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 Chris Staloch and Joe Skorczewski of Chartwell visit the Engineering Influence podcast to discuss how to use an ESOP to drive company performance.  Host:Welcome to the ACC engineering influence podcast brought to you by the ACEC Life/Health Trust. Today, I am joined by Chris Staloch and Joe Skorczewski from the Chartwell Financial Advisory. Chris is a managing director with Chartwell and has been with the firm for over 23 years. He has spent the past 12 years leading Chartwell's architecture and engineering practice. Joe is a director at Chartwell and has been working with Chris in the practice for most of his 15 years at the firm. We've invited Joe and Chris to speak with us today about some of the emerging trends with regard to ownership and compensation in A/E firms.Host:To start, what is the state of the current market? What are engineering firms looking for?Staloch:After some initial panic, when COVID first broke out, we actually saw a pretty quick return to what we would call normalcy. We actually managed to close a couple of transactions back in April, much to our initial surprise. We're seeing companies come to us looking for not only traditional third party sales transactions, but also new ESOP formations and a fair amount of just consulting around helping them think through their ownership, advisory issues. We see a number of companies that are currently struggling with how do they infuse enough capital into their organizations as companies transition out some of their previous ownership.Host:Are there any specific issues that you see as commonplace in the projects that you're working on?Staloch:One of the things that has become a recurring theme for us is that the companies that are privately held have this constant issue of having to transition the ownership of the business. And that's true whether the company is formed as an ESOP or whether they just have broad-based ownership in their organizations. And so what is happening right now is given the demographics of society. we're having a lot of people who are retiring from companies and the amount of capital that is available to come back into the organization through investments by other employees to replace those shareholders who are leaving is oftentimes not significant enough to make it worthwhile and to actually effect those transactions in a manner that you would hope to see on a recurring and regular basis.Skorczewski:I have a story to add. There's a client of ours who recently came to us. They do a fun Friday--this was pre-pandemic--morning trivia question. Everybody goes to the chalkboard and answers a question. And the question was if you won a million dollars, what would you do with it? And the answers were: A, I would go buy a boat; B, I would put it in savings; or C, I would pay off my student loans or other debts. And 80% of the firm answered C. The owner of the firm came to me and he said, "Joe, who am I going to sell my company to? My employees do not have the personal balance sheets to buy me out. So what should I do?"Staloch:That really speaks to the significant shift in the way the ownership has transitioned in businesses today. We've heard stories from our clients and older folks in these firms, who've talked about how they came to their ownership in the business. And they went out and got a second mortgage on their house and did things of that nature to be able to buy into an organization. Today we're not seeing people having the willingness to do that. Or in many cases, really even having the capability of doing that because of the amount of student debt that they're saddled with when they're coming out of school. For a lot of people, it might take them 10 years to pay off that student debt. They don't have the financial resources available to them to actually invest in these firms. So that presents a quandary for firms.Host:What are some of the considerations that companies should take when they're thinking about compensation and ownership questions then?Staloch:One of the things that we have seen is companies really trying to understand how they align their compensation programs with what they're trying to accomplish from an ownership perspective. Too many times, there's a disconnect between those things. Oftentimes they're thought about in a sort of vacuum. You have a firm that puts together this great compensation program, but it doesn't necessarily get them to where they need to be from an ownership perspective. And by that, I mean, oftentimes you'll see companies utilize stock as part of their compensation programs, either in the form of a long-term incentive program or as part of their annual bonus structure. But if there are not enough dollars or stock being utilized in those programs to actually effect the transitions of the older folks in the organization, that's not going to really work from a sustainable ownership perspective, if indeed the goal is to maintain the ownership of that company as a privately held organization inside the existing construct.Host:So what are some of the tools that firms can use to address these issues?Staloch:There's a variety of things out there. Oftentimes we see people think about programs such as stock appreciation rights, utilizing stock options, or Phantom stock. Things of those natures that generally are some sort of what we call synthetic equity. So they're equity-like instruments, but they're not actual equity in the organization. And so people will use those as part of their compensation programs, usually in the form of some sort of long-term incentive program. The other component that we often see companies look at is just going to stock bonuses or setting up programs where a portion of the cash bonus that the company is providing to their employees is expected to be utilized as part of the repurchase, or I should say, the purchase of stock in the organization.Staloch:There's an interesting psychological element that we hear people talk about, and management teams have different philosophies on this front. Sometimes they'll utilize stock bonuses as part of the program and they feel like they're, quote-unquote, giving stock to their employees. But if they cut them a check for their bonus, and then the employees need to make a decision to actually turn around and write a check back to the company, to buy stock in the organization, that there's a different sort of mentality behind that for the employees. There's more of a feeling of having skin in the game in that regard. So, so that's something that we see frequently as well.Skorczewski:One unique tool that we've seen come back to life is deferred compensation. And again, I'll walk through a particular story. As has been well-documented, the talent war in this industry is real. And further, there's a specific gap of these 10-to-15 year folks, project managers, future leaders of the firms. There's a shortage of them actually dating back to the recession of 2008. Many owners of firms don't want to reach down too far to provide ownership to a 30-year-old, for example, but they really want to retain that individual. But that individual is in high demand, and they don't want to lose them. What we've seen happen in that case is there's can be some sort of deferred compensation plan put into place where you might award that individual, a series of bonuses, $10,000, $20,000, whatever the number is that vest over a period of years, say three or five years. The presumption is that at the end of three or five years, that person would then be in a better position. And like Chris said that award would vest, that person would get paid, and that person would turn around and purchase stock in the company. So it's a way to extend a little bit deeper down into the organization, which can be useful depending on the demographics of your specific firm.Staloch:Two other elements of this to add to the discussion. One of the other tools that we've seen companies utilize is their 401K. What they'll do in some instances is create a stock fund inside the 401K of their own company stock that they allow their employees to invest in, or utilize stock in the company as part of their matching contribution to the employees' dollars to get more shares into circulation in the organization. Frequently we're seeing companies look at that as a creative solution. And then the other element that is becoming more common is a contributory ESOP? The idea behind that is that would use the stock of the corporation to make contributions into a retirement plan for the employees. It works very similar to what I mentioned on the 401k front, but it's really in the form of an ESOP and gives the company certain tax benefits that you do not necessarily have with other forms of compensation that are provided to employees.Host:ESOPs are usually thought of within the context of transitioning ownership in a company. Can you explain the difference between a traditional ESOP and a Contributory ESOPSkorczewski:An example of a traditional ESOP that most have come to learn and know in the industry space is the ESOP can be any percentage of the company, but traditionally, some pretty big milestones are 30 percent ESOP, 51 percent ESOP, and 100 percent ESOP. I'll walk through an example that's been very prevalent in the industry. You have a company that's a C Corp, let's call it a $30 million company. You might have four or five shareholders getting to retirement age and they might own about 30 percent of the shares. In that situation, the company would set up an ESOP. Next, the company would go to a bank, get a loan for $10 million, which is about 30% of the overall value. Then the company would loan that $10 million to the ESOP and the ESOP would go ahead and purchase those shares directly from the departing shareholders. There is, in that situation, an internal loan that's created between the company and the ESOP, and those shares are essentially collateralized and then released over a period of time, let's say 10 or 20 years. That would be the traditional ESOP, a leveraged transaction, which is a significant event in a company's history.Skorczewski:Now let's compare that to a contributory ESOP. What occurs in that situation is the company goes and sets up an ESOP, but rather than entering into a transaction, the company simply issues newly issued shares, let's say 3 percent of qualified payroll, and deposits those shares into the ESOP. Over 10 years, uh, you might get to the same spot, where the ESOP would own 3 percent in year one, 6 percent in year two, 9 percent in year three, etc. Over that period, all of those shares are allocated and you essentially arrive at a similar spot. You just get there in a different way.Staloch:And I'll just add to that, that one of the reasons that companies tend to think about utilizing a contributory ESOP, as opposed to a traditional ESOP structure, is that in the concept that Joe just described, you are reducing the fiduciary exposure significantly for the trustee overseeing the plan. Because now the trustee is not necessarily making a decision to purchase stock in the company. They're just accepting a contribution of shares into the plan each year. And so the amount of risk that's associated with that type of a model is substantially less than what it would be under a traditional ESOP construct.Host:Are there other benefits or reasons why owners and sellers would choose to go with a contributory ESOP versus a traditional ESOP?Staloch:Some companies, particularly as we sit here today, are looking for ways to incentivize the employees to go above and beyond and really drive growth in the organization. A contributory ESOP is a way to provide ownership to the employees and start to build that kind of ownership culture without providing direct ownership in the business, which carries its own complexities that go along with that.Skorczewski:In addition, as you compare those two examples. In the contributory ESOP, there's a small amount of capital that's invested in the company, but it's not a $10 million transaction. It's a small contribution of shares. So it doesn't impact the balance sheet in a way that a traditional leveraged transaction would. We've seen it work really well with very long runways, meaning folks that are maybe 50 or in their lower fifties who might have 15 years to retirement. They might feel it is just too early for them to sell. Maybe the next 10 years are going to be really good and they may not want to exit or liquidate their holdings so soon. In a contributory ESOP model, the percent ownership changes slowly over time. So you're not timing the market, so to speak, with a particular transaction on a particular date. It's more of a thought-out interval, a process over 10 years. So if you have good years in front of you, or particularly in the environment that we're in today, if the value is low, you might not want to sell today. But a contributory ESOP would put a market in place, communicate to the employees and the company where we're trying to take this entity over time, and provide clarity to all the stakeholders in the firm.Host:Finally, what are some of the challenges of utilizing an ESOP in this manner?Skorczewski:On the flip side, if we're dipping our toe into the water, we're creating a lot of flexibility for our departing shareholders, but it takes some time to create meaningful balances into folks' retirement accounts. It will not be an overnight success, and communicating to your employees that they own the company while contributing $575 to their retirement account that they're going to have access to in 40 years isn't a big bang out of the gate. But that's okay. It takes time. And that's not the intent. Over the course of a generation, over the course of a decade, you will start to accumulate shares in your account. The value of that will grow. And over time as you communicate that it will work, it can work very well. But the small dollar amounts right out of the gate are sometimes contradictory to someone feeling like they're an employee-owner.Skorczewski:In addition, a lot of folks would rather have a dollar in their pocket today than a dollar in their retirement accounts. So knowing and communicating around that would be important. And, and there are some explicit costs of trustees and valuation firms and third party administration. So, just from a dollars-and-cents perspective, you'd want to make sure that you are committed to going down this path. Otherwise, if you do this for a few years and then revert to something else, you'd have spent some fees that could have been gone elsewhere.Host:Great. Well, that's, it's been an illuminating discussion into contributory ESOPs. I appreciate you taking the time. 

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Doctors know that celiac disease is a real medical condition, but too many people treat it like a trendy diet choice. Dr. Z. Jennifer Lee discusses the dangers of gluten exposure in patients with celiac 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: 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! Nice to be here. Host: Today we’re talking about treatment options for celiac disease, an autoimmune disorder in which patients suffer intestinal damage after eating gluten, a protein found in wheat, barley and rye. There are currently no effective celiac disease treatments approved by the Food and Drug Administration, but a promising new drug is headed into phase two clinical trial. Dr. Lee, could you give us a brief overview of what celiac disease is and how it affects patients’ quality of life? Dr. Lee: Sure. Celiac disease is a disease process which falls under the spectrum of gluten-related disorders. It is something that we know a lot about. It’s a genetically-based disease. It happens to genetically susceptible individuals where upon intake of gluten, they can get a reaction. It’s an immune mediated reaction. And so, what we used to tell patients, was that they were allergic to gluten. So, as we delve a little bit deeper into the topic today we’ll see that there are other gluten-related disorders that result in symptoms even without the diagnosis of celiac disease. So, another one would be wheat allergy. And another one that is actually quite commonly talked about these days is non-celiac gluten sensitivity. But getting back to celiac disease, the patients can manifest in many different ways--It can be chronic diarrhea, it could be bloating, it can iron deficiency anemia. And so, it needs to be on our minds when we see patients with these possibly non-specific symptoms. Host: Why is the advancement of this drug, Nexvax2®, into phase two clinical trial exciting for the celiac community? Dr. Lee: So, it’s exciting and not. Right now, as you mentioned, there are no medications for celiac disease. We have a very good treatment for celiac disease and it’s dietary--we avoid gluten, and it works for the vast majority of our patients with celiac disease. But, the difficulty is inadvertent gluten intake. Sometimes there’s cross contamination if you’re eating out. It can be an issue, and so I think it would be nice to have some sort of medication that helps with that. It’s also important to remember, though, that this is a phase two trial, and so, again, the majority of drugs that go in to phase two trials actually don’t make it past phase two. So, while it is exciting, I think we have to keep in mind that the most important thing is gluten avoidance. Host: How is it that a disease as common and well-known as celiac disease has no effective treatments? Dr. Lee: I think it’s because it’s a complex disease. It’s a genetically based disease. However, not everybody who has the genetic predisposition gets celiac disease. It’s a very complex thing, and where you have the propensity, genetically, and then you have other factors, and we’re not entirely sure what all those factors are. And so, it’s difficult to pinpoint or target something exactly. The medication that’s in trial now, the target would be a genetic target but, we don’t know with 100 percent clarity what causes it. So, it’s hard to say. Host: How long would a person have to suffer symptoms before they go see a gastroenterologist for a possible celiac diagnosis? Dr. Lee: You know, I’ll be honest with you, I’ve seen the whole spectrum. I’ve seen patients who’ve had diarrhea for many months without a diagnosis and they come and we’ve made the diagnosis at that point. But I’ve also seen patients who don’t really know that they’re anemic and they have iron deficiency anemia and we find that on testing and we’ve been able to make a diagnosis that way. Host: What are some of the common and more uncommon symptoms of celiac disease? Dr. Lee: Within celiac disease, very commonly we’ll have chronic diarrhea, weight loss, joint pains, even headache, rashes. So, as you can see, some of them can be very non-specific. And the important thing to note here is even across the different gluten-related disorders, you can get these types of symptoms. For instance, non-celiac gluten sensitivity and celiac disease can both present with brain fog - that’s a very common complaint that you hear about. So, very important that patients with these symptoms see a gastroenterologist and nail down a diagnosis. Host: How can gastroenterologists help patients understand whether they have celiac disease or another gastrointestinal condition? Dr. Lee: There are significant differences in long-term health consequences, depending on what you are diagnosed with. It’s very important to be diagnosed with celiac disease because, down the road, you need to be monitored for certain things like autoimmune diseases, even certain cancers, down the line. Whereas non-celiac gluten sensitivity and even wheat allergy may not necessarily result in this same long-term sequelity. Host: If a person’s really struggling with these symptoms, what would you recommend as their first action to get care? Dr. Lee: To definitely come see a healthcare professional. Whether that be their primary care doctor or if they want to come straight to a gastroenterologist, that’s...you know, we are happy to see these patients. Diagnosis involves some blood testing, and, in most cases, an upper endoscopy, where we take samples of the small intestine to evaluate for any signs of inflammation. Host: Could you talk a little bit about your patient population? Dr. Lee: Absolutely yes. I would say, when we first started learning about celiac disease, you would think that it was a disease found only in Caucasians or those of European ancestry. But now we’ve learned that really it can be in any population, any race. And, to follow that, it’s in anybody of any age. It’s commonly diagnosed in childhood, but I have made plenty of diagnoses in adulthood. Host: What kind of damage do you see in your patients after years and years of symptoms? Dr. Lee: I think the most dramatic patient I’ve seen, and dramatic being that when I first met him, he was emaciated. I mean, he had lost so much weight. He showed me a picture of his driver’s license and how he was before his symptoms started - and they didn’t start until he was in his 40s. But he looked like a completely different person. The weight loss was very marked. And so, after making the diagnosis and after starting him on a gluten free diet, and seeing him in follow-up afterwards, it was like seeing a brand-new person. It was amazing. I still keep in touch with him, to this day, you know, there’s not much that I need to do for him now that he knows exactly what he can eat, what he can’t eat. He has appropriate follow-up. We check his vitamin levels once in a while. But, I think it’s just...it’s such a great feeling when you see that they have returned to, you know, their normal life. Yes, they need to change the way they eat but it’s possible to feel healthy and to feel like you can go out and have a normal life. There’s data to suggest that, in children, the thought of having celiac disease produces anxiety and reduces quality of life. And so, we know it is something that people think about and worry about so I think, you know, even in the quality of life aspect--eating out, being social--it’s rewarding to see that we can, you know, get someone to that point. Host: How is it that a disease that has genetic components can manifest so late in somebody’s life? Dr. Lee: There’s so much that we still don’t understand about celiac disease. We are not sure why, in one person, it would manifest in childhood and another it manifests in adulthood. Host: What do you say to people who say, “Oh, celiac disease is just a trend and it’s not real.” Dr. Lee: I think I just tell them what we know, based on the evidence that we have. What trials we’ve done. And I explain to them that there IS a spectrum of gluten related disorders - celiac disease, wheat allergy, non-celiac gluten sensitivity. And, you know, it can be a bit of a fad thing. I mean, right now we’re all hearing about a gluten free diet. I would say that many people who are on a gluten free diet don’t have a gluten related disorder. But there are a subset of people who don’t have celiac disease yet feel very poorly on a gluten containing diet. So, these would be the non-celiac gluten sensitivity patients. And, you know, it is a very poorly defined disease but yet, it’s there. There is some evidence to suggest that there may be a little bit of inflammation in these folks as well but we’re very early on in our research in that aspect. You know, all three of these conditions have overlapping features, which is why it can be confusing. So, with the fad diet - of a gluten free diet - it’s, I think, both a good and a bad thing. I love that it allows my celiac patients to have more possibilities, especially going out to eat. Many restaurants offer a gluten free diet now and I think that’s great because before, patients were stuck with very little to eat. They would have to cook at home, stick to maybe like a tiny little space within the grocery store where the gluten free stuff was. But now, you know, the possibilities are much more. However, having said that, because it is a bit of a fad, I think some people tend to maybe roll their eyes at it and say, ‘Oh well, you know, you don’t really have some allergy or sensitivity or whatever, you’re just following this fad diet.’ And so, the danger in that would be that maybe like a restaurant person would not take it as seriously and not take into account the cross contamination that’s possible. I mean, some people with celiac disease really just take that one exposure and they can, you know, throw them into their symptoms. So, it’s both a good and a bad thing. But, again, it’s important, you know, from patient to patient like, to know what it is that you have and what is potentially life threatening and what is not. I just want to bring up another point and that to test positive for celiac disease, you have to be on gluten at the time. So, you have to be eating gluten and so you’re therefore not feeling well, but you need to have that exposure in order for us to pick it up on our testing. Host: You mentioned that there are three main conditions. Could you give us a small recap of each of them? Dr. Lee: Sure. Well, there’s celiac disease and that, we’ve spoken about, it’s in genetically susceptible individuals. They have this proven inflammation in their small intestine resulting in a gamut of symptoms. There’s wheat allergy and that is your typical ‘quote/unquote’ food allergy where you, you know, can potentially get anaphylaxis to it. And then there’s non-celiac gluten sensitivity and that’s the very poorly defined one. But, again, there can be a lot of common symptoms. But, I think that, based on my patients, what I usually hear, is the abdominal pain, the fatigue, and the brain fog. Those are three of the very common ones for gluten sensitivity. Host: Are there any health benefits for going gluten free for people that don’t have a gluten sensitivity or celiac disease? Dr. Lee: That’s a good question and I think it’s going to be a bit of a complex answer. When people tend to take out gluten they do take out a lot of carbs and so, you know, limiting your carb intake can be healthy. But what are you replacing that with? Are you replacing it with, you know, a bread that you’re buying in the gluten free aisle, in which case, that’s actually a heavily processed food item. It can be very high in calories and so it makes a difference what you’re replacing that food with. One thing we do need to think about though is, are there any consequences of going on a gluten free diet. And the answer to that is potentially yes. We do have some studies showing that there can be nutrient or/and micronutrient and vitamin deficiencies, you know, even ten years down the road. And these are based on our celiac patients, but we think it’s due to them being on a gluten free diet for a long period of time. We’ve seen some data showing that patients who have been on a gluten free diet for a prolonged period of time are more obese than patients who have not been on a gluten free diet. And then not to mention the cost. You know, it’s very...it’s not cheap buying the foods from the gluten free section. Host: I’ve noticed that a lot in grocery stores, it seems like any kind of health product seems to be more expensive than the assumed not healthy product. Dr. Lee: And I think part of that is a little bit of marketing preying on consumers. If you’re in the shampoo aisle and you see a shampoo labeled gluten free and it’s three times the price of regular shampoo, people don’t necessarily know that. They just think that gluten is bad, and they may buy the shampoo that’s gluten free, but really that makes no difference. There was one small study suggesting that in adults who follow a gluten free diet, they may be at risk for cardiovascular complications because, the thought process was that they were consuming less whole wheat. But again, very early on in our research regarding this. You know, the most scientific way to go about it would be to remove gluten from your diet and then you’ll notice that you feel better. And when you reintroduce gluten, do it in a blinded fashion. Then introduce something that you may or may not know whether it has gluten or not and see how you feel. Maybe your friend knows, maybe your friend knows which bread is the, you know, gluten free bread and which one’s the regular bread. But, I think mostly, it’s how you feel - how you feel on it, how you feel off of it. Host: Thanks for joining us today, Dr. Lee. Dr. Lee: Oh, you’re very welcome. 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.

Some pituitary tumors need immediate treatment, while others may benefit from a wait-and-see approach. Dr. Susmeeta Sharma discusses the different types of pituitary tumors and how we care for them.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thank you for joining us today. We’re talking with Dr. Susmeeta T. Sharma, director of pituitary endocrinology at MedStar Washington Hospital Center. Welcome, Dr. Sharma. Dr. Susmeeta T. Sharma: Thank you for having me. Host: Pituitary tumors often cause no symptoms, but when they do, the symptoms typically are vague and easily can be mistaken for other less serious conditions. Pituitary tumors may be functional, which means they secrete excess hormones, or non-functional, which means they do not secrete excess hormones. Dr. Sharma, when symptoms occur, what do patients typically experience? Dr. Sharma: The symptoms of pituitary tumor kind of depend on the size of the tumor and whether it’s a functional tumor, what hormone it’s making, is it causing any hormone deficiency. So, I always think that in order to understand what symptoms a pituitary tumor can cause you have to understand the basic physiology and anatomy of a pituitary gland. So, the pituitary gland is a pea-sized gland located at the base of the brain. And I think of it as a conductor of an orchestra. It basically makes a bunch of different hormones, which then regulate other endocrine glands in the body to make other hormones. So, for example, it makes TSH (thyroid stimulating hormone) which then acts on the thyroid gland to make thyroid hormones. It makes ACTH (adrenocorticotropic hormone) which then acts on the adrenal glands to make...regulate cortisone production. It makes prolactin which acts at the level of the breast for development of the mammary glands and milk production. It makes FSH and LH which are gonadotropins which act on the gonads, ovaries, and testes to make female and male gonadal hormones, testosterone and estrogen. And then it also makes growth hormone which really acts on the entire bodies involved in growth, especially in children during puberty, achieving, uh, their full height potential. So, it’s a really important gland and any small, uh, dysfunction, whether it’s related to an inflammatory disorder or a tumor that’s causing compression - any of that can lead to either hypofunction of one of these hormones or increased function of one of these hormones. A pituitary tumor has the potential to make any of these hormones. So, it’s...if it’s a functional pituitary tumor, it can cause symptoms related to excess prolactin, which will then be breast milk production or irregular menstrual cycles or infertility in a female. In a male it may be even harder to detect because of the lack of the menstrual irregularity as a symptom so while they may present with is decreased libido. And later on, as the tumor grows, it may cause symptoms related to the size of the tumor, so headaches and vision problems. So, it all depends on the kind of hormone that the pituitary tumor is making. Another example would be if it’s making ACTH which is then leading to excess cortisone production that can lead to a patient gaining a lot of weight, muscle weakness, fractures, diabetes, high blood pressure, developing purple stretch marks on their body. So, a variety of symptoms that could be related to excess production of a particular hormone in the body. Uh, so that would come from hormonal excess. But then you could have symptoms related to hormonal deficiencies. So, if the tumor is large enough that it’s compressing normal pituitary cells, you could have a low cortisol state, a low growth hormone state, a low thyroid hormone state, which can then lead to other symptoms of their own. And lastly, like I mentioned earlier, from the size of the tumor. Even if it’s not producing any hormone, as the tumor grows, by the size of the tumor, it can cause headaches to the patient and also, in the space where the pituitary gland is located, it’s a very tight space and it’s very close to the optic nerve or the optic chiasm, and those are fibers that control our vision, especially our peripheral vision, and so, as the tumor grows, it can compress on these nerve fibers, leading to vision problems - double vision, loss of peripheral vision - it may manifest as that. Many times though it may be the patient may not have any symptom at all and it may get detected on an MRI done for other reasons - for example, for headaches, for...which are...may or may not be related to the pituitary tumor. So, the presentation can really be varied and depends on how big the tumor is and if it’s making any particular hormone. Host: When symptoms arise, is treatment urgent, or do the tumors grow slowly? Dr. Sharma: The majority of these tumors are slow growing tumors. These are benign tumors, not cancers. Often, patients may hear a diagnosis of brain tumor but this is very different from other tumors that arise in the brain and that have a much higher malignant or a cancerous potential. So, pituitary cancer is very rare and so these are mostly benign tumors. Benign in the sense of them being cancerous but not benign in some of the effects that they can cause if they go undetected. But most of the time, yes, given the fact that these are slow growing tumors, the symptoms often develop gradually. Uh, many times these symptoms can be non-specific so a patient may just have some fatigue and some inability to lose some weight and that could even be a symptom for a hormonal disorder. So, um, sometimes the presentation may be very obvious, very florid, and we may even walk into a room and see a clinical appearance of a patient and think that, “Oh, this patient has to have a pituitary hormonal disorder” while other times it may need a much more lengthy interview in the clinic and exam and for the blood test before a diagnosis can be made. Host: What are some of those immediate symptoms that would cause you to think a patient you’re visiting with has a pituitary issue? Dr. Sharma: Um, so, in particular in women, if they have irregular menstrual cycles and there is breast milk production and they have not had a baby and so that would be a situation where there has to be a prolactin elevation in the majority of the cases. Uh, that may or may not be related to a pituitary tumor; that there are other disorders that can cause a prolactin elevation. But that definitely means that they need to be evaluated by an endocrinologist and need to be tested to see if there is a pituitary disorder there. So that would be one example. Other times, especially in conditions where the pituitary tumor makes growth hormone or the hormone ACTH (adrenocorticotropic hormone) which then leads to cortisol excess—those two particular hormonal disorders can often present very floridly, where the clinical appearance can be very dramatic and easy to detect if it has gone undetected for quite a period of time. So, for example, a growth hormone secreting tumor or excess growth hormone leads to enlarged, fleshy hands and feet. The patient would complain of change in ring size, change in shoe size. They would have changing facial features, coarsening facial features over time that one can detect on...while examining or looking at the patient. Another example would be Cushing’s Syndrome, or excess cortisol in the body. In that, also you have a change in facial features, rounding of face, a reddening of face which we call plethora, excess fat positioned on the upper back of the body in the base of the neck area where...near the clavicles. And so all of that can make us at least suspect that this patient could have Cushing’s, and then those patients would need to be screened for that disorder. Host: What are some of the common diagnostic tests when a doctor suspects a pituitary disorder? Dr. Sharma: If we suspect that a patient has pituitary disorder, sometimes the clinical presentation is so florid that we may want to test for a particular hormone and other times we may need to test for all of the pituitary hormones. And again, anytime I am thinking of a pituitary tumor, I need to make sure both that A) the tumor is not making any excess hormones, so those would be blood and urine tests to start off with for these particular various hormones and then I also need to make sure that it is not deficient. Many times, the blood and urine tests may not itself be sufficient for the diagnosis - that would be the initial screen, followed by some more dynamic testing that may need to be done to confirm that their patient has a particular hormonal deficiency or hormonal excess. And then again, we need to have sophisticated MRI to be able to detect the full location of the tumor, and then you need to collaborate with the neuropthamologist to make sure we are looking at any possible visual deficits related to the pituitary tumor. So definitely a team work - you need the endocrinologist to be able to assess for these hormonal deficiencies and hormonal excess disorders, you need the neuropthamologist and the neuroradiologist to look at...um, visualize the tumor on the MRI and assess if there are any visual field deficits related to the tumor, and then we need, of course, the neurosurgeon if surgical treatment is indicated. Host: What is the approximate size of the pituitary gland? Dr. Sharma: In a three-dimensional structure, the height of a normal pituitary gland is around 6 millimeters in size so, overall again, yeah, the pituitary gland is about the size of a pea. And then, any time there’s a tumor within it—so just a few millimeters above is the optic chiasm and so any time the tumor is growing there is a potential of that gland with the tumor encroaching onto the eye nerves, especially if the tumor is greater than a centimeter, which is what we call a macroadenoma while in the centimeter. When the pituitary tumor is less than a centimeter it’s called a microadenoma. Host: How big are the tumors that you’re taking care of in these patients? Dr. Sharma: So, very variable. So microadenomas, may come to our attention two ways. It might just be that in this era of MRIs, an MRI is done for other reasons and we find a small tumor now. Once the tumor is found, you do want to make sure that it’s not making any hormones and then you have to follow it once a year, at least, to make sure that it’s not growing significantly in size that it needs surgical attention, just based on the size of the tumor. Otherwise, it may be that it’s a small tumor but it’s making a particular hormone so mostly functional tumors can get detected at a smaller stage just because of...they’re causing much more symptoms to the patient from the hormonal excess related to them. And so functional tumors may get detected at a size when they’re less than a centimeter. Non-functional tumors though, most of the time if they’ve not been incidentally detected on an MRI, would be greater than a centimeter. So, we have had tumors that are 5 to 6 centimeters, especially many times in patients who have not sought medical attention or have not been seeing physicians regularly. Um, other times the tumor could be very large but it’s just that the patient has not paid attention to the visual field deficit that it may be causing. So, they just get used to not being able to see peripherally and that can be very dangerous, especially if they’re out there driving with the visual defect. So, as an example, we had a young male with a prolactin secreting tumor. And so, this tumor was about 5 centimeters in size. And, these are slow growing tumors so it was probably present for several years but a prolactin secreting tumor in the male, all it was doing in his case was lowering his testosterone levels and thereby probably causing decreased libido but it had to grow to that big a size and to finally, during a testing for a DMV related driver’s license, he failed his vision exam and that’s how his visual field loss initially came to attention. Host: Is a functional or a non-functional tumor more dangerous? Dr. Sharma: A non-functional tumor, whether or not it needs immediate attention, would depend on the size of the tumor and what mass effects it’s causing. But definitely a functional tumor always needs attention. So, I’m not sure if one is more serious than the other but definitely a functional tumor always needs attention immediately. And so, uh, most functional tumors, actually the first line of treatment would be surgery. The only functional tumor that can be purely treated medically in the majority of the cases is a prolactin secreting tumor. So, although there are medications available for treating various different functional tumors, in prolactin secreting tumors using medications that are available are so effective that we can actually shrink the pituitary tumor and normalize the prolactin levels with medications alone and they don’t need surgery. And, in fact, outcomes from medical treatment can even supersede what we can achieve surgically and so that is why an endocrinological evaluation is really important for pituitary tumors because we want to make sure that we assess whether or not surgery is indicated and also make sure we’re not missing these, this particular kind of tumor—the prolactin secreting tumor—where we can make a difference medically instead of the patient having to undergo any unnecessary surgery. Host: When a patient requires surgery, is there a minimally invasive option? Dr. Sharma: Surgical techniques for pituitary tumors have really advanced. And the majority of the pituitary tumors can be safely resected through the transsphenoidal route. So, we have an endoscopic or a microscopic approach and it depends on the size and location of the tumor when the pituitary surgeon decides which approach to take, but they’re all being done minimally invasively now. And so, this would be a route either under the lips sublingually or trans nasal so through the nasal passage, through the sphenoid sinus and then through the base of the sella, which is what we call where a pituitary gland is located. So, that would be a minimally invasive approach. Patients are usually in the hospital for 2 to 3 days after surgery and are able to leave so compared to the earlier times where you would actually have to cut open the skull and then approach a large pituitary tumor. So even tumors of the size of 5 to 6 centimeters can be safely removed through this route these days. Host: Is there any scarring related to the surgery? Dr. Sharma: So, no actual visible scarring. Many times, in the path that the surgeons take, you may have some superficial nerve fibers that are affected and so people may have temporary, um, either altered or loss of taste or smell sensation. They’re definitely going through the sinus so sometime you can have sinus-related issues but those are usually temporary and there’s, uh, no visible scarring. You can’t really tell that the patient has had surgery, in fact. Host: Why is MedStar Washington Hospital Center the place for people to seek care? Dr. Sharma: Oh, I think what we provide is a multidisciplinary team approach. It’s really important to see a patient and treat them as an individual and see what would be the best treatment option for them. So, any time I think of a pituitary tumor, I think what it needs is a team and not just a single physician operating in isolation. So, you need an endocrinologist to evaluate the hormonal excess or deficiency related to the pituitary tumor. You need a neuroradiologist to properly evaluate the tumor and make sure they’re using up to the mark MRI techniques and developing newer localization techniques for that. A majority of the tumors do need to be surgically removed so we definitely need an experienced neurosurgeon. Not every neurosurgeon is doing the number of transsphenoidal surgeries I feel that are necessary to develop the expertise, so it’s really important to have an experienced neurosurgeon who does a lot of these. And we are lucky to have Dr. Edward Aulisi as one of our neurosurgeons here. And so, an experienced neurosurgeon and then an experienced neuro-opthamologist to look at visual field deficits related to it. And then as an adjunct treatment, other than surgery and medical therapy, you may also need radiation therapy for the pituitary tumor. So, we have focused stereotactic radius surgery options available at MedStar Washington Hospital Center as well. So, having it all under one roof helps because we all are communicating and trying to develop a treatment plan that is best for the patient...that’s optimal for the patient. Host: Are you currently doing any research on pituitary tumors that you’d like to share with people in the community? Dr. Sharma: So, we are starting the research process. We do have Dr. Joseph Verbalis, who’s at our counterpart institute which is Georgetown University Hospital, where he’s already doing a lot of research on posterior pituitary and sodium disorders. And then Washington Hospital Center - we are developing other research programs to look at the path of physiology of tumors so what leads...for different patient populations to develop various kinds of pituitary tumors. We are working with our pathology department to try and see what molecular markers we can identify to better, um, identify what treatment option would be better for a particular patient based on those molecular markers. And then, of course, devising better, more refined surgical techniques for making these surgeries possible in a minimally invasive manner. Host: Thank you for joining us today, Dr. Sharma. Dr. Sharma: Thank you for having me. 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.

Panel: Aaron Frost Brian Love Special Guest: Amir Tugendhaft In this episode, Aaron and Brian talk with Amir Tugendhaft who is a web developer who is located in Israel. He finds much gratification developing and building things from scratch. Check out today’s episode where Aaron, Brian, and Amir talk about just that. Other topics include UI Design, Flexbox, UX design, PrimeNG, and ag-Grid. Show Topics: 0:00 – Advertisement: AngularBootCamp.Com 0:52 – Host: Welcome! Today’s panel is myself, Brian, and our guest is Amir Tugendhaft! 1:13 – Guest: I am a developer and experience with Angular and React. 1:56 – Host: You spend your days/nights there? 2:03 – Panel: He is committed. 2:08 – Host: I am going to back up a second, and Brian could you please introduce yourself, please? 2:26 – Brian: I am the CETO at an Angular consulting firm (Denver, CO). We have the pleasure with working with Aaron from time-to-time. My Twitter handle is @brian_love – check it out! 2:52 – Host: What is CETO stand for? 2:59 – Brian answers the question. Brian: I oversee the crew among other things. 3:31 – Host: What do you want to talk about today, Amir? You are the guest of honor today! 3:40 – Guest. 4:00 – Host: That is a lot of information – that might be more than 1 episode. We have to stay focused! 4:14 – Host: I read one of your recent blogs about Cross Filled Violators. I met you through your blog before we did the Host: Give us your own ideas about starting your own app. 4:50 – Guest answers the question. 6:17 – Host: I am biased. But here is a fact. I used to work on a large team (60 people) and everyone committing to the same page app. We were using Angular.js 1.5, which I think they are still using that. I know that it worked but it wasn’t the easiest or fastest one to maintain, but it worked. 7:05 – Brian. 7:10 – Host: What are you trying to do? React doesn’t fulfill that need. I think you are being hyperballic and using extreme cases as the norm. Let’s be honest: we do cool stuff with jQuery plugins when we didn’t have a framework. When they say that the framework is stopping them then I say: I agree to disagree. 8:00 – Host: What do you think, Amir? 8:04 – Guest: I don’t have preferences. I try to build applications through the technologies and create components and simple applications. 8:30 – Brian. 8:33 – Guest: You create the component, and then... 9:21 – Brian: You don’t have to have a template file and another file – right? 9:35 – Guest. 9:48 – Host: I do in-line styles and in-line templates. One thing I learned from React is that I like my HTML, style and code. I like it being the same file as my component. I like that about that: I like single file components. This promotes getting frustrated if it gets too big. Yeah if it’s more than 500 lines than you have to simplify. That’s one of the things that l like. 10:47 – Brian: Modules versus... 10:55 – Guest. 11:07 – Host: I think in React and Vue you have the word module but in JavaScript you have a file that exports... 11:26 – Host: I have my opinion here and talking with Joe. He made a good point: at a certain level the frontend frameworks are the same. You could be doing different things but they basically do the same thing. 13:57 – Guest: Basically what that means is that the technology used it will do the same thing. Your patterns and practices are huge. 14:17 – Brian: If you are talking about the 3 popular frameworks out there – they are basically doing the same thing. I like Angular a little big more, though. Like you said, Aaron, people tend to pick the same one. I like the opinionated things about Angular. You get properties, components or called props or inputs you are getting a lot of the same features. It comes down to your personal preference. 15:31 – Host: What else Amir? 15:35 – Guest: Let’s talk about the UI. 16:05 – Brian. 16:08 – Guest asks a question. 16:25 – Brian: How have you tackled this problem? 16:34 – Guest: I kind of ran with it. If there wasn’t something that I liked I started from scratch, because it really didn’t feel right. 16:51 – Brian: I am an enemy of starting over type of thing. You have a lot of engineers who START projects, and they can say that they start this piece, but the experts and choice team members have what it takes to ship a feature. I mean fully ship it, not just 80%, but also the final 20%. I think it takes a lot of pose decision making to say I want to rewrite it but not right now. I still need to ship this code. I have always been a bigger fan as not rewriting as much as possible; however, if you started with good patterns then that’s true, but if you are starting off with bad patterns then maybe yes. I like that opinion b/c you have to start right. Brian: How do you do your CSS? 19:05 – Guest. 19:52 – Advertisement: Get A Coder Job! 20:30 – Brian: How do you make those decisions, Amir? 20:39 – Guest: I see something that I like and ask myself how do I apply this to my design and I start scaling things. 21:50 – Host: Are you using a tool like Sketch for your initial UI design? 22:05 – Guest. 22:54 – Host: I worked on a project where the client had a designer (UX). 24:00 – Host and Guest go back-and-forth. 24:51 – Host: I am sure it’s all about the quality from your designer, too. Hopefully it works well for you and it’s quality. 25:18 – Host: There is a lot to building an app from scratch. I am not a good designer. I am not a designer – I mean straight-up. I got nothing. I appreciate team members that can do that. 26:06 – Guest: Do you write...? 26:35 – Host: Only on the most recent project. The designer didn’t own the HTML CSS but he initially wrote it and then gave it to me and now I own it, and it’s in components. If he wants updates then I have to go and make changes b/c he doesn’t know Angular. If it’s a sketch or a PNG you have to make it look like that. That’s what most of my career has been. Host: HTML and CSS got me 762x easier once Flexbox came around! I know there is a decimal there! 28:23 – Host talks about Flexbox some more. 28:42 – Guest asks a question. 28:50 – Host: I suppose if I really had heavy needs for a table then I would try CSS grid could solve some problems. I might just use a styled table. 29:12 – Brian: ag-Grid or something else. 29:21 – Host: On this recent project...I’ve used in-house design and other things. If I ever needed a table it was there. I don’t rebuild components b/c that can get expensive for me. 30:50 – Brian: Accessibility. 31:00 – Host: Your upgrade just got 10x harder b/c you own the component loop. I really don’t build tables or drop-downs. Only way is if I really need to build it for a specific request. 31:30 – Brian. 31:58 – Host: Let me give you an example. You can think I am crazy, but a designer gave me a drop-down but he told me to use PrimeNG. I had the chose of building my own drop-down or the designer has to accept whatever they gave him. I made the UI make what he wanted and I made the drop-down zero capacity and then... Host: When you click on what you see you are clicking on the... Host: Does that make sense? 33:35 – Guest. 33:50 – Host. 34:25 – Brian: That is interesting; remember when... 34:58 – Host: We will send this episode to Jeremy – come on Jeremy! Any last ideas? Let’s move onto picks! 35:20 – Advertisement – Fresh Books! 30-day free trial! END – Advertisement – Cache Fly! Links: Vue jQuery Angular React C# What is a UX Design? UI Design Flexbox Sketch ag-Grid PrimeNG Brian Love’s Twitter Aaron Frost’s Medium Amir’s Medium Amir’s Twitter Amir’s GitHub Amir’s LinkedIn Amir’s Facebook Sponsors: Angular Boot Camp Fresh Books Get a Coder Job Course Cache Fly Picks: Aaron Movie: “A Star Is Born” Concept - Model Driven Forms Amir Puppeteer Arrow Function Converter Brian TV Series: “The 100” Angular Schematics

Panel: Aaron Frost Brian Love Special Guest: Amir Tugendhaft In this episode, Aaron and Brian talk with Amir Tugendhaft who is a web developer who is located in Israel. He finds much gratification developing and building things from scratch. Check out today’s episode where Aaron, Brian, and Amir talk about just that. Other topics include UI Design, Flexbox, UX design, PrimeNG, and ag-Grid. Show Topics: 0:00 – Advertisement: AngularBootCamp.Com 0:52 – Host: Welcome! Today’s panel is myself, Brian, and our guest is Amir Tugendhaft! 1:13 – Guest: I am a developer and experience with Angular and React. 1:56 – Host: You spend your days/nights there? 2:03 – Panel: He is committed. 2:08 – Host: I am going to back up a second, and Brian could you please introduce yourself, please? 2:26 – Brian: I am the CETO at an Angular consulting firm (Denver, CO). We have the pleasure with working with Aaron from time-to-time. My Twitter handle is @brian_love – check it out! 2:52 – Host: What is CETO stand for? 2:59 – Brian answers the question. Brian: I oversee the crew among other things. 3:31 – Host: What do you want to talk about today, Amir? You are the guest of honor today! 3:40 – Guest. 4:00 – Host: That is a lot of information – that might be more than 1 episode. We have to stay focused! 4:14 – Host: I read one of your recent blogs about Cross Filled Violators. I met you through your blog before we did the Host: Give us your own ideas about starting your own app. 4:50 – Guest answers the question. 6:17 – Host: I am biased. But here is a fact. I used to work on a large team (60 people) and everyone committing to the same page app. We were using Angular.js 1.5, which I think they are still using that. I know that it worked but it wasn’t the easiest or fastest one to maintain, but it worked. 7:05 – Brian. 7:10 – Host: What are you trying to do? React doesn’t fulfill that need. I think you are being hyperballic and using extreme cases as the norm. Let’s be honest: we do cool stuff with jQuery plugins when we didn’t have a framework. When they say that the framework is stopping them then I say: I agree to disagree. 8:00 – Host: What do you think, Amir? 8:04 – Guest: I don’t have preferences. I try to build applications through the technologies and create components and simple applications. 8:30 – Brian. 8:33 – Guest: You create the component, and then... 9:21 – Brian: You don’t have to have a template file and another file – right? 9:35 – Guest. 9:48 – Host: I do in-line styles and in-line templates. One thing I learned from React is that I like my HTML, style and code. I like it being the same file as my component. I like that about that: I like single file components. This promotes getting frustrated if it gets too big. Yeah if it’s more than 500 lines than you have to simplify. That’s one of the things that l like. 10:47 – Brian: Modules versus... 10:55 – Guest. 11:07 – Host: I think in React and Vue you have the word module but in JavaScript you have a file that exports... 11:26 – Host: I have my opinion here and talking with Joe. He made a good point: at a certain level the frontend frameworks are the same. You could be doing different things but they basically do the same thing. 13:57 – Guest: Basically what that means is that the technology used it will do the same thing. Your patterns and practices are huge. 14:17 – Brian: If you are talking about the 3 popular frameworks out there – they are basically doing the same thing. I like Angular a little big more, though. Like you said, Aaron, people tend to pick the same one. I like the opinionated things about Angular. You get properties, components or called props or inputs you are getting a lot of the same features. It comes down to your personal preference. 15:31 – Host: What else Amir? 15:35 – Guest: Let’s talk about the UI. 16:05 – Brian. 16:08 – Guest asks a question. 16:25 – Brian: How have you tackled this problem? 16:34 – Guest: I kind of ran with it. If there wasn’t something that I liked I started from scratch, because it really didn’t feel right. 16:51 – Brian: I am an enemy of starting over type of thing. You have a lot of engineers who START projects, and they can say that they start this piece, but the experts and choice team members have what it takes to ship a feature. I mean fully ship it, not just 80%, but also the final 20%. I think it takes a lot of pose decision making to say I want to rewrite it but not right now. I still need to ship this code. I have always been a bigger fan as not rewriting as much as possible; however, if you started with good patterns then that’s true, but if you are starting off with bad patterns then maybe yes. I like that opinion b/c you have to start right. Brian: How do you do your CSS? 19:05 – Guest. 19:52 – Advertisement: Get A Coder Job! 20:30 – Brian: How do you make those decisions, Amir? 20:39 – Guest: I see something that I like and ask myself how do I apply this to my design and I start scaling things. 21:50 – Host: Are you using a tool like Sketch for your initial UI design? 22:05 – Guest. 22:54 – Host: I worked on a project where the client had a designer (UX). 24:00 – Host and Guest go back-and-forth. 24:51 – Host: I am sure it’s all about the quality from your designer, too. Hopefully it works well for you and it’s quality. 25:18 – Host: There is a lot to building an app from scratch. I am not a good designer. I am not a designer – I mean straight-up. I got nothing. I appreciate team members that can do that. 26:06 – Guest: Do you write...? 26:35 – Host: Only on the most recent project. The designer didn’t own the HTML CSS but he initially wrote it and then gave it to me and now I own it, and it’s in components. If he wants updates then I have to go and make changes b/c he doesn’t know Angular. If it’s a sketch or a PNG you have to make it look like that. That’s what most of my career has been. Host: HTML and CSS got me 762x easier once Flexbox came around! I know there is a decimal there! 28:23 – Host talks about Flexbox some more. 28:42 – Guest asks a question. 28:50 – Host: I suppose if I really had heavy needs for a table then I would try CSS grid could solve some problems. I might just use a styled table. 29:12 – Brian: ag-Grid or something else. 29:21 – Host: On this recent project...I’ve used in-house design and other things. If I ever needed a table it was there. I don’t rebuild components b/c that can get expensive for me. 30:50 – Brian: Accessibility. 31:00 – Host: Your upgrade just got 10x harder b/c you own the component loop. I really don’t build tables or drop-downs. Only way is if I really need to build it for a specific request. 31:30 – Brian. 31:58 – Host: Let me give you an example. You can think I am crazy, but a designer gave me a drop-down but he told me to use PrimeNG. I had the chose of building my own drop-down or the designer has to accept whatever they gave him. I made the UI make what he wanted and I made the drop-down zero capacity and then... Host: When you click on what you see you are clicking on the... Host: Does that make sense? 33:35 – Guest. 33:50 – Host. 34:25 – Brian: That is interesting; remember when... 34:58 – Host: We will send this episode to Jeremy – come on Jeremy! Any last ideas? Let’s move onto picks! 35:20 – Advertisement – Fresh Books! 30-day free trial! END – Advertisement – Cache Fly! Links: Vue jQuery Angular React C# What is a UX Design? UI Design Flexbox Sketch ag-Grid PrimeNG Brian Love’s Twitter Aaron Frost’s Medium Amir’s Medium Amir’s Twitter Amir’s GitHub Amir’s LinkedIn Amir’s Facebook Sponsors: Angular Boot Camp Fresh Books Get a Coder Job Course Cache Fly Picks: Aaron Movie: “A Star Is Born” Concept - Model Driven Forms Amir Puppeteer Arrow Function Converter Brian TV Series: “The 100” Angular Schematics

Panel: Aaron Frost Brian Love Special Guest: Amir Tugendhaft In this episode, Aaron and Brian talk with Amir Tugendhaft who is a web developer who is located in Israel. He finds much gratification developing and building things from scratch. Check out today’s episode where Aaron, Brian, and Amir talk about just that. Other topics include UI Design, Flexbox, UX design, PrimeNG, and ag-Grid. Show Topics: 0:00 – Advertisement: AngularBootCamp.Com 0:52 – Host: Welcome! Today’s panel is myself, Brian, and our guest is Amir Tugendhaft! 1:13 – Guest: I am a developer and experience with Angular and React. 1:56 – Host: You spend your days/nights there? 2:03 – Panel: He is committed. 2:08 – Host: I am going to back up a second, and Brian could you please introduce yourself, please? 2:26 – Brian: I am the CETO at an Angular consulting firm (Denver, CO). We have the pleasure with working with Aaron from time-to-time. My Twitter handle is @brian_love – check it out! 2:52 – Host: What is CETO stand for? 2:59 – Brian answers the question. Brian: I oversee the crew among other things. 3:31 – Host: What do you want to talk about today, Amir? You are the guest of honor today! 3:40 – Guest. 4:00 – Host: That is a lot of information – that might be more than 1 episode. We have to stay focused! 4:14 – Host: I read one of your recent blogs about Cross Filled Violators. I met you through your blog before we did the Host: Give us your own ideas about starting your own app. 4:50 – Guest answers the question. 6:17 – Host: I am biased. But here is a fact. I used to work on a large team (60 people) and everyone committing to the same page app. We were using Angular.js 1.5, which I think they are still using that. I know that it worked but it wasn’t the easiest or fastest one to maintain, but it worked. 7:05 – Brian. 7:10 – Host: What are you trying to do? React doesn’t fulfill that need. I think you are being hyperballic and using extreme cases as the norm. Let’s be honest: we do cool stuff with jQuery plugins when we didn’t have a framework. When they say that the framework is stopping them then I say: I agree to disagree. 8:00 – Host: What do you think, Amir? 8:04 – Guest: I don’t have preferences. I try to build applications through the technologies and create components and simple applications. 8:30 – Brian. 8:33 – Guest: You create the component, and then... 9:21 – Brian: You don’t have to have a template file and another file – right? 9:35 – Guest. 9:48 – Host: I do in-line styles and in-line templates. One thing I learned from React is that I like my HTML, style and code. I like it being the same file as my component. I like that about that: I like single file components. This promotes getting frustrated if it gets too big. Yeah if it’s more than 500 lines than you have to simplify. That’s one of the things that l like. 10:47 – Brian: Modules versus... 10:55 – Guest. 11:07 – Host: I think in React and Vue you have the word module but in JavaScript you have a file that exports... 11:26 – Host: I have my opinion here and talking with Joe. He made a good point: at a certain level the frontend frameworks are the same. You could be doing different things but they basically do the same thing. 13:57 – Guest: Basically what that means is that the technology used it will do the same thing. Your patterns and practices are huge. 14:17 – Brian: If you are talking about the 3 popular frameworks out there – they are basically doing the same thing. I like Angular a little big more, though. Like you said, Aaron, people tend to pick the same one. I like the opinionated things about Angular. You get properties, components or called props or inputs you are getting a lot of the same features. It comes down to your personal preference. 15:31 – Host: What else Amir? 15:35 – Guest: Let’s talk about the UI. 16:05 – Brian. 16:08 – Guest asks a question. 16:25 – Brian: How have you tackled this problem? 16:34 – Guest: I kind of ran with it. If there wasn’t something that I liked I started from scratch, because it really didn’t feel right. 16:51 – Brian: I am an enemy of starting over type of thing. You have a lot of engineers who START projects, and they can say that they start this piece, but the experts and choice team members have what it takes to ship a feature. I mean fully ship it, not just 80%, but also the final 20%. I think it takes a lot of pose decision making to say I want to rewrite it but not right now. I still need to ship this code. I have always been a bigger fan as not rewriting as much as possible; however, if you started with good patterns then that’s true, but if you are starting off with bad patterns then maybe yes. I like that opinion b/c you have to start right. Brian: How do you do your CSS? 19:05 – Guest. 19:52 – Advertisement: Get A Coder Job! 20:30 – Brian: How do you make those decisions, Amir? 20:39 – Guest: I see something that I like and ask myself how do I apply this to my design and I start scaling things. 21:50 – Host: Are you using a tool like Sketch for your initial UI design? 22:05 – Guest. 22:54 – Host: I worked on a project where the client had a designer (UX). 24:00 – Host and Guest go back-and-forth. 24:51 – Host: I am sure it’s all about the quality from your designer, too. Hopefully it works well for you and it’s quality. 25:18 – Host: There is a lot to building an app from scratch. I am not a good designer. I am not a designer – I mean straight-up. I got nothing. I appreciate team members that can do that. 26:06 – Guest: Do you write...? 26:35 – Host: Only on the most recent project. The designer didn’t own the HTML CSS but he initially wrote it and then gave it to me and now I own it, and it’s in components. If he wants updates then I have to go and make changes b/c he doesn’t know Angular. If it’s a sketch or a PNG you have to make it look like that. That’s what most of my career has been. Host: HTML and CSS got me 762x easier once Flexbox came around! I know there is a decimal there! 28:23 – Host talks about Flexbox some more. 28:42 – Guest asks a question. 28:50 – Host: I suppose if I really had heavy needs for a table then I would try CSS grid could solve some problems. I might just use a styled table. 29:12 – Brian: ag-Grid or something else. 29:21 – Host: On this recent project...I’ve used in-house design and other things. If I ever needed a table it was there. I don’t rebuild components b/c that can get expensive for me. 30:50 – Brian: Accessibility. 31:00 – Host: Your upgrade just got 10x harder b/c you own the component loop. I really don’t build tables or drop-downs. Only way is if I really need to build it for a specific request. 31:30 – Brian. 31:58 – Host: Let me give you an example. You can think I am crazy, but a designer gave me a drop-down but he told me to use PrimeNG. I had the chose of building my own drop-down or the designer has to accept whatever they gave him. I made the UI make what he wanted and I made the drop-down zero capacity and then... Host: When you click on what you see you are clicking on the... Host: Does that make sense? 33:35 – Guest. 33:50 – Host. 34:25 – Brian: That is interesting; remember when... 34:58 – Host: We will send this episode to Jeremy – come on Jeremy! Any last ideas? Let’s move onto picks! 35:20 – Advertisement – Fresh Books! 30-day free trial! END – Advertisement – Cache Fly! Links: Vue jQuery Angular React C# What is a UX Design? UI Design Flexbox Sketch ag-Grid PrimeNG Brian Love’s Twitter Aaron Frost’s Medium Amir’s Medium Amir’s Twitter Amir’s GitHub Amir’s LinkedIn Amir’s Facebook Sponsors: Angular Boot Camp Fresh Books Get a Coder Job Course Cache Fly Picks: Aaron Movie: “A Star Is Born” Concept - Model Driven Forms Amir Puppeteer Arrow Function Converter Brian TV Series: “The 100” Angular Schematics

Hip and knee replacements have played an important part in the treatment of arthritis and other painful joint conditions for decades. However, recovery from surgery and subsequent inflammation can be painful. Many patients had to rely on opioid medications, which can lead to stomach problems and sometimes addiction. Fortunately, today’s patients have another effective, safe option: multimodal pain control techniques. Dr. Savyasachi Thakkar discusses how multimodal pain control lets us tackle your pain before, during and after joint replacement surgery to significantly reduce pain, shorten recovery time and reduce the need for strong pain medication after surgery.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thank you for joining us today. We’re talking with Dr. Savyasachi Thakkar, an orthopaedic hip and knee reconstruction surgeon at MedStar Orthopaedic Institute at MedStar Washington Hospital Center. Welcome, Dr. Thakkar. Dr. Thakkar: Thank you very much for having me. Host: Today we’re talking about multimodal pain control for total joint replacement. Recovery from total joint replacement can be lengthy and painful. Opioid pain medications can help, but can lead to addiction or might not be effective on their own. These concerns have led orthopaedic surgeons to seek alternative pain control strategies for joint replacement patients. Dr. Thakkar, what is multimodal pain control? Dr. Thakkar: Thank you, that’s an excellent question. So multimodal pain control pathways deal with multiple sources of pain that patients have with their arthritis. Arthritis, typically, is associated with significant inflammation so one of the cornerstones of arthritis management, with regards to pain, is to take down that inflammation using anti-inflammatory medication. With multimodal analgesia – multimodal pain control – we aim to reduce that with several anti-inflammatory agents in the pre-operative setting. We do that during surgery with our multimodal anesthesia protocols. We also do it with a multi-source cocktail, a joint replacement cocktail, uh, if you may, that we inject around the joint capsule when we do the surgery. And then in the postoperative setting – we rely less and less on narcotic pain medications as that can make patients confused, it can leave them constipated, and it can leave them dependent on several narcotic agents. Host: So, it’s a three-step, kind of ‘check-the-box’ to make sure that they’re coming out of the surgery with as little pain as possible. Dr. Thakkar: Absolutely. With this protocol what we try to do is that we try to build up some pain control medication levels in their bloodstream, even before they undergo the procedures. Once they get the procedure, our anesthesia is now more and more reliant on nerve blocks or regional anesthesia so that we can just isolate the limb we’re operating on without any systemic effects on their heart, on their lungs, on their other organs and make them less likely to have nausea and less likely to have low blood pressure after anesthesia. Once they’re through the surgery, we also continue with the same medications that we’d started them on in the preoperative setting, to continue in the postoperative setting, with a touch of narcotic pain medication to get them through acute pain crisis. By doing so patients become less reliant on narcotic pain medications, they take medications for a less number of weeks postoperatively. On average, we’re only giving patients two or three weeks of narcotic pain medications postoperatively. And, in the long term, they have less side effects from such medications, which can be pretty significant. As we all know, that there’s a national epidemic when it comes to narcotic dosage, narcotic overuse, and narcotic dependence. And I think that using this multimodal pain regimen reduces that in a significant fashion. Host: With the multimodal pain management approach, how does the duration and the dosage of those narcotic pain medications compare to, say, traditional knee replacements ten years ago? Dr. Thakkar: Right. So traditionally, the last ten years, we’ve been giving patients only narcotic pain medications in the postoperative setting. What happens with that is that A) we don’t tackle their pain preoperatively or intraoperatively - we’re only tackling one phase of their recovery, which is postoperatively. B) Patients come in complaining that they still have pain and we keep giving them higher doses, more frequent doses, and hence, leading to that epidemic by giving patients more and more pain medication. And, still having patients who are not satisfied. So, we realize that there’s something amiss. We need to understand pain on a multiple-dimensional level because it’s not just the opioid pathways, that are controlled by the narcotic pain medications, that lead to pain. There are also significant inflammatory part pathways with number of agents that can be targeted. Now this has obviously been a focus of research with our anesthesia colleagues and also orthopaedic colleagues interested in controlling pain from multiple sources. So, this has been years and years of study and what we found now is that by using such a protocol, we reduce the duration off narcotics, we reduce the dosage, we reduce the frequency, and in turn, we give patients better functional scores, better relief from pain, and a more healthy, active lifestyle. Host: Do you find that patients are hesitant to take opioid pain medications in light of the current addiction problems in the U.S.? Dr. Thakkar: Absolutely. We see two kinds of patients. The first kind of patient is averse to take any medications and they want to try all kinds of natural therapies, all kinds of alternative medications, and…and for the most part, we can...we can work with such patients and work with the therapies that they would like to try. However, there’s a second subset of patients, that has been taking opioids for various other reasons - they may be chronically dependent on them - and it almost becomes our duty to try and reduce that intake, to try and get them off the opioids, and try and take other forms of anti-inflammatory medications that may help them in the long run. So, I think that, at this institution, at the MedStar Washington Hospital Center and at MedStar Orthopaedic Institute, we see patients that come from all strata of society and that have all kinds of pain management needs. And our individualized pain management protocols can help them achieve the best pain management strategies while minimizing the dependence on narcotics. Host: What sort of alternative pain management techniques do you recommend to patients after surgery if they’re averse to or cannot take opioid medications? Dr. Thakkar: One of the biggest innovations that we’ve had in recent times, and..and MedStar Washington Hospital Center is a pioneer for this, is a nerve ablation protocol. What we do with our pain management specialists is that we target the sensory nerves around the incisions where we performed the surgeries and by using radiofrequency ablation, they try and reduce the sensitivity of the nerves, the pain. So in essence, they’re making the nerves quiet after surgery so that patients have less pain, less inflammation. They’re able to use that joint that we replaced a lot more effectively. And then, of course, the nerves start coming back to life again, but by that time, the skin, the scar, everything has healed up so that the patients can not notice any pain and the nerves don’t notice that there’s any kind of intervention that’s been performed. And there’s no noxious stimuli to those nerves and they can come back to life without any trouble. Host: What sort of lifestyle changes or what sort of environmental changes, do you recommend to patients after they go home from their surgery? How can they alleviate pain at…in the home or alleviate instances in which they might injure themselves causing subsequent pain? Dr. Thakkar: This leads to the outpatient surgery discussion because once patients go home, once they have their own bed, they have their own food, they have their own family members, they have less disturbances and they get a good night’s sleep - all of those have been shown to be associated with reduced pain scores, a happier patient, a more satisfied patient and a more active patient. So, I think controlling the environment very carefully, so that they can go back to feeling that they’re back at home, back in their normal environment, back with their own people, their own loved ones, I think has a tremendous effect in reducing pain levels and in reducing dependence on pain medication, be it anti-inflammatories or narcotics, to achieve the recovery that they desire. Host: So really that team based approach to care, both in the outpatient setting and at the hospital center. Could you talk a little bit about the MedStar Orthopaedic Institute’s approach to team based care and how you work with your colleagues to make sure pain is mitigated for your patients? Dr. Thakkar: Absolutely. So, at the MedStar Washington Hospital Center and the MedStar Orthopaedic Institute, as a whole, orthopaedic surgeons are not working in a silo. We work with our anesthesia colleagues, we work with our pain management specialists, to try and identify at-risk patients who may require more attention with regards to their pain management needs. We identify such patients beforehand. We make sure that we control their pain, even before we perform the procedures on them. And then set very realistic goals for them, in the intraoperative and the postoperative setting, to try and reduce their dependence on pain medications. Now, for the patient in the community who does not require such pain medications, once again, we have protocols in place to target only the specific limb that we are going to work on, surgically, so we will have local anesthetics. We will also have nerve blocks that are very carefully designed for patients getting knee and hip replacements. After surgery, we have our pain management specialists work with them very closely to try and identify early triggers of pain. These could be social triggers or they could be surgical problems that the patient is having, and to try and mitigate that, to try and reduce that, so that patients don’t have to take medications for a long period of time. Host: Why is MedStar Washington Hospital Center the best place for a patient to go for total pain management after joint replacement? Dr. Thakkar: I think at the MedStar Washington Hospital Center, we have a team of experts, not just focused on orthopaedic needs but also on anesthetic needs, on pain management needs – there…there’s significant amounts of research and significant amounts of projects that these providers devote themselves to, to try and achieve a better balance, a healthier lifestyle for these patients. And we have significant...we have several counseling sessions for these patients that they can avail of before surgery, during surgery and after surgery to try and identify triggers of pain and try and reduce those triggers to achieve a more healthy lifestyle. Host: Are you currently conducting any research on pain management, either multimodal pain management or outpatient, that you’d like to share with the community? Dr. Thakkar: One of the things that I’m involved with is, with our pain management specialists, is the nerve ablation tests. We’re looking at patients with primary and revision and total hip implants to try and reduce pain in these patients by doing nerve ablation in the preoperative setting, and also repeating it at 6 weeks in the postoperative setting. And we’re starting to see that patients who have this nerve ablation performed seem to do a lot better than patients who don’t have nerve ablation. So, I think that that’s an interesting area. The data is still emerging and it’d be an exciting phase to see these patients not take any pain medication after these procedures. Host: Thanks for joining us today, Dr. Thakkar. Dr. Thakkar: Thank you very 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.

Every year in the U.S., 20 per 100,000 people experience sudden hearing loss, a medical emergency commonly caused by upper respiratory tract infection. Dr. Selena Briggs discusses how early, specialized treatment can help restore hearing.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today, we’re talking to Dr. Selena Briggs, a neurotologist skull base surgeon within the Department of Otolaryngology at MedStar Washington Hospital Center. Welcome Dr. Briggs. Dr. Selena Briggs: Thank you, thanks for having me. Host: Tell us a little about yourself, why did you go into medicine, and how did you come to practice at MedStar Washington Hospital Center? Dr. Briggs: I’ve had an interest in going into medicine, I think, from my youth. It actually stemmed from my pediatrician, Dr. Frank Newburger who practiced here in Silver Spring, and he was a great mentor, and a great pediatrician and that spurred my interest, and then later I developed an interest in music and dance, I was a ballerina, and I loved ballet.  And while I was younger, there was a miss America who was deaf and a ballerina, and that sparked my interest in understanding more about deaf culture and hearing loss. So, throughout my career it’s just kind of moved in that direction of hearing health and this direction. Host: Today we’re talking about upper respiratory infections that can lead to hearing loss. Dr. Briggs, how can an upper respiratory infection cause hearing loss? Dr. Briggs:  That is an excellent question.  Most people are unaware of the association between upper respiratory tract infections and hearing loss.  It’s not uncommon for an individual to wake up in the morning after experiencing an upper respiratory tract infection and state that they can’t hear out of one ear.  They’ll commonly call their primary care provider and try to get an appointment to be seen, and nothing gets seen on examination.  That is the main concern.  That is of pinnacle concern, in fact.  Those individuals may be suffering from something called sudden idiopathic sensorineural hearing loss or simply sudden hearing loss.  That’s most commonly associated with upper respiratory tract infections or the common cold. Host: So, I know when I have colds or even allergy problems and anything really affecting my sinuses I get that kind of clogged feeling in your ear—what are some symptoms patients tell you about when they get this hearing loss going on? Dr. Briggs: The clogged sensation in the ear and the sudden sensory no hearing loss actually are two separate entities.  Both cause hearing loss and both have similar symptoms of presentation, but the source of it is very different and the treatment for it is very different as well. So, when you have an ear infection or even pressure in your ear from a sinus infection, that’s usually caused by something called your Eustachian tube.  I don’t know if you’ve ever been on a plane and your ears popped and you feel that sensation?  It’s your Eustachian tube opening and closing that allows you to equalize your pressure while you’re on a plane.  But when you have a sinus infection, oftentimes that Eustachian tube becomes plugged, and doesn’t open and close normally. That causes pressure, muffled sensation, and sometimes can even cause fluid to develop in your ear.  That typically is a short-lived, self-limited process.  The sudden sensorineural hearing loss or sudden hearing loss is a completely different process, where it doesn’t cause a pressure problem, but it actually causes injury to your nerve. It may cause permanent damage to your ear. It’s not something that you should take lightly. It can be a long term even permanent issue for individuals. So, if one wakes up with sudden hearing loss, from the sudden sensorineural hearing loss, the nerve type of damage, about one out of three people it will resolve on its own, one out of three people it’ll improve but not go back to its normal, and one out of three people it won’t change at all.  There are interventions that we can do to make your likelihood of returning back to normal greater, but the key thing is that you have to get in and be seen within three days to three weeks.  Outside of that window, the likelihood of it becoming permanent loss is significantly greater. Host: How many people experience this? Dr. Briggs: So, on an annual basis, so every year within the United States, it’s speculated that approximately five to twenty out of 100,000 individuals experience sudden sensorineural hearing loss. Host: So, since this is suspected to be caused by viral problems or a virus, what can the doctor do either that primary care doctor, and then at what point do you need to be transitioned over to a specialist? Dr. Briggs: The key thing first is being evaluated by your primary care provider or even urgent care and having an ear examination.  Making sure your ear drum looks normal, there’s not wax that’s occluding or plugging up the ear canal, and make sure there’s not fluid behind the ear drum, as we talked about before associated with allergies or sinus problems.  It sounds strange, but a normal ear exam is an emergency. So, if you have a normal ear exam, and hearing loss, you need to be seen and have a hearing test right away Host: What about those individuals who do put it off? Is it damaged to the point where they can never get that back then if they wait too long? Dr. Briggs: There is a time window, and there is a time urgency.  A few days, ot so much out of the window of treatment. Typically, we state 21 days is when medical therapy is most effective, and those therapies tend to be steroids either taken orally or via an injection through the eardrum into the middle ear space. Host: Once the patient has had this hearing test, how quickly do they receive that treatment, and how long does that treatment take? Dr. Briggs: So once an individual has a hearing test that documents sudden sensorineural hearing loss, they should be seen by an otolaryngologist or a neurotologist within 24-48 hours.  The treatment is started rather urgently, because it gives them the best opportunity for the best outcome.  So the treatment, depending on the patient’s associated comorbidities such as diabetes or hypertension, may include oral steroids vs injection steroids in the middle ear space vs a combination of the two, and that’s started immediately.  There are other therapies that are recommended within the literature or can be used, such as hyperbaric oxygen therapy for restoration therapy as well. Host: What’s the hyperbaric oxygen therapy? Dr. Briggs: Essentially it simulates diving, scuba diving.  So, it puts you in a chamber where you have increased oxygenation or oxygen levels, to increase the oxygen to your nerve, in a hope that increasing its oxygenation it’ll help it to heal faster. Host: And what do the steroids do to help mend the hearing loss? Dr. Briggs: It decreases inflammation on the nerve similarly, helping to increase blood flow and hopefully improving the hearing Host: So, the more blood that’s flowing through the ear in a healthy way of course the better you’re able to hear. Dr. Briggs: Right, exactly. Host: So aside from that sudden sensation of not being able to hear, are there any other symptoms that an individual should be aware of or talk to their doctor about? Dr. Briggs: Oftentimes individuals who have this sudden hearing loss may experience other symptoms that can prompt them to know it is the sudden nerve type of loss vs the conductive type of hearing loss with the fluid and the sinuses.  Some of those symptoms include ringing in the ears, so if you have a high-pitched sound or even a sound of white noise like when you turn the radio between stations, that’s another indicator that you may have a nerve type of damage in your ear.  Vertigo or dizziness in association with the hearing loss is another indicator that it may be a nervous type of loss. Host: Are there other conditions aside from respiratory infections that might cause that sudden hearing loss? I know you think about construction workers and the loud noises and things, is that the same, or is that different? Dr. Briggs: That’s a different entity, that’s noise induced hearing loss, and that can cause a sudden we call it a sudden threshold shift, so sudden changes in your hearing. For example, if you’re exposed to a loud sound or a blast, that too can cause a sudden hearing loss. It’s similarly treated, interestingly, however. There is a host of disease processes that can cause hearing loss in addition to the viral ideology, and that’s why it’s even more important for you to come in and be seen and evaluated.  Individuals with diabetes can have it associated with neuropathy, it can be an early sign of strokes, it can be a sign of tumors of the skull base, thyroid disorders, autoimmune disorders, there’s a whole list. Host: So really since upper respiratory, obviously, probably one of the more common causes of hearing loss but since there are so many things that could cause it, it’s really about getting to the root of that issue.  Could you talk a little bit about how you do that and how your team works together to do that? Dr. Briggs: Yeah, definitely. So, the patients will come in and be evaluated with a physical examination and a history, and that largely directs which direction we’ll go in terms of diagnosis and treatment.  It’s very common for individuals who have a sudden hearing loss to have an MRI of their brain and their inner ear to evaluate for any changes of the hearing and balance nerve, or any lesions that might be compressing the hearing and balance nerve.  And then based upon the patient’s other history and family history and comorbidities, they may undergo various laboratory testing to assess for diabetes or other autoimmune disorders that might be contributing as well as Lyme disease and other infectious processes. Host: Could you talk about a compelling story that you’ve had come in with that upper respiratory problem and how that treatment looked for that patient Dr. Briggs: There is one individual who is a clinician as well, who presented with bilateral involvement so most often individuals come in and it’s involving one ear. In exceptionally rare cases it involves both ears.  This individual needed their hearing in order to perform their work, and so we were able—he got in almost immediately after onset of symptoms, started oral steroids, and inter-tympanic steroids, and hyperbaric oxygen therapy and remarkably had restoration of his hearing.  At his initial visit we had to communicate via typing on his computer and him speaking back, because he couldn’t hear at all. Host: He couldn’t hear at all?  It wasn’t just a decrease? Dr. Briggs: No, and that’s the other thing to understand with a sudden hearing loss, it’s not always just a sudden decline in hearing, some people actually wake up and be deaf in one ear. Host: What’s the emotional or the mental state of people when they come into the office? Dr. Briggs: Completely scared, definitely.  It’s life changing and life altering. I think we often take for granted our hearing, and then once we lose it, or lose some aspect of it, we realize how important it can be to your life. It can be jarring, and it can be life altering and scary for patients to experience, but as long as an individual’s gotten in early, the opportunity for treatment is significant. Without treatment, yes, one third may have no change, one third will have some change, and one third will improve somewhat.  But with treatment that can dramatically improve the odds of improving the hearing back to their baseline. Host: Is there anything an individual maybe that’s prone to those upper respiratory infections can do to reduce their risk? Dr. Briggs: Unfortunately, not. There’s no treatment, there’s no preventative therapy that’s been identified in the literature to reduce your risk of developing sudden sensorineural hearing loss from these upper respiratory tract infections. Host: Could you talk a little about the importance of an individual coming to an otolaryngologist Dr. Briggs: It’s critical for patients to come in and be seen by otolaryngologists or a neurotologist because of the specialized care and therapy that can be provided. We work as a team with primary care providers, with urgent care providers and with emergency department providers to get the patients in early and provide them with the treatment that’s necessary, but it is important that they are ultimately referred to an otolaryngologist who could provide them with that inter-tympanic steroid therapy injection which is a very specialized procedure, only performed mostly by neuro-otologists, but also by some otolaryngologists. In addition, it’s important that they be evaluated for those other disease processes that might be mimicking the sensorineural hearing loss, the idiopathic type. Host: Thank you for joining us today Dr. Briggs. Dr. Briggs: Thank you for having me 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.

Nearly 25 percent of all heart attacks might be silent myocardial infarctions, or silent MI. These heart attacks can cause serious, long-term damage without any noticeable symptoms. Dr. Allen Taylor discusses who is at risk for this condition and how to prevent it.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thank you for joining us today. We’re talking with Dr. Allen J. Taylor, Chief of Cardiology at MedStar Heart and Vascular Institute at MedStar Washington Hospital Center. Today we’re talking about silent myocardial infarction, or silent MI, which is a heart attack that goes unnoticed by the person who has it. Silent MI might have no symptoms, or the symptoms might be so mild that they’re mistaken for muscle pain or heartburn. But the lack of symptoms is deceiving. Research has found that Silent MI, without a history of traditional heart attack, increases a patient’s risk of heart failure, heart attack, and death in general. Dr. Taylor, how can a condition that feels and seems harmless be so dangerous? Dr. Taylor: Silent MI is an unrecognized problem. It’s the same as a recognized heart attack, in terms of its risk. Seems surprising, how can something silent be so dangerous. And it’s not just the recognition that’s the problem, in terms of risk, but it’s the fact that when not recognized, we don’t have an opportunity to apply the right treatments that improve outcomes. So, silent MIs are risky and they’re just as risky as MIs that patients recognize. So, it’s important that we find them and get patients on the right treatment. Host: Are silent MIs common? Dr. Taylor: So, about a quarter of heart attacks are thought to be silent. And I think that when we use the word silent, we have to explain a little bit. Cause some MIs are truly silent - the patient never even has a symptom. Some MIs are unrecognized and so, silent to the patient, although there was a symptom that the patient didn’t recognize as being typical for a heart attack. Patients may mistake their symptoms - for instance, they may say “Oh, that’s just heartburn”, or they may experience heart pain as back pain. Or, in older patients in particular, they may simply have no symptoms at all or simply be feeling down or fatigued or just “off” a particular day. We hear all these stories and, whether it’s truly silent or unrecognized, it’s about 1 in 4 heart attacks that occur in the community. Host: How are silent MIs detected if they cause no symptoms? Dr. Taylor: Detection of unrecognized or silent MI can be a problem because it takes a test to detect it since the patient didn’t experience warning symptoms. Some ways we’ll identify them are using a simple test such as an electrocardiogram, that if it shows the changes of a heart attack, that we would then do further investigations to confirm if the electrocardiogram was true or not. Electrocardiograms can be very useful tests in detecting heart attacks that have been unrecognized, although it’s important to note that there’s both false positive test as well as negative tests. So, the electrocardiogram is not perfect, but it’s our primary tool to detect them. Another test that is very common in use is a heart function test called an echocardiogram. It’s a test using sound waves that looks at the heart function and if an area of the heart was shown to be not functioning properly, we might suspect that it had been impaired by an unrecognized heart attack. And that might lead to further investigations to determine if that was true or not. But the detection is difficult. And so, it takes going to your doctor and having one or two of these tests to see if your heart’s in really good shape. Host: What happens after you discover that a patient has experienced a silent MI? Dr. Taylor: Well, the first thing I say is “Don’t panic.” Let’s dive a little deeper into this. But, what happens then is we’ll just basically use the same evaluation as someone that had a known heart attack and run them through generally simple tests to see. For example, if the EKG or ECG electrocardiogram was abnormal, we’d perhaps get an echocardiogram to see if the heart function was ok. And then maybe a stress test - having somebody walk and then lightly jog on a treadmill while placed on an electrocardiogram to see if that shows any signs of heart stress when being active. And, if that’s not enough, we have very sophisticated tests that we can really dive very deep into heart function and to make sure the arteries are in good shape or, if not, what the depth of the problem is. So, it’s really the same evaluation as someone who has a known heart attack. And if we find there’s truly an abnormality, what then begins, after it’s assessed, is pick the right treatments. Does someone need an artery treatment right up front, and clearly then we’ll move them on to the right preventative treatments to prevent anything further from happening. Host: Who’s at risk for silent MI and should patients worry? Dr. Taylor: It really can be anyone because if it’s truly silent or unrecognized, any of us could mistake, say back pain, for back pain when it was really truly a heart attack. But there’s a few patient populations we’ve really focused on. One would be patients with diabetes. The patients with diabetes often don’t feel pain in the same way. And, they truly can be silent, or they may even experience a heart attack in a day when they simply don’t feel well and maybe their blood sugar control gets worse all of a sudden and they can’t figure out why. In an older patient, particularly in older females, the heart attacks can also be truly silent or unrecognized because they present in odd ways like back pain or a day in which they feel tired or just simply off. But it’s important to know that if anyone is feeling any symptoms that are unexplained - heartburn that’s just a little different than the usual heartburn they’ve experienced and longer lasting - they shouldn’t assume it’s heartburn, but get seen promptly to make sure that, nothing’s going wrong with their heart. Host: What can patients do to reduce their risk of silent MI? Dr. Taylor:  In terms of reducing the risk for it, well it comes down to the core risk factors for heart disease. That is, high blood pressure, high cholesterol, diabetes, tobacco use, and then leading an optimal lifestyle, regular exercise 30 to 60 minutes most days of the week, avoiding tobacco, eating a diet that’s low in fat and low in sugars. So, it’s a lifestyle approach. Really, knowing your numbers and leading a healthy lifestyle to prevent it. But then not taking symptoms that you think are a little funny for granted. Host: Why is MedStar Washington Hospital Center the best place to seek heart care? Dr. Taylor: Well, I’m very proud of what we do at MedStar Washington Hospital Center and MedStar Heart and Vascular Institute because we simply can take care of anything from the most simple to the most incredibly complex. And we have every possible diagnostic tool to help uncover heart disease and every possible tool then to treat it. No matter the severity, we have a team that can help and that’s another unique aspect of MedStar Heart and Vascular Institute is that when you see one person, you’re really seeing an entire team. An entire team of experts that work together for making your care optimal. Host: Could you share some success stories from your patient population? Dr. Taylor: I have an interesting case - a young man, he’s very overweight but he had come in the hospital in terrible shape and things weren’t quite right. And in fact, in looking at his electrocardiogram, we noticed that there were signs of an old heart attack. And, in fact, what we indeed found in investigating it, was in fact he had an artery that was totally blocked, and it really had helped contribute to this whole illness that started with just a little breathing difficulty and retaining fluid. And by diagnosing the artery blockage, now we’re on a completely different course of care and now we’re seeking some really novel ways to restore blood flow past the total artery blockage. And while it’s unusual for a 30-year-old to have a blocked artery, it was the EKG that tipped us off and it’s really changed the way we’re caring for him. And, while I don’t want to alarm every 30-year-old person out there to say, “Oh my goodness, I could have a totally, artery totally blocked”, it raises the point of leading an optimal lifestyle. Good diet, exercise, maintaining good body weight, avoiding tobacco are the real ways to preserve your artery health. Host: Thank you for joining us today, Dr. Taylor. 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.

PET-CT scans provide detailed information on where cancer is located, whether it’s spreading and if treatments are working. Dr. Carlos Garcia explains how this test works, what to expect if you’re having one and how your doctor uses the results.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re talking to Dr. Carlos Garcia, Medical Director of Nuclear Medicine at MedStar Washington Hospital Center. Today, we’re talking about the benefits of PET CT scanner. Dr. Garcia, what is a PET CT scanner and when is it used? Dr. Garcia: So, a PET CT scanner is kind of a gold standard for cancer imaging. Just like in the past it was called a CAT scan, now they’re called CT scans, are for anatomic imaging of multiple causes, whether they’re cancer or not. PET CT is 99.9 percent dedicated to cancer imaging. The difference between a PET scanner and a CT scanner is that a PET scanner will rely on the cells being alive and consuming a specific type of substance that makes them show up on the scan. This substance is normally either produced or it circulates in your body. And we add radiation to it and that’s why we can see it on the images. So, it’s a combination now of anatomic imaging from the CT portion of the exam and functional or metabolic imaging from the PET portion of the exam. PET stands for positron emission tomography. Positrons are just basically an energy source that will, you know, produce an amount of radiation that we can translate into images, and the more active a cell is--especially the cancer cells tend to be more active than normal cells--the more they’re going to emit this type of energy, the more they’re going to take up this type of radioactive substance that they would normally not, and that’s how they show up in a more avid, or they light up on the scan, if you will.          Host: So, how is the substance introduced to this other substance that you mentioned in order for it to show up on the PET scan? Dr. Garcia: So, what we do is we make the patient the source of the radiation. We inject the patient with a modified version of glucose, which is the most common one; that’s why I am going to use that as an example. It’s called fludeoxyglucose, or FDG for short. You’ll see that many of our exams have acronyms for that same reason. It’s kind of a hard, long word. So, we inject the patient with this glucose substance, and all the cells in the body normally will use glucose as energy. Cells that replicate faster or grow out of control, as cancer cells do, will use more glucose because they require more energy to sustain this growth pattern. So, the cells that take up more glucose will take up more of the radioactive glucose that we have injected into the patient, and that’s why they will shine in comparison to the background of normal cells. These cells will look bigger, darker and brighter because they just take up more of the radioactive substance that we tricked the body into taking because it doesn’t know it’s radioactive; it just thinks it’s glucose.   Host: So, what are the advantages of combining a PET scan with a CT scan for cancer? Dr. Garcia: For many, many years, when we did not have PET images available, we only used CT imaging, which could provide us only with an anatomic version of whatever is going on inside the body. The problem with this is sometimes you can see a tumor—we’ll just use that as an example, and only the inner portion of the tumor might be where all the cancer is, and the rest of it might be just inflammation resulting from the presence of that cancer or tumor. The PET scan can differentiate that sometimes. It can show you what is the actual size of the live tumor inside of a structure that might be, let’s say for example, 5 cm larger, but it’s not all tumor. This helps in many ways to guide the therapy. One of the main applications of knowing this difference between what is functional or what is metabolically alive versus just the anatomy, is that when you apply this to radiation purposes for treatment, for example, the radiation field that will be attached, I’m sorry, that will be used for that particular tumor will only be the size of the part of the tumor, or the part of the mass, that is actually alive, so you can actually make it a little more circumscribed and more directed. So that’s one of the applications when you talk about it. Now it’s called all hybrid imaging--that is the gold standard nowadays of all cancer or oncologic imaging. And now the new hybrid imaging scanners like the ones that we have here, will overlap these images, and they’re called fused activity, and you can definitely see the background and over the background of anatomy overlap with the cells that are actively replicating that turn out to be cancer cells.      Host: So, having the fused images really provides a deeper layer and a deeper perspective for both the imaging team and the physician. Does the patient also get the chance to see those images? Dr. Garcia: When we have the opportunity to show the images to the patients, by all means. Nine out of 10 times, the physicians that have ordered the tests are comfortable with the patients knowing the results. We always want to extend the courtesy of the referring physician to be directly involved with the patient and them communicate the results, but we have had scenarios in which the patients are very comfortable knowing and they are very, very well versed in their own disease process, as it should be nowadays, and we are happy to show them the images. The overlapping of the anatomic portion of it and the live cell, the metabolic portion of it, it completely takes away from having to even point at the screen. Everything becomes very, very obvious and you can use different color schemes to bring out certain cell types, so it makes a picture worth a million words instead of a thousand words. And all the physicians within the hospital, they have the opportunity to be able to see these images on Enterprise-wide imaging viewer that they have access to as well. So, that makes our job very easy. Even though they’re always welcome to come to the reading room and have us show them the images directly, we can have phone conversations, them looking at the exact same images that we are looking at, and we can tell them slice number and position, and target everything they need to know. Host: Are there certain cancer types for which PET CT scan is most applicable or certain body parts that are easier to do? Dr. Garcia: That’s an excellent question because, for a long time, PET CT imaging was considered to be the, you know, savior for all types of cancer, and that unfortunately is not true. It has limitations and then it has indications that make it much more favorable. So, off the top of my head, I can tell you the top three indications that we use it here at the hospital are for breast cancer, lung cancer and lymphoma.  So, these tend to be tumors that are very metabolically active. When I say metabolically active, it means that they have a tendency to take up more glucose than normal cells would, than other types of cancer would, so as long as they take up this increased amount of glucose, they will be brighter on the images and they will really stand out from the background, making the ability to detect them much, much easier. Host: It really makes the cancer sound like a living thing and like a living disease, if you will, as opposed to just this abstract. Dr. Garcia: I’m going to actually start using that way of explaining it because that actually sounds exactly right. That is, it’s a live being that has a mind of its own sometimes, and our job is to be able to detect it early, be able to apply what we see to a treatment program, and then, after the treatment program, be able to monitor the response to the therapy by seeing whether that activity that translates into a lot of glucose uptake, seeing if it went down, meaning the number of cells is going down based on the therapy. If you have less amount of cells, it’ll be less glucose that will be taken up and the shine on the exam, if you will, will decrease over time.  So, we measure, we have units to measure the intensity of this activity and we use them very specifically, you know, to monitor the response to therapy because those units should go down as the number of cells within the cancer start dying as a result of the therapy.         Host: If my doctor tells me that I would need a PET CT scan, what should I expect from that appointment? What will that process look like? Dr. Garcia: So, the first thing that you’re going to do is you’ll be contacted by one of our staff members from the PET CT Center, and they’re going to ask you to prepare your body to be able to absorb the glucose better, and that’s going to require for you to be fasting for at least six hours prior to the examination. So, the first glucose that you will receive, meaning the first source of energy that your body that has now been without food or drink for six hours, it will be starving. So, you prepare the body to eat something, and then the first thing that it sees is the glucose. And like I said before, it doesn’t know that it’s radioactive. It just thinks it’s glucose, so it’ll latch onto it immediately, and that way you won’t have any competition with glucose from your diet, I mean, which are carbs basically from your diet, competing for a space to latch onto certain cells. So, everything that you will have will be radioactive glucose it’ll latch on. And you arrive to the center. We give you the injection. It’s going to an intravenous injection in your arm. You’ll sit in a quiet room for anywhere between 40 or 60 minutes, and the reason why you want the quiet room is because you don’t want any stimulus to any organ in your body, so we’ll get you in a nice warm-temperature room, you’ll relax, and then about after 60 minutes from that, we will place you in the PET CT camera, and with the new cameras, the amount of time that you will spend under the camera is a lot less, so you’re looking at anywhere between a 20 to 30-minute scan from the level of your eyes down to your mid thighs. And once you conclude that portion of the exam, then the images get sent over to the radiology reading room, to the nuclear medicine reading room, for interpretation.    Host: How does that doctor then use the imaging to suggest treatment for me? Dr. Garcia: So, we use a staging system, and I’m going to just use cancer, you know, as an example, which is the majority of the reasons why you do a PET CT scan. There’s a staging system to know how far or how advanced, your cancer is. And depending on how advanced your cancer is, the treatment modalities will change. Let’s use, for example, if we have a patient with lung cancer and they have a small lesion in a very circumscribed area and nothing anywhere else because the PET scan did not show that there was spread to any other organ in the body, then, in these particular cases, one of the treatment modalities might be surgery, for example. You know, I’m not a surgeon, but this is, you know like, this is, you know, one of the treatment modalities, one of the treatment options would be surgery. If, for example, the same patient has that same spot in the lung, but also has spots in his liver, also has spots in his bones, surgery may no longer be an option and a more systemic approach is necessary, meaning something, a form of therapy that will apply to your entire body since there has been spread.  So, it can guide the clinician to knowing what the treatment options are for the patient, and that opens the discussion, you know, with the patient that these are now your options and this is your staging, you know, this is what we consider it to be. Because nowadays patients will do a lot of research on their own, and they come in asking you, you know, like, what is my stage? Am I stage I or stage II? What are my options based on these stages? So, that’s really, really what helps to kind of tell the patient where they are and what their options are.   Host: So, really mapping the progress of that tumor through the body and then the patient’s progress, thereafter, is mapped by the images. Dr. Garcia: Correct. Mapping is a good word to use specifically for this because you will do a PET scan in various clinical phases. One of them is going to be for initial diagnosis. If a patient comes in and has an x-ray and they see a small spot on his lung, that could qualify him for having a PET scan, and they’ll isolate a nodule. Then, after that, they will apply whatever treatment option is available to the patient based on the images, and then you will have another PET scan after the therapy has been installed to monitor treatment response. So, there’s an initial treatment strategy and then a subsequent treatment strategy. That’s how PET scan is divided nowadays.  So, it’s early, it’s a very important early on in the initial staging and diagnosis, and also in the monitoring treatment response phase to see if it all cleared up, if it’s spread more, or if it’s actually regressed completely. And we see patients that sometimes showed up in their doctor’s office with a small tickle in their throat. And it turned out, then they went over to their ear, nose and throat doctor, and they saw a little growth--you know, a little something, a little bulging inside their throat. And when they ordered a PET scan for this, it turned out that it was not just in that little spot, but it was in many other areas within their neck or within their chest. And, like I said, you know, once you know that, it’ll change the treatment options, but I can say definitely, this is something that I share with my colleagues, is that you sometimes, you know, you get, your day brightens up, when you compare it to a study before that showed a tremendous amount of disease, and after chemotherapy or radiation, it’s all gone. So, it’s always nice to have that dramatic effect when you see live cancer cells everywhere and all these cells are dormant--you know, they disappeared basically. We call them night and day scans.     Host: For many imaging tests, patients have asked questions about or have been concerned about the level of radiation to which they’re exposed. How does the PET CT radiation dose compare to MRI or another imaging?   Dr. Garcia: That’s an excellent question because that is the one thing that people will worry about a lot is radiation exposure. Yes, PET scanning alone will produce much higher radiation exposure than a chest X-ray, but you have to think about the amount of information that comes as a result of that, you know, slightly over, you know, the normal degree of exposure. People sometimes don’t understand that you just by standing around, you know, are getting a little bit of radiation from nature. And living in Denver for a year, you actually get more radiation than by having a PET scan. So, it all depends, you know, like on what kind of information you get out of it. When you do CT imaging of certain parts of your body, depending on what part of your body you’re going to image, that part of your body gets an amount of radiation. PET scanning is the injected dose that will distribute throughout your body, so the dose that you receive will be spread out through your entire body, and that is, in essence, less of a dose to each organ in your body than if you only imaged one particular area at a time. So, it is a little bit more than CT alone if you only did CT imaging, but again the risk, benefit, and the amount of information you get for only a small amount of extra radiation, which is very, very below what the maximum amount of radiation you can receive in a year is, you know, is a wealth of knowledge.   Host: Are there any patients for whom PET CT scan just is not an option because of either the radiation dose or another complication? Dr. Garcia: Actually, I can’t think off the top of my head of a case in which you could not use a PET scan. We more, we more will see it in cancers that either don’t take up glucose, radioactive glucose, so it’s not the appropriate test for that particular type of cancer. Other limitations, of course, are that it has been proven through many, many studies that it is not the best examination for that particular type of cancer. There are some types of diseases that we wish we could use them on there, for those, but it’s not approved to be used for those cases. Host: Thank you so much for joining us today. Dr. Garcia: Oh, it’s my pleasure. Thank you for having me. 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.

Can talcum powder cause ovarian cancer? Dr. Louis Dainty discusses why he recommends women not use the product on their genital area.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re talking to Dr. Louis Dainty, Regional Director of Gynecologic Oncology at MedStar Washington Hospital Center. Welcome, Dr. Dainty. Dr. Dainty: Thank you. It’s great to be here. Host: Why don’t we begin by telling us a little bit about yourself. Why did you go into medicine, and how did you come to be at MedStar Washington Hospital Center? Dr. Dainty: My interest in medicine began as a, as a kid. I knew I wanted to be a doctor and going the long way to get there, I went in the military, went to medical school after spending some time in infantry and just retired from the military a physician after 26 years just last year. Host: What led you into women’s health and women’s oncology? Dr. Dainty: I fell in love with women’s health as soon as I rotated on my OBGYN rotation as a medical student. Initially I thought I was going to be interested in orthopedics but then it was much easier working with women—they were a lot tougher than men. Host: Today we are talking about ovarian cancer and talcum powder, or baby powder. So, a jury in August 2017 awarded a woman $417 million in a case against Johnson and Johnson. The woman claimed that her terminal ovarian cancer was caused by the company’s baby powder, which she said she’d used for decades. And this isn’t the first time that talcum powder has been blamed for causing ovarian cancer. So, Dr. Dainty, what does science say about whether baby powder can cause ovarian cancer? Dr. Dainty: The first concern about the possible link between the use of talcum powder and ovarian cancer dates back to 1960s, and that sprung from the initial contamination of talcum powder with asbestos. For some time now, there hasn’t been any asbestos in talcum powder, but still the question remained whether or not there was an association between the use of talcum powder on a female perineum and risk of developing ovarian cancer. The data has been studied, mostly not in a prospective manner but in an observation manner, and the data is mixed—most studies showing that there is no association between the use of talcum powder and ovarian cancer, and others showing that there is a small increased risk of ovarian cancer with the use of talcum powder. When scientists have gone back and looked at the data in total, it seems that statistically there is a very small increased risk of ovarian cancer with the use of talcum powder on the perineum, with specifically a single type of ovarian cancer, and that’s the most common type which is papillary serous carcinoma of the ovary. Host: What do the studies suggest about a woman’s risk for developing ovarian cancer if she’s used talcum powder? Dr. Dainty: Your lifetime risk of developing ovarian cancer is about 1.6 percent of all women, so slightly less than two women out of 100 will get ovarian cancer during their life. And the majority of women die from that cancer because it usually doesn’t present until it’s very advanced. Some of the studies suggest slight increase of a risk of ovarian cancer where, if the baseline risk was 1.6 percent, some studies have shown that it might be as high as 1.8 percent. Now that doesn’t sound like it’s a lot, but instead of 14 women out of a thousand, 16 women out of a thousand would develop ovarian cancer. So those two additional women would certainly not feel that that’s not a significant increased risk from talcum powder. So, while statistically it seems like a very small increase, anything we can try to do to try to decrease your risk of developing ovarian cancer, especially something as simple as not applying talcum powder to your bottom, is worth the effort. Host: So, would it be fair to say that you do recommend that women who use talcum powder stop doing so, or use it less frequently? Dr. Dainty: Yeah, I would recommend that they don’t apply it directly to their perineum because the vagina is interesting in that there is a communication, obviously, physiologic communication, between the outside world and the inside of your body by means of the vagina and the cervix. And so, in theory, talcum powder could be transported from outside of your body into your vagina and up through your cervix because that’s where sperm travel. Talcum powder certainly also could be transported that way, physiologically. So, yes, I’m recommending that if you’re going to use talcum powder that you use it sparingly around your bottom and not apply it directly to your perineum or your vagina. Cornstarch, without any other additives, seems to do some of the same functions as talcum powder without, the, any obvious risks or any clear association between risk and, so if you have to use something, maybe a more natural subject like cornstarch would do. But again, so just avoid using talcum powder. Host: Why do women use talc in these areas, and are there certain groups of women who use it more often? Dr. Dainty: Historically, generations past, I think that a lot of women were taught to put a sanitary pad on, and prior to application of the sanitary pad on their vaginas, they would put talcum powder just to absorb moisture and to also combat bad smell. I think a lot of women, especially older women, grew up doing that. I think younger women, there’s very few women that do that anymore. And so, that’s why people started using talcum powder in the first place. Host: And when you say that it affects the perineum of the woman, could you explain what that body part is, for individuals who might not know. Dr. Dainty: So, the perineum is anything, the vagina, the labia, external genitalia basically, between your thighs, from your pubic bone down to your anus. Host: Are there other products a woman may use, internally or externally, such as petroleum jelly, that may raise her risk for ovarian cancer? Dr. Dainty: Yeah, that’s an interesting question and the bottom line is there is no evidence to date that there is any increased risk with those, at least not that I am aware of, but you bring up a good point—any petroleum-based product that’s applied to your perineum could have, theoretically have, a risk. The bottom line is what I tell most of my patients is when people ask me, you know, “should I use douching or anything like that,” I say “no” and basically that God designed the vagina just the way it’s supposed to be and you shouldn’t mess with that—mess with it as little as possible. So, I don’t recommend using any foreign products, that are artificial products, that you don’t have to. Obviously, people that need artificial lubricant in order have comfortable intercourse, the products with the least number of additives, either color or perfumes or anything like that, are, are, going to be the safest. Host: Is it safe to use baby powder on a baby’s bottom? Dr. Dainty: We don’t know what that risk is, but certainly the use of baby powder for babies is pretty common, and we don’t know whether or not that increases risk. It’d be hard—it’s hard to design a study where you take a hundred babies and expose half of them to talcum powder and the other half you hold back, so all you’re left with is recollection of whether or not a mother said that she used talcum powder on her baby’s bottom or not. So, it’s difficult to get at those kind of exposures through scientific investigation. If I had babies again, I would probably not use talcum powder on their bottoms. Host: If you have a woman who’s used talcum powder for years or for decades, should she be concerned, or should she see her doctor more frequently? Dr. Dainty: No. There is no—there’s no call for alarm and there’s no call for increased testing or surveillance. There is no current routine screening that is recommended for the prevention or diagnosis of ovarian cancer in people that are at baseline risk. That means a lifetime risk of 1.6 percent, perhaps, in the United States. So, no, I wouldn’t say that anybody who has used talcum powder in the past should do anything different except maybe stop using talcum powder. Host: When you’re talking about screening for ovarian cancer, there is really no great test, like mammography for breast cancer or pap smears for cervical cancer. What does screening look like, then, for ovarian cancer? Dr. Dainty: There is no routine screening. As you just said, there is no routine screening for baseline risk, women at baseline risk for ovarian cancer. There are some screenings that we recommend for women who fall into the category of familial or hereditary ovarian cancer, which is a different topic altogether. But for the baseline-risk, general population, there is no routine screening. The only thing that, as an individual and/or a provider, that you may ask a patient to look for are symptoms. So, early satiety, bloating, increased abdominal girth, abdominal pain that occur more days than not—if that’s a new finding, that’s something you need to bring up to your OB GYN. And so that’s really the only screening that I would recommend for all folks. Host: So, you alluded to this a little bit before. What are those main risk factors for ovarian cancer? Dr. Dainty: Probably the biggest is age. So, the average age for ovarian cancer is about 63. So, the older you get, the higher risk you are of developing ovarian cancer. Obesity is the number one modifiable risk factor. If you are 25 pounds overweight, which we all are, you are at 400 percent risk of having endometrial cancer. So, we talk about talcum powder because it increases your risk by 20 percent, and being overweight by 25 pounds, you increase your risk by 400 percent. If you are 50 pounds or more overweight, the risk goes up to 10 times the baseline risk. Certainly—and let’s not even talk about smoking, right? So, yes, talcum powder is real, but it’s not, the data is not so strong. Certainly, the most common talked about risk of ovarian cancer is familial risk. Now, right now, familial risk accounts for maybe 15 or 20 percent of all ovarian cancers. So, most are sporadic or just happen spontaneously. Family history is certainly, though, very important. So, if you have other family members who have breast or ovarian cancers, especially those that have had those cancers prior to age 50, those are folks that may need to be referred to a geneticist for testing. Host: Does that include both sides of your family—so my mother’s side of the family or my father’s—or does that run more prevalently in one or the other? Dr. Dainty: No, it includes both sides. That’s an excellent point. It’s all first-degree relatives. So, if your father’s sister had ovarian cancer early or your father had breast cancer, that would be something that would be very concerning and something that would possibly warrant referral to see a geneticist. Host: This has been very insightful and eye-opening so thank you again, Dr. Dainty, for joining us to discuss this very delicate but also very important women's health topic. Dr. Dainty: I appreciate the invitation. Thank you. 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.

Researchers expect a 77 percent growth in joint replacements over the next decade as increasingly younger patients have the procedure. Dr. Savyasachi Thakkar discusses the benefits of outpatient joint replacement, which allows patients go home within 24 hours of 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: Thank you for joining us today. We’re talking with Dr. Savyasachi Thakkar, an orthopaedic hip and knee reconstruction surgeon at MedStar Orthopaedic Institute at MedStar Washington Hospital Center. Welcome, Dr. Thakkar. Dr. Thakkar: Thank you very much for having me. Host: It’s estimated that there will be 77 percent growth in joint replacements over the next decade. Increasingly younger patients are seeking joint replacement—people in their 40s, 50s and 60s who are working and active and can’t afford to slow down. Advances in joint replacement techniques allow for shorter hospital stays and quicker recovery than ever before. Dr. Thakkar, how is it that a total joint replacement can be performed as an outpatient surgery? Dr. Thakkar: Oh, that’s a fantastic question. So, up to ten years ago, we didn’t quite understand how to perform surgery with the adequate pain control that we have now. So, I think that what’s changed the last ten years is how to attack pain management from a multimodal perspective and try and get patients outside the hospital within 23 hours. So, we call that an outpatient joint replacement. At the MedStar Washington Hospital Center we perform several such surgeries—we perform partial knee replacements, partial hip replacements, total knee replacements, and total hip replacements within that 24-hour window. Some patients are candidates to leave the very same day if they’re healthy, they’re active, they have a low BMI, which is a body mass index, and they are non-smokers and otherwise have a very good social support system at home. So, if all those things and all those parameters match up, we’re able to get them home the very same day or sometimes have an overnight stay and get them home the next day, understanding very well that they have to have a robust coaching system at home, maybe a friend, maybe a family member who can care for them. And they also have to have all their needs addressed beforehand. So, at our institution, we have the social workers who are called the post-acute care coordinators, or the PAC coordinators, that coordinate the patient’s perioperative care with regards to physical therapy, with regards to transportation needs, all in one setting, done before surgery. Host: So, aside from some of the benefits that you mentioned—the shorter hospital stay, the ability to go home quicker - what are some of the other major ways that patients benefit from same-day or outpatient therapy? Dr. Thakkar: You know, one of the biggest things that patients can experience with a same-day program is that they have surgery at a very well-established surgery center or a hospital and then they can recover in the comforts of their own home. So, they can have physical therapy come out to their house for approximately two weeks after surgery, and that reduces the number of falls that they have, to try and leave their house and transport themselves to a physical therapy institution. The other thing is that they can control the cleanliness, they can control their pain a lot better because they’re not being woken up at all hours of the night for vital checks, for blood pressure tests, and even to draw their blood. So, the recovery is a lot healthier, it’s a lot quicker and it’s a lot more effective. Host: How does the process of outpatient total joint replacement compare to traditional joint replacement? Dr. Thakkar: Traditional joint replacements and outpatient total joint replacements differ in the perioperative care. So, the surgical procedure is very similar for both...both settings. But, once you have patients that want to stay in the hospital, we have to plan for inpatient rehab needs, we have to plan for them to get to a rehab center. All of these things increase the cost to the healthcare system and to the individual. They increase the risk of infection because patients are now in less controlled environments. They also lead to patients who have higher pain scores than patients that have outpatient joints just because patients are not in their normal realm of life, which is where they want to be, either before or after surgery.  So, I think that traditional joint replacements are applicable to a certain subset of patients now that are elderly, that don’t have support systems at home, that are less active. But, for the more active, the...the younger patient population, I think that outpatient joints are the way to go. Host: How long is the recovery process for a younger, more active individual, say in their 40s to 60s, as compared to one of the older patients maybe that had to go through the traditional route? Dr. Thakkar: So, what I like to tell patients, either knee replacement or hip replacement patients, is that on average they take about 6 weeks of physical therapy to recover from surgery. Now, for that younger, more active individual, it could be on the order of 3 to 4 weeks. For the elderly, that could be about 7 to 8 weeks. So, the average is about 6 weeks for each individual. Now just this morning in my clinic, I saw several patients that have had these procedures about 6 weeks ago, and most of them are raring to go back to work. Most of them got out of the hospital overnight. So, we’re starting to see that a larger proportion of patients want to get back into the daily stream, or their daily activity, just because they miss it and they feel like they need to get away from the distraction of having surgery and reduce their outliers, and reduce their pain, by going back to work sooner. Host: Will these individuals be able to recover 100% of their previous activity before their joint began to deteriorate? Dr. Thakkar: Absolutely. So, joint deterioration happens over a number of years. The symptoms may only present for a few months or a few years, but the deterioration has been in place for a number of years. That is associated with several other problems, such as, losing muscle mass, losing the ability to perform activities of daily living, to enjoy life as it may, and those things take about 3 or 4 months to get back to 100% normalcy. But, for the most part, patients, when they are rid of their pain, they experience such relief that they are able to tackle life and life situations at a much faster pace. Host: As a academic medical center, MedStar Washington Hospital Center and the Orthopaedic Institute really take a lot of stock into and a lot of collaboration with each other as a team. Could you talk a little bit about your team-based approach to care for your orthopaedic patients? Dr. Thakkar: Absolutely. So, that’s a fantastic question. At the MedStar Washington Hospital Center at the MedStar Orthopedic Institute, as a whole, we have several specialists devoted to patients with arthritis. So, let’s start with the providers themselves. Dr. James Tozzi and myself, we focus on primary and revision hip and knee replacement surgeries. We also have Dr. Wiemi Douoguih and Dr. David Johnson, who focus on primary knee replacement surgeries. Along with that, we have a team of physical therapists that evaluate the patients in the preoperative setting, immediately after surgery and then 6 to 8 weeks after surgery on a continual basis. We have specialized nursing devoted to orthopaedic patients on our orthopaedic floors and we also have social workers that are geared towards caring for patients just with knee and hip replacement surgeries without any distractions and they’re used to caring for such patients with complex medical needs, with complex social situations. The other advantage of being in a tertiary care facility like ours is that we have access to neurosurgeons, to cardiac surgeons, to all kinds of physicians and all kinds of specialists, so that if a patient were to have a complication in the perioperative setting, it can be easily addressed. And, a final point is that in a tertiary care hospital, if we have to convert a patient from being an outpatient setting to staying overnight, or maybe even staying for 2 nights, it’s very easily accomplished. Now, this is in contrast to numerous surgery centers that are mushrooming across our communities where they do not have such facilities, they do not have such expertise, and that can lead to drastic complications. Host: How does the volume at the MedStar Orthopaedic Institute compare to other centers within the region? Dr. Thakkar: I think that the MedStar Orthopaedic Institution, as a whole, is a much busier orthopaedic practice just because we see patients that need simple hip and knee replacements and also need complex revisions. So, from a volume perspective and from a complexity perspective, we are significantly higher in terms of the number of procedures that we perform than other comparative situations or other comparative hospitals. On average, at the MedStar Washington Hospital Center alone, we’re performing about 600 to 700 joint replacement procedures each year, and these are primary joint replacement procedures. With regards to revisions, we’re probably performing about 200 or 300 revision procedures, so an average of about 1000 procedures. Now, if you account for all the MedStar Orthopaedic Institute practices that are in the area, we’re looking at lines of about 3- or 4,000 joint replacement procedures performed each year. Host: That’s several a day, if you just go by the calendar year. Dr. Thakkar: Yes, absolutely. I mean, I operate 2 days a week and on average I’m doing between 7 and 10 or 7 and 12 cases per week, so that number adds up very quickly. Host: Are you doing any research currently on total joint replacement that you'd like to share with the DC community? Dr. Thakkar: Yeah, I think that joint replacements have come a very long way, and especially the last decade. So, there’s several areas of focus on research for joint replacement patients. One of them is optimizing protocols for such patients, whether they be in-hospital protocols or outpatient protocols. Second are pain management strategies. Pain management is also making leaps and bounds with regards to joint replacement patients, and I think that addressing the multimodal issues that patients have is significant, so we’re doing research on that. We’re also focused on looking at pre- and postoperative nerve ablation for patients that may have chronic pain issues. We have pain management specialists that can go in and ablate with radiofrequency the skin nerves around the incision sites where we’re going to make the incision for our surgeries. By doing so, they reduce the overall narcotic burden that these patients see in the postoperative setting. We’re also looking at advanced technologies like robotics or computer-assisted navigation to help us reduce our operative time, to help us reduce blood loss and the need for blood transfusion, so we’re calling this bloodless surgery for our patients. And, that also helps us optimize our outcomes. And, finally, we’re looking at alternative bearing surfaces. A bearing surface is where the bones are capped with different materials, and they help form the new joint. So, alternative bearing surfaces will give patients better pain control, better mobility and also longevity with regards to their prosthesis. Host: So, the bloodless surgery—that one really stuck in my ear when you said that. Is that something that you currently offer to patients? Dr. Thakkar: Absolutely. So, what I like doing for a lot of patients, and a lot of patients will have bilateral knee or bilateral hip problems. In those situations, I will use a surgical navigation device, which is also known as a GPS device or a computer-assisted navigation. That allows me to work outside of the bone on the joint surface as working inside of the bone. Working inside of the bone leads to significant blood loss, and it also leads to significant risk of having blood clots either in the legs or in the lungs, and using this computer avoids these issues for these patients so that I can perform these safely without the risk of blood transfusion because their blood loss rates are low and also without the risk of blood clots. Host: That’s fascinating. Could you share some success stories from your patient population regarding the same-day, joint replacement surgery? Dr. Thakkar: Absolutely! So, I saw a very active individual. Unfortunately, she had a high BMI and she was refused to have surgery at multiple different institutions. However, when she came to me, she clearly demonstrated a need to get back to her lifestyle that she desired and she needed a knee replacement surgery. We brought her in for surgery. We performed the operation without any complications. In fact, she was so ecstatic with the pain control and the mobility that she received that she was eager to leave the very same day. However, it being, bad weather, she stayed overnight and she was able to leave the very next day, and had very good pain control and she hasn’t had any concerns. So, I think that patients overall do very well. I’ve also tried to perform bilateral total knee arthroplasties. Now, these patients need to stay in the hospital for a little bit longer, maybe a day, maybe 2 days. And, we recently did a story on a patient that was not able to cook for her family for the last several years, but just this Christmas was the first Christmas she was able to cook for them, and I think, in my mind, that’s a…a big success for this patient. Host: Do you often see individuals who are turned away from other centers or refused surgery from other centers? Dr. Thakkar: Absolutely. So, at the MedStar Washington Hospital Center and the MedStar Orthopaedic Institution overall, we have, like I mentioned, experts that can deal with multiple problems, so a lot of patients come to us who either have significant joint deformities or they’ve had several procedures that have been unsuccessful in the past, and we have to evaluate them to try and revise them and to try and provide a more stable functional prosthesis. And, we’ll frequently see those patients at our institutions because we have the ability to care for them for a multidisciplinary approach. Host: What makes MedStar Washington Hospital Center the best place to seek same-day or outpatient total joint replacement? Dr. Thakkar: At the MedStar Washington Hospital Center and the MedStar Orthopaedic Institution, we focus on individualized multidisciplinary specialized care that encompasses the entire perioperative care for a patient from the preoperative setting, during surgery, and in the postoperative scenario. We have specialists that can help patients and help each individual with their customized needs and provide the best possible outcome for this patient. And, I think that using a tertiary care facility to achieve this goal is remarkable because we have 24/7 support and we have residents on staff which are seeing patients at all hours of the night, taking phone calls, which is just not possible in outpatient situations. 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.

Everyday choices affect our colorectal cancer risk – even what we eat and drink. Dr. Brian Bello discusses how eating a high-fiber diet and cutting down on certain beverages can help reduce your risk of developing colorectal cancer.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thank you for joining us today. We’re talking with Dr. Brian Bello, a colorectal surgeon at MedStar Washington Hospital Center. Welcome, Dr. Bello. Dr. Bello: Thank you very much for having me. Host: Nutrition and dietary factors have been tied to a wide range of diseases in the past decade, including colorectal cancer. The choices we make every day about what we eat and drink can have a dramatic effect on our current and future health. Dr. Bello, what food and beverage options are most alarming to you as a colorectal surgeon? Dr. Bello: Well, as a colorectal surgeon, we tell them to try to avoid processed meats, like bacon, sausage, ham and jerky, beef jerky. Unfortunately, the bacon and ham and sausage are the things that people love and like to eat, especially and also red meat, so we just try to tell them to substitute leaner meats or skinless poultry or fish, and that usually can help them. Host: What is it about the red meat, specifically, is it more harmful as compared to leaner meats? Dr. Bello: Yeah, scientists don’t know for sure. It’s probably the way that the meat is processed and preserved - maybe some chemicals there, it’s unclear. Host:  So I know we talked about food, are there any drinks that may contribute to a person’s risk? Dr. Bello: We know that obesity and diabetes are risk factors for colon cancer. So, we know that people that drink a lot of these high sugar beverages may get diabetes. So, we usually tell people when we’re counseling them about their diet, to try to avoid those high sugar drinks, those energy drinks, those fruit drinks, and tell them to drink water, low dairy. Host: And what about alcohol? Dr. Bello: Alcohol, if consumed in a mild or moderate fashion’s okay, but we tell people not to drink excessive amounts of alcohol. Host: Are your patients ever surprised when you mention diet and nutrition as a factor in colorectal cancer risk? Dr. Bello: Yeah, people seem to be surprised, and many people don’t even realize that their diet is not a healthy one. So, usually we go over their usual daily intake and figure out what they can do better. We try to give them a lot of education about this. We try to give them menus and lists of things that they can do and eat so that they can have a better diet. We also find it helpful that, if they come with a family member, specifically the person that cooks for them, that they’re involved in that discussion. Host: Now you mentioned some of the things that you recommend that your patients avoid. What would you consider an ideal nutrition plan, say for a lunch or a dinner, for someone at average risk of colon cancer? Dr. Bello: We always recommend our patients be on a high fiber diet. So, when people come in and they tell me they’re eating a lot of red meats and processed meat, I immediately try to give them some education. I tell them what foods are rich in fiber which include raw fruits, like apples and bananas; vegetables, especially raw vegetables, like lettuce and spinach; legumes, like beans, all have a lot of good dietary fiber which has been associated with less colon cancer risk. So, it’s always good to have a variety of food, specifically a variety of fruits and vegetables, whole grains. I mentioned a high fiber diet - usually about 25 to 30 grams a day. Skinless poultry and fish are good. Nuts and beans. And we try to tell them to limit these things that aren’t good for you, so fatty food, fried food, sweets, foods that are high in sodium - those are the key things to limit. Host: Should patients who admittedly make poor nutrition choices, or just really enjoy junk food, be screened more often for colon cancer than say an individual with a healthier diet? Dr. Bello: That’s a good question. I’d say we haven’t had enough data to make that choice yet. I think we still take in account the other risk factors where the patient symptoms, are they having symptoms like bleeding or abdominal pain, change in their bowel movements. I think poor nutrition alone, we don’t recommend that they get screened more often than other people. That would probably lead to unnecessary tests. But I think we take the whole picture and see what their other issues are and what their other risk factors are. Host: Could you discuss your team approach to care when it comes to balancing nutrition with colon cancer screening and awareness? Dr. Bello: Yeah, so here at MedStar Washington Hospital Center, we have different experts in different fields. So, not only do we have surgeons and oncologists, we have nutritionists that can help patients find a good balance of what’s healthy and what tastes good. That’s an advantage that we have at Washington Hospital Center. Host: So, why is MedStar Washington Hospital Center the best place to seek that colon cancer screening and guidance? Dr. Bello: Yeah, I think we see a lot of colon cancer - we’re a high-volume center. So, a lot of us do primarily colon cancer and rectal cancer - those are our primary patients, such as myself and my colleagues. We do present any new colon cancer at a multidisciplinary tumor board, where there’s a lot of experts from different fields weighing in. With that, we come up with the very individualized treatment plan for each patient. So, because of that, we’ve shown that those patients have better outcomes. Host: Could you share any success stories from your patient population, perhaps an individual with a very poor diet or a cancer risk that maybe turned their diet around? Dr. Bello: Yeah, I think I get the most satisfaction when I’m seeing patients for a long time. For example, if I do a colon surgery on them, I usually follow them for several years, up to five years after surgery. And then I see that they’re following my recommendations of leading a good, healthy lifestyle. They’ve stopped smoking. They’re eating better. They’re eating more fiber in their diet. And they’re exercising. Those are the patients I feel that we’ve helped. Host: Thank you for joining us today, Dr. Bello. Dr. Bello: Thank you very much. My pleasure. 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 pelvic pain can cost women productive time at work and lost opportunities with family and friends. Dr. Vadim Morozov discusses which populations are most at risk for chronic pelvic pain and the personalized treatment options that are available.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re speaking with Dr. Vadim Morozov, a gynecologic surgeon at MedStar Washington Hospital Center. Today we’re discussing chronic pelvic pain which can be a symptom of a variety of gynecologic disorders. Welcome Dr. Morozov. Dr. Morozov: Thank you. Glad to be here. Host: What do you mean when you say chronic pelvic pain? Dr. Morozov: So, chronic pelvic pain, by definition, a pain in your pelvis that’s been there for longer than six months duration. It could be caused by multiple reasons, but most common one in the female population are things like endometriosis, fibroids, scar tissue. Host: What symptoms might prompt a woman to seek treatment? Dr. Morozov: So, things like very painful menstruation. Pain with intercourse for, example. Pain with going to the bathroom and just the one that doesn’t go away - the one that’s not getting better with just something like Motrin or Advil. Those are the conditions that I would suspect that she has something else and needs to be addressed. Host: When we’re talking pain, are you talking a burning sensation or cramping? What are...what are women complaining about? Dr. Morozov: That’s a very interesting question. So, actually women can complain about any type of pain and in the pelvis, it’s highly non-specific, meaning you could have a certain condition but the pain could range from, as you mentioned, burning, pinching, to doubled over with stabbing—“I can’t even take a breath.” Host: Is it always in the pelvic area or does it radiate? Dr. Morozov: It does go to other things and other parts of the body. For example, pain with endometriosis’ very commonly go down toward the back. It can go down the legs. It can shoot down toward out the stomach or in your buttocks. It’s very difficult to pinpoint the location of the pain and the specific cause of the pain in a lot of cases. Host: Who is most at risk for chronic pelvic pain? Dr. Morozov: Obviously, uh, women are 95 percent. So, if you look at the all population of chronic pelvic pain, 95 percent of the chronic pelvic pain happens in the female population. We’re still unsure why it happens. Males do too, but very unfrequently, as you can, tell from that statistic. If you had endometriosis in your family—if your mother or your sister was affected by endometriosis, you are much higher chance to have an endometriosis and pelvic pain. If you had fibroids in your family, you are at a higher risk of having a fibroid. If you’re African American, for example—race plays a specific role. African Americans statistically are three times as likely to have fibroids as white women. Asians, for example, almost unheard of having fibroids on the other hand. So, very specific genetic component that plays a role. Host: Is there any sort of genetic testing or any testing that can help determine a woman’s risk? Dr. Morozov: Unfortunately not. There are multiple companies that are trying to get commercial testing on the market. So far, we do not have anything that can predict a risk of developing endometriosis. Or even a chronic pelvic pain for the condition. The interesting thing about chronic pelvic pain and endometriosis or fibroids is that you could have endometriosis and not have pelvic pain. And almost the opposite is true. You can have the most severe pelvic pain and then, when we investigate, you will have very minimal or very mild endometriosis. So, there is no direct correlation between the cause and effect. Host: Once a cause is defined, if a cause can be defined for chronic pelvic pain, what are some of the treatment options that are available? Dr. Morozov: We usually start with discussing what causes the pain, as you said, right? So, if we can identify that, let’s say, it’s a fibroid, for example, or endometriosis or pelvic scar tissue (adhesive disease), usually we try some medical intervention in the beginning. Maybe some sort of a non-steroid anti-inflammatory, otherwise known as Advil, Motrin, and Ibuprofen. Maybe we try to have some sort of a physical therapy intervention. In my experience, in the majority of cases, that doesn’t work. Very few times it actually will make women asymptomatic, meaning she’s happy with that treatment and done. The next step would be the surgical intervention. So surgical intervention, nowadays in 21st century, we truly believe it needs to be done minimally invasive, laparoscopic way, meaning small, tiny, less-than-an-inch incisions in the belly with one of them in the belly button. Go home the same day within 2-4 hours. Very quick recovery time. Almost no blood loss. Having said that, the surgery just the first step in the long way to recovery. So, identifying and treating the cause of the pelvic pain, let’s say an endometriosis or whatever, will not make you pain free unfortunately. And that’s a very complicated topic and people wrote books and chapters and actually I wrote some chapters and research and that. You will need to do a lot of other things on top of the surgery, meaning we will have to suppress your hormonal fluctuation one way or the other. The fewer menstrual periods you have as a woman, the shorter they are, the better your chance of not having the recurrence of endometriosis. Pelvic physical therapy would be the next step. There is a highly interesting phenomenon that’s called central sensitization and to explain it in the lay terms, this is where your central nervous system gets used to the pain over many, many years. And technically speaking, no matter what we do in your pelvis, you still feel the pain. So, we’ll have to address that problem. So, it’s a multi-specialty approach before we can get patient to the level where she can function comfortably. Host: If a woman, say, doesn’t have severe symptoms or has just gotten used to living with them, is there a risk for leaving chronic pelvic pain untreated? Dr. Morozov: Not the pelvic pain. Now obviously, the chronic pelvic pain is, puts the huge burden on society. The estimate that it costs several billion dollars a year for economy from lost wages, lost time from work, lost...lost time from spending with your family and kids. Endometriosis, for example, left untreated, could become severe enough and could affect other organs next to it—so it could affect your bowel, it could affect a kidney. And I have dealt with cases before where the endometriosis was bad enough that the kidney almost died off because it was obscured in the outflow. So, eventually, it can get you in trouble. Host: Have you had any women come in with chronic pelvic pain who just had a very severe condition and you were able to help them and get them back to a functional level?   Dr. Morozov: Absolutely. That’s what we do. I mean, the worst endometriosis - although some expert will debate - is called a stage 4 endometriosis - was severe. And we do surgery, we restore the anatomy, we remove the endometriosis that affects the organ. And, they seem to be doing great. They’re fully functional, they still have pain here and there, but at least we can get them to the point where they can function on an everyday basis and have a normal life. Host: Do you have any one patient that stands out in particular who was maybe very severe and has done really well? Dr. Morozov: Yeah, we have, just recently - about a month ago - I did a surgery on a patient and she’s great, she feels absolutely phenomenal. Host:  Are there any environmental factors associated with the risk of endometriosis or other chronic pelvic pain? Dr. Morozov: Absolutely. There’s been a lot of research done on the environmental factors in endometriosis. One of them is well known, organa pollutants or organa phosphorus components that exist everywhere. Actually, very common product on the market is a sunscreen that has them. And I’m not abdicating, I’m not saying don’t use sunscreens, but we have to be cognizant about what we buy and use. There’s been studies saying that the specific components that are used in the industry actually produce both to develop an endometriosis. Host: Are you conducting any research, you or your colleagues, regarding chronic pelvic pain that women in the community should know about? Dr. Morozov: Not currently. I mean, I’ve been involved in the research for chronic pelvic pain and endometriosis. The problem with the research in this arena is that it’s hard, as I mentioned before, to correlate the extent of a disease with the sensation of pain. Multiple commercial companies been in the market trying to develop some sort of the either medication or pain control, endometriosis control or fibroid control drugs and some of them are successful, majority are not. So, it’s a tricky area of research. Host: What innovations in chronic pelvic pain do you hope to see in 10 to 20 years? Dr. Morozov: So, there is some research right now that I find very fascinating. There’s a company that’s testing the RNA fragments, which is a blood sample, and actually they claim they can get yours out of your saliva, so it’s just a little swab out of the mouth. And they are saying that if you can analyze, sort of fragments of RNA, which is nucleic acid in your blood, they can predict whether you have an endometriosis or not. So that would be very useful diagnostic tool which we don’t have right now at all. As I said, the only way to diagnose endometriosis is to perform the surgery, which, of course, carries the risk of any surgery. Bleeding, infection, you name it, damage to the surrounding organs. If we can have a test, either by blood drawing or by swabbing the mouth and sending it to the lab, tells you as a patient and me as a physician that you have a certain degree of, you know, sensitivity that that will be the endometriosis. What is more important, that test would be absolutely phenomenal to see the progression after the treatment. So, let’s say we do the surgery and then we test that patient six months to a year later and see if that test becomes negative. That would be even better application. Host: Why is MedStar Washington Hospital Center the best place for a woman to come for chronic pelvic pain care? Dr. Morozov: Because we have the best interdisciplinary team on the East Coast. I mean, our Center for National Advanced Pelvic Surgery has multiple specialists that deal with nothing else but with chronic pelvic pain, fibroids, endometriosis. We have multiple fellowship-trained urogynecologists. We have a urologist that works with us with interest in woman health. So, this is a place where, if you have a problem, you would expect that they will be detected and solved. Host: Thank you for joining us today, Dr. Morozov. Dr. Morozov: Thank you for having me. 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.

A paraesophageal hernia can have symptoms as simple as acid reflux or feeling bloated after a small meal—or no signs at all. Dr. John Lazar, Director of Thoracic Robotics, discusses how we diagnose and treat paraesophageal hernias.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Thanks for joining us today. We’re speaking with Dr. John Lazar, Director of Thoracic Robotics at MedStar Washington Hospital Center. Today we’re discussing benign esophageal diseases, a group of non-cancerous disorders in the esophagus, which is the tube that connects the throat to the stomach. Dr. Lazar, what are some of the benign esophageal diseases you see most often in your patient population? Dr. Lazar: I would say that the most common benign disease that we see is something called the paraesophageal hernia. And what that is, is that over time, the diaphragm weakens and the stomach starts to track up into the chest. Um, and it can be quite uncomfortable at certain points which is generally when people start seeing us. Host: What are some of the common symptoms of paraesophageal hernias? Dr. Lazar: So, the most common one is reflux, meaning that you have this taste of acid coming up into your mouth or sometimes it causes you to cough. Other ones are after eating a small meal you feel very bloated. Sometimes it even causes you to actually have to vomit in order to feel better. This is something that happens gradually over time, so a lot of times, people don’t realize they even have these problems until someone points it out to them. Other issues with the esophagus which are less common is something called acalasia, which is the inability for the lower part of the esophagus that is connected to the stomach to open up all the way. So, food actually sits there at the end of the esophagus and usually you have to wash it down with a glass of water or unfortunately, even then, sometimes things come back up. Host: So, they sound like pretty similar symptoms to other disorders. How common are these esophageal diseases? Dr. Lazar: So, I would say that achalasia is probably very small, in the single digits, if you took the population as a whole. Or I would say that paraesophageal hernias are probably around 10 to 15 percent of the population. And most of the time they’re asymptomatic, meaning no one has any symptoms and they’re only...only found incidentally, meaning you went in for a chest x-ray or something else was bothering you and they did a CT scan and they ended up finding some of these things. I think when you’ve had long standing gastroesophageal reflux, it’s time to talk to your doctor about maybe even getting screened when a...with a EGD by a gastroenterologist, just to make sure that there’s no permanent damage done to the esophagus. I think if you’re in the category of, “Oh, you know, this happens every year, once a year,” you’re probably OK, but if it’s happening more and more often, then you really should talk to your doctor about getting screened. Host: Are there certain groups of people who are more at risk, say men or women? Dr. Lazar: So, generally people who have increased abdominal pressure, so that would be people who are overweight, uh, sometimes women who’ve had multiple babies, and over time, the diaphragm weakens. It’s...it’s kind of hard to predict who will or who will not have it. Host: In terms of treatment, what are some of the most common first-line treatments for these disorders? Dr. Lazar: Sure. So, basically the only treatment is for the symptoms, unless you fix the problem. So, a lot of times people will take antacids, over-the-counter or prescribed by a gastroenterologist or a primary care physician. But if you want definitive therapy from it, surgery’s the only cure. Host: Is there an issue with people taking antacids and things like that long-term as opposed to having surgery? Dr. Lazar: Yeah, so there’s a growing debate as to whether a certain type of drug called proton pump inhibitors, or PPIs, also has long-term damage to other organs and that’s an area in which people are looking into but it’s become very popular in the news and so a lot of patients have been talking to their doctors about whether or not surgery’s right for them. Host: Could you explain what a PPI is for individuals who might not know? Dr. Lazar: So, a proton pump inhibitor works on suppressing the acid on a molecular signaling level and so therefore people have less symptoms from reflux because the pills tell the body to make less acid. Host: When a person does need surgery, what are some of the more common procedures that are done? Dr. Lazar: So, if we’re talking about a paraesophageal hernia, generally paraesophageal hernia repair involves pre-operative testing with an esophagram, which is drinking of contrast, and then they get x-rays that shows how the contrast goes down. The other common test is a CT scan of the chest, which is about a ten-second test. And then the other test can be something called manometry, which tests how well the esophagus squeezes food down the length of the esophagus. Host: So they’ve run through all of these tests...and then, once they go in for treatment, what...are you doing a...an open surgery with these folks, if it’s necessary...minimally invasive? What does that look like? Dr. Lazar: So, almost all surgeons are doing minimally invasive paraesophageal hernia repairs. In the old days we would generally go through the left chest, which was a very painful procedure. Now we’re doing it minimally invasively through the abdomen where there’s less nerve endings and, uh, they’re able to go home much sooner. We do it robotically. Patients are brought to the operating room. They’re put to sleep. They’ll have five ports about the width of my index finger. And then we will use the robot, which is completely controlled by the surgeon, to then bring down the stomach back into the abdomen, take down all the scar tissue that was holding it in there, and then close the opening that’s in the diaphragm that...where the stomach was going in. Host: Could you talk a little bit about the recovery from that type of procedure? Dr. Lazar: Sure. So, the great advantage of robotic surgery or any kind of minimally invasive surgery for paraesophageal hernia, is that generally people go home anywhere from one to three days afterwards, uh, depending on the surgeon’s preference. So, generally they have less pain, they’re able to eat and drink much quicker, and so there’s really no reason to keep them in the hospital. Uh, they still take about seven to ten days to really get back on their feet once they’re home. Host: What is the risk of not seeking treatment for long-term symptoms? Dr. Lazar: So, I think that there’s a group of people who are very scared of surgery, and rightly so, who have paraesophageal hernias. Unfortunately sometimes the stomach can twist along the esophagus and cut off the blood supply, and therefore, it becomes a surgical emergency to reduce the stomach and get it back down and there’s a risk of the stomach becoming what we call ischemic, or there’s no blood supply to it. Uh, and that...that can be life or death in some cases. In the past we had talked about only treating symptomatic paraesophageal hernias, but there’s growing evidence because of this that maybe we should start taking care of these patients earlier when the hernias are smaller and they’re actually in better health. Host: What are some of the emerging technologies or procedures that you’re using at MedStar Washington Hospital Center? Dr. Lazar: So, I would say that the biggest technology that’s really catching on both nationally here and that we brought to the Washington Hospital Center is...is robotic technology. And, in most senses, this is robotic assisted technology, so the surgeon still remains completely in control of what’s going on. The robot is there just to enhance visualization, enhance their ability to operate within a confined space, and to basically make it a smoother operation for the surgeon. Host: Have you had any patients in the past who have had severe hernias who you were able to help with this type of surgery? Dr. Lazar: Sure. So, I think, in a lot of senses, because of the enhanced visualization, we’ve been able to do a better operation than we would open in the abdomen, and in some cases, just as good as we would have done through the chest but with much smaller incisions and therefore better recovery because we’re able to take down all the scar tissue that basically keeps it up there. We’re able to reduce, you know, the stomach back in to the abdomen or in to the belly area and then close these large defects. Because we have wristed instruments, we’re able to then suture in a much better way or close the defects in the diaphragm and then make sure that the patients reestablish the normal anatomy. Host: So, in...in doing so, in reestablishing that anatomy, is there a follow-up procedure that these patients will have to have? Dr. Lazar: No. Generally, once the surgery is performed, and then they’re able to get out of the hospital in a couple days, uh, we follow them along, at least a couple weeks, and we’ll see them back yearly just to make sure that everything’s OK. But generally speaking, uh, there’s no other procedure that’s usually required afterwards. Host: Why is MedStar Washington Hospital Center the best place to go for treatment of hernias and other benign esophageal diseases? Dr. Lazar: Well, we have a team of specialists in thoracic surgery who are very dedicated to understanding esophageal disease. We’ve all been specially trained in the esophagus. A lot of people get training in a lot of different things. Our passion is, uh, esophageal disease, whether it’s cancerous or non-cancerous. And, so therefore, I think that we have a lot of experience and knowledge in identifying esophageal disease and, technically speaking, we’ve dedicated our lives to...to perfecting it. Host: Thanks for joining us today. Dr. Lazar: Thank you. 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.

Uterine fibroids affect millions of U.S. women. Dr. Saher Sabri, Director of Interventional Radiology, discusses uterine fibroid embolization, a minimally invasive procedure that can relieve painful symptoms without removing a woman’s uterus.    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 with Dr. Saher Sabri, Director of Interventional Radiology at MedStar Washington Hospital Center. Today we’re talking about uterine fibroid embolization as an alternative to hysterectomy. More than a third of all hysterectomies are performed due to fibroids. A recent study found that almost half of women diagnosed with uterine fibroids have never heard of uterine fibroid embolization, which has been around for a couple of decades. So, Dr. Sabri, why do think so few women have heard of this procedure?   Dr Sabri: When we saw the statistic that 50% of women have not been offered or heard about uterine fibroid embolization prior to being offered hysterectomy, it was somewhat surprising that uh, a procedure that has been so effective and popular for the last two decades have not reached all women. This is, uh, an effort that we should, as physicians, do a better job at. The health system should as well try to reach out to as many women, as many families as possible, to let them know about a procedure that can provide a minimally invasive way to treat the fibroid and by improving quality of life with minimal interruption of your daily routine with a lower complication rate and, actually, from a cost perspective, it actually costs less. So, this is an effort that we’re gonna work on to improve awareness of this procedure.  There’s a lot of national campaigns trying to improve the awareness of this procedure, and locally in our community, that’s something that we’re gonna be working on to improve awareness for this procedure. And know that all women who have fibroids need to know their options.   Host: So, how does uterine fibroid embolization work?   Dr Sabri: So, uterine fibroid embolization is a minimally invasive, image-guided procedure. The procedure starts by placing a catheter, which is a small plastic tube, in the artery at the top of the thigh, or through the wrist. Through any of these arteries in the wrist or the thigh, we advance this catheter, which is a small plastic tube, using image guidance under x-ray guidance into the arteries that supply the fibroid. Once that catheter is there, then we inject through it small beads, that are like sand grains, into the arteries that supply the fibroids. The fibroids will then shrink and the symptoms that accompany the fibroids and the enlarged uterus will improve. The procedure is done as an outpatient procedure. At the most, the patient will have a one-night hospital stay, but less than 24 hours, and usually the women that have..undergo this procedure can go back to their daily routine a week after the procedure. We see them, evaluate them, before the procedure, discuss all the options that they have, talk about hysterectomy, talk about the fibroid embolization, and talk about some of the other minimally invasive surgeries that they can have. And then, from this point on, if they decide to go with a uterine fibroid embolization, we counsel them on the process, and the symptoms that they would have afterwards, and the side effects and how they cope with it, and the time frame when they can go back to work.   Host: What is a uterine fibroid and what would some of the symptoms be that would spur a woman to come in for treatment?   Dr Sabri: Uterine fibroids are benign growths inside the uterus. The uterus will enlarge and the fibroids can be anywhere from one to more than a dozen. And, the symptoms that happen are mostly bleeding, heavy periods, and, uh, pain and cramping. They can also have what we call bulk symptoms, which is increase in urination, frequency, waking up at night to go to the bathroom, constipation at times. It affects around a third of women above age 35. African-American women, per se, they’re.. have a higher incidence--they have a threefold increase in incidence of fibroids, so..and can affect them at an earlier age of life. After the age of menopause, which is, you know, in the 50s and 60s of their age, the fibroids tend to shrink and the symptoms will go away for most women. So, you know, it affects women at this age, in their 30s and 40s and early 50s, and can cause significant interruption to their daily activities. They cannot have an interruption for two or three weeks for a hysterectomy and they’re seeking a minimally invasive procedure that can help them get back to their daily routine faster, and this is what this procedure offers. It’s very effective. Around 90% of women show significant improvement in their symptoms and that success rate is what drove this procedure to be that widely adopted as an alternative to hysterectomy.   Host: These women are potentially dealing with these pretty awful-sounding side effects for, you know, 15 up to 20 years sometimes. What would drive a woman to say, “I’d rather keep my uterus and have this embolization procedure” as opposed to just remove it and be done with it?      Dr Sabri: It’s a personal preference and I truly believe in individualized medicine. I think not two patients are the same and each patient needs to hear about all their options. And then it’s up to them, once they’re fully informed, to make the decision that best suits their life. Some women do not want to deal with hysterectomy and, to them, they would not seek medical advice because they think that their only option is hysterectomy, and if they’re not informed about this procedure, they can live with some, you know, awful symptoms that affect their daily life.  On the other hand, there are some women, once they hear that their uterus has fibroids in it and causing them issues, they would just rather have hysterectomy and not have to deal with any other option or any other considerations that the fibroids may come back, you know, down the road. So, that’s something that we inform women about. We talk in detail about the science behind each of these procedures and they can decide. On the note that would..can fibroids come back after uterine fibroid embolization, the incidence of that is around one in five, but that’s after five years, so most women, by the time that this time frame comes back, they are already getting close to menopause and they rarely need additional procedures to address their fibroids. From the women that we’ve seen, 90% of them have success and they don’t have to actually have a second procedure or have to deal with it afterwards. The ten percent that the procedures does not work, then they can still undergo hysterectomy or other procedures to deal with it. I would like to add that there’s some other minimally invasive options other than hysterectomy, other than uterine fibroid embolization, that are performed by our colleagues in Gynecology here at the Washington Hospital Center, so we have a comprehensive approach to this. We have a fibroid center, where specialists from OB/GYN and Interventional Radiology meet and discuss every patient, and we offer all the options for the patient, including uterine fibroid embolization, hysterectomy and minimally invasive procedures performed by the gynecologists. After offering these options the woman can decide what works best for her out of these options.   Host: So, at your..at your fibroid center, what are some of the..the specialists that you work with and..and how did they help women come to these determinations?   Dr Sabri: The specialists are.. there are GYN specialists, gynecologists and interventional radiologists. We have advanced care practitioners who have a lot of experience in this..in this field, who help us counsel the patients. We discuss all these options, and present it to them, and then they would decide what works best for them based on our counseling. The fact that this procedure is popular and we perform a large number of it, we’ve had many, many patients who come to us and they’re giving hugs to everybody of our team because of the impact it had on their life and how much it improved their symptoms with minimal interruption. I remember a woman who was offered a hysterectomy because of a large uterus. She had around 20 fibroids and, um, she did not want to have a hysterectomy. And she came to us in tears at how much it’s affecting her life. She had her kids with her at the time and she was saying how she’s not been able to take care of them the way she wanted to and the interruption she’s had to her work. So, we performed the procedure for her and after a week she managed to get back to her work and go back to her daily activities. And when I saw her three months afterwards, her symptoms were completely gone and she was..she could not be happier with her decision to undergo the uterine fibroid embolization. And she was saying that “I would volunteer to talk to any woman who would like to hear about this because I can’t believe that some women don’t even hear about this procedure and don’t get offered this option, and I’m so glad that I, you know, saw you and saw that you offered this procedure and came to talk to you, and it was a life changing for me.” So, this is one of the examples of what we see for a lot of these women, the impact it can have on their lives.   Host: So this is a very common condition among women of a pretty wide age range. For women that are younger, maybe in their 30s or even early 40s, is there hope for fertility still after a procedure like this?   Dr Sabri: Yes. There’ve been studies done that showed that fertility is not significantly affected by this procedure. Initially, when the procedure started, this was an issue, and women seeking fertility, they were hesitant to undergo this procedure, but since the wide adoption of the procedure there’s no significant effect on fertility after the procedure, and there’ve been many, many successful stories. Patients of mine and many other colleagues have had successful pregnancies and healthy babies after the procedure, So, we, again, counsel the women about their options, and talk about the science and the evidence behind it. Women who seek fertility, there’s some other excellent options and minimally invasive surgeries that our gynecologists do that can fit them as well, and these are options that we present to them to hear about it, and then they can choose which of the two they prefer and which evidence they feel more comfortable with.   Host: So, you mentioned also, that as women get up to that menopause age, the fibroids tend to shrink in many of these women. So if you have a woman who comes in presenting with these symptoms, close to that menopause age, would you ever, at some point, counsel them maybe just wait?   Dr Sabri: That’s a very good question. This happens frequently. And we talk about the severity of symptoms, their lifestyle. We discuss the risks with them. We’ve had many women close to menopause come to us and they say their symptoms are so lifestyle limiting that could not wait two or three years or so to wait for the symptoms to eventually improve on their own. And again, it’s not like menopause shows up one day and then the symptoms are completely gone. It takes a while to get to it. It depends on the severity of  symptoms, the type of symptoms. The bulk symptoms that I mentioned, like the having to go to the bathroom a lot, and constipation, and things like that--they are the last to actually improve with menopause. The bleeding symptoms tend to improve sooner because, you know, the patient does not have a period anymore. So, we counsel them and we discuss with them. We’ve seen it both ways. Some will just say, “Let’s wait it out and not get a procedure done.” For some others, since it’s a minimally invasive procedure with minimal interruption, that way we would go ahead with the procedure and they’re happy that they’ve had it done. On an average, it’s around a week to 10 days, and they’re back to their normal activity. Generally speaking, the most symptoms that they feel after the procedure is pain and it’s moderate to severe pain. And, there’s a regimen of pain medications that we provide to the patients to help them through this process. Again, everything is done through a pinhole in the upper thigh or a pinhole in the wrist, so there’s no incision to deal with. There’s no..the risk of infection is much lower and the risk of complications is much lower. The recovery time for uterine fibroid embolization is somewhere between five days and up to three weeks. The majority of patients, seven to 10 days they go back to their normal activities. And this can be compared to around two to three weeks for hysterectomy. For some of the minimally invasive surgical options, the recovery can be shorter; it can be closer to the uterine fibroid embolization. But, not all patients are candidates for such a procedure.   Host: Are there any work restrictions like lifting or anything that women would need to be aware of?   Dr Sabri: So, for the first week we tell them to take it easy, don’t lift anything more than five to 10 pounds the first week and just to not to do a lot of activities around the house or at work, so we just tell..ask them to take it easy. Most women, because of the, you know, some degree of pain, they also feel like as if they’re coming down with the flu. They don’t feel like doing much. We just say because it’s just a pinhole through the groin or through the wrist, it looks like they should be more active, but what’s going inside the body with the fibroids can have an effect on them. So, usually these are the restrictions. Definitely, they can walk around the house and do activities and do some trips outside the house, but as long as they don’t exhaust themselves. Then, after a week time, it’s OK to get back to work and resume your normal activities gradually. Again, for a hysterectomy this can be two to three weeks. There’s a high risk of infection, such as wound infection, longer hospital stay compared to uterine fibroid embolization, so definitely the recovery time and going back to work is shorter with uterine fibroid embolization.   Host: Why should a woman choose MedStar Washington Hospital Center?   Dr Sabri: At MedStar Washington Hospital Center we have a lot of experience with treating women with fibroid. We have a dedicated fibroid center, where you’re gonna meet several specialists to talk about your options. We offer all the options for..for fibroids. Considering uterine fibroid embolization, we have a lot of experienced interventional radiologists who have done hundreds of these procedures with excellent outcomes. I think if you have these symptoms and you were not offered uterine fibroid embolization by your gynecologist, you owe it to yourself to explore the options and we’re here to help you.   Host: Thank you for joining us today.   Dr Sabri: 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.

Pituitary tumors are more common than many people realize, with up to 17 percent of people at risk for developing one in their lifetimes. Dr. Susmeeta T. Sharma, Director of Pituitary Endocrinology, discusses how our team of experts recognizes and treats pituitary tumors. TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.   Host: Thank you for joining us today. We’re talking with Dr. Susmeeta T. Sharma, Director of Pituitary Endocrinology at MedStar Washington Hospital Center. Welcome, Dr. Sharma.   Dr. Sharma: Thank you for having me.   Host: Today we’re discussing pituitary tumors, which are much more common than many patients and physicians realize. Dr. Sharma, what types of pituitary tumors do you treat?   Dr. Sharma: So, one of the most common functional pituitary tumors would be a prolactin-secreting pituitary tumor. So, prolactin is a hormone that the normal pituitary gland makes that’s involved in the development of breast mammary glands and milk production in females, and so when a tumor is making prolactin, that excess prolactin in females can lead to irregular menstrual cycles, can lead to breast milk production, feeling of breast engorgement, breast pain. This irregular menstrual cycle and excess prolactin levels can also lead to difficulty or inability to have children, and that’s many times how it comes to attention to a physician. In men, it can cause decreased libido and some signs and symptoms of low testosterone, so low energy levels, decreased libido, erectile dysfunction, inability to have children, um, decreased hair growth, some of the symptoms that you see related to low testosterone levels. Given that we don’t have the menstrual cycle marker in men, many times the prolactin-secreting tumors in men tend to be larger in size, and so many of them can have headaches and vision changes related to just the size of the pituitary tumor, and so that’s how they may manifest to a physician.   Host: How do you determine if the patient’s symptoms are caused by a pituitary tumor or another condition?   Dr. Sharma: Right, so some of the symptoms a patient may present with, for example, low energy levels, decreased libido, can be related to various different hormonal disorders, or it may not be related to a hormonal disorder at all, and so the first time, if the patient is presenting with these symptoms, we need to assess the levels of these hormones to see if there is a hormonal disorder there. So, one would measure testosterone, prolactin levels in a woman, FSH, estrogen levels, get a detailed history and exam, and all of that can help detect whether or not there could be a hormonal dysfunction, which can then lead us to assess for a pituitary tumor. So, they may come to us already with a diagnosis of a pituitary tumor where we are trying to see if it’s making some hormone, or they may come to us with these symptoms where we are trying to see if there could be hormonal dysfunction, which can then lead us to a diagnosis of a pituitary tumor.   Host: After a patient is diagnosed with a pituitary tumor, what is their next step for getting treatment?   Dr. Sharma: So, yeah, once we have...there might be 2 or 3 steps involved in the diagnosis of a hormonal dysfunction. We may do some initial screening tests, followed by some confirmatory testing, but, yes, once the diagnosis has been made that a person has a functional or a nonfunctional pituitary tumor, then we would go on to treatment. The treatment can vary from just simple observation and monitoring, which would be the case in a nonfunctional small tumor that’s not causing any mass effect, to medical treatment, which would be a case in a prolactin-secreting tumor, which we can treat effectively with medication group called dopamine agonist therapy, which are now well-tolerated medications, uh, to surgeries. So, most functional tumors, other than the prolactin-secreting tumor, will require surgery, and any nonfunctioning tumor that’s causing mass effect would require surgery. Many of the pituitary tumors after surgery may require further adjunct therapy, uh, so if there is residual hormonal excess or residual tumor, um, they may require radiation therapy for that or adjunct medications for further hormonal control.      Host: How common are prolactin-secreting pituitary tumors?   Dr. Sharma: So, pituitary tumors in general, I think, they are underrecognized. If you look at the studies done for diagnosing pituitary tumors, the data that comes available comes from either radiological studies, so MRIs that are done in the general population, or autopsy studies, so done after the death of a person, and so, uh, the data coming from there shows that among the population, about anywhere from 10 to 20% of the individuals, depending on the study you look at, can have a pituitary tumor, and in some it may be causing hormonal excess or hormonal dysfunction; in others it may be not. Among those pituitary tumors, about 40 to 50% are actually gonna be a prolactin-secreting pituitary tumor, so I always say, when I’m talking to a group of people, that if we are about 100 people sitting in that room, about 10 to 15 of us could have a pituitary tumor, and out of that about 5 to 6 could have a prolactin-secreting tumor, and that’s how common it can be.   Host: What surgical options are available for individuals with prolactin-secreting pituitary gland tumors?   Dr. Sharma: So, for a prolactin-secreting tumor I would say about 80 to 90% of the time we are able to manage that medically. The time that we need a surgery for a prolactin-secreting tumor would be A) if it has gone undiagnosed for a long period of time and it has become really large, and then it bleeds into itself, so as the tumor grows the blood supply sometimes is not able to keep up with itself and it may bleed suddenly into the tumor, which is what we call pituitary apoplexy and, if that happens, that’s a surgical emergency. The patient can develop sudden-onset hormonal deficiency, sudden-onset vision changes, sudden severe headaches, and so that is definitely a time when they would need pituitary surgery. Other times a prolactin-secreting tumor may need surgery is if the patient is not able to tolerate the medications, so most of the time these medications are well tolerated, but occasionally the patient may develop gastrointestinal side effects, dizziness, or...and is just not able to tolerate the medication. In those cases, one may need surgery. Uh, another scenario would be although the majority of these tumors do respond to this group of medication called dopamine agonists, there are a small percentage which are resistant to the medication, so resistant prolactinomas. If a tumor is growing or the prolactin levels are increasing while being on an optimal dose of the medication, then that would be another case where we would need surgical intervention.   Host: Are there any life-threatening complications associated with prolactin-secreting tumors?   Dr. Sharma: Uh, so, it…from the prolactin itself, the high prolactin levels may not be life threatening, but from the pituitary tumor, as the tumor grows, you can have hormonal deficiencies, so the hormonal deficiency that can be life threatening is a cortisol deficiency, so again, in the scenario where it’s very large, and over time the patient develops, from mass effect of the tumor, loss of pituitary cell function that makes ACTH, which then leads to cortisol production, they can have cortisol deficiency, and cortisol is a life-sustaining hormone. The same way, you can have TSH or thyroid-stimulating hormone deficiency, which then leads to thyroid hormone deficiency. And, again, those are both two life-sustaining hormones, and if that goes undetected, one can have serious consequences.   Host: Is the physiological response to starting therapy gradual, or is it a big shift for patients?   Dr. Sharma: These tumors are very...if they’re going to respond, they’re very responsive to the medications where the prolactin levels start to decreasing within days, and so even in patients where you actually have the tumor compressing on the eye nerve and causing vision changes, you can...and the medication will start making a difference right away, and as long as they are compliant with the medication and we are titrating up the dose to get the prolactin levels normal, uh, the tumor size will also respond in most cases.   Host: What about some of the more rare tumor types you treat?   Dr. Sharma: Other functional tumors that are more rare, it can be a growth hormone-secreting tumor, so that’s called acromegaly or gigantism, so if the growth hormone-secreting tumor occurs in a child who is still growing and their growth plates have not fused, uh, they can become really tall and that’s why the disorder is then called gigantism. On the other hand, if the growth hormone excess happens as an adult, you have a condition called acromegaly, and so these patients have a change in facial features. The facial features become really coarse. They will have change in...increase in ring size, increase in shoe size, they develop these enlarged hands and feet. They can also develop high blood pressure and have an effect on their heart, so the heart gets enlarged, uh, which can then make them prone to developing arrhythmias or irregular heart rhythms. Um, they can have increased chances of polyps in the colon and the intestine, and so although not clearly established, they can be at an increased risk of colon cancer. They can develop sleep apnea, they can develop carpal tunnel syndrome and then they can also develop pre-diabetes and diabetes, so many comorbidities can be associated with a growth hormone-secreting disorder. So, when that presents, the treatment for that functional pituitary tumor is surgery. One does want to make sure that they don’t have other hormonal deficiencies or hormonal excess. Sometimes, these tumors can be co-secretors, so they can secrete more than one pituitary hormone, but after that initial hormonal evaluation the treatment is gonna be surgery. Many times, because these growth hormone-secreting tumors are large, because the presentation can be subtle and the transformation in the clinical features can be gradual, they do often get detected in a larger size, so as a macroadenoma, and so many times they require adjunct treatment after surgery in the form of medical therapies or radiation therapy. So, we actually had a patient, a young male, who presented to his dental surgeon for jaw surgery, and so basically his main complaint was that he’s lost his smile. And so, he ultimately ended up having a growth hormone-secreting disorder, and exposure to these high growth hormone levels had led to protrusion of his jaw such that when he smiled, only his lower teeth were visible and his upper teeth were no longer visible, so that’s why he said he lost his smile. But, an astute dental surgeon at MedStar Washington Hospital Center, while looking at his dental x-rays, saw that the bone where the pituitary gland sits, that sella, that looked enlarged, and so he referred the patient to us for evaluation, and for sure he had a pituitary tumor about a centimeter and a half that was making growth hormone. He’s now status post-surgery for the pituitary tumor and his growth hormone levels are much lower now, but he’s requiring adjunct treatment with a medication that is a once a month injection.   Host: In adults, are the physical changes gradual or sudden?   Dr. Sharma: Yeah, no, these...most of these changes in an adult will be very subtle and so, many times they get overlooked, especially if you are seeing the person every day, the changes in facial features can be very subtle. Many times, the change in ring size or shoe size, um, a patient or a person may attribute it to gaining weight or fluid retention, things like that, or just aging process and it may not get detected. I have had people whose shoe size has changed from an 8 to an 11 before it gets diagnosed so no, it doesn’t happen overnight. It’s a gradual process. Many times, um, we ask people to bring out their driver’s license or other prior photographs to actually compare how they have changed. Many times, it takes for a visit to a relative who has not seen you for a year, and they comment that you look different and sometimes that can lead to an evaluation, but many times it can be because they have developed high blood pressure or a heart issue or a diabetes that then leads to being seen by a physician and that leads to further evaluation, so the presentation can be at various different points.   Host: So, for these patients, is medication management a more likely treatment option than surgery?   Dr. Sharma: For most functional tumors, it will be surgery as first-line treatment. The only medical treatable pituitary tumor is prolactinoma, but many times medical therapy is needed as an adjunct, even after surgery has been done, and so you need to look at various different treatment modalities, with the goal being to optimize hormone levels and make sure that the tumor is either completely gone or, um, the residual tumor is...remains stable over time, and so it would be a mix of different treatment modalities.   Host: Why is MedStar Washington Hospital Center the place to go for pituitary tumor care?   Dr. Sharma: So, I think whenever we think of a pituitary tumors, it’s important to remember that not one physician can treat all pituitary tumors. The pituitary tumors involve hormonal dysfunction, which needs an endocrinologist, who is...has expertise in the evaluation of pituitary disorders. You need an experienced neurosurgeon as most functional tumors and many nonfunctional tumors require surgical treatment. You need a neuro-ophthalmologist who is experienced in recognizing the visual field defects that can go with pituitary tumor disorders. You need improved MRI techniques and a good neuroradiologist to detect these pituitary tumors. And you need state of the art radiation therapy, stereotactic radiosurgery modalities, as another treatment option to be available. And then you need a team that is keeping in mind and discussing the treatment plan with each other and coming up with a treatment plan that’s best optimized for the patient instead of just giving a one-sided recommendation. So, the reason I think a pituitary center is really important, rather than just going to a physician, is because we are looking at the patient as a whole and coming up with a multidisciplinary team approach for these pituitary tumors.   Host: Is there anything patients can do to prevent pituitary tumors?   Dr. Sharma: So, yeah, we don’t completely...there are certain hereditary disorders where you...that are associated with pituitary tumors, and if...those are very rare, um, most commonly multiple endocrine neoplasia, and if that runs in the family, then that could be something that you need screening for, but otherwise it’s not completely understood what causes pituitary tumors. That’s another area of research. We are developing more and more mutations, but those are not specific for a pituitary tumor and not everybody with that mutation is going to have pituitary tumors, so we are still at a learning stage for that and nothing in particular that one can do to decrease their risk of pituitary tumors because primarily we don’t completely understand why they develop. One of the most common questions that patients ask me is that they had a very stressful period where they were leading a very stressful life, and that by increasing their cortisol levels, did that cause Cushing’s or any other form of pituitary tumors, and no, we do not think that, at least as of now we don’t have any current evidence to suggest that. Uh, so the main thing that one can do is to be in tune with your own body, to recognize any new symptoms that one may be developing and make sure you’re following up with your physician as many times they may detect if there is any evidence of any pituitary disorder and then, if needed, refer to an endocrinologist or a pituitary specialist.   Host: Are certain patient populations more at risk than others?   Dr. Sharma: Oh, so yes, uh, age-wise there is. But also, there are certain pituitary tumors which tend to occur in a younger age group or in more in females versus males. For example, Cushing’s disease, which is a tumor, where the tumor makes ACTH, which then causes cortisol excess - that tends to be more common in young females compared to males, so there are certain gender predilections in some of the pituitary tumors, but not always.   Host: Thanks for joining us today Dr. Sharma.   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.