave them in overnight to slowly dissolve a clot that may have been around for a longer period of time. So, we have the tools to treat your DVT and, also then, take care of you because the DVT is a symptom of something else, most likely. Maybe you have something wrong with your veins that we can diagnose and treat with a stent. Maybe you have another underlying condition, like a blood disorder, or you’re sick with something else so the DVT is the first thing we diagnose. So, when you come to Washington Hospital Center with a DVT, it’s not just about treating your clot. It’s about making sure we understood why it happened. And, we have every single surgical and medical sub-specialty service you could want here to help you deal with that process. Host: How often can DVT be a gateway to other conditions? Dr. Abramowitz: Well, the DVT is a condition in and of itself, but you have to ask yourself why it happened. And, for a lot of patients, sometimes the first sign that they may have cancer, for example, is the blood clot. And so, they need to be screened for conditions that would make their blood more likely to clot. Or, for someone who’s younger, if they have a blood clot, it may be a sign that they’re actually more likely to have a genetic condition. So, anytime someone has a DVT, it always prompts us to ask the question, “Why did this happen?” and “What can we do to figure out, for THIS patient in particular, what led to this state of being?” So, I’d say 80 percent of the time someone has a DVT we’re able to figure out the reason why, be it another medical condition, an anatomic predisposition, meaning there’s something in their body maybe compressing a vein, or we find out that they have a genetic condition that’s related to their blood in and of itself. Host: What are the risks of leaving DVT untreated? Dr. Abramowitz: That’s a great question. So, really it depends upon where in the body the DVT is. For the most part, blood clots below the hip, those being in the top part of the leg or the bottom part of the leg, they tend to result in swelling in the short term, but don’t necessarily result in long-term damage to the leg that would cause wounds to form or prolonged swelling in the future. But what we find is blood clots that are above the hip or above your groin that affect the veins in your belly and in your pelvis. Those can lead to long-term drainage problems from the leg and that can result in long-term swelling or even wound-care formation. And we call that post thrombotic syndrome. So, it’s really important for us to identify the extent of the blood clot and where exactly in the body it is so that we can predict what someone’s risk is in the future for developing problems as a result of their DVT. Host: Thank you for joining us today, Dr. Abramowitz. Dr. Abramowitz: My pleasure. Thanks for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

BPH, or an enlarged prostate, affects about 50 percent of men between the ages of 50 and 60, causing symptoms ranging from frequent urination to a weak urine stream. Dr. Daniel Marchalik discusses GreenLight laser surgery, a minimally invasive treatment for BPH.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Daniel Marchalik, the Director of Ambulatory Urologic Surgery at MedStar Washington Hospital Center. Thank you for joining us, Dr. Marchalik. Dr. Marchalik: Thanks so much. Happy to be here. Host: Today we’re discussing a newer treatment for benign prostatic hyperplasia, or BPH, which often is referred to as an enlarged prostate. This treatment is called greenlight laser surgery. Dr. Marchalik, could start by explaining what greenlight laser surgery is and how it works? Dr. Marchalik: Yeah, of course. So, as a lot of listeners know, BPH is a really common issue. In fact, we know that half of all men in their 6th decade of life have signs of an enlarged prostate. And so, as a result, this is something that we have to deal with very often and treat very, very often. And there are different ways of treating BPH. Traditionally, BPH has been treated surgically by shaving the prostate down using an electrode that can actually shave it from the inside. Recently, in the past 5 to 10 years, we’ve started to use something called the greenlight laser to do a photo-vaporization of the prostate. Now what that means is that we use a laser to actually vaporize the prostate tissue. The greenlight laser is a really interesting device because the laser itself is absorbed by the hemoglobin molecules - those are the red cells...red blood cells. What that allows us to do is to actually make the tissue vaporize without causing as much bleeding as other ways of treating BPH. Host: What’s the process in which you diagnose a patient with BPH, or enlarged prostate, and who are the best candidates for greenlight laser surgery? Dr. Marchalik: The diagnosis is really usually made by symptoms. So, when somebody comes in and they complain of having difficulty urinating, waking up at night to urinate, feeling like their stream has gotten weaker, feeling like they’re always rushing to the bathroom - basically, like the guys in the commercial who are going to the baseball game and they always have to sit on the aisle because they need to know where the bathroom is at all times. Or, the guys that are running in and out of meetings because they feel like they’re just not going to make it through the whole meeting without peeing. Those are the symptoms that we tend to see with BPH. Now, we do questionnaires to try to get an objective measure of exactly how much this is bothering them. We can also measure the flow of their urine to see how strong their stream is. And, if we then diagnose them with issues urinating, we then go on and measure the size of their prostate to objectively demonstrate that it is enlarged and sometimes even look inside the prostate using a small camera called a cystoscope. Every patient is obviously going to be different. But, the general approach is to first establish what the symptoms are that the patient is experiencing, and then to get some objective data, like the size of the prostate and the way that the prostate looks. Host: What is recovery typically like following greenlight laser surgery? Dr. Marchalik: The big difference between a greenlight laser surgery and the traditional surgery called a TURP, a transurethral resection of the prostate, which is the way that prostates used to be treated more in the past and still are treated today, is that the greenlight laser surgery could be done as an outpatient, meaning it’s in and out surgery. The big difference there is that you don’t have to spend the night in the hospital. And, that means that the recovery tends to be a little bit smoother. Generally, patients who undergo a greenlight laser photo-vaporization of the prostate get sent home with a catheter that they can either remove themselves the next day or come back in to the hospital and we can remove it for them. Most patients will immediately see a difference in their stream. What I mean by that is that patients who have really struggled to try to push the urine out or felt like their urine just doesn’t tend to flow the way that it used to when they were younger, will often experience the return of that type of force right away, and so they might be able to see the results immediately. Now, of course, because they had the surgery and because their prostate was shaved down, that means that they need to abstain from things like heavy lifting and exercise, cycling, for the next four weeks or so to prevent them from developing bleeding from that raw area in the prostate. Host: Are there any risks involved with greenlight laser surgery? Dr. Marchalik: Of course. As with any surgery, there are inherent risks associated with anesthesia. But for the surgery itself, there are some things that tend to be risks for the procedure. For example, about three-quarters of guys who undergo this procedure will develop something called retrograde ejaculation. It means that when they ejaculate, nothing comes out or less comes out. Now, it doesn’t change their ability to have erections. It doesn’t change their ability to have an orgasm. But it does change the actual experience because there is no ejaculate. About 3 to 5 percent of guys can develop some leakage. It’s called incontinence, meaning when they sneeze or cough or do strenuous activity, some urine might leak out. For a lot of guys, it’s just a few drops and it tends to be transient, meaning it goes away after a few weeks. But there’s a small subgroup of guys that can develop a more long-lasting issue with the urinary leakage. Of course, there’s always a risk that the procedure doesn’t actually help someone, meaning even though we shave the prostate down, they have some underlying problems with their bladder that prevent their bladder from squeezing as well as it should. And in those cases, the procedure might help them but maybe not as much as we would hope that it would. Host: When speaking of risks,  is there usually any hesitancy from patients and how do you walk them through, you know, why maybe they shouldn't be hesitant? Dr. Marchalik: It’s funny that you use the word “hesitancy” because urinary hesitancy is why the guys come to see me in the first place. But, I think that’s a good question. And, I think that as with any surgery, you have to remember that each individual patient is going to be different. There are people for whom this surgery is not ideal. For example, if somebody comes to me and they say, “I want a procedure for my BPH, but we want to have some more children.” And, for a patient like this, this is not a good procedure because the retrograde ejaculation certainly puts you at risk of not being able to have children anymore. Now, there are people that say, “Hey, I really want a procedure, but I can’t go under anesthesia. I’m scared of anesthesia. This is not something that I’m willing to do.” This is not a good procedure for them because this does require anesthesia. There are other people that come to me and they’ll say, “What type of procedure can I do that I know is going to last more than a few months or that has a lot of research behind it?” And then we talk about this procedure because I think this is a very good option for them. There are things that give people pause. For example, the retrograde ejaculation and the risk...the need to have a catheter for one day afterwards. But a lot of times, when we actually talk through this, this is not something that is an issue for most people that I see. Host: What makes greenlight laser surgery superior t o other treatment options? Dr. Marchalik:  The biggest advantage that I see for a greenlight laser TURP is the fact that this could be done as an outpatient, meaning a patient gets to go home at the end of the procedure and spend the night at home versus the hospital.  However, we still see the same benefits with greenlight laser TURPs as we see with regular TURPs, meaning we still see the same effectiveness of the procedure. Guys get the same urinary function that they have with the regular TURP with this greenlight laser TURP. They have the same side effect profile as a regular TURP. And, the same risk of having to need a surgery down the line. So, by that I mean that it is really a comparable procedure, just as good, but the risks are lower and there’s no need to spend the night in the hospital. Host: Is there anything patients should do beforehand to prepare for greenlight laser surgery? Dr. Marchalik: There’s nothing that they need to do in particular that’s different from any other surgery. And, of course, those instructions will differ by each individual patient. But usually it means having nothing to eat or drink after midnight and this is the same approach as they would for any other surgery. The big difference is they don’t need to pack a bag to bring with them to spend the night in the hospital. Host: Why is MedStar Washington Hospital Center the best place to receive treatment for BPH through treatments like greenlight laser surgery? Dr. Marchalik: We have a very good interdisciplinary team that discusses each individual patient. And, we have a good track record of performing this surgery that is an advanced greenlight laser surgery, including for some people who have larger prostates. Traditionally, the greenlight laser TURP has been reserved for smaller prostates, but we’ve been doing it with great success on guys with larger prostates and we’ve had really good patient outcomes. And, of course, we are very committed to our patients, which means that we continue to see them in our clinic and to make sure that their results are not just good successes initially but are durable and they maintain the good urinary function throughout the years afterwards. Host: Could you share a story where a patient received an optimal outcome through greenlight laser surgery? Dr. Marchalik: Yeah. I had a patient recently who had been in and out of the emergency room multiple times over the span of several months. He kept having difficulty urinating. It’s called urinary retention, where basically no urine comes out. It could be an extremely uncomfortable and extremely painful condition. So, he kept coming in to the emergency room, would have a catheter placed, the catheter would be removed, he would be OK for a few days, and then it would return. Leading up to it, he’s a guy who was in a lot of business meetings and he said that this was starting to really interfere with his job. He kept having to leave meetings early, he kept interrupting meetings because he had to rush to the bathroom. And, he said his quality of life just wasn’t what it used to be. He underwent this procedure and immediately, the next day when the catheter was removed, he saw a difference. He said that the stream was the way that it used to be when he was in his 20s, which I think is a pretty good endorsement. A few weeks went by and some of the initial urgency that he felt after the procedure, as he was going through the healing phase, went away. I saw him in clinic a few months afterwards and he told me about how he can now sit through a meeting with no problem. He feels like he can go to a baseball game and he can sit through all 9 innings and it’s not a big issue for him which, honestly, I don’t know a lot of guys who could sit through 9 innings without having to go to the bathroom, but I guess he’s not one of them. Host: Thanks for joining us today, Dr. Marchalik. Dr. Marchalik: Thanks so much for having me. My pleasure. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Skin cancer, which often appears as brown or red spots, is the most common type of cancer in America. Dr. Sanna Ronkainen discusses the best ways to prevent it, as well as how we treat it.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Sanna Ronkainen, general dermatologist at MedStar Washington Hospital Center. Thank you for joining us, Dr. Ronkainen. Dr. Ronkainen: Thanks for having me today. Host: Today we’re discussing key ways to prevent skin cancer, which affects millions of Americans each year. Dr. Ronkainen, could you start by discussing the most common types of skin cancer you see? Dr. Ronkainen: Absolutely. So typically, in our dermatology clinic, we see kind of three main types of skin cancer. There are basal cell skin cancer, squamous cell, and then melanoma. There are a few other more rare skin cancer types that we also treat here at this facility. However, those three are kind of the ones that dominate our interest. Host: Could you walk us through what differentiates these common types of skin cancers? Dr. Ronkainen: Absolutely. So, basal cell and squamous cell skin cancers we typically lump under the non-melanoma skin cancer category. And those are usually non-pigmented or non-mole-like skin cancers that can show up, usually on sun-exposed areas, that will show up kind of like a pimple that is just not going to heal or as a rough spot that bleeds easily. These are much more common in our older patient population. Melanoma is well known, I think, to most listeners. It’s a type of skin cancer that is one of the more dangerous types of skin cancers and those typically look like dark spots that come out of the cells that produce pigment called melanocytes.  Host: Could you describe your typical patient population? Dr. Ronkainen: Here at Washington Hospital Center we see patients from all walks of life and from the whole spectrum of ages. For patients who are coming in for skin cancer, we’ve seen everything from teens to people who are elderly. So, you know, it can really be anybody who walks through the door. Often, we’re seeing young people in their 20s for skin cancer screenings because they have a family history of either melanoma or non-melanoma skin cancers and just want to get a physician’s eyes on them to make sure that we don’t see anything concerning. Host: What are some common risk factors for developing skin cancer? Dr. Ronkainen: There are a few main risk factors that we think about when it comes to skin cancer. First and foremost, is UV radiation. Cumulative exposure to the sun or to tanning beds can increase your risk of skin cancers, including the worrisome melanoma type. In addition to that, as patients get older, there’s a higher risk just because of that cumulative damage. Also, if they’re more fair, that’s a risk factor. But I’ve seen skin cancers in our African American patients here in the District of Columbia, so it really can happen across the whole spectrum of how dark your skin is. Also, if you have a family history or a personal history - if you’ve had a skin cancer before - those certainly play a role. And then last, if you have had a history of a medical treatment such as radiation for an underlying cancer or if you have immunosuppression, whether that’s from a transplant or HIV, those can certainly play a role and do increase your risk of all three types of skin cancer, but particularly the squamous cell type. Host: When it comes to preventing skin cancer, what are some key things people can do? Dr. Ronkainen: In preventing skin cancer, sun protection is very important. Staying out of the sun between the harshest hours, between 10 and 2, during the midday is important. Wearing sun protective clothing or getting that sunscreen on can be very helpful. And also, keeping a close eye on your own skin and seeing if there’s a spot that has come up that bleeds easily or is scaly or rough or is growing - those are things to keep an eye out for. Certainly, I love going outside and exercising outside and enjoying the good weather when we have it here in the district, but just being mindful that those UV rays do add up over time is important. Host: And, speaking of sunscreen, there are a lot of options out there. Some people prefer things like all-natural ingredients. What are some important things people should look out for when they’re picking out sunscreen? Dr. Ronkainen: Absolutely. The number of different types of sunscreen has exploded, and every five minutes I’m hearing about a new type of sunscreen that’s come out. When thinking about what type of sunscreen to use, certainly the higher the SPF the better. However, sometimes when you’re using a higher SPF sunscreen it can come out pretty chalky and it can make you look like you’re wearing glue on your face. So, I often say that the best sunscreen that you can put on is the one that you don’t mind putting on. So, certainly testing out some different brands to figure out which ones you like is helpful. But in terms of trying to go towards all-natural ingredients or ingredients that don’t absorb into your skin, I typically tend to recommend sunscreens that have the physical blockers such as zinc or titanium or iron oxide. However, those tend to be a little bit thicker and less cosmetically appealing to patients because they don’t blend in as well as the chemical blockers. Host:  For sunscreen, is there an SPF level that you usually recommend? Dr. Ronkainen:  When I’m talking about sunscreens with my patients, I always recommend that they use an SPF 30 or above every day. And, typically I recommend that patients get that on in the morning as part of the moisturizer that they apply while they’re getting ready. And then, SPF 30 to 50 is typically what I recommend when they’re out being active, on vacation, at the beach, or things like that. Host: Are there symptoms of skin cancer that people should look out for? Dr. Ronkainen: When patients develop a spot that is new, growing, changing, is very sensitive or painful, or bleeds easily - those are signs of skin cancer. Certainly, sometimes patients will come in with a mole that’s just been irritated but rubs on the clothing or gets caught by the razor blade if it’s in the beard area, and we provide reassurance to that, but those red flag symptoms that I mentioned earlier certainly warrant just an extra vigilance of that spot.  Host: What are some common treatment options for people who do develop skin cancer? Dr. Ronkainen: Treatment of skin cancer depends on the subtype of skin cancer and that is a conversation between a patient and a dermatologist. However, typically most of the skin cancers that we’ve discussed today require excision, so cutting the spot out. We either do that as a conventional excision where we cut a little rim of healthy skin around the spot to cut it out completely or we send the patient for a special type of surgery called Mohs surgery. We have a Mohs surgeon here at Washington Hospital Center who is available to do surgeries like that. Very rarely, certain types of skin cancer can be treated with a topical cream. However, that decision needs to be made at the time of diagnosis. Host:  Could you further discuss the topical skin cancer treatment? Dr. Ronkainen:  Sometimes, when a skin cancer affects only the very top layer of skin, a topical cream can be used to treat the area. This is usually done by the patient at home over the span of several weeks, with close follow-up with the dermatologist to ensure that this spot is resolved completely with the topical treatment. Again, it does require that close follow-up to ensure that there’s nothing left over once the area is healed up. Usually, using the topical creams, the area tends to get red and inflamed, which is a sign that the cream is fighting off the skin cancer cells. Sometimes we use creams like that as a preventative measure in patients who have a high risk of skin cancers like the squamous cell-type, who have a lot of the pre-skin cancers, or sun damage, called actinic keratosis. Host: Could you describe what Mohs is? Dr. Ronkainen: So, Mohs surgery is a specialized type of surgery that is done by a dermatologic surgeon where the patient comes in to the clinic and has the cancer cut out with a very narrow margin. They try to spare as much of the healthy skin around the cancer as possible. The patient then waits until the surgeon is able to look at the slides, that are processed in-house, to make sure that the edges of the tissue that was taken out show no signs of skin cancer. If there is still cancer left at the edges of the spot that was taken out, then the surgeon will go back in and take out more of the skin until they know that the entire cancer is out. Sometimes it can take a little bit longer than just doing a general skin cancer surgery. However, it does spare as much of the healthy tissue around the skin cancer as possible to try and minimize any cosmetic defect there. So, it usually takes about a half a day and the patient waits in the clinic between the different stages of the surgery. However, the ultimate cosmetic result is usually very good. Host: Could you discuss the risks of not treating skin cancer? Dr. Ronkainen: Sure. So, for skin cancers like basal cell skin cancer, this seems to be a slow growing skin cancer that grows on the top layer of skin, which patients might be tempted to leave alone without treatment. However, it can cause a lot of discomfort as the spot continues to grow, bleeds easily after even just gently scratching the skin, and can eventually erode in to the tissue under the skin. Sometimes I’ve seen basal cells even go so deep as they go in to bone. However, things like melanoma or squamous cell skin cancer can travel to the lymph nodes and become more widespread and metastatic, which then would require systemic treatment with chemotherapy instead of just having the spot cut out. Host: Why should people who have skin cancer seek treatment at MedStar Washington Hospital Center? Dr. Ronkainen: We do offer comprehensive care for skin cancer here at Washington Hospital Center. It’s nice because we do have a specialized surgeon who does Mohs surgery here. We also have multiple dermatologists who feel comfortable doing general local excisions on kind of more simple skin cancers. So, it’s nice to see your own dermatologist for the procedure, that they initially diagnosed by biopsy. But also, if, unfortunately, you have an aggressive type of skin cancer, such as a more invasive melanoma, we do have the ability to work with our colleagues in general surgery or oncology or radiation oncology to optimize a multidisciplinary form of care. Host:  Could you share a patient story of someone who came in with a minor skin condition, or what they perceived as minor, and ended up needing serious treatment? Dr. Ronkainen: Sure. I’m thinking of one patient in particular who came in for a spot on his back that was just a rough, raised growth that caught easily on his clothes. And on evaluation of that spot, we realized that it was a benign seborrheic keratosis, which is just a benign warty growth that tends to come up with patient’s age. However, when we were examining the patient, we happened to notice a dark spot very close to that that the patient had not noticed because, again, it was on his back so that he couldn’t see it, that ended up being a melanoma. Thankfully, we were able to get a biopsy of the melanoma early enough and we were able to excise it and we were able to treat it completely without it causing him any further grief other than causing a scar from the surgery. But thankfully we caught it early. Host: Thanks for joining us today, Dr. Ronkainen. Dr. Ronkainen: Thanks for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

One of the main concerns for surgical patients is how much pain they will experience after their procedure.  Dr. Kenneth Fan discusses the Enhanced Recovery After Surgery (ERAS) protocol, which not only reduces pain after surgery, but also decreases the use of opioids.    TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Ken Fan, a plastic surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Fan. Dr. Fan: My pleasure. Thanks for having me. Host: Today we’re discussing ways to reduce pain after various types of plastic surgery. Dr. Fan, pain has to be one of the most common fears patients have prior to plastic surgery. Can you explain how much pain patients can expect from surgery? Dr. Fan: Yes. With the enhanced recovery after surgery, multimodality, multidisciplinary protocol, the most important thing is to set the expectation of pain. So, the first part of the series of treatments is the pre-operative assessment of the patient. So, we go through a detailed discussion with how the patient has recovered in previous surgeries and how they tolerate pain. I discuss with them how they can see themselves recover from this particular surgery. This discussion is very important because not all patients perceive pain the same way and not all surgeries have the same amount of pain. Host: How long does recovery normally take after plastic surgery? Dr. Fan: Recovery varies, based on the type of procedure. Some procedures are out-patient, meaning that patients are discharged and go home. Some procedures require a 3 to 4-day in-patient stay. The benefit of using this ERAS multimodal analgesia protocol is that no matter how long the recovery, it’s shortened - patients return back to base-line functioning sooner and have decreased narcotic usage. Host: What kind of treatments do you provide patients to help them deal with pain or discomfort after plastic surgery? Dr. Fan: So, we use a combination of pre-operative non-narcotic medication that decreases the way the nerves fire. So, they don’t fire strongly, and they don’t fire as hard. Intraoperatively we work with our anesthesia colleagues and they provide a lot of medications that decrease nausea and vomiting after surgery and decrease the amount of pain. We also use wide-spread local blocks, meaning we use local anesthesia that also targets the nerves and prevents them from firing. This also decreases pain. After surgery, we usually provide a cocktail of medications that are also non-opioid anesthesia. They also target the way the nerves fire and they subdue everything and decrease the pain levels for patients. And we found with this ERAS protocol after major surgery, patients are only taking 1 to 2 narcotic tabs after surgery. And, this is research that is being published soon. Host: Is this one way that MedStar Washington Hospital Center is trying to decrease narcotic usage in light of the current opioid epidemic? Dr. Fan: Absolutely and thank you for asking. Yes, opioid use across America has reached a tipping point to where it’s been declared a health emergency. And this protocol especially addresses narcotic use across the board. With our research we’ve been able to demonstrate that application of this protocol has reduced opioid use significantly. And this is great because patients are not reliant on narcotic usage. This takes them out of the cycle of pain and opioid dependence that we unfortunately have seen as health care providers. And this also has the additional benefit of just returning patients to baseline and making them feel a lot better. Host: Does pain tolerance vary from person to person? If so, to what extent? Dr. Fan: Absolutely. I think some patients have higher pain tolerances, some patients have lower pain tolerances. Some patients have had extensive history of opioid use. And therefore, it’s up to us, the provider of the patient, before surgery, to have a discussion and so we can better manage their pain after surgery. Host: Could you share a story in which a patient received optimal care for their plastic surgery with minimal pain at MedStar Washington Hospital Center? Dr. Fan: Yes. There’s one patient in particular that comes to mind. This is a patient who has given permission for me to share her story. She previously has had more than six hernia operations. Her most recent one required a prolonged hospital stay, over two weeks, part of which was in the ICU. As you can imagine, she was not excited to come to the hospital after her hernia came back. In fact, she was putting off her surgery since July of 2018 and her hernia, subsequently, got a lot more complicated. But, long story short, because of the collaborations between the general surgeons, the anesthesia providers, and us, the plastic surgeons, we were able to devise a plan that decreased the amount of pain and decreased the amount of surgery that we had to do. She ended up doing great after surgery. She was with this ERAS protocol, was walking postoperative day 1. She said that this was the best she’s ever felt in her 7 previous surgeries and that she was very excited to tell all her friends that MedStar Washington Hospital Center offers this service. Host: Thanks for joining us today, Dr. Fan. Dr. Fan: Thank you for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Tree nuts are filled with high-quality nutrients, such as vitamin E, fiber, and phytochemicals. Dr. Patrick Bering discusses how tree nuts can decrease heart disease risk, particularly in people who have diabetes.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Patrick Bering, a cardiologist at MedStar Washington Hospital Center. Thank you for joining us, Dr. Bering. Dr. Bering: Thank you for having me. It’s a pleasure. Host: Today we’re discussing how eating nuts may lead to lower heart disease risk for people with diabetes. According to one study, people with diabetes who ate at least five small servings of nuts a week were 17% less likely to develop heart disease. Dr. Bering, what do you make of these results? Dr. Bering: These results are very interesting, and they seem to add to our understanding of how diet plays a key role in our risk or avoidance of cardiovascular disease. These studies were observational in nature, meaning that they relied on self-reporting from a group of patients, but they were perspective, enrolling patients at a younger stage in their life and then, following up along with them over time to see whether or not they developed any heart disease. I think that they’re very exciting and add to our understanding of what constitutes a healthy diet, especially for our patients who have already developed diabetes. Host: Why do you think these expanded on our understanding of what we already know? Dr. Bering: Nuts are an interesting topic. There’ve been some health conditions where nuts were thought to be a food to avoid and that’s been debunked with time. That includes things like diverticulosis, which is a condition of your large intestine. One of the cornerstones of a very popular diet that is practiced by people in the Mediterranean region is the Mediterranean Diet. From our observations, populations who eat a Mediterranean diet have a lower incidence of cardiovascular disease. One of the key constituents of the Mediterranean Diet is actually the inclusion of nuts for regular consumption as part of their usual diet. Host: Why are nuts so beneficial to our health? Dr. Bering: Nuts are jam packed with lots of quality nutrients. They have unsaturated fatty acids. They have plant chemicals that are called phytochemicals. They have fiber. Certain vitamins including vitamin E and folic acid. They also have important minerals for our body like calcium, potassium and magnesium. They are really jam packed with all these great nutrients, great nutritional benefit. And, because of that, we get a lot of bang for our buck, so to speak, when we consume nuts. Host: The study’s authors mentioned that tree nuts were especially associated with lower heart disease risks. What do you think makes tree nuts particularly beneficial for people with diabetes who want to lower their heart disease risk? Dr. Bering: It’s interesting that this was seen more with tree nuts than other kinds of nuts. It’s important to note that probably one of the most popular nuts, so to speak, is the peanut, which is not a true nut, it’s a legume and it grows underground. Tree nuts grow above ground and they seem to have more of these high-quality nutrients that are beneficial to our health, especially for patients with diabetes. Certain of these minerals, fibers and chemicals are more likely to provide anti-inflammatory effects, and inflammation and diabetes is one of the key driving forces of a lot of the complications in the eye and the kidneys and the vasculature. Host: For people with diabetes who want to lower their heart disease risk, what kind of nuts do you recommend? Dr. Bering: That’s a great question. There are so many good ones out there. I think almonds are a great one, cashews, pistachios, walnuts, pine nuts or hazelnuts. And, you can get very creative in the ways that you incorporate these into your diet. My wife, who is a dietician and provides my expert advice at home, will often incorporate nuts either into our breakfast with some yogurt or will add it to a salad as a way to provide some extra texture, crunch and flavor to something that we’re eating. I think there are many great examples of recipes out there, especially with the internet, where you can see how incorporating these into your diet can be helpful. Another thing is that they’re also easy to transport and so they’re a good snack on the go if you’re a little bit hungry and a much healthier option than more food of convenience or junk food. Host: Are there any potential downsides for people with diabetes when they start incorporating nuts into their diets? Dr. Bering: It is important to recognize things like portion of nuts is, as well as what salt content they may have. For example, a usual guideline is that one serving of nuts is about a third of a cup. And, if you eat much more than that, you can actually be eating too many nuts. So, you want to make sure that portion control is an important part of your diet. Secondly, some nuts come pre-salted or pre-flavored and many of these flavorings contain salt in them. For patients with diabetes who may have other problems with their kidneys or their heart disease, it’s important to note the salt content and to prefer buying nuts that are unsalted. If you want to add additional flavor to your nuts down the line, you can often use a unsalted preparation in order to give them extra flavor. Host: Nuts have been shown to lower high blood pressure. What is it about nuts that lowers high blood pressure? Dr. Bering: That’s still something that’s under a little bit of some investigation, but it seems to be partly the anti-inflammatory effects, there inclusion of unsaturated fatty acids and, most importantly, probably the potassium content. A diet that’s rich in potassium is often one that is very useful at controlling high blood pressure. Potassium is a key component in our diet at making sure that we control blood pressure. Host: What other diet tips should people with diabetes follow to prevent heart disease? Dr. Bering: As we talked about before, I think portion control is a very big issue. Many of our portions that we receive outside the home or that we see in advertisements are much too large for what we should actually be consuming. And so, following recommendations, either on the American Heart Association website or the CDC, as far as what a certain portion of different nutrients is, can be very important. As I said before, an optimal portion of nuts when consumed a few days a week or, in this study, up to five days a week, is about a third of a cup. Additionally, a great thing to keep in mind and very simple is that ultra-processed foods - and, what I mean by that is foods that don’t look like anything that occurs in nature - those are foods that often have the worst health effects. Those are foods that have a lot of sugar-enriched sweetening or artificial sweeteners and colors and those are often the foods that lead to adverse cardiovascular health or obesity-related illnesses, such as diabetes or high cholesterol. Host: Why is MedStar Washington Hospital Center the best place to seek care for heart disease? Dr. Bering: We have a very comprehensive and passionate team that loves to serve their community here in the DMV. We have experts in every level of care, from primary care to preventative care as well as to emergency care, if you happen to have the misfortune of suffering from cardiovascular disease. I’m very honored to work with my colleagues, who inspire me every day. But, most inspiring to all of us is our interactions with the patients whom we serve. Host: Could you share a story where a patient with diabetes started following a healthier diet and experienced a decrease in their heart disease risk factors? Dr. Bering: Yes. Interestingly, I recently had the pleasure of taking care of a young man who was obese and had high blood pressure and diabetes, both of which were more recently diagnosed. He unfortunately came to the hospital with a small heart attack. But, after treating the heart attack, he made really positive health changes in his life. He started doing a cardiac rehab program, exercising on a regular basis, and made positive dietary changes, cutting out a lot of the food of convenience - things like fast foods or snacks that are not natural and are these ultra-processed foods. Since then, he’s lost a good deal of weight, says that he’s much happier and has improved energy and overall quality of life. He’s made great progress and it’s a nice journey to go on with him together, to help support him and his improved cardiovascular health.  Host: Thanks for joining us today, Dr. Bering. Dr. Bering: Thank you. I appreciate it. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Riding an electric scooter is fun and convenient. But it’s important to be careful, as accidents can result in serious injuries, such as fractures to the lower and upper extremities. Dr. Robert Golden discusses how we treat these injuries, as well as tips for riding safely.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Robert Golden, Chief of Orthopaedic Trauma Surgery at MedStar Washington Hospital Center. Thank you for joining us, Dr. Golden. Dr. Golden: My pleasure. Thanks for having me. Host: Motorized scooters are a growing form of transportation in the US. You see people riding them all around the streets and in traffic. As a result, injuries are always a possibility. Today we’re going to discuss some of these injuries, plus some key safety tips. Dr. Golden, could you start by explaining some of the most common injuries you see from people riding motorized scooters? Dr. Golden: Well, we’ve seen a fair breadth of different injuries from them. It’s not a typical single pattern that we’ve seen from them, which you see in some other injuries. With the scooters we’ve seen everything from upper extremity injuries to lower extremity injuries and pretty much everything in between. It seems like part of this is probably because of the different mechanisms where you can get injured while on these. Depending on how you get injured and what you were doing at the time, what happened can really change what gets hurt. Host: Can you share some specific examples of some of these injuries? Dr. Golden: Sure. We’ve seen a couple people who have just fallen off of them, from simply not negotiating a curve right or hitting a bump in the street or in the sidewalk. Some of them have had fractures of their upper extremities and to their arms. A couple of them had been open fractures, meaning the bone came out through the skin. A bunch of wrist fractures, as well, for the same reason. The other sort of spectrum that we see from these are when they’re hit by cars. Some of them have had lower extremity injuries, in mostly their legs and their tibias, the bone below your knee and above your ankle. Again, sort of the same kind of mechanism that they’ve either simply hit a bump or didn’t negotiate a turn quite right and just fell off. Or, they get hit by a car, which you can imagine causes a lot more injuries. Some of them simply get on them and don’t realize how fast they’re going. Then, in haste to sort of slow down or to make a turn, kind of jump off of them without really slowing down and realize they’re going pretty fast after they’ve jumped off. Host: Can you think of some of the most frequent treatments you’ve given patients for their scooter-related injuries? Dr. Golden: Sure. Well, a lot of that depends on what’s been injured. Most of them have, or at least a lot of them, I guess, have required surgery for them which generally would then involve realigning the bone and then stabilizing it either with a nail or plates and screws to hold it still and in the right position until the bone can heal. Host: What are some tips you offer patients to help them avoid getting hurt while riding their scooter? Dr. Golden: I think a lot of it is just knowing the capabilities of the scooters themselves and realizing if they’re new to riding these, they’re not exactly the same kind of scooters you were riding when you were little - the little Razor scooters and you would just kind of push them along. Some of them pick up a fair amount of speed - kind of realize that, at that speed, if you hit something or you get thrown off, there’s a good chance that you could injure something. And then, of course, it’s a pretty busy city down here and you always have to watch out for the cars and the pedestrians. Host: Are there certain people you would recommend not to use a motorized scooter? Dr. Golden: I think if you’re careful and know your capabilities, you’d probably be ok. Probably not a great idea for anybody with a history of osteoporosis or issues with their fragile bones to try them out. And, I think if you DO, you should just start off slowly, figure out how fast these go, make sure you can maintain control on them before you really see how fast they can go. Host: Why is MedStar Washington Hospital Center the best place to seek care for any motorized scooter-related injuries? Dr. Golden: Well, we have the MedStar trauma unit here which allows us to provide a comprehensive care from multiple disciplines. So, the orthopaedic surgery teams are involved, the general surgery teams are involved in case they have any other injuries - internal organs, that sort of thing. And, we’re also plugged in with the physical therapists, the occupational therapists, to get people back to their jobs, get back to walking, depending on which injuries they have, as well as the plastic surgery teams because sometimes these injuries, when the bone comes through the skin, creates a defect that needs to be covered. So, fortunately, we have everything all in one place and all the teams are coordinated so whatever injury you have, we can service. Host: Could you share a story in which a patient received optimal care for a motorized scooter-related injury at MedStar Washington Hospital Center? Dr. Golden: Sure. We had one patient who came in - again, same kind of thing - he was riding one of these and fell off of it. Had a fairly complex fracture of his...what’s called his tibial plateau, which is the top part of your tibia, right by your knee. He had to go through several surgeries until that could be stabilized. Eventually, it required some coverage by the plastic surgery team, so they took care of that for him, as well, and, eventually, healed that up. Host: Can you explain what recovery typically is like? Dr. Golden: I mean a lot of it depends on what’s broken. In general, bones take about 3 months to heal, somewhere around 12 weeks. Some bones heal a little faster, some heal a little slower. But, in general, they’re looking at some sort of immobilization. Or, once they’re fixed, the point of fixing them is to get them up so that they can move, minimize any stiffness. Usually there’s a short period of immobilization right after the surgery, just to let the wound settle down. Then that’s followed by getting them up and moving and making sure they don’t get too stiff on the joints near where things were broken. We see them back in the office during the entire time that they’re healing to make sure that everything’s healing appropriately, that it’s staying aligned the way we left it, make sure that there’s no other complications coming up or they’re having difficulty with anything else as a result of these things. Host: Is physical therapy usually a part of recovery?... Dr. Golden: Yeah, often they do get some physical therapy. Some of it depends on where they were injured and what the treatment was. In general, if it’s in the middle of what’s called a long bone, generally your femur or your tibia, and we can put a rod into it to fix it, they can get up very quickly and put weight on it right away and the bone just heals around it. So, some of those people require less intensive physical therapy because they can just kind of get up and start walking around on their own. Some of the people, where it breaks into the joint and it kind of shatters - it doesn’t break in to clean fracture lines - a lot of those people do require a fair amount of physical therapy to get their joints moving again, minimize their stiffness, rebuild the strength that they lose. Host: Thanks for joining us today, Dr. Golden. Dr. Golden: Thanks for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Blood clots, prior abdominal trauma, or abdominal surgeries can lead to scarring in the iliac veins. Dr. Steven Abramowitz discusses how endovascular iliocaval reconstruction can restore healthy blood flow.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Steven Abramowitz, a vascular surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Abramowitz. Dr. Abramowitz: Thanks for having me. Host: Today we’re discussing endovascular iliocaval reconstruction, a treatment for iliocaval thrombosis and other vascular conditions. Dr. Abramowitz, could you begin by discussing who the best candidates are for endovascular iliocaval reconstructions? Dr. Abramowitz: Sure. It’s a mouthful. Endovascular iliocaval reconstruction is our way of rebuilding the connection in the veins, the structures that bring blood back to your heart. And, when the veins drain from your legs, they merge in your belly, like an upside-down Y and they form one big vein called the inferior vena cava. So, when we say iliocaval, we mean the iliac veins, which drain your legs, and the inferior vena cava, the main vein that they form inside the belly. What can happen is, in certain patients who have had blood clots in the past, or a history of trauma - maybe a gunshot wound to the belly, or even things like radiation therapy for cancer, or prior surgery - scar tissue can form around those veins. And those patients present with significant swelling in their legs and that swelling can also result in significant wound formation in both of the legs, as well. So, what we can do is, in a minimally invasive way, reconstruct the pathway, restoring flow from the legs back up to the heart to alleviate that jam of blood that’s increasing pressure in the veins. Host: Can you explain how endovascular iliocaval reconstruction works? Dr. Abramowitz: Absolutely. So, as I mentioned before, when these veins scar down, or block off and narrow, there’s usually a thin little bit left. And the best example I can give is your veins, normally, are like four-lane highways. But let’s say there’s a massive snowstorm and a snowplow has to get through. And it only puts a small path and it piles up all this snow on the sides of the road. Maybe only a bicyclist can get by, or a single car. And that narrowing, when you think about how blood has to flow, is just too little and so the blood builds up in pressure.  But what we can do is say we find that pathway, where that one snowplow went, and we can use a series of balloons and stents, which are metal tubes like tunnels, and we can expand and push that snow or scar tissue to the side, making sure that you get all four lanes flowing back again, and alleviating any pressure that’s built up in the legs. Host: What is recovery normally like following this procedure? Dr. Abramowitz: Recovery from this procedure is actually pretty easy. For the most part, we’re not making any incisions. So, this surgery is done through punctures, usually behind the knee or in the groin. So, people have some soreness at those puncture sites. The biggest complaint actually is back pain. We don’t really have nerves that tell us our veins are being stretched and so, after this procedure, the most common thing that people experience is a sense of muscle spasm that can last up to 2 to 3 weeks. And that’s really the stretch of that vein sitting in the body. So, you may not feel like you can get comfortable in your chair but you’re not going to feel like you’re in extreme pain. Host: Are there any risks involved with the procedure? Dr. Abramowitz: So, the biggest long-term risk from this procedure is actually tied to what caused the procedure to be needed in the first place. Most people who require iliocaval reconstruction - again, stenting and opening up those veins - had those veins shut down as a result of a blood clot. So, once we open those veins up again, we’ve reestablished a pathway from the legs back up to the heart. And so, it’s really important that people stay on their blood thinners. Now, for a variety of reasons, people can develop scar tissue or other ways that the stents can shut down over time. But the biggest danger is if they shut down suddenly through another new blood clot. And that’s if somebody maybe needs to stop their blood thinner to have another procedure. Or, they stop their blood thinner because they don’t think it’s important anymore. So, the biggest risk that I counsel people about is the risk of future DVT and future pulmonary embolism, or that clot moving back from the legs or from the stents to their heart. Host: Is there anything patients need to do to prepare for surgery? Dr. Abramowitz: No. For the most part, to prepare for this procedure, it’s to make sure that you’re ready for your surgical date - you have someone to come pick you up from the hospital - and you’re prepared to have your medications ready, which include your blood thinner and some pain control for those potential back spasms. Host: Why is this procedure superior to other techniques used to treat similar conditions years ago? Dr. Abramowitz: That’s a great question. I get asked that a lot. The old way of reconnecting these veins was actually to bypass around them. And a bypass in the venous system is a huge surgery. It means making a big incision, all the way from the bottom of your chest all the way down to below your belly button. And then it means opening up both of your groins, taking plastic tubing or a vein from someone who maybe just died recently and donated their veins for use in medical procedures, sewing them all together, closing you back up, and then waiting for you to heal. But not only was that the problem, the blood that flows in your veins doesn’t flow at a very high rate. It flows actually pretty slowly. So, when we talk about blood pressure, most of the time we’re talking about what it is in your arteries, or the pressure at which it comes out of your heart. And that’s 120 millimeters of mercury. So, just remember 120. On the veins, our pressures are much lower and they’re somewhere between 8 and 12 - so, one tenth that of what’s in your arterial system. So, not only did you just have this huge surgery to bring the blood flow back to your heart, with all this plastic tubing or donor vein, but then, on top of that, the blood that moves through it isn’t moving very fast. So, it’s a very big surgery. And, in the past, it wasn’t really worth it because the failure rate was so high. Over time, most of the things that were done from an open surgical standpoint thrombosed, or clotted off. Now that we can do this within the body, in its natural pathway, we find that the patency rate, or our stents staying open (is really what we call patency), is much higher. And 87 percent of people that undergo iliocaval reconstruction have open stents at five years, which is much, much higher than the previous open bypass rates. So, if you had the bypass, it’s a big, open surgical procedure, usually resulting in a hospital stay that’s anywhere from 5 to 7 days, and then there’s recovery time after that. And, as I said before, the likelihood of that bypass staying open is pretty low. Not to mention, once you have all that scar tissue from the bypass, it pretty much eliminates a lot of other surgical options you may have in that area. Whereas, on this endovascular side, we can do things in a minimally invasive way, via some punctures, you can go home the same day, and it doesn’t necessarily limit your options in the future, should, in the small case that you’re that 13 percent your stents don’t stay open at 5 years, they do fail. Host: Why is MedStar Washington Hospital Center the best place for patients to seek an endovascular iliocaval reconstruction? Dr. Abramowitz: Well, there are a lot of great facilities out there that can perform venous stenting. MedStar Washington Hospital Center was one of the first in the country truly performing endovascular iliocaval reconstruction in its entirety. Not only that, we also are engaged in a lot of novel techniques to do this in a way that improve patency and outflow. So, we’re really one of the leaders in this field and we have a lot of new technology that we’re developing, as well as new techniques for patients who may have failed therapy before at other institutions. So, we’re on the forefront of this field and we really do have a comprehensive program in place to care for patients, both before and after their reconstruction. Host: Thank you for joining us today, Dr. Abramowitz. Dr. Abramowitz: My pleasure. Thanks for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Each year, more than 500,000 people visit an emergency room because of a kidney stone, which can cause severe kidney pain and blood in the urine. Dr. Daniel Marchalik discusses outpatient tubeless mini PCNL, a minimally invasive procedure for large kidney stones.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Daniel Marchalik, the Director of Ambulatory Urologic Surgery at MedStar Washington Hospital Center. Thank you for joining us today, Dr. Marchalik. Dr. Marchalik: Thanks so much. Happy to be here. Host: Today we’re discussing percutaneous nephrolithotomy, or PCNL, a technique used to remove kidney stones. Dr. Marchalik, could you begin by discussing who would be a candidate for mini PCNLs? Dr. Marchalik: Yeah, so PCNLs are...actually, it’s a very interesting procedure because traditionally we’ve always thought of PCNLs as being a very invasive and a very difficult procedure. But increasingly, what we’re finding is that PCNLs, or the indications for PCNLs, have been expanded. So, anyone who has a large kidney stone - and by that I mean a stone that’s bigger than 1-½ centimeters - is automatically a better candidate for a PCNL than other types of surgery, barring other considerations, of course. But for mini PCNLs specifically, what we’re finding is that patients that have intermediate-sized stones - so maybe a lower pole stone that’s a little bit bigger than a centimeter or other stones that are bigger than a centimeter and a half but maybe less than a full staghorn calculus, which is a stone that occupies the whole kidney - those are the perfect patients. Host: What are some common symptoms people have before they’re diagnosed with kidney stones? Dr. Marchalik: A lot of times people will present with pain in their kidney or in their back. They might feel like they are actually passing a kidney stone, in which case they will have spasms. In fact, people have actually compared kidney stone pain to childbirth. And, they did a study on this and it turns out that passing a kidney stone is as painful as giving birth. It’s one of the few times that guys can actually feel what women go through. Also, sometimes you can present with an infection in the urine or blood in the urine. And, all of those could potentially be caused by kidney stones. Host: How does a mini PCNL operation work and what are its greatest benefits? Dr. Marchalik: So, percutaneous nephrolithotomy - if you actually break the word down, it means that we are going percutaneously through the skin into the kidney. And nephrolithotomy means that we’re taking the stone out of the kidney. So, we put a small opening into the kidney, through the back, and through that opening we’ll put in a scope and a probe that can break the stone up into smaller pieces and actually suction those pieces out. The greatest benefit of the mini PCNL versus a regular PCNL is that with this procedure we still get all the benefits of a PCNL. So, we still can get patients out of the hospital with less stones or no stones at all. We can decrease the number of surgeries that they need to become stone free. But, it’s got some new benefits - meaning, we do it through a small opening so there’s less pain afterwards. We don’t have to leave a tube behind in the back a lot of times. And, a lot of times we can actually send patients out the same day. So, traditionally people would have to stay in the hospital for several days to get this procedure. But now we can actually get patients in and out and still be able to clear way more stone than we would be by other techniques. Host: What can patients expect during recovery? Dr. Marchalik: There are certain things that necessarily will happen whenever you have surgery - so, grogginess after anesthesia. Some people can get nauseous after the anesthesia and that happens with any type of anesthesia that you get for any procedure. With this particular procedure, sometimes patients can have pain in their back where the opening was. And they can see blood in their urine for several days. And, they can feel some discomfort in their stomach or in their back afterwards, and a lot of times that’s actually from a small tube that we call a stent that’s left behind to allow the area to heal. Host: How is the way you perform mini PCNLs compared to traditional PCNLs or similar treatments from years ago? Dr. Marchalik: The main difference here, the thing that really separates mini tubeless PCNL from a regular PCNL, is that we’re doing it through a smaller opening. Before, we would have to put a larger opening to accommodate our large instruments but as we began to miniaturize these instruments, we’ve been able to do this through a much smaller incision. And, as you can imagine, a smaller incision leads to a better recovery, less pain, less discomfort. The biggest difference is - and the biggest barrier to doing PCNLs traditionally - has been the length of stay, meaning you want the benefits of the PCNL to get as much of the stone out as possible, to do it quickly, but you don’t want the longer hospital stay, possibly coming in the day before, possibly staying a day after the procedure. With this procedure, we’re now able to send patients home the same day as the procedure itself. So, we get the benefits of the PCNL but not some of the barriers that we’ve seen in the past. Host: Why is MedStar Washington Hospital Center the best place to receive mini PCNL and similar operations? Dr. Marchalik: I think a lot of it comes down to us having a high volume of this procedure. It’s a procedure we do a lot of and we feel very comfortable doing. We also have a really fantastic interdisciplinary team. So, sometimes we’ll review these images with our interventional radiology partners, if it’s a more complex case. But more importantly, we also think about this holistically. It’s not just a surgery. At the end of the day, we also follow these patients for years after. We make dietary modifications and any type of other changes that we need to make to make sure that we don’t just treat the stone. We treat the patient. And we prevent these stones from coming back in the future. Host: Could you share a story where a patient received optimal care at MedStar Washington Hospital Center through a mini PCNL? Dr. Marchalik: Well, actually I had a really great case recently. This was a patient who had a large stone. It was blocking his kidney, causing a ton of pain in his back, some nausea and other discomfort. And he was really concerned because he thought that he would require multiple surgeries to get rid of the stone. We were able to do a PCNL - a mini tubeless PCNL - on him. He came in for an 8:30 case. He was home by 1 o’clock. No pain. No discomfort. No tubes left behind. I ended up seeing him in my clinic the week after and he reported that he actually had a great postoperative course. He didn’t have any discomfort or pain. No issues with his back. And all the pain that he had before the surgery was now gone. Now, we still have a long road ahead of us. We still have to figure out why it is that he was making stones in the first place, but at least this part is now over. Host: Are there any risks associated with mini PCNLs? Dr. Marchalik: As with any surgery, you have inherent risks associated with the anesthesia itself. And it doesn’t matter what type of surgery it is, anesthesia always poses a risk. But, there are some inherent risks to this procedure itself. Because we’re going through the back, there’s always risk of damage to the organs that are around the kidney. Now, that risk is small. The only time that this could be a little bit more concerning is with stones that are very high up in the kidney, but we take measures to mitigate that risk, as well. The real risk is that we don’t get all the stone out. And sometimes when you have a very large stone, even despite using this technique, not all the stone gets cleared. That being said, this is the procedure that gives you the highest chance of being stone free at the end. But, we still have to remember that, as with any surgery, every case is different. So, you have to always be able to adapt and do what’s right for each individual patient. Host: Thank you for joining us today, Dr. Marchalik. Dr. Marchalik: Thanks so much. Happy to be here. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Obesity is the number one cause of cardiovascular disease in the U.S. However, new research shows that bariatric surgery can reduce heart attack and stroke risk in patients with obesity and diabetes by 40 percent within five years.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Timothy R. Shope, Chief of Bariatric Surgery at MedStar Washington Hospital Center. Thank you for joining us, Dr. Shope. Dr. Shope: Thanks for allowing me the time to talk to you. Host: Today we’re discussing 2018 research that suggests that bariatric surgery can dramatically lower the risk of strokes and heart attacks in obese patients who have diabetes. Dr. Shope, could you begin by discussing how obesity, diabetes, and the risk of heart attack and stroke are connected? Dr. Shope: Sure. Many of our patients that we see coming to surgery for surgical weight loss purposes do have diabetes as a component of the multiple medical problems that they have. Obesity is becoming more and more common in our society. Diabetes is becoming more and more common in our society. They’re, without question, intertwined. And what we see is, particularly with this research that’s been done recently, patients that are diabetic and obese that have surgery, have a much lower risk of ultimately having a heart attack or stroke than diabetic, obese patients that do not have surgery or manage with medications alone. Host: How can bariatric surgery reduce the risk of stroke and heart attack in a patient with diabetes? Dr. Shope: Bariatric surgery not only helps patients lose weight - pretty simple thing. We put you on the scale - we can tell that you’ve lost weight. But a lot of these patients will have dramatic improvement in their medical problems as well. Specifically, in this case we’re talking about diabetes, patients that undergo particularly the gastric bypass surgery can have rapid improvement in their diabetic profile. We have some patients, not many, but a few a year will actually leave the hospital not taking their diabetic medications - simply checking their sugar and if it is a little bit too high, then they still have the ability to take some of these medications but they’re not taking them on a regular routine basis. The rest of the patients that do go home on their medications, within weeks and months they are dramatically reduced if not off of them. Similar results can be achieved with either the sleeve gastrectomy or the lap band, but usually it’s directly related to the amount of weight that these patients are losing. So with the sleeve gastrectomy, they do lose weight rapidly and often can get down on their dosages or converted from injectable medications to pills or come off all of the above within several months with the sleeve gastrectomy. With the lap band, which takes a little bit longer for patients to lose the weight, they can ultimately, in many cases, get down or off of their medications, particularly if they’ve been recently diagnosed with diabetes. Host: After bariatric surgery, how likely is a patient to resolve or improve their diabetes? Dr. Shope: Well, based on historical information, we know that, particularly, again, with the gastric bypass procedure, upwards of 85 to 90 percent of patients will resolve or substantially improve their use of diabetic medications and essentially not be diabetic any longer. A little bit less of a likelihood if they have a sleeve gastrectomy. And, with the lap band, it’s really only more like 50 to 60 percent of patients will ultimately be able to get off these medications. And again, if we’re talking about making the patient so that they are no longer diabetic from the standpoint of not needing medications and from the laboratory studies that we do to surveil these patients whether or not they’re diabetic - if we can claim that they’re no longer diabetic, the recent paper that we’re talking about today suggests that there’s around a 40 percent reduction in the risk of having a heart attack or stroke. Host: Which patients would you consider ideal to have bariatric surgery, in part to improve their cardiovascular health? Dr. Shope: Well, there are very strict NIH guidelines around these topics. The patients need to have a certain body mass index, or BMI. It’s basically a ratio of our weight to our height. So someone who’s very tall would also have to weigh a lot in order to meet the criteria for surgery. Likewise, someone very short might not have to weigh as much. But if you have a body mass index of greater than 40, or greater than 35 with certain medical problems like diabetes or obstructive sleep apnea or certain severe medical problems from other types of body systems, you might meet the criteria for weight loss surgery. Other ways of looking at this include things like being more than 100 pounds over your ideal body weight. These are some softer ways to look at whether or not someone might meet the criteria for surgery. So, if the patients otherwise meet the criteria for surgery, then all of the medical troubles that they come with, including those for cardiovascular risk, should improve with losing weight. There are some things that we can’t help patients with. For example, there are some downright skinny people that have high blood pressure. So, you may have high blood pressure for other reasons - family history, age, race, gender. These are things that obviously the surgery is not going to change about you. But if we can help you with your weight and that’s what’s maybe making you be hypertensive or making you be on three medications for high blood pressure, then we can hopefully reduce some of that. And again, most patients that are diabetic, with substantial weight loss, will at least improve, if not resolve, their diabetes. Host: Could you share a story of a patient who had bariatric surgery and had a fairly dramatic cardiovascular outcome? Dr. Shope: So, we’ve had many patients definitely improve their diabetic profile, and include their cardiovascular risk as well. It’s hard to prove that any one of our patients did not have a heart attack because of the weight loss and the improvement in their medical problems that they had just because of their surgery. The research that we’re looking at today talks about a population of patients. And, if you look at the population, we can see that there’s reduction in risk for these things. But for the individual patient, I’d love to be able to say that we prevented heart attacks - and we likely have - I just can’t point to a single individual that we know for certain we prevented. What I can tell you is that there have been a number of patients over the years that have dramatically reduced their reliance on diabetic medications and high blood pressure medications, so clearly improving their cardiovascular risk. We’ve had a couple of patients over the years that have even had prior heart attacks that come in for surgery, lose a whole bunch of weight, and their cardiologists are just so happy with the improvement in their cardiac function and their, again, reliance on these medications. Host: Why should somebody with a history of diabetes come to MedStar Washington Hospital Center for bariatric surgery? Dr. Shope: Well, I think bariatric surgery can be part of the treatment for these types of medical problems. In fact, potentially a cure in some patients. If we can get you off of your medications and your lab profile suggests that you’re no longer at risk for diabetes, I would consider that a cure and that’s quite a powerful statement to say that an operation can actually cure a medical problem. That’s not something that’s common at all. I think that, you know, we have experts in the field, we know how to do these operations, we know how to look after patients afterwards. And yes, of course, we’re going to include your diabetologist and your primary care doctor and be certain that the entire patient is taken care of here. But I think that we’ve got, you know, the right team in place at MedStar Washington Hospital Center to take care of this difficult problem. Host: Thanks for joining us today, Dr. Shope. Dr. Shope: Thank you. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Treating cancer on the head or neck can seem intimidating, as people fear surgery could leave unwanted scars around their face. However, with the techniques we use today, people often end up cancer-free with very few changes to their appearance.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Jonathan Giurintano, a head and neck cancer surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Giurintano. Dr. Giurintano: Thank you so much for having me today. Host: Today we’re discussing reconstructive surgery for head and neck cancers. When a patient has cancer in such a visible area of the body, it’s important for them to have options to not only remove the cancer, but also keep them looking like themselves after surgery. Dr. Giurintano, what are some of the more common cancers for which patients might need reconstructive surgery after treatment? Dr. Giurintano: So, while approximately 90 percent of cancers that occur in the head and neck region are a type of cancer called squamous cell carcinoma, this type of cancer can affect multiple areas within the head and neck. Some examples include the tongue, the jaw bones, the palate, the inner surface of the cheeks, the back of the throat, carotid or saliva glands, and the voice box. Oftentimes, the surgery required to remove tumors from these locations results in very large, noticeable defects that affect not only the patient’s physical appearance but oftentimes their ability to speak, breathe or swallow. More recently, legendary Buffalo Bills quarterback Jim Kelly has been in the news for his fight against head and neck cancer. His cancer was a squamous cell carcinoma located in the maxilla, or the upper jaw bone, and he initially underwent treatment consisting of chemotherapy and radiation therapy but unfortunately developed a recurrence of the cancer after his initial treatment. Because of this, surgery was performed to remove the recurrent cancer in his upper jaw bone and the salvage setting. And, in a patient who’s previously had radiation therapy, it’s very difficult for this area to heal after surgery and the result leaves a communication between the mouth and the nose, which can make speech abnormal, as well as swallowing. So, Jim Kelly underwent his surgery in New York by Dr. Mark Urken, who’s one of the most nationally known and most experienced surgeons, using what we call free flaps to reconstruct head and neck defects. So, a free flap is a piece of tissue that’s harvested from an area of the body outside of the head and neck, that often consists of either skin, fascia, muscle, bone, fat or a combination of all of these. And, it’s a piece of tissue that can be harvested with an artery and a vein that can supply blood to this piece of muscle or bone or fat. We can then take that tissue from the leg or the arm or the thigh and then transfer that up into the defect site and use it to reconstruct things like the tongue, the voice box or the jaw bone. Then, using a microscope, under very high magnification, we can actually sew the artery and the vein that are from the flap to an artery and a vein in the neck and that will actually provide that piece of tissue with its own blood supply. This is especially important in head and neck cancers because most of our patients receive radiation therapy as part of their treatment and without a robust, healthy blood supply, most pieces of tissue will die from the radiation therapy. We do know these pieces of tissue have a robust vascular supply and that they can withstand the radiation treatment, leading to very good results in reconstructing the donor site defect. In Mr. Kelly’s case, Dr. Urken performed what’s called a fibula free flap. And that’s when a piece of bone from the lower leg, called the fibula, is harvested with some overlying skin and an artery and a vein and he was actually able to use that bone to recontour the upper jawbone that was missing after the surgery. And he was able to use the skin from the flap to seal the hole in the palate so that Mr. Kelly was able to talk, eat and look normal essentially. In Mr. Kelly’s case, he was then able to have titanium dental implants inserted into that bone so that he could actually have teeth in his upper jaw again. And, if anyone’s seen him in the news lately, they did a fantastic job and he looks almost the exact same as he did before surgery. And, that is really the ultimate goal of cancer and reconstructive surgery nowadays. Host: How do patients feel when they learn that their appearance might be affected by the surgery that will remove their cancer? Dr. Giurintano: So, patients often feel a mixture of emotions. Receiving a diagnosis that you have cancer is very difficult. And, to add on to that diagnosis that you might require major surgery that might result in a physical deformity can be even more devastating to patients. Our facial structure is often a major part of our identity and it can be very psychologically devastating to learn that your visual appearance might be affected. This goes for the voice, as well. We all have unique voices that we can recognize very distinctly. And the possibility that you might lose your own unique voice can be very devastating to patients. In the past, patients would often have these tumors removed without any technology to reconstruct them and this could lead to crippling deformities that were very easily noticeable upon first glance.  And this has a major psychological impact on patients. Some can often lead to depression and anxiety in our cancer patients. And while it’s impossible to perform a surgery that’s completely scar-less, all surgery requires at least an incision, today we have advanced techniques that limit the deformity that’s caused by removing cancers from the head and neck. We also have to give credit to the body itself. The body is pretty incredible in that anytime we take skin from the arm or the leg and we place it into the mouth, the body can actually recognize this change in the environment that the skin is in and it actually begins to change the cell types of that flap. And through a process that we call mucosalization, the flap actually begins to take on the appearance of the native tongue or the native surface of the mouth. In many of these patients, when you see them one or two years down the road, it is actually very difficult to tell which piece of tissue in the mouth came from the arm or the leg. It just looks like normal tissue. Host: Is the reconstruction procedure performed separately from the cancer surgery? Dr. Giurintano: So, we actually work together in what we call a two-team approach so that we can both remove the cancer and reconstruct the defect at the same time. This means that while the ablative, or the cancer removing surgeon, is working in the head and neck to take the cancer out, the reconstructive surgeon is, at the same time, working on the arm or the leg to harvest the flap so that as soon as the cancer is removed and the defect is made, the reconstructive surgeon can then take that flap, remove it from the arm or the leg and begin in-setting it into the defect. So, by doing the cases in this manner, we can typically finish an entire cancer removal and reconstruction in anywhere from 6 to 10 hours. Back whenever these types of surgeries were invented 20 or 30 years ago, the cases could often go over 24 hours. So, it’s actually been a big advance in our medical practice that we can finish these cases generally in under 12 hours. Our goal, essentially, is to limit the time the patient has to spend on the operating table under general anesthesia and to try to get patients back on their feet as quickly as possible after surgery to help quicken the recovery process. Host: What does a patient have to do to prepare for head and neck surgery with a reconstruction? Dr. Giurintano: Most of the preparation, from the patient standpoint, is more mental and emotional. We recommend that they have a good support system in place, whether it’s family or friends, to help them cope with the psychological impact of undergoing a major surgery and a, typically, 7 to 10-day hospitalization. There are some tests that we may perform in our clinic or in the radiology suite before we schedule a patient for a free flap. Nowadays we really try to tailor what type of free flap we are doing individually to each patient. In the past, physicians would often do one flap as their main flap, regardless of what the defect was or what the patient’s lifestyle included. But nowadays, for example, say if a patient of mine was a classically trained pianist and they wanted to continue playing piano after their surgery, I would be very hesitant to take any tissue from around their forearm or wrist. I would not want to interfere with their ability to play the piano at all. So instead I would go to a different donor site, either the side of the body or the leg. I’d take a similar piece of tissue and contour this to match the defect site. Occasionally, some patients require some tests such as angiography. This is a special test performed in the radiology suite to determine if the blood vessels are good enough to support a flap. For the fibula flap, especially - that’s a flap of the bone called the fibula in the lower leg that we often use to reconstruct the jaw- we know that there’s 3 distinct blood vessels that carry blood into the lower part of the leg to supply the foot. By taking the fibula, we have to take one of those blood vessels out to apply the flap, leaving 2 blood vessels to supply the leg. Normal patients - this is not a problem to remove this blood vessel. However, some patients only have 1 or 2 blood vessels supplying the lower leg, not 3. In these cases, it could be potentially disastrous to take the 1 blood vessel that’s supplying the lower leg. So, in this type of flap, we’ll always do a test before to make sure that the blood vessels are sufficient to sustain the flap. But otherwise, typically, we do not have many other special tests that are required before pursuing a major reconstruction.    Host: How long is the recovery time for these patients? Dr. Giurintano: So, in general, our patients who undergo free flap reconstructions generally spend the first two days after surgery in the intensive care unit setting. During this time, it’s not that they’re so sick they require a stay in the intensive care unit. It’s actually that we have to frequently check the blood vessels supplying the flap to ensure that the blood is flowing to the flap and that the flap is getting the nutrients that it needs. Once the first two days have passed, as long as the patient is doing well, they often go to the floor. And from that point on, most patients spend anywhere from 3 to 5 days on the floor, receiving basic medical care as they recover. Oftentimes they’re receiving physical therapy or occupational therapy during this time to recover their strength. And all of the basic preparations for that patient to go home are being arranged. Typically, if all goes well during the surgery and during the hospitalization, most patients spend about 5 to 7 days total in the hospital and then either go home or sometimes go to a lower level of care, such as a rehabilitation facility to help regain their strength before they’re ready to go home. Once at home or in a rehab facility, it still takes a couple of weeks for the patients to completely recover. And, in general, the entire recovery process takes about 4 to 6 weeks total. But, most patients are back swallowing, speaking, and doing normal activities within 2 weeks of surgery.  Host: What additional treatment or care do patients need after reconstructive surgery? Dr. Giurintano: Depending on the complexity of the case and how the hospitalization proceeds, some patients are able to go straight home and essentially require very minimal extra care. Occasionally, patients require the placement of feeding tubes or tracheostomy tubes. Tracheostomy tubes are special breathing tubes that are inserted into the neck that some patients may require because, occasionally, there’s too much swelling or the flap is too bulky inside of the mouth for them to breathe or to swallow well. Generally, this is a short-term procedure that patients do not require permanently, but sometimes this may require some extra care by a home health nurse or at a rehabilitation facility. Occasionally, if patients have trouble swallowing in the post-operative period and we a concerned that they might accidentally aspirate their foods, a tube can be placed into the stomach to help facilitate nutrition while they’re recovering. And, generally, this is also a short-term procedure that most patients are able to have removed after 6 to 8 weeks. Host: How do the surgeons at MedStar Washington Hospital Center help patients achieve the best cancer related outcomes and cosmetic outcomes with these complex procedures? Dr. Giurintano: So, at MedStar Washington Hospital Center, we work together as a team. Our team includes multiple members within the department of otolaryngology head and neck surgery. And this includes both ablative cancer surgeons (so those are surgeons who remove the cancer), reconstructive surgeons (such as myself), as well as facial plastic and reconstructive surgeons (so these are surgeons who are specially trained in cosmetic procedures of the head and neck). In caring for these patients, we, as surgeons, are responsible for the removal and the reconstruction of their cancer and the subsequent defects. But, in treating their cancer, we also share equal responsibility with our colleagues in the departments of radiation oncology and medical oncology. There are some types of head and neck cancer that can be managed through surgery alone, but most patients who have a head and neck cancer will also require either radiation therapy or chemotherapy as part of their treatment algorithm. We actually have a regular meeting at the MedStar Washington Hospital Center where the surgeons (such as myself), the medical oncologists, the radiation oncologists, the speech pathologists, the pathologists and the radiologists all meet to discuss new patients who have been diagnosed with cancer, as well as patients that have recently been treated for their cancers. And, during this meeting, which is what we call a multidisciplinary treatment conference, we are able to actually stage each patient’s cancer. We’re able to decide on a treatment that best suits that patient’s cancer. And, we’re able to put all of the right consults and all of the right steps in order so that patient can begin their treatment as soon as possible. Host: Could you share the story of a patient who had a particularly successful outcome? Dr. Giurintano: Yes. A patient, who had recently had several previous head and neck cancers, presented to the MedStar Washington Hospital Center, in my partner, Dr. Matt Pierce’s, clinic. This patient had previously undergone multiple surgeries and he had essentially received the maximum dose of radiation therapy that the body could receive in that area. And, unfortunately, there was a new cancer that had developed. This was a very devastating diagnosis to him, as he was a cancer survivor already. But, we were able to perform, essentially, a removal of the entire voice box and the entire back wall of the throat and then reconstruct that with tissue from his upper thigh. And, he had an absolutely amazing postoperative course. He was out of the hospital by postoperative day number 7. And this gentleman, who had not swallowed in 6 months, we had just obtained a swallow study to evaluate how the flap had healed, and he was able to swallow again - well - for the first time in 6 months. So, he was a particularly good outcome and we were very pleased with how he healed. Host: Thanks for joining us today, Dr. Giurintano. Dr. Giurintano: It was my pleasure. Thank you so much for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

The adrenal glands respond to signals from the nervous system and produce hormones that regulate many of the body’s normal responses. Dr. Erin Felger discusses what happens when a tumor develops on the adrenal glands and how we treat it.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Erin Felger, an endocrine surgeon at MedStar Washington Hospital Center. Thanks for joining us, Dr. Felger. Dr. Felger: Thank you for having me. Host: Today we’re discussing adrenal surgery, or procedures to remove the adrenal glands. Dr. Felger, to begin with, what do the adrenal glands do? Dr. Felger: The adrenal glands are located on the kidney. The adrenal glands make different hormones that help regulate different systems in your body. A hormone that everyone is familiar with is adrenaline and that is one of the main hormones that the adrenal gland makes. Host: What symptoms might cause a patient to visit their doctor and ultimately lead to a diagnosis of an adrenal problem? Dr. Felger: Well, it depends if the adrenal tumor is producing hormones or if it is not producing hormones. If it is what we call a functional tumor, the patient may have high blood pressure, headaches, palpitations, skin changes, weight gain, diabetes, fatigue or weakness. If the tumor is not producing hormone, the patient may not have and likely won’t have any symptoms at all.  Host: Why might a patient need to have the adrenal glands removed? Dr. Felger: Usually, we only remove one adrenal gland. It’s very rare to have bilateral tumors that need to be removed from those adrenal glands. One adrenal gland with a tumor usually needs to be removed for one of two reasons, the first being that the tumor is producing hormone and causing the patient to be sick or the tumor is too large in size and needs to be removed because of concern for cancer. Host: How do you advise patients to prepare for adrenal surgery? Dr. Felger: Again, it’s first having a consultation with your surgeon and then following the steps that need to be completed prior to surgery, which usually include labs, EKG, physical, extra imaging and any clearances that need to be had by other physicians. Host: What does recovery entail after a procedure? Dr. Felger: Recovery is very straightforward for adrenal procedures that are done laparoscopically or retroperitoneally. The patient is able to eat and walk and do most regular activities except for heavy lifting. Laparoscopic adrenal surgery is done from the belly side and it includes using a camera and small instruments and small incisions to remove the adrenal gland and the tumor.  Retroperitoneal adrenal surgery uses a camera and small instruments and incisions but is done from the back and not the front. Host: Do patients need additional therapies after surgery? Dr. Felger: It depends on what type of adrenal tumor a patient has. They may need to have follow-up with their endocrinologist to adjust medications. They may need further imaging studies and potentially treatment if they have a cancer. Host: What sort of medications would they patients have to take ongoing? Dr. Felger: Depending on the type of adrenal tumor, some patients may need to take long-term steroids in order to have normal function until their other adrenal gland wakes up. Other patients may need to have further imaging or frequent follow-ups and, potentially, medication if they have a cancer. Host: Could you share a success story of a patient who overcame adrenal issues, thanks in part to surgery? Dr. Felger: Yes. I had one patient who was a young man and he had excessively high blood pressures and was taking multiple medications and it was affecting his activities of daily living. His doctor did a full work up and found an adrenal tumor on one side. He came to see me and I completed the work up and had a good discussion with him about the operation to remove the adrenal tumor. I explained to him that it would hopefully help his high blood pressure but it may not cure it completely. The patient had the operation and he did very well during the surgery and afterwards. When he came back for his postoperative visit, he was doing quite well and he was off all of his blood pressure medications and he was quite thrilled because he was already getting back to his activities of daily living that he had been unable to do prior to the surgery. Host: Why should a patient come to MedStar Washington Hospital Center for their care? Dr. Felger: We have a multidisciplinary approach with our adrenal patients. They can be seen by our endocrinologists as well as have nuclear medicine studies done and then follow-up with the surgical team. We do an excellent volume of adrenal surgery at our institution and we are trained in both laparoscopic and retroperitoneal approaches so we can offer as many options as possible to our patients. Host: Thanks for joining us today, Dr. Felger. Dr. Felger: Thank you again for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Caregivers can spot dementia in numerous ways, ranging from a loved one forgetting about their favorite television program to suddenly not remembering to pay their bills on time. Learn who Dr. Cesar Torres says is most at risk of dementia and how to manage it.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Cesar Torres, a geriatric and house-call doctor at MedStar Washington Hospital Center. Thank you for joining us, Dr. Torres. Dr. Torres: Good afternoon. Host: Today we’re discussing dementia, a neurological condition that tends to develop in older adults and is characterized by memory loss and confusion. Dr. Torres, could you start by discussing how dementia develops in the brain? Dr. Torres: Certainly. Dementia develops as a result of the production of a neurotoxic protein called beta amyloid and, as a result of accumulation of this protein, nerve cells in certain areas start to die, specifically the memory centers of the brain - the hippocampus, the parietal lobe - and, as a result, people start to experience neurocognitive deficits. The most dramatic ones tend to be in the memory realm, but there are other cognitive deficits that also develop. And these eventually lead to significant social dysfunction and impairment, and it’s, unfortunately, very progressive. Host: Are there any populations of people who are at increased risk for dementia? Dr. Torres: Well, the number one risk factor for dementia is age. The older you are, the higher the prevalence. Recent estimates - generally, by the time you’re 70-75, there’s upwards of a 20 percent prevalence rate. Dementia encompasses a few different pathologies. There’s Alzheimer’s dementia, there’s Vascular dementia, there is a dementia associated with Parkinson’s, there’s a Lewy body dementia and there are some other much more esoteric subtypes. The vast majority are Alzheimer’s-type dementia, generally in the range of 60, 70 percent. After that, Vascular dementia rounds off the list, mostly around 15 to nearly 20 percent. And then, all the others. So, each one tends to have certain predispositions. For Alzheimer’s, there’s a genetic predisposition. It’s not 100 percent correlative, but there is a genetic predisposition and it can run in families. Vascular dementia tends to affect folks who have vascular disease - hypertension, coronary artery disease, people who are more prone to strokes. Brain trauma can predispose people to another subtype of dementia, and there’s a lot of focus now on this Traumatic encephalopathy that we see in a lot of professional, high-contact sports. Some of the other more esoteric subtypes - probably more of a genetic predisposition. So, as far as high-risk groups are concerned, that’s not an all inclusive list but there are certain groups that are at greater risk. But like I said, age is the number one risk factor. So, if people could stop growing old, we wouldn’t have a problem. Host: In these high-risk individuals and these aging individuals, what are some of the warning signs of dementia that families should start watching for? Dr. Torres: That’s a very good question and unfortunately, it’s also a very broad question. Generally, the onset of Alzheimer’s tends to be extremely subtle. You’ll tend to see problems with the acquisition of new knowledge or new information, the retention of new knowledge and new information. A family member asks how to get to a grocery store over and over again, in spite of having been there not too recently. You can see difficulty with social functioning as well, as the disease progresses. An individual who was extremely capable of managing their finances suddenly forgets to pay their bills and the electricity gets turned off. As things progress, now you can see personality changes. Sometimes the person starts to retreat into themselves - more withdrawn as some awareness of the social dysfunction starts to creep into their consciousness. Generally, the family will feel something isn’t quite right with their loved one and that’s when they actually probably bring it to the attention of their primary care physician or caregiver. The social functioning piece becomes more dramatic and is more distressing for folks, and they tend to pick up on that fairly quickly because it’s a dramatic departure from previous level of functioning. Host: If someone notices that a loved one is showing signs of dementia, where should they turn for help? Dr. Torres: Generally, most primary care physicians can do at least the initial screening. This generally can include blood tests, neuro imaging - in the form of a CT scan or an MRI. There are some blood tests that can also help rule out reversible causes of memory loss. But generally, the primary care physician should be the first point of contact. Host: Are there any treatment options available to help patients with dementia manage their symptoms or reverse the condition? Dr. Torres: Well, unfortunately, we have no way to reverse it at the current time. And that’s the Holy Grail. There have been many, many, many attempts to find drugs and various treatments but none have really been successful up to this point. As far as medications to modify the progression of the disease, there are a few, the most famous one being Donepezil, trade name Aricept and Namenda, generic Memantine. If  you make a diagnosis of dementia, you don’t automatically use the medication. It’s best to have a conversation with the patient and the family and to decide whether or not the patient has reached the stage where they would benefit from this medication because all of these medicines has toxicity. What the medicines offer, really, are slowing the progression. And, you may see unfortunately temporary improvements in certain memory functions. But, unfortunately, over time, the effect diminishes and the disease starts to progress again. If you look at it on a bell curve, most folks will fall in the middle. They will get some, but there are those who can get a lot and there are some who, unfortunately, don’t get anything. The middle is where the bulk of the patients will fall. But on an individual, case by case basis, you can get a substantial amount of improvement. The biggest benefit, I feel, from starting treatment with these medications is time. You buy time. And time is very precious for people. So, on the basis of that, if we’re at a relatively early enough stage, I think it’s a worthwhile choice. Host: You mentioned a couple of different potential causes for dementia. What can patients do to reduce their risk of developing it? Dr. Torres: We have looked at lots and lots of different options - herbal medications, anti-inflammatories, Vitamin E - and the list goes on. But, to date, the only two things that I can recommend honestly? A healthy lifestyle and daily exercise. Daily exercise actually has evidence behind it. So, among all the other benefits that a person can obtain from daily exercise, prevention of dementia is another one. There was a sub-analysis of the Women’s Health Initiative Study that was done a few years ago that looked at the impact of exercise and noted that it reduced their relative risk by about 40 percent, as a result of daily cardiovascular exercise. The reasons for that, the mechanism behind it - still remains a bit unclear but I suspect it has to do with just overall benefits of exercise and physical activity. And it doesn’t need strenuous exercise also, but some form of daily cardiovascular exercise would be a great benefit. Well, I would recommend being very judicious with alcohol intake. There is an Alcoholic dementia that exists. Otherwise, avoiding smoking. Smoking can lead to vascular problems that can lead to Vascular dementia. Good sleep, weight control - things like that. Host: How do the dementia experts in the geriatrics program and the house-call program at MedStar Washington Hospital Center help patients and families achieve optimal outcomes? Dr. Torres: The number one way is in the diagnosis of the condition because sometimes it can present atypically. Sometimes it can present, as I said, very subtly. So, sometimes it has to be teased out. And again, it’s time. We can gain time for better interactions, more complete interactions with the patient and the family member. And there are a few conditions that can masquerade like dementia that we can treat and reverse the symptoms that we associate with dementia - the memory loss. The one that is most well known is depression. Depression can manifest itself as a type of dementia with memory loss, with loss of concentration, with apathy, as well. And so by treating that, the patient -- effectively treating that -- the patient can regain their function and their memory. Host: Could you give us an example of how you care for a dementia patient through the house-call program? Dr. Torres: Well, we have a very focussed approach with really educating and helping the caregiver meet the needs and ease the process for the patient. There’s usually a lot of frustration that the caregiver feels with their loved one as the disease progresses. And the deficits become more and more overwhelming. So, we tend to review behavioral techniques that can ease the tension in the household. We can help them with treating comorbidities to maximize their time at home. And we do everything we can to help the patient age in place, which is often a great benefit for everyone - avoids unnecessary trips to the emergency department, unnecessary hospitalizations. Host: Thanks for joining us today, Dr. Torres. Dr. Torres: It was my pleasure. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Undergoing bariatric surgery can be the beginning of a longer, healthier and happier life for many patients. In some cases, however, surgery doesn’t deliver optimal results, and a second procedure is needed. Dr. Timothy Shope discusses the benefits of revisional bariatric surgery.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Timothy R. Shope, Chief of Bariatric Surgery at MedStar Washington Hospital Center. Thank you for joining us today, Dr. Shope. Dr. Shope: Good morning. Thanks for having me. Host: Today we’re discussing revisional bariatric surgery, or revisional weight loss surgery. Having bariatric surgery can be the beginning of a longer, healthier, and happier life for many patients. That said, some patients need a second procedure to ensure optimal results. Dr. Shope, could you start by discussing factors that might make a patient eligible for revisional weight loss surgery? Dr. Shope: Sure. The most obvious reason someone might require revisional weight loss surgery would be if they have not achieved everything that they need to achieve from their primary procedure. We see patients that have had surgery as early as maybe a year or two ago and as far back as 10, 15, even 20 years ago. These patients have varying results after their initial procedures. Some of them do very well initially and then regain some weight. Some of them fail to achieve substantial weight loss in the first place. Another reason that patients may want to seek revisional surgery would be if they have some problem related to their initial procedure. One of the more common things that we see are things like bad reflux after one of our newer procedures - sleeve gastrectomy. We see long term complications of gastric bypass surgery including problems with the connections that are made and, actually, recreation of a connection between the pouch of the stomach and the bypassed part of the stomach. So these are some reasons why patients might need some revisional surgery. Host: Could you describe your patient population? Are they older, younger, male, female? Dr. Shope: Most of the patients coming in for revisional procedures are a little bit older. Not necessarily old, but 50s and 60s. Remember that some of these folks had surgery 20 years ago so they were probably in their 20s or 30s at that point in time. Some of the younger patients that we see are patients that maybe weren’t as well prepared as they thought they were for their initial procedure. They hadn’t committed to making some of the lifestyle changes that are necessary and therefore they ultimately don’t get that success that they really needed with their first procedure. Host: Do certain procedures tend to require revision more frequently than others? Dr. Shope: That really depends on the reason for the revision. As I had mentioned, the sleeve gastrectomy operation, in a small percentage of patients, can actually create some reflux, even if patients didn’t have reflux disease initially. Those patients - some of them can be pretty debilitated by it and really seek a treatment for the reflux disease. But that’s not common. The common things that we see are patients who had, for example, a lap band surgery 10 years ago or so that did okay but ultimately they didn’t get what they wanted and they really just want another option, another way to lose some more weight. The revisional surgeries we do for gastric bypass patients - many times those are - again, I’ll use the word complication but it’s really more of a natural progression of having that operation. The connections that were created can dilate over time. So it’s not really a severe problem that some folks might think of when they think complication but sort of a natural progression of having that operation in some patients. Host: Just things getting more and more difficult or affecting their quality of life? Dr. Shope: Yeah, and they’re just not able to use the tool that they had been given to its maximal effect that perhaps they had been able to 10, 15 years earlier. Host: What procedures are available to revise a previous bariatric surgery? Dr. Shope: Again, that’s gonna depend greatly on what was done previously. For example, if the patient had a lap band placed before, we would obviously have to remove that band but then their options include sleeve gastrectomy or conversion to a gastric bypass procedure. If patients have had a previous sleeve gastrectomy, really we can convert that operation to the gastric bypass procedure or a more complex operation that we hadn’t mentioned before called a biliopancreatic diversion duodenal switch. And, if you’ve had a gastric bypass procedure in the past, the revisions are limited. We can lengthen the bypass. We can revise either of the two connections that are created for that procedure. But again, it would depend greatly on what the specific issue is, why we might revise one versus the other. The biliopancreatic diversion duodenal switch procedure is a procedure that actually is where the sleeve gastrectomy came from. Originally, about 10, 15 years ago, surgeons were performing that procedure in two steps. Essentially they would, for patients who had complex medical problems or were at extremes of weights or body mass index, they would perform a sleeve gastrectomy, allow the patients to lose some weight with that, perhaps improve their medical problems a fair bit, and then come back for what is essentially a very lengthy small intestinal bypass procedure. They recognized that many patients weren’t needing that second procedure, and that’s how we came to have a sleeve gastrectomy as a stand alone operation. But combining the two - the sleeve gastrectomy with the lengthy small bowel bypass - creates a very nice operation called the biliopancreatic diversion duodenal switch. Host: What risks are involved with an original bariatric surgery versus a revisional procedure? Dr. Shope: Well, the patient’s going to be accepting essentially all the same risks that they accepted for their initial procedure. Some of these are a bit more likely to happen, for example, staple line problems with either the sleeve or the bypass. More likely to happen in a revisional procedure than they are in the primary procedure just because we’re operating on previously operated organs. Those risks aren’t dramatically increased but they are definitely slightly higher. Host: What’s the minimum amount of time that a patient should wait before seeking a revision surgery? Dr. Shope: Well, I think the patient needs to have tried...I don’t know exact number and some of it, again, depends on the reason that they’re seeking revision. If it’s primarily about losing more weight, then they need to have at least several years. And, in fact, insurance companies will probably halt an approval based on the length of time they have given it a good effort. Host: What do patients have to do differently during recovery after revisional surgery to meet their health goals? Dr. Shope: Well, they definitely need to re-approach the process of weight loss. If they haven’t achieved their weight loss goals initially, we need to understand part of why that is. Sometimes the surgery wasn’t appropriate for them. Sometimes the surgery was done correctly but wasn’t exactly what they needed. So they really need to reframe how they approach their dietary intake, their exercise patterns, and then use this new tool properly this time to help them get where they need to get to. That’s the biggest thing - is this time around, let’s make sure that we do it right. Let’s make sure that you have proper follow-up. 15, 20 years ago, centers across the country would have patients come in, get some brief pre-op counseling, perform surgery, see the patient once or twice postoperatively, and then the patient was essentially on their own. Over the past years, our societies have recognized that patients really need that close follow-up and certainly in the first several years. But we see patients that have had surgery, as I said, sometimes 15, 20 or even longer years ago. Yeah, the benefits of a revisional bariatric procedure would be essentially the same as benefits of the original procedure. Patients should expect to lose a fair amount of their excess weight. That will depend greatly what they come with and what we convert them to. But they should expect to lose more weight with these procedures. They should expect to get better control of many of their medical problems. And then if the reason that they’re coming for revision has nothing  to do with excess weight - let’s says there’s some issue with the prior surgery - they should expect us to be able to help them with that issue by re-creating more functional anatomy for them. Host: Could you talk a little bit about the program for follow-up for bariatric patients here? Dr. Shope: Sure. We see patients for their immediate post-op visit within 10 days to 2 weeks after the procedure, which is often, especially for somebody who just had revisional surgery - they might be in the hospital a day or two longer. So, it ends up being a week - give or take - after they leave the hospital. At the visit, they will see not only their surgeon but also our team of dieticians. Critical stuff, especially early on, as these patients are not only getting what their body needs from the standpoint of fluids but also the nutrition that they need to thrive and to heal their recent wounds from surgery. After that first visit, we see the patient, depending on how their doing, anywhere from the following week if they’re really struggling to get their nutritional needs in, or maybe as much as a month or so afterwards. From that visit we progress on, usually about 3 months and then about 6 months after that which brings us close to a year after surgery. And then yearly from that point on for a minimum of 5 years. And we always tell the patients that like anytime you have a problem that you think you need to be seen, you need to get in touch with us. Any abdominal issue. Any pain, nausea, vomiting. Any GI tract issue - we certainly need to hear about it. I have no problem with them contacting their other providers but we need to be involved in that process as well.  Host: So clearly, the follow-up is key in avoiding revisional surgery. What else can patients do to reduce their risk for potential revisional weight loss surgery? Dr. Shope: Do their best to follow along the program we’ve developed, as have other centers across the country. I’ll say strict but I think very doable programs for the dietary progression afterwards. It’s certainly not something that any one of us would want to choose to be on forever, but if they follow the dietary progression afterwards and really make the changes that are necessary in their life, not only from an intake standpoint but from a physical activity standpoint, from removing the stressors or triggers in their lives that lead to food seeking behavior, making sure that if somebody else lives in the home with them that those people aren’t bringing in tempting foods and the like. So, they really need to address a lot of spheres in their lives. And, in addition to the follow-up that I already mentioned, we have the capacity to bring patients back for one-on-one visits with dieticians to review food journals. We can have them seek behavioral modification, psychiatry, these types of added measures to help them not need a revision. Host: Is revisional weight loss surgery usually covered by insurance? Dr. Shope: Revisional weight loss surgery usually is covered by insurance. Medicare does not like to cover it. But, if there’s compelling reasons to do so, they will. The other insurance companies generally will but most of the time patients have to recommit to the entire process - all the pre-operative program that’s necessary the first time. Host: Could you share a success story from your practice? Dr. Shope: Sure. We’ve had a number of patients do really, really well after revisional surgery. And again, some of these folks have done well initially. They just, over the long term, needed some extra help. The patients that come to mind include patients that have had, I’ll say, an issue with their previous surgery. We’ve had a few folks that have had sleeve gastrectomy, as I mentioned. One or two from our institution but several from within the city or elsewhere in the country that really have had severe, severe reflux and we’ve converted them to gastric bypass anatomy. The one woman, in particular, the next day was just so thankful that she didn’t have reflux anymore. Very simple, straightforward fix for her. That changes around a lot about how she has to approach things afterwards but we gave her proper counseling and she’s doing great from that standpoint. From the patients that just needed to lose more weight, we definitely have had folks that have been converted, most of them, I think, from lap bands, who just didn’t get everything they needed. And they gave it an honest effort—5, 7 years in some cases—even people that have come in for regular adjustments when they needed it with their lap bands. And we’ve converted them either to sleeve or to gastric bypass and then they’ve done very, very well with, not only getting rid of the weight, but addressing their medical troubles as well. I revised a patient who, his original bypass, the length of the bypassed intestine was about 50 centimeters. Now when he had his original procedure in the late ‘90s, and at that point in time, that was relatively standard of care. What I can tell you is that when I re-operated on him, the entire length of the small intestine was over 700 centimeters. So, he had a very small percentage of his intestine bypassed. And so, we gave him now a more appropriate length of bypass. In addition he also had a gastrogastric fistula, which is an abnormal connection between the pouch and the other part of the stomach, likely because when his original procedure was done, the type of stapler that was used is different than the one that we use today. That stapler didn’t actually separate the tissue. It just partitioned it. So, based on the instruments that were used, and the way that the surgery was done 10, 12 years ago, his procedure in today’s world would not have been what we do. Another guy, about a year ago now, he came to us after having had a procedure which was much more similar to the biliopancreatic diversion operation I talked about earlier. This was done in the early ‘90s. And his understanding from that point in time was that he actually had a gastric bypass operation. He was doing rather poorly from a nutritional standpoint. In other words, he wasn’t able to get what his body needs, despite having a very large pouch. The way that that procedure was done back in the ‘90s, they created a very large pouch for patients and then did a very long bypass. And so, despite him being able to eat a lot of food, which many of our patients aren’t able to eat a lot at one setting, he was not able to extract the calories and nutrition that he needed because of how long his bypass was. Because of how long ago that operation was done, I wasn’t able to get records for him so I didn’t know exactly what was done. But at surgery, when I eventually operated on him, I found, again, a very large stomach pouch and a very, very long bypass, which, again, may have been standard of care at the time, but certainly wasn’t something that we would do today and also was NOT helping this gentleman - he really needed from a nutritional standpoint. I actually ended up making his pouch a lot smaller so that he could eat less, but I substantially shortened his bypass so now his body’s gonna be able to get those calories and nutrients that it needs.      Host: Why should patients who are having some difficulties after previous surgery or who want to lose more weight after bariatric surgery come to MedStar Washington Hospital Center for revision? Dr. Shope: Well, because it’s what we do. One of many things that we do in our program. We have certification through the American Society of Metabolic and Bariatric Surgery, through their metabolic and bariatric surgery quality assurance program (MBSAQIP). We take a lot of pride, actually, in that because it’s a certification that says we’re here and we do this and we do it well and we have the data to support that. We have the outcomes to support that. Not a lot of places around will do revisional surgery because it’s technically difficult sometimes. It’s a little bit more risky for the patients so you have to be willing to not only accept that risk WITH the patient but be able to identify it, be able to mitigate it, be able to minimize the problems that they can have with these things. So, it’s easy to do some of the straightforward cases. These more complex cases need to be at a place like ours where number one, we’ve got a program, we’ve got the accreditation and certification to back it up and we’ve got the experience. We’ve got several fellowship-trained surgeons. We’ve got two of us that have been doing bariatrics for more that 15 years. And we know how to take care of these problems. Host: Thanks for joining us today, Dr. Shope. Dr. Shope: Well, thanks again for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Transcatheter Aortic Valve Replacement (TAVR) has come a long way since it was introduced in the U.S. in 2007, as doctors’ experience and technological advancements have improved. But the medical community still has work to do. Dr. Toby Rogers discusses the current and future state of TAVR.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Toby Rogers, an interventional cardiologist at MedStar Washington Hospital Center. Thank you for joining us, Dr. Rogers. Dr. Rogers: It’s a pleasure to be here. Host: Today we’re discussing the future of transcatheter aortic valve replacement, or TAVR. TAVR is a treatment for patients with aortic stenosis, or narrowing of the aortic valve. Dr. Rogers, could you discuss how a doctor can replace an aortic valve without open-heart surgery? Dr. Rogers: That’s a great question and it’s one that every patient wants to know. So, I think open-heart surgery makes sense. You open the chest, you stop the heart from beating, you cut out the old valve, you sew in a new one, you restart the heart beating again, you sew the chest up, and you have a new heart valve. TAVR is very different. In fact, we don’t actually take the old valve out at all. And, what we do is we thread a new valve through the artery from the leg, all the way up to the heart, and then we open the new valve inside the old one, just pushing the old one out of the way, and we leave the new valve behind, opening and closing inside the old one. And, the beauty of this is that obviously we’re able to that, as I said, thread it from the leg, without having to do open-heart surgery, without having to stop the heart from beating, without having to even put the patient asleep. And so, it’s much less invasive and much less of a stress on the body. Host: What are some of the improvements in TAVR that you’ve witnessed or been a part of in your practice? Dr. Rogers: So, I think you can divide the benefits into two broad areas. The first is technology. So, we are now on to the third generation of TAVR valves, meaning that the companies that develop these, and the doctors and scientists that work with them, have gone through three iterations now, or improvements, on the valve technology.  And each iteration, each new improvement, has brought dramatic improvements to the whole procedure. Specifically, the catheters that we deliver the valves through from the groin have gotten smaller and smaller. And the smaller a catheter, the less invasive the procedure and the more patients are able to have this procedure because even patients now with very small...even patients with some blockages in the arteries down to the legs, are able to have TAVR whereas in the past they wouldn’t have been able to do so. There’ve also been some key technology improvements that reduce the need for pacemakers after the procedure, that reduce the risk leaking of blood around the new valve after the procedure. And, we know that all of these things put together make for a much more durable and lasting result. And then, the second area that there’ve been improvements is just in our comfort and our experience with the procedure. To the point that when we started doing TAVR, we actually used to put all the patients asleep with general anesthetic. We used to have an echo probe, an ultrasound probe, down the esophagus so that we could monitor the heart very, very carefully during the procedure. And, with experience, we’ve learned that those things are actually not necessary. And so now we do TAVR, as I mentioned before, under just a little bit of sedation. We don’t put patients to sleep. And we don’t even need the ultrasound probe to guide the procedure anymore. We can do the whole thing using x-rays, which is must less invasive. And so, if you put these technology advances and the procedural advances and experience together, it makes for a much less invasive...in fact, we use the word “minimally invasive” approach to TAVR now, and all of those things put together make for better outcomes, faster recovery, shorter time in hospital, and overall better results. Host: Even with all of those amazing benefits, what do you think should be improved in the next generation of TAVR? Dr. Rogers: So, we have great devices to replace TAVR valves that are tight, meaning they’ve gotten tighter and tighter over time. We see a lot of patients who have leaky valves, and actually, we don’t have great technology for those yet. That technology is just coming along and MedStar is actually one of just two hospitals in the country that is testing a new valve for this specific problem. But up until now, we’ve really been in a bind in that these patients with leaky aortic valves, we’ve had to say, “Sorry, we don’t have a minimally invasive treatment for you. Open-heart surgery is your only option.” So, that’s one area where I think there is definitely room for improvement. I mentioned the size of the catheters. Smaller catheters are always better because it makes for an even more minimally invasive procedure, so I anticipate that in years to come these catheters and devices will get even smaller, and I think that’s only a benefit for patients. There’s been a lot of work to improve how well these heart valves sit inside diseased aortic valves that aren’t completely round, and aortic valves that had a lot of calcium in them, which is something that we commonly see. And, those patients are particularly prone to having electrical conduction problems after TAVR, and needing pacemakers. And so, there’s still a lot of work to be done, I think, to improve the technologies so that patients really don’t need pacemakers after TAVR because again, if you do need a pacemaker, that often extends the time you’ve been in hospital and it’s an additional procedure that you have to undergo. Host: What do you think will be the biggest challenges or barriers in improving or providing TAVR in the future? Dr. Rogers: So actually, I think the answer to that question doesn’t have much to do with TAVR technology or the procedure itself. It’s about access and availability to TAVR. If you live in a big city that has a hospital like MedStar Washington Hospital Center that does TAVR, and you have aortic stenosis, then there is a hospital just down the road that can provide you this treatment. If you live far from a big city, then often your local hospital doesn’t have access to this technology because it is still a specialist procedure. And so, there are a lot of patients out there across the country who live far from hospitals and don’t have access to this. And so, I think there are a lot of patients who could benefit from this treatment, if only it was close to them. So, one of the big challenges we have going forwards, is finding a way to give patients access, to educate patients that TAVR is available, that open-heart surgery isn’t the only choice and then also, find ways to either bring the technology closer to where they live or find ways to make it easy for them to travel to where the technology is. Host: How will you and your colleagues help overcome these challenges? Dr. Rogers: The first answer has always got to be education. We have to educate other doctors that this is available so that doctors outside in the community, when they see patients, know that these options are available. As I said, this technology is moving very quickly and, those of us who work in this day to day, have to work very hard to keep abreast of all the new advances and the new technologies. And so, we have to work very hard to help other doctors who aren’t TAVR doctors to understand what’s available, what’s changed, what’s new. And then, that allows those doctors to teach their patients, “Look. These are the options for you.” As I said to you before, there are many areas in the country where patients live many hours from a hospital that offers TAVR and so, those patients may be tempted to say, “Well, I’ll stay close to home and have open-heart surgery,” when we all know that if you’re an elderly patient with lots of other medical problems, TAVR is a better option for you. And so, I think education’s got to be the first try. And then, at a bigger level, we have to think, as a society, “How do we improve access to these technologies?” Host: Why is MedStar Washington Hospital Center uniquely positioned to offer TAVR? Dr. Rogers: So, MedStar Washington Hospital Center has been at the forefront of TAVR since it was first introduced to the United States over a decade ago. And, we have great experience with all of the TAVR technology, right from the very early days. We’ve been involved in all of the major clinical trials of TAVR. We’ve run our own clinical trials, most recently in low-risk patients, so patients who would otherwise undergo surgery. And, we also - because of this - we have access to all the new technologies, so when a new valve becomes available, either under clinical trial or for just commercial use, as a hospital, we get access to that very early. And clearly that gives us an option when a patient comes to us to say that we have not just one option we have many options for you. And, I think research drives our day-to-day mission and that can only make patient care better. Host: Thanks for joining us today, Dr. Rogers. Dr. Rogers: Thank you. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Skin cancer is common in the head and neck area because of exposure to ultraviolet (UV) radiation from the sun. Dr. Jonathan Giurintano discusses the most common types of skin cancers and how we treat them.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Jonathan Giurintano, a head and neck cancer surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Giurintano. Dr. Giurintano: Thank you so much for having me today. Host: Today we’re discussing treatment options for skin cancers of the head and neck. Dr. Giurintano, how common are skin cancers of the head and neck compared to skin cancers that affect other areas of the body? Dr. Giurintano: Skin cancers in the head and neck region are extremely, extremely common. The most common types of skin cancers (these are basal cell carcinomas, squamous cell carcinomas and melanomas), are found in areas of the body that receive exposure to the UV radiation from the sun. As the head and neck are the most frequently sun-exposed areas of the body, it follows that these are also extremely common areas that we see skin cancers, often occurring on the scalp, the face, the ears, nose, cheeks or on the neck. Host: In less visible areas of the body, cancerous moles, spots and other tissues often are removed. How do you approach treatment of the very visible tissue of the head and neck? Dr. Giurintano: So, it’s similar to other areas of the body, especially for larger skin cancers. The best treatment is typically surgical excision. Our colleagues, the dermatologists, are often times specially trained to perform a procedure called Mohs micrographic surgery. So, this is actually a very special type of surgery in which the skin cancer is removed and normal appearing skin around the periphery of the skin cancer, and this is sectioned by the dermatopathologist and looked at under the microscope at the time of the surgery to confirm that there is no further cancer cell present. By doing this, the dermatologists are able to not only completely excise all cancerous cells from the region of the skin cancer, but oftentimes are able to limit the amount of normal skin that must be sacrificed in order to completely resect the skin cancer. In areas such as the nose, the ears or the cheeks, there oftentimes is not much elasticity to the skin that allows for the defect in the skin to be closed simply. Other times, the defect might be closed simply, however the resultant scar might result in an unattractive cosmetic appearance. So, for these types of patients, we do have special ways that we can rearrange the tissue on the face in order to not only reconstruct the defect left behind by the resection of the skin cancer, but also do so in a way that the scar is camouflaged and has the most cosmetically appealing appearance.    Dr. Giurintano: Well, basal cell and squamous cell carcinoma are the most common types of skin cancers that we treat. Other skin cancers such as melanoma require different types of treatment. Host: What makes treatment different for melanoma? Dr. Giurintano: So, one of the concerning features of melanoma is that we really cannot do Mohs micrographic surgery for melanomas. Whereas Mohs surgery relies on freezing the samples of normal skin from around the periphery of the tumor and looking at that sample under the microscope with very good success rates for ruling out the presence of cancerous cells, we know that that technology does not work quite as well for melanoma cells. As a result, most melanomas require pretty large resections. So, not only do you excise the melanoma itself, but oftentimes we excise at least one centimeter of normal appearing tissue around the periphery of the melanoma up to two centimeters of normal appearing tissue, dependent on how deep the melanoma is traveling underneath the skin. So, what initially starts out as a very small defect in the face, might soon become a defect that measures 4 or 5 centimeters and needs a major reconstruction. Another facet of melanoma is that it tends to spread very easily to lymph nodes in the neck. So, anytime patients have a melanoma in the head and neck region, very commonly we want to know what is the status of the lymph nodes in the neck. One of the special tools we have for helping determine the lymph node status in the neck is something called sentinel lymph node biopsy. So, this is a special procedure where, on the day of the surgery, before the melanoma is removed, the area around the melanoma is actually injected with a dye that has kind of a radioactive uptake. And then after the melanoma is excised, we can then actually go down to the neck and determine where the lymph nodes are that that melanoma was draining to. So, instead of having to do a large incision to take out all the lymph nodes in the neck without knowing if any of the lymph nodes are positive, we can actually pinpoint only one or two lymph nodes that we know the melanoma would have most likely been draining to and we can go take those lymph nodes out and then look at those lymph nodes under the microscope. And if those lymph nodes do not have any evidence of melanoma, then we know that it’s generally safe to watch the neck and not perform any major surgery or give any other therapeutic treatments. So, if that lymph node is involved with tumor, then we could go into the neck, make the incision larger and do a complete neck dissection or complete removal of the lymph nodes in the neck to help prevent recurrence of the melanoma in the future. Host: Can these cancers spread to other parts of the body? Dr. Giurintano: Yes. So, that is where my job as a head and neck cancer surgeon often takes the most importance in treating patients with skin cancers. For some people, they might have a small skin cancer on the scalp or on the ear. This is removed by a Mohs surgeon, with negative margins. The area is closed, the patient’s happy, and then 5 or 6 months down the road, that patient might develop a small lump in the parotid gland or in the neck. In short, yes, these skin cancers can also send metastasis to the lymph nodes in the face and lymph nodes in the neck. And whenever these lymph nodes do occur, they can often become very aggressive and distort the tissue surrounding them. So, my job as a head and neck surgeon in dealing with skin cancers, often occurs once the skin cancer has spread or metastasized to lymph nodes. And my job is to go into the neck or into the parotid gland and to remove these lymph nodes to remove all the cancer that has spread. Host: How do you recommend that patients prepare for treatment? Dr. Giurintano: A large part of the preparation for these patients is mental and emotional. Oftentimes, when the Mohs surgeon performs their portion of the procedure, which is the removal of the skin cancer, the resultant defect might be left in place with a bandage over it so that they can then be reconstructed secondarily by an otolaryngologist or by a facial plastic surgeon. It can be very distressing for patients to see a large hole in their face immediately after surgery, but they must be assured that this will be reconstructed in a manner that is both cosmetically appealing and functional. Occasionally, in order to repair defects in the skin on some parts of the nose, we have to take tissue from adjacent sites on the face, such as the skin on the forehead, and use that skin to resurface the lining of the nose. In order to do that sort of procedure, what’s called a local tissue flap, the patient has a very odd appearance immediately after surgery as the piece of skin still has a bridge connecting it where the artery, that is supplying the skin flap, is running. This can result in a very strange physical appearance for the 3 to 4 weeks immediately after reconstructive surgery while the skin is healing in to place on the nose. However, we have to encourage the patient that within 6 weeks, a second procedure is performed where that skin bridge is removed, and the remaining tissue is reoriented so that there is a normal cosmetic appearance with only a minor scar present on the forehead. Host: What does recovery from head and neck skin cancer treatment entail? Dr. Giurintano: So, aside from the actual recovery from surgery, which is often performed either on an outpatient basis or maybe with a 1 to 2 day hospital stay, if the lymph nodes in the neck need to be removed, recovery from head and neck skin cancer treatment, most importantly, requires a very close follow-up, with either an otolaryngologist or a dermatologist, in the future to ensure that no other areas of skin cancer arise within the head and neck. While it is impossible to completely reverse the many decades of damage the UV radiation from the sun has often done to patients’ skin, it is never too late to begin applying sunscreen and to do precautionary measures to help limit the amount of damage to the remaining skin and to help prevent further skin cancers from occurring in the future.  Host: You mentioned sunscreen. Are there any other prevention tips that you can offer to people in the community? Dr. Giurintano: So, aside from wearing sunscreen daily, which should be part of all of our daily routines anytime we go out - the face, the ears, and, especially for men who might be balding, application of sunscreen on the scalp, a few other very good preventative measures are to wear a wide brimmed hat if you are going to be out in regular sun exposure and to not only apply sunscreen whenever it’s sunny outside. Even if it’s cloudy outside, the UV radiation from the sun can still cause damage to the skin, so sunscreen in encouraged and recommended anytime patients are going to be outside.  Host: Could you share a story about a patient who had a particularly successful outcome after skin cancer treatment? Dr. Giurintano: So, I previously had a patient who was actually a transplant patient - previously had a kidney transplant - and, as part of his transplant protocol, he was required to take immunosuppressive drugs to ensure that the body did not reject the transplanted kidney. The unfortunate thing about immunosuppressive drugs is that if a cancer does develop in the body, the immune system is not present to help fight that cancer and it can spread very rapidly. So, I previously had a patient who was a transplant recipient, who developed what was initially a very small skin cancer present on his left face that very rapidly increased in size, to the point where nearly the entirety of his left face was involved with the skin cancer within only a few weeks. This patient required a large radical resection of the tumor as well as the underlying parotid gland and the lymph nodes in the neck. In this patient, we actually used a free flap (so, that’s a piece of tissue from the thigh that we connected with an artery and a vein in the neck), and we used that tissue from the leg to resurface the skin, fat and parotid gland that was resected during the cancer resection. And, the patient had an excellent cosmetic appearance afterwards and was able to complete radiation therapy and chemotherapy, and since that time, has not had any further skin cancers develop. Host: Why is MedStar Washington Hospital Center the best place for patients to come to receive treatment for skin cancers of the head and neck? Dr. Giurintano: MedStar Washington Hospital Center is an excellent place to come for head and neck skin cancer treatment as we have all the tools necessary to handle the most minor skin cancers up to the most complicated of skin cancers. While many small skin cancers can be handled in the community setting, for those type skin cancers which become very aggressive and which might invade locally into structures of the face - this includes the muscles of the face, the parotid gland or the large saliva glands on the side of the face and even the facial nerve, the nerve that controls all facial movements on one side of the face -  for all these patients, even if the tumor is involving these structures, we have the surgical capability as well as the capability to provide adjuvant radiation therapy and chemotherapy, for even the most aggressive skin cancers to help patients have not only the best oncologic outcome possible but also the best cosmetic and physical outcome possible. Host: Thanks for joining us today, Dr. Giurintano. Dr. Giurintano: It was a pleasure. Thank you so much for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Symptoms of bunions include pain, restricted movement of the big toe, swelling and redness.  Dr. Ali Rahnama discusses what causes bunions and how we treat them.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Ali Rahnama, a foot and ankle surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Rahnama. Dr. Rahnama: Thank you for having me. It’s a pleasure. Host: Today we’re discussing bunions, which are painful, bony lumps that can develop at the base of the big toes. Dr. Rahnama, what’s going on within a patient’s foot when a bunion forms? Dr. Rahnama: So, as you very nicely said, a bunion is a large bump at the base of the great toe joint that forms. There are multiple reasons that can contribute to a bunion’s development. We think that, for the most part, the average patient that we see with bunions, it’s likely hereditary in nature. Most experts will agree that shoe gear and high heels and tight shoes - while they can exacerbate or make it more painful or symptomatic, they’re likely not the cause of why a bunion would form. Host: Often, people think of older adults as most likely to develop bunions. Is that accurate? Dr. Rahnama: Well, it’s true that by the time most people present for help and evaluation of their bunion, the bunion can become prominent and painful as early as the teen years. And, this is usually a condition called juvenile hallux valgus. These individuals are usually hypermobile or ligamentously lax, think of highly flexible people. So, to answer your question, no. The bunion can really affect people of all ages. Host: Do patients usually know what’s going on with their foot, or are they surprised by the diagnosis when they come see you? Dr. Rahnama: No, this is actually one of those things where usually people know exactly what is going on when they come and present to us. They’re really looking more so for an answer on what they can do about the pain and discomfort that they’re experiencing, more than wondering what’s going on. Pain is the number one thing at the base of the great toe joint. A lot of times it becomes red and hot and swollen, particularly after they do have to be in a pair of tight shoes. We see this a lot in females but certainly we do see it in our male patients as well. A lot of times, because of that bony prominence or protuberance that’s there, the body will produce a small bursa sac as a little cushioning or type-mechanism to help protect itself and so, that even, a lot of times, makes the bunion seem larger, more prominent than it actually is. Host: Sort of like a blister? Dr. Rahnama: Similar, but it’s more...it’s on the inside. It’s inflammatory tissue. The actual skin around the great toe joint can become thickened. So, these things can all contribute to the bunion becoming or appearing larger than it actually is. Host: Could having a bunion indicate that something else is going on within the foot? Dr. Rahnama: Absolutely. A lot of times, we can see that a bunion comes hand-in-hand with a larger orthopedic or foot and ankle deformity, such as a flat foot or a tightening or contracture of the heel cord, can contribute to the bunion’s formation as well. Host: What are the most effective treatment options for bunions? Dr. Rahnama: We can try things like toe spacers, shoe inserts, oral anti-inflammatories, topical anti-inflammatories to start, but none of these things will actually get rid of the bunion. They may just help with simply alleviating the pain that the patient is experiencing. The most definitive way to treat them is by surgically correcting them. But one thing I will add is that, at least my philosophy when it comes to bunions, is that I will try not to operate on a patient who’s telling me that the bunion’s not painful. So, we try to typically stay away from cosmetic foot surgery. That’s something that I will not do. If it’s not bothering you and it doesn’t hurt, my recommendation is to leave it alone.  Host: Is there any long-lasting ramifications for leaving a bunion untreated? Dr. Rahnama: The biggest thing with that is that not having a symptomatic bunion fixed or repaired can do two things - the pain can become worse with time and the bunion can become worse with time. So, those are the two big things that I would caution patients when it comes to their bunion. The third thing is that, over time, the great toe joint can actually become arthritic. And so, if they wait too long, instead of having bunion corrective surgery, that they would have to have fusion of that great toe joint. And, while most patients do well with that, it would be great to avoid that with a lesser procedure, if possible. Host: During or after treatment, what activity restrictions should patients expect? Dr. Rahnama: Well, after surgery, depending on the type of bunion procedure that they’ve needed to have, some patients would be able to start weight-bearing, in a surgical boot, as soon as the day after surgery. In patients who have to undergo a slightly larger procedure because of how bad their bunion may be, they need to stay non-weight-bearing on the operative extremity, or foot, for a period of time, typically no more than 3 or 4 weeks. Host: Is treatment typically “one and done,” or do bunions often return? Dr. Rahnama: It depends on the type of treatment that they had. Bunions can certainly return after surgery but there are surgical procedures that we can choose so that it gives the patient the best chance at not having a recurrence of the deformity. Those procedure sometimes may take a little longer for the healing of the patient and they may require them to remain non-weight-bearing, or staying off of the foot, for maybe a few more weeks. But, in the long run, particularly if they’re younger, those juvenile hallux valgus patients, as an example that we talked about a little earlier, if we DO do the slightly larger procedure, it can avoid a recurrence as they get older, into their 40s, 50s.  Host: Could you describe a general bunion removal or a bunion treatment procedure? Dr. Rahnama: So, if you look at a textbook on foot and ankle surgery, you can find over a hundred ways to surgically correct a bunion. The most common two procedures, I would say, are head procedures, is what we call them. It’s when we physically shave the bump down with the saw in the operating room and then we make small cuts in the bone and shift the bone over, and we typically fixate it with one or two screws. That is a smaller procedure. Patients are typically able to weight-bear almost immediately after surgery. But again, that is the smaller of the two procedures. But, if a patient has that done and they have a really severe bunion or if they’re very young, they’re always susceptible to having a recurrence. The slightly larger procedure is where we fuse the joint that is distoproximal, or towards the midfoot. Patients are a lot of times surprised to see that we want to go after an area of the foot that doesn’t appear to be symptomatic for them. But that joint is really where the root of the bunion is. And so, if we can correct the bunion at that level and fuse the joint end close to the midfoot, then straighten out the bone, then we avoid a recurrence. Host: Can you recall a patient who had particularly bad bunions but was able to return to an active lifestyle? Dr. Rahnama: I would say that, luckily, most of our patients who undergo bunion surgery are able to get back to not only the things they want to do, but also wearing the type of shoes that they want to wear without discomfort. Really, the aim of the surgery is to be able to help them have a better quality of life to begin with so that’s why we decide to proceed with it to begin with. Host: Why should someone with bunions consult with the foot and ankle surgeons at MedStar Washington Hospital Center? Dr. Rahnama: I think it’s really important for patients to be able to consult with a specialist who can help the patient choose the best procedure that’s right for them. And, I would say that we have a very highly skilled team of surgeons here, more than equipped to deal with patients and their foot and ankle needs. Host: Thanks for joining us today, Dr. Rahnama. Dr. Rahnama: Thank you so much for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Transoral thyroid surgery is a procedure we use to remove thyroid nodules by going through the mouth, as opposed to making incisions in the neck. Dr. Erin Felger discusses who’s a candidate and what recovery is like.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Erin Felger, an endocrine surgeon at MedStar Washington Hospital Center. Thank you for joining us today, Dr. Felger. Dr. Felger: Thank you for having me. Host: Today we’re discussing transoral thyroid procedures, or thyroid surgeries done through the mouth instead of through open incisions in the neck. Dr. Felger, why would a doctor recommend a transoral thyroid procedure instead of a traditional approach? Dr. Felger: The main reason that someone would offer a transoral procedure to their patient or an endocrinologist would offer to have a patient seen for transoral procedures is because of scar issues. These can be scar issues related to a medical problem like hypertrophy or keloid, which a number of people in our population have, or scar issues that are psychological, in that nobody wants to have a scar on their neck. Host: What symptoms do patients share with their doctors that ultimately lead to a diagnosis of thyroid issues? Dr. Felger: It depends on the type of thyroid issue. The main symptoms that people usually discuss are symptoms of fatigue, constipation, hair loss, skin changes - which are all associated with hypothyroidism, or anxiety, racing heart, heat intolerance - which are due to hyperthyroidism. With respect to surgical issues, the most common symptoms are symptoms related to compression of the thyroid because of its size and they include voice changes, swallowing difficulties or inability to lay flat at night. Host: What are some of the most common conditions for which the transoral approach is most effective? Dr. Felger: For most patients, the best reason to have a transoral thyroid approach is, again, for the scar issues. But in terms of actual disease processis, almost any disease process could be taken care of through a transoral approach. The best options are a solitary nodule or a small thyroid cancer, on occasion parathyroids and, very rarely, a large multinodular goiter. Host: How does the conversation go when you start talking about surgical approaches for your patients? Dr. Felger: Basically, I start the conversation with explaining why they would be a good candidate for the operation. I also tell them that there is a standard operation so that they hear that there’s another way to do it. And then I go into the details about how many we’ve done, what the procedure is and how it differs in terms of pain control and postoperative care afterwards. And honestly, there isn’t that much that’s different between the two procedures when I’m talking to patients, except for the oral care with the transoral approach. Everything else is very similar. Host: What does a patient have to do to prepare for surgery? Dr. Felger: The patient needs to have been seen by the surgeon for their initial consult. And at that time, the surgeon will be giving the patient a list of items that need to be completed prior to the day of surgery. Those usually include labs, EKG, and a preoperative physical at a minimum. The surgeon may require other testing to be done, which might include imaging or a biopsy. Host: How long is the recovery time after a transoral thyroid procedure? Dr. Felger: In general, I tell everyone it’s a week, but most patients feel really good after a couple days. But, I also want them to understand that it’s not going to be perfect for a period of time, which is usually around a week, so that’s why I give that as my standard approach. After surgery, patients can expect to have some swallowing difficulty, secondary to the breathing tube. They can expect to have numbness around the mouth where the incisions are placed, as well as on the chin. The chin numbness can last for several months but it does resolve after a period of time which is different for each patient. Host: What additional treatment or care do patients need after surgery? Dr. Felger: For transoral patients, they do have to do an oral care regimen until they come back for their first postoperative visit, which just includes a salt water swish and spit after each meal and at bedtime. Host: Could you share a story of a patient who had a successful outcome? Dr. Felger: I had a wonderful lady who I saw in my clinic who has terrible hypertrophy with her other scars from other surgeries. She was very concerned about having a scar on her neck that would be visible with this medical problem. She had a nodule that was quite large that needed to be removed. And she and I talked about doing the transoral approach and she was very interested in it. She was hesitant at first to sign up for surgery but ultimately, after discussing with her family, she decided to have the transoral approach. Her surgery went wonderfully and she came back to see me the week after the operation for her first postoperative visit and she was thrilled. She said, “I know that my chin is numb, my mouth doesn’t feel quite right yet. If I had it to do over again, I’d do it this way again. I have no scar on my neck.” Host: Why is MedStar Washington Hospital Center the best place to seek care for thyroid conditions? Dr. Felger: We have the best multidisciplinary group in the region. We work with our endocrinologists, our nuclear medicine doctors and our radiologists to provide the most comprehensive care available for any thyroid condition. From the standpoint of doing transoral thyroid surgery, we’re the only hospital in the DC and Maryland area that is doing this procedure. And, again, we have a comprehensive team that we work with so that the transoral procedure can be done as successfully as possible. Host: Thanks for joining us today, Dr. Felger. Dr. Felger: Thank you.

Lupus can affect a person’s immune system and cause damage to the skin, joints, blood cells and organs. The key to treatment? Knowing what symptoms to look out for and seeking medical attention when necessary.    TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re speaking with Dr. Konstantinos Loupasakis, a rheumatologist at MedStar Washington Hospital Center. Thanks for joining us today, Dr. Loupasakis. Dr. Konstantinos Loupasakis: Thank you for having me. Host: Today we’re discussing systemic lupus erythematosus, which is also known as SLE or simply lupus. This autoimmune disease can affect the joints, blood cells, and vital organs of the body. Dr. Loupasakis, what does autoimmune disease mean when it comes to lupus? Dr. Loupasakis: Autoimmune means that the immune system, which is the defense mechanisms that our body is equipped with to fight infections or to heal injury, for reasons that are not entirely understood, goes out of control. When the immune system goes out of control, it can become very active for no obvious reason, as if there were an infection or as if there were an injury, even in the absence of either. When that happens, structures of the body, which can include the joints, the skin, but also vital organs such as the heart, the kidneys, and the brain, can be targeted by the immune system, which otherwise is supposed to be there to protect us. And that can lead to very significant complications. Host: What are some of the most common symptoms of lupus? Dr. Loupasakis: The most common symptoms of lupus include joint pain and inflammation of the joints, which we call arthritis. It’s usually affects the joints of the hands, the wrists, but also the feet and the ankles. And it can affect also the larger joints of the body. In addition to that, it can affect the skin. Some very typical rashes happen on the face. The most known one is the one that has been described as a butterfly rash because of its shape. These rashes are usually photosensitive, which means that they get worse by sun exposure. Other symptoms that can also happen at the same time include patchy areas of hair loss, inflammation of the kidneys or the heart, inflammation of the eyes - depending on each individual, patients can have a very different presentation. Host: What should a patient do if they notice a strange rash on their face? Dr. Loupasakis: They should definitely consult with their rheumatologist because it may or may not be related to their lupus. There are certain criteria and certain characteristics that a rheumatologist can recognize when they examine the skin rash, that can suggest whether the rash is related to the lupus. Usually, the classic butterfly rash is very red. It can be itchy or burning, and it’s very photosensitive, which means that it’s usually triggered by sun exposure or it can get worse by sun exposure. However, not every rash that happens on the face is a lupus skin rash, and that’s why it’s very important to consult with a rheumatologist and, oftentimes, with a dermatologist, a skin specialist, because it’s not always very clear and there are other conditions that can manifest with a very similar presentation. So, it’s very important to distinguish those conditions from lupus. Oftentimes, a skin biopsy performed by a dermatologist is a necessary test that we end up getting in order to confirm the diagnosis. Host: Do these symptoms tend to present slowly, quickly, in bursts - or how do they usually make a patient feel? Dr. Loupasakis: The onset of those symptoms can be very gradual. But occasionally we see patients that have very acute presentations. For example, the skin and the joint manifestations oftentimes happen more gradually. Oftentimes, with a trigger. After a sunny day, patients can present with a skin rash that is really prominent that was not there before. The joint symptoms are usually more gradual, over a period of weeks or even months. However, there are other complications. For example, inflammation of the brain or the kidneys that can present more suddenly. Or, they might have been happening for a long period of time, but the patient sometimes only realizes that something is wrong suddenly, or more acutely. Host: Could you describe your patient population for lupus and who’s most at risk? Dr. Loupasakis: Sure. Lupus affects women more than men. In fact, nine times more, women compared to men. When men are affected, the disease is usually a little bit more severe, and usually it starts at an earlier age. For reasons that are not entirely understood, it affects African Americans more than Caucasians. And, there are many research studies that have been focusing on that question. It’s a very complex issue but we think that there might be some genetic component. But also, at the same time, social disparities come in to play and may affect the outcomes and why African American patients may seem to suffer more from lupus. Maybe their disease seems to be more severe. But it’s not entirely understood whether that is because they truly have a different version of lupus or because their access to care might be more limited, at times. Host: Around what age is a patient typically diagnosed with lupus? Dr. Loupasakis: Lupus predominantly affects females at the age of 20s and 30s. However, we have had patients that were diagnosed when they were children. And, even though that’s not a classic presentation, it can happen and, obviously, it can be very devastating sometimes for the families. But I would say that the majority of our patients are usually diagnosed in their 20s and 30s. Host: Is there anything patients can do to reduce their risk for lupus? Dr. Loupasakis: There are no known risk factors that can be modified by the patients. Sun exposure is a trigger of active disease and patients who have lupus they know that they should avoid sun exposure and that they should definitely use a good sunscreen with an SPF of at least 30. That could be one of the modifiable risk factors for triggers. But not...we don’t really have any modifiable risk factors for the development of the disease. There is some genetic predisposition and some environmental risk factors that are not entirely understood, that, in combination, can lead to the development of lupus in some predisposed individuals. Usually, there is a family history of the disease, usually in the first-degree relatives, but we don’t really have any other risk factors that have been recognized to lead to the development of lupus. Host: It has to be very frustrating for patients and their families. Dr. Loupasakis: It is very frustrating because they want to know if there’s anything that they did wrong. They want to know if there’s anything that they can do to prevent it from getting worse. And, the answer is that there’s nothing that they did wrong. Unfortunately, that’s...a lot of our diseases have that kind of course. And, what our patients can do to prevent it from getting worse, to prevent their lupus from flaring, is really to maintain a good relationship with their rheumatologists, to have frequent follow-up with us, with the rheumatologists, and have frequent blood checks and report any new symptoms that they may develop over the time in order to catch it early and treat it accordingly, if they have a flare.   Host: What complications can happen if a person has lupus but doesn’t get treatment for it? Dr. Loupasakis: Lupus is a multisystemic disease, which means that it can potentially affect many different parts of the body. Even though most of the patients that we see usually have arthritis -  so joint inflammation and also inflammation of the skin - there is a significant percentage of patients that can develop more severe disease, which can affect the kidneys and other vital organs, such as the heart and the brain. That’s why it’s very important that the disease is treated early so that it doesn’t lead to the development of those complications. Not everybody is going to develop those unfortunate complications, but a very significant percentage that can reach up to 50 percent of patients can have kidney involvement. And, this is a manifestation of the disease that can be very severe, and it can lead to significant problems in the future. That’s why it’s very important that we treat it very aggressively and very early. The most important thing is that some of these manifestations may not be very easy for the patients to realize that are happening. For example, kidney inflammation doesn’t really cause pain, but it can manifest itself with symptoms such as swelling of their ankles or swelling of their face or changes with their urination - they might see blood in the urine, or their urine might become very foamy. So, sometimes subtle changes in their symptoms may reflect some more severe disease. That’s why it’s very important that patients with lupus follow-up very closely with their rheumatologists in order to be able to identify those subtle changes and do the appropriate lab testing. Host: How is lupus diagnosed? Dr. Loupasakis: Lupus is diagnosed by combining a number of blood and urine tests with a very thorough examination in the office, a very thorough history-taking, and also, occasionally, with x-rays of the affected joints. Other imaging studies such as CAT scans or MRIs - these are studies that are done in radiology - they can give us some more information and sometimes we order those tests, as appropriate. Host: What treatments are available for lupus? Dr. Loupasakis: We have many medications that can modify the course of the disease, in addition to the corticosteroids, in addition to the cortisone, which we usually reserve only for patients that have very acute worsening of their disease activity. We have medications that patients can take by mouth, in tablet forms. We have some injectable medications. In fact, we have a medication that can be administered by the patient at home. And, we also have some infusions that can be taken through the IV, intravenously, at the infusion center. The combination of different medications, depending on the severity of the manifestations, can lead to cooling down the inflammation and preventing the affected organs from getting damaged. Host: How long does it take for those medications to take effect for a patient? Dr. Loupasakis: That’s a very good question. Oftentimes, these medications can take up to three months to kick in and that’s very important for our patients to understand because sometimes, our patients think that the medication is not working and they may end up stopping it, whereas the truth is that the medication might be, in fact, working but it just needs some more time to exert its effect. So, I would say from a few weeks up to three months for some of our medications. Host: During that time frame, where you’re waiting for the medications to really kick in for a patient, how can you tell that they’re beginning to work? Dr. Loupasakis: We always bring our patients back, especially when we have newly diagnosed them with possible lupus. We want to see them very frequently in the beginning and re-examine them and get blood and urine tests. We want to make sure that after the initiation of the new treatment, their labs and their symptoms are improving. So, even though I said that the maximum effect of some of our medications can be achieved in a period of weeks or months, it is important to note that we want to make sure that their patient’s labs or symptoms are at least improving during the course of that period of time. Host: In that probably very frustrating timeframe, how do you help patients remain positive and control their symptoms and their pain as they’re going through treatment? Dr. Loupasakis: We try to take care of the symptoms with other medications. If they’re in a lot of pain, we try to take care of the pain with pain killers. Depending on the manifestation that they have, we try to treat the symptoms while we’re waiting for the actual lupus medication to kick in. Emotionally and psychologically, we provide them with resources such as instructions of how to participate in a support group or referrals to psychiatry or psychotherapy because, oftentimes, patients might be depressed because the burden of the disease can be quite significant. I would say that I’m very optimistic with the majority of our patients and they do very well, if they stay in touch with us and take their medications consistently. It takes time for the improvement to happen so, during that period of time, it’s very important that we provide a good support to the patients and their families who suffer through this process. Host: What sort of outcomes can a patient with lupus expect once their treatment has kicked in to full effect? Dr. Loupasakis: That really depends on the severity of their disease. Lupus is a disease that has a very variable course. I would say that the majority of our patients have a very good outcome. They might have a minor disease, which usually affects the joints and the skin. And, usually with a regular follow-up, usually every three to six months, some blood and urine tests, taking their medications as instructed, they can have a very good quality of life. They can be completely asymptomatic, they can be functional, and they can have a normal life, maybe with some brief periods of flares of more active disease, which, whenever they happen, we try to treat them promptly in order to get our patients back to their life. There is a minority of patients that they may suffer more severe complications. And, in these unfortunate cases, we really try to be aggressive early on and we really try to do the best we can to prevent them from having long-term damage. And I would say that, in a great majority of them, we succeed. Host: Could you share a success story from your patient population? Dr. Loupasakis: I will never forget that young lady in her 20s who had lupus for a very long time. She essentially grew up with lupus. And, her disease had been fairly controlled until the time when she was about to go to college. At that time, her lupus became very, very active. She was admitted to the hospital. And, she had inflammation in multiple organs, including her joints, her skin, her brain. She wasn’t even able to recognize me at the time. That was really shocking to me. I had never seen her like that before. And, I recognized that this was a part of the disease, that this was her lupus that was really acting up. Very promptly, our team did the work-up the way we were supposed to do - the blood and urine tests, the imaging studies. We figured out what was going on, and we treated her very aggressively early on with the medications that we usually use in these cases. And, within 24 to 48 hours, she really improved, and she was able to recognize me. And, of course, her recovery took longer, took weeks to months for her to go back to her baseline. But, we were able to bring her back to her normal life and, with regular follow-ups and with the right medications, she was able to become functional again. She went back to college. And, now she’s enjoying her life with her peers. Host: Why is MedStar Washington Hospital Center the best place to seek care for lupus? Dr. Loupasakis: We have the largest group of patients with lupus, so we have had a great experience treating patients with this disease. And, we follow a very multidisciplinary approach. We work closely with other subspecialties such as the kidney doctors, the neurologists, the heart specialists. And, this is very important for a disease such as lupus because it is a condition that can affect many different parts of the body. So, working closely with all of these different subspecialties can really make a difference in patient’s outcome. And, we refer these patients to our colleagues, whom we stay in touch with during the course of a flare but also during the course of the follow-up with our patients. Host: Thanks for joining us today, Dr. Loupasakis. Dr. Loupasakis: It was my pleasure. Thank you for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Many adults are caregivers for elderly relatives.  Dr. Cesar Torres discusses common problems these caregivers face and his best tips to keep elderly loved ones safe.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Cesar Torres, a geriatric and house-call doctor at MedStar Washington Hospital Center. Thank you for joining us, Dr. Torres. Dr. Torres: My pleasure. Host: Today we’re discussing advice for adults caring for older relatives. Dr. Torres, in terms of safety, what are some of the key areas of concern that caregivers often worry about? Dr. Torres: I think the number one area would be falling. Falls can lead to very life altering fractures, specifically fractures of the hip. And, study after study has shown that a hip fracture will have significant effect on mortality rates. Your odds of dying within the first year of a hip fracture are, unfortunately, quite high. Falls, household accidents - the ability to communicate with loved ones in case of a household accident is something that a lot of caregivers worry about. But if I had to rank it, I would put the risk of a fall as the number one thing that really keeps up everybody at night. Host: Is this concern just for seniors with medical conditions such as dementia or heart disease? Dr. Torres: No. All seniors are at risk for it. There are a lot of different reasons for this. There are sensory inputs into increasing the fall risk, such as loss of vision or impaired vision. There’s a loss of proprioception - by that I mean balance. There’s a loss of muscle strengths, so the elder will literally not be able to lift their feet high enough to clear very simple obstacles in their path and so they end up falling or tripping. There’s also the problem with improper medication or over-medication, which we, unfortunately, as physicians, sometimes contribute to and then we have to be mindful of, to try to avoid and mitigate the risk.   Host: What would be the risks involved with over-medication? Dr. Torres: Well, some medications, and there are over-the-counter medications also that are guilty of this, predispose elderly patients to sedation, dizziness, and these increase the fall risk. By that, medications like over-the-counter sleep aids, Benadryl, antihistamines - they can impair the elderly patient’s ability to manage their household environment. Host: What can seniors and their caregivers do to reduce the risk of falls at home? Dr. Torres: I think the biggest thing I see, in doing house calls, is reducing the amount of clutter in the house - throw rugs, items just left on the floor. All of these are potential obstacles and they can lead to a very bad fall that can result in a fracture. Lighting - improving the lighting for seniors is also a great help. Making sure that they’re wearing their glasses. Some folks really do not like wearing glasses. Having handrails. Trying to minimize the need for an elder to go up and down stairs - moving them onto a single floor may also prevent a fall. Host: They seem like really common sense type things that anybody should follow. Dr. Torres: But, they get overlooked because they are so common. Sometimes you need that person who comes in to your home and is taking care of your mother or father and she has to point it out and that little bit of added emphasis leads to a change. Host: How do the geriatrics and house-call experts at MedStar Washington Hospital Center help patients and families care for their aging loved ones at home? Dr. Torres: Well, since we travel to the home, we have a good sense of what are the environmental obstacles in the home. As part of our program, we’ll do environmental assessment and we’ll make specific recommendations, making sure that all the sensory inputs are optimized for the senior also go a long way. And we can make referrals to eye doctors, ophthalmologists, otolaryngologists, and they can help with making sure the senior’s sight and hearing are improved to the maximal point that they can. Host: Are there any additional general tips that you would give to families who are caring for aging loved ones at home? Dr. Torres: I would foster open communication as to what your loved one needs help with, okay? Don’t just assume that they’re doing OK because they’re not calling you for help. A lot of times what we see is that the elder will do everything they can NOT to bother their family members. And, the more open the communication, the more likely you are to know when there is a problem. And I think that goes a long way. Another safety issue that seniors and their families face is the issue of driving. The ability to drive does change with age, but just because a person is of a certain age, that does not necessarily mean that they can’t drive. But the issue is one that needs to be explored as the person ages. Don’t just assume because the person just renews their license automatically that they can actually drive. There are laws - they vary from state to state - that can help but the family should periodically check in. Reaction time diminishes as the person ages. There are the visual changes. There are the hearing changes. There can be significant osteoarthritis of the cervical spine that prevents the elder from turning their head. Driving safety is something that really needs to be a top priority - not just for the patient themselves but for the society at large. The District of Columbia, fortunately after a certain age, there are requirements that the driver undergo vision testing as well as getting the authorization to drive from their primary care physician. So, that’s something I am in favor of. Host: What are some of the more common conditions you’re seeing in these older adults as you’re going out on house calls? Dr. Torres: Chronic pain from degenerative joint disease such as arthritis. Hypertension. Diabetes. Obesity. Mood disorders. Sleep apnea. Chronic kidney disease. Heart attack and stroke. Host: So, when you’re making your house calls and seeing your aging parents, are you seeing issues with medication adherence? Dr. Torres: Unfortunately, we can. We try to reduce that as much as possible by physically, visually looking at each one of their pill bottles. And, that’s something that, I’m happy to say, that’s becoming much more of a common practice. When the elderly patient comes in to see their primary care physician, they should be instructed to bring all their medicines in their favorite paper bag. We call it the brown bag. The major problem with adherence is the difficulty with remembering complicated medication regimens. Medications that have to be taken three times a day, generally, are extremely difficult. So, yes, adherence is an issue. The more that the physician can simplify the regimen, the better the outcome will be. Some of the tips I can offer: pill boxes can be a help. Any form of reminder, be it visual or even auditory - I mean, there are lots of apps out there that can be programmed to give reminders to take medications. But generally, just being aware that the loved one is on some type of medication regimen. Generally, that’ll spin off into the appropriate technique to make sure that they are getting their medications. Host: Could you share the story of a family that maybe had a particularly stressful time at home that you were able to help through your program? Dr. Torres: A patient who was living by herself. The apartment was less than optimal. She had no handicap accommodations. And, I basically, through a series of letters, we were able to help her move into a handicap accessible apartment with more than reasonable accommodations. And, she had been experiencing some mild depression that was starting to impact her adherence to the medication regimens. But that improved dramatically once she was able to move and that was just on the basis of the move itself, into a much safer environment, a much more friendly environment. Host: Thanks for joining us today, Dr. Torres. Dr. Torres: My pleasure. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Adult circumcisions are common in the Mid-Atlantic for men who never received a circumcision as a baby boy. The reasoning? Some men feel self-conscious about the way they look, while others develop skin conditions. Dr. Krishnan Venkatesan discusses the procedure and what men can expect during recovery.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re speaking with Dr. Krishnan Venkatesan, Director of Urologic Reconstruction at MedStar Washington Hospital Center. Welcome, Dr. Venkatesan. Dr. Krishnan Venkatesan: Hi. Thank you for having me. Host: Today we’re discussing adult circumcision, a reconstructive procedure that, while not widely discussed, is growing in popularity among men in the Mid-Atlantic region. Dr. Venkatesan, could you start by explaining what circumcision is for listeners who might not know? Dr. Venkatesan: Of course. Circumcision is basically removal of excess foreskin from the shaft of the penis. It can be done for many different reasons, which I think we’ll delve into later in this conversation. Host: So, in the U.S., circumcision is typically performed on baby boys, so why are more men requesting the procedure, as adults, when they’ve been uncircumcised all their lives? Dr. Venkatesan: There could be many reasons to undergo circumcision as an adult. Sometimes there are specific medical conditions. One is called phimosis, where the foreskin is actually tight and can trap urine underneath the skin and cause inflammation or infection of the head of the penis or the skin or even in the urinary tract. Sometimes, if they have warts or genital warts, men may want circumcision to have those removed. There are also other skin conditions. Lichen sclerosus is an immune mediated skin condition. We actually don’t know exactly what causes it, but basically, it can cause some scarring of the foreskin so the skin gets very tight around the shaft of the penis and onto the head of the penis and some patients may even feel that the head of the penis itself, the skin has lost its elasticity and instead of having a lot of small folds, it’s very flat and shiny, and some patients even will experience itching of the head of the penis, especially after sex, or even some fissures, like cracks in the skin, that can get very irritated after sex or even if the area is manipulated too much. In about twenty percent of those patients, they can also involve the opening of the penis where men urinate from and this can have other implications along the urinary tract, as well. All in all, circumcision is popular here in the U.S. and it’s not practiced that widely in the rest of the world. So, there are otherwise some social reasons that men tend to request circumcision, mainly because they’re self-conscious about being in a locker room or in a team shower or something, if they play sports, where some men may be circumcised, and some are not and they don’t really want to stick out. Host: Do you ever have men come in who are concerned what their partners might think or their sexual partners might think? Could you address that? Dr. Venkatesan: Yeah, absolutely. And that kind of goes along that social line that because, overwhelmingly, large number of men are circumcised in the U.S., men may worry that female partners may find it unusual or abnormal and because of that, they may feel more self-conscious about it. And they may also find that it’s less pleasing in intercourse or, in some cases, they may find that it’s uncomfortable for intercourse because the skin is getting irritated or something. Host: If a man grows up this way his whole life, he’s uncircumcised his whole life, if he chooses to remain uncircumcised, are there any health implications to be concerned about there? Dr. Venkatesan: No. There is evidence that suggests that circumcision at a young age, before puberty, can have some protective effect as far as decreasing the risk of penile cancer. But, in adult men who have already undergone puberty, there’s no significant benefit to circumcision at that point. The cancer of the penis is very rare, regardless, so as long as they maintain good hygiene and examine themselves reasonably frequently, then they should be able to avoid any serious problems from something like cancer of the penis. I would also like to say that, in other parts of the world, not the U.S., that circumcision sometimes is used as a means of HIV prevention or prevention of transmitting any other sexually transmitted diseases. That has been shown to have a benefit in places where HIV is endemic, like in Africa, but from a medical standpoint, otherwise, there’s no reason that it has to be done in childhood. Host: Approximately how many adult circumcisions are performed at MedStar Washington Hospital Center each year? Dr. Venkatesan: I’d say we probably do somewhere between fifty and a hundred a year, between myself and all of my colleagues. Like I said, there’s a wide number of reasons that we do them. Some are more for social reasons and others are for specific medical problems. Host: Could you describe your patient population for adult circumcision? Are these men young adults, middle-aged, teenagers? Dr. Venkatesan: Yeah. There’s a wide range of men who come in seeking circumcision. Quite often, there are young men in their late teens or early twenties who were not circumcised as children but, as they are moving out of home or becoming sexually active and exploring that realm, so to speak, they recognize that they’re different from their friends or colleagues and they want to have less inhibitions or less to be self-conscious about it, and they come in seeking it. And, similarly, there are men with medical conditions that can occur at any age, including tightness of the foreskin, or other skin conditions like lichen sclerosus, that need circumcision for actual medical treatment. And there’s no specific age range where it’s right or wrong for them to come in to seek that treatment. Host: What questions do patients or their partners ask about adult circumcision? Dr. Venkatesan: The main question they ask, of course, is whether it will be painful. And, like any surgery, there will be some discomfort initially, but typically the healing period is relatively short and within a month after surgery most men are back in normal function and form. I think the main other questions are whether it will cause any effect on sexual function or urination. And, typically, it shouldn’t have any effect of either of those things. Host: What are some of the risks that are involved with adult circumcision? Dr. Venkatesan: The risks involved with circumcision include general risks of any surgery, like infection and bleeding, and then, of course, risks associated with the specific area we’re operating on. So, there’s always a risk of needing further surgery if the patient is not happy with the cosmetic outcome. And also, risks of the stitches coming apart or having some scarring requiring further surgery. There’s a pretty low chance of any deeper structures in the penis being affected, like the urinary tract, or any nerves that would provide some function for sexual function or anything like that or sensation. Of course, there are risks with any anesthesia, as well. Host: What does a patient have to do to prepare for this procedure? Dr. Venkatesan: I would think that the main preparation really ought to be consulting with their urologist beforehand and understanding the risks of the procedure, the indications for the procedure, and the expected recovery. But other than that, there’s nothing they need to do at home as far as physical preparation or diet or anything like that. Host: Could you describe how the procedure’s performed? Dr. Venkatesan: Yeah, absolutely. We basically make two parallel incisions around the circumference of the penis - one upstream from the skin we want to remove and one downstream from the skin we want to remove. And, then we basically unwrap that part of the skin off of the shaft of the penis. And, then the two edges that are remaining, we sew them back together. Host: What does recovery entail? For example, are there restrictions for having sex, using the bathroom, or exercising? Dr. Venkatesan: The recovery usually does entail some activity restrictions. We don’t typically leave a catheter or anything like that, so the patient should be able to urinate on their own immediately after surgery and use the restroom, otherwise, without difficulty. I do typically ask my patients to refrain from any sexual activities for about four weeks while the stitches and the incision are healing up. And similarly, for that first couple of weeks, I’d like them to avoid any heavy exercise mainly to avoid any sweating or strain or stress on the incision that might affect it’s healing. We typically do send patients home with some pain medication and some antibiotics. The expectation, for the most part, is that patients generally will not need any narcotic pain medication beyond one week after surgery. By that point, they’re usually up and around doing most of their normal activities, aside from the other activity restrictions that I had described. And, usually by that point, aside from specific, unique jobs that may require further activity restrictions, most patients will usually be able to go back to work within that one week. Host: Could you share a story from your practice? Perhaps you had a man come in requesting this procedure and was incredibly happy with the results? Dr. Venkatesan: Yeah. I can recall specifically one man who was in his 50s and diabetic and, as I had described earlier, he had a very tight foreskin so he was getting frequent infections with urine getting trapped between the skin and the head of the penis. And, once we did a circumcision, he was basically infection-free and symptom-free and he was able to maintain much better hygiene there and, overall, was quite happy with the results within a month after surgery. Host: Like anybody, men would have a specific hygiene regimen prior to being circumcised. Is there anything in that regimen that would have to change or that they would do differently after they were circumcised? Dr. Venkatesan: No. So, I suspect and expect that hygiene maintenance after circumcision should actually be easier than before circumcision basically because, before circumcision, men would have to pull back the foreskin and really ensure that every crevice and fold of skin is properly cleaned and scrubbed. After circumcision, there’s no excess skin, so the skin covering the shaft of the penis basically has a very smooth transition and should be very easy to clean. Everything’s that there, visible to the eye, can be cleaned easily and there’s... much easier not to miss anything. Host: Why is MedStar Washington Hospital Center uniquely positioned to take care of men who want to have circumcision as an adult? Dr. Venkatesan: I think we’re in a strong, unique position to take care of adult men requiring circumcision because we are a tertiary care referral center in our Dept. of Urology. We see patients with very complex problems including complicated skin conditions that require circumcision and reconstruction of the penile shaft and skin. And we see a wide range of men, even ranging to men with no significant problems but who have straightforward circumcisions. But, based on our skill set and the complexity of things that we do and the volume that we do, I think that we are positioned well to offer patients good preoperative counseling and good postoperative outcomes. Host: Thanks for joining us today, Dr. Venkatesan. Dr. Venkatesan: My pleasure. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Sleep apnea, or when patients temporarily stop breathing during sleep, can be cured with corrective jaw surgery. Dr. Ravi Agarwal explains how it works and what to expect during recovery.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re speaking with Dr. Ravi Agarwal, an oral and maxillofacial surgeon and the residency program director for the Department of Oral and Maxillofacial Surgery at MedStar Washington Hospital Center. Welcome, Dr. Agarwal. Dr. Ravi Agarwal: Thanks for having me here today. Host: Today we’re discussing corrective jaw surgery for obstructive sleep apnea and breathing issues. Dr. Agarwal, how is the jaw related to breathing conditions such as obstructive sleep apnea? Dr. Agarwal: Great question! Most people do not realize that the top jaw and the bottom jaw do more than just allow us to eat and chew. These bones also serve as attachments to a lot of muscles around the face and neck, which support both the tongue and the airway. For example, patients who have an obstructed upper jaw may also have a narrowed nose, making breathing through their nose more difficult. Or, patients with small lower jaws will have a smaller area for their tongue to sit in and have more tongue obstruction while they’re sleeping, leading to obstructive sleep apnea. Host: Could you describe your patient population for this type of corrective jaw surgery? Dr. Agarwal: There are two different populations that we see for corrective jaw surgery. The first population are those patients who have jaw deformities, like underbites, deep bites, jaw asymmetries, or usually working with an orthodontist for braces and ultimately would need jaw surgery to correct the alignment of their jaws. These patients often have issues like difficulty with chewing, breathing problems, speech problems, jaw pain, and even concerns about their appearance. All of these complaints we are able to adjust with corrective jaw surgery. As you can imagine, a significant portion of these patients are teenagers, young adults - but we are starting to see a lot of adults who wish to undergo the same procedures. The second population that we see are patients with obstructive sleep apnea or breathing issues related to sleeping. They have a diagnosis of sleep apnea and they acknowledge that they stop breathing at night and have a lot of associated problems with that, such as excessive daytime fatigue, sleepiness, unable to perform their jobs, have fallen asleep while driving. Most of these patients are working with a medical provider. They maybe have tried CPAP, the mask that they wear at nighttime to help them breath. But many of them find this problematic and look for a surgical solution. As I mentioned, the relationship of the jaws to the airway, corrective jaw surgery - those same procedures can be used to advance the jaws, which would help open up the airway. Host: When we’re thinking about these two different patient populations, how do you decide whether jaw surgery is appropriate for them? Dr. Agarwal: There’s a lot of factors that we look at when we evaluate a patient. Most often, if there’s an anatomic abnormality that we can detect, they may be a good candidate for jaw surgery. We determine that by 1) a clinical examination - looking at their mouth, looking at their teeth, looking at the shape of their face, the shapes of the bones. We also utilize x-rays, 3 dimensional x-rays, to look at the size of their airways, the dimensions of the airways, and the dimensions of their jaws. Based on their problems, and what we see clinically, we can discuss with the patient if they’re a candidate for corrective jaw surgery. Host: Could you describe how these types of surgeries are performed? Dr. Agarwal: Corrective jaw surgery is a surgery that’s done all from inside the mouth. A significant number of patients will probably be working with an orthodontist, so they may have braces - which we actually use during the surgery. What we do is we make incisions in the gums around the jaws, we access the bones, and we use specialized instruments to make cuts in the bone. Once these bones are split, we’re able to reposition them in a new predicted position using splints that we had made before the surgery. The bones are then stabilized with small plates and screws, which you won’t feel or know they’re there and we then use dissolvable stitches to close the gums. The surgery is done under general anesthesia in the operating room and most patients will have an overnight stay in the hospital. Host: Is there anything that patients have to do to prepare for surgery, perhaps the day of or getting any tests beforehand? Dr. Agarwal: In general, patients who are getting corrective jaw surgery are undergoing a preoperative medical clearance, very similar to other major surgeries that are happening. Preparation is different, depending on what the patient’s desires are. Someone who wants to straighten their teeth and straighten their bite with the corrective jaw surgery to help their breathing, may be in braces and have undergone orthodontics for one to two years prior to even having the surgery. When they’re in that situation, we work closely with the orthodontist to make sure everything is done correctly prior to taking them to the operating room for the surgery. Host: How long does recovery typically take and are there any restrictions for eating, talking or exercising afterward? Dr. Agarwal: The recovery for corrective jaw surgery starts immediately after surgery. Usually there’s an overnight stay in the hospital, where we’re monitoring them to make sure they’re recovering well. But once they get home, there are a few restrictions. Most patients will need about two weeks at home due to the amount of swelling they’ll have. During those two weeks, we ask that they do not do any heavy lifting or exercises. But they can do daily activities such as washing the dishes, cleaning, and housework. After two weeks, most patients can start doing light exercise. But generally, we wait to six weeks before they can perform full physical activities. In terms of their diet, obviously we’re doing a lot of work inside the mouth and the bones of the jaws, and so patients will need to be on a full liquid diet for six weeks. Host: What about teenagers who are playing sports? How long do they have to sit out? Dr. Agarwal: For most sports we ask them to sit out for about six weeks. But, after two to three weeks, they definitely will be able to do light physical activities such as jogging and light weights. After six weeks they can return to full sports. The only caveat to that is patients or teenagers who play sports where facial injuries are common. In those situations, I may ask that they refrain from those sports for three months, because at that point the bones have really matured and there’s no further risk to them. Host: Are these patients sitting with their jaws wired shut? Dr. Agarwal: Nope. Patients jaws are not generally wired shut after this type of procedure. Using the techniques we utilize today and the plates and screws that we use, we’re able to not have to wire a patient’s jaw shut. Host: Obviously there are some things that you can’t control - so, the way your jaw is built, your anatomy. But for something like obstructive sleep apnea, is there anything that patients can do to reduce their risk for needing surgery or that they can do to improve their condition otherwise? Dr. Agarwal: You know, obstructive sleep apnea is definitely a multifactorial medical disease. A vast majority of patients, it may be related to weight, size - so exercise, weight loss would be some of the biggest things that could help reduce their chance of developing or having obstructive sleep apnea. There are non-surgical treatments for obstructive sleep apnea. The biggest one is CPAP. But for patients who don’t tolerate CPAP, there are options for oral appliances. These are devices that are generally made by dental or dental providers that would fit into their mouth and, essentially, shift their bottom jaw forward while they’re sleeping at night. By shifting the bottom jaw forward, it opens up the airway and reduces the obstructive sleep apnea. Host: Could you describe some of the benefits of this type of surgery? Dr. Agarwal: There are a lot of benefits to corrective jaw surgery. Obviously, getting the teeth and the jaws in a better position, patients are able to chew better, chew more efficiently, some of their speech problems may be improved. If they have concerns about pain, having the jaws in a better position can reduce their pain. And obviously, like we discussed, breathing. There are other nice results that come from jaw surgery such as an improved smile and an improved facial appearance. One of the things we keep in mind when we’re doing jaw surgeries - how to improve their facial harmony. So, patients often have more confidence about themselves and appreciate the way they appear. However, with all the benefits, there are side effects to every surgery that we perform. Outside of the recovery that we discussed earlier, one of the side effects of corrective jaw surgery is that patients may have some numbness of their lips, teeth and gums, as when we are working in these bones, the sensory nerves are in that region. After one year though, a vast majority of patients have no issues related to the numbness. Host: Could you share a treatment success story from your practice? Dr. Agarwal: As you can imagine, there are a lot of treatment successes when you do corrective jaw surgery to help someone breath. One that comes to my mind was a gentleman we took care of who came to his consultation with his family and his kids. And, the patient was trying to explain to me about how he struggled with sleeping and snoring. And then his young child just drops everything and says, “Daddy snores really loud!” And the dad just looks at me and says, “See? I really have a problem with sleeping.” And, you know, a few weeks after surgery, I see him for his post-op and I said, “How are those kids doing with the sleeping?” He says, “It’s peaceful in the house. Everybody’s so happy that I can breathe and I’m not snoring anymore.” And these are the things that really, really...why we enjoy doing this procedure because it really can be life changing, both from a functional standpoint but even from a family standpoint. Host: What are some of those other issues that you can help correct when you do these types of surgeries, either for the patient or their quality of life at home? Dr. Agarwal: In the teenage years, if there’s a jaw deformity, there are a lot of psychosocial components - that a patient may have trouble at school with their appearance or may have lack of self-confidence. And, corrective jaw surgery, I’ve seen, has changed the way a patient will present themselves afterwards. They’re excited, they have a lot more confidence, they’re doing better at school. As well as those who are concerned about being able to chew and chew efficiently and get a lot of jaw fatigue. By getting the teeth and jaws in a better alignment, those problems will go away. Host: Why is MedStar Washington Hospital Center the best place to receive corrective jaw surgery? Dr. Agarwal: Our hospital is one of the rare institutions in the region that have a dedicated oral and maxillofacial surgeon working. We are one of the busiest centers in the region when it comes to corrective jaw surgery. You will not find a center in the state of Virginia or Maryland that does more jaw surgery than we do. With that comes experience. We’ve seen a lot of different types of deformities, we’ve really advanced our skills in specializing in corrective jaw surgery. One of the technologies we use is taking 3D CT scans and performing virtual planning, working with a third party provider, for us to virtually plan your surgery before you’re in the operating room so that we can pick up on, ‘are there are going to be any issues and are we going to be happy with the outcome that we’re providing.’ The other reason to consider choosing our team is that we’re in a large hospital that has access to every specialty and we take care of some of the most complex patients in the region. So, having a team approach to all surgeries is really beneficial to outcomes. Host: Thanks for joining us today, Dr. Agarwal. Dr. Agarwal: Thank you for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Colorectal cancer is expected to affect about 146,000 Americans in 2019. Dr. Jennifer Ayscue discusses the advanced techniques we use to diagnose and treat this disease.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Jennifer Ayscue, section director of colorectal surgery at MedStar Washington Hospital Center. Thank you for joining us today, Dr. Asycue. Dr. Ayscue: Thank you so much for having me. Host: We’re discussing colorectal cancer and the minimally invasive techniques now used for the procedure. Dr. Asycue, could you start by discussing what colorectal cancer is? Dr. Ayscue: So, colorectal cancer is a cancer of the large bowel or large intestine, which includes the colon, whose job is mainly to absorb water, among other things, and the rectum, which holds stool until it’s ready to be expelled. Cancer occurs when the inner lining of the colon or rectum develops abnormal cells which have the ability to then invade through the bowel wall and even spread to other parts of the body, like the lungs or the liver. Host: Recent studies have suggested that colorectal cancer has increased in young adults. Could you explain why this is, plus other groups of people who are most susceptible? Dr. Ayscue: Yeah, we’ve been patting ourselves on the back because for a number of years we’ve been noticing that the rates of colorectal cancer have been decreasing and this is, we think, in large part due to widespread colorectal cancer screening. However, unfortunately, as we’ve taken a closer look, we’ve found that the number of cancers diagnosed in young people, even in their 20s or 30s or 40s, has actually been rising and now they actually have a higher risk of colorectal cancer, in some cases, than people over the age of 50. We’re not really sure the reason of this but it may have something to do with increasing rates of obesity, sedentary lifestyle, drinking more alcohol - especially in men, smoking, eating processed food or red meats, and all of these really increase our risk for getting colorectal cancer. Or it could just be some other environmental factor that we have yet to figure out. Host: Are there symptoms people can experience with colorectal cancer? Dr. Ayscue: The most common signs or symptoms that I see are people who have rectal bleeding or urgency, meaning they need to get to the bathroom quickly but even after they use the restroom, they still feel this urgency. They may also have some mucous, maybe even mixed with the blood that we talked about before. They may have a persistent change in their bowel habits, which usually lasts for more than a few days or weeks. They may have abdominal pain or rectal pain. So, these are pretty non-specific and don’t always result in a diagnosis of colorectal cancer but should raise suspicion. Host: In what ways do you typically diagnose colorectal cancer? Dr. Ayscue: So, we offer many options. And some of the less invasive options for colorectal cancer screening include tests that may just test for blood in our home tests. Unfortunately, these do require some dietary restrictions and multiple stool samples, but it’s a cheap test and it’s only performed on a yearly basis. The ability for that to detect polyps and some cancers using that method are just limited. Another more sensitive test is called the fecal immunochemical test, or the FIT test, as it’s more widely known. This test tests for blood products as well, but it’s more sensitive and detects blood that definitely comes from the rectum and colon. It’s not great for smaller polyps but it’s a little more expensive than the guaiac test but not overly expensive so that it’s able to be used by a pretty large population. It’s offered for free, actually, through our community program for patients who qualify in certain wards in DC. And it’s usually covered by insurance for those who do have insurance. The last fecal test is fecal DNA test which may also test for blood but like the FIT test, and it’s very good, but it also tests for the fecal DNA which makes it more sensitive and is able to find over 90% of colorectal cancer and more polyps than the FIT test can. It’s only required every 3 years instead of yearly like the other two. However, it is more expensive and can be a limitation if someone is uninsured or if the insurance doesn’t cover it. Another option is to perform a CT colonography or what’s known as a virtual colonoscopy. This is recommended every 5 years and up to 94% of larger polyps and cancers can be found with this. But it generally requires a bowel prep, similar to colonoscopy, and no biopsy can be formed at the same time. Also, other findings on CT may prompt further workup on those findings - sometimes, unnecessarily. So, I should also mention that if any of these minimally invasive tests are positive, then that person has to proceed on to colonoscopy, where the colon can be evaluated and either lesions biopsied or even removed, if anything’s found. Unfortunately, sometimes these tests can be positive and then no lesion is found on colonoscopy, and this is pretty stressful and frustrating for the patient. Host: Could you discuss some of the minimally invasive techniques your team uses to treat colorectal cancer? Dr. Ayscue: We offer a range of colorectal cancer treatments that are minimally invasive, but probably the most common would be the laparoscopic route. And, that would be when a colon cancer or a rectal cancer has to be removed. This is usually in conjunction with, sometimes, radiation or chemotherapy. So then, we can remove it either laparoscopically where we place instruments through very small incisions into the abdomen and then remove the colon through a relatively small incision as well. We can also use robotic techniques where the small incisions are also used but these instruments are connected to robotic arms which are controlled by the surgeon who is in the room at the same time but also allows us to have more fine control of the instruments and get in to spaces that we might not otherwise be able to get in to so that we can remove cancers more efficiently and with less post-operative pain and sometimes better outcomes overall. Host: Can you discuss the importance of why getting screened early can help your treatment? Dr. Ayscue: So, the newer recommendations are actually to get screened at 45, whereas it used to be 50 years old, because of patients having a higher risk of colorectal cancer in younger ages. If we’re able to get to people early and get them screened, meaning that they don’t really have any symptoms of colorectal cancer and we’re just looking to see if they have anything like a polyp or an early cancer, then we think by treating the polyp and removing the polyp that we can help prevent that polyp from becoming a cancer, which will hopefully decrease the risk of them ever getting a cancer. If we do find a cancer and it’s in an early stage, it’s much more curable. Host: What does recovery typically consist of after surgery? Dr. Ayscue: Well, most patients are in the hospital for anywhere from 1 to 4 days after surgery and most patients are treated with a very specialized program to help avoid narcotic usage and uses a lot of non-narcotic medications. And, with the combination of the minimally invasive surgery and this protocol, we’re able to get patients on their feet very quickly, eating diets within a day of surgery and home, usually, within the 1-4 days with minimal pain medications when they go home. Host: How do the minimally invasive treatment and diagnostic techniques today compared to techniques used 10, 20, 30 years ago? Dr. Ayscue: Well, the diagnostic techniques are getting better and better with each year and are able to diagnose now smaller lesions at earlier stages than they have in the past. And I suspect that they’ll become the primary tests of the future with colonoscopy reserved only for positive results in all patients, even high-risk patients. As for the treatment techniques, some of these didn’t even exist or were in the very early research stages 30 years ago, and have become better and better each year and...I suspect that laparoscopic and robotic techniques will merge and we will basically have robotic techniques that allow us to do almost anything in the abdomen without the need for an open incision. Host: Could you share a story of a patient who had a successful outcome with minimally invasive surgery at MedStar Washington Hospital Center? Dr. Ayscue: I had a mid-50s female who hadn’t been screened yet and she decided to get a FIT test and it came back positive. She saw me, and we did a colonoscopy at that time. And, I found a large polyp which I couldn’t remove using the colonoscope and I found several other polyps that actually could be removed. She then needed to have a robotic-assisted colon and rectal resection. And, I’m happy to say her pathology revealed a benign polyp which had some pre-cancerous cells. She was cured by that surgery and will just get regular surveillance to avoid needing any surgery in the future. But, if she’d waited another year or two, she might have had a cancer that would have required more treatment. So, we were very happy with this outcome. Host: Why is MedStar Washington Hospital Center the best place to seek care for colorectal cancer? Dr. Ayscue: So, our hospital has a significant focus on colorectal cancer, and this starts with the robust screening program that we have, with a nurse navigator who can help patients get the right screening for them and assist with any concerns. We also have a really strong team of gastroenterologists, surgeons, radiologists, and, if needed, cancer treatment doctors who are all very dedicated to the prevention and treatment of colorectal cancer. We definitely have the newest technology and we’re in the process of getting accreditation as one of the first hospitals in the nation for a multidisciplinary treatment of cancer. Host: Thanks for joining us today, Dr. Ayscue. Dr. Ayscue: Thank you for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

From 2017 to 2018, vaping increased by nearly 80 percent among high schoolers and 50 percent among middle schoolers. Dr. Jonathan Giurintano discusses the short-term effects vaping can have on dental health and the lungs.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Jonathan Giurintano, a head and neck cancer surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Giurintano. Dr. Giurintano: Thank you so much for having me. Host: Today we’re discussing how vaping affects oral health. Typically, when doctors talk about the effects of vaping, the concern is for patients’ lungs. Dr. Giurintano, what are some of the more common oral health side effects of vaping? Dr. Giurintano: So, of the more common health side effects, simple general irritation of the oral mucosa is probably the most common side effect that we see. However, there have been recently published studies that show that there are higher rates of colonization of the oral cavity mucosa with a fungal organism called Candida albicans in patients who vape or who use e-cigarettes regularly compared to patients who do not use vape devices. The importance of this fungal organism is that if there is an overgrowth of the fungal organism in the mouth, patients can experience what is called oral candidiasis or more commonly known as oral thrush. This can be an inflammatory and very uncomfortable situation to have when it is located on the tongue or on the inner cheeks and can require the use of an antifungal medication in order to resolve the infection. Host: What concerns you the most about vaping? Dr. Giurintano: The thing that concerns me the most about vaping or e-cigarette use is that many people see this as a healthy alternative to smoking cigarettes. Among a lot of vape users a common phrase that you’ll hear is, “Oh, it’s just water vapor. It’s safe” which we’re finding to be untrue. There was a big article that was published on CNN as the FDA released the results of an initial study showing that, just over the past year, that the use of vaping among high schoolers has increased nearly 80 percent and among middle schoolers, the use of vaping has increased almost 50 percent. One in five high schoolers has vaped and this is just a really, really shocking number. The reason this is so concerning to head and neck cancer surgeons, such as myself, is that we know that most patients who vape do not only limit their use of nicotine products to vaping itself. Many of these patients often go on to use traditional tobacco cigarettes or other tobacco products in order to fulfill the desire for nicotine, which is the addictive substance that’s often present in the vape liquid. And, any potential benefit that one might have seen from vaping rather than smoking quickly disappears whenever you’re both vaping and smoking cigarettes in order to get the nicotine effect. Host: How do you address the health hazards of vaping with your patients? Dr. Giurintano: So, one of the things I like to do is I actually like to explain to the patient how a vape pen or an electronic cigarette works. So, located within that vape pen or that e-cigarette, there’s one or two lithium ion batteries that powers separate heating wires that are composed of a heavy metal that then evaporate a flavored liquid which most oftentimes contains nicotine. And, the carrier substance for this nicotine typically consists of the chemicals glycerin or propylene glycol. We know that these are not inherently dangerous substances themselves. However, whenever you are evaporating these substances such as nicotine, glycerin or propylene glycol, we do know that more harmful or possible carcinogenic side molecules can be released. One of the most concerning things about the vape usage is that the FDA only began to regulate the vape industry in 2016. And today, there’s over 7000 different types of flavorings which have been described in the liquids. The majority of these flavorings are used in the food industry. However, they were only truly developed for oral consumption, not for vaporization. So, the long-term effects of taking these substances that are typically meant for oral consumption and converting them into a vaporized form that’s then inhaled into the oral cavity and into the lungs, is largely unknown at this point. A few of these substances have been studied in the past and have been shown to cause severe inflammation of the bronchi and of the lungs. And, it is assumed that these chemicals that are irritating to the bronchi and the lungs, could also have an irritant effect to the mucosa of the upper aerodigestive tract as well. The American Head and Neck Society, so this is the society of head and neck cancer surgeons across the United States, recently issued a statement stating that ‘given the lack of clear scientific evidence regarding the safety and effectiveness of e-cigarettes for the sensation of, as well as the bystander risk of e-cigarette emission, the American Head and Neck Society does not endorse the use of, e-cigarettes as a safer alternative to traditional tobacco cigarettes.’ The H & S agreed that e-cigarette emissions are not simply harmless water vapor, as they are often promoted and advertised. And this organization further expressed the concern that e-cigarettes represent a viable potential for harm to both individual health and environmental pollution. We’re still in the process scientifically investigating these vape and e-cigarette devices to help provide a clearer understanding of what the risks and/or benefits are of using vape or e-cigarettes and the indications for or against their use.  Host: What are the long-term oral health implications for patients who vape? Dr. Giurintano: Well, we’re not 100 percent sure at this point what the 20- or 30-year health implications will be for patients who vape. We do know that there are substances within the vapor that’s inhaled that harbor carcinogenic potential. We know that studies have shown that these typically are in much lower quantities than the chemicals produced in traditional cigarette smoking. However, we have yet to see what the long-term effects of regular application of these chemicals to the lining of the upper air digestive tract might cause. The biggest thing we do know is that most e-cigarette or vape users do not exclusively use vape devices in order to obtain nicotine and that many of them will also smoke traditional cigarettes, as well. And for these patients, they are at risk for the typical long-term complications seen in most cigarette smokers, including periodontal disease and increased rates of cavity of the oral cancer, voice box, and lungs. Host: Thanks for joining us today, Dr. Giurintano. Dr. Giurintano: Thank you so much for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Ulcerative colitis affects nearly 700,000 Americans and causes symptoms ranging from diarrhea to arthritis to skin rash. Thankfully, medication options and surgery can significantly reduce symptoms and even bring about long-term remission for patients.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re speaking with Dr. Nidhi Malhotra, a gastroenterologist and Assistant Professor of Medicine at MedStar Washington Hospital Center. Today we’re discussing ulcerative colitis, which is an inflammatory bowel disease that causes long-lasting inflammation and ulcers, or sores, in the digestive tract. Welcome, Dr. Malhotra. Dr. Nidhi Malhotra: Thank you for having me. Host: Could you tell us what causes ulcerative colitis? Dr. Malhotra: So, ulcerative colitis is thought to be an auto-inflammatory condition in a genetically susceptible individual. Let me simplify that. So, someone with a genetic predisposition, meaning that they have genes that make them more susceptible to acquire this disease, and then there is an inciting event that triggers the inflammation. The inciting event could be an infection. It could additives or preservatives in our diet which have directly implicated in IBD. It could be chemicals. Or, it could be antibiotics. Or really, sometimes, a completely unrecognized reason as a triggering factor. But once triggered, the inflammation causes damage to the colon, and patients will start having symptoms. Host: What are some of the common symptoms of ulcerative colitis? Dr. Malhotra: So, I usually divide up the symptoms into GI and non-GI related symptoms, because the inflammation can actually affect really any part of your body. So, GI-wise, patients may present with abdominal pain, diarrhea, bloody diarrhea, nocturnal diarrhea - meaning they are waking up at night to have a bowel movement, tenesmus - meaning they have feelings of incomplete evacuation and have to keep going back to the bathroom constantly, and severe urgency. And then the non-GI symptoms may be related to inflammation of other body parts. They could have severe arthritis - which is inflammation of the joints. They could have uveitis or episcleritis - which is inflammation of the eye. They could have skin rashes. So, a whole slew of symptoms. Host: Can ulcerative colitis be serious or life threatening? Dr. Malhotra: Yes. So, let’s talk about short term. Untreated disease, first of all, is a huge burden on the patient. They can have debilitating symptoms and therefore, it’s not just a burden on their workforce where they are forced to miss work due to their symptoms but also, you know, people miss out on their social and family life. So there is the personal, social and financial impact. But then there’s untreated or complicated disease that can certainly become bad enough to require urgent or emergent surgery and hospitalization. So we always try to avoid a situation where an emergency surgery may be needed. Patients may need emergency surgery for refractory bleeding where their colon is bleeding so much that they may be exsanguinating. They can get a toxic megacolon where the colon swells up and does not function and can cause life threatening infection if not taken out emergently. So those are sort of the short term serious, life threatening implications. Long term, the risk of untreated ulcerative colitis is a huge risk of cancers. So, untreated disease puts patients at risk of colon cancer almost 8-fold compared to someone without ulcerative colitis. And non-colon related patients are at risk for developing something called PSC, which is primary sclerosing cholangitis. It’s inflammation and scarring of the bile ducts and it puts them at risk for a bile duct cancer called cholangiocarcinoma as well as gallbladder cancers. So really, long term and short term implications on their health. Host: Could you tell us a little bit about your patient population for ulcerative colitis? Dr. Malhotra: Sure, ulcerative colitis has a bimodal peak of incidence, so patients may present in their mid to late teens all the way up to early thirties. And then there’s a second peak with patients in their 50s to early 60s Host: So often ulcerative colitis begins gradually and then gets worse. How is it diagnosed? Dr. Malhotra: So actually, about a third of patients may present with mild disease and continue to have mild disease throughout the course of the disease. A third of patients may present with mild disease and at some point gradually or sometimes all of a sudden worsen to have severe disease. And about a third of patients may present with severe or even what we call fulminant disease, where they need emergent hospitalization, aggressive therapy and sometimes even surgery immediately. So, diagnosis is based upon endoscopy and biopsy. So, most patients will need a colonoscopy. Sometimes we just do a flexible sigmoidoscopy if the colon is really inflamed and not go the entire length of the colon. And it’s really important to make sure that the patients, at the time of diagnosis and really at any point when their disease is worsening, don’t have a concurrent infection with clostridium difficile, which is C. diff. C. diff is a bacteria that’s increasing in the community in general, but it’s present in patients with colitis in a significant more proportion than patients without colitis. And, the presence of C. diff makes ulcerative colitis more difficult to treat. It increases the risk of getting hospitalization and the risk of getting an urgent colectomy. Host: What medical treatments are available for ulcerative colitis? Dr. Malhotra: There actually many treatments available today. Mesalamine, which is a very old drug and we still use it in practice, is used for mild disease as first line therapy. Then there’s immunomodulators, such as Azathioprine or 6-mercaptopurine, which modulate, as their name suggests, modulate the immune system. So they decrease inflammation over time. We’re sort of steering away from those medications as first line as better and improved drugs are available on the market. And then there is biologics, which are medications that bring down inflammation and actually help heal the lining of the colon. And in reality, since the advent of these biologics, the face of colitis has changed. Less patients are getting surgery and more patients are achieving healing. The first biologic that was approved was infliximab. Now it’s been on the market for almost 18 years and it works very well in patients with colitis. And then there’s two other similar biologics - adalimumab and golimumab. There was another mechanism of drug that was approved in 2014 called vedolizumab which works completely different and, again, works really well in colitis. So, overall, we have a lot of medications. We are also anticipating approval of two new medications with different mechanism of action, hopefully this year - tofacitinib, which is a jak inhibitor and ustekinumab, which is actually approved in Crohn's disease and is hopefully going to be approved for ulcerative colitis as well. Host: Is surgery an option to cure ulcerative colitis? Dr. Malhotra: Yes. Removing the colon is actually curative of ulcerative colitis. We usually reserve a colectomy, a removing the colon, for patients who are not responding to our best medications or they’re extremely sick and their chances of responding to a medication is very low. But, I always tell my patients, getting surgery to remove colon is not failure of treatment - it’s just another modality of treatment. Surgery is done best when it’s planned. So, emergent surgery can sometimes be difficult as it can involve up to 3 procedures for the patient to complete the surgery and can even involve having a temporary ileostomy. But yes, in short, removing the colon is curative of ulcerative colitis. I do want the listeners to be aware that primary sclerosing cholangitis, which is inflammation of the bile ducts, can still happen or occur as a complication of ulcerative colitis, even years after their colon is taken out. So, even if they’ve had a colectomy, it’s important for them to follow up with their GI provider at least once a year to make sure that it’s not a complication they’re developing. Host: When you have patients who you recommend surgery - what is their emotional state, what is their mental state, when you recommend that they have their colon removed? Dr. Malhotra: You know, nobody wants to hear that they need emergency surgery or part of their organs removed. The good thing about the colon is we don’t really need the colon for any nutritional support. The colon’s there to absorb water. Now, that being said, of course we are finding  more and more that the microbiome, which is the life of bacteria, fungi and viruses that live in our colon, have a lot to do with our overall health. So maybe there are some long term implications of getting your colon taken out that we don’t recognize to date. However, studies have actually been done in patients who did undergo a colectomy for their colitis, and most of those patients, in retrospect, were relieved after the surgery as they got their life back. They lived a better, fuller life. And most of the patients did respond saying that they wish they had gotten the surgery earlier. Host: Could you share a story about a patient who had a poor prognosis and you were able to help them? Dr. Malhotra: I saw a young lady, in her late 20s, single mom, she’d been battling with ulcerative colitis for many years, and because of social issues had very fragmented care and had been on steroids for many years. As we know, we’re really deviating away from using steroids. Steroids have long lasting implications on a person’s body and health overall. I saw her when she was first admitted to the hospital. She was anemic, losing weight, having 20 bowel movements a day and just very depressed, understandably so, from her disease. We actually had our surgeons also see her because we were worried she may need a colectomy, but we initiated infliximab. She did extremely well with two treatments, was able to be discharged from the hospital, four months later, I just recently saw her in clinic. She’s doing great. She’s off of steroids and she actually has a part-time job and was just out of her depression and it just felt really good to see her getting her life back. Host: Are you conducting any research regarding ulcerative colitis that people in the community should know about? Dr. Malhotra: Yes. We’re currently partnered with Georgetown University Hospital to bring trials to Washington Hospital Center. We just completed enrolling for a trial for ustekinumab for ulcerative colitis, which we have completed enrollment at this time. We currently have a trial looking at the new drug filgotinib, both for ulcerative colitis and Crohn's disease. We’re also just about to start a trial looking at stem cell treatment for Crohn's disease with perianal involvement. And we’re also looking at novel ways to treat colitis that’s being caused by immunotherapy.  Immunotherapy-induced colitis appears very similar to ulcerative colitis and so we’re looking at novel ways to treat that colitis, as well. Host: Why is MedStar Washington Hospital Center the best place for patients to seek care for ulcerative colitis? Dr. Malhotra: For diseases such as ulcerative colitis, which fall under the umbrella of inflammatory bowel disease, these conditions require very specialized and patient-oriented and patient-centered approach. We have a team of highly trained gastroenterologists with advanced training in inflammatory bowel disease, as well as a group of highly trained colorectal surgeons. We work together in a multidisciplinary approach for these complicated patients. Host: Thanks for joining us today. Dr. Malhotra: Thank you. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Multiple ankle sprains can lead to chronic ankle pain for some patients. Dr. Ali Rahnama explains how minimally invasive surgery can help these patients avoid much larger procedures in the future.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Ali Rahnama, a foot and ankle surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Rahnama. Dr. Rahnama: Thank you for having me. Host: Today we’re discussing chronic ankle pain after a sprain and what could be going on inside the foot and ankle. Dr. Rahnama, many of us have experienced an ankle sprain. How many would you say you treat in a year? Dr. Rahnama: I would say it really depends on the time of year, especially as we get closer to the winter months. Sometimes I may see as many as 4 to 5 of these a week, sometimes even more. Host: Student athletes and leisure athletes are at risk of sprains. Are there other groups of people who are susceptible? Dr. Rahnama: While it’s true that typically we do see a lot of athletes with sprains because of the increased level of activity that they engage in on a day to day, we do see them in various patient populations and even non-athletes, particularly as we get closer in to the winter months. Slip and falls, especially in cities like Washington where people use a lot of mass transit and are walking outside on the sidewalk. We, a lot of times, see people slip on little patches of ice and things like that, and injure themselves and get sprains and even sometimes fractures. Host: How do you determine whether an ankle sprain is mild, moderate, or severe? Dr. Rahnama: I typically look at three things. I want to see how much tenderness there is, swelling, bruising, that kind of thing, the patient’s ability to bear weight or not be able to bear weight. Those are typically how I determine how bad the injury is. Host: How long should a patient expect to fully recover from a mild or moderate ankle sprain? Dr. Rahnama: Typically, a mild to moderate ankle sprain, I would expect to clear up in the ballpark of about 2 to 4 weeks, depending on how bad the injury is and exactly what part of the ankle they’ve injured. Typically, the lateral ankle ligaments are the ones that are affected more commonly. Those would be the ankle ligaments on the outside, as opposed to the inside ligaments. Host: How long should a patient expect to recover from a severe ankle sprain? Dr. Rahnama: Severe ankle sprains can take anywhere from up to 6 weeks to even up to 12 weeks to heal, depending on the injury. Host: Is there anything special that an individual would have to do when they’re taking care of a severe ankle sprain? Dr. Rahnama: Typically, with a severe ankle sprain, I would say it’s important for them to initially have a period of immobilization, rest, where they can ice it and elevate it and stay off it. And then, it’s really important for them to get with a physical therapy colleague of ours that I’ll very often send my patients to, who will work with them on proprioceptive exercises and strengthening exercises, to help get them to strengthen the tendons and muscles in and around the foot and ankle to help the patient avoid having a similar injury again in the future. Host: Of course, spraining an ankle is painful, but how long does the pain typically last before it’s considered “chronic?” Dr. Rahnama: The chronicity of the sprain isn’t just based on how long it takes for them to heal. It really has to do with how many spraining incidents they’ve had total. So, if I have a patient who comes to me for an acute sprain, meaning that they recently had one and so they’ve decided to present for care, or somebody sent them to me for evaluation, the first thing I want to make sure and ask them is that have they had similar incidences in the past that maybe they didn’t see somebody for and that maybe healed on their own and that now they’re noticing a pattern, where they had an initial sprain, sometimes even up to years ago, and as time has gone on, they, every so often depending on what they’re doing, particularly if they’re active, if they continue to have more and more of these incidences - and, so then, that’s when I start to think that it’s something chronic because there’s multiple episodes of it. Host: So, it’s just being more and more susceptible to sprains? Dr. Rahnama: Exactly right. Host: What’s the standard first-line treatment for a sprain? Dr. Rahnama: So, I would divide it into three things. One, I would say resting and protecting the ankle with a brace or boot, sometimes even a splint. And then second, I would follow that with resting range of motion, strength and stability exercises. And finally, maintenance exercises that would slowly get them back to more intense physical activity and for them to be able to engage in sports that would need sharp cutting, like tennis or basketball, for example.     Host: At what point do you typically recommend surgery for an individual with chronic sprains? Dr. Rahnama: Well, first I’d like to emphasize that, even as a foot and ankle surgeon, the vast majority of sprains are treated nonoperatively. Only in the setting where a patient has not healed for more than 6 or 8 to 12 weeks and they’ve oftentimes had multiple incidences of sprains, will I start to think of surgery for correction of it. The surgical procedure is actually quite simple for a straight-forward, isolated, chronic lateral ankle tear, or laxity. We make a small incision, and oftentimes we’ll try minimally invasive techniques where we can make small, few-millimeter stab incisions and enter the joint and evaluate for any type of synovitic or pre-arthritic tissue, debride that. Debridement is when we use a shaver and the guidance of the camera, once we’ve gotten into the joint, to essentially just clean up and take out any of that arthritic or inflammatory tissue that doesn’t belong into the joint. And then we can even do our lateral ankle repair through those same incisions so that we don’t have to make any large incisions and open the patient up. It’s fairly straight-forward surgery. So, they actually did studies where they split two groups of surgeons up who had never done minimally invasive surgery before. And, in the first group, they had the surgeons do video games. And then, they had the other group not do anything at all. And, then they trained all...both groups at the same time in minimally invasive surgery and arthroscopic or laparoscopic surgery. And the group that had had the video game training before the surgical training actually got it a lot faster and did much better. So, if you’ve got a kid at home who’s good with video games, he may be good with minimally invasive techniques someday. Host: When it comes to foot and ankle surgery, why is minimally invasive surgery a good approach?   Dr. Rahnama: Minimally invasive surgery is good for patients for a number of reasons. But, probably the most important things are many times patients undergoing minimally invasive surgery get back to doing what they want to do a lot sooner. There are much smaller incisions that need the body to heal them. And so, overall, they tend to have better outcomes, is what we found. Host: Have you ever had a patient come in thinking they had sprained their ankle, but it was actually something else? Dr. Rahnama: So, that’s a great question. We actually see this quite often where somebody will come in with the complaint of a sprain, or what they think to be a sprain, that’s not getting any better and it doesn’t really fit the description of what we would like to see for classifying it as chronic ankle sprainers. And, that’s really when we start to think about, ‘what else could this be, masking itself as an ankle sprain?’ Things like osteochondral defects of the talus, meaning an injury to the cartilaginous surface of one of the bones in the ankle, can cause pain, especially if there’s loose pieces of cartilage from that injury that are now in the joint. Those oftentimes can mask themselves with the same symptoms or similar symptoms as an ankle sprain. Also, tendon injuries can also mask themselves as sprains, where it may really be a tendon tear or even a rupture and the patient comes to us with an ankle sprain that’s just not healing. And so, those would definitely be a couple of things that we see fairly often that patients think are ankle sprains but they’re not. And, obviously, the last thing would be fractures, particularly if the patient was seen in an environment...because a lot of times, primary care offices don’t have X-ray available and so the patient is sent to us with a sprain. And, one of the first things that I’ll do, if the patient doesn’t already have one, is obtain an X-ray to make sure they don’t have any fractures anywhere. Host: What can people do to reduce the risk of ankle sprains? Dr. Rahnama: I would say it’s really important for people to keep in to consideration the type of shoes that they wear and particularly be mindful of the type of activity they’re trying to engage in. Runners, a lot of times here in the city particularly, it’s best for them to try to avoid, especially in the colder months, the wet months, avoid trying to go out for a run right after a snow or the rain. And, in the summer months, when we’re out on trails and things like that, really make sure you know the terrain that you are about to go out for a run in, for example, or embark on any type of physical activity, so that you don’t find yourself with any surprises. So, what I would say is that, particularly in the winter months, if you’re a runner, make sure you have the appropriate shoe gear. Make sure your laces are tied nice and snug. And, maybe avoid the day right after a snow storm. Make sure you know the environment that you’re going to be running in so that you can avoid little slicks of ice and the really wet, deep puddles. Those are really where we see the biggest problems or people will say, “I slipped on a patch of ice,” or “I went off the curb and it was just too wet, and I slipped and I sprained my ankle,” or sometimes even worse. And in the spring and the summer months trail runners - I know that’s very popular these days - familiarize yourself with the terrain that you are about to go on a nice run for. Make sure you understand where there might be a ditch or a hole that you might want to avoid. So, before we go full speed ahead it’s nice to pause and try to really familiarize yourself with our environment. Host: How do you recommend that patients prepare for foot or ankle surgery? Dr. Rahnama: I strongly believe an informed patient can help the surgeon help them by developing protocols that are specific for them and their needs. If they feel they don’t have the upper body strength, for example, to stay on crutches and remain non-weight-bearing, they should share that with their doctor -  and so that we can work with our physical therapy colleagues to help them gain the upper body strength, for example, to then get them ready for lower extremity surgery so that they can stay off of it. It’s not just about doing our portion of the procedure and then having patients go out and be on their own. We want to avoid that as much as possible. So, certainly in my exam, I try to assess the patient’s whole body to make sure that they have that ability, if they’re overweight, or have other things that impede them to remain non-weight-bearing, I definitely try to address that. But, we definitely want to encourage our patients to be forthcoming with any reservations or any concerns that they might have so that they can help us help them. Host: What does recovery after surgery entail? Dr. Rahnama: Typically, a period of non-weight-bearing for 2 to 3 weeks. And I will say that these protocols vary sometimes between surgeons. But there is research now that shows that the quality of new collagen that your body puts down when repairing ligaments depends on the stress being put on them. This is very similar to what we’ve known for a very long time about bone healing and bone turnover in your body. The stress of gravity and the stress of weight bearing actually helps your body heal it the way that it should be healed. And so, after a short period of non-weight-bearing, and making sure that our incisions are healed, I get my patients to therapy as soon as I can right after that to make sure that they engage them with a week to two of fairly aggressive, non-weight-bearing exercises. And then, in under a month typically, I will try to get my patients weight bearing again, again with the help of our physical therapy colleagues, to get them back on their feet and to make sure they have the best outcomes possible. Host: What are some of those exercises that your patients are participating in during that initial couple of weeks and then the following month? Dr. Rahnama: So, a lot of them might be resistance exercises, proprioceptive exercises, exercises that really strengthen the muscles, the tissues around the foot and the ankle and to really be able to support the repair that we’ve done. So, collagen are the little building blocks of ligaments and connective tissues in our body. And so, anytime you have an injury to the soft tissues and ligaments included in that, collagen is what your body uses to help repair things. Host: Could you tell us about a patient who had foot or ankle surgery after a bad sprain and was able to return to an active lifestyle? Dr. Rahnama: I had a college athlete in her twenties last year who had been spraining since she could remember and now it was getting to the point that, even with the best wrapping by her trainers, she couldn’t do what she wanted to do. So, she came and saw us. Obviously, being an athlete, she had some great trainers and therapists trying to rehab her with no good results. So, we proceeded to surgically fix the ankle ligaments, utilizing a minimally invasive technique and arthroscopy, where we make small incisions, just millimeters wide, and place a small camera into the joint and use that to help guide our repair. Surgery went as planned and we proceeded to use her training team again to help us get her back. And, she was back training in under two months, without restrictions. Now, she’s an extreme case of very aggressive rehab, but the point is that it can be done and there’s no reason to think that even the most physically demanding athletes can’t get back on their feet and get back to doing what they love. Host: I know a lot of folks can be kind of stubborn when it comes to thinking about surgery. What are some of the reasons that you would give patients if they’re hesitant to come have surgery because they don’t want to take time off their activities? Dr. Rahnama: That’s a great question. The one thing that I would emphasize is that a small problem, if not addressed by the right specialist, can a lot of times turn in to a much larger problem down the road that the patient then can’t avoid having taken care of. If a patient doesn’t see somebody for a chronic ankle sprain and thinks that this is something that they don’t want to have addressed, the reality is if they DO have it addressed and they have a small procedure now, that may help them avoid a much larger procedure, such as the need for a total joint replacement or joint fusion even, later on in the future as they get older. Host: Why should someone with chronic ankle pain or a bad sprain speak to a surgeon at MedStar Washington Hospital Center? Dr. Rahnama: We’re here to help and make sure our patients and individuals suffering from foot and ankle conditions can get back to life and do the things they love and be active. And so, that’s what we do every day, and we just want to make sure the local public knows we’re here, and if they need us, we’re happy to help. Host: Thanks for joining us today, Dr. Rahnama. Dr. Rahnama: Thank you so much for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

One way to protect your heart is to choose the right diet. Discover why Dr. Allen J. Taylor believes the Mediterranean Diet—which relies on foods such as fruits, vegetables and white meat—is the best for preventing heart disease.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re speaking with Dr. Allen J. Taylor, Chair of Cardiology at MedStar Heart and Vascular Institute. Welcome, Dr. Taylor. Dr. Allen J. Taylor: Thank you. Host: Today we’re discussing diet choices for heart health, specifically the Mediterranean Diet. With so many ideas online and from well-meaning friends and family, it can be tough to make the best food and beverage choices for on-going heart health. Dr. Taylor, patients hear the recommendation to eat a healthy diet all the time. What does that really mean? Dr. Taylor: Yeah, everyone’s an expert on their own diet, aren’t they? We’ve long known that (quote) “healthy diets” - and those are typically defined, from a heart perspective, as diets that are low in fat, high in fruits and vegetables - tend to be seen more frequently in patients who don’t suffer from heart disease. On the converse, people that eat poor diets are more likely to have heart disease. And that is true. The question is, where is diet science going? And in 2018, what’s the best diet to prevent heart disease? And that’s where there’ve been changes. Host: What questions do your patients often ask about how their diets relate to their heart health? Dr. Taylor: When you talk to patients about diet, there’s usually two things. The first is controlling body weight. And then the second is about controlling specific health problems, such as their blood pressure or their diabetes or their cholesterol. And as you tailor diets to different patients, it often has to be highly customized to the health problems that they have. But overall, it’s about reducing heart risk. And, it can get very confusing to think, “Oh, I have to avoid salt and I have to avoid fat and I can’t eat sugar because of my diabetes.” And the question is, “What can I eat?” And patients get confused. And they get so confused, they can’t make good food choices and they give up. And they eat things which aren’t good for their health. So, how do you bring it all together? There’s so many diets - there’s fad diets, the keto diets, the low carb diets, Atkins diets, South Beach - it’s all over the place these days. And today...tomorrow there’ll be another one. The optimal diet from a heart perspective is one, if you were going to design it, is one that makes good metabolic sense and has been tested. Tested and proven to reduce heart disease risk. Now, when it comes to weight loss, that’s a simple thing. It’s about calorie balance. It’s calories in and calories out. One reason people gain weight as they age is because, they don’t realize it, with every decade they age their daily calorie requirements go down about a hundred kilocalories. Now, the average 20-year-old can probably eat 2,000 or 2,200 calories a day. The average 60-year-old has to eat 400 calories less a day just to stay in balance, 1,700 or 1,800 calories. If you’re eating like you did when you were 20 or 22, you’re gaining weight. So, calorie balance is the most important thing from a weight perspective. But then it’s about what goes in to those calories; what’s making up those calories - how much is fat, how much is sugar, how much is protein? It’s hard to eat like that. It’s hard to eat...how much protein am I going to eat today? How much sugar should I eat today? And, some people can do that. What I try to do with my patients is to make it as simple as possible and to use the best evidence-based diet as possible because we’re trying to reduce the risk for heart disease. And today, that diet is the Mediterranean Diet.   Host: What about the Mediterranean Diet makes it so heart healthy and so, quote/unquote, “easy to follow?” Dr. Taylor: Well, the first thing about a Mediterranean Diet, and it’s just simply a name for it, but it’s really a style of eating, it’s food choices. And, it has been rigorously studied, both in people with known heart disease and without known heart disease. Very important study, published about five years ago now, was a study called the PREDIMED study. And, it was a study of about 7,500 individuals who were either asked to eat a Mediterranean Diet or an otherwise really high-quality American diet. The American diet was things like using low fat dairy products, saying that things like pasta and rice were ok, and fruits and vegetables are encouraged, and lean fish and seafood are also okay. That sounds pretty good, doesn’t it? It’s pretty much what a lot of us eat. What was interesting is that the Mediterranean Diet is different than that. It’s a diet that’s, again, rich in fruits and vegetables but includes fish. It includes beans. White meats, such as chicken. Wine is okay with meals and that’s often a good selling point for the diet. And then it can include nuts and supplementation with olive oil - olive oil to cook or even olive oil to simply add to your food, like put it on top of salads. When those two diets - this really good quality American diet and the Mediterranean Diet - were compared, Mediterranean Diet won, hands down. There was nearly a 20 percent lower risk for heart events in people who ate the Mediterranean Diet. There was a 30 percent reduction in heart disease risk in the patients that ate the Mediterranean Diet. So, that’s a large reduction - 30 percent risk - that’s the same risk reduction seen with taking cholesterol pills, for example. So, very impactful. The thing about the Mediterranean Diet that I like in particular - while those are the things you should eat, and again, to repeat them, fresh fruits and vegetables, fish, white meat, beans, nuts are okay, wine is okay, and olive oil supplementation - it discourages certain things like soda drinks, commercial baked goods and sweets, spread fats and red meats. And what I like about it in particular is it doesn’t say you can never have those things. It’s about how frequently. For instance, most of those things should be fewer than one serving per day. And commercial baked goods, less than three servings per week. And so, when you stand in the line at your favorite coffee shop, what you’re tempted with while you’re waiting is nothing but commercial baked goods and sweets. And it’s okay to have one once in a while. Not every day, if you’re going to eat the Mediterranean Diet. And, I ask my patients, is that worth a 30 percent reduction in your risk for heart disease? And most become very interested in this type of diet because it’s about the food choices you make. And it’s not like you can never do certain things because look, eating’s supposed to be fun and eating is a part of life many times a day. It’s a social function; it’s what we enjoy. And so, the Mediterranean Diet, I think, can be compatible with a very healthy diet, a very heart healthy diet, but also one you can sustain. The problem with many of the fad diets is they’re great for a week or a month and people will often lose weight and that entices them into it, but frankly, we don’t know the safety of those diets. We don’t know if they’re heart safe. We don’t know what it does to their cholesterol and their blood pressures. In the end, that’s the most important thing. So, if you really want to follow an evidence-based diet, a diet that’s been proven to work, to reduce heart risk, it’s the Mediterranean Diet. Host: When you give that example, what do you say to those patients who say, “Well, if it’s similar to taking a pill, I’ll just take a pill and still enjoy my cheeseburgers.” Dr. Taylor: That’s great. Well, I say, “You know what? This was in addition to people taking pills.” So, this doesn’t replace pills and lowering cholesterol is not the goal of this diet. It’s about lowering heart risk. So, if you have a cholesterol problem, you probably will need a pill. If you have a blood pressure problem, you probably will need a pill. But this diet reduces heart risk. And it’s the types of food you’re eating and the types of foods you’re not eating that is driving it. So, it’s the diet that, from my viewpoint, we should be following for heart risk in this country. To come back to the diet that it was compared to, it was the previously recommended diet by the American Heart Association. So, those recommendations - and if you grew up through the ‘80s and the ‘90s, you were told, “avoid fat, avoid red meat, and the rest is gonna be fine.” Now, I’m summarizing, but that was what people were trying to avoid. And what do they substitute? They substituted sweets and baked goods and pasta, which are great, but small amounts. And, the Mediterranean Diet is by far a better diet from a heart risk perspective. Host: What about those trendy diets like Atkins or like keto. What do you say when folks are wanting to try those types of diets? Dr. Taylor: The goal of those diets is usually weight loss, and they do work in the short term. You can eat a ketogenic diet, and that’s a fancy term for a diet that is simply carbohydrate poor. So, it takes rice and breads and sweets out of the diet and focuses on vegetables and meats. And so, it’s a high protein diet. And in the short term, people will lose some water weight and they’ll lose water weight very quickly. Then it tails off. And, what the evidence is, is that, in the end, if you eat simply a calorie-restricted diet versus a ketogenic diet, the weight loss is the same. So, there’s no specific advantage of eating a ketogenic diet, when you look at 6 and 12 months out. What we’re talking about with things like the Mediterranean Diet is a diet that is more about prevention of heart disease. It’s not about weight. So, if you want to lose weight, it’s really about ins and outs - how many calories you’re taking in; how many calories you’re burning. Oftentimes patients aren’t quite aware. They’ve got a certain pattern of eating and often there’s some overeating. And, you’ve got to measure it. There’s some great health apps like MyFitnessPal. It’s a free app and you put in all your foods. It tells you exactly what you’re eating and how many calories. And there’s other ones as well. That’s important - to measure where you are and how much you’re eating. And it’ll tell you how much protein and fat and sugars you’re eating. And again, if you want to lose weight, you’ve got to measure your ins and monitor your outs. More exercise, less eating. It’s the only way to lose weight in a stable, long-term way. But from a heart risk perspective, it’s about the types of foods you’re eating. And, the best diet now is the Mediterranean Diet. That diet is better than the best American diet, 30 percent better for heart risk. It’s an easy sell.   Host: So, when you’re thinking about all these diets - you have paleo and you have keto and you have Atkins and they have all these flashy names - well, Mediterranean Diet just sounds very fancy and complicated. How do you break that down for people so it’s something relevant to them that they can really do? Dr. Taylor: Yeah, it can sound exotic and it isn’t and that shouldn’t scare anybody away. It’s actually just a diet that changes the quantities of things you eat to one, things that are healthier and away from things we’re probably eating too much of. And nothing in this diet is not freely available to people on a daily basis. So, it’s about the quantities. And the thing I love about this diet is that it’s...you don’t have to go to the Mediterranean to eat it. And you don’t have to eat foods you don’t like. It’s about the choices you make. So it’s about eating lean meats, fruits and vegetables. It’s about eliminating sodas and baked goods and sweets. And the occasional red meat is okay. And people that like red meat will find that really comforting and think that they can really sustain this. Host: What questions should patients ask their doctor if they’re considering trying one of these newer, trendier diets or going on to the Mediterranean Diet? Dr. Taylor: I think it’s important to talk about the goals of the diet and what the risks are or unknown risks are. If the goal of the diet is weight loss, the answer is simple. You’ve really just got to do it a calorie restriction and more activity. It’s hard work. It’s slow going. The fad diets - you’ll lose a little more weight quickly, but it’s a fake-out—it’s usually water. If the goals are other things like you want to improve your blood pressure, well, there are blood pressure improvement diets, such as the DASH diet. It restricts sodium, it supplements potassium, magnesium. It’ll lower your blood pressure. So, if you’re worried about your blood pressure, you’d like to avoid meds, there’s a diet out there for you. Similarly, for cholesterol. You can lower your cholesterol with a diet - somewhat. Restrict fats, eat lean meats. But by and large, cholesterol is pretty unresponsive to diet. And so, we usually use medicines for cholesterol. So as you talk about what diet to eat and fad diets, define your goals. Is it weight loss? Then the answer is ins and outs. And, if it’s a specific health problem, that is a little bit more of an in-depth discussion because there are some diets that are proven to work - the DASH diet is the best example. But I choose, typically, to focus on the global risk for heart disease because, no doubt, the most effective diet is this Mediterranean Diet. We’ll treat the blood pressure and cholesterol with other ways, but reducing heart risk is so important and the Mediterranean Diet is very effective. Host: Could you share a success story from your practice about changing their eating habits and reducing their heart attack risk? Dr. Taylor: Yeah, I can share a few. One is simply weight loss and have had many patients and I’ll describe one that, you know, everyone walks in with their smart phone and they think they’re all app’ed up. And, many patients have turned on to these apps like MyFitnessPal. And I’ve had patients come in and they’ve shown me exactly what they’ve eaten and how they’ve changed what they eat. They found foods that they thought they liked but really are quite unhealthy for them - they have a lot of sodium or a lot of calories. And, have changed their diet and have lost weight. And that’s really gratifying. And they’ve done that simply by more monitoring - and these apps, these health aids can really help. The Mediterranean Diet is a different story. And, a week doesn’t go by where I’m in the hospital talking to some patient, and it’s usually the wife that’s asking the diet question, about how to change a diet to reduce the risk of a future heart event. And, I try to be very optimistic in talking about the Mediterranean Diet - that it is a lifestyle diet. There’s nothing you can’t do, but it’s about food selections and these days, you know, we’re fortunate that the access to fresh foods and to healthy foods can be made without a lot of sacrifice. And so, it’s about shifting the types of foods you eat and usually the wine’s a big seller. People don’t mind a glass of wine with dinner, and that’s in this diet as well. So, people want to know what they can do that’s active to improve their health and eating is such an important part of life. You want to know that you’re eating a diet that’s not just you enjoy but that is healthy for you. So, I think the Mediterranean Diet is really worth a look. You can find simple information online. And even, you know, you can find the study I referenced - the PREDIMED studies - free online. You can go and look that up. And, it’s got the diet simply laid out. So, you can really start to look at the foods you’re eating and choose the right ones. I think diet is an important discussion to have with your doctor, and it’s not a quick discussion. You’ve really got to define the goals and then make a commitment toward changing diet that you can sustain. And, if you can outline a way forward. And I’ll even give patients a copy of the study and a page that summarizes the diet so they can ... somebody can look and say, “I can do that. I like that food. Ah, I’ll just have that once a week. I’ll skip it three times a week.” They sound like they can be successful, and they are. And it’s nice to see that people can make sustainable changes that you know reduce their heart risk. Host: Thanks for joining us today, Dr. Taylor. Dr. Taylor: Thank you very much. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

In the past, the only way to treat aortic stenosis was to perform open-heart surgery—a very invasive procedure. Discover how TAVR, a new minimally invasive surgery, can replace a heart valve without surgery, allowing patients to recover faster.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Toby Rogers, an interventional cardiologist at MedStar Washington Hospital Center. Thanks for joining us, Dr. Rogers. Dr. Rogers: It’s great to be here. Host: Today we’re discussing high, medium and low risk transcatheter aortic valve replacement, or TAVR. Dr. Rogers, could you start by discussing what TAVR is? Dr. Rogers: That’s a great question, and a lot of patients are quite confused by this terminology. So, aortic stenosis is a condition that is very common, particularly in older patients. And, it’s caused by a narrowing or blockage of the main heart valve through which blood flows from the heart to the rest of the body. And, as that gets progressively tighter with time and with age, patients can start to get very symptomatic, particularly when they’re trying to be active. So, they get very short of breath, they can get dizzy, they can even get chest pain when they’re trying to be active, even just walking across the room. And, historically, the only way to fix this problem was to do open-heart surgery and literally stop the heart from beating, cut out the old valve, and surgically sew in a new valve. But you can imagine, open-heart surgery is a big deal and it’s very stressful on the body and, the older you are, the more stressful a big surgery is. And so, TAVR is an amazing new technology that over the last decade has revolutionized cardiac surgery, in that we can now replace that heart valve through a little tiny catheter in the groin, with the heart still beating - in fact, with the patient awake. We don’t even have to put the patient asleep. And, we can replace the heart valve and improve the blood flow to the rest of the body. Host: What do you mean when you say high, medium and low risk TAVR? Dr. Rogers: So, again, this is a concept that we use very freely in medicine, but patients often get confused by that. And, what we’re actually saying is, ‘What would the risk be for that patient to undergo the old fashioned open-heart surgery?” Meaning, if they were to have open-heart surgery tomorrow, would that be a low risk procedure, an intermediate risk procedure or would it be a very high-risk procedure. And that’s not really determined by the heart at all. It’s often determined by other medical problems they have. And obviously, older patients are more likely to have more than one medical problem. So, if you have trouble with the kidneys, if you have trouble with your lungs, if you have trouble with your liver - then all of those things will make a big procedure, or a big surgery, more high risk. And so, for every patient that comes along with aortic stenosis, we make an assessment based on a whole barrage of tests, looking at all the different organs in the body, as well as the heart, to say, “What would your risk of surgery be?” And that, then, helps us judge whether the open-heart surgery is the best treatment for them or if, in fact, they’d be better to have a procedure like TAVR, which is less invasive.  Host: Who would you consider to be an optimal candidate for TAVR? Dr. Rogers: Well, certainly anyone who is very high risk for surgery. So, if undergoing open-heart surgery would be very high risk, and there would be a risk of not making it through the procedure, then clearly those are patients who should have less invasive procedure. And certainly, that’s the way TAVR started. It was really only available to patients who were so high risk that they just couldn’t have surgery. But then, as we’ve gotten more comfortable with the technology, and we’ve gotten more data for the technology and as we’ve run clinical trials - very rigorous clinical trials - across the US and across the world, we’ve actually demonstrated that TAVR’s actually a very good option for anyone with aortic stenosis. And, I think within the next 12 months, we’ll expect that the FDA will approve TAVR so that we can offer it to anyone with aortic stenosis. So, for sure if you’re high risk, but the truth is, moving forwards and in years to come, I suspect that TAVR will be the first line treatment for anyone with this condition. Host: You mentioned inserting the catheter through their groin and replacing the artery that way. Could you describe how TAVR is performed? Dr. Rogers: Yes. So, of course, each procedure is slightly different for different patients. But, a typical TAVR is performed with a patient under conscious sedation. By that we mean we give you some medication to make you relaxed, make you a little bit sleepy, but you’re breathing for yourself, you’re not on a ventilator and, in fact, some of these patients even sort of, you know, are able to talk to us and are fairly awake during the procedure. And that has a lot of advantages because putting a patient on a ventilator and breathing for them with a mechanical ventilator under general anesthetic increases the risk of the procedure. There’s more risk of picking up a chest infection, needing to be in hospital longer after their procedure, whereas if it’s all done under conscious sedation and with local anesthetic, then patients bounce back much faster and are able to get up and about much faster and that speeds up the recovery. So that’s the first step - it’s done under conscious sedation. And then, what we actually do, is we take the heart valve, the new heart valve, and we crimp it down or we’ll crush it down onto a catheter. So, we squeeze it down so it’s small enough to now go through the artery and the groin. We all have big arteries that go from the heart all the way down through the belly, down the legs, and so, we actually access one of those arteries and thread the catheter, with the new valve on it, all the way from the artery in the groin, all the way up to the heart and then position it inside the heart using x-rays and ultrasound so that we know we’re in the right place. And then, we open up the new heart valve inside the old one and “Hey, Presto” - you have a new heart valve. Host: What does a patient have to do then to prepare for the procedure? Dr. Rogers: So, I think we have a great team here that really guide the patients through the whole process, right from the very first contact, through all the testing to work out whether TAVR is the right treatment for them, all the way through the procedure. So, there are a lot of steps to this. This is not just a sort of come in and have the procedure and go home the next day. We always see patients beforehand. We usually bring patients in for a day or two several weeks in advance of the procedure to do all the tests we need to do to make sure that we know everything we need to know about this patient before we embark on the procedure. And then if we’re talking specifically on the (sort of the) day of the procedure, we usually ask people to come in the night before or very early in the morning. There’s a whole series of tests that we do - blood tests, to make sure that there’s...nothing’s cropped up in the meantime. And then, the procedure itself takes 3, 4 hours. And then, the patients typically go to either the cardiac ICU overnight or increasingly, actually, just go back to the normal ward, just to be monitored by the nurses there. And then we try and get people up and about the next day, and the average hospital stay for this procedure now is 2 or 3 days. So, actually, we’ve gone from a process where open-heart surgery patients would be in hospital for a week or more to a process where people are having heart valve replacement and they’re out, sometimes the day after the procedure, which, I think, is a revolution in this treatment. Host: What are the benefits of TAVR compared to traditional open-heart surgery? Dr. Rogers: Ok, so the first benefit is that some patients simply can’t have open-heart surgery. They’re too sick. They have too many other medical problems that would make the procedure too high-risk. And therefore, surgery just isn’t an option for them. Whereas, we’re able to perform TAVR safely in those patients because it’s less invasive. For the more general population, TAVR has the clear advantage that recovery is faster. Patients, after surgery, often have longer hospital stays. They end up staying in hospital for a week or so after the procedure. The complications are more common after surgery because it is just a bigger procedure and a bigger stress on the body. TAVR patients, in contrast, tend to go home within 2 or 3 days of the procedure and the recovery after they get home is much faster because they don’t have to deal with the surgical wound, the incision, and all of the problems you can get related to having just had a much bigger procedure. And so, in terms of getting back to normal daily activities, getting back to work, TAVR allows for much faster recovery. Host: And the recovery process - how does that look for patients? Dr. Rogers: So, the great advantage - and I think I’ve highlighted it a little bit already - the great advantage to this procedure is it’s not surgery and it doesn’t require cutting the chest open, it doesn’t require general anesthesia. And so, the great advantage of TAVR is the recovery. Patient’s bounce back and recover from this procedure must faster because it’s just less stressful on the body. Now, that being said, it’s still heart surgery, we’re still replacing a heart valve, and so I always try and temper patient’s expectations and say that, “You’re gonna have to take it a little bit slow here at first.” But, it depends. Someone who is in their 60s is going to recover from a big procedure like this much faster than someone who is in their 90s. And so, every patient is a little different. But certainly, the whole goal of doing this procedure is to get someone back to their normal activities, not just what they were like before they had the procedure but what they were like before they had symptoms from the aortic stenosis. So, back to being active, back to playing sports, whatever they want to do. Host: Could you share the story of a patient who had a particularly successful outcome with TAVR? Dr. Rogers: Sure. So, one patient, he’d had open-heart surgery to replace the same valve about 10 years or so ago. And, that had been a great success. He felt wonderful afterwards. But, the truth is, prosthetic heart valves don’t last a lifetime. And so, his “new” heart valve started to get tight and he a started to get those same symptoms again. And he was very, very worried about the prospect of having to have open-heart surgery again. He felt like he had done it once; he did not want to go there again. So, when he found out that there was an alternative to avoid having to have open-heart surgery again, he jumped at it. And, he came in the hospital, we did the procedure the same day, we got a great result with the new valve, and he actually went home, I think, the day after the procedure.  Now, not everyone goes home so soon but, for him, the difference experienced from the first surgery, where he was in hospital for a week, to going home, literally, 24 hours after his procedure, I think, that’s really remarkable. And certainly, he was overjoyed by the result he got. Host: Why is MedStar Washington Hospital Center the best place for patients to come for TAVR? Dr. Rogers: I think that one of the strengths we have is that we’ve been part of the whole TAVR program since it very first took off. The very first procedure was done in France in 2002, and TAVR came to the US in around 2007, and MedStar was part of the first wave of hospitals to perform this procedure. And, we have performed almost 2,000 of these procedures now. We have a great deal of experience with all the different types of technologies which are out there to treat this. It’s not just one valve available. Now we have a whole series of different types of valves, which are...different patients need different valves. And, we’re also very active in research. So, not only do we have access to all of our past experience in research, but we also have access to all of the new technologies. So, when a new valve is made available, we’re one of the first hospitals to get access to it to offer that to our patients. Host: Thanks for joining us today, Dr. Rogers. Dr. Rogers: Thank you for your time. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Relaxing is important an important part of life—especially for the heart. In fact, when the heart has difficulty relaxing between beats, people can develop diastolic heart failure, a serious functional condition. Discover which treatment options can help.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re speaking with Dr. Valeriani Bead, a board-certified cardiologist at the MedStar Heart and Vascular Institute, with extensive experience in nuclear cardiology and echocardiography. Welcome, Dr. Bead. Dr. Valeriani Bead: Thank you for having me. I’m really happy to be here. Host: Today we’re discussing diastolic heart failure which occurs when the left ventricle or the lower left chamber of the heart can’t properly fill with blood. Dr. Bead, is diastolic heart failure a common heart condition? Dr. Bead: Yes. But first we need to understand what diastolic heart failure is. In simple terms, it’s defined as an abnormality of the diastolic filling, or what we call the relaxation, of the left side of the heart, despite the fact that the heart pumping function is normal. And usually it occurs when the ability of the left side of the heart...when it can’t really accept blood or it’s impaired. And this can lead to a higher pressure inside the heart. Then, that can lead to fluid build-up in the lungs and also to the rest of the body. Now, to answer your question, diastolic heart failure is quite common, and it’s thought to be as prevalent as 20 to 70 percent in some patient populations and is thought to be responsible for about two-thirds of the incidence of congestive heart failure that we see in general. Host: What are some of the main symptoms of diastolic heart failure? Dr. Bead: Some of the most common symptoms that we experience with diastolic heart failure are shortness of breath, fatigue, lightheadedness or fainting, and sometimes even an irregular or abnormal heartbeat. Host: How is this condition diagnosed? Dr. Bead: Typically, we diagnose diastolic heart failure by good, comprehensive history and physical exam. And then, based on that, we may order some imaging tests called an echocardiogram, which is a sonogram of the heart. This is often combined with the stress tests to show how blood is flowing in the heart during exercise. Finally, we may do additional blood tests or even an invasive procedure called a cardiac catheterization, which is when a thin tube is inserted into the heart in order to see how the heart is functioning and to determine whether or not there are any blockages in the arteries. Host: Could you tell us a little bit about your patient population for diastolic heart failure? Dr. Bead: So, the most common individuals we see, those at highest risk for diastolic heart failure, is the older population, so typically individuals over 65 years old and those who have high blood pressure. Sometimes those who have problems with their heart valves, particularly the aortic valve, and typically when that valve is narrowed or doesn’t open well. We also see the diabetics and people who have clogged arteries, and, for unclear reasons, you see it more common in women. Host: Once you’ve diagnosed an individual with diastolic heart failure, what treatment options are available for them? Dr. Bead: We always start off with lifestyle modifications, which include smoking cessation, increasing physical activity, and dietary changes. Next, we offer treatment to address the stiffening of the heart and that typically includes controlling the blood pressure, controlling the diabetes, and also, if they have high cholesterol, we also treat that. And some of the medications we use may include a class of medication called beta blockers, which are used to slow the heart rate in order to allow it to function better. We also use medications called calcium channel blockers, which help reduce the stiffness of the heart. Other medications include diuretics that help reduce the fluid accumulation. And, if those are not sufficient, sometimes we offer an invasive procedure called a cardiac catheterization or even surgery to fix any blockages or narrowings in the blood vessels. Host: What are some of the risks if a patient doesn’t receive treatment for diastolic heart failure? Dr. Bead: Now that’s a great question because, the main risk we worry about, if a patient doesn’t receive treatment for diastolic heart failure, is death. The other risk we worry about is congestive heart failure, which is when an individual has a sensation that they can’t breathe, and they have evidence of fluid overload. Other things we may see are abnormal heart rhythms called atrial fibrillation. Other things that we may see are passing out, also called syncope. Host: Is there anything that patients can do to reduce their risk of diastolic heart failure? Dr. Bead: Yes. The most important thing patients can do to reduce their risk of diastolic heart failure is to keep their blood pressure under control, to control their diabetes or their blood sugars, and to control their cholesterol. And, of course, I mentioned lifestyle changes. So, meaning making sure they don’t smoke, they stay active, and they eat a heart healthy diet. Host: Could you explain how diabetes is related to diastolic heart failure? Dr. Bead: Diabetes affects every organ in the body. And in fact, in cardiology, we consider diabetes ‘heart disease’ until proven otherwise. Although the ideology is unclear, diabetes is thought to lead to direct stiffening of the heart, either by having too much glucose in the system or by causing premature stiffening of the blood vessels surrounding the heart and, thereby, stiffening the heart itself. Host: When you said that, it made me think of a ‘starch,’ like you would put in your clothing to make it stiffer. Dr. Bead: You know what!? That’s an amazing analogy! Yeah! Cause that’s basically what it does. When you have all this excess glucose in the circulation. It’s basically, because it can literally surround cells and kind of ‘coat’ them so they don’t function so well, and they can become stiff like a starch. Yeah, like starch. Host: Could you share a treatment success story from your practice? Dr. Bead: This is always my favorite part! I love talking about my patients because they’re so amazing. There was one middle-aged lady who came to me as a consult from her primary care physician. Initially, it was a semi-urgent consult because the EKG, the electrocardiogram, was abnormal and showed, an abnormal rhythm that was initially concerning for atrial fibrillation when, in fact, she had a lot of skipped beats. When I saw the patient, she was complaining mostly of shortness of breath and the inability to do her Zumba exercises. Oh, she loved to exercise about three days a week. But then she started noticing that her legs were more swollen. She got tired easier. She had a ‘flooded’ sensation in her heart and she really couldn’t do her usual activity of daily living. And, I did a good exam. Her lungs were clear. Her heart actually sounded pretty good, with the exception of some skipped beats. But she did have some swelling in her legs and her blood pressure was quite elevated. And so, based on that, we talked, we adjusted her medication in order to get her blood pressure under better control. I prescribed a diuretic in order to reduce the fluid on her legs. And then we discussed her lifestyle changes such as reducing the sodium from her diet. When we saw her back within a couple of weeks, I had her get an echocardiogram or a sonogram of her heart which showed that her heart was strong but, using certain diagnostic techniques, we could tell that her heart was a bit stiff and it was also thickened from long-standing high blood pressure. So, we were very vigilant in terms of getting her blood pressure under good control. We were able to keep the fluid off. She was...did her part by making the lifestyle changes that she wanted to. And then, within about 6-8 weeks, she was back to doing her Zumba classes with no restrictions. And then, when I see her back every 6 months, she’s actually to the point that she’s helping teach the Zumba classes, which is always awesome. Host: Why is MedStar Heart and Vascular Institute the best place for patients to seek care for diastolic heart failure? Dr. Bead: The MedStar Heart and Vascular Institute, really is the best place for general cardiology patients, but, in particular, for patients who have specific diagnoses, such as diastolic heart failure, because it offers comprehensive, state-of-the-art care in a compassionate environment that is patient-centered and evidence based. Host: Well, thanks for joining us today, Dr. Bead. Dr. Bead: Thank you for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

When you have a team of experts dedicated to caring for your heart condition, you’ll always see providers you know and trust. Dr. Vinod Thourani explains how collaboration among a variety of experts improves our patients’ outcomes and experiences.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thank you for joining us today. We’re talking with Dr. Vinod Thourani, chairman of cardiac surgery at MedStar Heart and Vascular Institute and MedStar Washington Hospital Center. Welcome, Dr. Thourani. Dr. Vinod Thourani: Thank you so much. Host: Today we’re talking about who makes up a patient’s heart team. When it comes to managing a heart condition, the ‘who’ is just as important as the ‘what.’ Heart team members have specific roles, and the way they collaborate together and with patients can make the difference between successful outcomes and simply managing symptoms. Dr. Thourani, what do you mean when you say “heart team”? Dr. Thourani: I think that’s a great question and I think that really needs to be defined more because I’m not sure people understand. And a lot of the patients, when I talk to them in the clinic, I have to explain to them exactly what a heart team is. So, this is really evolved. Where the original heart team, meaning a group of doctors on a common theme, was really in heart failure. So, if somebody was coming to get a heart transplantation, they would be evaluated by a multitude of people. They’d be seen by a regular cardiologist, they’d be seen by nurse practitioners or physician’s assistants, and they’d be seen by the surgeon. And that was a very small group of patients. And over the last decade, where it really exploded—the aspect of the heart team—was in valve disease. A study called a Partner Study—and the reason the study was called Partner Study is it was the definition of a heart team. Because we’re going to see surgeons and cardiologists partner together for the treatment of valve disease. And that idea has really been an organic growth over the last decade. So, the heart team now has really modified since when I knew about this about 12 years ago. And currently the heart team constitutes a specifically—and it can be for coronary disease or valve disease; it can be for any disease process but at the least it includes now a non-invasive cardiologist, a general cardiologist, an invasive cardiologist who puts in stents or helps treat a heart attack with some type of angioplasty procedure. It includes an echocardiographer who’s also a cardiologist—so these are the specific physician who does the sonogram, and sometimes that’s called a transthoracic echocardiogram or TTE. And so you really have those three cardiologists that help the initial part of the heart team. Of course, there’s the cardiac surgeon, especially for those patients who can’t be treated with catheters. And I will tell you now that is grown into something that we call advanced practice clinicians, and those are nurse practitioners and physician’s assistants, so APCs are now an integral component of the heart team. There are other people who are called in to the heart team—sometimes a neurologist is called in if someone has stroke issues or has dementia issues. A nephrologist can be called in for obviously patients who have kidney problems. But really, we have five or six key people that make the heart team, especially at the MedStar Heart and Vascular Institute. Those really five people are key to the process of evaluating a patient. Host: Is having APCs involved with the heart team more regularly common or is it something unique to MedStar Heart and Vascular Institute? Dr. Thourani: So, I think that early on, including APCs within the heart team was a unique aspect. So, we really use APCs, which could be a physician’s assistant or a nurse practitioner, almost as an extension of the physician. Their knowledge is unbelievable and they’re able to really bring the patient into it—this family, is what we end up creating. And as I see valve patients, I tell them that you’re now part of the heart team family and that we’ll be managing your valve problems or your coronary problems for the rest of your life. So, the APCs are critical to the preoperative, the intraoperative and the postoperative management of our patients, so they’re really a critical component of the heart team. Host: Do you work with the palliative care program as well? Dr. Thourani: We do, and what we’re able to do, uh, for the heart team—if we believe that someone has a life expectancy of less than a year, then we really bring in palliative physician specialists, but also oncologists, ‘cause a lot of those people who have less than a 1-year expectancy of life have some type of malignant cancer that we’re worried about. So, the heart team can really have a multitude of people that we call on, too, and then there’s our core heart team that we use. We’re very fortunate at the MedStar Heart and Vascular Institute that we’re integrated within MedStar Washington Hospital Center that has world class care in all aspects, so we’re really fortunate to be able to call on our colleagues within minutes and we’re able to get someone to see these patients. Host: What is your patients’ reaction when you mention that they’re now a part of the heart team family? Dr. Thourani: They love it because sometimes in our care in the United States has become fragmented. So, you see one doctor one time and then you may not—the next time you come to the hospital or the next time you come to the office, you may not see that person again. And so I think that they get lost in the shuffle. And our goal is for the patients to feel very comfortable that they’re coming to a team of physicians who are with them for a long period of time. And I really believe the APCs are a good extension of that because if I’m in, let’s say, in surgery and I can’t see them, they already know our APCs, so they feel very comfortable talking to them and really using them as our extensions. Host: Why did you choose to come to MedStar Heart and Vascular Institute? Dr. Thourani: You know, I was in Atlanta for 37 years, and so for me to leave, it really had to be somewhere where I thought it was going to be the next level for me as far as taking care of my patients. And, I looked around the country and, to me, MedStar Heart and Vascular Institute was the place that felt the best to me as far as synergy of not only the medical devices that we treat people, but the actual people, and I think the human interactions in the team that’s here really attracted me to coming here. I’m overwhelmed by the quality of physicians and the interest in taking care of patients. It really is a patient-centric focused pathway and so I couldn’t be happier. Host: You’ve talked a lot about that collaboration between all of the different physicians. How does that then translate to the patient outcomes and patient care? Dr. Thourani: So, patient outcomes therefore, I think, benefit because when a patient comes in, we don’t necessarily pigeonhole them into one or two procedures. We have a bevy of procedures we can provide for them, if they need that, of course. Sometimes they don’t and they get medical therapy.  But, if they do need a procedure, then we’re able to provide them that traditional pathway or we can give them the pathways that are innovative and new technologies. And so, with our relationship with the FDA and the NIH, we get sometimes therapies here that no one else in the country has, or only two or three sites in the country have, so we’re fortunate with that. That has, therefore, left us with looking at our outcomes, and we find that we are, for instance in cardiac surgery, we are three stars, the highest designation given to a cardiac surgery program, in all 3 categories that exist. And therefore, that puts us within the top 1 to 2 percent of hospitals performing cardiac surgery in the United States. So, we feel that this heart team approach also benefits, not only the patients, but it also benefits our outcomes to give us a program that is unique amongst the entire country. Host: How does the research portion of being an academic medical center benefit you as a surgeon and your team as well as benefit the patients? Dr. Thourani: So, that’s a great question. And I’ve been a big proponent of research, and that’s a big part of what I like to do. And my research has been specifically more in the clinical end of taking care of patients with new technologies. And it’s just not mine, but it’s our entire heart team that does that. And what we’ve been able to do is offer patients, when there was no hope, or were able to offer therapies that are less invasive and easier on the patient for recovery. So, it has completely changed with the research aspect, the new technologies we’re able to get here and available to patients. It has completely transformed how we manage patients and I think it’s the future of why patients have great outcomes here. And it’s one of the reasons I also came here. I knew the team here were very interested in providing the best technological support we can. Host: If there is an individual in the community who has a serious heart condition, what would be the most important thing to impress upon them as to why they should come to MedStar Heart and Vascular Institute for their care? Dr. Thourani: The most important reason is that you have a dedicated heart hospital here at MedStar Washington Hospital Center, so the MHVI is a functioning, over 200 beds, that are exclusive for the care of cardiac patients. We have nurses that are exclusive to that. We have ICUs that are exclusive to that. Our operating rooms are completely situated with that. And so, we have a MHVI, the MedStar Heart and Vascular Institute, is a really a hospital within a hospital, an institute within a hospital, that allows us to concentrate on the patients with coronary or valvular or heart failure conditions. So, we really have it really finetuned to managing these patients. And this is very unique and it’s not very common to have this type of energy and vision towards this entire pathway. Host: Thank you so much for joining us today, Dr. Thourani. Dr. Thourani: It was my pleasure. Thank you so much. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Artery buildups serve as silent danger signs of a heart attack. Discover how a coronary calcium score calculates patients’ risk by measuring the amount of calcium in their arteries through the use of a computed tomography (CT) scan.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re speaking with Dr. Allen J. Taylor, Chair of Cardiology at MedStar Heart and Vascular Institute. Welcome, Dr. Taylor. Dr. Allen J. Taylor: Thank you. Host: Today we’re discussing coronary calcium scoring, which is a non-invasive heart scan that a cardiologist can use to help calculate a patient’s risk for coronary artery disease or atherosclerosis. Dr. Taylor, what are you looking for in a patient’s heart when you perform coronary calcium scoring? Dr. Taylor: Great question. This is a very simple test that very accurately and easily detects the beginnings of atherosclerosis or what otherwise people call (quote) “hardening of the arteries.” It’s that development of plaque, cholesterol buildups and other things that are filling up the arteries as we age. And so, when we’re doing coronary calcium scoring, we’re looking for little pieces of calcium, like in your bones, but that are in the arteries and it shouldn’t be there. And it’s a marker for these buildups that we can easily detect and measure and through that, evaluate a patient's risk for heart disease. Host: How does the calcium end up there when it’s not supposed to be there? Dr. Taylor: The calcium comes because the arteries are becoming damaged from the buildups and as they heal, the body naturally lays down some calcium. So, it’s part of these plaques or buildups and it’s the one that we can detect with x-rays because x-rays detect bone, and this is basically bone in your arteries—little pieces of calcium. So, it’s easily detected with a simple scan, a CT scan, that we call a coronary calcium scan. Host: Are there certain populations of patients who are at increased risk for high levels of coronary calcium? Dr. Taylor: It’s interesting because simply by aging, that’s your major risk. Now, some people with high cholesterol or high blood pressure or diabetes or smokers - they may develop calcium in their heart arteries at a faster rate. But, just because you don’t have those things, doesn’t mean you’re not developing buildups; it doesn’t mean you don’t have coronary calcium. And the challenge is that by measuring those risk factors, we can detect somewhat of a patient’s risk for heart disease, but it’s only part of the story. And, the important thing about calcium scoring is that it tells us more of the story. It adds to what we already know about a patient and helps us to determine who really is at risk for heart disease. Host: Is there anything that a patient has to do to prepare for this type of scoring test? Dr. Taylor: The beautiful thing about this is it’s a very simple test. It’s done using a CAT scanner or CT scanner, but it uses very low doses of radiation. There’s no needle. There’s no medicines. All the patient does is lay down, get hooked up to a few electrocardiogram electrodes, and hold their breath for about 15 seconds. Within 5 minutes, they’re done, and the scan is complete. Host: Now why does the patient have to hold their breath while they’re getting this test? Dr. Taylor: The reason that you have to hold your breath is because if the heart is moving when you breathe, it’ll blur the images. So, it’s done during a breath hold. But, the breath hold is very short. The scans are very fast. And, virtually all patients can tolerate the scan. The scanners are very wide profile, there’s not a lot of claustrophobia or that feeling of being closed in by the scanner tube. And the radiation levels, which is previously or often a concern, are very, very low. They’re really like a couple of mammograms worth of radiation exposure. So, it’s a very simple test and actually they’re also very inexpensive. Most health systems will do these tests for under a hundred dollars, if insurance doesn’t cover it. And many insurance payers will actually cover the test. Host: What happens next if a patient’s scan shows high levels of coronary calcium? Dr. Taylor: Right. If you find calcium, what does it mean? It means you’re at increased risk for heart disease. By the converse, if you don’t find calcium, it means you’re at low risk for heart disease. So, it really puts a lot of clarity on who is and who’s not at risk. So, when you detect coronary calcium, there’s certain things you’re going to do. The most obvious things are live a better lifestyle since lifestyle changes are so important to heart disease risk. Eat a better diet, exercise more, get good rest, avoid stress, for example. And then, other health habits, like don’t smoke, make sure your cholesterol is well controlled, make sure your blood pressure is well controlled. Maybe you’ll need a cholesterol medicine to control your risk. Maybe you’ll need aspirin to control your risk. With this information, you can make the right lifestyle changes. And also make sure you’re on the right treatments to optimize reducing the risk for heart disease. Because, remember - heart disease is still the number one killer in this country. Host: If those lifestyle changes don’t work, what treatment options are available to take care of that coronary calcium buildup? Dr. Taylor: A common question we get is “Can you remove the calcium?” And, you can’t. But remember, if there’s calcium there, there’s plaque or other buildups. And it’s that other parts of the buildups we’re trying to treat by treating cholesterol, for example. Mostly we can show that we can stabilize the plaques, for instance, by lowering cholesterol a lot using very simple cholesterol medications that are very safe and very effective. But, some other choices might be there for patients, like do they or don’t they take an aspirin a day, for example, or what blood pressure targets should they be looking for? Or, maybe they’ve been avoiding diabetes treatments and they should get on treatments. Or, what types of diabetes treatments? So, with your doctor, there’s many healthcare choices that can be made to reduce the risk for heart disease. But, that’s the connection. You get the test, you clarify your risk, and then you treat the risk using those other interventions - lifestyle and then targeted treatments for certain heart risk factors. Host: You’ve given us a lot of really good reasons to get this test and then to seek treatment after. But what if a patient doesn’t seek treatment? What are some of the risks to their health? Dr. Taylor: Well, one thing we know is that many patients fear heart disease but may not have to fear it at all because, if you have no calcium in your arteries, the evidence shows the risk for heart disease over the next 10 years is extremely low, like .1 percent per year, one in a thousand. Very low. Now, if a patient does have coronary calcium and doesn’t seek treatment, that would not be the outcome we would want because anytime you do a test, you want to use that test to make better health choices. And, the evidence shows that, in fact, that is what happens. So, when people get this test, they’re more likely to get appropriate cholesterol medication, for example. They’re more likely to take appropriate measures, like taking aspirin. And, they’re also more likely to make other healthy lifestyle choices. So, I think the test has some great utility to help both patients and doctors more carefully identify risk and then respond in the right way. And, the evidence suggests that that’s actually what happens. Host: Could you tell us about a patient who came in for a coronary calcium scoring test - maybe found that they had some calcium and made some changes to their life or were able to reduce their heart disease risk? Dr. Taylor: Oh sure. I can tell you stories on both sides of the story. A friend of mine, he’s in is early 50s and has a family history of heart disease, has always worried that something inside of him is not...won’t be right, that genetics have led to him to have risk for heart disease. But he lives a healthy lifestyle, doesn’t have any risk factors. He got a scan - there was no calcium. So, he has been reassured that, in fact, whatever it was that led his loved one - it was one of his parents - to have heart disease, he, at least at this point in his life, doesn’t appear to have it. And it’s a pretty good time to screen, as people turn middle-aged, 50 to 60. That’s when heart disease risk really goes up and we can detect calcium, if it’s present, and how much. On the other side of the story, many, many successful stories that show how this test can be well utilized. For example, a woman who was also middle-aged, in her 50s, and she had been worried about her heart health and didn’t have a lot of risk factors. Not a smoker, good cholesterol. And, in fact, she has very high levels of coronary calcium. And, she’s way above average for age and that says that her risk is much higher than it should be. So, what did we do? Well, she’s now on a cholesterol medicine - her cholesterol wasn’t bad, now it’s perfect. And, not all healthy people should take aspirin, but her risk is high enough with this that we have, in fact, placed her on aspirin - carefully, because aspirin can cause bleeding, so you only want to use aspirin when patients have risk for heart disease. So, her treatments have been changed. Now, she’s still active and she’s still eating well. She was always doing those things. But now we’ve gone from the normal lifestyle changes to, in fact, a very proactive approach to reduce her risk and hopefully that risk is being optimized. Host: What would you say to a patient who feels like maybe this isn’t for them or they don’t need this type of test? Dr. Taylor: The interesting thing about calcium testing is that we can only predict, with heart risk factors, about a third, meaning a minority, of actually how much buildup is actually there. You only know by looking. You know, they’ve said ‘a picture says a thousand words?’ That’s the case with this. By doing this very simple test, you can get a complete view of heart risk within 5 minutes, and it’s something that no other test can provide. Host: What makes the program here at MedStar Heart and Vascular Institute so unique for patients who have coronary artery calcium buildup? Dr. Taylor: In the mid-Atlantic, MedStar Heart and Vascular Institute has been doing calcium scanning longer than anybody. And, many of our doctors, myself included, have conducted some of the seminal research, the important research, that’s shown the value of this test. And we provide this as a low-cost health service. So, even if patients’ insurance won’t provide it, we so strongly believe that this is the best test that a patient, age 50 and above, could take to really know their heart risk, that we provide this at very low cost. So, we believe in the test. We think it’s very important. And we provide that care so that no patient shouldn’t have the benefit of a coronary calcium scan. Host: Thanks for joining us today, Dr. Taylor. Dr. Taylor: Thank you so much. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

People who are concerned about their thyroid health may turn to supplements. But thyroid supplements can cause the very problems they’re supposed to correct.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. In today’s episode, we talk to Dr. Kenneth Burman, Director of Endocrinology at MedStar Washington Hospital Center about thyroid supplements. The thyroid is a tiny organ that’s involved in regulating several major bodily functions including breathing, heart rate and body temperature. Over-the-counter thyroid supplements may seem like a good idea to someone who believes they may have a thyroid condition. But thyroid supplements actually can cause problems with the thyroid and we may not know exactly what’s in them. Host: Dr. Burman, thanks for joining us. Dr. Kenneth Burman: Sure. Thank you for the invitation. Host: You bet. So, over-the-counter thyroid supplements—helpful or dangerous? Tell us about that topic. Dr. Burman: Sure, be glad to. Over-the-counter supplements for the thyroid come into various categories. So, one type of supplement would be iodine or iodine containing substances. Another type would be substances that contain one type of thyroid hormone, or thyroid hormone analog. There are other ones that are much less well characterized, and we’ll focus on the iodine and the thyroid containing supplements. So, iodine is an interesting substance. It is required for the synthesis of thyroid hormone synthesis and also required for secretion of thyroid hormone. And, thyroid hormones, which are abbreviated T-4 and T-3, contain about 68 percent iodine. So normal iodine in a diet, minimum daily requirement is about 150 micrograms per day and some substances that we use in medicine such as IVP dyes or cat scans contain thousands of micrograms of iodine per day. Supplements can vary over-the-counter and are not necessarily regulated as to how much iodine they contain. So, if a supplement contains something close to the minimum daily requirement (about 150 micrograms) that should be fine and maybe even beneficial. But many of the supplements are not quantitated in terms of iodine, but also contain iodine that is very high in thousands of micrograms in a tablet. And if you take one a day, that would be thousands of micrograms a day. So, what are the effects of iodine on the thyroid gland? They’re multiple. For a short period of time iodine in these concentrations will lower thyroid hormone secretion so we actually use supplements to very hyperthyroid people under very controlled circumstances. But that control of thyroid synthesis only occurs for 10-14 days approximately, and after that time, they escape from that effect and the iodine fuels worsening hyperthyroidism. Normal people may or may not have those reactions but those are possible, especially in the large percentage of patients in the population that have autoimmune thyroid disease and may not even know it. So, in summary, with regard to iodine, large amounts of iodine should be avoided by normal people and anyone with thyroid disease, a normal amount of iodine, a minimum daily requirement, is reasonable; and everyone, but especially people with a family history or known history of thyroid disease should avoid large amounts of iodine. With regard to thyroid hormone analogs, one of my former fellows and now colleague, Vick Burnett who is the head of endocrinology at Mayo Clinic, Jacksonville, did a nice study that he published of looking at supplements and measuring thyroid hormone in them. And it turned out, that of the 10 or 20 supplements that he looked at, almost all of them had a significant amount of thyroid hormone in them, even if they didn’t put that on the label. So, thyroid hormone itself, given to a normal person, can cause hyperthyroidism, which may be associated with a fast heart rate, palpitation, bone loss, and even more severe problems such as atrial fibrillation and should be avoided. And that these thyroid hormone analogs are difficult to identify in these supplements unless you specifically look for them. And it’s not just the standard hormones of T-4 and T-3 but there are various analogs of thyroid hormone that can cause similar problems that are not necessarily quantitated in these supplements. Host: When we talk about over-the-counter supplements, are these people who self-diagnose themselves and then they just go out and they get the supplements? Dr. Burman: Either because they are self-diagnosing themselves but perhaps, more commonly, they’re using it as health food or health additives to try to make them feel better or have more vigor. Of course, regular vitamins are key, and everyone should have adequate amounts of regular vitamins but iodine in excess, or thyroid hormone in excess, in any of these supplements should be avoided. And, of course, the FDA does not regulate supplements like they regulate medications. Host: So, we don’t even know what’s in them necessarily. Dr. Burman: Correct. So, this study by Dr. Burnett, it was unknown or unidentified exactly what the contents were and he was very surprised that it turned out to be significant amounts of thyroid hormone in many cases. Host: So, for the most part, would you recommend people do not take them then or do consider them? Dr. Burman: We would recommend that, in general, patients with any known thyroid disease not take supplements, and even normal individuals should ask their physicians to examine whether those particular supplements may contain thyroid hormone. Host: What can happen if you take supplements and you don’t have a problem? Dr. Burman: If you take supplements and you don’t have an endogenous thyroid problem, there could be enough thyroid hormone in them to cause overactive thyroid activity, just as if you had bona fide hypothyroidism. That can result in atrial fibrillation, heart irregularities, bone loss, and other significant problems. Host: What other tips do we have on this topic? Anything else we need to share that people need to be aware of? Dr. Burman: Yeah, it’s always of interest that people wonder where iodine comes from and in food, etc. in our normal American diet. So, I frequently ask the medical students “What’s the most common source of iodine in the American diet?” and they always, unanimously say, “salt.” But it turns out salt doesn’t contain that much iodine. That rather, it’s processed foods that contain iodine as a preservative—bread and pastries, to name one large source of iodine. And then another source of iodine that relates to health food is kelp. Kelp is seaweed which, of course, no matter how it’s prepared, has a large amount of iodine in it that can cause the problems of over or under activity. Host: Great. Well, thank you for joining us on the show today and I appreciate everybody listening and hopefully you found this information helpful. Thanks again. Dr. Burman: Thank you. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.  

Rheumatoid arthritis causes inflammation that primarily affects joints in the hands, feet, and ankles. While treatment was limited to managing pain years ago, new medications now can prevent further joint damage and restore patients’ functionality.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re speaking with Dr. Konstantinos Loupasakis, a rheumatologist at MedStar Washington Hospital Center. Thank you for joining us today, Dr. Loupasakis. Dr. Konstantinos Loupasakis: Thank you for having me. Host: Today we’re discussing rheumatoid arthritis, or RA, a chronic inflammatory condition that affects the joints of the hands and feet. Dr. Loupasakis, what does inflammatory mean when it comes to rheumatoid arthritis? Dr. Loupasakis: Inflammatory means that the affected parts of the body, which are usually the joints: the hands the feet, the ankles, the knees. The parts of the body that are affected by rheumatoid arthritis display signs of inflammation. inflammation is a reaction of the body. It’s a reaction of the immune system which is the part of the body that defends ourselves against injury or infection. The signs of inflammation usually include pain, swelling, warmth, and limited range of motion. Also, stiffness, which is particularly prominent in the morning hours. Host: What are some of the most common symptoms of rheumatoid arthritis? Dr. Loupasakis: So, the most common symptoms are pain, stiffness, warmth, and swelling of the joints and the typical joints that are affected are the small joints of the hands, the wrist, the feet, and the ankles, but also larger joints such as the knees, the elbows, and the shoulders. It’s very important to note that in addition to the joint pains, rheumatoid arthritis can affect the whole body. It’s a systemic inflammatory disease, so it’s not just a disease of the joints. It can cause inflammation of vital organs, sometimes, and it can also affect the blood vessels and that’s why it’s been recently recognized as a factor for accelerated cardiovascular disease. Host: When a patient comes to you with rheumatoid arthritis symptoms, do they look differently or is it just how they feel? Dr. Loupasakis: It can be both. That depends on how severe the rheumatoid arthritis is and it depends how long they’ve had it for. So, if the rheumatoid arthritis has been persistent for many years and it hasn’t been recognized and hasn’t been treated, the patients can look ill. They might have lost weight, they might have felt very weak for a very long time, and in general, they might have been very fatigued, which has affected both their physical function, but also their psychological and emotional states. Host: I was thinking about the swelling of the joints. Do they get large enough that they would be visibly swollen? Do they become red? Dr. Loupasakis: That can happen. That usually depends on the size of the joints that are affected. For example, the small joints of the hands, it’s less easy, let’s say, for a non-rheumatologist to recognize the swelling. For us, it’s pretty easy when we examine our patients to even acknowledge even small changes in the normal size of the joint. But to the patients, usually sometimes that’s not something that is striking aside from the pain and the stiffness that they experience in the morning. However, larger joints such as the knees, they can accumulate a lot of fluid in a short amount of time and that can be very obvious, even to the patients or their relatives, their family members, sometimes. Host: Could you describe your patient population for RA? Who’s most at risk? Dr. Loupasakis: Rheumatoid arthritis typically affects women two to three times more frequently compared to men. The age range that we usually see is, ranges between 20s and 30s. It can also occur at a second wave in the 60s or 70s. Host: Why is it that RA affects such a young population? Dr. Loupasakis: We don’t know. What we know is that there is a genetic predisposition, there is a genetic component to this disease. So depending on the risk factors that the patients have in addition to that genetic predisposition, the manifestation of clinical disease can happen earlier or later in life. The peak age onset is usually the 50s, but we do have patients in their 20s and 30s as well as patients in their 60s and 70s. But it’s not really known why this disease affects the age groups that we just discussed. What is important to note is that oftentimes people confuse rheumatoid arthritis with osteoarthritis. And osteoarthritis is predominantly a disease of the elderly. It’s a different kind of arthritis and it’s not inflammatory - it’s what we call degenerative which means wear and tear or overuse arthritis. So, the frequency of osteoarthritis is much higher in the ages of 60s and 70s. Especially in people that have risk factors such as being overweight or having done too much physical workout when they were younger. So what people call arthritis, in general, oftentimes refers to osteoarthritis and I think that gets commonly confused with rheumatoid arthritis, which typically affects younger patients or middle-aged patients. Host: How is rheumatoid arthritis diagnosed? Dr. Loupasakis: Rheumatoid arthritis is diagnosed by a combination of a very thorough and careful physical exam, history taking by a specialist, a rheumatologist, in combination with blood and urine tests, and occasionally with X-Rays of the joints that have been affected. There is no single specific test that can confirm the diagnosis, but there are certain tests that, if they are positive in conjunction with a history that is convincing and a physical exam that is positive for joint swelling, signs of inflammation such as the warmth, the swelling, the tenderness, all of these things together in the right age group, that can give us the clue and that can lead to the diagnosis of that disease. Host: Is there anything patients can do to reduce their risk for RA? Dr. Loupasakis: That’s a great question. Science has recently revealed some risk factors that we didn't’ know in the past. For example, smoking is a very significant risk factor for the development of RA. Especially in patients who have had some genetic predisposition. Let’s say, patients who have had rheumatoid arthritis in the family history. They’ve had a first degree relative with rheumatoid arthritis. So, smoking is a risk factor that may increase their chances of developing active disease. Another risk factor is poor oral hygiene, poor dentition. And that’s very important to note because both of these are modifiable risk factors, so our patients can prevent those risk factors from contributing to their development of the disease. Host: That’s very interesting. I wouldn’t think that smoking or dental health would affect your joints. How do you explain that to patients when you’re talking through that? Dr. Loupasakis: There are very complex immunologic mechanisms that underlie this concept. There is a scientific explanation that has to do with alterations, changes that happen in normal tissue, normal cells, in the mouth or in the lungs and those changes that happen because of the irritation that smoking or the, let’s say, the bacteria in the mouth in patients who may not take very good care of their oral hygiene. That irritation can lead to the stimulation of the immune system and that stimulation of the immune system which starts outside of the joint, let’s say in the mouth or in the lungs, under certain circumstances and triggers can eventually transition into the joint and cause inflammation of the joint. It’s a concept that has only been recently recognized and it’s fascinating. Host: Is the smoking or the dental health factor only for individuals that have a hereditary risk, or could it be for anyone? Dr. Loupasakis: It could be for everyone because the genetic predisposition is not necessarily something that the patient knows that they have. The genetic predisposition is more obvious when patients come to us knowing that a family member has a history of rheumatoid arthritis, but it can still be there, and they may not have been aware of that. Host: What treatments are available for RA? Dr. Loupasakis: I’m very excited to discuss this topic with you because things have really changed for the better in the recent years. Scientific breakthroughs have really led to the development of really effective medications and these medications have really revolutionized the care of our patients. We used to have only corticosteroids, what most people know as cortisone. And we still use it for patients that have very bad flares because they work very quickly, and they can cool things down very easily and very quickly in a short period of time. However, these days we have a great range of other medications, some of them in tablet form, patients can take them by mouth. Others as an injection that patients can self-administer at home. And then there’s a third category of medications that are administered as an IV infusion, for which our patients have to make an appointment and come to the infusion center. Host: What are the long-term health consequences if RA is left untreated? Dr. Loupasakis: That depends on the severity of RA. However, we know that rheumatoid arthritis has the potential to really cause significant damage to the joints and that can lead to permanent disability especially when the joints get stiff, limited range of motion, and deformed. That shouldn’t really happen in these days because of the availability of all these treatments that we have that are very effective. However, unfortunately we still see that sometimes. It’s a problem that has to do with access to care, but it’s strongly recommended that all patients with rheumatoid arthritis should be treated promptly because in addition to the joints, rheumatoid arthritis can affect the whole body. It’s a systemic inflammatory disease and it can affect other vital organs including the heart and the vessels and that’s why it’s important to treat it very early so that it doesn’t cause changes to these organs which can potentially lead to development of many other problems aside from the arthritis itself. Host: When a person’s RA symptoms are really acting up, that’s called a flare. Could you explain what that process is like for the patient? Dr. Loupasakis: Sure. Rheumatoid arthritis is a disease with relapses and remissions. What that means is that even if the patient does everything correctly, they take their medications very consistently, they take very good care of themselves and their health, they follow up with us on a regular basis as they should, their disease can still become more active from time to time for reasons that are not exactly very well understood. Sometimes a viral infection such as the flu or the common cold can trigger their immune system to become more active and under those circumstances the rheumatoid arthritis can flare. When that happens, the patients can feel worsening pain in the usually affected joints - their hands, their feet, their wrists, their ankles - it’s usually the same joints that bother them every time their arthritis is active, so those joints can become more stiff, especially in the morning, they can get more warm, they can get more painful, and that’s what we usually call a flare. This can happen in a very short period of time, usually within a few days and unless it’s treated, sometimes it can last for many weeks or even months. So, it’s very important when that happens that these patients communicate those findings to their rheumatologist because they will have to be reevaluated in the office and their medication regimen might need to be modified. Host: So, you mentioned there are all of these different sorts of advanced treatments that are available to patients now. Maybe ten, fifteen years ago what would the options have been for a patient? Dr. Loupasakis: Very few. And it is unfortunate because we still see patients who developed rheumatoid arthritis many years ago and unfortunately, since those treatments had not been available back then, we are in the unfortunate position to see deformities that have already happened in their joints. Thankfully we don’t really see those patients anymore. Patients we diagnose these days, they almost never progress to the extent that they would develop deformities in the joints. The patients that were diagnosed with rheumatoid arthritis, let’s say twenty years ago, the medications that we had back then were not as effective and the options were very limited. So, cortisone and maybe a few different types of tablet form medications that were not that effective and therefore they were not enough to prevent the rheumatoid arthritis from causing damage to the joints. So unfortunately, a lot of these patients ended up progressing and developing joint deformities and joint damage that limited the function of the hands. Host: Would it be fair to say that treatments have progressed from just symptom management to really treating and preventing damage with this disease? Dr. Loupasakis: I think that would be a very fair statement. It is true that with the older medications we would try to just treat the symptoms, the pain, but we would not necessarily target the source of the pain which is the inflammation itself and, also, we were not able to target the pathways that make the inflammation happen. Because of that, those medications they could potentially mask the symptoms, they could potentially make the patients feel a little bit better without slowing down the progression of the disease, so these patients oftentimes would still have a lot of joint damage down the line. Host: Could you share a treatment success story from your patient population? Dr. Loupasakis: Sure. I have quite a few, thankfully, I guess that’s a good thing. But I will never forget a woman in her 50s with severe rheumatoid arthritis. She had been treated with many different medications including high doses of cortisone and even though she would have brief periods of relief of her symptoms, she had never been able to go into what we call remission, a very persistent low disease state. She would always have flares every few weeks. She wasn’t able to enjoy her life. She had lost her functional capacity and she was really depressed. Thankfully, we have had so many newer treatments coming out and of course my patient had been discouraged, understandably, but knowing that improvement of her disease is possible, I wasn’t discouraged, and I tried to maintain the optimism in her treatment plan and I kept trying different medications. At this point, I have to highlight the importance of time. Her medications did not kick in right away and I think that this is something very important for our patients to remember, that sometimes these medications can take from a few weeks up to three months to really kick in. So that’s what we did with my patient. We kept trying different medications until we found a medication that was the right fit for her. And her disease dramatically improved. Her joint swelling and pain went away. She became much more functional again. She was able to enjoy her life with her family and with her grandchildren and she was really the happiest person. She was extremely thankful, and her depression really went away. Host: It’s clear that you really care about your patients a lot. When they’re in that time frame where they’re waiting for their medication to become more effective, how do you help them stay positive and how do you help them manage their pain? Dr. Loupasakis: We try to follow a multidisciplinary approach. We work closely with other subspecialties and we’re really open to referring these patients to psychotherapists, psychiatrists, to support groups, and we can provide them with resources in order to make that happen. I think it’s very important, it’s a very important part of the treatment because these are chronic diseases. They have long lasting symptoms and it’s understandable that a lot of our patients can be very depressed because their life changes because of the pain and because of the loss of function. So, until we get them back in good shape, which hopefully happens in most of the cases these days, it is important to maintain a sense of optimism and support them emotionally and psychologically in order to go through that very unfortunate and unpleasant phase. Host: Once a patient has found a medication that’s working for them and they’re really on the road to recovery, what sort of outcomes can they expect? Will they go back to a full functionality? Back to work, back to exercise and enjoying their hobbies? Dr. Loupasakis: The outcomes really range from complete restoration of their functionality to a reasonable improvement that would allow them to go back to some of their activities, but maybe not all of them. That depends, oftentimes, on how severely affected their joints have been. For example, if they have developed very severe damage to their hands or the knees, even if we take care of the inflammation, we can improve the pain significantly, but maybe the damage sometimes may not allow for a full restoration of their functional capacity. We really try our best to maximize the effect of our treatments, also combining that with physical therapy. And I think that’s very important because it really strengthens the muscles, it increases the range of motion of the affected joints, and in combination with the treatments that we provide, oftentimes we see very good outcomes with patients being able to go back to running, swimming, and playing sports. Depending on what they like to do. Sometimes maybe with some modifications in their activity, maybe the level of their activity can be a little bit decreased or they can modify the equipment that they use. For example, we can use some in-soles for patients with severe arthritis in the knees. Anything to minimize the impact in the affected joints. Host: Can weather or the environment affect a person’s RA symptoms? Dr. Loupasakis: It is a very interesting question because it is true that, I would say, even most of our patients have noticed changes in their pain and in their stiffness depending on the weather conditions. So even though it’s not easy to study those things in a structured clinical study, it’s something that our experience shows that it does happen. It’s not entirely understood why, but it’s been speculated that changes in the atmospheric pressure, sometimes that are associated with weather changes, can affect the joints and for reasons that are not entirely understood, patients can experience more pain during the winter months. Host: Why is MedStar Washington Hospital Center the best place to seek care for rheumatoid arthritis? Dr. Loupasakis: What the rheumatology division and my colleagues in this hospital do, is that we all strive for multidisciplinary approach and we all try to provide the best care that we can based on the needs of our patients. We are very up to date about the newest treatments. We educate the future rheumatologists of the area - we have the teaching hospital and we want to be on the cutting edge of the treatments and the scientific progress that have been accomplished in our field. That, and also the fact that we work with orthopedic surgeons, physical therapists, radiologists, to achieve the best outcomes for our patients. Host: Thanks for joining us today, Dr. Loupasakis. Dr. Loupasakis: Thank you. It was my pleasure. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Why are more people younger than 50 developing colorectal cancer? Dr. Brian Bello discusses the disturbing trend.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thank you for joining us today. We’re talking with Dr. Brian Bello, a colorectal surgeon at MedStar Washington Hospital Center. Welcome, Dr. Bello. Dr Bello: Thank you. Host: Today we’re talking about why more younger patients are dying of colorectal cancer. Once considered an older person’s disease, patients in their 30s and even 20s are being diagnosed with colorectal cancer, which is baffling the medical community. A 2017 study found that, after years of decreasing mortality rates, colorectal cancer deaths in adults age 20 to 55 increased 1 percent per year from 2004 to 2014. Dr. Bello, what do you think caused this seemingly sudden spike in colorectal cancer deaths? Dr Bello: That’s a tough question to answer. Many people have been looking at this. The answer is really unclear. We think it’s probably a combination of factors. I think if we look at the population now compared to 15 years ago - the population is more obese, that’s probably the driving factor. Patients diets are different than they were 15 years ago. People may not be exercising as much. And then there’s maybe genetic factors that we quite don’t understand. But we are looking at this very closely, but I think the number one issue is probably diet and weight. Host: Is this something that you’re seeing in patients locally in the Washington DC area? Dr Bello: Well, certainly people now are asking about it. Many patients come in and have read about this New York Times study and ask do they need a colonoscopy or they have friends that have recently been diagnosed with colon cancer and they are asking if they need one. So, certainly more people are asking about it. I think the key take-home lessons are people need to be educated about what signs and symptoms to look out for. So, if young people are experiencing abdominal pain that’s chronic, that doesn’t go away, or if they have rectal bleeding or unexplained anemia or weight loss, providers should be more willing to provide or give education about a colonoscopy. Host: What do you mean by unexplained anemia? Dr Bello: Yeah, usually this blood work is done by a primary care physician and it’s usually a yearly blood work laboratory value that can be checked. If a patient’s blood count is lower than normal and there’s not a good reason for it, then we need to investigate other causes of the blood loss. Host: How has the increase in colon cancer changed the screening recommendation? Dr Bello: Currently we’re not changing our screening recommendations. Usually the screening for Americans is everybody over the age of 50 needs a colonoscopy, which is the gold standard for colon cancer screening. For younger patients, as I mentioned earlier, we look for signs and symptoms. If they have concerning things that are chronic, then we recommend a colonoscopy. If we started screening earlier, that would probably mean more unnecessary tests - tests that are very costly and these tests that we do aren’t without risk. We do the CT scans for many reasons, and sometimes we’ll pick up things that are of benign cause, meaning that there’s nothing really to worry about but that usually prompts more tests which mean that patients are paying maybe more money, and these things are clinically relevant, meaning that you could find like a cyst in your liver and then we do additional tests and you really didn’t need to look at that at all. So, we try to avoid unnecessary tests just because they’re costly and could provide risk to the patient. In today’s field of medicine, we’re trying to be more cost efficient, cost effective. So, right now we haven’t changed our screening recommendation - we’re just looking for signs and symptoms -  if these younger patients have those, then we recommend a colonoscopy. Host: How can a young adult patient determine whether they’re at risk for developing colorectal cancer early in life? Dr Bello: So, one thing that we always look for in these patients are a good family history. So if a patient has any family history of colon cancer in their family, especially relatives that were diagnosed at age 50 or younger, we’re more likely to recommend a colonoscopy. And again, those signs and symptoms that I had mentioned already - bleeding, abdominal pain, weight loss - those are the things we look out for. Host: What can patients can to reduce their risk of developing colorectal cancer? Dr Bello: Yeah, we always recommend a healthy lifestyle. Number one is definitely watch what you eat. So, we try to encourage people to eat a high-fiber diet, try to avoid fatty food, avoid fried food. In addition, we recommend that people exercise. Also, we recommend no smoking and try to avoid a lot of alcohol use. Host: How does smoking and alcohol use affect the colon? Dr Bello: So, that’s a good question. It’s unclear but we know that people that smoke more are at significantly increased risk of many different things - heart problems, stroke - but specifically for colon cancer we find that there’s an increased risk. It’s an unclear connection. It might have to do with some weird effect that smoking has with the bacteria in the colon or the lining of the colon. It’s unclear. But we just know that from studies there’s an association with it. Host: What makes MedStar Washington Hospital Center the best place to seek screening and treatment for colorectal cancer? Dr Bello: Well, here at MedStar Washington Hospital Center, we have a multidisciplinary team. That means we have experts in different fields - like surgeons, gastroenterologists, medical oncologists, pathologists, radiologists - that all see a lot of colon cancer and rectal cancer. So, we just do a lot of high volume. We do this day in and day out and we’re just specifically looking at colon cancer. Because of that I think we see better results and better outcomes for patients. Another thing we do at MedStar Washington Hospital Center is we promote the use of laparoscopic surgery. So that is surgery that we use very small incisions to do major, complex abdominal surgeries in. So we can do, for example, a colon resection with 3 or 4 very small incisions, and when we do this, patients tend to do a lot better. They have less wound complications, we can feed those patients earlier, and they tend to get out of the hospital much faster. So that is another thing we do at Hospital Center that makes it a great place to go for your colon cancer surgery. Host: What is a colon resection? Dr Bello: So, a colon resection is a surgery where we remove part of the colon and the fatty tissue surrounding the colon. Usually treatments for colon cancer or other colon problems. So, the old fashioned incisions usually were anywhere from your sternum to your pubic bone. But usually now we can do them with some stab incisions, which are about a centimeter and maybe one other incision that’s maybe 4 or 5 centimeters, where we pull out that part of the colon. Host: Are you currently doing any research on colorectal cancer that you’d like people in the community to know about? Dr Bello: Yes, I have research interests in colon cancer, specifically about screening, which we’re talking about today. Specifically, we’ve been looking at why people aren’t getting their colon cancer screening. So, again, everybody over age 50 should have some sort of colon cancer screening, whether that be the gold standard with the colonoscopy or some sort of stool test. It should be done. But for some reason people aren’t getting them done. Approximately 40% of patients across the U.S. and in DC don’t get the appropriate colon cancer screening. So, we’ve done some surveys to find out why. The number one reason why people don’t get colon cancer screening is that they felt that they weren’t educated about it, they didn’t know about it, their primary care physician didn’t tell them about it. Those are the driving factors, but we’ve also found things like people were worried about the bowel preparation they have to do before a colonoscopy or they were worried about procedural risks or they just didn’t like talking about their GI system. Host: How do all of the surgeons and physicians work together to provide a team approach to care for colorectal cancer? Dr Bello: So, usually when somebody is diagnosed with colon cancer, we present each of these cases at a multidisciplinary tumor board. We review the CT scan images, the biopsies, and we come up with an individualized treatment plan for the patient. And that’s when everybody can chime in and give their recommendations and we come up with one plan for each individual patient. Host: Could you share some screening or treatment success stories from your young adult patient population? Dr Bello: I was involved in the treatment team of a young 20 something year old gentleman. He had some routine blood work done, which showed anemia. His primary care physician recommended that he get a colonoscopy. Unfortunately, that colonoscopy showed multiple large polyps throughout his colon and many of the biopsies showed that these polyps had pre-cancerous cells in them. So then he was referred to me and then I recommended that he undergo a colon resection and we did that. We did that with small incisions called laparoscopic surgery. He did great post-op and now he’s on a very good surveillance plan where we’re doing routine colonoscopies. He did great. If he doesn’t get that blood work or if he doesn’t get a colonoscopy, these polyps would have likely have turned in to cancer by now and then a lot more difficult to treat. Thankfully, we caught them early, and we did his surgery early, and now he’s doing great. Host: In those younger patients, where they have unusual lab testing, is surgery usually the best option to treat them? Dr Bello: Oh, hopefully, if the lesions are small, like if they’re just polyps, we can remove those with a colonoscopy. Only if these polyps grow very large or they are cancerous do we recommend surgery. The goal of the colonoscopy is to find these polyps and to remove them at the same time. Host: So the colonoscopy can serve both as a screening tool and as a preventive measure? Dr Bello: Yeah, what’s really good about colon cancer screening is, if you get a colonoscopy, we’re able to find these polyps before they turn into cancer - that’s the key. Host: Thanks for joining us today, Dr. Bello. Dr Bello: Thank you very much. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Thoracic surgery has come a long way in the last century. Dr. John Lazar discusses how patients in Washington, D.C., can benefit from safer, more precise surgeries with faster recovery through minimally invasive robotic technology.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re speaking with Dr. John Lazar, Director of Thoracic Robotics at MedStar Washington Hospital Center. We’re discussing robotic surgery, a minimally invasive technique, which increasingly is being used for esophageal, lung, and other thoracic conditions. Dr. Lazar, what do you mean when you say robotic thoracic surgery? Dr. John Lazar: So, basically, we mean we’re doing minimally invasive surgery and it’s robotically assisted, meaning the surgeon is in total control of the robot. Nothing is automated, and yet we’re taking advantage of robotic technology, which would be 3-D visualization, uh, removal of any tremor, and basically being able to manipulate the robot in small, hard to reach areas. Host: When you say removal of tremor, is that from the physician’s hand? Dr. Lazar: not necessarily the way you would think about a tremor, but for every three motions I make, the robot will make one. So, it sort of stabilizes the hand - there’s no big lunging motions - so we call it stabilization. Host: What are some of the more common thoracic procedures that are performed with robotic surgery? Dr. Lazar: So, when we think about robotic surgery, we think about three main areas, one of which is the lung. Uh, the other one is called the mediastinum, which is the central part of the chest - the soft tissue’s there, which includes the thymus. And the other part is the esophagus as well as the stomach. Host: Are you treating conditions that are just cancer or what sort of conditions are you looking for? Dr. Lazar: So, we treat conditions that are both cancerous or malignant as well as benign, meaning non-cancerous. Um, non-cancerous conditions are especially prominent in the esophagus - such things as paraesophageal hernias, where the stomach actually over time goes up into the chest. Uh, we also treat things like lung cancer. There are some benign diseases of the mediastinum which we also treat, but they have to be treated with excision. And, that’s pretty much it when it comes to the robot. Host: So, what are some of the patient benefits that people can expect when they get a robotic surgery as opposed to a traditional surgery? Dr. Lazar: So, traditional surgery we’re talking about usually a large incision, something anywhere from six inches to twelve inches. Uh, when we talk about robotic surgery, we call it port-based surgery. It’s minimally invasive and instead of the instruments kind of grinding back and forth, they go through a port and so there’s only one small area where the port is touching the skin, and so generally we find that there’s less pain afterwards. People are able to get back to their daily lives quicker. So, in terms of comparison in after-care for robotic surgery versus open surgery, uh, most people who have open surgery are in the ICU anywhere from one to three days, maybe sometimes five days, whereas most patients who get robotic surgery do not need to go to the ICU and therefore, they’re up and out of bed and walking around the floors much quicker and the tubes - there’s usually a tube after surgery - that can come out. And I tell most of my patients that they’re in the hospital three to five days. Everybody’s a little bit different, but that’s about it. Um, most people are walking - they’re walking up the stairs - they’re eating, they’re drinking. Uh, they’re usually...their biggest complaint is they’re a little bit sore, but nothing compared to open surgery. There’s less narcotic use, uh, for minimally invasive and robotic surgery and they’re usually 90 percent better by ten to fourteen days after surgery. That’s not out of the hospital - that’s after surgery itself. Host: How do patient outcomes with robotic surgery compare to those of traditional surgery? Dr. Lazar: So, robotic patients are minimally invasive patients. So, generally speaking, if you’re able to get a minimally invasive procedure, meaning smaller incisions, patients usually do better quicker. Over the long term, they do just about the same. But the idea that robotic surgery is just another type of minimally invasive surgery, the advantages being more for the surgeon and less from the patient when we talk about things like VATs or laparoscopic surgery which are other types of minimally invasive surgery. For the surgeon, we’re able to get into smaller places, we’re able to visualize things in 3-D as opposed to just on a flat screen TV, which is the way we do it in traditional minimally invasive. And this allows us to do more highly technical procedures in a smaller space. So, in comparison to open surgery, I think where robotics has really helped the patient is getting them a better...technically a better operation, whether it’s cancer operation or whether it’s for something like paraesophageal hernia, and I think that’s because the surgeons can see better. They are not constrained by stiff instruments like you have in VATs and laparoscopic surgery. In robotic surgery there’s...the wrists are able to flex just like your own wrists and we’re able to see things that we normally couldn’t see and therefore we’re able to do better operations. You’re better to see the margins, and I think that that plays a big role in the post-operative care. Host: Why is MedStar Washington Hospital Center the best place to seek thoracic surgery from a robotic or a minimally invasive standpoint? Dr. Lazar: I would say that the group of surgeons across multiple disciplines are outstanding here - and that’s one of the major reasons why I came to join the thoracic team. They have a great deal of experience. They’ve been doing this for many years. They have gone through their learning curves already, and they’re able to offer patients an advanced level of robotic care at the cutting edge. Robotics is being employed by a lot of different specialties, not just thoracic. So, ENT is doing some cancer operations, uh, for tonsils and tongue-based cancers. Gynecology, urology are using it a lot as well for both malignant and non-cancerous procedures. Host: Thinking about those patients as you were talking, have you had any outstanding or really interesting patients that you could talk about in generalities? Dr. Lazar: There was an example of a young man who was, uh, working at home, felt his, uh, back sort of twinge, didn’t think anything of it. And then a week later went to his primary care physician who got a chest x-ray and saw that there was a mass along the left side of his chest. It led to a cat scan and showed a mass. His other surgeon was gonna do a large open procedure. Uh, luckily for him, they didn’t accept his insurance and so he came to me as a second referral. And, uh, we were able to do it minimally invasively. It turned out to be a benign cyst that was growing along his major artery called the aorta. We were able to do the surgery safely and he went home the next day and so far has not had any other issues and went back to work within two weeks. Host: You mentioned that your patient had had back problems, and that’s what prompted him to see his doctor. What are some of the other symptoms that patients often notice before they get to you? Dr. Lazar: I would say that pain is usually the number one, um, issue that patients have when it comes to the esophagus or the stomach. There’s usually things like nausea, bloating, indigestion, reflux - those types of things. Also, weight loss can be a big part of it. Fatigue. Host: Tell me a little bit about your patient population. Are you seeing mostly older folks or what does that look like? Dr. Lazar: So, I think, you know, being in the D.C. area, you see a lot of different people that you normally wouldn’t see. It’s a...it’s a much different population, probably because so many people move here from different parts of the country. So, we see people from 16-years-old to, you know, people in their 90s. And they have a variety of different issues. Um, some are cancerous and some are not. Um, so there’s... it’s really hard to pinpoint it on one thing, which is one of the nice things about practicing here at the...the hospital center is...is you do see a large variety of people. Host: Who’s at risk for these types of conditions? Dr. Lazar: So, I would say that the youngest people that we usually see are in their 30s but it goes all the way up in to the 90s, especially for the benign esophageal. This can happen to anybody at any age because it’s just a weakening of the muscle lining. Host: Is surgery the first line of defense, or the first treatment for these types of conditions or do you typically try another therapy first? Dr. Lazar: So, when you’re talking about non-cancerous things, obviously people try to avoid surgery at all costs. But usually once the symptoms become impinging on their quality of life, they generally seek surgical opinion. They’re not necessarily sold on surgery at that point but they at least want to keep their options open, especially if medical therapy tends to get more and more expensive, such as anti-acid medications and things like that. Host: Do your patients typically have to see their primary care doctor first or can they refer right to you? Dr. Lazar: It depends. Some people come right in to the emergency room, and if that happens, then it kind of bypasses the primary care but I think if they have a primary care, they should see their primary care first and get properly worked up. Most conditions are not surgical. Host: Are you or your colleagues participating or conducting any research right now on thoracic surgery field that you’d want people to know about? Dr. Lazar: Um, we are looking to become one of the first centers to robotically repair something called tracheobronchial malacia, which is a weakening of the trachea which is the windpipe that connects your mouth to your lungs. And basically, if it loses its integrity and it just starts to collapse, it can be very difficult and easily winded. In the old days we didn’t really have a lot for this, but now we can buttress it and sort of reinforce that integrity of the trachea and allows them to have a much better quality of life and not feel continuously short of breath. Host: Thanks for joining us today, Dr. Lazar. Dr. Lazar: Thank you. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Due to advances in imaging scans, kidney cancer often is detected by chance and early in the disease process. Dr. Ross Krasnow discusses minimally invasive robotic surgery and other treatment options for localized kidney cancer.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re talking to Dr. Ross Krasnow, a urologist who specializes in urologic oncology at MedStar Washington Hospital Center. Welcome, Dr. Krasnow. Dr. Krasnow: It’s great to be here. Host: Today we’re talking about management options for localized kidney cancer and, in particular, the minimally invasive surgery options available to some patients. Dr. Krasnow, what do you mean when you say localized kidney cancer? Dr. Krasnow: So, localized kidney cancer is cancer that originates from the kidney but is confined to within the kidney or the fat surrounding the kidney or adjacent structures surrounding the kidney. It can also be in some of the lymph nodes, but it has not yet spread to far away lymph nodes and other organs that are not directly touching the kidney. Host: How common is kidney cancer, in general, and then how common is localized kidney cancer? Dr. Krasnow: So, kidney cancer is the seventh most common cancer generally, in men and in women. When it presents, most of the time it is localized at the time of presentation. And that’s really because of a stage migration that’s occurred over the years. The kidney lies in the back of the body, and as you can imagine, before we had advanced imaging, it was only picked up when it became symptomatic and at that point it was very large, it would cause pain, it would cause blood in the urine, and it had often already spread at the time of presentation. Now there’s been a stage migration and what that means is often it is picked up incidentally. A patient has imaging such as an ultrasound or a cat scan for another purpose. They have gallstones, they have vague pain, they have indigestion. And they end up getting some sort of imaging and that imaging just happens to show a small renal mass. More and more we’re picking this up when it’s asymptomatic and confined to the kidney, and it’s easier to treat. Host: So, an individual could come in thinking that maybe they’re just having some back pain and they get an MRI for example, and it turns out that it’s cancer. What is somebody’s reaction to something like that? Dr. Krasnow: Just to be clear, often when they get that MRI for back pain, the pain is not even related to the cancer; it’s completely unrelated. I think most patients, when they learn that they have a renal mass, are very nervous. And I hope that when I see them and talk to them I can reassure them that they’re going to be fine, most all of the time. Especially when these tumors are small. They’re very easy to manage and very rarely life-threatening until they get to a certain size or demonstrate evidence of spread. Host: So, does kidney cancer tend to strike certain individuals or certain demographics of people more often than others? Dr. Krasnow: It’s actually quite sporadic. There’s a slightly increased risk in patients who are smokers, patients who are obese and have diabetes. Certainly, there’s an increased risk in more unusual patient populations such as those with certain genetic predispositions or those on dialysis. But I would say, for the most part, the vast majority of patients I see it in, it‘s completely sporadic. Host: So, if an individual is diagnosed with a localized kidney cancer - so that fairly contained cancer - what types of treatment might a doctor recommend? Um, you know, traditionally they talk about active surveillance, they talk about radiofrequency. Can you talk about those common types a little bit, and then some of those minimally invasive options? Dr. Krasnow: When I first see a patient that comes to me with a renal mass, I’m actually reluctant to call it a cancer right away. And that’s because one third, one out of three patients with a small renal mass less than, say, three or four cm, don’t actually have cancer. They just have a growth on the kidney. The other two thirds of those patients do have a cancer, but it actually tends to not be very aggressive, and these cancers are not very aggressive until they’re over, say, three or four centimeters. Once I frame it like that, patients are immediately reassured. And then I talk about some of the management options. Active surveillance is a great option for certain patients. Even renal masses less than three cm have almost no metastatic potential. And that ultimately is what we worry about, not actually having a tumor on the kidney but having a tumor on the kidney that has the potential to spread. Knowing that allows us to offer active surveillance for patients. That means that we watch the mass every, say, three to six months for some time, maybe extend that out to every year, and if the tumor doesn’t seem to be growing, we may not need to treat them at all. This is a really great option for patients who are older, have a lot of other medical problems, or, for whatever reason, are reluctant to have surgery. Maybe they have just one kidney, and were very concerned about preserving their kidney function. When the tumors are over three or four cm, I do tend to recommend some form of treatment, although that’s not always the case. And, of course, it’s not realistic to watch tumors in patients who are very young. You’re not going to watch a tumor in a thirty-year-old for forty years. So, when we talk about the treatment options, again, there are many.  One is often we don’t even have to biopsy these masses but sometimes we do biopsy them to confirm that they’re a cancer.  The treatment options from the least invasive to the most invasive, would be having our colleagues in radiology simply put a needle in it, and through that needle they can burn or freeze the mass. That is called radiofrequency ablation when you burn it or cryoablation when you freeze it. Again, that’s a great option for patients who are older, have some other medical problems. It’s also a great option for tumors that are small and in a location where the damage from freezing it or burning it would be confined to just the cancer and not damage other structures that are nearby. The long-term results of cryoablation and radiofrequency ablation are not as clear. The short-term results show very good efficacy, maybe just a little bit less than radical surgery—but not by much.  There are certainly situations where ablative techniques are not appropriate. If the tumor is large, is in the middle of the kidney close to blood vessels, close to adjacent organs such as the pancreas, the duodenum, the liver, if it’s close to where the urine collects in the kidney - those techniques aren’t controlled enough.  So, at that point, we do recommend radical surgery. Also, patients who want the most effective treatment, the gold standard, we recommend radical surgery. Most often for a small renal mass that is a partial nephrectomy. So, that’s removing the part of the kidney that has the cancer in it while leaving the rest of the healthy kidney behind. In the past, we did too many radical nephrectomies. That’s when we remove the whole kidney for small renal masses. It was really unnecessary. While effective as a cancer therapy, it hurt patients in terms of their renal function, and we really concentrate on maximizing and preserving renal function now. Host: When you have those treatments such as radiofrequency or cryoablation, those very focused and targeted type therapies, do you also have to undergo chemo or radiation, or any other subsequent treatment? Dr. Krasnow: It actually is one of the few cancers that doesn’t respond well to chemotherapy at all.  And agents for the management of kidney cancer tend to work on the immune system. They also tend to be reserved for patients with metastatic disease or disease that’s already spread. Radiotherapy is ok for kidney cancer. The problem is that it damages the rest of the kidney. So, for localized kidney cancer, chemotherapy and radiotherapy are not…are not needed and they’re not great options. Host: So, what about something like immunotherapy? That’s…that’s becoming more and more common for so many types of cancers. Could you talk about that a little? Dr. Krasnow: Yes. So, immunotherapy for kidney cancer has made a lot of waves lately as second line therapy for patients with metastatic disease who have failed first line therapy. There are investigational studies looking at it for localized kidney cancer. Those would be patients who have a very large mass that may not be able to be treated surgically, and you may consider giving them some sort of therapy before surgery to see if you can shrink it to the point where surgery is a viable option. The other space that it’s being looked at is in patients with high-risk localized cancer, so they had surgery but the tumor appeared very aggressive, and the risk of recurrence is high. In that…those are patients you may consider giving an agent such as an immunotherapy agent right after surgery, even if they don’t have evidence of metastatic disease. Those two settings are completely investigational right now and are not the standard of care. Host: Let’s go back and talk about those surgical options.  So, could you elaborate a little bit further on partial nephrectomy? Dr. Krasnow: So, partial nephrectomy is when we remove the part of the kidney that just has the cancer in it, leaving the rest of the healthy kidney behind. This is in order to preserve renal function and also to maximize cancer control, arguably better than the ablative techniques, such as cryoablation and radiofrequency ablation. The great progress that we’ve made in partial nephrectomy is that we’re now able to do it in a minimally invasive fashion, specifically using robotic laparoscopy. This allows us to make small keyhole incisions, get to the kidney, remove the part of the kidney that has the cancer in it using excellent visualization that the robotic optics provides for us, and then reconstruct the kidney afterwards, to close up all the vessels, and to close up where the urine drains out, in order to achieve a good outcome for the patient. And we can now approach the kidney from the front or from the back, which is helpful for patients who have a tumor in the back of the kidney or for patients who have had prior abdominal surgery where the abdominal cavity may be very scarred and adhesed. Both of these techniques are also extremely good for patients with obesity, because otherwise an open incision would be very large, painful, and lead to a longer recovery. Host: So, when you’re talking keyhole incisions, about what size is that? Could you give a visual? Dr. Krasnow: The incisions are between half and one centimeter. Host: And how does that work when you’re going in through such a small incision - how are you able to remove part of an organ? Dr. Krasnow: So, we have a camera that has 3-dimensional vision. When we’re doing the surgery, we can actually get depth perception. And, the instruments we place are wristed, so we get more dexterity than we would otherwise through what we would call straight laparoscopy. The last option for localized cancer, when we can’t spare the kidney, we do have to often remove the whole kidney, and maybe remove some of the lymph nodes around the kidney, and we’ve also made advances in minimally invasive techniques for more advanced localized kidney cancer. When kidney cancer that’s localized is very advanced, it can even extend into big vessels within the body, and traditionally that type of surgery would be approached open in order to perform a vascular operation where you’re not only removing the kidney, but you’re removing tumor that’s within blood vessels. This can now be done oftentimes using the robotic platform as well. So, whereas patients would be staying in the hospital for a week or two after surgery with a prolonged convalescence, they can go home in a day or two with very little blood loss. Host: So, when you approach a patient who you’ve determined needs surgery for their kidney cancer and you say, “We’re gonna offer you this robotic treatment method,” what’s their reaction, or what questions do they usually have? Dr. Krasnow: Most patients are just interested in how long they’re going to be in the hospital for and how long it’s going to take them to recover. And also, they want a treatment option that’s going to offer the best chance at cure. And I tell them that the robotic partial nephrectomy or a minimally invasive radical nephrectomy is the best way to achieve cure but also provides them to have a fairly rapid recovery. Host: What does that recovery time look like in comparison to that traditional open surgery? Dr. Krasnow: So, the traditional open surgery, in order to get to the kidney, we would have to make a very large incision in the front or the side of the patient, have to go through many layers of muscle, and sew that back together. Patients after were extremely sore, they would have difficulty walking and breathing afterwards because of the soreness. Also, during the surgery there was an increased risk for blood loss and other complications. Because we’re making small keyhole incisions, the patients have very controllable pain after surgery. They can restart their diet much earlier, the next day really. Most patients can go home one or two days after surgery compared to staying in the hospital for a week or longer, and they can get back to work much quicker. Host: What sort of, uh, restrictions at home or restrictions at work would an individual have after that minimally invasive surgery? Dr. Krasnow: So, after surgery, actually the day after surgery, we want them up walking, moving around, sitting, eating, trying to get back to as much normal functioning as possible. The only thing I ask the patients not to do for a few weeks after surgery is to avoid really heavy straining, heavy lifting, running, strenuous exercise, swimming - things like that, but for the most part they can go about their day when they get home. Host: What are some of those other benefits for the patients or for their caregivers to minimally invasive surgery? Dr. Krasnow: For some people, cosmesis matters. And the small incisions are much more cosmetically pleasing than the large incisions we made in the past. So, for certain patients who are looking to go swimming that summer and want to wear a swimsuit, you can hardly ever tell that they had surgery. I think that technology is even going to get better. Host: Thanks for joining us today, Dr. Krasnow. Dr. Krasnow: Thank you so much for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

As younger adults receive total knee and hip replacements, and as people continue to live longer, more replacement joints will need to be replaced themselves. Dr. Savyasachi Thakkar discusses how a revised knee or hip can give patients decades more of the improved mobility and activity they’re used to.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thank you for joining us today. We’re talking with Dr. Savysachi Thakkar, an orthopedic hip and knee reconstruction surgeon at MedStar Orthopaedic Institute at Washington Hospital Center. Welcome, Dr. Thakkar. Dr. Thakkar: Thank you very much for having me. Host: Today we’re talking about total joint revision, which is a procedure in which a worn-out joint replacement device is replaced with a new one. Because more patients are seeking joint replacements at younger ages and because seniors are living longer now than ever before, the need for revision procedures is expected to increase over the next few decades. What are some of the common signs that a joint replacement device is wearing out or has become not as effective as it once was? Dr. Thakkar: That’s an excellent question. So, joint replacement failures can occur due to several reasons, but the patient will manifest with 1 of 2 or both problems. The first problem is pain and this is pain in excess of pain they have had previously, and they will notice a specific instance that is associated with that pain or increase in pain. They may also have increased reliance on pain medications to try and control that pain. The second thing that patients most commonly describe is instability. They’ve had a stable, pain-free joint for several years and now all of a sudden, they’re tripping more, they’re falling more, they need a cane, they need a walker to try and walk. These are the hallmarks of a failed total knee or a total hip replacement surgery that need to be evaluated, and we, at the MedStar Washington Hospital Center and the MedStar Orthopaedic Institute, are fellowship trained in dealing with such procedures and dealing with such patients, and we see such patients on a routine basis and perform about 200 or 300 revision surgeries each year with patients requiring them. Host: How long should a typical hip or knee replacement device last? Dr. Thakkar: That’s an excellent question. So, with the newer bearing surfaces that we have today, a current knee replacement or hip replacement lasts on the average of 20 to 30 years. For the most part, about 60 to 70% of patients around the age of 50 will continue to have their prosthesis either after total knee or total hip prosthesis for 30 years. In the older days, these devices would last only for about 10 or 15 years, so frequently, with the current healthcare standards that we have in patients outliving a number of their surgeries, we will see patients that have had these procedures done only about 10 or 15 years ago with the older implants that need a revision, and we at the MedStar Washington Hospital Center can care for such patients. Host: Could you talk about your patient population who are receiving total joint revisions? What…about what age are these individuals and about what health? Dr. Thakkar: Most of these...most of the patients that come to the MedStar Washington Hospital Center and the MedStar Orthopaedic Institute seeking a revision hip or a revision knee replacement are about 60 or 70 years old. They’ve had their primary hip or primary knee done when they were about 50 or 55 years old, and that’s lasted them for the last 10 or 15 years. These are active individuals that want to maintain that activity level that, in fact, want to try and achieve a lot more in their golden years. They want to try and live pain free, they want to try and get back to work if they’re still working or else find new jobs, and I think that’s a testament to the fact that these surgeries have been successful and now doing a revision surgery gives them another 30 years of the lifestyle that they desire and the lifestyle that they seek. Host: Is there anyone who wouldn’t be a candidate for total joint revision? Dr. Thakkar: Patients that have pain and instability and that are living with total joint replacements are always a candidate for total joint revision, and unless they have very dire medical comorbidities that preclude them from having surgery, everyone is a candidate for revision total joint replacement. Some of those comorbidities are significant cardiac comorbidities or significant cancer burden that these patients have with limited lifespan, and the risk of operating on them is not worth, as these patients may end up losing a significant amount of functional status after the procedure. Host: So, total joint replacement, the first time around, can be kind of a lengthy process with a lengthy recovery. How does the total joint revision recovery compare? Dr. Thakkar: That’s an excellent question. So, if the revision is for a simple bearing surface that has worn out, we can usually get the patients back feeling back to normal without a lengthy recovery. However, if the revision is for a more deep-seated problem, like an infection or a fracture, we may need to extend the period of recovery for these patients for up to 3 to 6 months. After that time period, most patients come back to their pre-revision activity level and in fact supersede that because they’ve been dealing with instability or pain issues for the last several months before coming to see us. Host: Do your patients typically have to enter rehab facilities, or how does that process work? Do they rehab at home? Dr. Thakkar: For the most part, if they get a single joint revised, whether it’s a single knee or a single hip, patients are able to go home and have the outpatient physical therapist visit their home for the first 2 weeks and then transition on to outpatient physical therapy. However, if their needs are more profound, we’re able to get them to a rehab facility for the first 1 or 2 weeks after surgery and then transition them to a home setting. Host: Total joint revision procedures can be fairly complex, if not more so complex than initial joint replacement. So, could you describe how the two procedures compare? Dr. Thakkar: Absolutely. At the MedStar Washington Hospital Center and at the MedStar Orthopaedic Institution, when a patient walks into our offices that requires a revision hip or a revision knee surgery, the first place we start is by understanding the patient’s expectations. Along with that, we have imaging studies, dedicated imaging studies focused on radiographs, CT scans, sometimes even MRI scans, to try and get the full picture of why that joint replacement prosthesis has failed. Along with that, we send patients for blood work to make sure that there’s no infection, which can happen in some of these long-standing implants. Once all of these things have been thoroughly evaluated by our fellowship-trained experts in total joint replacement and total joint revision surgery, we then proceed to surgical planning. We work with a dedicated team that focuses its attention on custom implants which are sometimes needed in these patients. We work with companies directly to try and order these implants and plan for them in advance so that we do not run into situations on the day of surgery where the implants are not available. Then we work with our physical therapists to evaluate the patient’s mobility beforehand. During surgery, we routinely use the same anesthetic protocols as we use for outpatient joint replacement surgeries to try and minimize the overall anesthetic effects that the patient sees. And in the postoperative setting, we work with the same multimodal protocols to try and control their pain, which may be a little bit more severe in the initial first few days after surgery, but then with this multimodal pain protocol, it tends to get reduced pretty significantly and patients tend to have a better outcome. With regards to my colleagues, Dr. James Tozzi and myself are fellowship-trained experts that focus on hip and knee revision surgeries, including primary surgeries. We have over 40 years of experience performing such procedures on a routine basis. Dr. Wiemi Douoghui and Dr. David Johnson in our department focus on primary joint replacement surgeries. Host: Is there anything that a patient who currently isn’t having problems with their joint replacement device--is there anything that those individuals can do to help make their device last longer or to care for it better? Dr. Thakkar: Absolutely. Devices are mechanical objects which are subject to failure. However, one of the things that I tell patients routinely is to use those devices to the fullest maximum potential that they are comfortable with. If they feel that they can achieve their maximum activity status without compromising on pain levels, without compromising on their activities of daily living, I think that the device is working just well and just perfectly for this patient. However, if the patients start noticing that they’re hurting more or that they’re feeling more unstable, I recommend these patients to come and seek out attention at the MedStar Washington Hospital Center, MedStar Orthopaedic Institute. Host: Why is MedStar Washington Hospital Center and the MedStar Orthopaedic Institute the best place for a patient to go for a total joint revision? Dr. Thakkar: So, total joint revisions can be tricky situations. First and foremost, you need to understand why the joint replacement surgery has failed. For this purpose, we have several experts, including Dr. James Tozzi and myself, that deal with such procedures on a routine basis. Not only that, you also have to understand the overall medical picture of this patient.  The MedStar Washington Hospital Center has experts in cardiology, experts in neurosurgery, experts in various other departments that are trained to deal with complex patients with complex needs. Having a revision procedure performed in a non-tertiary hospital is always challenging because they cannot care for this patient and its entirety.  At the MedStar Washington Hospital Center and the MedStar Orthopaedic Surgery…at the MedStar Orthopaedic Institute, we’re fortunate to be working in a tertiary care facility which can deal with patients as a whole and not just piecemeal, and hence this is the best place to get a revision joint replacement procedure performed. Host: Dr. Thakkar, how many total joint revisions does the orthopaedic team at MedStar Washington Hospital Center perform annually? Dr. Thakkar: At the MedStar Washington Hospital Center in the MedStar Orthopaedic Institute alone we perform about two or three hundred revision surgeries each year. We have Dr. James Tozzi and myself who specialize in primary and revision hip and knee replacement surgeries. We also have Dr. Wiemi Douoghui and Dr. David Johnson who focus on primary knee replacement surgeries. Knee revisions or hip revisions can be multifactorial and at the MedStar Washington Hospital Center we have an expert team with over 40 years of experience devoted to the care of such patients. We've used traditional as well as cutting edge technology for caring for these patients, and overall our outcomes are far superior to many other institutions in the area. Host: Could you share some success stories from your patient population? Dr. Thakkar: Absolutely. So, one of our patients…she was suffering from systemic lupus erythematosus. It’s a autoimmune disorder. She was referred to me by my rheumatology colleagues as she had several hip replacement surgeries and several surgeries in the past that had failed for instability issues. We were able to identify the instability, the cause of the instability, and we were able to very successfully try and replace a certain component in her prosthesis that had worn out, and after that she’s been able to get back to her activities of daily living. She’s very active, very active in the community, and likes to contribute to her church and to her society, and has been able to get to that in a very successful way, despite having a significant limitation. Host: Thanks for joining us today, Dr. Thakkar. Dr. Thakkar: Thank you very much. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Colonoscopy can be an uncomfortable topic, but the fact is that it saves lives. Dr. Jennifer Lee discusses common excuses for not getting the test, who should be screened and why colonoscopy is so important.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thank you for joining us today. We’re talking with Dr. Jennifer Lee, a gastroenterologist at MedStar Washington Hospital Center. Welcome, Dr. Lee. Dr. Jennifer Lee: Hello. Thanks for having me. Host: Today we’re talking about colonoscopy and the national campaign 80 percent by 2018. The goal is to increase the colorectal cancer screening rate to at least 80 percent of eligible adults by the year 2018. Colonoscopy is the gold standard of colon cancer prevention and with regular screening, precancerous masses called polyps often can be removed before they turn into cancer. Dr. Lee, why do people avoid colonoscopy, a screening that can effectively prevent devastating colorectal cancer? Dr. Lee: I think for many reasons patients would avoid colonoscopy. One is maybe they don’t want to know. But I think the biggest reason is they find it to be uncomfortable, or, you know, who wants to come in and have something inserted in their backside? Host: Could you discuss why someone wouldn’t want to know? Dr. Lee: Yeah, I think some patients know that you maybe they have symptoms. Maybe they have a little bit of bleeding. Maybe they have a change in their bowel habits. And so they kind of suspect that something’s wrong, but, you know, you don’t want the devastating news of cancer, which is why screening colonoscopy is so important. We do it in asymptomatic individuals, and the goal is to prevent cancer. I often get asked, “Is colonoscopy the only way to screen for colon cancer?” And the answer is no. We have other noninvasive ways to screen for colon cancer, and they’re very good. But colonoscopy is a test of cancer detection, but also cancer prevention, and it’s because we’re able to take off polyps and prevent them from growing into colon cancers. Host: What are some of the alternatives if someone is really averse to colonoscopy? Dr. Lee: They’re mostly stool-based tests. Your primary care doctor can provide it. We provide it, as well. The oldest method which is fecal occult blood testing or, FOBT or otherwise known as guaiac testing. But there are better tests now and those include the FIT test and the Cologuard. Host: Are those tests done at home or at the doctor? Dr. Lee: They are done by providing a stool sample, so they are arranged through the doctor, but most patients just, sort of, do it at home. I think a misconception is that your doctor is supposed to take your stool sample with a rectal exam in the office, but it’s supposed to be a spontaneous stool sample. Host: How do you discuss colonoscopy and why it’s so important with your patients if they come in with fear or anxiety about the test? Dr. Lee: The way I describe it to my patients is the hardest part is the prep. You can’t eat the day before. You are drinking a laxative that potentially is not the best tasting laxative.  And then you have to stay by the toilet. And you know, I tell my patients to think of it as a cleanse and I think people get that. And then by the time you’re coming in, you just have an IV inserted and you get to take a nap. After you take your nap, you wake up, you’re done. So, it’s not as bad as people think it is. I think if you ask most of the patients in recovery, they will tell you that. “Yeah, it wasn’t that bad, it wasn’t as bad as I thought it was going to be,” and I’ve had patients say “I’m going to go tell my friends it wasn’t that bad. I’m going to send them all here.” As a field, gastroenterology is moving towards more advanced procedures in the care of colon cancer patients. And so, we do have experts—our advanced endoscopists—who can take care of advanced polyps, large polyps and even very, very early cancers. I’ll give you an example. I had a patient who came in for colonoscopy, average risk, completely no symptoms. You would not think that the patient had any...was at any increased risk for colon cancer. We did find a mass on colonoscopy that was suspicious for cancer. We took biopsies. The same day, I called the colorectal surgeon, and we were able to get them in to see the colorectal surgeon that same week. The pathology results were available the next day, and the patient had a curative resection for colon cancer. Host: When should a person of average risk of colon cancer start getting screened? Dr. Lee: Yeah, average-risk individuals should start getting screened at age 50 unless they’re African-American, in which case they should start their screening at age 45. Increased-risk individuals would include those with a family history of colon cancer. Those patients usually start their screening at age 40, or even before. Host: Why should African-Americans start earlier than other cultures? Dr. Lee: We’ve seen, epidemiologically that African-Americans are, more prone to colon cancer, and so therefore we want to prevent colon cancers. So, really focusing on preventive care, we want to catch them earlier. Host: If a patient has a loved one who should be screened, you know, because of their age or their risk factors, what advice could you give that individual to share with their loved one to help nudge them along and schedule that colonoscopy? Dr. Lee: You know, you think of it as any other cancer screening test—mammogram, you know, for women, GYN exams. It’s just like those, and it’s so important because you could prevent this potentially devastating disease. It’s absolutely preventable. So, while the thought of it may be displeasing, I think the end result is you are reassured and to know that you’re taking care of your body and making sure that you have a clean bill of health. Host: What do you feel is your role in the 80 percent by 2018 national campaign? Dr. Lee: Personally, this is day in and day out, this is what I do. I want to prevent colon cancer. I do colonoscopies. I remove polyps. That is, so much of what I do, and I’m such a big believer in preventive care that, you know, I feel very passionately about it. You know, I’m like a colonoscopy cheerleader. You know, like get your colonoscopy.  While it may seem a strange, topic to be excited about, it, nevertheless it’s—I am excited about it. If we could reach 80 percent, that’d be amazing, you know, and I think that, you would be saving lives, you would be saving healthcare dollars, for just, you know, one day of being hungry. You know, and I’ve done the one day of being hungry. It’s bad, but it’s, you know, you live through it, and then you can think about the meal that you’re about to have after your colonoscopy. Host: What do you feel needs to happen at a local or a national level to reach that 80 percent goal or even exceed it? Dr. Lee: You know, I think that having that part of, uh, general health be at the front of your...your mind. I think our primary care doctors are doing a great job of identifying who needs to be, screened, and so providing, access to colonoscopy, I think, is crucial. We do many of them, but there, you know, we need to do more.  And so, thinking about any patient that you are seeing --do they need to be screened, yes/no? And, if they do, send them over.  And, these days the prep is not as bad as it used to be. It’s a—we have lower volumes, better tasting things. Host: Are there any risks involved with colonoscopy? Dr. Lee: Sure. I think some patients are afraid of the complications of colonoscopy and absolutely there are complications, but I often tell them that they’re rare—the complications are quite rare--you know, 1 in 10,000, less than that even, and that’s a great aspect of having your procedure done at Washington Hospital Center. We are big believers in the multidisciplinary team approach, so we work closely with surgeons and other colleagues in case something does happen, but I should say that we are experts, we’re experts in colonoscopy, and we’re good at what we do, so patients are in good hands when they come see us. Host: Thanks for joining us today, Dr. Lee. Dr. Lee: Oh, thank you for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Birth control can come in many forms—but men’s options can be more limited. Dr. Krishnan Venkatesan discusses how a vasectomy can be a solution for men who want effective birth control while maintaining sexual function and the ability to orgasm.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re speaking with Dr. Krishnan Venkatesan, Director of Urologic Reconstruction at MedStar Washington Hospital Center. Welcome, Dr. Venkatesan. Dr. Krishnan Venkatesan: Hi. Thank you for having me. Host: Today we’re discussing vasectomy, a birth control procedure for men that prevents their partners from becoming pregnant without affecting natural sexual function. Dr. Venkatesan, is vasectomy a popular birth control option for men and their partners? Dr. Venkatesan: Yeah, I would say so. Vasectomy is effective for birth control because it really allows a non-invasive way to cut off the sperm from being delivered into a partner that could cause conception, but it doesn’t interfere with erectile function, sensation, orgasm or ejaculation. So, essentially sex should still feel and be the same but without the concerns for pregnancy. Host: Approximately how many vasectomies are performed at MedStar Washington Hospital Center each year? Dr. Venkatesan: I’d say probably between fifty to a hundred vasectomies, at least, per year between myself and my colleagues. Host: Why do you feel that so many couples or so many men chose to undergo vasectomy? Dr. Venkatesan: I think vasectomy is a popular option and a good option because it’s relatively non-invasive, it’s an outpatient procedure and has a quick recovery. And, it allows patients to stop using other forms of birth control, whether it’s oral contraceptive pills or condoms, and it’s certainly easier for men to undergo this than for women to have a tubal ligation. And so, it basically allows for natural sexual function without the risks of conception. Host: Could you describe your patient population for vasectomy - are they older, younger or who is a good candidate? Dr. Venkatesan: Any man, really, is a good candidate but typically our patients are those who are in their 30s or 40s, sometimes in their early 50s, who have children, who have had some time to give this some thought and, for the most part, these are men who are in stable relationships and have had a shared discussion and a shared decision making with their partner before they come in to discuss or commit to vasectomy. Occasionally, we do have men who are not in a relationship but are fathers of children or who have decided they do not want to have any children and, after giving it a lot of thought, they come in for counseling about vasectomy and may decide to proceed with that. Host: Are there any factors that might make a man ineligible for vasectomy? Dr. Venkatesan: Patients that may not be good candidates for vasectomy are generally those who may have had prior surgery on their testicles, either to bring an undescended testicle down during childhood or maybe some surgery on their spermatic cord or even prior hernia surgery, where it may be just more difficult to identify the vas deferens and may make them more prone to having the procedure fail or have a complication. Host: So, just like any reproductive issue or reproductive procedure, there is an abundance of incorrect information online about vasectomy. Do your patients or their partners express any fear or anxiety about the procedure? Dr. Venkatesan: Yeah, and I think that’s natural and completely reasonable to have those anxieties. The biggest concerns men have, of course, are that this may affect their other sexual function, including erectile function and the ability to orgasm or to enjoy sex the same way and whether they will still be able to ejaculate after vasectomy. And, generally we’re able to assuage all those fears by explaining that this really should not affect erectile function and men will still ejaculate because most of the fluid that comes out with orgasm or with ejaculation is actually made downstream in the prostate. The only difference is that the semen won’t contain any actual sperm that can cause conception. Host: This sounds like a very safe procedure. Are there any risks involved with vasectomy? Dr. Venkatesan: Yes, there are. And, of course, any procedure has its risks. The main risks here would include general risks of any surgery, like infection and bleeding and injuring other structures that are nearby the vas deferens, including the artery to the testicle and the vein coming from the testicle, as well as some nerves that travel along the spermatic cord, which could result in chronic pain in the testicle, although that risk is very low. And the main other risk really would be the risk of remaining fertile if the two ends of the vas deferens somehow remain connected or find their way back to each other and get reconnected. Host: Could you describe how the vasectomy procedure is performed? Dr. Venkatesan: Yeah, absolutely. Basically, each testicle, after it makes a sperm, delivers that through a tube called the vas deferens. That travels up the scrotum on each side into the groin and then makes kind of a hairpin turn and goes back behind the bladder to join the urethra, which is how men are able to urinate and ejaculate through the same pipe. What we do in vasectomy is basically find the vas deferens at the top of the scrotum on each side, bring it out through a small nick in the skin or through a small spread incision to open the skin, and cut out a small segment, burn each side of the tube on the inside, and then tie off each end and fold them away from each other and, basically, put them back into the scrotum but in different tissue layers, all to help minimize the risk of the tubes reconnecting. Host: With all of the steps of this procedure, is vasectomy permanent? Dr. Venkatesan: Yes, and that’s an important point. I’m glad you brought it up. I always counsel all my patients that, for all intents and purposes, vasectomy is intended to be permanent. Now, technically, it can be reversed. And, there are specific surgeons who have microsurgical training who can do the vasectomy reversal but it’s also important for patients to know that the success rates for that reversal are variable and, from a practical matter, it’s usually not covered by insurance. Host: How long does recovery take and are there any restrictions for having sex or using the bathroom? Dr. Venkatesan: Yes. So, because there’s constant sperm production, there’s already gonna be sperm downstream from where we cut the vas deferens. So, men need to be counseled that they are not immediately sterile when they go home that day. So, typically, immediately after the procedure, I will ask my patients to refrain from sexual intercourse or any ejaculation for two weeks. And, after that, they need to continue using contraception, in any other form, whether it’s condoms or with the oral contraceptives with their partner but continue to have sexual intercourse. After 8 weeks, we’ll see the patient back in the office to ensure they’ve healed up okay and, at that time, we’ll have them give a semen sample to make sure that the sperm count is zero. Once the sperm count is zero, then they’re okay to stop using other forms of contraception. The recovery from the procedure itself is pretty easy. Usually, we’ll do it later in the week so that guys can recover over the weekend. We don’t have them take any significant activity restrictions, but they may be a little bit sore for a few days. But usually by one to two weeks after the procedure, they’re able to resume all their normal activities. Host: When you hear about people having vasectomies, like on sitcoms or in books, you always have this mental image of a man sitting there with frozen vegetable on his private area. What do you typically give for men for pain management or inflammation management afterward? Dr. Venkatesan: We usually do send patients home with some pain medications. It really depends on, subjectively, what the patient thinks they may need. Quite often, even some extra strength Tylenol or Ibuprofen may be sufficient, but if the patient requires more pain medication, we’re certainly not averse to giving them a prescription for a narcotic pain medication. And aside from taking it easy for the first few days, we also do recommend that they can put some ice packs or frozen vegetable packs on their incisions until everything is starting to feel more comfortable. Host: Now, on the flip side, is there anything a patient has to do to prepare to have a vasectomy? Dr. Venkatesan: Not really. Similar to any other surgery, they should make sure they talk to their urologist beforehand in the office and get all their questions answered. I often will encourage patients to bring their partner along because it’s always good to have a second set of ears, and partners tend to have different insights than men, and collectively, you may remember more from the conversation than one person alone. But, physically speaking, there’s no specific preparation that is required. Host: Can you think of any standout patients who particularly benefited from having a vasectomy? Dr. Venkatesan: All of them. And, it really depends on their goal but, for the most part, because there’s a very specific goal with regards to achieving sterility, most of our patients have been very happy with the results. I will say that probably the better example cases are the cases where the female partner may have a difficult time taking oral contraceptives or may have some other medical conditions that prevent tubal ligation. And, in those cases, then this really allows them to enjoy a full quality of life and takes some strain off the partner, in addition to the patient themselves. Host: Why should a patient choose to come to MedStar Washington Hospital Center for vasectomy when they could really go to any hospital? Dr. Venkatesan: So, I think Washington Hospital Center is a great place to choose to have vasectomy, mainly because of the surgeons we have here who are very experienced in doing it and because, I think, we all do a good job at counseling our patients and answering their questions beforehand, and meeting their expectations with regards to the procedure and everything before and afterwards. And, I will say that traditionally vasectomy is usually done in the office but here we do, quite often, offer our patients to have it done under anesthesia, depending on their comfort level. And, quite often the patients will select to have that done just so they can be more comfortable during and after the surgery. Host: Thanks for joining us today, Dr. Venkatesan. Dr. Venkatesan: My pleasure. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Excess skin after weight loss surgery can be purely a cosmetic issue for some patients. But for others, excess skin causes rashes, infections and irritation.  Dr. Alexandra Zubowicz discusses how skin reduction surgery can help.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re talking to Dr. Alexandra Zubowicz, a bariatric surgeon at MedStar Washington Hospital Center. Welcome Dr. Zubowicz. Dr. Alexandra Zubowicz: Thank you for having me. Host: Today we’re talking about what people can expect after weight loss surgery when it comes to excess skin. Dr. Zubowicz, why does excess skin remain when you lose a lot of weight? Dr. Zubowicz: So, essentially the skin is a covering, so as people lose all that fat underneath the skin, the skin can lag behind. Now, younger people tend not to have as much of an issue with it because your skin’s more elastic and can stretch back and forth, but especially as you age, which is why you start to develop wrinkles, your skin loses elasticity, so when you lose hundreds of pounds, you have that skin that just can’t bounce back. Everyone will have some excess skin to some degree, however, not everyone has a problem with it. Some people have the excess skin and it doesn’t bother them.  Some people have the excess skin and it’s extremely irritating. So, really there’s wide variations in the amount of excess skin and then the extent to which that excess skin causes issues. Host: When we’re talking excess skin, are we talking about a little bit of bagging and hanging, or are we talking about a lot of skin? How could you put that in perspective? Dr. Zubowicz: So, both. It depends again on lots of different factors—genetics, age, how much weight you lose—but, you can have just a little bit of overhang, up to a point where we remove 40, 50, 60 pounds of excess skin. Host: That’s a lot of skin. Dr. Zubowicz: Yes. Host: I can imagine somebody that’s been through this journey—they’re really transforming what they look like already. And then, do you find when patients get to this stage where they’re talking about having this excess skin taken care of—what is their emotional mindset? Dr. Zubowicz: Some people don’t care at all about the excess skin, either because they don’t have much or it just doesn’t cause issues. For the people that do have issues from the excess skin, it can be extremely debilitating. It can cause severe rashes, it makes it hard for certain types of clothing to fit, it can be painful and irritating, especially when you’re exercising. I don’t think it’s anything that would ever cause someone to say they wish they hadn’t gotten the surgery, because once they lose all that weight, they feel so much better, their joints don’t hurt, they can start exercising, but it’s definitely something that not an insignificant number of people who get bariatric surgery want to get taken care of. Host: I think a lot of people might think about the cosmetic implications of it, so you know, what does it look like, but you mentioned also rashes and some pain associated with that. Could you elaborate on that a little bit? Dr. Zubowicz: So, one, obviously there’s the cosmetics of it, but then having all that excess skin creates a warm, wet environment, so people get yeast infections or bacterial infections under the skin folds. From an insurance standpoint, it’s for those reasons that we can get at least the abdominal excess skin covered by insurance. Host: For an individual who maybe it doesn’t bother them so much to have that extra skin, what do you recommend that they do so they can fit in their clothes or so that they can avoid some of those complications? Dr. Zubowicz: So, main thing is keeping the area clean, keeping it dry.  You can use different kinds of powders. There’s anti-fungal powders you can put to help prevent the rashes or help clear up the rashes if you are having issues with rashes. Host: So, it’s compression type support garments? Dr. Zubowicz: Exactly, yeah, that can basically suck everything in and keep it up and keep it tight. Host: For folks who it does bother them, what sort of procedures are available to help remove that extra skin? Dr. Zubowicz: Skin reduction surgery, now that we’re doing more and more of the bariatric surgery, is becoming more and more prevalent with all the plastic surgeons and I do recommend going to someone who’s specifically trained in doing plastic surgery and does these types of procedures a lot.  And we usually recommend waiting at least a year after bariatric surgery before getting anything surgically done because you don’t want to get the procedure done, get the excess skin, then lose another 30, 40, 50 pounds and then you’re kind of back where you started. In terms of the procedure itself we actually physically cut out that excess skin.   Host: What does the scarring look like from that, and what’s the recovery time? Dr. Zubowicz: The scar of the abdomen is like a C-section scar. We keep it right at the bikini line, and try to minimize it. The scarring on the legs and arms, we try to keep it on the inside.  Now, there definitely are scars, but that’s why I stress going to someone, a plastic surgeon, who does this kind of procedure a lot because you can minimize those scars. And the cosmetic result is definitely superior to having that excess skin if you do have large amounts of it. Host: How much weight does an individual have to lose to have that kind of excess skin? Dr. Zubowicz: I’d say probably in excess of 80 to 100 pounds or more. Again, age and genetics play a huge role, but you’re really not going to see horrible amounts of excess skin unless you’re at the 80-100 pound mark. Host: Of the patients that you treat with bariatric surgery, what percentage of those would you estimate do go on to get that excess skin removed? Dr. Zubowicz: I’d estimate it at probably 20 to 30 percent. Again, some people don’t have excess skin problems, especially the younger patients, and some people, unfortunately, it’s a cost prohibitive thing, and some people that just don’t, it doesn’t bother them. Host: Do you find more men or women prefer to do this, or is it about equal? Dr. Zubowicz: About equal. Host: Are there any complications to the skin reduction surgery, and what makes MedStar Washington Hospital Center the place to go for that? Dr. Zubowicz: The major risk to getting this surgery would be a wound infection. Otherwise, it’s a pretty uncomplicated procedure, and then, just the risk of undergoing general anesthesia, but because of all the weight loss, usually these people are coming in much healthier than when they came in for their original bariatric surgery. So, I would say the wound infection would be the main thing that you have to worry about. In terms of coming to Washington Hospital Center, because we do so much bariatric surgery here, our plastic surgeons are very well versed in the excess skin removal. So, we work in partnership with them very closely to allow the full gamut of bariatric procedures and that’s both the actual bariatric surgery as well as the skin reduction surgery and anything that goes along with weight loss surgery. Host: So, in 2017, we’re still living in that, uh, reality show nightmare or world, however you want to look at it. There are a couple of shows out on tv right now that focus on the skin reduction surgery. Is this something, do you think, that increases people’s awareness that such a procedure is available? Dr. Zubowicz: I absolutely think it’s gonna grow in popularity, because more and more people are, uh, seeing how beneficial weight loss surgery is, and with the rise of weight loss surgery, is gonna come the rise of the excess skin removal surgeries. Host: Do you have any compelling stories of patients that you’ve worked with who, you know, were really struggling with this excess skin problem and then went on to have the procedure? Dr. Zubowicz: Yes, I’ve had several patients that get the skin reduction surgery and they definitely liked the cosmetic benefit from it can be tremendously helpful from a cosmetic standpoint, and then also, they don’t get the rashes, it helps free them up in terms of mobility, they can exercise more, and then, on top of that, you’re also losing some more weight almost instantaneously by taking off all those extra pounds of excess skin. Host: Is there anything that you really want the community at large here in DC to know about either bariatric surgery at MedStar Washington Hospital Center or the skin reduction procedure? Dr. Zubowicz: I think it’s very important to go to an actual bariatric center, like we have at Washington Hospital Center, where you have not only the surgeon, but you have dieticians, you have psychologists, you have plastic surgeons, you have all the people that go together to make weight loss surgery a success. Because the surgery alone isn’t going to do anything. It’s all the lifestyle changes that come along with the weight loss surgery. And then, in addition to that, having people that are knowledgeable about all the things such as excess skin after the surgery that you can only know if you continue to follow your patients long term, which we follow our patients for life after the surgery. One of the most common questions is cost. So, insurance, and obviously it varies by the type of insurance you have, but for the most part insurance will cover what’s called the abdominoplasty, so or a panniculectomy, where we take off the excess skin of the abdomen. For approval standpoint, you need to show that you’re having issues from that, and those are things like rashes and irritation, etc. And, you know, as long as you let your surgeon know, or your primary doctor know, afterwards and we document it, we can do a pretty good job at getting that covered for our patients and that’s another reason why it’s good to go to someone who does this a lot, because they have, you know, established relationships with different insurance companies and we know the documentation we need to get that covered by insurance.  Legs and arms are not covered, at least not as of yet.  I think that’s something that will change down the road because it doesn’t make any sense, because you’re going to have the same exact issues with excess skin on your arms and legs as you do with your abdomen. But, in terms of arms and legs, it’s about $10,000, eight to $10,000 for arms, eight to $10,000 for legs. So, it’s not inexpensive, which is why I think one of the biggest reasons why people don’t end up getting the surgery after the excess weight loss, at least the arms and legs. Host: Thanks for joining us today, Dr. Zubowicz. Dr. Zubowicz: Thank you for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Drinking too much alcohol and smoking can contribute to chronic pancreatitis, a painful condition that disrupts the digestive process. Dr. Mitesh Patel discusses how we spot the signs of this disease.   TRANSCRIPT Host: Thanks for joining us today. We’re talking with Dr. Mitesh Patel, a gastroenterologist and director of pancreatobiliary services at MedStar Washington Hospital Center. Today we’re talking about controlling your risk for chronic pancreatitis, which is inflammation of the pancreas that can cause abdominal pain, nausea, vomiting and unintended weight loss. Dr. Patel, can you start by telling us what the pancreas is and what it does? Dr. Mitesh Patel: Sure. The pancreas is an organ that sits in our abdomen, kind of tucked in behind most of the other intestinal organs. The purpose of the pancreas is to aid with digestion. There are two generally large categories of digestive processes that go on. One involves the hormones, like insulin and glucagon. These are required to regulate our blood sugar. The other set of enzymes that come from the pancreas are to help break down starches, fats, and proteins in our diet. When we eat a meal, it’s a process to go from the actual plate of food to nutrients that our body absorbs and figuring out what is waste that we eliminate. So, the pancreas plays a vital role in breaking down macro particles—large particles—into small, absorbable nutrients that the body can use. Host: So what can cause chronic pancreatitis, or what causes that inflammation of the pancreas? Dr. Patel: The pancreas is a very delicate organ. And so, the most common causes of inflammation of the pancreas in society—there’s usually two major things: chronic alcohol use, and the other would be gallstones. So, alcohol is a toxin. And when it goes through the body, the liver has to metabolize it and break it down into parts that can be eliminated. Unfortunately, as that alcohol is in the bloodstream, as well as some of the metabolites of its breakdown, those can be damaging to cells. And not only can the liver be damaged but the pancreas as well. A lot of people don’t realize that smoking also has very similar effects on the pancreas. A lot of the compounds in combustible cigarettes are very detrimental to the pancreas specifically. And with years and years of this behavior, it can lead to inflammation of the pancreas. Gallstones are formed in the gallbladder but not in everybody. And it’s really hard to tell who’s going to get them. We characteristically believe that younger people, women in their fertility ages, patients who have a high body mass or elevated cholesterol and triglycerides, are at risk. When stones get out of the gallbladder and enter the bile duct, they can then misbehave, get stuck at the end of the bile duct and lead to pancreatitis, or inflammation of the pancreas. So that can cause an acute pancreatitis, but it’s uncommon for just that condition alone to cause chronic pancreatitis. The reality is drinking alcohol and smoking cigarettes are probably the most common causes of chronic pancreatitis. Finally, there are a hereditary component. There are some people who have unfortunate genetic conditions that might predispose them to developing recurrent pancreatitis that can then become chronic pancreatitis. And so, for that reason, some of these patients may fly under the radar if their symptoms are very mild but can develop progressive disease over time. The pancreas gland itself does not have the ability to heal itself fully. So, that with each episode of inflammation, the gland is going to get some architectural changes. And over time, when those changes manifest themselves, the pancreas gland cannot go back to being normal. So that’s why it’s an additive effect over the years, and it can gradually become a chronic and permanent problem. Host: Do other organs behave that way as well, or is the pancreas kind of an anomaly, where it can’t heal itself fully? Dr. Patel: Well, there are many organs that, unfortunately, don’t recover if you insult them over and over. So, the heart after a heart attack, the muscle can become thin and replaced by scar. Kidneys with high blood pressure and diabetes can have damage to the glomeruli, and those can be reduced in number over time. And so, there are some organs—many of the organs, actually—that will have the added detriment from bad behavior like smoking and drinking that cause damage to them. Certain organs, such as the liver, can actually regenerate itself, so if a person were to drink a large amount of alcohol at once, that could damage the liver in the short term. But if that same person stops drinking entirely, the liver has an ability to regenerate itself and completely recover that damage. The unfortunate problem with this is that most patients don’t stop the bad behavior. It keeps going and going, and that vicious cycle leads to the chronic and the changes to the glands. Host: It makes sense that alcohol would damage, because it’s going right into your digestive tract, it’s affecting those organs. How is it that smoking also can affect the pancreas? Dr. Patel: Well, everything that’s inhaled can still get into the bloodstream. And so, it is the compounds that are in a combustible cigarette that get into the circulation, the liver and kidneys are responsible for trying to break down whatever’s considered a waste product, but, invariably, a lot of those compounds still manifest themselves through the circulation and then lead to recruiting our own inflammatory cells. So, our body tries to get rid of bad things—bacteria, viruses, parasites. However, the body doesn’t always recognize what is truly an organism versus what’s just another sort of invader. It’s believed that, with cigarette smoking, the toxins that are in that are recruiting the white blood cells. The white blood cells are being forced to come in to help out because of these signals, and that damage that’s caused by this recruitment of inflammatory cells can lead to the damage over time. There also are cells within the pancreas that, when activated, can cause scarring. So, there is a theory that some of these cells are being activated by the cigarette smoking and the alcohol as well. Host: Are there certain populations—we mentioned people that use alcohol in excess, we mentioned smokers and some genetic risk—are there other populations or age groups of people who are more at risk for chronic pancreatitis? Dr. Patel: Well, generally speaking, if you have pancreatitis, we need to get to the root cause as to why that developed. As I mentioned before, the stone disease coming from gallstones that pass into the bile duct and block the pancreas, that is a process that may happen just once in a person’s lifetime. If they get managed accordingly and get the gallbladder removed, it really tremendously reduces the risk of getting recurrent attacks. We have an obesity epidemic in America, and that is very concerning, because it could be leading to higher rates of gallstone disease. Now, whether or not having excess body weight in and of itself is a risk factor for developing chronic pancreatitis, I think that’s debatable. I think that we’re still learning a lot about this condition. We now have commercially available blood tests to help screen for some of these genetic components. If you think about, a car has gas and the brakes. And if your brake pedal goes bad, your car’s going to keep moving. Well, we have the same kind of checks and balances for the pancreas. Activating the enzymes. So, we have a way to activate enzymes and we have a way to turn them off. If the enzymes that are turned off aren’t working, then that means you have activation of those enzymes, and that can attack the pancreas of itself. And so, we can help screen some of these populations who get recurring attacks, but when we find out they have a genetic mutation, we don’t really have a solution for that. There’s no gene therapy at this time. And if we have this knowledge, maybe we can direct our patients to make healthier lifestyle choices, but we also risk causing undue anxiety in these patients. So now they think they have this genetic predisposition—they may fear going out to a restaurant and indulging. But the reality is we don’t really know what their true risk is for developing pancreatitis, pancreatic cancer are, just by knowing that they have these enzyme or genetic deficiencies. Host: What are some of the symptoms a person might experience when they have a pancreatitis attack? Dr. Patel: So, the most common manifestation of acute pancreatitis is severe pain in the upper abdomen. And that pain can sometimes bore itself into the back. Sometimes it can radiate up toward the shoulders. These patients also may feel very nauseated and have vomiting. The body has an amazing ability to defend itself so that when something like inflammation is going to the pancreas, knowing that the pancreas is an important gland in digestion, the body is now telling you, “Hey, we’re not ready to digest. Our pancreas is not well. Anything you put in, we’re going to send right back out.” And that’s the vomiting component of it. It’s not like there’s a blockage happening. It’s simply the body’s way of defending itself because the body thinks that when food comes in, it may keep coming in, and, you know, the pancreas has to work to do that, to help digest that. And so, when our body tells us, “Stop,” that is the symptoms people have: nausea, vomiting, abdominal pain. Sometimes it can be mild, and it passes on its own. Other times, these patients end up in our emergency department. And it’s very important, because getting quick access to medical attention -- and specifically getting hydrated with fluids -- because, again, you can drink a cup of water, but the body doesn’t know if a meal is coming after that, and you may even vomit the fluid. And the activity of pancreatitis—the inflammation that happens and the use of our fluid—actually can dehydrate a patient. And if they get excessively dehydrated, the circulation to the pancreas is poor, and that can compound the risk of the pancreatitis getting worse. So, patients need to be resuscitated with fluid at a relatively aggressive rate when they present at the emergency department. But if they’re not coming to the emergency department, they’re at risk for their condition getting worse. Host: So, for individuals who either have chronic pancreatitis or are at risk for it, are there certain lifestyle choices—aside from rein in your smoking, rein in your drinking—what foods should they avoid, do they have any activity restrictions? Dr. Patel: There are no real known foods that are going to put you at risk for pancreatitis. There’s a theory that some foods in the tropics might predispose people to it if they consume it in high enough concentrations. But for the most part, the traditional Western diet will not be anything that could put you at risk for developing pancreatitis on its own. And in terms of physical activity, obviously, when you’re going through a bout of acute pancreatitis, you’re not going to be up for going for a run. However, after you recover from your pancreatitis, for the most part, there should not be restrictions to your level of activity. Host: Why is MedStar Washington Hospital Center the place for an individual to come for treatment for their chronic pancreatitis? Dr. Patel: Well, chronic pancreatitis can be a very debilitating condition. Patients can manifest with abdominal bloating, weight loss, diarrhea, and even oily stools. When we think about weight loss that’s not intended, we worry that something is driving that to happen. Conventionally speaking, in adults, we worry about cancer being the most common cause of unintended weight loss. That being said, when a person has symptoms including weight loss, a workup needs to be done. We cannot just say that this is X, Y, or Z without doing some history-taking and testing. And so, that’s why it’s really important to come to a center that has expertise with excellent diagnostic testing available, great clinicians, and the type of interventional procedures that might be needed to help deal with some of the chronic changes that come with pancreatitis. I had a gentleman who had several issues with his health. He had abused heroin in the past and had thankfully given that up. He manifested with Hepatitis C and that led to cirrhosis of the liver. We, thankfully, were able to treat that as well with medications. He did have chronic pancreatitis as well. And when we looked at a CT scan of this pancreas, there were little flecks of calcium studded within the pancreas. And that’s abnormal. Calcium should not be in the pancreas, in a normal healthy gland. But, through the years of intense inflammation, healing, inflammation, and healing, the calcium that’s in our bloodstream kind of binds to the free-fatty acid and it becomes these little stones. And that gets into the pancreas and there really is no way to get them out, unless they’re in the duct and that’s when a person like me can use our equipment to help treat this. That being said, this patient was losing weight, and at a profound rate. He started to have to walk with a cane, had a hard time getting out of the house. Based on his clinical history—some lab testing, we could determine that he was having exocrine pancreas insufficiency, which is, enzymes that are important for digestion, were lacking in this gentleman. His pancreas was sort of burnt out—wasn’t functioning at the rate it was supposed to. Thankfully there is great pharmaceutical agents that can be taken with meals. These are actual enzymes packaged in a capsule. They’re generated from pigs, actually. And when a patient takes this enzyme capsule, at the time of the meal, that capsule breaks down and it’s got little spheres of enzymes that mix with your food. And now, because your pancreas is not working so well in this condition, these medications act like a surrogate pancreas—allows the patient to get better absorption of nutrients and improves some of their symptoms. I saw him several months after starting this medication. He had actually gained a few kilograms. And 6 months later, he had lost the cane, was walking, had more energy, had a nice little sheen to his hair. He felt great. He followed the prescription recommendations he was using with his meals as well as with snacks, had a significant weight gain, had an overall improvement in the quality of his life. Something like that can be under-recognized in certain populations and that’s why it’s important for patients to be evaluated, as sometimes it might be beneficial to see a specialist who has expertise in this condition. This is something that the patient has to buy into. It’s a lifestyle, lifelong change. Like I said, the pancreas is never gonna go back to normal. So, once you buy into the fact that this is the way your body is now, we can adapt to that. We can work with you on educating you on what healthy lifestyle choices are, how to use your medicines, the appropriate timing to use medications and following up with us and going through your regular checkups. And so that can get patients back on track towards a healthier life. Host: Are there any other treatments people should know about for chronic pancreatitis? Dr. Patel: So, believe it or not, there are some patients who have intractable suffering from their chronic pancreatitis. Severe, hard-to-control diabetes. Severe pain. And the weight loss just doesn’t get better despite enzyme-replacement therapy. We do know that the gland itself, when damaged, won’t go back to normal. And, because of where it’s located, it can exert inflammation on nerve endings that can be very debilitating. Certain patients may benefit from seeking expertise regarding either a pancreatic transplant or what’s called an autologous islet-cell transplantation. You’re taking out the diseased pancreas and, in the laboratory setting, they’re finding those important islands of cells that form insulin and glucagon—important hormones that are required to regulate our bloodstream. And the glands basically digested, and the healthy cells siphoned off into the liver directly, where they take up shop, and they provide their normal activity. Then the patients will go on a lifelong treatment with medications but maybe benefit from the fact that the diseased gland is out of the body, their pain could be better-controlled and potentially have an improvement in the quality of life. Host: Thank you for joining us today, Dr. Patel. Dr. Patel: Thank you. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

New technology and guidelines allow us to use PET-CT scans to locate cancer earlier than ever before, with faster scans and less radiation. Dr. Carlos Garcia explains what this means for patients and how we continue to stay ahead of the curve in this area of testing.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re talking to Dr. Carlos Garcia, Medical Director of Nuclear Medicine at MedStar Washington Hospital Center. Welcome, Dr. Garcia. Dr. Carlos Garcia: Hi. Thank you for having me. Host: Today we’re talking about advances in PET CT technology. Dr. Garcia, what is PET CT technology and when is it used? Dr. Garcia: So, PET CT technology is a combination of anatomic and functional imaging. We use the anatomy from the CT portion of the exam and the self-function or the live cell portion of the exam from the PET CT exam. We use it mainly for oncologic imaging. It can be used for other purposes as well, but right now the mainstay, the gold standard, for cancer imaging is PET CT imaging. Host: How has PET CT scanning technology improved in the last 10-15 years? Dr. Garcia: It’s improved by leaps and bounds, actually. So, in 2006, the new kid on the block was time-of-flight PET CT imaging, which was the most advanced cancer imaging tool at that point in time. Now that’s evolved as technology does into digital imaging. So, analog vs digital imaging. Host: So, why should a patient come to MedStar Washington Hospital Center for a PET CT scan? Dr. Garcia: We’ve been very fortunate in the past to, in 2006, to have the first, the most advanced machines in the region. It was called the Time of Flight PET scan, which was the upgrade from, you know, analog imaging from way before 2006, and for many years we were the only ones that had that type of imaging. And now, as of August this year, we have a digital PET scanner, so it’s the step up from the Time of Flight. It’s the most advanced PET CT unit available in the world right now and we are very fortunate to, once again, be one of the first in the region to actually have this kind of technology. When you compare it to the Time of Flight PET scan that we had prior to the one we have right now, it’s basically comparing a flat screen TV to a State-of-the-Art 4K curved screen. You’re talking about night and day when it comes to resolution. Images are 10 times, you know, as crisp as compared to what they were before, that everybody, you know, joked around they were a little fuzzy. Now, the lesion detection has increased. The size of the lesion can be much smaller and still be detected. The amount of time it takes to acquire the images has been cut back almost by 50 percent and the dose that we give the patient in order to obtain these higher-quality images can also, in some cases, be cut back as far as 50 percent as well. So, from a patient point of view, they get a much more reliable scan and half the amount of time with half the radiation exposure, and these are all valid concerns to the patient, you know, because coming to the hospital, you know, you can have a PET scan anywhere. You can have any kind of exam anywhere - it’s the experience you get from, you know, the center, the staff, the amount of time, the comfortability you experience. All those things put together makes it a much better experience to have a higher quality machine in the hands of somebody with much more experience. The result of that has been increase in detectability, increase in being able to see lesions that were too small to be seen before. And, that leads to early detection, early treatment application and, you know, being able to catch a disease when it’s still a time when something can be done about it. Host: What sort of research are you working on right now for PET CT scanning, and what do you see coming down the road, either at MedStar Washington Hospital Center or nationally? Dr. Garcia: So, there’s a ton of research being done at all levels with PET CT imaging and cancer applications. There’s many novel tracers, or let’s say substances, that the body produces that are getting linked to radiation and injected into the body and seeing exactly where it will go, known places that you know or known organs that you know it will go to, places that it would take up normally and now it takes up abnormally, and that gives us information. Here at the hospital, we are considered a thyroid/cancer center of excellence, so a lot of the research that we do will be related to imaging with radioactive iodine. There’s many different types; used some for therapy, some for imaging and in our case, we use it to be able to see lesions that are not taken up by the normal exams we do, the normal iodine scans that we do, and sometimes these tumors, in thyroid cancer specifically, may stop working the way they do and they don’t take up iodine. So, we do PET imaging in those particular cases, and that’s actually a proved indication, a reimbursed indication, for patients that are iodine-negative and that still have blood markers that show that there is still cancer and in those cases that’s an indication. Host: When you’re talking about radioactive iodine, how is that being introduced into a patient’s body and what does that look like for thyroid cancer? Dr. Garcia: So, in thyroid cancer patients we rely on the fact that the body does essentially one thing with iodine. When you eat it in your normal diet, the iodine gets absorbed, it goes straight to your thyroid gland, and your thyroid gland uses iodine to make thyroid hormone. The body can’t tell the difference between radioactive iodine or normal iodine or between different types of radioactive iodine. So, nine out of 10 times it is introduced as a pill. The body thinks it’s just normal iodine and it’ll take it to wherever there is thyroid tissue. If there’s a little bit of thyroid tissue left behind after the surgery, which happens 99 percent of the time, it will absorb the iodine because it still, you know, retains its function. So, the same thing will happen if the cancer has spread to other parts of the body and wherever the cancer cells have gone and attached themselves to, it is still thyroid cells now growing on, for example, a lung, a bone, you know, or in your brain. It’s still thyroid cells so they retain that function of taking up iodine. So, the body absorbs the pill it took and it’ll circulate through the blood and it’ll find the thyroid cells. And the thyroid cells will latch onto it, look at the iodine, try to make thyroid hormone out of it, but we’ve altered it chemically to get essentially stuck inside the cell and not be able to be metabolized further. All of this translates to being able to see it on images. Wherever the iodine has been absorbed it will show up on the images and that gives us an idea of the degree of spread throughout the body. Host: Interesting. So, the difference between the PET CT and the regular CT scan is that ability to really track that cancer throughout the entire body. How does that benefit patients, especially in the situation of thyroid cancer, and then how is that helpful for the physician team to treat them? Dr. Garcia: Not only does it track where it has gone throughout the body because CT exams can show you, as well, irregularities in anatomy, differences in what, you know, patterns are supposed to look like in every part of the body. It will show you where there are cells that are still alive. Sometimes it takes longer for a change to happen on a CT scan, based on the therapy that was applied, then it will take with the level of metabolic function of a cell. Sometimes you can have a tumor that’ll shrink a little bit on the scan when you compare one scan before and after the therapy and when you look at the PET scan it’ll show that there was a very active lesion and then it’s completely inactive. It’s essentially gone, although there’s only been a small shrinkage of the tumor on the CT scan. So, it’s very complimentary to the anatomy that would be shown on a CT scan. This helps physicians to monitor a treatment response. And many, many - even research studies - will take into account the degree of metabolic activity and the change before and after the therapy to see if the treatment is working and should continue or if the treatment is not working and they should switch gears altogether and try something different. It’s called the metabolic response to therapy. In thyroid cancer, we use it in those cases in which we know there’s thyroid tissue still in the body because it’s producing a protein that shows up in the blood, that’s only made by thyroid cells. Sometimes these thyroid cells lose their function to capture the iodine and makes a iodine scan basically not the right study to be able to monitor the response. So, you have to migrate over to the basics of the cell function, which is to take up glucose, for example. So, it will still, it still might be able to take up glucose even though it won’t take up iodine and that is still very, very helpful to know whether or not this patient would benefit from being treated with radioactive iodine or if they need to be treated with another form of therapy, based on the examination - the PET CT exam. Host: So, a very technical and very advanced way to get back to the basics of what the cancer does. Dr. Garcia: That’s nuclear medicine, in essence. We rely 100 percent on physiology, which is the normal function of the body. The kidney has a normal function, the brain has a normal function - and when they deviate from that normal function, they stop using the materials or the substances in your blood that they normally would. If you can attach radiation to that substance and then you see that it doesn’t go into the liver when it should, that gives us information - we know what that means. So, you’re basically relying on the body doing what it’s supposed to do, and variations of that function will translate into disease entities, into diagnosis that we can establish. So, we trick the body into doing what it would normally do - it doesn’t know it’s doing it - and we can see it all on images. Host: What sort research are you and your and your colleagues working on right now in the field of PET CT? Dr. Garcia: Right now, we are working mostly in thyroid cancer research. We are looking into how much iodine is absorbed in individual tumors. In the past the fact that it showed up on the scan at all was very productive, but what we need to see is how much radiation is being delivered to each individual lesion. And that will make a difference. So, it’s very important to figure out - this is the ongoing research for us - to figure out how much radiation actually gets delivered in a particular lesion. And that will sometimes answer the question of how come we gave the same radiation level to two different patients and it didn’t quite work the same way. And we need to figure out how much is absorbed in each piece of tissue, if you will, that is malignant, and that way, if we know that, then we can start tailoring lesion radiation delivery more so than patient radiation delivery. We will go, I mean, we treat the patient as a whole, of course, you know…but we will go after targeting specific lesions and making sure that that lesion receives as much radiation as possible. We’re very happy to not have repeat customers, you know, and that’s kind of our goal, I mean, like we’ll try to get it all on the first try and if not, leave as little behind as possible if we have to do it again. Host: Thank you for joining us today. Dr. Garcia: Ah, it was a pleasure. Thank you for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Missing teeth is never easy. It can cause some people to feel uncomfortable smiling for pictures, while others experience difficulty eating. Discover why Dr. Ravi Agarwal says dental implants can be the perfect solution.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re speaking with Dr. Ravi Agarwal, an oral and maxillofacial surgeon and the residency program director for the Department of Oral and Maxillofacial Surgery at MedStar Washington Hospital Center. Welcome, Dr. Agarwal. Dr. Ravi Agarwal: Thanks for having me here today. Host: Today we’re discussing dental implants which help support dental prosthetics such as bridges, crowns and dentures. Dr. Agarwal, could you explain what a dental implant is? Dr. Agarwal: Sure. The dental implant is essentially an artificial tooth root in the shape of a metal screw. These screws are surgically anchored to the bone and, once anchored, the body will grow bone on to them and stabilize them. Once that fusion happens, these posts then can be used by your dentist to make supporting teeth such as crowns, bridges and dentures. This is currently the best long-term solution that we have today for tooth replacement. Overall, our success rates are 95 percent, especially when a patient sees a surgical specialist for placement. Host: So, this sounds like something a patient might see a dentist for instead of coming to the hospital center. Could you explain why that’s a better idea for people who need dental implants? Dr. Agarwal: Correct. Most of the patients who come to see us start with their dentist because it is a team effort for a patient to have a tooth replacement. However, most commonly a dental implant is a surgical procedure, so you want to see a surgeon who’s specialized in training to take care of all the surgical aspects of placements of dental implants. However, it is a team effort and once the surgery’s done and healed, the patient would then return to their dentist to have the prosthetic made. Host: What are some of the most common dental implants that your patients need? Dr. Agarwal: The need for dental implant varies amongst the population. In general, any patient who wishes to replace a tooth can be a candidate for a dental implant. Generally, the most common patients that we see are those requesting a single tooth replacement. This can be a patient who’s missing a front tooth affecting their smile. This could be a patient who’s missing a back tooth affecting the way they eat. However, as the baby boomer generation continues to grow, we’re starting to see a larger population requiring replacement of all their teeth. Most of these patients may have already been in dentures or they have a failing dentition. So, failing dentition is patients who have had a long history of dental work. They’ve had a lot of work done to their teeth. Their fillings or crowns are starting to fail, and it really becomes more and more expensive to repair all these things and it gets to a point where they may be better off considering replacing all of those teeth. So, our team has an excellent reputation in this area to help patients with solutions to replace either one of their teeth or all of their teeth. In the end, we work with all of our patients and their dentists to help come up with surgical solutions. Host: So, you mentioned the baby boomers. Could you describe your patient population for dental implants? Dr. Agarwal: Yeah. As I mentioned, we see a variety of different needs that come through our department and our clinic. I have maturing teenagers who are naturally missing some of their front teeth that we’ll replace implants for them. And I also have a 75-year-old patient who’s had a denture for 15 years and says, “Hey, I really want to taste my food better. I want to eat better. I want to chew better. I want to smile better.” So, our dental implant team can help manage all of them with some of the best experience in the region. Host: What does a patient have to do to prepare for getting a dental implant? Dr. Agarwal: There’s not a lot to prepare. Most of the patients - we generally request that they have a dental provider. As I mentioned earlier, this is a team effort. You can consider a dental implant like a foundation. I need an architect to tell me how they want the tooth designed so that I can lay the foundation in the correct place. So, most of our patients, we’ll require that they’re working with a dental provider. Otherwise, if they’re missing a tooth or a tooth is failing, the best thing to do is have a consultation with us because there’s not much more preparation before that. Host: The day of an appointment, do they have to do anything differently - maybe change their eating or medication? Dr. Agarwal: Well, the day of the procedure...usually we’ll see the patient prior for consultation to determine what their medical conditions are, what medication is taken - any of that can affect the surgery. So, if someone’s on blood thinners, we may require them to stop or discontinue it for a few days during the surgery. And occasionally we start patients on antibiotics or mouth rinses. Usually we’ll work these things out during a consultation appointment. Host: Could you describe the process of creating and then placing that dental implant? Dr. Agarwal: So, very simply, placing a dental implant is a short office procedure. An incision is made in the gums to access the bone. We use specialized equipment to create space in the bone for us to anchor the screw that we put in. We then will suture the gums with dissolvable stitches. And most of these procedures, for example a single tooth implant, can be as short as 30 minutes in the office. Host: It sounds like a very painful procedure. How do you keep your patients comfortable getting them in there, making sure that they’re nice and calm when they go in?  And then how do you keep them comfortable and pain free during? Dr. Agarwal: You know, surprisingly, this is a very common concern amongst the patients who come to see us. Dentistry, in general, has always been thought as a painful...but nowadays our techniques and local anesthesia have really improved, the office environment has really improved. For most patients, we see them first for consultation. At that time, you really get to develop a relationship with a patient - explain to them what the expectations are. However, anxiety is still a concern and, since we are oral and maxillofacial surgery specialists, we have the ability to offer pain, anxiety reducing techniques, such as office anesthesia. Most dental providers cannot provide this same service, so this is another reason that a patient may want to come see our team, is that we can also provide office sedation for these surgical procedures. Host: What is the recovery period after receiving a dental implant? Dr. Agarwal: Very similar to having a tooth removed. Most patients will be uncomfortable for a few days, most often requiring over-the-counter pain medications. Depending on the procedure, they may have a little bit of swelling, which mostly resolves after 3 to 5 days. We ask them to modify their diet, avoiding hard, crunchy foods. And, we also put an emphasis on oral hygiene, that brushing their teeth and we prescribe oftentimes antibiotics and antibiotic mouth rinses. So, for the most part, you know, for procedures done at the end of the week, most patients can return to doing most of their daily activities through the weekend. Host: One thing I would be concerned with is would I be able to drink coffee or hot beverages or eat right away after I got my implant. Dr. Agarwal: Sure. The day of the procedure we generally ask everyone to take it easy, possibly more of a soft, mushier diet, considerations to avoid extremes of temperature, but there would be no harm in someone having a warm tea or warm coffee. Host: Why should a patient choose a dental implant instead of another treatment option? Dr. Agarwal: Over the years, there have been a lot of methods to provide tooth replacement, but the dental implant is the one that is...generally has a high success rate. It’s a treatment that, if done well and done properly, can be there for a lifetime. The other number one reason to have a dental implant is that as you lose teeth, you start to lose the supporting bone. It’s just a natural process that the body has. By placing a dental implant, it stimulates the bone and the patient will lose a lot less bone. Host: Do you have any treatment success stories regarding dental implants from your practice? Dr. Agarwal: Well, every patient who comes to us and gets a tooth replaced is a success story for us. However, there is one gentleman that comes to my mind. There was a patient we treated who had sustained a fall while he was on vacation and he suffered a significant amount of trauma to his face, breaking some of his bones in the face, but also losing some of his front teeth. He was initially treated outside, at the hospital where he was on vacation, but once he came back to the D.C. area, he came to see our team to help reconstruct his jaw and his teeth. When I first started seeing him, I could tell he was a little dejected and had a little bit less motivation about his smile and his mouth, and you could tell, even when he was with his wife, that he was just sensitive about the topic. We worked with him. We got him in touch with a dental provider to help him restore the teeth. And our team ended up doing it first -  a reconstructive procedure for his jaw bone. But once that was done, we replaced all his top teeth that he had lost, and the ones that were failing, with dental implants. Once we did that surgery and anchored that teeth that same day for him, I remember seeing him the following week and thought this was a completely different person. I’d never seen anyone talk so much. He was chatting with all our team members. He was just so excited. He was telling us how he was looking forward to seeing his grandkids. And it really, at that point, gave him a new lease on life with something sometimes we think as such a simple procedure.  Host: Why is MedStar Washington Hospital Center the best place to receive a dental implant? Dr. Agarwal: So, our dental implant program is one of the earliest centers in the country that dedicates one and a half days a week to dental implant related procedures. One of the unique aspects of our program is that every patient gets both a surgical and prosthetic consultation. As an oral maxillofacial surgeon, we concentrate on doing the surgical procedures. However, having a prosthodontist, who is an individual who specializes in complex dental prosthetics, as a consultant has only enhanced our ability to provide the best care to our patients. For example, our program has key opinion leaders in the field of dental implants who actually go out and train and teach other practitioners around the country, who then use our protocols developed at MedStar Washington Hospital Center. We’re on the cutting edge of digital technology, having virtual implant planning, in-house 3D printing for surgical guides and even an implant navigation equipment. All of these technologies have allowed us to reduce treatment time, minimize errors and provide temporary teeth on the same day as the dental implant surgery. Even with all of this technology, I think the biggest reason to choose our team is the ability to provide all this advanced care at a reduced cost. Host: Thanks for joining us today, Dr. Agarwal. Dr. Agarwal: Thank you for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Many treatments for BPH, or enlarged prostate, can cause side effects such as erectile dysfunction or headaches. Dr. Saher Sabri and Dr. Keith Horton discuss prostate artery embolization, a new treatment that can improve BPH symptoms without side effects.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re talking to Dr. Saher Sabri, Director of Interventional Radiology at MedStar Washington Hospital Center, and Dr. Keith Horton, an interventional radiologist at MedStar Washington Hospital Center. Welcome to you both. Dr. Keith Horton: Thank you. Dr. Saher Sabri: Thanks for having us. Host: Today, we’re talking about prostate artery embolization, a minimally invasive treatment for an enlarged prostate, also known as benign prostatic hypertrophy. The condition can cause lower urinary tract symptoms and is one of the most common prostate problems occurring in men older than 50. In fact, it strikes 50 percent of men between the ages of 51 and 60, and up to 90 percent of men older than 80.  A new device to perform prostate artery embolization received FDA approval in June 2017 and is now available to patients at MedStar Washington Hospital Center. Dr. Sabri and Horton, how does this procedure work to treat an enlarged prostate? Dr. Sabri: So, the procedure involves a minimally invasive technique. It involves a catheterization and the catheter is a plastic tube that is placed in the artery in the top of the thigh of the patient and we’ll use X-ray guidance to advance the catheter, which is that plastic tube, into the arteries that supply the prostate. We watch the catheter go into the artery under X-ray guidance and then we inject small beads, which are like, grains of sand, into the arteries that supply the prostate, and that would result into the prostate shrinking. And once the prostate shrinks, with time, the symptoms that the patients would have will start to improve.          Host: What are those beads made of? Dr. Sabri: They’re gelatin microspheres. That’s a long term, but it’s something that would stay in your body. It doesn’t cause a lot of inflammation or any issues, but it’s very effective at blocking the arteries, and we’ve used them in other applications in the body before and this is a new application for them.      Host: Is there a certain patient population for whom this treatment would be most effective? Dr. Horton: Yes. For most male patients above the age of 50, a lot of them are going to start to have symptoms, and symptoms are generally related to urinary straining, frequency, they start to notice bathrooms in places they never had used them before, and it’s quite common, so we’re trying to appeal to those patients.     Host: Now, does this cure the condition, or does it just relieve and manage the side effects? Dr. Sabri: It will relieve and manage the side effects, or the effects of the prostate being enlarged. It would not cure the prostate enlargement, but it would just make it more manageable. The symptoms can be really lifestyle limiting--you know, having to wake up several times at night to go to the bathroom--you know, not having a good stream, and all these issues that affect men at this age. It can, you know, have a negative effect on their lifestyle. So, this will decrease the severity of the symptoms, can improve it, improve the quality of life. It would not get rid of the entire prostate altogether, but it will shrink it to a level that would allow the… what’s called the urethra, which is the tube that connects the bladder and allows for the urine to come out, for that to actually expand and then for the urine stream to get better. Host: How has benign prostatic hypertrophy been treated in the past? Dr. Horton: Currently, most patients who have these symptoms are seen by doctors - urologist, and the urologist will oftentimes start with medications. And, a lot of those patients have a lot of side effects, and as this disease actually affects patients who are a little older, those side effects become more significant with age. One of the biggest side effects is dizziness, and also, they have difficulty with ejaculation and other problems. And, so as you increase the medications, the more the side effects occur. Other ways of treating it include surgery, which is where they actually place a scope via the penis and try to remove a lot of the prostate tissue internally, and that also is accompanied by bleeding and other problems, such as inability to ejaculate externally, so because of that, a lot of patients don’t seek treatment, and so this gives them an alternative for those patients.       Host: How does the preparation for this procedure compare? Dr. Horton:  Well, the preparation isn’t much different. Generally, those patients who’ve been on the medications and who have had a bad experience with the medications come to see us in the clinic. We can evaluate them. We can determine how strong their stream is and other urological testing, and then they generally come in. It’s a procedure that’s done as an outpatient. They can come in and have the procedure, as Dr. Sabri described, where we go into the blood vessel, do that, we can generally do that in a couple of hours. And then we watch them afterwards and then they’re able to go home. Dr. Sabri: I would like to add that the surgeries that are performed, there are several levels of them. There’s the one with the scope. There are some other technologies, including laser and other options. There’s no one right answer for all patients. You know, each patient can be treated individually and that’s something that we would evaluate. We would work collaboratively with other urologists at MedStar Washington Hospital Center, and then talk about what’s the best option for this patient. And offer the patient all these options and they can choose what works best for them. This treatment that we’re proposing, the prostate artery embolization that’s performed by us in Interventional Radiology, and that’s our specialty, which is an image-guided procedure in Interventional Radiology, this is something we can discuss and see. It may not be amenable to get that procedure, and they may be better suited to have surgery, so, or some sort of minimally invasive surgery that’s done by the urologist, and that’s something we would collaborate on. We’ll evaluate the patient and decide what’s the best option for them. I mean, there's several things that we have to look at in terms of the size of the prostate, how healthy the blood vessels are. Is it possible for us to go and perform this procedure through the blood vessels and, you know, several other issues related to testing that we do to patients who have actually have, cancer in their prostate. So, there’s a different process that we have to look at and make sure that they truly just have the benign prostate hypertrophy, and this is what we’re dealing with and have, you know, somewhat healthy blood vessels that we can perform the procedure. For some of the others, you know, surgery would be better suited.              Dr. Horton: The biggest divider is that the prostate grows. I mean, it starts at the size of a walnut, and as it enlarges a lot of therapies are available up to the size of about 100 grams.  At that point, there are no minimally invasive options other than what we perform. Then, you move into the realm of where you have to have a surgical procedure, which is where a lot of patients tend not to really want to have an open prostatectomy. But, we have a model already. We also do uterine fibroid embolization, and it started out much the same way as this did. And because of our collaboration with OB/GYNs, we developed what we call a fibroid center, and so a lot of those patients we saw them together in the same setting. And hopefully, in the future, we may be able to do this with the urologists, so the patients are able to get proper counseling. They have options put before them and they can make a decision based on being truly totally informed. Host: How effective is this procedure compared to the traditional surgery? Dr. Horton: Well, the data goes out to about six years now. It’s been a fairly new procedure, but it was started by the Portuguese, and the Portuguese have seen about 1,000 patients now. And, at this point, it’s about a 70 percent efficacy out to five to six years, which is basically on par with other minimally invasive therapies, and actually exceeds some of the efficacy of some of the minimally invasive therapies they’re offered today. Host: What would you consider to be a successful outcome for the surgery? Dr. Sabri: I mean improvement in these symptoms and that we mentioned before, which are how often do you go to the bathroom, having a good urine stream, not having to wake up in the bathroom at night, and just improving your quality of life. And, there’s like a survey that we have the patients fill before and after, and we see significant improvement in their quality of life, and that’s something that we focus on, want to make sure the patients feel better, they have without interruption to their daily life, and offer them a minimally invasive outpatient procedure, that they can, you know, see that it’s not interrupting their daily life a lot.     Host: If a person doesn’t seek treatment for an enlarged prostate, what would be some of the complications or side effects of that?   Dr. Horton: Well, the prostate can continue to grow, the side effects get worse. Well, as the prostate enlarges, it can place more pressure on the urinary stream, requiring, at some point, for patients to actually have to self-catheterize themselves in order to go to the bathroom, or a catheter may have to remain within the bladder, you know, for quite some time.         Dr. Sabri: I agree. I mean, that’s one of the issues, that, you know, if you have to leave a catheter in for long-term to be able to go to the bathroom, it can be quite lifestyle limiting for these patients, and, you know, trying to seek medical advice before that happens because if the prostate becomes too enlarged, it becomes really hard for us to do anything about it and the options are very limited outside of an extensive surgery, So, medical therapy can be effective for a lot of patients. The patients that medical therapy does not work for them or they have side effects from medical therapy are the ones that we need to evaluate for some of these other options, but if they seek medical advice really late and the prostate is too enlarged, the options that we have become limited. So, we encourage patients to seek advice when they have issues with their urinary tract, which is issues with urination and the slowing of urination and poor stream and having to go to the bathroom a lot and waking up at night, to seek advice sooner before the prostate gets too enlarged and the options become more limited. Host: Do you have an examples of patients who’ve had really great success with this treatment? Dr. Horton: Yes, the majority of patients that we have seen in the past are patients who had large prostates that were able to be a surgical candidate, and the urologist sent them to us, either basically because they had catheters or they were having a lot of bleeding via the penis, and to our knowledge at least 90 percent of those patients had improved symptoms. I had one recently in June in which I can recall in which he had pulmonary emboli, or blood clots to the lungs. And what you do is you treat that with anticoagulations, or blood thinners, the patient developed even more bleeding. He had prostate problems, and so we ended up having to embolize his prostate and then coming back he ended up with blood clots in his legs, which we also treated, so we were able to do quite a bit for him, and I see him in clinic and he is, you know, no catheter, his lungs are fine, his legs are great, he’s very happy.  Host: Thank you very much for joining us today.   Dr. Horton: Thank you for having us. Dr. Sabri: Thanks for having us. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

From pelvic pain to fertility problems, endometriosis can affect women’s quality of life and relationships. Discover which treatment options Dr. Vadim Morozov says can reduce symptoms, and what to expect during recovery.   TRANSCRIPT Host: Thanks for joining us today. We’re speaking with Dr. Vadim Morozov, a gynecologic surgeon at MedStar Washington Hospital Center. Today we’re discussing endometriosis, a gynecologic condition that affects more than 11 percent of women between 15 and 44 in the U.S. Welcome, Dr. Morozov. Dr. Vadim Morozov: Thank you for having me. Host: Could you start by telling us what is endometriosis? Dr. Morozov: Endometriosis is a disease where endometrium, which is normally growing on the wall of the uterus and inside the uterus, starts growing outside of the uterus on the surface of your intestines and the surface of your bladder, all around the pelvic organs in the areas. And, as a result of that problematic growth, you start having pain and symptoms associated with it. Host: What are the most common symptoms of endometriosis? Dr. Morozov: Most common ones would be very difficult menstrual periods, cramping, severe pain with that. Pain with sexual intercourse. Pain when you go to the bathroom, having the bowel movements or when you’re urinating. Those are the top four that comes to mind when we’re talking about endometriosis. Pain perception is individualized, obviously, right? So, as you know, one person hits the finger and barely notices, and the other person hits the finger with the same strength and like, you know, ‘I’m dying, that’s it, call the ambulance.’ So, having said that, it obviously depends on the patient, her perception of the pain, support structure that she has, and her goals in life. Host: How is endometriosis diagnosed? Dr. Morozov: Unfortunately, the only way to diagnose endometriosis nowadays is by laparoscopy. We can make a presumptive diagnosis that the patient might have an endometriosis just by symptoms of what she’s describing and the physical examination. But to be 100 percent sure, usually we have to look and see the lesions of endometriosis and even better to biopsy those lesions and send them to pathology to tell us that, ‘yes, it is exactly endometriosis.’ Host: Are there any genetic or environmental components associated with the risk factors for endometriosis? Dr. Morozov: There are some. We know, for example, that if you have a mother or a sister or an aunt with endometriosis, you as a patient are at higher risk of developing endometriosis. There are some studies also saying that the environmental factors such as organic pollutants that we have in the atmosphere also affect the development of endometriosis. Um, but there are no conclusive results yet that can pinpoint us with 100 percent accuracy. Host: Can endometriosis go away on its own? Dr. Morozov: That’s a very interesting question. The short answer is probably no. Um, you might be asymptomatic, meaning you don’t as a patient don’t have much of the symptoms related to endometriosis. But if you have them, highly unlikely that the disease will resolve and go away on its own. Host: What are the treatments for endometriosis? Dr. Morozov: Normally if we diagnose somebody with endometriosis, it’s not unreasonable to start some sort of a medical treatment, such as non-steroidal anti-inflammatory, birth control pills. There are some other medications that are a little ‘heavy drugs’ as we call them - anything that controls hormonal fluctuations in your body - usually is the first line of treatment. In my experience, most patients don’t do too well on those, um, medications. And inevitably ends up with a surgery. Um, so the gold standard would be something like minimally invasive surgery by laparoscopy, with small, tiny, less than an inch incisions that made in the belly, and then the endometriosis diagnosed and removed at the same time.  Host: Are there any risks for a woman’s health long term if she doesn’t get her endometriosis treated? Dr. Morozov: There are. Endometriosis, to a certain extent, is almost like cancer. Obviously, it doesn’t kill you but it tends to spread in the abdomen and in the pelvis in a similar way. It can actually involve and invade your bowels, it can invade your bladder, it can invade other structures and organs that are in the pelvis. So, technically, if you leave severe endometriosis untreated, you are at risk of developing complications related to it. Host: Can endometriosis affect fertility? Dr. Morozov: Yes. Technically we’re saying that endometriosis does not cause infertility, but rather it causes what we call a subfertility, meaning if you’re a woman with endometriosis, for you it is going to be much harder to get pregnant than for a woman who doesn’t have it. The reason being is because endometriosis creates the inflammatory environment in the abdomen and pelvis. Your pelvic organ is constantly in the state on inflammation that lowers the chances of becoming pregnant.  Host: Does all of that inflammation and all of that scar tissue and so forth that happens with endometriosis increase cancer risk or anything like that for women? Dr. Morozov: There’s been some association between endometriosis and endometrioid type ovarian cancer. There is no direct correlation, but some researchers are looking that they, some particular endometriomas, which is a chocolate-filled cyst of the ovary, can lead potentially to endometrioid-type cancer.  Host: Have you seen any exciting research that has you excited for women’s health in the future? Dr. Morozov: There are a couple of good areas of research in endometriosis. One of them is to develop markers of endometriosis that allows us diagnosis without doing the surgery. So, the markers are done from drawing the blood from the patient or even the saliva test that goes to the laboratory and tells you as a patient and me as a physician that there’s a good chance that you might have a disease. It’s in the research phase right now but the results, at least preliminary results, are looking very promising. The other field of interesting research is to develop better laparoscopic visualization tools. Very often we go into laparoscopy with a small camera is placed in the abdomen and pelvis and we don’t see anything or maybe we miss a lesion because our eyes are not trained to recognize highly specific lesions in the pelvis. So, some companies are working on the, what’s called filters, that allow a better visualization of endometriotic implants during laparoscopic surgery. Host: Are there any questions that a woman should ask when she goes to her doctor? What does she need to know to take care of herself going forward after she’s received treatment? Dr. Morozov: Well, one thing is, what’s the long-term prognosis? What kind of endometriosis I have. Is it the mild disease that’s easily treated or versus a severe disease that involves surrounding organs such as rectum, bowel or bladder or anything else? The next question the woman should ask, depending on her fertility age, will it affect my fertility? Can I get pregnant? Can I get pregnant on my own or do I need to go to see an infertility specialist for this? The next question would be, in 10 or 15 years when I’m done with my childbearing, what are the options for me as far as having a definitive surgical management of this condition? So those are something that every woman diagnosed with endometriosis should keep in mind. Host: What is recovery like for women after undergoing surgery for endometriosis? Dr. Morozov: Usually it takes about 6 months to feel better. So, within the couple first months, you’re sore with the surgery itself. After that time the surgical pain starts going away and you’re feeling great. But it still lingers for some time. So, within the 6 months period we expect to see a result of the pain improvement and the symptoms related to endometriosis improvement. How long does it last as recovery depends. I’ve seen patients that are very good and for years don’t have any symptoms and then sort of slowly starts coming back. And I’ve seen the patients who recur within 3 to 6 months after surgery. Unfortunately, it’s unpredictable. Host: Can a woman expect to become pain-free eventually, after she has treatment for endometriosis? Dr. Morozov: Very tricky question. The answer is, depends on the conditions and the extent of the disease. Very often, by the time we see those women, the disease is severe enough that it’s near impossible to make them completely pain-free. And I try to have a very honest discussion with my patients in anticipation of whatever treatment options we choose, saying the goal of, whether we do surgery or anything else, the goal is not to make you 100 percent pain-free. The goal of everything we do is to bring it to the point where you can function normally every day. You’re probably going to have pain here and there, but that pain shouldn’t be debilitating. You shouldn’t be missing school or work because of the pain. In my experience, it’s near impossible to make a woman diagnosed with endometriosis 100 percent pain-free. Host: Why should a woman come to MedStar Washington Hospital Center for endometriosis care? Dr. Morozov: Well, we are the largest and probably the best equipped group on the east coast, mid-Atlantic. We have multiple fellowship trained specialists that deal with nothing else but endometriosis and pelvic pain. Our group at the National Center for Advanced Pelvic Surgery have multiple urogynecologists and the specifically trained female urologists that deal with the conditions of the pelvic pain and of the reproductive disorders.   Host: Thanks for joining us today, Dr. Morozov. Dr. Morozov: My pleasure. Thank you for having me.

Dr. Mitesh Patel discusses what hemorrhoids are and when symptoms such as blood during a bowel movement could be signs of a more serious condition.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re talking to Dr. Mitesh Patel, a gastroenterologist and Director of Pancreatobiliary Services at MedStar Washington Hospital Center. Welcome, Dr. Patel. Dr. Mitesh Patel: Thank you. Host: Today we’re talking about how you can tell whether you have hemorrhoids or some other condition. Dr. Patel, what are hemorrhoids and what causes them? Dr. Patel: Well, believe it or not, we’re actually born with hemorrhoids. What hemorrhoids are—essentially veins that are returning the blood from the anal rectal area back towards the heart. So, these veins are naturally there in all of us. They can misbehave as we get older because of the things we do. So, we normally have connective tissue that keeps these veins sort of tacked down, sort of like the way we have pipes underneath the sidewalk. You never see the pipes because the concrete’s laid down. But if something were to disrupt the under-surface of the concrete, now these pipes could essentially bulge up and break through the sidewalk. Well, that’s what’s happening with hemorrhoids. The vein’s normal connective tissue, the connective tissue’s thinned out and these veins are now bulging up. So, what causes connective tissue to thin? Well, pressure. And so long-standing pressure in the anal rectal area, as well as some kind of strain, can do that. Naturally speaking, people defecate. Having a bowel movement is a normal activity. Some people normally have one bowel movement a day, sometimes a few more than that. Other people can go several days without having a bowel movement. And when we look at the definition of constipation having three or fewer bowel movements a week is sort of what textbook definition of constipation is. So, what’s going on? Well, our colon is responsible for taking liquid waste material, packaging into a solid waste material, and then evacuating it. So, if you think about it, the colon acts like a sponge. It really is absorbing water, electrolytes—encasing this thin liquid into sort of a thicker, pastier form and then eventually to a semi-solid or even a solid form that our body then holds on to. The rectum is the reservoir, so it holds our stool and this allows us to take an overnight flight and not have to worry about things. But, when it’s socially acceptable, the muscles of the sphincter relax, other pelvic floor muscles squeeze, and that promotes the act of defecation. So, when some of this gets thrown off, and the additive effect over time, can cause strain at that connective tissue level. So, the most common problems are people who are constipated with dry, firm, hard stools that get bulky, often having to strain with defecation. Because when you’re straining, you’re exerting forces into that area of the anal rectum and that can help to break down or thin the connective tissue over time. Also, spending a lot of time sitting on the toilet. Right now I’m sitting on a chair—I have support under myself—but a toilet is carved out. There’s an opening in the center and so now, the perineum, which is the area of the anal and rectal connection—the perineum actually descends. It drops down an inch or two during the act of defecation. And that kind of strain puts pressure on those fibers and that can thin out the connective tissue as well. So people who are on the commode for a long period of time, who are straining to defecate, might be putting themselves at risk for developing symptomatic hemorrhoids in the future. But there are other conditions that can happen around the anus and that includes anal fissures. An anal fissure is a little crack in the tissue and it’s believed to be high pressure, especially within the sphincter ring. When that break happens in the tissue, it’s extremely uncomfortable. It feels like a razor blade poking you. Patients often can’t even sit comfortably. They have to sort of lean on one side, the pain is so intense. And so that can also bleed and that can mimic what a hemorrhoid can do and so that’s why when there is the symptom of rectal bleeding, whether it’s painful or painless, it’s worthy of getting it checked out by a specialist. Host: Since we’re all born with the propensity to develop this condition, how common are those symptomatic hemorrhoids? Dr. Patel: Well, it’s estimated that, in one’s lifetime, 75 percent of people are gonna have some degree of a symptomatic hemorrhoid. Now, that’s a big number but really only about a third of that number are patients that are probably going to need some kind of medical attention. The fact of the matter is diet alone can really be beneficial in the form of increasing the amount of fiber in the diet, as well as the amount of fluid that you take in each day. There are a lot of people who work in an office job setting who may not have…be going to the water cooler as much as they need to. They’re so busy with their work, they’re maybe not exercising regularly. And the diet may not be full of vegetables and fruits. It could be more processed foods. And we know that when that happens we shift away from the high fiber diet. And we get into some of these issues where people can then develop constipation. Vegetables and fruits, especially fruits with peels on them, can be very beneficial for increasing fiber. Bran and oat are another great way of getting fiber into the diet. A lot of people add flax seeds to food because that’s also a naturally derived fiber. For people that are sort of hesitant to change their diet, there are fiber supplements available. And so things like Benefiber and Metamucil which are commercially available over-the-counter…products that you can just take a heaping tablespoon and add to a clear liquid or your food and ingest it that way. And so there are ways of getting fiber into the diet without making radical shifts in the diet. But definitely, not only adding fiber but then adding fluid because remember, that colon is a sponge. And so if you’re not drinking enough fluid, your cells need the water. Your kidneys help regulate that but the colon is sort of a back up to draw and hold on to water. And so the more water is removed from the fecal matter, the more at risk of bulking up, becoming dry and hard, more difficult to pass, and then we get into this vicious cycle of straining with defecation and then potentially developing symptomatic hemorrhoids. Host: What does fiber do in the diet to promote healthy bowel movements? Dr. Patel: Certain fibers, our body cannot digest fully and therefore they end up as a waste product. When fiber enters the colon, we have an abundance of bacteria in our colon. For example, you know, why is it that a horse or a cow can eat grass and hay but if you and I tried to do that right now we’d become violently ill. But we come close. We eat cabbage and brussel sprouts and kale. So we don’t have the makeup to break down plant sugars and plant fibers fully. We use the bacteria that live in our colon to assist with that process. The bacteria thrive on that. They actually multiply in number as they’re feeding on this plant fiber. A big percentage of our fecal matter is bacteria. And that effect of the digestion, the fermentation that’s going on inside is also generating fluid and it’s keeping the fecal matter bulky. Bulk is actually a good thing in the colon. Our colon is a, basically a hollow tube of muscle and so that muscle’s gonna squeeze rhythmically but it’s gonna be more inclined to squeeze when there’s bulk inside because it knows it has to move it along. So, adding bulk into the stool, the best way to do that is with fiber. Host: So, when an individual has symptomatic hemorrhoids, what are some of those common symptoms that they’re going to feel? Dr. Patel: You know, hemorrhoids—the most common manifestation of the patients that present to me is just bleeding. They notice that when they have a bowel movement and they wipe, there might be blood on the paper. Sometimes there’s actually blood coating the stool itself. In severe cases there can even be drops of blood going in to the toilet. If a blood vessel in the anus gets thrombose, means a blood clot forms in the hemorrhoid, that can be exquisitely painful. And so these patients, again, are the ones that are sort of shifting around, can’t really sit comfortably. And those patients often need either some form of first-line therapy which can be stool softening, but in extreme scenarios, they actually need to have a small office procedure to lance this blood clot and then relieve it. Other common symptoms with hemorrhoids include just anal itching, discomfort, burning, itching in the anal area. And then pain really is a manifestation, like I said, of the thrombosis of the hemorrhoid—just sort of prolonged damage to the lining of that area. The anal fissure can be a more extreme manifestation of pain, it’s a different mechanism. And that’s where a physical exam will be able to help delineate between the two. Host: If a person chooses to just live with these symptoms and not come and seek treatment, what are some of the complications that could arise from that? Dr. Patel: Well, talking about bleeding. There should not be bleeding from the bowels, from the GI tract. And so, when we think about a person who’s having rectal bleeding, we have to think about all the conditions that can cause bleeding. There are minor things like hemorrhoids. But there are some more aggressive things, like vascular malformations within the colon or little pouches that form in the colon that can erode and cause bleeding. And the worst-case scenario are advanced polyps or even cancer of the colon. So, when we meet a patient who has these complaints, we often take a very careful history. We examine our patients, may incorporate some lab work to see what degree of blood loss is really going on. If we lose more blood than our body has the ability to make, then we, by definition, become anemic and our blood count goes down, our stored iron gets utilized to make more red blood cells but then we may even drop the amount of stored iron we have in our body. So, there are some blood tests that are available that could help us get a sense as to how long this process is going on. Sometimes patients aren’t very good about looking at their stool or, uh, you know, and this could be going on for months and months if not years. And so that could have an additive effect and that’s where seeking medical attention could be valuable because then we can put the story together, examine patients, do some lab work and get a better feel for how long this process has been going on and whether this person could potentially be at risk of one of the more concerning findings. Host: Should a person go see their primary care doctor or should they go straight to a gastroenterologist for this? Dr. Patel: You know, primary care is very valuable because, this is, for the most part, hemorrhoids can be managed by an internist, you know. This is something that first-line intervention of…increasing the fiber in the diet, adding ample fluid daily—we’re talking about anywhere from 48 to 64 ounces of fluid a day—and getting a little exercise. Remember that the colon, that hollow muscle tube inside of us, well, it squeezes but, you know, it also helps when our abdominal wall muscles also are contracting periodically ‘cause that helps move things along. So, the person who walks, who takes the stairs instead of the elevator, who does aerobic activity—all of that promotes good colon health and good colon motility. So, you don’t need a specialist to get that advice. And so that’s the kind of thing that a first-line intervention could be beneficial. Now, if you tried that for several weeks and the bleeding persists, or your symptoms change, that might be the sign that seeking help from a gastroenterologist could be useful. Host: Thank you for joining us today, Dr. Patel. Dr. Patel: Thank you. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Diarrhea can be a hassle when you’re at work, traveling, or doing everyday activities. Dr. Nidhi Malhotra discusses tips to manage diarrhea at home and when to see a doctor.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Dr. Nidhi Malhotra: Thank you for having me. Host: Most of us have experienced diarrhea at some point in our lives, but could you give us the medical definition of diarrhea? Dr. Malhotra: So, diarrhea is if someone is having loose stools, more number of stools or frequency of stools, or stools that are causing discomfort, such as other symptoms of bloating, abdominal pain, or just generalized discomfort. So, out of the norm. Host: What conditions can cause diarrhea? Dr. Malhotra: Diarrhea is a very common symptom. It can present as another symptom of a disease. But just looking at diarrhea itself, I think it’s important for our listeners to know and differentiate what’s acute and what’s chronic, because the reasons vary and the way we treat it varies. So, acute diarrhea is changes in your bowel habits that have been present for less than 3 weeks. Usually the reasons behind the acute diarrhea is infections, food poisoning, gastroenteritis, self-limited conditions. Most of these conditions get better on their own. Chronic diarrhea is where we sort of come into the realm of real diarrhea where patients have been having symptoms for more than 3 weeks. And there are different reasons for this and we sort of have to talk to the patient to differentiate what may be the cause of the diarrhea. But important reasons to think about would be inflammatory bowel disease, celiac disease, small bowel bacterial overgrowth, pancreatic insufficiency and more benign things such as fructose or lactose intolerance that, like I said, are benign but can cause a lot of uncomfortable symptoms to the patient. Host: When should people with diarrhea seek treatment? Dr. Malhotra: So, certainly when there are what we call quote/unquote red flag symptoms. So, if anyone is seeing blood in their stool, that’s a red flag symptom. If they’re having what we call nocturnal stools or waking up in the middle of the night to have a bowel movement, that’s a red flag. If they’re having associated symptoms of weight loss or flushing or fevers, that’s a red flag symptom. And if they’re having diarrhea without eating, on an empty stomach, then that’s a red flag symptom. Those are times when you certainly need to come in for evaluation. Host: What health problems can arise because of chronic or untreated diarrhea? Dr. Malhotra: So, a lot depends on the cause of the diarrhea. If, for example, let’s say the cause of the diarrhea is celiac disease. So, untreated celiac disease can result in abnormalities such as low iron levels causing anemia, low thyroid levels causing various other issues and even as severe as lymphoma of the small bowel, which is a very deadly cancer. So, treating something like celiac disease is very important. On the other hand, for example, if the cause of the diarrhea is microscopic colitis, Other than making the patient have uncomfortable symptoms, there’s not any long-term implications of untreated microscopic colitis. I would say a lot depends on what the underlying cause of the diarrhea is. For example, and I don’t want the listeners to think that this is a first cause of their diarrhea but there are, hormone secreting tumors. They’re called neuroendocrine tumors, so undiagnosed neuroendocrine tumors certainly can be life threatening if it goes undiagnosed. Host: What testing can a patient expect to diagnose the cause of their diarrhea? Dr. Malhotra: Usually, we’ll start with stool studies to make sure it’s not an undiagnosed infection. We may do basic lab work to see if anything stands out - for example, anemia or abnormal liver numbers, that may point to one reason over another. After the initial tests, a lot depends on the symptoms of the patients which dictate the testing. An endoscopy sometimes may be necessary where we have to take biopsies of the small bowel and sometimes even a colonoscopy may be necessary, especially if there’s blood in the stool or ongoing nocturnal stools, it may be necessary to rule out inflammatory bowel disease or microscopic colitis. Host: What should a patient with diarrhea do to relieve their symptoms? Dr. Malhotra: So, most of the time, acute diarrhea is self-limited, 24 to 48 hours, and it resolves on its own. During that time, hydration is key. And actually, WHO (World Health Organization) has a recipe for an oral rehydration solution. They sell it in pharmacies, but it’s a very easy way to make it at home. And I tell the patients to just make it at home. So, the recipe goes - there’s 6 spoons of sugar, ½ teaspoon of salt, and a liter of water. A liter would be half a gallon, approximately, and you can keep it in the refrigerator and drink it throughout the day. For longer diarrhea, actually, in developing countries, they even recommend taking zinc, especially in children. It has been shown to reduce the severity of diarrhea and the duration of diarrhea. We don’t use it as much in this country, but something to keep in mind if you’re having ongoing acute diarrhea. So, antibiotics are usually not indicated for acute and self-limited diarrhea. Most of the times, antibiotics can be more harmful than beneficial in the acute situation, unless there is an actual diagnosed infection that needs an antibiotic. And I just want to stress on that fact, with the whole antibiotic task force in reducing the unnecessary use of antibiotics. Antibiotics mess with your microbiome. They can actually cause more long-lasting symptoms and even cause severe infections, that’s just C. difficile. So, antibiotics themselves can cause what’s called antibiotic associated diarrhea. Most of that is thought to be just changes in your colon bacteria or irritation from the antibiotic. And, I actually tell patients to eat yogurt. Lactobacillus, which is a probiotic, which is the bacteria in yogurt, has been shown to reduce the severity of antibiotic associated diarrhea. The one point I would like to make is if there is ongoing diarrhea after you have completed antibiotic, it would be important to make sure and rule out the clostridium difficile infection. Host: Would you explain the difference between prebiotics and probiotics? Dr. Malhotra: So, probiotics are healthy bacteria or what we think are healthy bacteria for our gut. Most of the probiotic products that are marketed, they’re not FDA approved. They’re not regulated by the FDA. They’re just medical food. And anyone can really set up shop and start selling probiotics. So, I really want the listeners to be aware that, you know, there’s been limited studies that have shown positive results with using probiotics in very specific conditions, for example the antibiotic associated diarrhea that I mentioned before. However, really, buying the probiotic and expecting vague GI symptoms to improve, could be a shot in the dark. Prebiotics, on the other hand, are foods that are thought to feed the good bacteria in our gut. So, most of these are plant-based foods, some of these are fermented foods - fermented foods have been used in many Asian civilizations for thousands of years, too, for a healthy gut microbiome. Some examples of fermented foods would be sauerkraut (it’s better to obviously ferment it at home), kombucha tea, tempe, and fermented miso, not the soy we use in tofu. Host: What can a patient do to reduce their risk of complications with diarrhea or the conditions that cause it? Dr. Malhotra: So, acute diarrhea is self-limited, and like I mentioned before, during those times, hydration is key. Now, sometimes patients who have acute gastroenteritis may have a change in their bowel habits that lasts for a long time. Either they can have ongoing diarrhea or sometimes even revert to constipation. This has actually been recognized as an entity called post infectious IBS. It’s likely related to changes in your gut microbiome as a result of either the infection or perhaps an antibiotic that you took for the infection, can last anywhere from 3 months, 2 years or perhaps even longer. So, I usually advise my patients to keep a healthy, nutritious diet full of plant-based protein, if they can. Increase yogurt intake, Kefir, and even add prebiotic to their diet to help. Host: Could you share a story about a patient who had a poor prognosis who you were able to help? Dr. Malhotra: So, one patient actually really stands out. It was a young lady - really no past medical history but had been on antibiotics multiple times for sinusitis, urinary tract infection - so really, you know, a very strong history of multiple courses of antibiotics. And, she really just had chronic diarrhea that had been going on for months. Had had an extensive workup with another physician and nothing really came back positive, and she was really just living on Imodium just so she could leave the house. And actually, we did a breath test that showed that she was positive for bacterial overgrowth in her small intestine. Probably her previous history of antibiotic use and dysbiosis predisposed her to a small bowel bacterial overgrowth. Initially, I treated her with antibiotic (funnily) and she improved, but, in small bowel bacterial overgrowth treatment with antibiotic, a non-absorbable antibiotic works well for the short term but then patients usually quickly relapse and have recurring symptoms, usually within 3 months. And so, we really worked on her diet, adding prebiotics to her diet and adding probiotics as well as working with a plant-based diet, to just help her with her dysbiosis, and she did really well over the next few months and has continued on her diet and done well. Host: Thanks for joining us today. Dr. Malhotra: Thank you for having me. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Chronic obstructive pulmonary disease, or COPD, has skyrocketed over the past 35 years. Dr. Matthew Schreiber discusses what it means for D.C., and how you can be as healthy as possible if you have the disease.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re talking to Dr. Matthew Schreiber, associate director of the Medical ICU and an attending physician in Pulmonary Disease/Critical Care Medicine at MedStar Washington Hospital Center. Welcome, Dr. Schreiber. Dr. Schreiber: Well, thank you for having me. Host: Today we’re talking about a September 2017 report that showed that the number of Americans who died from chronic respiratory diseases, particularly chronic obstructive pulmonary disease known as COPD, skyrocketed over the past 35 years. In 2014, 53 people out of every 100,000 died of a chronic respiratory illness, up from 41 in 1980, a 31% spike. 85% of those deaths were from COPD, which is now the third leading cause of death in the U.S. Dr. Schreiber, how does Washington, DC compare to the national rates of chronic respiratory diseases and COPD? Dr. Schreiber: Well, Washington DC, if you were to just look at it as a city, it’s doing great. The CDC and the NIH did a report starting in 2011 that talks about state by state, how much COPD is there, and I think when you’re talking about chronic respiratory diseases, COPD is really kinda the marker for what you’re talking about. There are a ton of different things that are chronic diseases in the lung, but the biggest bulk of them is going to be COPD, and even if someone had asthma their whole life, they can later have COPD, because of the chronic nature of that destructive disease.  Coming back to what you asked, DC is ranking in with only 4.6% of its residents having COPD and that’s actually pretty darned good, if you look at our neighboring states. It’s 5.9% in MD; 6.1% in VA; and 8.9% in WV. If you dive into the data a little bit deeper though, DC is a tale of two cities. There are a number of things that the CDC and the NIH found had associations with being diagnosed with COPD, and what they found was that in Washington, you had 2.1% of white respondents saying they had COPD, but up to 6.7% in the African American population, and they didn’t report on other ethnic backgrounds. So, 4.6 sounds awfully nice, it’s at the low end of the national levels, but then when you start breaking that down, there are definitely some groups in our district who are suffering from this condition, uh, at higher than average levels for the nation. If you look at people who are unable to work, and this might be because of their lung disease, but, of course, being unemployed can have any number of reasons—19.9% of folks that were unable to work reported being diagnosed with COPD. If you had less than a high school education, 9.6%. Nearly 1 out of 10 people with less than a high school education had been diagnosed with COPD, and age was a big factor. If you looked at folks 18-44, it’s down to 2.2%, but once you’re over 75, almost 10. So, even though you could say we’re doing great, being at the low end of the national level, we’ve got some work to do. Host: Why would there be such disparity between the education and the types of work that people are doing? Is there some kind of a cause environmentally? Dr. Schreiber: COPD is a condition that no one can say they know absolutely what causes it. There’s a number of theories behind it. What I can tell you is COPD is exactly what the name says. It’s chronic, so once you have it, you have it. It doesn’t get cured, it doesn’t go away, it might not progress very fast, but you have it, and it’s all about obstruction. The ‘O’ in the name says the whole thing. People with COPD have trouble moving the air in and out of their chest. And so, if you can’t move the air out, and you’re trying to do some activity or exercise, the faster you’re breathing, the more air that you’re breathing in that you can’t then get out, and you get short of breath. And it’s pulmonary disease, lung disease. So, if you look at it as a pure aspect like that, this could be caused by inhaling something that can damage your lungs over and over again. Cigarettes are the model example for that, and in truth, this seems like common knowledge to a lot of people now, it’s new. We didn’t have studies that showed cigarettes caused things like lung cancer until the 1950s. And we didn’t have a surgeon general’s warning about the damages of smoking until the 1960s and 70s, so progress has been made. But you’ve got a lot of history in the United States with tobacco use and tobacco exposure, and a lot of science going into cigarettes since the early 1900s, that have done its job, so to speak, on getting people to use cigarettes, and the consequences of that use, that we’re only now seeing. When you think about other types of inhaled irritants, different jobs can cause different problems. I ask in my clinic all the time, ‘What kind of work have you done through your whole life?’ And people will focus on the things they might have enjoyed or liked and then I always come back, ‘Did you ever do anything that was around smoke, around fires, around a lot of chemicals, around inhaled irritants where you had to wear a mask, or maybe wish you had worn a mask?’ And people will think about what they did earlier in their life. And the lungs are remarkable things. We have “extra,” so to speak, that when you look at the lifelong duration of how much lung function you have and when it would have to get low enough to cause symptoms, we’re all, for the most part, born with enough lung and develop enough into our late teens early twenties that we can all fortunately die of something else before our lungs become an issue. But when you have these exposures or even some people who just have genetics that predisposes their lungs to dropping off function faster than the average person, when you get to later in life, you start to have this obstruction and then these symptoms, and that’s where people come in and we make this diagnosis. Host: What can a person do to reduce their risk for COPD? Dr. Schreiber: Quit smoking. That’s clearly from a research based standpoint, the thing that can have the greatest impact on reducing your risk. If you have a strong family history, you know, ‘both my parents and one of my brothers has been diagnosed with COPD.’ If that’s your story, you can talk to your professionals in your clinics and your primary care, uh, centers to say, ‘Is there anything that I should be tested for because it seems like everyone in my family is getting COPD or getting it at a young age,’ or ‘I have a non-smoker in my family who’s been told they have COPD.’ They’re a deficiency; something called alpha-1 antitrypsin. Incredibly rare disease, but important enough because of how it gets passed along in families that it’s something you can consider having testing for if it seems like there’s a higher than average risk for COPD in your family. Um, if you are in a career path or a job that gives you a lot of, what we call occupational lung exposure - you’re around something where you’re just breathing in things that seem to irritate you all the time, or, you know, in the back of your head, you’re just saying ‘Gosh, I’m breathing a lot of this stuff,’ it’s…it’s worth it to come talk to your primary care physician or if you have a pulmonologist you can see otherwise, to talk about your risks and being tested. The American Academy of Family Practitioners recommends that anyone who has ever smoked, meaning 100 cigarettes in their life, so the, ‘Well, I only have a cigarette or two if I’m out on the weekends at the bar,’ well that only takes two years of weekends before you’ve had a hundred cigarettes. Host: That’s five packs. Dr. Schreiber: There ya go! And a cough should be tested because we want to catch people early in COPD so we can both manage their symptoms and encourage them to make lifestyle changes that will hopefully not let the disease progress. Host: So, you talked about some disparities in education and across the work force. Who’s most at risk for developing chronic respiratory diseases and COPD? Dr. Schreiber: The research shows that far and away the most at risk are still going to be the smokers. Now the question is, who becomes the smokers? There are a number of scholars that have looked into the impacts of tobacco on public health. So, they point out that there’s a disproportionate, meaning a lot more than you’d expect, of advertising for tobacco products in poor neighborhoods. Their arguments that things like menthol cigarettes are targeted at particular socioeconomic or racial backgrounds and advertising has been done in a way to actually target different groups. Now, these are all theories. I…I can’t overtly say there’s proof, but, I think if you walk around a neighborhood that may be lower on the socioeconomic scale, and walk around a very affluent neighborhood, you will notice there are more billboards in some than others, that there are more advertisements on your corner store for cigarettes than in others, and in fact, this has gotten to the point where laws had to be passed about advertising cigarettes in certain proximities to schools and daycares, because of how it seems that there’s not only this risk of socioeconomics and education having to do with developing COPD and as a proxy of that, maybe using tobacco products, but also the way that marketing is being applied because of how those populations are vulnerable when more people may have this condition and smoking and you add fuel to the fire. So, it is a bigger question of social structure than I think I could ever answer, but there are a lot of people very interested in why these disparities are there. Host: If a person has smoked in the past and they quit, maybe they quit ten years ago, or they used to work in a chemical plant or a place where they’re exposed to smoke, is there anything particular that they can do to either be screened or to reduce the effects of that damage? Dr. Schreiber: Being screened, absolutely. The only way to diagnose COPD is with something called spirometry. It’s a breathing test. It’s looking for that obstruction. We have someone basically blow into a tube connected to a small computer, and we see how much air came out and how much came out in the very first second.  Because someone with COPD, they can get all the air out, they just can’t do it quickly, and if I asked you to blow out for the six seconds it takes for that test and you have normal lungs, it’s hard.  Like at the end you’re really trying to push out that last bit. People that have obstructions, I’ve read results from these tests and they’re still breathing out at 13, 14, 15 seconds because that’s how long it takes to get the air out because of the slowness of it. You can’t diagnose COPD with a cat scan, an x-ray, a stethoscope, a physical exam, a history – unfortunately, that still happens all the time. In the NIH/CDC data talking about COPD in all these different states, DC for example - three out of ten people reported never having had spirometry, yet were given a diagnosis of COPD. I would bet they probably have it based on the symptoms they had, but there are other things that could be going on and getting tested with spirometry, which can be done in the clinic, you don’t necessarily have to get what we call full pulmonary function tests which are done in the hospital, um, not as an admitted patient, but just in…in our hospital facilities, to get some of that answered. And a number of primary care clinics can do spirometry in the office. Um, we can do it in our pulmonary clinic, if that’s all the information we need. Or we can send people for additional testing with full pulmonary function tests. What can somebody do to slow the effects? That’s the tough part. There was a…a landmark study that gets talked about all the time in healthcare where a group of researchers developed a diagram showing the natural history of what happens to lungs. It’s called the Fletcher Peto Curve. And, what they showed is that for a person with no lung disease, we have our best lungs at about 20-25 years old. And then it’s literally all downhill from there. For somebody who has vulnerable lungs and has that bit of damage happening from smoking or whatever their particular cause is, if they can get away from that or quit smoking or get rid of that damaging effect, their lungs never grow back. The lungs aren’t like skin and muscle and bones. You kinda have what you have after the age of 25, but the rate of decline slows down. And so, you ask…started off this conversation saying, ‘Where is this large uptick in COPD coming from?’ It’s coming from us finally recognizing what’s been going in a lot of people for probably the last twenty or thirty years. If you look at that Fletcher Peto graph and you say, ‘Well ok, if a 50-yr. old quits smoking at age 50, they might not get bad enough lungs to have symptoms until they’re 75.’ It doesn’t mean they didn’t have COPD at 50, just wasn’t causing them disability where they actually might have gone in and gotten tested for it.  If you have someone who’s 73 and maybe has no symptoms because they’re one of those people that you’ve met that smoked their whole lives and did fine, then in 2 years later they start having lung problems, they had COPD all along. It’s just they got so close to that symptom marker that now, you know, a year after they quit, they’re on oxygen or can’t go up the three steps to go in their house, and in truth, that’s the scary thing. I don’t understand the response sometimes from patients but they’ll say something like, ‘Well, I’m not worried because this family member, uh, did well with this or did well with that, and so I’m not worried about smoking.’ But it’s not about necessarily the death with COPD, it’s the disability.  Losing your independence and…and I’ve met people in my clinic who literally get short of breath eating. Taking a shower leaves them winded, and that’s the kind of life changing event that is so horrible about COPD, that it takes away your freedom. And, people surveyed in DC talking about how COPD has affected them, almost 2/3 said they have some kind of exercise limitation because of breathing, and that’s why we need people to get checked early, to hopefully get them to either start medication to prevent flare-ups and exacerbations or maintain their symptoms under control, or to make lifestyle changes that might slow the progression. Host: How do you go about addressing that risk with your patients? Dr. Schreiber: I spend a lot of the time counseling smoking cessation, and encouraging activity, referring people to something called Pulmonary Rehabilitation, which is different from just physical therapy because they’ll have respiratory therapists and people that are trained on ways you can manage your breathing a little bit better and how to push your limits but not get exhausted, to still make progress. We talk about nutrition, and keeping people physically fit and being preventative, like getting vaccinations where they’re appropriate. Um, so there’s a lot of things when someone has COPD that we can offer them or counsel them to try to keep them as healthy as possible. Medications have been shown to help when you have COPD. And, it’s an interesting split to me and…and I say this to my patients in the clinic all the time - you wouldn’t wait until you’re having a heart attack or a stroke to start taking your blood pressure medicine, even though you feel fine. For some reason with inhalers people say, ‘Well, I’m breathing ok so why am I taking this inhaler every day?’ But these are preventive medicines, and if I can stop you from having a flare-up this year, which then will affect your lung function next year, that’s a win.  And so, the things that we prescribe in the pulmonary clinic are not always just to make you feel better, they’re also to prevent you from falling apart in some way, because nature is still going to cause those lungs to decline a bit, but if I can NOT have you in an urgent care or hospital with something that’s gonna make it decline even faster, to then keep you independent and doing things, even though you quote ‘feel like you’re breathing ok,’ then I’m doing my job. Taking a pill for folks just seems to be simpler than using an inhaler, and granted, there’s a lot more coordination going on with using an inhaler, and a lot of people use them wrong, and there’s no point in medicating the back of your throat when we need it to get it down into your lungs.  But, it’s another task in the day that takes a few more seconds than just swallowing something with water and, you know, it’s something that I think when you look at a patient and they’re using an inhaler, there might be social or, you know, other biases where you look at them and say, ‘Oh, you’re doing that, as compared to just discretely swallowing a pill with a glass of water.’ And so, I think a lot goes into it. Um, it also comes back to that idea of ‘well why am I taking this medicine if it’s not making me feel better?’ And, with the way that our society, uh, has a healthy and appropriate fear of heart disease and strokes and diabetes and hypertension, um, medications for those, I think, are something people buy into and I don’t think we’re there yet with breathing disorders to say, ‘This is something that you really should do and here are the risks and here are the dangers and here’s why.’  I think, in some ways, that’s a…a blessing, that this is a new enough common disease, so to speak, that we’ve only been dealing with this for forty or fifty years, um, that people don’t have a hundred years of being afraid of heart attacks and strokes the way that, uh, they don’t necessarily have that fear with COPD, but it means we’ve got a lot of catching up to do really quickly. Host: Thank you for joining us today, Dr. Schreiber. Dr. Schreiber: No, it’s been my pleasure. Thank you. 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