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Host: Welcome to Executive Insights, the podcast for UK directors and C-suite executives, where we dive deep into the latest trends, challenges, and opportunities shaping the business landscape. I'm your host, Adrian Lawrence, and in today's episode, we'll explore topics that are crucial to leaders at the helm of organizations across industries in the UK. Host: Let's kick things off with one of the most pressing topics on every boardroom agenda: the rise of Artificial Intelligence. While AI promises greater efficiency, cost savings, and innovation, it also forces a rethink of traditional leadership roles. Guest Speaker - AI Expert: We've reached a point where AI is not just a tool but a strategic partner. For UK directors and C-suite executives, this means balancing technological adoption with human capital. It's about using AI for data-driven decision-making while ensuring that it doesn't undermine the human element of leadership. Host: Exactly! AI is great for automation, but leaders must focus on fostering creativity and emotional intelligence. How do you see UK businesses adjusting to this balance? Guest Speaker: Many are using AI to optimize operations—logistics, supply chains, customer service—but the best-performing organizations also emphasize reskilling their workforce and building a culture of continuous learning. Host: A great point. Leaders can't overlook the human aspect. As AI grows in influence, directors and executives will need to sharpen their skills in empathy and emotional intelligence. Host: Next, let's talk about the economic landscape. Post-Brexit, UK businesses are navigating uncertain waters. Between changes in trade regulations, fluctuating exchange rates, and shifting supply chains, many C-suite leaders are rethinking their business models. Guest Speaker - Economist: Absolutely. The UK is facing a challenging economic environment, with inflationary pressures and supply chain disruptions. Directors and C-suite executives must focus on building resilience by diversifying suppliers, re-evaluating international markets, and even exploring new trade agreements. Host: How do you see UK companies adapting to these challenges? Guest Speaker: I see a focus on regional trade partnerships, particularly with non-EU countries, and an increasing interest in nearshoring. Directors are also exploring innovative financing models to mitigate risk and ensure liquidity in this volatile environment. Host: That's a key takeaway—resilience and adaptability. Leaders who proactively seek new opportunities while managing risk will be better positioned to weather the storm. Host: Another crucial topic on every director's mind is sustainability and ESG compliance. Investors, regulators, and customers are demanding more from businesses in terms of environmental responsibility and ethical governance. Guest Speaker - ESG Consultant: That's right. ESG is no longer just a compliance checkbox—it's a strategic priority. Directors and executives must embed sustainability into the core of their operations. This not only enhances brand reputation but also drives long-term financial performance. Host: What specific actions should leaders take to improve their ESG standing? Guest Speaker: Start with a materiality assessment—what issues are most relevant to your stakeholders? Once identified, set measurable goals, whether that's reducing carbon emissions, enhancing diversity in leadership, or improving supply chain transparency. And most importantly, communicate your progress transparently. Guest Speaker: Organizations that invest in mental health programs, promote work-life balance, and create opportunities for career development will stand out in a competitive talent market. To keep up to date with news and events from FD Capital and Exec Capital why not read our popular news blogs?

Join Anne Ganguzza and guest co-host, Lau Lapides, as we share the personal rituals and support systems that keep us at the top of our game. From the mental clarity of Anne's Pilates routine to Lau's cherished moments with her furry friends, the BOSSES unravel how these treasured practices not only lift spirits, but also propel BOSSES through the most demanding business battles. The BOSSES guide you through the creation of an optimal workspace designed to awaken your most productive self. They also tackle the often-overlooked aspect of sound, from the tranquility of headphones to the creative surge provided by the right playlist. Plus, discover tried-and-true methods for diffusing work stress, to improve your business performance #likeaboss  00:02 - Anne Ganguzza (Host) You know your voice has the power to move, to persuade, to inspire. Imagine taking that power to its fullest potential. With guidance and expert production, I can help elevate your voice to new heights, making every voice script resonate with your audience. Let's empower your voice together, one session at a time. Find out more at anneganguzza.com.  00:29 - Intro (Announcement) It's time to take your business to the next level, the boss level. These are the premier business owner strategies and successes being utilized by the industry's top talent today. Rock your business like a boss a VO boss. Now let's welcome your host, Anne Ganguzza.  00:48 - Anne Ganguzza (Host) Hey, hey everyone. Welcome to the VO Boss Podcast. I'm your host, Anne Ganguzza, and I am here in the Boss Superpower Series with my amazing special guest co-host, Lau Lapides. Oh hey, Annie, hi Lau.  01:01 - Lau Lapides (Host) So good to be here.  01:03 - Anne ganguzza (Host) So good to be here too. I am all set to record another amazing episode with you, and I've got my trusty cup of coffee right here, you got your cup of coffee and I got my trusty big dunks.  01:18 - Lau Lapides (Host) I think that's 32 ounces of water from dunks.  01:21 - Anne ganguzza (Host) Wow, look at that. Do you get your water from dunks?  01:25 - Lau Lapides (Host) Not always, but if I'm going to go and get coffee anyway or something there anyway, I always ask for a large water. Even if they charge you a little, I ask for a large water, my double-fisted coffee.  01:36 - Anne ganguzza (Host) And these are actually my Ultima replenishers, which are electrolytes, which I love so I make sure that I'm drinking. I'm supposed to drink close to 100 ounces a day, and these help me to do so and to make sure that I'm getting all the nutrients that I need so that I can run my business like a boss.  01:54 - Lau Lapides (Host) I love it, I love it.  01:55 - Anne ganguzza (Host) So those are just a couple of my I guess, tools that support me while I am working and keep me energized and going and running my business like a boss. Let's talk about, maybe our tools or our support mechanisms that help us to keep running our businesses like bosses today.  02:15 - Lau Lapides (Host) Oh, that's a great topic. I love that. Just thinking about that makes me all cozy and fluffy inside, because when I think about the rituals, the routines, what I consider to be necessities of the daily run, what keeps me engaged and energized, going from morning till night, what is it that does that? For each individual person, there's so many different support options.  02:43 - Anne ganguzza (Host) We just showed you one. Yeah, and I'll tell you what right now. It was so funny because I happen to be watching Saturday Night Live last night and that tells bosses that we're here on a Sunday. I'm just saying we're here on a Sunday recording some boss episodes, but I happen to be watching Saturday Night Live and there's a whole comedy skit on Pilates, because it makes me think of. I've been getting into Pilates this year and it is something that I do early in the morning before I start my day. Usually I have a 7 o'clock class that goes till 8, and I get myself in the studio by 8.30 and really start running either with students or recording stuff in my studio, doing demo production by 9 at the very latest on a day-to-day basis. So Pilates, or getting my daily exercise in, has now become one of my go-to things. That is something I need to do. I need to feel like I've been able to exercise and get my heart rate up and be invigorated. Mm-hmm.  03:37 - Lau Lapides (Host) I love that, I love that. And if you miss it, if you miss that routine or ritual, how different do you feel, how different is the start of your day? So it's like patterns, you know. We're also talking about the discipline of creating a pattern in your social comfort that you need to really perform. There's all sorts of different things I pull out depending on the season and how I feel, but one of the things you and I discuss is the importance of our fur children. Oh gosh yes.  04:07 Because we're fur mamas and I've got my two Frenchie bulldogs, you've got your beautiful cats and we both love animals so, so much.  04:16 - Anne ganguzza (Host) Oh, my goodness, yes, and that love, that passion, helps to fuel the business as well, right when I need a break, when I'm having a lunch break or something, I make sure that I go and have playtime with the cats or I'm like I need a hug from one of my kitties, and so I'll go seek them out and get a hug and it's funny because animals, I love animals.  04:37 The other thing is that the horse show season has started here by me and for those of you that have not seen my photos on social media, I love, love, love horses and back in the day, Law and I, when we were talking about what we used to do when we were in our younger years, I used to ride horses and show horses. And so for me to live literally a mile away from a showgrounds where they have amazing, top-rated shows every weekend during the season Just makes me so happy.  05:08 - Lau Lapides (Host) It's such a big deal and it really infuses your spirit in a different way that really, I would say even redirects any kind of negative energy that I'm feeling, which we all have for different reasons. You know what's going on in the world, or what's going on in your family, or what's going on in your home, or whatever. It has the power to redirect you onto something very specific, very detailed, that is positive, that is something uplifting for you and something you can take that energy and put it right into your work. And I know you feel the way I feel about the animals. After a while I literally forget they're animals and I treat them as people and I feel like the energy and spirit of people are in the room. It really feels that way.  05:55 - Anne ganguzza (Host) I just live in the house with my cats. They run it pretty much. They let me live there and anybody that has been to my house knows there is a cat condo in just about every room. I think we have five. I think we have five cat condos.  06:10 - Lau Lapides (Host) Those condos are HOAs, aren't they? They're gated communities.  06:14 - Anne ganguzza (Host) They really are, and I'll tell you what the good thing is is that our cats actually use them, so that's a good thing If they never looked at them.  06:19 I would feel really bad and they also have their boxes of toys which they dig out and get new toys. And you know it's funny because Law I don't know if this is the way with your dogs but like, literally I've collected cat toys for the past. I mean I've owned cats ever since I was little and since I moved to, I would say, new Jersey, like in my 20s, I mean I've got like 40 years worth of cat toys that they just keep getting reused by the cats that I acquire.  06:44 - Lau Lapides (Host) It's hard to get rid of them, isn't it? Oh?  06:45 - Anne ganguzza (Host) it is. It's like a favorite stuffed animal. I mean, how can you when the cat plays with it? And of course they have boxes and boxes of toys, but really it's the paper bags that they like.  06:55 - Lau Lapides (Host) And we have those plastic bags. You know those really beautifully designed. So we have one on every floor brimming with stuff and I'm literally praying at times that the dogs rip them apart so I can start throwing them away. Oh my God yeah. Because I won't throw them away unless they need to be thrown away for some reason. Like I'm hoarding dog toys, so I get you right there. I get you right there, and it's like the joy of watching them play with one of those toys while you're working is so fun.  07:23 - Anne ganguzza (Host) Well, you know, as much as I say that we're working on a Sunday, I mean, and we work hard both of us, I mean there's something to be said for just taking that time to kind of reset and refresh and re-engage and have things that we enjoy doing and that we need in order to continue moving forward in our businesses, and that is watching our animals play, watching our fur babies play, or going to a horse show, or something that really takes us out of the work day so that it can really refresh our brains, which I need. I need to have that brain power to run my business as efficiently and as effectively as possible.  08:02 - Lau Lapides (Host) There's a softening there too. There's a softening of a hardness which happens throughout the day, not necessarily becoming jaded or cynical, but becoming expectant of difficult things or expectant of challenges on a daily basis. It softens those blows I always say it keeps me more human. It keeps me more human as they're human. It keeps me more human in the keeps me more human as they're human. It keeps me more human in the situations that I'm dealing with. How about the room itself that you're in the studio, the office, the space you're in, having a support within that space that really allows you to flourish and grow? I know I love having sayings that I believe in so much so when I'm in a meeting I can stare at them and remember what they mean. Remember what they mean. Here's one of my favorite ones that's hanging on my wall in my office and I'm not always in my office, but when I am I remember it says create the things you wish existed. Oh, I like that. That's wonderful.  09:01 And that gives me a little frisson every time I see it.  09:03 - Anne ganguzza (Host) That is wonderful. Well, I think that I might have shown this to you before, but when I open the door of the studio and I don't know if you can see it, but I do have pictures of my fur babies, and over on the other side I have a picture of Jerry and I. And so that is something I can look at, and I plan on getting another one, actually, and hanging it, and so I think that being able to look at those things that just give me joy and some creative inspiration is paramount in the studio and of course I think for me I have to have windows with sunlight.  09:39 I am a big, big sunlight person. For me, and especially when it's the winter months and I get cold and you work and you know we're not moving a lot when we sit, sometimes when we're in the studio, or if I've got the headphones on and I'm doing some editing. I like to be able to get out into the sun and just soak up that vitamin D for a few minutes, when I get a break and that always, always refreshes me.  10:05 - Lau Lapides (Host) Always. I have a porch, annie, that's a screened-in porch. I also have a patio, which I love during the summer months, but the porch during the winter months, when we have some of the harsher, colder weather, has the sun pouring in so I can go out right in the middle of a winter and it's 30 degrees warmer on the porch where I can get that like you get that vitamin D, get that solar energy going to take a nap or refresh me or whatever the case may be. How about this? Sounds really weird, but the CEO of Starbucks was one of the first ones to study this over years and years and that was the shape of the desk. The shape of the table and where you sit in the table affects you socially and it affects the quality of connections you make with others.  10:56 - Anne ganguzza (Host) The shape of the table. So in regards to, I have a standing desk, which I love because if I don't feel like sitting, I can stand at it, but for me, placement-wise, I like to be right in the middle. I also like to also be in a cozy corner with a high back in terms of. If I ever go out to a restaurant, I always feel like I have to sit in a certain place. But tell me more about the shape of the table.  11:20 - Lau Lapides (Host) Oh it's really interesting.  11:22 - Anne ganguzza (Host) In terms of like, if the table is round versus rectangular versus L-shaped versus….  11:28 - Lau Lapides (Host) Yeah, I don't know these days, I don't know if they've kept to this original thinking, but they found through their studies, through Starbucks, that the round table, the circular table, is more connecting in terms of the community that you're sitting in oh that makes sense Than a square table that has edges Right of the community that you're sitting in oh, that makes sense Than a square table that has edges right. I don't always find that, though, because I sit at a lot of square and rectangular tables that I feel really good at.  11:52 - Anne ganguzza (Host) So I don't know. You know that's interesting, but I think, if maybe you're talking about community, yeah, community. It's why it's always nicer to sit at a round table, because it's easier to talk, easier to communicate. Right At a round table, I think, well, a square table because you can have people on equidistant sides, but rectangular, you might have somebody all the way over you can't see people on your side, right, that makes total sense.  12:15 Or they're far away, Right, but in terms of placement on my desk, right, I like to be right in the middle and for me as much as sunlight, right. I was talking about light. I love a lot of light and actually I love a lot of white light in my office area, Like for me, fluorescent lights make me happy and I don't know if that's just me.  12:35 There's a lot of people that don't like fluorescent lights. I like a lot when I'm living and not necessarily working. I like more of a softer yellow light, but for me, for working, I love the white lights and, as a matter of fact, I have LED lights that are white lights that I can actually change the percentage of the lumens, but I like to have very white, bright light in my work area.  12:57 - Lau Lapides (Host) That makes me happy, fascinating, and I like to have, if I can. Of course, for us in New England, weather permitting, I like to have an open door or an open window at all times. Oh, interesting, if I can. I can't always do it, but even in the winter, if it's not horrible out and I have the fireplace on, I have the heat on, I can still have the porch door open, or I can even have a window open to fresh air. There's something about air and wind that the dynamics of that re-energizes me in a certain way.  13:31 - Anne ganguzza (Host) Luckily in California I can do that quite a bit.  13:34 - Lau Lapides (Host) And I like to keep windows open for the cats.  13:36 - Anne ganguzza (Host) It's interesting because when I moved to California, there's a lot of Californians that will just leave their doors open if they're in the house.  13:43 - Lau Lapides (Host) Yeah, I grew up that way too. My neighborhood was that way too, but I don't love bugs and so if a bug happens to fly in.  13:50 - Anne ganguzza (Host) Living in the East Coast, in Mosquito, Aladdin, New Jersey, or humid places where there's a lot of bugs or moths at night. I just no, yeah, of course Cannot have an entryway for bugs to get into the house. Okay.  14:03 - Lau Lapides (Host) I got a good one for you. I got a good one for you, and maybe this is bordering on my OCD, I don't know but I need it neat and organized to a certain degree, where I do the physical cleanup right before I work, and it might be a minute, it might be five minutes, it might be whatever that activity gets me going in the dynamic of doing things.  14:29 - Anne ganguzza (Host) Interesting, so I like to, before you start, have a clean desk. Is that correct? Or one that's not cluttered?  14:36 - Lau Lapides (Host) That's me, I'm not so sure it's about the cleanliness per se. I think it's telling my brain that you're physical, you're active and you're able to accomplish something, even if it's very small and detailed. So cleaning up my papers, neatening my pens and pencils, making sure my monitors are there, making sure my coffee is ready to me, sets a dynamic in the feng shui of my energy that is easier for me to tackle my goals than if everything is all over the place.  15:06 - Anne ganguzza (Host) I have to have a clean sheet of paper because I have my little to-do pad and I still write it down and I know I have lots of lists.  15:11 - Intro (Announcement) Do you have your stickies? I don't have stickies.  15:13 - Anne ganguzza (Host) I don't have stickies but I have like a long to-do pad and that's where I write everything that I need to do, and I do that on the night, like when I'm done with work. I write things to do for the next morning and sometimes, when I sit down, if I do have things that I need to do for the day, I'm writing that down too. But I like to have a fresh, clean sheet of paper.  15:30 - Lau Lapides (Host) That's a generational thing. I do that as well. I think it's our generation. And it's tactile, it's physical. There's a physical thing there you're interacting with, you're writing, you're checking things off. I can barely write anymore.  15:43 - Anne ganguzza (Host) I mean, but you're still doing it, You're not doing it on your computer, right, I'm still doing it. Yeah, I'm still doing it. You're right, I can barely write legibly anymore and I don't even know if they're teaching like— Are they even teaching cursive writing anymore today? They're coming back to it, Annie. They're coming back to it.  16:02 - Lau Lapides (Host) There's something about handwriting.  16:03 - Anne ganguzza (Host) After my mother passed away. There's something so special about seeing her handwriting that brings back so many good memories.  16:10 - Lau Lapides (Host) Oh, I got a tear because it's so—why do we keep the cards, the letters, the notes? Because it's that handwriting for us it really is. You know, I also want to say too and this may seem a little odd, like to go into this, especially when you have other priorities, but I feel like if I can make it through X amount of emails, first thing in my morning number one I'll catch all the time priorities, and then, from the agency perspective, it's like you better catch it, Okay. But beside that, there's a click in me, there's something generated that's very open and very fresh and excited when I can make it through X amount of those and then I can get to the new thing, the next thing, the layered thing, whatever that is. If I have a lot waiting, if I have a lot in the wings that hasn't been done, my brain has a hard time getting into gear fully of what is happening throughout my day.  17:05 - Anne ganguzza (Host) Very interesting. Right, it's interesting You're talking to the girl that has all these unread emails in her mailbox. Some people have to clean their mailbox, right.  17:13 - Lau Lapides (Host) I kind of I guess I have to clean my mailbox because I have to clear my brain in that way so that I can have the appointments or go through the new things or whatever has to happen, and I feel like, even if it's just three or four or 10 or 20, I feel like that's an accomplishment. That's an accomplishment, right? Yeah, absolutely. It may not be the biggest one in our day, but it is one. It is something to celebrate in the day, whatever that means for you, whatever kind of organization that means for you. What about, like do you listen to a TV or music in your day or have that outside entertainment source coming in as you're working?  17:55 - Anne ganguzza (Host) Very rarely do I listen to anything other than my own audio or somebody else's audio during the day, because I need to be focused on it. Every once in a while, though, there is certain music that I can play, and it can only be like ambient music. Right, that can't disrupt my thinking, if I need to focus Like a white noise.  18:16 Well, no, it can be like Sirius XM chill, because chill is very, there's not a ton of dynamics to it and it can just be chill music and so I can listen to that and sometimes I like that. It's therapeutic. But it's very rare that during the day that I listen to anything other than the headphones are on my ears pretty much the whole day, because I'm either working with students or I am recording in the studio or I'm editing audio or I'm editing a demo or whatever that is. I Pretty much have these on and I could put music on, I absolutely could, but I need to make sure that I'm focused on the audio that comes through my ears, which is not always music and not always for enjoyment, but for work-related purposes.  18:59 - Lau Lapides (Host) Gotcha. I have to say I've always loved music.  19:03 - Anne ganguzza (Host) I love music too.  19:03 - Lau Lapides (Host) Well, meaning that I've always had to have music around as I'm functioning throughout the day. And it's funny, my husband is opposite. He never has music on. He almost never has to listen to music. Well, he's a numbers guy, is he not?  19:17 - Anne ganguzza (Host) He's a numbers guy he might need to concentrate on. I'm just thinking that for me it's hard to concentrate with certain types of music. Maybe, maybe.  19:25 - Lau Lapides (Host) Yeah, it just gets in the way of his thought process and his patterning For me. I was a dancer for many years in my younger years and I always had some sort of sound. There was some sort of sound happening that would transport me in a certain way. So I yearn in the day for a transportation of moments where I can daydream or I can concoct a new idea or I can think about something else. Oh, that's lovely. That's an interesting vehicle for me to do it, and I know it is for many people too.  19:55 - Anne ganguzza (Host) Well, when I'm not at my desk, then yes, and I do love music, I mean and music is so important when I'm exercising, for sure.  20:05 I mean, that is so very important that I have music that can help motivate and inspire me while I'm exercising. And it's funny because if I'm doing something like out in my gym, in the garage, which might be like on the pre-core or on the bike, and I'm not following a class and I'm just moving and doing long-term movement, that is where I need to have music. And it's funny because I have lots of playlists that my husband and I, through the years I met my husband he was my spin instructor we've created all these playlists.  20:35 We have hundreds of playlists that are pretty much essentially our favorite music and it's a whole lot of fun. So for that, yes, I do need music to inspire and motivate myself. But then it's funny because when I go to Pilates classes there are some instructors who like music kind of in the background and some of them that find it to be very distracting and really don't want the music on because they want you to concentrate and focus on the muscles of your body and not worry about the music they're playing.  21:03 - Lau Lapides (Host) Do you ever find that you need to step away in the middle of the day and do something completely different? Yes, absolutely Absolutely the day and do something completely different. Yes, absolutely, absolutely. That's a support right there, whether it's exercise or clean, something like do the dishes or make a phone call to a friend that you have to make a contact with, or whatever. Absolutely. I find that's very refreshing. That's a support that I look forward to.  21:26 - Anne ganguzza (Host) I think it's since my transition of working out in the world to working from home and working in my own studio.  21:33 Getting out is one of those things. It's kind of like going out to lunch or running an errand, and I do love the fact that we work for ourselves, that we can schedule those things. In. A lot of times on my off days, when I'm not coaching, I might have a doctor's appointment, or I might have a regular appointment where I go shopping or I pick up stuff at the grocery market and that, to me, is just a nice getting out, breathing the air, going for a walk and getting the mail. That is something that can really help Huge.  22:03 - Lau Lapides (Host) They may sound like small, insignificant tasks, but I really feel like they can not only fulfill my sense of accomplishment, but also recalibrate my whole mind and my body, to relax, to pull out of a situation recalibrate and then come back in more refreshed, more rejuvenated and more balanced right.  22:24 - Anne ganguzza (Host) What can you do? Or what do you do if something at work is frustrating you right Outside of trying to resolve it immediately? What do you do for support?  22:34 - Lau Lapides (Host) Well, of course it depends on what it is. So if I feel like I need outside support of the problem solving, I have my little inner circle that I'll call or email and say hey, I got a situation, what are your thoughts on this? I'd like to get your thoughts and I usually get really quick response of those inner circle of people. It's exhausting because you're going from one session to another, one moment to another, one audition to another, or people are misbehaving, people are misbehaving Any number of things right that you can't really help or do People are misbehaving.  23:04 - Anne ganguzza (Host) I have my circle of friends. You are in that circle a lot and I will like I'll be like texting you.  23:11 - Lau Lapides (Host) I love it. In the middle of the night we'll be like, yeah, let's just talk it out on text, let's just make it happen so that you get to a new place, you get to a new place. I still tend to physically do something because I feel like, kinesthetically, my muscles need to shift out of stress or tension mode into accomplished mode. Even if it's like do the laundry or do the dishes or something simple like that, I do find that helps me a lot. It allows my brain to rest through an activity that I need to do anyway. That's useful anyway, but something that is not taxing.  23:47 - Anne ganguzza (Host) I will say I will. Sometimes. I'll either get off of social media because that might be the source right, or I will go to social media, but it won't be within voiceover. It'll be looking at something in social media that is, other interests of mine Like cooking or something Right, I watch a lot of horse jumping. I watch a lot of cats. Does that surprise you?  24:08 - Intro (Announcement) I watch a lot of cat videos, no, so all those things, it does not. A lot of humor, it does not.  24:19 - Anne ganguzza (Host) A lot of entertainment, music, so that sort of thing. So I will either unplug or plug into the social media. That brings me joy and entertainment versus work stress.  24:25 - Lau Lapides (Host) Exactly To me. They're not only ritualistic disciplines, but they're also support. They're not only ritualistic disciplines, but they're also support. They're comfort and support that we know how to self-medicate in a really positive way. Here's the thing. I don't want to dull out my senses, I don't want to dumb myself down, I don't want to water myself down, so I don't feel it. I just want to give myself a momentary break and then be able to come back to it with a fresh eye and a fresh ear and a fresh thought. I think there's a big difference between the two of like I have to run away from this, I don't want to think about this and I don't ever want to come up against this. Right, you have to be willing to come back.  25:00 - Anne ganguzza (Host) You know it's interesting. I'm trying to think like I've never really tried to run away from things because for me, the sooner I can resolve them, I think the better.  25:10 - Lau Lapides (Host) I feel and for me.  25:12 - Anne ganguzza (Host) I really am trying not to run away from things, and I don't know if that's a personality thing or if that's something I don't know. Bosses what do you think I mean? Being bosses of our own business? Sometimes we can't run away and we have to face issues and try our best to resolve them, and these emotional support mechanisms, or support mechanisms that Law and I have been talking about, may be something that can help us to ease our minds, ease our emotional psyche, so that we can come back better, stronger and resolve them, so that we can move forward in our businesses.  25:48 - Lau Lapides (Host) I love that and it's so interesting how we do this unconsciously until we really recognize. It takes time to recognize. What am I doing, what am I actively doing to either soothe myself, help myself, whatever, and what am I doing? That's not helping, that's counterproductive, right? And really being honest about that, like being aware, having a self-awareness about that yeah, absolutely Even just like writing it down or taping yourself or having someone report back if they're seeing you doing certain activities or doing certain things, I think it's really important to document that and figure out what's working for you as a business.  26:28 - Anne ganguzza (Host) Absolutely so. Yeah, I mean it's been a fun episode. I mean talking about our little emotional support mechanisms and bosses out there, as you said, it may seem like, oh, it seems like just well, this is what we do every day, but in reality, they do a lot to help us to move ourselves forward in our businesses. And so, bosses, what do you do, Right? What do you do to help get yourself through the day? What are your rituals? What things do you need? We'd love to hear from you.  26:55 - Lau Lapides (Host) Absolutely and really claim them, really own them and really be proud of them. You want to make sure that you're able to talk about them and be proud of them and not hide them away.  27:05 - Anne ganguzza (Host) Cool episode Law. Very cool, Very cool. I'm going to give a great big shout out to our sponsor, IPDTL. You too can connect and network like bosses. Find out more at IPDTLcom. Bosses, have an amazing week and let's hear from you guys. We'll see you next week. Bye.  27:23 - Intro (Announcement) See you next time. Bye, join us next week for another edition of VO Boss with your host, anne Ganguza, and take your business to the next level. Sign up for our mailing list at vobosscom and receive exclusive content, industry revolutionizing tips and strategies and new ways to rock your business like a boss. Redistribution, with permission. Coast-to-coast connectivity via IPDTL. Via IPDTL.  27:52 - Anne ganguzza (Host) Hey, hey everyone, welcome to the VO Boss Podcast and the boss. Did I say podcast? I didn't say podcast. Take two, take two.   

www.atravelpath.com https://delicioats.com/  https://delicioats.com?sca_ref=2606128.heLxZNHtFuUse Code “PATH” Welcome back Pathfinders! Today we have a great episode in store with Joe and Kalyn from Open Roading. Going Full Time Open Roading originally only planned on traveling for a year, but they soon fell in love with the lifestyle. Learn about how they were able to continue traveling and some of the obstacles they had to overcome that almost sent them back home. Workamping From python catching to gate guarding to a beet harvest, we discuss a ton of information about getting into workamping. We discuss the requirements to get into this industry as well as websites you can use to find jobs. And of course, I couldn't change the subject without asking them their favorite and least favorite workamping jobs! Budgeting If you are familiar with their Instagram or YouTube, you'll know that Open Roading are very detailed and open about their budget. We break down what a typical month looks like for them, and talk about some of the things they are spending most of their money on, like health insurance, fuel, and internet. Open Roading also shares their favorite budgeting app to make budgeting easier for them. The biggest takeaway I found here was that they meet with each other once a week to go over their budget. Most people will sit down on a monthly basis to go over this. You could almost hear the glass shatter as I came to the realization that if you only sit down once a month and are setting a monthly budget, it really doesn't do you any good… Routines We talk about the importance of having routines while traveling. Although it can be difficult because they are never in the same place for long, Open Roading provides us with some insight on some things you can do stay consistent. For example, you can always wake up early, schedule a meeting, and exercise or take the dog for a walk (weather permitting!) YouTube Open Roading has made three attempts with YouTube after getting burned out and pumping the brakes a few times. In their latest effort, they have been met with some pretty big success. We discuss what they have done differently this time around as well as some of the reasons they believe their channel didn't take off at first.   And much more!   Chapters ·        00:00 Introduction ·        04:30 What is Work Camping? ·        08:00 Gate Guarding ·        09:15 Work Camping Requirements ·        13:00 Favorite/Least Favorite Work Camping Jobs ·        16:00 Balancing Work Camping with Exploring ·        17:15 Biggest Challenges to Start Traveling ·        18:45 How Did You Know When You Were Ready to Hit the Road? ·        20:30 What Adjustments Did You Make to Continue Traveling? ·        23:30 Delicioats “PATH” ·        24:30 What Are Your Biggest Travel Frustrations? ·        26:15 What Are Your Most Helpful Travel Routines? ·        27:30 What Do You Love Most About Your Travel Lifestyle? ·        29:45 How Long Do You Plan on Continuing Full Time Travel For? ·        30:45 Budgeting ·        35:00 What Are Your Favorite Money Saving Travel Hacks? ·        39:30 What Is It Like Traveling with a Bunny & Dog? ·        42:00 What Has Been Your Coolest Travel Experience? ·        45:15 What Can You & Can't You Live Without? ·        48:15 What Tools Should Every RV Owner Have? ·        49:15 How Have You Been Successful Your 3rd Time Around with YouTube? ·        53:00 How to Start Planning ·        54:45 Influential YouTube Channels   Open Roading on Social ·        YouTube: https://www.youtube.com/@OpenRoading ·        Instagram: https://www.instagram.com/openroading   Videos From Open Roading ·        5 Years of RV Life Cost: https://www.youtube.com/watch?v=qVHSnw-1jI4 ·        Solar Setup: https://www.youtube.com/watch?v=5De9SPEddfc ·        Clouds Rest Hike: https://www.youtube.com/watch?v=CX0dv05Z6yA&t=683s ·        Gypsum Cave: https://www.youtube.com/watch?v=4ajkUK1Iarg&t=135s ·        How Much We Make on YouTube: https://www.youtube.com/watch?v=i5h49_LH4Ag   Work Camping ·        Kamper News: https://www.workamper.com/ ·        Workamping Jobs with Wages: https://www.facebook.com/groups/workampingjobswithwages/ ·        Workampers: https://www.facebook.com/groups/weloveworkamping/ ·        The UNBEETABLE Experience: https://www.theunbeetableexperience.com/ ·        Mackinac Mill Creek Campground: https://www.campmackinaw.com/   Budgeting ·        You Need a Budget: https://kalynbrooke.com/refer/YNAB   Camping/Boondocking ·        Harvest Host: https://www.harvesthosts.com/ ·        Boondockers Welcome: https://www.boondockerswelcome.com/   Internet ·        Starlink Roam Plan: https://www.starlink.com/roam   Favorite Experiences ·        The Presidential Chain Trail: https://www.alltrails.com/trail/us/new-hampshire/presidential-traverse-trail ·        Channel Islands National Park: https://www.nps.gov/chis/index.htm   What Can't You Live Without? ·        Portable Waste Tank ·        Solar Panels   What Have You Learned You Don't Need? ·        Extra Clothes   YouTube Channels ·        Less Junk More Journey: https://www.youtube.com/@LessJunkMoreJourney ·        Kara and Nate: https://www.youtube.com/@KaraandNate ·        Flying the Nest: https://www.youtube.com/@flyingthenest   Books ·        Alyssa Padgett RVing Across America: https://amzn.to/43bcV7B ·        (Commissions may be earned through purchases on this page)   Music ·        Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/abbynoise/rocky-mountains   Disclaimer *All content from atravelpath.com, including but not limited to The Travel Path Podcast and social media platforms, is designed to share general information. We are not experts and the information is not designed to serve as legal, financial, or tax advice. Always do your own research and due diligence before making a decision.   Transcript Host: Joe and Kalyn, welcome to a travel path podcast.   Guest: Thanks so much for having us on. Yes, it's so exciting to be here with you.   Host: Yeah, we're looking forward to getting to know you guys. Um, so we know you guys on Instagram as Open Roading. You guys turned a year-long road trip into just about five years full-time in your fifth wheel. You post content on your YouTube channel, everything from RV how-tos to work camping, and very detailed budgeting videos, which I'll tell our audience right now to make sure they pay close attention to once that part comes. Um, but no pressure on you guys. Um, and I know you're very hard to miss driving down the road with your fifth wheel and your setup with your motorcycle attached to the front of your truck, so clearly, anything is possible. Um, but yeah, why don't we start by having you share a little about yourselves and letting your audience know what your current travel lifestyle looks like.   Guest: Sure. So, we both grew up in Upstate New York. That's where we met, and then we ended up transitioning down to Florida, just love the Sunshine State, and that's when we started thinking about a potential travel lifestyle. She says "we," she means her; I was the one that started the conversation, like, "Hey, wouldn't this be cool?" And Joseph was still working at the time, so he was in the news industry as a videographer. And um, eventually, I was, you know, working on my online business. I had a blog that I was writing on different articles and starting to earn some money with that, and it got to the point where it was a full-time income, and Joseph could come home and work on it with me. And that was kind of the catalyst for like, okay, like, can I convince you now that we can get an RV? We don't, you know, have jobs that are tied outside our house. We can work from anywhere with a good cell phone connection. And so in 2019, that's when we started off. Yeah, and it was a whirlwind for that first year. We were traveling like every five days, and because we didn't have much black tank capacity, basically, we always had to dump and fill, so it was like every five days, why not move somewhere else? And we were trying to do the YouTube content all at the same time, and we really got burnt out over that first year. And then we tried again with YouTube a little while later, got burnt out again. So, our travel style now is a lot different than it used to be. Like now, we are trying to settle into a travel style where we only move every about two weeks, maybe 10 days if there's a reason. But two weeks is kind of what we're trying to get into, where we can kind of settle into a place, still do our work, you know, do a 30, 40-hour-a-week job from the RV, and then continue on.   Host: Very cool. I'm not sure if you noticed there was a thumbs-down sign that got sent. I don't know if that was you or me, but that we were not giving you a thumbs down. I don't know where that came from, but that was weird.   Guest: We have somebody watching, so weird.   Host: Yeah, well, great. So, every two weeks or so, that's the path we want to take on this next trip. Is it... it would be a lot more relaxing going at that pace as opposed to getting up and going every... I mean, we were going every like two days when we were traveling. But our next approach will be closer to a week, maybe two weeks if we're lucky. Um, but you guys do a lot of work camping. What is that? Or maybe not so much anymore 'cause you guys are done with that now. We'll get into that later on, but what is work camping?   Guest: We didn't actually start out work camping. We actually... because we were self-funded by my online business, and then Covid hit and the economy tanked, and we realized that our funding was not working and not as much anymore. And so that's where we started to look at how can we stay on the road as much as possible and also earn money with it. So, work camping is basically you work for someone else, like a campground, a state park, or even agricultural work with the beet harvest. And they are providing a place for you to stay for free, sometimes more. Resorts offer a discounted site. They don't exactly provide free housing. And then some jobs, you'll also get an hourly wage on top of the free housing. So, it's a really neat way to be able to still travel around the country, but yet you have these seasonal jobs and commitments throughout the year.   Host: And how are you finding these jobs?   Guest: Oh, this is all you. Yeah, there's a few different websites that I really, really like. So, one is Camper News, which is with a K, camper with a K, and sign up for their newsletter because they send out once-a-week emails organized by state, what kind of jobs are out there. And there is anything from, "We need help in the camp store for a campground in northern Michigan," to "Python control in the Everglades." So, you get a wide variety of opportunities through that. So, that's probably my favorite. And then, I would recommend two work camping Facebook groups, which is Work Camping Jobs with Wages and Work Campers. Both of those, people that are like management and owners of campgrounds or even farms that are wanting ranch hands, they are posting in there, like, "Hey, we'd love a camper to come for the summer or the winter season to work with us." And I think most of those, you can correct me if I'm wrong, are like resorts, campgrounds, ranch hands, stuff like that. Gate guarding isn't so much in that. You'd have to look specifically. We've been doing some gate guarding for the past three months. You kind of have to look for the gate guarding Facebook groups for those. And then the beet harvest is kind of its own animal. They have... it's a... if you just search the unbeetable experience M, um, that's a one-month-long work camping gig in several different locations across the northern US for sugar beet harvest. But look specifically for either of those, and you'll find those as well.   Host: And are you able to negotiate at all, or is there so much demand for it that on the work side, that you kind of... you're stuck with what they're giving you?   Guest: We never negotiated. We did with one, and we didn't get the job. So either we're really bad at negotiating, or... But I do think there is room, specifically in maybe the gate guarding, but it depends on demand at the time. So, in the summertime for gate guarding, we've been told it pays more because nobody wants to be down in Texas in the middle of the summer. But in the wintertime, there's a lot of people down there who are looking for jobs, and so actually, the pay goes down. And you can easily have a job if you're not taking what they offer, but you can still be picky about the jobs that you take. Like, you don't work for a specific company and have to go to each rig. It's they'll call you and say, "Hey, we have this gate available for you. Would you like it?" And you can say yes or no based on your criteria. And if people aren't familiar with what gate guarding is... Basically, it depends on the job that you have, but it's usually for the energy industry, the electric companies, or oil patch drilling sites. And you're basically just like checking people in and out, making sure that only the right people are there to work and keep the people out that are not supposed to be there. And our recent gate guarding job that we just finished was actually just security for an electric company, just watching their equipment, so we didn't have to check anyone in and out for that one.   Host: Very cool to get started with work camping. Are there any general requirements or certifications you need just to get started, or does that all depend on the job category?   Guest: It really depends on the job category, but I think the number one thing is a self-contained RV, one that has its own water tanks and waste tanks. We saw many, many work camping jobs that were just like "no tents," a lot of times no vans, no truck campers, unless maybe you could prove that it was completely self-contained. So, I would say that's the big one. Other than that, you just kind of look at each individual job. Yeah, and for gate guarding specifically, you actually do need a Level II security course for Texas at least.nYeah, for Texas, you need to take that, you need to take a drug test and screening. There's a security application so there's a little bit more involved with that one.   Host: Okay, and then for the python control, you just can't be afraid of snakes, right?   Guest: Yeah, um, crazy.   Host: So, it sounds like... I was going to ask, does the work camping dictate where you travel, or the other way around? But it sounds like you're finding out where these jobs are and then you're heading in that direction.   Guest: Yeah, that's what we try to do, I guess. At least like, what area do we want to explore and be in and would be satisfied to be stationary for six months.   Host: Is that the typical time frame, six months?   Guest: It depends a lot on what the job is, like if it's a seasonal campground, they're going to want you for the entire season. So, like, your Florida campgrounds are going to want you for the entire winter and up in Michigan, they wanted you from April through September or October. So, we specifically wanted to go to Michigan because we wanted to spend the summer near Mackinac Island and then that was close to the Beet Harvest. So, we just kind of did our planning ahead. We're like, well, we know we can get a job at the Beet Harvest because we did that the year before. So, we went from there to North Dakota and then for our goal that you talked about earlier, like, we were like, well, to make the most money to save would be gate guarding so we knew we'd need to head to different locations. Like, the agricultural jobs like with the Beet Harvest, that all depends on the harvest, the length of time, like how good is the weather for you to be able to go harvest. So, it typically takes two to three weeks for the Beet Harvest. There's more volunteer positions with state parks and national park services that usually require like a one to two month commitment at a time. And then the gate guarding, I mean they ask for a 30-day commitment and our first job was done after 12 days and then the next job lasted like 83 days so that's more of a wide range there. So, you just never know.   Host: I feel like we're talking a lot about work camping, but I'm interested in it. It sounds... I hadn't really heard much about it. So, about six months roughly? I mean, it depends a lot on what the job is, but how soon before you start working are you looking and applying for those jobs?   Guest: That's a good question. A lot of it depends on the season, to be honest. If you're applying for a winter job in Florida, Texas, Arizona at one of the resorts, not so much the gate guarding, but those resort-style RV park jobs generally a year in advance, you want to start looking. It doesn't mean you might not be able to get one a couple weeks before, you know, because somebody didn't come or somebody had committed and just backed out. But about a year before for those, for the summer jobs, a month before, there you'll still see places hiring, again, depending on the location. If it's a very in-demand location, they're going to have their stuff down right earlier, but cool, good enough.   Host: What have been your favorite and least favorite jobs?   Guest: That's a really tough one. So, I did the majority of the work camping because I was trying to bring in a second income while Kalyn was working on turning her business around. It's tough because my favorite job was the one at the campground in Michigan, but that one also was just something that it was like meeting our monthly expenses, you know, it was just kind of there to help supplement. It wasn't helping us put money aside for our future goals. So, when we finished the work camping job in Michigan, we kind of felt like we were still at the same place we were when we started that job, as opposed to like making progress financially. So, I really got to work with people, got to have front-facing customer service type stuff which I really enjoy. So, it was my favorite, but if I'm trying to save money for something then I would go with the gate guarding just because it's the easiest way, you're not having any expenditures really, you're just sitting there and making money, almost printing money in our second gate guarding job. But the first gate guarding job, I think, was our least favorite. I actually worked that one because it was a 24/7. So, we're there at the rig, we cannot leave together, we, it's like a constant, no time off. He's either sleeping or working, I'm either sleeping or working, and it just, even though it only lasted 12 days, was so exhausting. And it wasn't a busy gate. There are oil rigs we were checking in between 40 and 60 cars a day. There are rigs called fracking rigs where they have like over 100 cars or 150 cars coming in and out a day that you're checking in and out. So, we had an easy gate and we were exhausted after 12 days.   Host: Yeah, no, it sounds like it's a great opportunity, like you said, you were working full time, Kalyn, and then once your online business slowed down a little bit, you picked up this gig and it sounds like it's great for someone either starting out without that income or in your situation, you had to make that adjustment. And even if you have, it's even better if you have somebody who is working full time and then you have someone else like a spouse or a partner who is doing the work camping and you're getting a free site so your housing is basically free and you have that other source of income.   Guest: I did want to chime in there, are probably the majority of work camping positions look for couples. It doesn't mean the singles aren't out there because we're a prime example of that, like almost all our positions were singles, but Beat Harvest prefers couples over singles. A lot of the campgrounds prefer couples just because it's an RV site that they're providing and they want to have two people working from it. But don't let that deter you if you're a hardworking individual from applying anyway and saying, "Hey, I'm a super hardworking individual. I'm willing to work X number of hours a week and you can find a job."   Host: Were you able to have a good balance of kind of work and play when you're doing that? Like, in other words, would you work at this place for however long you were assigned that location then would you take some time off in between and explore? Or how did you balance your work and your travel lifestyle?   Guest: Yeah, that's what we did with the work camping. I felt like with the Michigan campground, it was a very nice balance of working and then being able to explore the area. When it came to like Beet Harvest and gate guarding, it was more you're just exploring in between driving to and from actual job locations. So, like when Beet Harvest was in North Dakota and the gate guarding, which was the next job was in Texas, so we kind of stopped on a couple places on the way down and then it was heads-down work again until gate guarding was done.   Host: You touched on it a little bit and I do want to dial this back to where this thing started because point of this podcast is we're helping people who want to reach their travel goals. They haven't quite gotten there yet, but they're listening to this because they want to get to traveling and reach their travel goals. So, you were starting out, you had this dream to go traveling, you were working on your blog, and you were, you ultimately had a full-time income that could support your travel lifestyle. So that's how you were funding your travels, yes. But what were some of the biggest challenges you faced in getting on the road?   Guest: This is kind of an interesting one. I feel like it was telling people that we were changing our lifestyle. It's a big hurdle to be able to go to people that you had commitments to and be like, "You know, we're selling our house, we're leaving the area, we're going to be traveling full time." And then it's even a little bit tougher too when you say, "We're doing it for like a year and then we'll see what happens." And now we're almost, you know, five years in and we're still not done. So, it's definitely having that conversation with people because they don't always understand like why can't you just do one to two vacations a year like normal people, you know, and have a house, an actual house. So that was probably the most challenging part. And then I would say on the road, staying on the road, something that I wish we had known before going on is that especially when you work for yourself, your income can really ebb and flow. And have a game plan, have multiple streams of income, you know, if you're getting on the road because you've spent years building a savings for a specific number of months, what are you going to do after that to fund? Just kind of like having a future game plan in mind of how you're going to be able to maintain staying on the road. It's like getting on the road is one thing but then being able to stay traveling is another.   Host: How did you know you were ready? Was it just a matter of how much you were making with your business? Did you have a number in mind and you said, "We're ready"? Or how did you know when it was time to hit the road?   Guest: I think when the right RV popped up. Yeah, we had a list of things that needed to happen, and one by one, they just started happening. We had a property in New York that we didn't think would sell because of the economy in New York, and it had been on the market for a long time, and it sold. Then we had an RV. We wanted to get an RV, but we had a specific list of, like, it needs to be this, it needs to be in our price range, which was not super high, and it popped up. The couple that was selling it was like, we told them we can't buy it until we sell our house, and they're like, "Oh, yeah, no problem." You know, and they actually sent us the deed in Florida before we even paid them a dime, so that we could get it registered. And it was just a super awesome couple, and like, everything just started falling into place. I'm like, "Oh, now's the time." And it solidifies that you're making the right decision, too.   Host: Sure. And once that house sells, you don't have much of a choice.   Guest: Yeah, now that doesn't mean we didn't have like nights of like tears or like, did we do the right thing, or freak out or anything like that. We totally went through all of that the first couple of months of travel, just like as we were getting used to everything.   Host: Well, I'm glad you say that because I've had those exact same thoughts, too, so it makes me feel better. Did you have to make any adjustments? So your original plan was to do a one-year-long road trip. You decided to extend it, obviously. Were there any adjustments you had to make to extend that and to keep going?   Guest: We had to, um, because we wanted to, like, Boondock more, I would say. We invested in... This is going to be like TMI, but, like, a portable black tank so that we could go longer because that was one of the things, like we had mentioned before, we were traveling, we thought this was going to only be one year, so that's where we're traveling every, like, four to five days. Um, and then we realized we wanted to slow down, we wanted this to be a lifestyle, and so we started buying things that would help us stay in places longer. Um, so things like that, yeah, the portable black tank, a macerator pump, a, uh, we have water storage that we have in the back of the RV, those are the only things that we really, we did buy a generator too, yeah, we bought a small generator, we have a, we have, we call it a minimal solar setup. It keeps us going, but it's not anywhere near what like some of these people have where the whole roof is covered in solar panels. Um, but the other transition I would say happened longer than a year, and that actually had to do with the work camping and everything, where we realized over the past year that if we want to keep doing this, we need to bring in another income stream. And so that has come down to, uh, YouTube and treating it as a full-time job to get that second income stream in so that we don't end up off the road because we literally did almost end up off the road uh, this last year.   Host: Yeah, yeah, keeps it exciting.   Guest: Oh, yeah. When, so when your back's against the wall like you try to do everything, yeah, now you got to find a way.   Host: You'd mentioned you like the water jugs. You, you, it seems like when we watch your videos, you have a couple of almost unique and original ideas. Like the one I'm thinking of is you have that it's almost like a 2x4 and a string of like 5-gallon water drums in the back of your truck for extra water. Do you think of that yourselves or where do you come up with these ideas?   Guest: That some people transport water with a like a 60-gallon water bladder. Some people transport water with a like a 60-gallon water bladder, to bring it from point A to point B. My problem with that is I can't, um, I can't functionally keep a 60-gallon water bladder full in the back of the pickup while on a travel day. Like, I want to have the RV full of water, and then I want to have extra storage. And so that's why we went with those, uh, with those, uh, six-gallon jugs in the back. And the 2x4 between it is literally when those jugs are empty and we haul the RV, they blow right out, like without the RV, they stay there fine. But when the RV is there, some wind suction comes in and just sucks them right out, uh, so the 2x4 is literally just to keep them from flying away.   Host: Did you learn that the hard way?   Guest: Yes, yes, on a, on a, like, 10-degree day. And so when The Jug hit the pavement, it shattered basically, yeah.   Host: Oh, man. Oh, it was full.   Guest: No. No, it was, it was empty, but it was, it was just so brittle. Brittle plastic and 60 miles an hour, just broken into a few pieces.   Host: Hey, guys, I wanted to take a quick break to tell you about Delicia oats. We've been enjoying Delicia oats for many years, and they have helped fuel us for those extra long hikes. They are flavored oats that come in a pouch and are very easy to set up. Just add water, give it a shake, and let it sit overnight and enjoy the next morning. Or you can add boiling water if you like them served hot. We've also added them to our morning smoothie, or I'll sprinkle some into my yogurt for some extra flavor and to help fill me up. You can make them in less than a minute, and there is no cleanup, which is huge for us on the road. Now, if you're like me, the first question you'll ask is how much added sugar is there? And here's a big one for me: no added sugar. They come in a variety of flavors. My personal favorite is Cherry Chocolate. Enjoy them for yourself by placing an order at Delicia oats.com and use the coupon code PATH at checkout. That's Delicia oats.com, D-L-I-C-I-O-A-T-S.com, and use the coupon code PATH.   Host: Well, on that note, we'll fast forward a little bit, talking about your past. We'll fast forward to kind of the future and leading up to where you are now. What have been some of the biggest frustrations you faced and currently face while traveling?   Guest: I would say our current struggle is balancing the work and the play side of things because, like, we've got sort of three types of days. We've got work days, we've got travel days, which will take a lot out of you, and then you have adventure days and exploring days. And so trying to make sure that, okay, we need to get in like five to six good work days that doesn't leave... that leaves room for maybe one travel day a week or, you know, one adventure day a week. Kind of have to choose, so it's not... I used to go into a location saying we have a list of like 10 to 12 things that we have to hit, and that's not enjoyable because we're so stressed trying to make time for it all. And now it's like I have a list of 10 to 12 things, but it's like we've prioritized them now, okay, these are the top three, and if we have time, we'll go to the next one on the list. And that's made a little bit easier. And this is somewhat Creator-focused but also being able to have an adventure day that isn't for YouTube. So getting to a location being like, okay, we want to put this in a YouTube video, this particular hike or whatever it is, but then we also want to go on a hike together where we don't have the stress of also trying to create content. That was something we failed on our first attempt to, maybe second attempt at YouTube, is we were just trying to film everything, which was just adding extra stress because we weren't actually having a day to ourselves.   Host: Yeah, I know, Kalyn, you have your business. It's you're helping women with planning, scheduling, and routines throughout their day, so clearly, I would assume like routines are your forte. Have you discovered any routines that have helped you specifically with travel?   Guest: Yeah, and we're also like implementing routines now that we're done gate guarding and work camping in general and we're on the same schedule because we were just on opposite shifts for so long. But the key to staying on the same page has been weekly meetings. As we plan our week, we go through okay, where are we traveling this week? What are our adventure days this week? What are our deadlines for work stuff this week? And making sure that we're on the same page, that everything's getting done. And then like a quick five-minute meeting in the morning. But I would say morning routines too have been really good for us. Just getting up at the same time, taking our dog Trinity for a walk or going running, and having breakfast, and then getting to work and just kind of having that stability because on the road, you don't have a lot of that all the time. You know, things are changing. We don't have a laundry day because it really depends when we can get to town, you know, to do laundry. So there's not those routines, but we try to establish structure, sure, where we can.   Host: So you put the routines in where you can control. You can't control where you are or what's around you, but you can control when you wake up, you can control those meetings wherever they are, um, and just that gives you more structure throughout your day. That's great. Um, what do you guys love most about your travel lifestyle?   Guest: I love the fact that we have a different backyard every couple of weeks. So we are very active people. When we're in our best element, we like going on hikes and exploring places. And when you're in the same place for years at a time, you run out of hiking trails, at least within a short distance. So the fact that we get to a new place, it's like, okay, now everything behind us is new, even just taking the dog for a walk. It's going to be a completely new area that we're exploring, even before going on a hike. And I think the other thing is just like getting to get a broader perspective on the country as a whole. And someday, maybe the world if we ever do any world travel. But just being able to see like, oh, this is where your food comes from, to sound super simple, like I grew up in the country so I was aware of some of that. But like you go to different states and see how different people live, and it just gives a broader perspective on how our country works and how people work and how people can work together.   Host: Same thing, Kalyn?   Guest: Yes. Sorry. Sorry. I was like, he's taking that question. If he wasn't going to mention the broader perspective, I was going to chime in with that one. But yeah, even things that we knew nothing about, like, su... Yeah, we had no idea there were sugar beets that people literally were eating sugar from sugar beets. So that's like a whole thing that you learn, the oil industry, you know, all the workers that come together and the things they do on the oil patch. So it's... It's... you really get to see like the American work ethic.   Host: Yeah, that, and I think going back to work camping, that's... that gives you those experiences at a deeper level. Like, yeah, you're in these areas, you can see things kind of from a distance, but when you're actually working those jobs, doing the gate guarding and doing the beet harvest, gives you even more of an appreciation for those things. That's great. You had mentioned world travels in your future, so how long do you plan on continuing this travel lifestyle for?   Guest: It's unknown. It's unknown. As long as we are capable of, and Kalyn and, you know, things align, eventually, we'll probably transition into more like 80% travel and 20% at some sort of home base that we can come back to, especially if we start adding international trips, um, just to have a place where you have the same doctor's appointments and dentists and, and can come back and kind of recover before you go out again. So that's what we see happening in our future. I think no matter what it looks like, travel will always be a part of our lifestyle.   Host: Yeah, that's great. We'll transition, we'll switch to budgeting tips, and I'll just remind our audience you're going to want to bring your pen and paper for this section here because you guys post on your YouTube and your Instagram, you guys are very thorough. You have not only monthly expenses but you break it down what you're spending money on, you have how much you're making with YouTube with work camping, your whole Alaska budget. We'll dig into. So breaking it down, stripping it down to kind of a monthly or weekly budget, what does that look like?   Guest: Well, obviously, it's going to be different for everyone, but for us personally, for someone who tries to be really budget conscious, doesn't have like a truck payment or an RV payment, and also tries to do as many free activities as possible, we spend about $3,500 to $4,000 a month. And that includes everything. It includes health insurance, vehicle insurance. I think sometimes when people say, like, well, you know, this is what you can find that you'll typically spend in the RV lifestyle, they're not necessarily including everything that maybe $3,500 to $4,000 roughly.   Host: And keep in mind, everyone, that's without the RV, that's without the truck payment either.   Guest: Which we don't... we don't have any payments on those.   Host: Yes, that's outside of that. So if you were going to finance just... you want to factor that into was that budget a little bit tighter when you started out? Have you been able to loosen that up since you've... own your business?   Guest: It's actually a little bit tighter now because... I mean, everyone's feeling the effects of inflation and we recently did a... um... five years of RV life costs and at the beginning of RV life, we were spending probably around $350 for groceries, which was just food. And now we're struggling to come in under 500 a month for the two of us. So it's not like we've changed our practices, I think it's just that inflation coming through.   Host: Yeah, yeah. Do you have any budget apps or tools that have helped you track your expenses?   Guest: We highly, highly recommend You Need A Budget. Um, it is an annual fee, I think it's like last I paid was like $106. So it is a little pricey, but it takes... it connects all your credit cards and bank accounts, import the transactions automatically, very easy to reconcile and categorize things. And I think it's why we've been able to stay on top of all those numbers because we know exactly like where they're being attributed, um, so that would... I absolutely love that app and maybe they'll sponsor us in the future. We'd be totally game for that. I just love that you keep saying we track, we track this, we... I'm the one hiccup in the budgeting process. She does it. It takes her like 15 minutes every Friday to check in, do everything, and probably 10 of those 15 minutes are locating receipts that I've misplaced.   Host: Yeah, I don't miss the days of scanning receipts and to get the copy online, and yeah, that's just painful. So, I was going to ask, my next question was how much time, so you're spending about 15 minutes a week, so about an hour a month, sounds like you've come up with a system where doing it per week is more efficient than just holding everything for the end of the month.   Guest: Yeah, and because you can check, because you check in more often, you can pivot quicker, you know, if you see something like, "Oh, you know, our eating out spending is getting a little out of control," and we're halfway through the month, we know to rain it in and eat more at home. So, the more check-ins you can have, I think, I mean if you want a check-in daily, if you feel like that gives you peace of mind, do it daily, but we found like, I've found that Weekly a good Cadence.   Host: That is a good point yeah checking in once a week because if you set a weekly or a monthly budget of you know 300 bucks for going out to eat but you only touch touch base every month then it's kind of pointless so actually doing that per week and then yeah that's a good tip right there yeah awesome um what has been some of the best travel hacks you've come across that have helped you save money?   Guest: Boondocking one 1,00% boondocking we have so you can Boondock people Boondock with generators I don't recommend it but you can get a solar setup for your RV uh and it doesn't have to be the $50,000 solar setup like we set up our solar system I installed it myself so I did save myself some money there but for $6,000 we didn't have to use a generator our whole first couple years um we if we ever got close to the batteries running low which was rare we would get a campground for a night plug in get everything back up but but um but now we even have just a I think it's like a $800 or even less $300 generator that we can just use to charge us up if we have a couple cloudy days in a row but for that $66,000 we have 700 Watts almost 700 watts of solar and three 100 amp hour batteries um an inverter converter Char inverter charger converter something um does everything clearly he's an expert yes clearly and uh but it has run flawless for the 5 years that that we've been rving and you don't need all the fancy smancy now we also don't have uh some power sucking things like we don't have electronic uh stoves like it's a gas stove and and things like that and we also don't have a giant TV uh if you have a giant TV and that's a necessity then you might need more battery I don't know how much they take and we have the typical RV gas gas electric fridge that we just r on gas for we boondocking nice and I'm sure there's a video on there we'll Link in the show notes that you guys posted and you said $50,000 that's how much those things cost be50 Grand think that's a little I've seen I've seen I've seen at least $25,000 solar setups that people have like when their whole roof is covered in solar panels and they've got 12 batteries underneath like as a general rule when we started rving as a general rule 100 amp hours of battery was $1,000 that has gone down depending on the brand of battery you get um but yeah you can you can get expensive in a hurry with a solar setup.   Host: Sounds like it yeah um and you did it for six grand setting up yourself the um so you talked about boondocking are you boondocking because obviously that replaces your camping expense how often are you boondocking when you're when you reference that $3,500 to $4,000 monthly?   Guest: Um budget most of the time yeah it's we we Boondock unless we absolutely cannot it is obviously harder when you're closer to cities or East Coast or on the East Coast we will like stay probably an hour and a half sometimes two hours outside of where we want to go just so we can Boondock because it's it saves more money to even pay the gas to get there in back than it is in the campground fees that are usually near CI so we do that and there's also um Harvest host and boondockers welcome that you can take advantage of as well um so staying in people's driveways and sometimes it's fun to like just meet new people and and get to know others on the road so that's an option too.   Host: Wow so that's almost 4,000 you're spending a month and that's really not including um housing or or finding a place to stay so your biggest expense is probably fuel groceries and you said your health insurance?   Guest:Yep yep health insurance I was when we have starlink turned on for internet then our internet sell bill is expensive um because starlink itself is is $150 a month but we've opted for the ram plan so you can turn it off um like every month you can decide whether you want to keep it going or turn it off and so if we're on the East Coast where we have Verizon sell signal and T-Mobile sell signal then we'll turn it off and save that money there well when we have all three running that's going to be about 300 a month to 4 just for just for Internet yep.   Host: Wow yeah like I said very thorough thank you guys for sharing so much detail on everything that's that should give everyone a really good idea of how much this lifestyle can cost um so you guys travel with Trinity your dog and Cody your bunny what's it like traveling with two pets like that and do you want to share how you came across Trinity or rather how Trinity found you?   Guest: Yeah, that's, yeah, CU, she was at an oil pad for our first gate guarding job, and as people were showing us the ropes, we're like, "Is this your dog? Whose dog is it?" And they're like, "Nope, it just kind of hangs around here." And we got to know some of the workers, and they're like, "Yeah, she's been hanging around here for a few months," and she just seemed to get really attached to us. So we provided her water, um, she slept in our chair, she slept in our outdoor chair, and started providing her some food. But the problem is, we were like, we have a rabbit, and dogs and rabbits don't necessarily get along, so that's one of the things where really, really, really worried about if we kept her. And we weren't looking for a dog. Um, we've always had rabbits since we've been married. So we actually ended up, like, outside the shelter, and we couldn't go through with it. We just couldn't drop her off because we obviously didn't want her to stay there on the oil pad trying to get scraps from trucks and sleeping by Slo pipe and like we wanted to get her a good home. Um, and yeah, we couldn't go through with the shelter, and so like, well, we'll give it a shot. And we just slowly introduced them. And now it's to the place where we don't completely 100% trust her alone with the rabbit, like we put barriers in place, doors pens just just to make sure. But that's not based on her, that's just based on better part of wisdom, knowing that instinct is a thing. She's never done anything like Cody literally will jump off the couch onto her sleeping, yeah, and she'll jump up, you know, like what happened, but there's not like anger or growl or anything. So, and so it's nice that they are able to to live together and it also makes travel days a lot easier too because like Trinity can lay on the back seat of the truck and Cody's kind of in the in the back of the truck on the bottom on the floor um, and he can hop around and they're totally fine. So, it worked out really well and we love her and she's a great addition of the family.   Host: That's funny, unlikely companions.   Guest: Yes.   Host: I feel like if if if we brought our dog into a camper with a rabbit that place would get flipped upside down faster than we could even imagine.   Guest: I think that would happen if a cat strolled into the camper she's not a cat fan.   Host: What has been your coolest travel experience so far?   Guest: H, we have two, can we have two?   Host: Yep.   Guest: I would, you want to do yours? Sure. So, we did, uh, was this two years ago, yeah, we did did close to your neck of the woods actually we did the presidential chain Trail in New Hampshire in the White Mountains. It's about a 21 22 mile hike and we set off at 5 6 in the morning and we had high hopes that we were going to be done by Sundown uh, we finished at about 4:30 the following morning um, Kalyn injured her knee about halfway through uh, we got up to the summit of Mount Washington and there actually is a tourist area there in roads and and we considered like do we jump off and it was at that we try to hit your ride back ride and Kalyn was at that point she's like no we I'm gonna do this I'm never gonna try this again we're gonna do it so she hoofed another 11 miles um through the dark for most of that and then we we got back and when we got down to the bottom her mom actually texted her and she's like oh I'm so glad you're back it looks like it's about to rain and we had the motorcycle and so we're like well we got to book it to our Campground so we booked it there and just the feeling of accomplishment I actually got back to the RV and just kind of like crashed and it was like at first it was like we will never do anything like that ever again and then after you kind of got over the exhaustion you're just like the feeling of doing something really hard um because we like Seven Summits yeah and we weren't expecting it to take that long we weren't expecting you know so we had a lot of roadblocks along the way but to come off the other side and just be like wow we accomplished something really hard was was huge. Yeah, and I would say mine is um at Channel Islands National Park which is off the coast of California I didn't even know existed it existed until like a couple years ago and you have to take a boat out to it and there is absolutely no cell service at all no like real buildings nothing um and so we tent came camped out there overnight and there's also a really cute little island fox that like run they run around there they're only native to that Island um and we'll get into your tent if you leave the door open so you have to be careful about that but you have on one side of the island these massive Cliffs with the Pacific Ocean beneath on the other side there's you know Rocky beaches you can see seals swimming it was just a really really neat experience in a national park that like I said we had not heard of and then for it to you know become like one of our favorites and a day and a half was not enough time.   Host: It leaves you with more more to do I was going to add that's the worst possible time to get hurt on a hike is when you're halfway done you're halfway it's not like three quarters or a quarter the way you're halfway so you're going the entire length back you guys you guys are Troopers and you finish it up that's awesome good job yeah after spending just about five years traveling has there been something you've learned besides Internet that you can't live without?   Guest: We can live without the portable waste but we can't really... I feel like we can't live without the solar panels. Yes, that would probably be my answer, just because of the sheer amount of boondocking that we do. That would... We don't want to listen to generator noise, so the solar panels allow us to be able to have a peaceful time in the middle of where...   Host: Yeah, very cool. So, you mentioned the portable black tank, so you're still using the same RV you started out with, I take?   Guest: Yes, oh yeah, yeah, it's a 2005 JCO Designer. We remodeled the inside; we're in the process of updating some of the outside decals and whatnot, but yeah, it's... it's a beast, it's sturdy. We don't... I'm not going to say we're never gonna buy a new RV, but a lot of times when I see people with new RVs and their suspensions breaking and stuff like that are break, I'm just like, you know, this 2005 RV is looking better every day, very solid.   Host: Yeah, they don't build them like they used to. Um, contrary to...   Guest: I hate it that you can say that about 2005, like when somebody says that it's supposed to be like 1950 something.   Host: I know, it's crazy. Like my truck's 2013 and it's like, it's... it's over 10 years old.   Guest: Yeah, yeah, yeah, you look at it, it's like you look, it's, you think it's like 5 years old. But yeah, 2005, it's what, 19 years old? Yeah, yeah, in 20 years I think is called vintage. Yeah, our RV is one year from vintage.   Host: Yeah, we had a 2002, we were going to, like, redo it and just make it vintage, where 20... it was, it was rough looking, so we just said it's vintage, yeah, exactly. Has there been something you've learned that you don't need while traveling?   Guest: There's... I would say we brought more clothes than we thought we had needed, especially like fancier clothes, and we just didn't end up wearing them. I like... we're not fancy people, no. So I, like, those, I think we ended up just giving all to Goodwill. I think maybe I kept one dress in case of something. But yeah, I don't know why you packed those. And if you have like sports equipment that it's like, "Oh, this is something I will do once a year." Like, I'm not a golfer, but I had some golf clubs, and I was like, "There's no point in having these if I'm going to use them once. I can rent clubs somewhere, you know?" Um, now we have paddleboards, but we use those more than once a year. Like, we just are very intentional about the sports equipment we have with us.   Host: It's a good rule of thumb: if you're not going to use it more than once a year, you can just rent it when you get to that destination. What tools should every RV owner have?   Guest: Oh, that's a... I hate this question because I'm not a tool person and I need to be. Um, but the one I'm using the most all the time is... is my drill. And like, I have a drill and a cordless drill. Like, those come in handy so often. I've got... I've got some drawers I need to fix and the idea of trying to do those with a like a hand screwdriver... I know it's like the most basic tool you can say, but if you don't have that in your toolbox, I think you should start with that.   Host: Sure. I was going to say WD40. I feel like you're using that in like every other...   Guest: I do use that a lot, on everything. Maybe that's the thing you can't live without.   Host: A few more questions before we wrap this thing up and I can't believe we're already at at 50 minutes. I do want to get into this YouTube thing a little bit because for someone who's looking to get into traveling full-time and getting into documenting and vlogging and creating content, um, you had posted on your YouTube channel that this was your third attempt. You had tried twice, didn't pan out, and this time you've been met with some pretty good success. Um, what's been different this time?   Guest: There's a lot of things. We are now like almost five years in, so our first year when we were trying to document and learn RV life, like, it was too much, too much new at one time and traveling so fast that we burned out quickly. Now we've slowed that down. The other thing was style. We wanted to make content around the locations we were going to and taking people along because we thought they'd just be interested in the hike because it was a hike. And we've learned that we are going to be primarily in the entertainment space and so we need to be more of a vlog style. And so that's what's completely different this third time around is it's much more doing projects around the RV, running errands, taking people with us to go grocery shopping and doing laundry and seeing what real life on the road looks like in addition to the locations. But we're very intentional about keeping those segments short and snappy. I feel like, yeah, we definitely have a lot more in terms of editing of like cutting and and making things shorter so that we can storytelling the shortest amount of time possible. I think a good example of that is if you look at our video about Cloud's rest uh, in yosity, yeah, I got that park right you look at that it's it's one video about one hike and it's about eight minutes long or so and then compare that to our video about uh, what's the thumbnail say it's New Normal I don't remember decision big decision and we explored some jips some capes and that and the whole video is about 20 our dog is snoring I'm sorry it's about 20 minutes it's about 20 minutes long and we have a cave exploring segment that is about two to three minutes long of that whole video and we still want to we still want to take people along for the journey through those things but we have realized that the attention span for those types of things it is much less so just keep things moving.   Host: Yeah, no, those are great points. Thank you for sharing that. And, as you touched on earlier, it sounds like with the editing taking longer, but you're also allocating time where you're not filming, so that kind of keeps you from being burnt out, right? So before it was go, go, go, but now you're actually taking the time to relax. It's not as hectic as it was.   Guest: Yeah, and I think being very selective about what we're filming. Like, a vlog is going to have, I don't know, three to five different segments of different locations and us maybe doing things, whereas we don't have to film the whole beginning to end of a hike anymore. So, you know, we're going on a hike tomorrow and we're just going to take a few B-roll clips, mention it in our next video, you know, show maybe talk about it for like 15, 20 seconds, and that's it. So, it does allow us to enjoy the locations more, because we know now that's not necessarily what people, at least for our audience, want to watch a whole video on. They would rather watch us do dishes. Do dishes and travel in the truck, get propane, and all that RV life real-life stuff.   Host: Nice. And I would ask, how much you're making with YouTube, but instead, I will say, check the video out in the description, we'll link that video you posted on how much you're making so people can go check it out. If someone's listening to this podcast and they want to get started traveling but just aren't quite there yet, what is one thing they could start doing today to get them there?   Guest: It sounds stupid, but planning, and specifically, if finances are a thing, if it's, you're going to retire and you're going to travel, then just start planning what type of RV and things like that you want to get. But otherwise, it's start making your financial plan for it. Is your financial plan YouTube? Well, if it's YouTube, then you need to build up savings so that you have a runway until YouTube starts earning you money, or you need to have a work camping job plan. And if that's the case, you need to find work camping jobs that leave you enough time to also create content. And so just start getting those things down on paper so that it's not just an idea of "Oh, I want to travel sometime," it becomes more concrete of "Okay, this is the plan that I'm going to tackle." Yeah, and I would say something that we had heard from other people that we actually followed was to not go super big. Like, when you're moving from a house into an RV, you think, "I've got to get like the 40-footer because I'm not going to have a lot of space," and we went with a 33-foot, and it felt... It's the perfect length for us. And I think that's another reason why we've stuck with the RV, the same RV for five years. See, it's not uncommon for someone to switch out an RV every couple of years, and they generally go smaller. They're getting a big fifth wheel, and then they're going to maybe a Class C, and then they're maybe doing a truck camper for weekend trips. So really trying to match your style of travel with an RV and making sure that you don't necessarily need all that space.   Host: You mentioned a few channels that influenced you. What were those channels? Any other like books or other influences that helped you?   Guest: Less Junk More Journey was the first one, and it was when I came to Joseph and I was like, "Hey, watch these people. They are a normal family like doing this." And we kept watching their videos, every single new episode that would come out, and it just kept inspiring us and convincing you to jump into full-time RV life. So we're really inspired when we see channels who are doing really creative things just to kind of see how that would inspire us in our own channel. So we really like Kara and Nate with their style that they do, and then also Flying The Nest. I think it's Flying The Nest. They are a family that travels the world, and their editing is really good. I was just going to say, to put a finger on what we mean by inspiring, we are ruined for YouTube now because when we watch YouTube, we're like, "Oh, that's how they're editing," or "Oh, that's how they're doing that." And Flying The Nest is one specifically that we were watching, and I looked at Kalyn and I'm like, "We're three minutes in, and they're on their like sixth background song. Like, they're not playing a background song for more than 30 seconds." And I said to her, "There's no way I'm doing that in our channel. That's just ridiculous." And we kept watching, and now we do that. But this wasn't before we were RV life, but I think Melissa Padet from Heath and Alyssa, she wrote a book. Now I can't remember the title of it, but working in all 50 states on, like, their journey through all 50 states, which was just so inspiring. And also with us work camping, kind of I don't know, felt like in a similar vein, like we're trying all these different jobs in different states. So I recommend them as well.   Host: Nice, perfect. And we'll link all those resources below in the show notes. And one last question for part two, travel tips. You guys are coming back. Where are we talking about for that?   Guest: We are going up to Northern Michigan and back in time to Mackinac Island. Awesome, everyone stay tuned. Joe and Kin, thanks again.   Host: Thank you so much for having us.

www.atravelpath.com   Hello Pathfinders, in today's show we welcomed back Kyle and Renee from Happily Ever Hanks! They shared their insight after spending ONE MONTH at a campground in San Diego, California and exploring everything it had to offer. In this episode learn about:   Time We covered everything from the best time of year to how long you should spend in San Diego. Although they spent a month, Kyle and Renee shared that you could spend 1-2 weeks and feel fulfilled. As far as the time of year, Kyle and Renee were there for the month of February. They shared that the weather was nice, but not “swimmable” and traffic was manageable. It was definitely the off-season during this time.   Price It's no surprise that San Diego is expensive. They shared how much they spent at their campground for the month and offered some tips so that you can prepare yourself for the prices.   To Do We discussed the San Diego Zoo, beaches, some historical activities, places to eat, and several other activities you can do in the area. They also offered some insight on things they would have done, such as roller blading or bringing bikes if they had thought about it beforehand.   Transportation Ride-sharing is expensive, but they shared that there is a transit system that is very affordable that they used a few times. We also discussed traffic, parking, and the complications of driving a larger vehicle through downtown.   3, 2, 1 Countdown 3 Things to Pack ·        Sunscreen (even if you visit in February) ·        Jacket ·        Bike 2 Complaints ·        Cost ·        Traffic/Parking 1 Thing ·        USS Midway Museum   Chapters 00:00 Introduction 01:00 How long should someone plan on spending in San Diego? 02:45 Where did you stay? 04:00 How was driving a large rig through San Diego? 07:15 How close was your campground to San Diego attractions? 08:30 How expensive was San Diego? 10:45 What was nightlife like in San Diego? 12:15 Daytime activities in San Diego? 16:30 What did you use for internet? 18:00 What are three things you should bring to San Diego? 20:15 What are two complaints someone might have about San Diego? 24:15 What is one thing you can't leave San Diego without doing?   Happily Ever Hanks on Social ·        Website: https://www.happilyeverhanks.com/ ·        YouTube: https://www.youtube.com/@HappilyEverHanks ·        Instagram: https://www.instagram.com/happilyeverhanks/ ·        Facebook: https://www.facebook.com/happilyeverhanks ·        TikTok: https://www.tiktok.com/@happilyeverhanks   Happily Ever Hanks YouTube Videos Referenced ·        San Diego Cost Summary: https://www.youtube.com/watch?v=uhWvcWyW87A   Camping Sun Outdoor Chula Vista: https://www.sunoutdoors.com/california/sun-outdoors-san-diego-bay   Driving Apps RV Life: https://www.rvlife.com/app/ Truck Map: https://truckmap.com/ All Stays: https://www.allstays.com/apps/ Google Maps   To Do USS Midway Museum: https://www.midway.org/ San Diego Zoo: https://sandiegozoowildlifealliance.org/ Coronado: https://coronadovisitorcenter.com/ 19 Mile Biking/Walking Path: https://missionbaygateway.org/biking-walking-paths   Kids/Pets Sesame Place: https://sesameplace.com/san-diego/ Dog Beach: https://oceanbeachsandiego.com/attractions/beaches/dog-beach   Beaches Ocean Beach: https://oceanbeachsandiego.com/ La Jolla: https://www.sandiego.org/explore/things-to-do/beaches-bays/la-jolla.aspx Mission Beach: https://www.sandiego.org/explore/things-to-do/beaches-bays/mission-beach.asp Imperial Beach: https://www.sandiego.org/explore/things-to-do/beaches-bays/imperial-beach.aspx   Restaurants La Puerta: https://lapuertasd.com/ Queens Town Public House: https://queenstownpublichouse.com/   *All content from atravelpath.com, including but not limited to The Travel Path Podcast and social media platforms, is designed to share general information. We are not experts and the information is not designed to serve as legal, financial, or tax advice. Always do your own research and due diligence before making a decision.   Transcript Host: Kyle and Renne, welcome back to the Travel Path podcast.   Guest: Tyler, Hope, Thanks for having us.   Host: So if anybody missed part one, they're happily with the hangs we talked about. They're happily ever hangs. We talked about everything from RV tips, budgeting, their travel nurse career. And today in part two, we're talking about travel tips and one particular destination. So guys, what are we talking about today?   Guest: Well, we just visited this destination. So it's fresh in our brain.   Host: First time?   Guest: First time. San Diego, California.     Host: Just to clarify, you're in California. So how much time did you guys actually spend there? Cause you said this was your first time visiting, right?     Guest: Yeah, we've always wanted to visit. So we gave ourselves like an entire month there, which we were nervous about because it's expensive. You know, a lot of people say you got to really make sure you have some money in the bank if you're going there, but we were ready after spending a whole summer in Alaska where there was maybe a few days of sunshine. I just said to him, like, Hey, we're doing San Diego this winter and we're going to book like a really nice resort down there and do the whole shebang.     Host: That's awesome. Good for you guys. So to get that full San Diego experience, obviously you guys spent a month there, but how long do you think someone should actually plan if they want to just go and enjoy the area?     Guest: I'd say anywhere from about one to two weeks, I would imagine would be a great amount of time to kind of get some city life in, see the surrounding areas. You know, we were ready to go about after a month. I don't know if that speaks to the RV life itself and that's always like in the pickup and go see something new or that was just applicable to the area. I'd say one to two weeks.     Host: Now you guys obviously went in February.     Guest: Uh, yeah, it was like a month of February. Whole month of February.     Host: And is that good weather for you or did you talk to anyone and find out, you know, there's other times of the year that maybe are better to go?     Guest: It's pretty funny because we thought it was like the busy time of year. We're used to when you go to Florida for say in, you know, February's boom and so many people, so we assumed it was like that in San Diego, we were in Northern California and Reading and it was cold and raining a lot. So we were really excited, but then we get there and it's not busy at all. And then we talked to some locals and they're like, Oh yeah, this is not considered the busy season the summer is. So we kind of felt like we scored because we're like, it's for us. It's nice weather. I mean, it wasn't swimmable beach weather, but if you're looking to go somewhere South where it's still decent weather, if you're used to snow, it's pretty much nice all year there is what I'm trying to say. You can go anytime of year and it's nice. And your pipes don't freeze in the RV. So that's always a plus.     Host: Yeah, there you go. That's definitely a plus for you guys. Now you said that you stayed in a resort. Is that an RV resort?     Guest: Yeah, we stayed at the Sun Outdoors in technically is in Chula Vista, just a little bit South of San Diego, but just a really quick drive to downtown.     Host: Awesome. Now, did you stay there for the entire time or did you move any spots?     Guest: No, we stayed there. Yeah, we ended up staying there, which was nice. And, um, it was a little bit more pricey, like Renee had said, but it was well worth it. So they had like a nice pool there. Like they go all out. It's Sun Outdoors. So it's a huge company that buys a bunch of, well, they pretty much build their own RV resorts across the nation, but they kind of have like that margarita feel to them, you know, they always have music playing events going on. So even though it was a slower time of the year, it's still made for a great time to get out and meet people out in the park. Still plenty. It was pretty about halfway full, I would say. So yeah.     Host: Yeah. Awesome. Yeah. We can attest to Sun Outdoors being a good RV park. We have spent the last three summers or seasons, I guess, living in an RV in a Sun Outdoors. So nice.   Guest: Yeah. You know, you're getting a pretty nice place when you book with them.     Host: Yeah, exactly. You know what to expect, which is nice, especially if you're going to be there for so long. So as far as you guys have a larger rig, so as far as transportation and getting your rig through San Diego to the campground, how is that process for you?     Guest: Not bad at all. We'd like to rely on a lot of apps on our phone. Basically, they are go-to for checking high clearances and making sure that the route we're taking is going to accommodate our fifth wheel because it does the height of our fifth wheel is about 6 feet, 6 inches. So we do run about the same height as most tractor trailers that you see out on the road. So you've got to be really careful to not just take any road and hope that it can accommodate your RV. We've gotten in some scary situations where you had a back out. I don't know if you guys ever seen the random YouTube videos where people are knocking their ACs off their RV roof. I mean, it happens a lot.     Host: But not to you guys.     Guest: Not to us. Knock on wood.     Host: So, you said you used some apps to check clearances. What apps are you using?     Guest: Our main GPS is Google Maps just to kind of see, you know, Google Maps is great. It shows like everything. But then like he was saying, we kind of have to dig into some other apps. So one of those is RV Life. It's like trip planning for RVs. And I'm sure maybe you guys use it with family too. You could do like it gives you like a radius of your travel day, like tells you kind of how far you want to go, where you pull over. It has all the resources. But then on top of that, it has a GPS and you can use that as your main GPS. It'll make sure based on your height, your width, all that stuff that you're not going near any low clearances.     Host: Oh, perfect. Yeah, that's pretty cool. And then what was that other one?     Guest: Truck Map. Yeah, there's a free one called Truck Map. Yeah. And like truckers use it. So you could if you're looking for something for free. And if Google Maps is we still like to use that and stuff. Most of the time we'll just verify with these other apps. Okay, the route we're taking on Google is the same that it's given us on these other apps. So then we could just stick to Google Maps.   Guest: Yeah, but since you know, you just got to be careful all stays pro is another one or I think it's sometimes called all stays. It'll have an icon to show you where all the low clearances depending on how you filter it. So I'm just in the passenger seat there like constantly being like, let me look for low bridges.     Host: Good. So once you see that low clearance sign, that's too late.     Guest: Yeah, no doubt. It's something you notice too when I'll just be driving with I'll be back home just driving around with a friend. And I'll be like, Oh, we want to fit there. Like you just subconsciously see it and you're like, I want to fit in an average. But before RVing, we would have never really noticed that we wouldn't pay attention to those signs.     Host: True. Yeah. Well, those are really good tips and definitely something you need to pay attention to when you are that tall. So as far as the campground you stayed at, the sun RV, how close is that in proximity to, you know, all the attractions you wanted to go to or, you know, if you want to go take a walk somewhere, what was that like?     Guest: Yeah, it was pretty nice. They did have some walking paths. I'd say it was about a mile walk out to the beach or to the bay, I should say. To the bay. Yeah, to the bay from that resort. Now, if you wanted to get into the city, probably about an 8 to 10-minute drive.   Guest: Yeah, maybe 15. Most if it's traffic. Right. And there was a like their transportation system like their, what's that called? Their railway.   Guest: Trolley.   Guest: Yeah. Trolley. There was the station right in walking distance from the campground and we did use that to go downtown the last night and it worked great. I mean, we just had 10 minutes. We were downtown and because we were going to do an Uber from the campground and during the really busy times, they were wanting $50 one way just into the city. And then we did the train like Renee was saying, and that was $2.50 one way. And just give you, yeah, terms of mileage. I think it was only like five miles away. Yeah. So not very long, but wow, they really took back those prices.     Host: Well, that's perfect. That's a good money-saving tip right there. Now, speaking of the finances, San Diego, California in general, typically a little bit more expensive. So what was it like for you guys staying there for a month and what should someone prepare, you know, their budget for when doing something like this?     Guest: Sure. Be completely transparent. I would say we spent what for one month stay at the RV resort. What would we spend? It was like close to three grand. Close to three thousand dollars. So that I don't know, comparing to other resorts around the area, it could be cheaper. I'm not exactly sure, but we had anticipated this was kind of like a vacation. So that's how we treated it. We kind of treated ourselves to that. But yeah, overall, you're going to see some hikes in grocery prices and then the fuel itself is going to be more expensive as well. I think we were paying like $5 a gallon or something for diesel when we're used to paying anywhere from like $4, maybe $4 or $5 somewhere.   Guest: Yeah. And we're actually our next video, not sorry, our maybe two videos from now, we're going to be closing out our series talking about RV expenses in California and we're going to be talking about what we spent in San Diego. We'll have we're still working on all the totals. So we'll have all of that in a future video or maybe it'll come out the same time this comes out. So be perfect.     Host: So go check that out for a real clean breakout on all your costs. So as far as but speaking back to the gas, I guess because you guys were staying in one spot for a month, you were leaving your rig there. Do you feel like you maybe were just driving less because you were so close to being able to use public transportation and just not having to move your camper back and forth to different spots?     Guest: Yeah, absolutely. Yeah. We weren't driving nearly as much as we normally would like the current location we're at. We have about I would say like  minute drive to the nearest town to the grocery store. But now that's the same distance, you know, time distance in San Diego as you know, to get from the RV park to San Diego. But it was a lot less mileage. So we didn't take the truck into the city all that much. We relied on that public transportation a lot. But just driving around San Diego to La Vista area, it's so condensed. Everything is just like right in your backyard at all times.   Host: So what'd you guys like to do at night? In general or in San Diego?     Guest: In San Diego. We would like to find a nice restaurant. And honestly, we did a lot of stuff during the day. Like we would go we went this one day to Miss Ocean Beach. Yeah, I think it's called Ocean Beach. And they had a dog park, which was fun to see all the dogs run around the beach. And then we watched the sunset from there. And then pretty much when the sun goes down, it's kind of like grab dinner and, you know, head on back. Yeah, we're kind of like early to bed people. But there's a lot of really cool bars, a lot of cool nightlife in San Diego. So if you're into that and breweries. So if you're looking, I mean, that would just be so much fun to be able to like, you know, if you're looking to Bar Hop, go downtown and do all that stuff.     Host: Absolutely. Yeah, of course. And I think that's nice that you mentioned you had a good sunset at that beach. But any other sunsets or sunrises that you maybe want to catch?     Guest: Hmm. We kind of had a nice sunset view from our RV because it would, you know, just set below the bay. Yeah. But any beach you go to because it's west facing is a good sunset. You're kind of right there. Yeah, you can't you can't have a bad one in that area. Yeah, of course.     Host: Now, any other activities you guys did during the day that were fun?     Guest: We're telling what we did. But we do. We were just. Let's see. We did the USS Midway tour, which was really cool. So that's an old. The naval ship. Yeah. I'm trying to say ship. Yeah, the Battle of Midway, the story behind the Battle of Midway, like the naval. That's really cool. So it's like decommissioned and it just sits there in the bay. You just pay an entrance fee and then you can walk it at your own pace with a guided tour, like an audio tour. And wow, that took us like four or five hours to get through that entire thing because they have an upper deck with all the old airplanes up there. You have a metal deck and then they have a lower deck for like kitchen and the infirmary were so it was pretty cool. But we're also the people that have to like listen and read everything. So we took the all day. We took it on. Also the zoo. I mean, the San Diego Zoo, you have to check that out. It's like one of the best zoos in the country. So we went there and that was that was a great day. Beautiful weather and just it's I don't know. We're not big zoo people, but it was just fun being out and seeing, you know, how they take care of the little bit of behind the scenes and how they take care of the animals, things like that.     Host: So the zoo and the ship, those are your two recommendations.     Guest: Yeah, do the zoo and the ship. Those are our two biggies and then check out some good restaurants. There was what was the name of that one restaurant? La Puerta downtown, which was really good.     Host: Yeah. What kind of food did they have?     Guest: They had Mexican, but it was kind of like in a rustic like the bar had a cool rustic vibe to it. We also went to a place called Queenstown Public House downtown and it had it was New Zealand inspired. That's what caught my eye. I was like, oh, this is interesting. Really cool vibe. And the food was delicious. Wellington Meatloaf. You will not be disappointed. That was really good.     Host: Awesome. We love to try new restaurants when we go out and like you we've talked about in episode one that can, of course, rack up a pretty big bill if you don't pay attention to it. But being able to try something either a local cuisine or, you know, just something like that New Zealand restaurant. Right. When do you ever see that anywhere? And enjoy something in each spot, I think is always so good.     Guest: Absolutely. Yeah.     Host: Perfect. Any other good food spots or coffee shops?     Guest: Oh, we did do that one coffee shop, but it was a really random one over in what was the name of the island. That's what we got to talk about. Coronado. Coronado Island. So that was across the bay a little bit from the RV park itself and the Naval Station is over there. And just like a really cool place to drive over. You could take a bridge. It's no toll. You don't have to pay any fees to get over there. You could park. There was a lot of parking and then you could walk along the beach and so many coffee shops and restaurants over there. Yeah, their beaches are so clean. Like we went to several of them and so clean. And the other thing I want to say, if you have kids, there's I think there was like a sesame place, sesame street world or something. Yeah. And, you know, their sea world, if people are into that, there's just like there's a lot to do for every of every age. And there was something we noticed we thought about doing, but we didn't. It was like a sunset cruise you could do on the bay. So going back to the nighttime activity is like taking a little boat ride and watch the sunset that way. Can't beat that. Yeah, that would be cool, too.     Host: So if you haven't mentioned it, are there any other nearby attractions that we need to know? It sounds like we covered all of them, though.     Guest: Yeah, those are kind of the ones off the top of our heads that we can think of. Yeah, there was a lot of the stuff we wanted to do was just too cold. Like I wanted to go surfing or paddle boarding or snorkeling. And I think what I read is if it's warm enough to do that. La Jolla or something. I can't remember what that place is called, but there's a beach way far north. Yeah, is this Bell with a J? Yeah, JOLLA. Something like that. I just can't remember how they pronounce it, but that's kind of like the go to if you want to hit up the beach. Go swimming like in a very nice beach. Yeah.     Host: Perfect. So it sounds like the consensus is February is a great time to visit, but it might be a little chilly for water activities.     Guest: Exactly. Oh yeah, for sure. But good for eating, you know, you got to like hibernate, put some good food in your belly during that time.     Host: Perfect. And then how was your internet?   Guest: Oh my gosh, it was. Well, the internet was ripping. Yeah, it was good. Starlink held up really well. Being around other people at Starlink and still did fine. Did really good. We had like a hundred down, didn't we? We can't complain about the internet there. Yeah. Our cell phone service was great the whole time.     Host: Perfect. Those are the things people need to know where to eat and if they can get internet.   Host: I know it was too cold. They do the water activities, snorkeling, swimming, surfing. Could you lay out on the beach? Were the people doing that?     Guest: There were people doing it. I mean, I had my puffy coat on several times when we were on the beach because it was so breezy. Um, but if you were brave enough and if it was like somewhat warmer weather, you could. Now we did lay by the pool at the resort, I think twice, but I had goosebumps. So I was really trying.     Host: Well, San Diego sounds like you go. It's the scenery. First of all, it's everyone talks about San Diego and then the nightlife, the food scene, but in those winter months, still, I mean, it's probably why it wasn't the biggest or the busiest time of the year is because those water activities. It was just too cold.     Guest: Oh yeah. Yeah. It seems like it's everyone. Like if you're obviously Arizona or anywhere away from the coast, seems like that's where we're flocks to in the summer to get there. What, uh, summer activities, winter, sorry, not winter water activities, water.     Host: Yeah. Great. Perfect. We'll transition to the three, two, one countdown. The final three questions of the podcast, starting with three, what are three things you're bringing to San Diego?     Guest: Okay. Well, the first two are not going to make any sense, but we'll explain. It's my sunscreen for sure. I add that like the only reason I say is because even though it's not like super hot, oh my gosh, I'll get eaten alive by the sun. That California sun. We're not all blessed with your skin tone here. My wife, very nice skin tone, but me, unfortunately, I had to rely on sunscreen a lot. So sunscreen, a jacket, if you're coming in February, that breeze sneaks up on you. So make sure you have like a little cover up. The sunscreen during the day and then immediately have your jacket put on because, you know, that sun goes away. It just gets chilly. And then on top of it, I think the last one that is really important is like a bike. If you have a bike, we don't have bikes, but we realize how nice it would have been to have a bike to get around.   Guest: Yeah. There was this, I can't remember how many miles. See how we're so good at presenting this information. Aren't we?   Guest: Yeah. Um, there's some really long bike slash walking path and it ran past our RV park. Like, so we walk that a lot to the bay, but I think it goes like  something miles.   Guest: Um, all the way out to Coronado Island and then you can come back. So bring your bikes if you have them.     Host: Yeah. Does that almost like a boardwalk? Is it hugging the water views along that bike path? Do you know?     Guest: I think when it gets to the Imperial Beach side, cause I looked at a map to see how far it goes. I think it does, but there was another area, um, Where we were walking a lot of mission beach and there was a boardwalk where people were just on. Roller skates. I mean, after being there, I really want to get roller skates for some reason and everyone's roller skating, skateboarding, biking, just very active. Fun community. Everyone's out doing something.     Host: I'm sure you passed rental shops for all, um, roller blades bikes.     Guest: Yeah. Yeah. Yeah. So then we had to make a decision like, do we really like, or after the price of the groceries and the dining, I had to scratch something off the budget, right?   Guest: The truth. I'm like, we'll just get our steps in. It's fine. It's free.     Host: Yep. There you go.   Host: That's it. What are two complaints or two things people should be prepared for before visiting San Diego?     Guest: Well, the one we talked about already being expensive, just the price, you know, I think most people are prepared if they are visiting San Diego, but to stay in a hotel, to stay at an RV park or wherever you're lodging, it's going to be pricey. We already told you about the  to stay one month at an RV park. And that's crazy. We've never paid that to stay somewhere, but we knew going into this, that their nightly rate was going to be outrageous. And that's a discount. If you actually like took their nightly rate and multiplied it by  days, it would have been like five or $,. So for them to give us three grand a month, that's like a monthly discount, quote unquote. And the other one, August, I guess, you know, just like with any city around traffic. So it's such a silly complaint. It's you can't complain about traffic in a city, but you can't. I mean, we are going to throw it out there. We don't visit a lot of cities like frequently, but we really, really enjoyed this one. But, you know, we're never prepared for the traffic, but it was there. And then I will say I just thought of this one is the truck parking with our big truck.   Guest: Yeah, we have a lifted truck.   Guest: And sometimes it's hard to find parking, especially, you know, when you're towing with a dually truck or anything.   Guest: Yeah, it'd be tight. If you have a dually and you want to go downtown, just take the public transportation because it's going to be such a headache to try and park that thing.     Host: Yeah, that's good to bring up. And it's especially good to bring up, especially it's in the off season and there was still traffic.     Host: So if someone's going there, when it is busier, tour season, they're going to be. Would you would that be a nightmare in your opinion?     Guest: Yes. Yes. I would not. I would not be able to relax and enjoy parking the truck and that that would be stressful.   Guest: Yeah, we love visiting areas that are like chill and it's not the busy season. So yeah, perfect for us to be there in February. So that would be stressful. Most RVers aren't used to traffic.     Host: San Francisco was the first city we went to after we were in the middle of nowhere for like a month and a half. And it was we were not ready for it. But that public, the transit you talked about, is that on its separate like road or does that actually follow? The streets that cars follow too.     Guest: Yeah, it was sometimes next to the main road. It was like a railway.     Host: Okay. So that so you'd avoid the traffic by taking that then that's its own cool.     Guest: Yeah. And I mean, it has to stop at every stop, but it's still it was really two dollars, two fifty one way. Yeah. Per person.   Guest: So really affordable and clean and just it was really, really nice.     Host: Yeah. Yeah. By the time it takes you to find parking and worth it.   Host: Was the area itself once you got to downtown, was everything pretty much walkable or would you recommend somebody do have a car or some form of transportation when they're down there?     Guest: I think the major areas that you wanted to hit were walkable. So once you found the parking spot or you're in that location, it was easy to just Google search what was in that immediate surrounding area and have some places to visit. So yeah, like I don't feel like you would have to have a rental car if you were flying in and going to a hotel, especially if you're already downtown. Because like you can get to the zoo and not just that railway system. They there that was a whole transportation system that had rapid bus transport. And they were just really good about the transportation. So you can get everywhere you need to go.     Host: Yeah. Yeah. Some of those big destinations you hear about, you think they're going to be huge. But we went to Nashville and I was shocked at how small Nashville was. It was like three blocks worth of bars. And that was the main strip. And so I was curious to see if San Diego was the same way. Once you get to downtown, you can pretty much walk around and walk to everything. So it sounds like it's a little bit bigger, but still doable. Yeah, fine. It was still like you would need to to hop if you want to go to the zoo and do the midway for some crazy reason. One last question.     Host: What is one thing you cannot leave San Diego without doing?     Guest: Oh, I would go back to that midway. I would have to say what I said before is going to do that midway tour was really cool.   Guest: Yeah, especially if you're into history or just enjoying like it's not every day you get to go walk on a ship like that and kind of be immersed into that lifestyle. So you learn a lot. You see a lot and it's worth the admission price.   Guest: Yeah, I would say the same thing that that U.S. I mean, I would have did it again. I thought it was so cool.     Host: And then when you're there, get the get the guide.     Guest: Oh, yeah, they'll have them right as you walk in the door. They'll just be like, do you want an audio guide? It's free. So yeah, pick it up. And the learning is your fingertips.     Host: Yeah, even better. Can't be free.   Host: Well, thanks again for coming on the show. This was a great episode, not only talking about things to do in San Diego in the February time of year. I think it helped people prepare for what that might look like, but also we named a few things you can do during that busy season and what to be prepared for when it does get busy.   Host: But Kyle and Renee, one more time, where can our audience find out more about you guys?   Guest: So our main platform is on YouTube, and you can find us by searching "Happily Ever Hanks." If you want to find our website, you can go to Google and just type in "Happily Ever Hanks .com," and we should pop up right there. So those are two main places to find us. Also, Instagram and Facebook, same thing, "Happily Ever Hanks."   Guest: That's true. Yeah, we have all the goodies. Just type in "Happily Ever Hanks," and it'll pop up somewhere.     Host: All right, sweet. Everyone check them out. Kyle and Renee, thanks again.     Guest: Thank you guys. We appreciate it.  

https://atravelpath.com/   Hey Pathfinders, join us as we welcome back Dakota and Courtney to the show. After hearing about their inspirational story of travel nursing and doing two van conversions, they sat down with us to share on of their favorite destinations. We chatted about Juniper Springs Campground in Florida and some of the nearby attractions. Learn all about:   ·        What makes Juniper Springs such a great destination ·        Paddleboarding and kayaking in the area ·        Nearby airports and transportation ·        Destinations within an hour including Kings Landing, Devils Den, and Daytona ·        Swimming with manatees And more!   Chapters ·        00:00 Introduction ·        01:15 What makes Juniper Springs such a great destination? ·        04:00 How far away are nearby attractions? ·        04:45 How long should someone stay there for? ·        06:30 How was it bringing your dog? ·        08:30 Juniper Springs campground amenities? ·        09:45 Nighttime activities? ·        11:45 How was the overall cost in Juniper Springs? ·        12:30 How was the food scene? ·        14:00 What are three things you need to pack when visiting Juniper Springs? ·        15:30 What are two complaints someone might have about Juniper Springs? ·        17:00 What is one thing you can't leave Juniper Springs without doing?   Links ·        Ocala National Forest: https://www.fs.usda.gov/recarea/florida/recarea/?recid=83528 ·        Juniper Springs Recreation Area: https://www.fs.usda.gov/recarea/florida/recarea/?recid=83676 ·        Ian and Ana's video (featuring Devils Den, 3 Sisters Springs, and Kings Landing): https://www.youtube.com/watch?v=9L2ZK09Jd5g&t=1057s ·        Lectric eBikes: https://lectricebikes.com/ ·        iOverlander: https://www.ioverlander.com/   Nearby Attractions ·        Kings Landing (1 Hour): https://www.kingslandingfl.com/ ·        3 Sisters Springs (1.5 Hours): https://www.threesistersspringsvisitor.org/sisters ·        Devil's Den (1.5 Hours) https://www.facebook.com/DevilsDenSpring/ ·        Daytona (1 Hour: https://www.daytonabeach.com/ ·        Disney World (1.5 Hours): https://disneyworld.disney.go.com/   Podcasts Mentioned ·        Disney World: https://atravelpath.com/disney-world/ ·        Florida Keys: https://atravelpath.com/florid-keys/   Nearby Airports ·        Orlando International Airport (about 1.5 hours): https://orlandoairports.net/ ·        Gainesville Regional Airport (about 1.5 hours): https://www.flygainesville.com/     *All content from atravelpath.com, including but not limited to The Travel Path Podcast and social media platforms, is designed to share general information. We are not experts and the information is not designed to serve as legal, financial, or tax advice. Always do your own research and due diligence before making a decision.   Transcript Host: Hi Guest and Guest, welcome back to the travel tips segment of the Travel Path Podcast. So for those of you who missed part one, Guest and Guest came on. They're on Instagram as Kota and Court. They've done two van conversions now. Um, Guest works as a travel nurse. We got into very specific details about getting into travel nursing and also their van build. Um, so if you haven't listened to that one, definitely check it out. But for part two, travel tips, where are we talking about today?   Guest: We're talking about Florida, specifically Juniper Springs area in the Ocala National Forest, and um, some of the stuff is kind of a broad range of surrounding areas, yes. So surrounding areas, there's a lot to do in Florida, there's a lot to do in that area.   Host: Awesome. Now, what made you guys want to share about Florida and the Juniper Springs area today?   Guest: So, we watched it. It was always like a bucket list trip for me. Um, I watched a video on it from Ian and Anna, and at the time theirs was called the other side, and uh, it looked really, really cool. It just looked almost like it was out of this world. So it was always a bucket list trip for me, and um, you know, we finally got to do it and so it was, it was really fun.   Host: What makes Juniper Springs such a great destination? Like, what type of activity should go there?   Guest: Just being outside. So, it's really cool. It's in the middle of the Ocala National Forest, it's a campground. Juniper Springs is a campground. And so, they've got like a neat little area that you can pull in and um, they got like a fire pit and tables, but it's really neat because they have the spring area and it's just really beautiful. It's blue water, it's clear, and it's close to Three Sisters, was the other part of that trip that I wanted to take, uh, so you can go and swim with the manatees. It's certain times of year they have them, uh, over there where you can swim with them, uh, swimming, kayaking, yeah, kayaking, hiking is a big one. There are lots of trails, um, actually when we checked in, there was somebody who was lost in the forest and emergency vehicles were pulling up and someone's like, yeah, somebody's like lost or hurt or something, we were like, oh my, so you know, hiking is a big one. I think probably backpacking, there's a lot of land over there to cover but we didn't go backpacking really or hiking, I don't think. We rode our bikes around a lot, um, just explored the area, but definitely like outdoorsy things. And I mean, there's, I think there's off-road trip around there too if you want to take like a dirt B, horses, ATVs, all different, it's really broad, you know, spectrum of things to do.   Host: So a lot of outdoor stuff though, that's perfect, and pretty much anyone going with their camper or their van, that's what they're going for is that outdoor experience. So that sounds awesome. Now did you guys bring your own bikes or did you rent them when you were there?   Guest: Um, we brought our own. We have, um, the electric e-bikes, so we brought those. We brought, um, I don't know if we brought our paddleboard, but we brought our kayak, um, which we used at King's Landing, a little like river flow type thing, um, so yeah, we brought, we did bring our own bikes, and the bikes we bought, they were like, she said the electric e-bikes, so they folded up and they fit in the back underneath the bed, so they're pretty compact and we could get them out and unfold them and ride around nice.   Host: Do you know if you saw anywhere around that you could rent like paddleboards or kayaks or bikes from?   Guest: So like when we went to King's Landing, I know that they had rentals there, you could take your own and that one was a really, really cool place to see as well. It's spring-fed and all the water's super clear, you can walk through lots of it, um, there are gators and stuff so there's like two different parts of that where you can go up one, um, just to see, you know, the scenery and then there's like a wildlife part of it where you're going to see more, um, like gators and stuff like that.   Host: Now, the campground Juniper Springs is in the National FL, and then in these other little areas, how far away are they? How far are you driving?   Guest: Oh, I mean, I think, like, I think like an hour or I think, yeah, yeah, 30 minutes to an hour, um, not super, not super long, all in our opinion, maybe an hour, yeah, which we're used to driving a lot. I mean, right now we're driving 1,500 miles a week and so I mean, our not very far to us can be a lot further to other people.   Host: But I think it's nice especially for the RV community to have somewhere that you can go that does only take, you know, an hour and a half to get to because then you can either just bounce the next day or stay over there. Um, or you can go and enjoy stuff and then head back to that campground if that's really where you just want to be staying now to get the full experience. How long did you guys stay there for?   Guest: We stayed, I think it was a week and, um, I mean it was more than enough to kind of see what was in the area but we moved pretty fast so, um, I mean there's plenty to do for longer than that. Uh, we kind of went in the off-season. Even when you're heading down, there's stuff to do along the way, like Devil's Den is, um, you know, along the way but there's a lot, there's a ton of springs, ton of places to kayak and stuff like that. There's a lot to do around the area.   Host: You said you went in the off-season, when was that? Like early March?   Guest: Yeah, so it was before, you know, all of the, before the summer crowd really. They were just kind of getting things started, even like the spring break crowd. Like I don't even think that we saw a lot of like, but Al weren't by the beach either so, um, we didn't, you know, it was, it was really pretty chill. We went to the beach but it was closed down, like not closed down but there wasn't like a whole lot of stuff going on.   Host: And in March, did you guys have good weather in this area?   Guest: Yeah, I mean for the most part. There were some days where it was kind of cloudy and I mean the, the April-May showers type of thing but it cleared up pretty fast. I mean I think it's not uncommon for it to rain and then be sunny in Florida so, it was, it was good. It was decent.   Host: And how was the temperature of the water in March?   Guest: It was cold. We put our feet in, let the little fish bite our toes but, um, I think it stays around the same temperature most of the year or if not all the year so it, I mean it's pretty chilly but it's not like you can't enjoy it, yeah, absolutely.   Host: Now, you guys do have a dog, did you have your dog when you went?   Guest: Yes, yeah, he was a puppy, trying to think. I was like, yes, we were afraid that the bears, we had to walk out in the dark a few times and we were afraid that the bears were going to come in, which I mean we're not from an area that there are bears, yeah, so like every sound we heard or even like in the van sleeping, we're like, do you hear that? Which now, you know, we're a little bit, since we've traveled more, yeah, it's not like as intimidating and they don't, we didn't see a single bear while we were there, nobody had any issues with a bear. I mean we had bear spray just in case, needed it but, I mean people were out at night, you know, cooking stuff on a campfire and all sorts of stuff. I mean nobody had any issues with a bear, I think it was just because we were new travelers, better to be cautious. They have like warning signs, like lock up all your belongings and so the, they do have, uh, warning signs when you come in, trash cans and stuff are all, you know, and in lock down bin. Yeah, yeah, Hank loved it, he, he was just a puppy we had just, we got him in January of that year and we went in March so he was only like two months old so he had a blast. We were still actually trying to potty train him at the time too so he was still doing really good.   Host: So, obviously, you drove there but how does transportation work like where is this National Forest in relation to some of those major airports if someone doesn't have a van and wants to fly and enjoy the campground in the National Forest?   Guest: Yeah, I mean there's, there's airports you can fly in, you can rent cars and get to all those places. Um, say we, the closest we were Orlando, yeah, it wasn't far from Orlando, it wasn't very far from there, maybe some closer options but I know that there, you know, it's not very far from a lot of those airports that are, you know, down there in that area. I think there's quite a few of them, um, I'm not sure right off the top of my head which ones exactly they are.   Host: Why don't you, um, tell us just a little bit about the campground and kind of some of the amenities that they had there?   Guest: Yeah, um, I mean they had biking trails, uh, they had walking trails, you could go backpacking in, uh, that specifically that area, they had like, um, they, a shower room, they had like a little room, um, beside the showers so you could go like with a sink and I think and you could go and wash your dishes, um, the Ocala National Forest is huge so, um, I think there's a lot of stuff just right there by it, there's different lodging and and stuff like that.   Host: Awesome, we love National Forests because a lot of times you can do dispersed camping there so it makes it nice where you can just kind of explore, pull off, find an area that doesn't have a no camping sign and you're usually good to stay there for the night and that's some of the best spots that we've found so it's nice that you have the option for the campground but you're also in the National Forest, you could probably drive out and stay somewhere for a night and you know, feel like you're really in the middle of the national forest.   Guest: Yes and things, I think things are a lot harder, you know, when you get, I think somebody said east of the Mississippi is a lot harder to find, you know, dispersed camping but it's definitely doable. I mean you, we use apps like iOverlander and stuff like that that help out too so, yeah.   Host: We've used eye Overlander a lot, and that has almost always pointed us in a good direction. So in this area, what is there to do at night?   Guest: We did a lot of just, you know, camping stuff. I mean, we just, you know, make s'mores or roast, you know, hot dogs, have a campfire. I think it's just mostly like outdoor stuff. A lot of the stuff seems to kind of close down at night. I mean, you can travel into some of the other places like Daytona Beach. There's a lot of stuff to do around there, so it just kind of depends on what you're looking for and what you like.   Host: Yeah, definitely. In Florida, there's something for everybody.   Guest: It's not too far from other things to do at night, but where we were at mostly, it was just, you know, kind of campfire activities, hanging out with each other, relaxing.   Host: Yeah, so that's perfect. That's what, you know, being in nature is all about. How was the stargazing? Were there open areas for that?   Guest: There were, for sure. I mean, you could get out of the campground and drive kind of through the forest, and there's places to pull off on the sides of the road and stuff, and you can get out. I mean, it's really dark, easy to see stars and stuff like that, but where we were at, there was a lot of coverage.   Host: Yeah, very good. Sunset or sunrise locations, did you get to see any good ones?   Guest: Yeah, more towards like the beaches. So, good pictures at Daytona Beach of our van with the palm trees and stuff in the back. So, in the Ocala National Forest is, you know, mainland, I guess you would call it, or inland, I think that's the word I was looking for. So if you travel more towards the beaches, I mean, that's not to say that there could be other places that we didn't see, but a lot of the sunset pictures at the beach and stuff like that were really, really cool. I mean, it's, there's not really anything like seeing a sunset at a beach.   Host: So, as far as overall cost for this trip for you guys, was it more expensive or less expensive than you expected?   Guest: I think it was less expensive than we expected, just because we had budgeted more just for activities and stuff, but a lot of the stuff wasn't very expensive. Like, we brought our own inflatable kayak to go on King's Landing. It was less expensive than renting a kayak there. And a lot of the amenities were just free, you know? I mean, we had to pay for our campsite, but it was fairly cheap. The biggest expense was gas to get there, actually.vSo under budget that we decided after we left that we were going to go up to Pigeon Forge, Tennessee, and see that too.   Host: That's always nice when you have extra money in your budget and you can just add something else in.   Guest: For sure. We did that. Yeah, it was fun.   Host: Awesome. Now, did you guys have any good food spots in the area that you were in, or did you have to really pack everything in and cook at your campfire?   Guest: That's, we kind of packed everything in and cooked everything, you know? We made sandwiches. At the time, she was T of money. She was a staff nurse and I worked at the school, so it wasn't like we had a ton of money. We were kind of on a budget then, so we just ate, you know, sandwiches and cooked cheap stuff and really just traveled to see the place, you know, and experience it, not necessarily spend a bunch of money. We've never been, you know, huge on like going and doing all these attractions and stuff. Ours was just really to see the environment, get to say we've been there, and just enjoy it for what it was, you know, what it had to offer. And I think we were excited to cook and do everything for the first time in our van, too.   Host: Absolutely, just really be in the van and experience that, of course. Plus, with the new puppy, you probably didn't want to venture out too far from him. Very cool. So if you haven't mentioned it already, are there any other nearby attractions?   Guest: Yeah, there's lots. I mean, there's, um, Orlando's not like crazy, crazy far, so you can go to, you know, Disney. We went to Three Sisters, we went to King's Landing. I mean, there's a lot to do.   Host: Perfect. And on your way, I guess you can stop and listen to our podcast with Eric Adventures. She did on Disney. Stop there and do that, and then head to the national forest and listen to your guys's podcast. That's perfect.   Host: All right, guys, well, it's time for the final three questions, the 3-2-1 countdown section of the podcast. So, what are three things you have to pack when you go to this Juniper Springs area?   Guest: Bug spray, yeah, bug spray for sure.   Host: I was gonna ask.   Guest: I think another one would be, if you can, like a bike or a kayak or something to kind of entertain yourself outside. So, I mean, you don't even have to have those, just like some sort of outdoor activity, whether it be like frisbee or ball, or you know, I guess you don't have to do that kind of stuff, but, you know, that was something that was important to us. And then with staying at the campground, it's not like it's super, super close to town. I think it's like 15 or 20 minutes to the town. So, you know, pack your food in there and then, you know, take your trash and dispose of it on the way out.   Host: Perfect. So bug spray, food, and something to do outside, some sort of activity, yeah, whether it's a bike or a kayak or a football. That's a good point. I feel like I've gone to the beach so many times and there you go to the beach, you lay down or you go for a walk or you go for a swim, but I remember thinking repeatedly, I wish I had like a football or just something to throw around, a frisbee, football, you know, whatever.   Guest: I'm the same way. I'm not much of a lounger. I like to do stuff that's, you know, fun, whether it be ride a bike or a one-wheel or, you know, whatever. Yeah.   Host: Yeah, I like to lounge, but it's good to, like, work up a sweat, throw a ball around, and jump in the water and just repeat, right?   Guest: Right, for sure.   Host: What are two complaints that somebody might have about this area? And not necessarily complaints, but things people should be prepared for. And I feel like I know the answer to one already.   Guest: Yeah, so like driving would be one. The other would be maybe like cell phone signal and service. I don't... which one were you thinking that I was thinking?   Host: The bugs, but.   Guest: Oh yeah, yeah, bugs for sure. That's the first one that came to my mind.   Host: So, in terms of driving, it's just the drive to get there or are you driving kind of for long periods to get back and forth to the town or like a grocery store is a little ways away?   Guest: So, like, like I said, it's like 20 minutes. So, it's not like you're just driving right on into town to get something. You know, it's a little bit of a... get something. So that may be a complaint some people. The other one is like signal, you know? There's not... now there's Starlink. When we went, there wasn't Starlink. So you may be able to have something like that, but for us, we didn't have any cell phone signal. We didn't have any way to contact anybody if we needed to, which I, you know, that's a blessing and a curse, I guess.   Host: Well, whether it's a blessing or a curse, it's still something you should be prepared for, so that's a good tip to bring up.   Host: And last question, guys. We talked about a lot of things in this episode, but what is one thing if you had to pick that you cannot leave Juniper Springs without doing?   Guest: I'd say going to do King's Landing. It's just a lot of cool, like, photo-like opportunities, like it's just really that, like, photo-like that picture-perfect moment that not even, like, really even your camera can capture. Like, it's just so beautiful. And we have tons of pictures of it posted, I think on our Instagram or maybe our separate Instagrams, but a very beautiful place. I think that's one place that I would... Yeah, like if you look up like videos of it or whatever or see pictures, you know, when you show up to that place, it's going to be exactly if not better than what you've seen online. So, it was just really beautiful, clear water, it just felt like you were in, you know, an oasis, yeah, but the trees over top of you and yeah, it was just a unique experience that I don't think you would get anywhere else.   Host: Yeah, yeah, there's a lot of those places where, like, you know, photos, they're always going to look better in person, but oftentimes, like, a thing that looks really cool in person, it doesn't look that cool in a photo. But the King's Landing is one of those things that it's both. In person, it's amazing, I would imagine. I haven't been there yet, but the photos of it look amazing too.   Guest: You've been to places where it looks really cool, you know, and you get there and it's not quite as NE, yeah, but this one, yeah, it's everything that you would imagine. So, we even tried to paddle, like, when we were... I think when we were heading up, we were going like with the current. So, we were like trying to slow down just so that way we could like just take it all in a little bit slower. Maybe it was on the way back, I'm not sure. When you go up, you go against the current, on the way back, you go with the current.   Host: Sweet, guys. This was another super informative travel tips segment. One more time, listeners, if you haven't tuned into the first episode, they talked about their travel nursing and their van builds, so definitely check that one out. And yeah, Hope and I, we're excited. We're going to go to Florida over the next couple of months here and we definitely want to add this to our list too. So maybe Disney and then we've got Florida Keys and we'll have to stop in Juniper Springs too. Awesome, guys. All right. And one last question, where can our audience find out more about you?   Guest: We're on Instagram @Kodaandcourt is our name. And we have a YouTube channel. Maybe we'll start uploading to it. We'll just, you know, see what kind of happens.   Host: Sweet. All right, Dakota and Courtney, thanks again.   Guest: Thank you.

It was so great to have Chad and Eileen back on the podcast to give us a very detailed overview of their six week trip to Alaska. Even better, they are planning on returning for an entire season so they let us know what they are doing differently to prepare for their next journey. Price It's no secret that Alaska is expensive. They share how even though they anticipated to spend a little more here, they still underestimated it. Internet If you want to have some sort of internet connection while you make the drive to Alaksa, Starlink is your best bet. They mentioned how they had very poor service, and even if they didn't need to use it, knowing they could fire up Starlink if they needed to gave them peace of mind. Things to Do From boat rides, plane rides, and hiking, they stayed very busy. They admit they didn't do a ton of excursions, but since Alaksa is such beautiful place to be, they really didn't need to. We discussed a few things they are looking forward to doing next time as well. 3, 2, 1 Countdown 3 Things to Bring to Alaska ·        Bug spray, fly swatter, bug net ·        Blackout curtains, eye mask ·        Binoculars 2 Things to Be Prepared For ·        Bugs and mosquitoes ·        Bears 1 Thing You Can't Leave Alaska Without Doing ·        The plane ride or jumping in a lake Chapters 00:00 Introduction 01:00 How much time did you spend in Alaska and what did you cover? 02:00 How much time should someone spend in Alaska and when should they go? 04:00 How was it bringing your dog with you to Alaska? 07:15 Sightseeing plane ride in Alaska 09:30 How did you get to Alaska with your van? 13:00 Favorite camping spots? 14:45 How expensive is it in Alaska? 15:15 What activities did you do in Alaska? 18:30 What is there to do at night in Alaska? 20:15 How long did it take to adjust to it not getting dark? 23:30 How was the food scene in Alaska? 24:30 How are you preparing differently for your next trip to Alaska? 26:00 What are three things people should bring to Alaska? 27:45 What are two things people should prepare for before they visit Alaska? 30:15 How are the roads in Alaska? 32:00 What can't you leave Alaska with out doing? Chad and Eileen on Social: ·        Miles Van Life: https://www.instagram.com/themilesvanlife/ ·        Eileen's Instagram: https://www.instagram.com/eileenrosemiles/ ·        Eileen's Website: https://www.eileenrose.me/ ·        Eileen's Podcast: https://podcasts.apple.com/gb/podcast/the-inward-journey/id1666397129 ·        Chad's IG: https://www.instagram.com/chadmmiles/ ·        Chad's Podcast: https://www.buzzsprout.com/2228949/share Locations ·        Fairbanks: https://www.explorefairbanks.com/ ·        Denali National Park: https://www.nps.gov/dena/index.htm ·        Hatche Pass: https://www.alaska.org/detail/hatcher-pass ·        Anchorage: https://www.anchorage.net/ ·        Kenai Peninsula: https://www.travelalaska.com/Destinations/Regions/Southcentral/Kenai-Peninsula ·        Whittier: https://www.alaska.org/destination/whittier ·        Hope: https://www.alaska.org/destination/hope   To Do: ·        Boat Trip to Juneau: https://alaskafjordlines.com/ ·        Plane Ride: https://www.katair.com/ ·        Katmai Bear Viewing Tours: https://katmaiair.com/   Restaurants ·        Karstens Public House: https://www.westmarkhotels.com/denali-food/ ·        Anchorage Breweries: https://www.anchorage.net/restaurants/breweries/   Camping ·        Dyea Flats: https://www.alaska.org/detail/dyea-campground   Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/sky-toes/gently-comes-tomorrow License code: JNNG98EA42W634JP   *All content from atravelpath.com, including but not limited to The Travel Path Podcast and social media platforms, is designed to share general information. We are not experts and the information is not designed to serve as legal, financial, or tax advice. Always do your own research and due diligence before making a decision.   Transcript Host: All right, Chad and Eileen, welcome back to the Travel Path Podcast.   Guest: Hi, we're happy to be back. So, in case you missed the first episode, we talked about all their van life adventures, and we took a pretty deep dive into some of the finances and a lot of the things that people don't think about with van life, including routines or lack of routines, getting kind of out of the routines you're used to living at home, and transitioning to van life. So, if you haven't listened, give it a listen. For part two, travel tips, we're talking about one destination. So, Chad and Eileen, what destination are we talking about today?   Guest: We're going to talk about Alaska.   Host: All right.   Guest: Our favorite place in the world for sure.   Host: So, I guess that's what made you decide to share about Alaska today, is just how much you love it?   Guest: Yeah, and I think last summer, we made our first trip up to Alaska, and we spent about six weeks there. And it was such an overwhelming experience trying to figure out and plan for all the things that we might need to go there, and so maybe we can make it a little bit simpler for people by sharing today.   Host: Awesome. How much time did you guys spend in Alaska, and what did you actually cover when you were there?   Guest: So, we spent a total of about six weeks in Alaska. That doesn't include the drive up or the drive back, but our six weeks in Alaska, we covered quite a bit. So, we went up the more northern route. We started in Fairbanks, and then we made our way south from there. So, we hit Denali National Park, we went to Hatcher Pass, we went to Anchorage, down to the Kenai Peninsula, and then on our way out of Alaska, we went down to Skagway and took a boat trip to Juneau as well. So, we covered quite a bit of it.   Host: Yeah, you certainly did. So, would you say for someone who is living this van life journey or taking a cross-country trip, how much do you think six weeks is a really good time for them to experience Alaska? Or would you say plan more or you could plan less?   Guest: We are going back for the entire summer, but I know that's not realistic for everyone, but you probably will fall in love with it as well and want to go back for longer. But we do feel anywhere from 4 to 6 weeks is enough time to get the most out of it and see, you know, the Denali National Park, which is our favorite place, and then the Kenai Peninsula for sure. So, four to six weeks would be good.   Host: Yeah, good. So obviously, you know, if you're going to really enjoy the national parks and probably have a great time, you want to go in the summertime when it's not the dead of winter. What are some of those seasonal highlights for you guys, at least when you were there?   Guest: Well, yes, you 100% need to see Alaska in the summer because in the winter, it is, I think, it's four or six hours of daylight, and the rest is all dark. And so in the summer, you get 20 hours of daylight. So, you have longer days in the summer. It's actually wild how long they are. We tried to see the Northern Lights, and it never got dark enough. So, that's what's great, though, about the summertime is the days are long, and you can start a hike at 4 p.m., for example. It's beautiful. There's a lot of fish out in the rivers that you can catch and enjoy fresh. There's beautiful flowers, and everything is just beautiful in the summer. So, there's lots of wildlife that are out in the summer. So, you're looking, if you're planning on going up to Alaska, your window to be there is about mid-June through September 1st. Outside of that, you're going to run into some colder temperatures. But when we were there, we were there mid-July through about September 1st, and I mean, it was beautiful, 60, 70-degree days. We had a lot of sunshine while we were there, so the weather is definitely a highlight if you're there in the summertime.   Host: Yeah, sure. And then you're traveling with Sadie, your dog. So, do you feel like she was able to go on all these hikes with you? Were there any restrictions that you kind of got snagged on?   Guest: She couldn't enjoy the Denali National Park hikes with us. But Hatcher Pass, for example, is a hidden gem south of Denali, is that right? Okay. And it's beautiful, and it honestly reminded me of Switzerland, even though I've never been to Switzerland. I've only seen photos, but it's just beautiful, stunning mountain ranges, super green, and she could hike with us there. So, we figured out a lot of places where she could adventure. And I mean, Alaska in itself is beautiful no matter where you go outside of the park. So, she could be everywhere with us. And they do say traveling with a dog or traveling in a pack does spook the bears away and animals away too. I don't know, we never had that encounter, thank goodness, with a bear. But it's good. They actually, it's good to travel with your pets and hike with them.   Host: So perfect, now diving just a little bit deeper into some of the things and places that you guys actually went to in Alaska. Do you have any highlights or spots that you think maybe you should spend a little more time or a little less time in that you went to?   Guest: I think the area that we'd like to spend more time in would be the Kenai Peninsula. It's an incredible place because you've got some beautiful mountains and you're right on the ocean, so you've got the mix of both. The climate's really interesting, and some of the little towns are fascinating. The little town of Whittier and the little town of Hope were these unbelievable places that it's hard to imagine exist. So, that area has got so much natural beauty, there's national parks down there, so the Kenai Peninsula is definitely an area that we spent a fair amount of time. We were there for maybe a week or so, but we definitely would like to go back and spend some more time. And Denali National Park is just an incredible place. You get to go see Mount Denali, which is an unbelievable sight, as long as you can see it, which you need to have a clear day in order to be able to see it. But that was an area—I actually have family in that area—so we hung around there for probably about two weeks and just really enjoyed it. And if you want a really unique experience while you're there, we would definitely recommend flying. So, we went for a flight in a small six-person plane, and it just gave you this incredible view of all the natural beauty that's out there and a really unique perspective.   Host: I remember seeing that Reel, it looked awesome.   Guest: It was, I still dream of it to this day. And when we go back, we're running to that small plane and going for another flight. I do want to say, though, I think, nothing against Fairbanks, but it's just another typical town. That's something that we wouldn't really recommend you don't need to go. We think that, yeah, spend more time down in Denali area, Hatcher Pass, Kenai Peninsula, and you'll be golden.   Host: Awesome. Now, speaking of that plane ride, because if anybody goes and looks at your Instagram and sees what that looks like, it's going to absolutely be on their bucket list. What do you remember, cost-wise, to do something like that? Like, what should someone prepare for?   Guest: So this is where it's not going to be very helpful because my cousin is a pilot, and so, shout out to Greg, he lives out there, and so he operates an air taxi service and operates a lodge within Denali National Park, so we got to fly for free. However, if you are looking to fly, you're looking to pay probably about $250 per person for like an hour sightseeing flight. So, it's not necessarily cheap, and it is absolutely worth it because the things that you will see are unbelievable. So, would still recommend, but I know that's not a super helpful answer. I will say, too, the Denali National Park, there's a road closure right now, and it will be closed for a couple more years. And so it's just the best way to see more of the park because, sadly, you can only drive in. It's still gorgeous, of course, but you can only drive in to a certain point, and then they make you turn around because it's not safe. The, I don't know how to explain it, but the road kind of just collapsed on itself, I guess. So, yeah, you definitely want to take that plane ride. And I'm someone who was really fearful of flying, and it was so peaceful once you just get distracted by how beautiful it is. And it's really, really beautiful, and you just can't think about how scared you are. So, it's worth it.   Host: Perfect. And you said Greg operates a company that'll actually take people out to do this, right?   Guest: Yeah, so his company is Kantishna Air Taxi, and so they offer private sightseeing flights, and he's a great pilot.   Host: Awesome. We'll put his information in the show notes, and then tell him Chad sent them.   Guest: That'd be great.   Host: So, as far as transportation to actually get there, obviously, you can fly in. There's tons of ways. But you guys are taking yourself converted van. So, what was that process like for you to actually drive into Alaska, and what did you need to prepare before?   Guest: So, there's two primary routes that you can take if you're going to drive to Alaska. One of them is the Alaskan Highway that starts in Dawson Creek, Alberta, and takes you through Northern Alberta into the Yukon Territory and then over into Alaska. That route is a little bit more commercialized. It's the most popular route to take. And so, there's just some more options for food or more options for lodging and more stops for gas along that route. We came that way back from Alaska down through Canada. The other route that you can take is the Cassiar Highway, which runs along the western part of Canada and takes you up through British Columbia. That route, in our opinion, is more naturally beautiful. It is also very remote. There was a period of three or four days as we were driving. This was during the work week, so we were driving maybe three to four hours per day, but there was a three to four day period where we did not have cell phone service one time. So, it is very remote. There's not a ton of options for lodging or for gas. So, you definitely would need to be in a van or an RV if you want to go that route so that you can find random spots to stay. And you need to have some pretty off-grid capable. But if that is the case, that was the route that we enjoyed the most. Going through the mountains of British Columbia was unbelievable. It was really, really nice, and that's probably the route that we will end up going back when we head back there this summer.     Host: Very good. I guess that's why in episode one that you guys did, you talked about getting the Starlink, and you're glad you had it going into Alaska, right?   Guest: 100%. Yeah, we talked to a couple of people that had gone to Alaska before, so that's a great tip too, you know? If you're thinking about going to Alaska, reach out to us for sure, and we can tell you all our tips and tricks. But someone said, "No, you for sure need a Starlink because there's just complete dead zones." And, yeah, anytime you pass a gas station, fill up no matter where you're at. And yeah, it's quite the adventure. As far as what else we'd recommend planning, I mean, if you have something like Starlink, then of course you can get access to the internet everywhere, and that gave us a little bit of peace of mind so that if something were to go wrong as we were traveling and we were in more remote places, you know that you could hop on the internet and you could get in contact with whoever you needed to. Otherwise, I would say just plan for the fact that gas is really expensive, especially in that part of Canada and in Canada in general. So, the cost of gas is going to be very high. That's something to plan for. And then as far as like your food and what you're bringing with you and some of your rations with water, you'll just want to be a little bit more intentional about some of those things because it is more sparse and it's more remote. And so, have a plan for food, pack a lot more dry food that you can have access to as you're traveling just in case you go longer spells without having access to a grocery store. But those are some of the things that I think would be a good idea to think about.   Host: Yeah, very good. Good tips. I like that. And then as far as once you got into Alaska, I assume you probably stayed the majority of the time in your van. Maybe you stayed with your family a little bit. But did you guys have any spots that were like these amazing spots you need to go find them to park your van at for the night? Or were there any campgrounds that you stayed at?   Guest: Oh, my goodness. There's so many spots that we loved. On our way up there, there's a spot in the Yukon that was really sketchy to drive down to, but we loved it. And the other thing, if you're going to caravan with people, definitely have walkie-talkies because that just makes it so much more fun when you see a black bear or see a moose. That's also something, definitely have walkie-talkies. And we used that when we were driving down this sketchy road to this beautiful spot in the Yukon. And then in Alaska itself, I mean, there's just... we... you can stay at Hatcher Pass, you can stay in... there's a place in Seward where we loved, and it's super flat, so there's a ton of different vans and Airstreams and all sorts of campers there too. We didn't stay in any campgrounds, though. I don't think we did. There's a spot called the Dyea Flats, which is if you go to Skagway, a really, really beautiful place, one of our maybe favorite camp spots that we had. So, we did a lot of... I mean, the nice thing about driving to Alaska is that there's tons of options of places to stay because you can stay pretty much anywhere. So, when you think of BLM or Forestry Service land out west as you're going through British Columbia and the Yukon and when you're in Alaska, that's a majority of what's out there. There's not many people, so you can just go to little pull-offs or if you find a place where you can fit your rig, for the most part, you can probably stay there. So, you can kind of get off the beaten path and find some really unique places to sleep and stay for a night or stay for a few days.   Host: Yeah, very cool. So it sounds like as far as finding a spot to sleep, you don't have to worry about shelling out a ton of money for that. Gas is a little bit expensive, but as far as other costs in Alaska, what do you guys feel like? Were you spending way more on food or do you feel like it was pretty comparable to other places you've been?   Guest: We were spending a lot more on food for sure. We went to this one small grocery store, I remember, and I felt like they had things shipped in from Costco but then jacked up the prices. So definitely, food is expensive because the grocery stores are really far away from each other. And those will definitely be the two biggest things to plan for: food and gas. Your typical food and gas budget for a month, I would multiply them by probably one and a half and expect that that's probably about what you'll pay for as you're traveling to Alaska and back. And then, of course, it's just kind of discretionary from there. But if you want to eat out, if you want to do activities, things are definitely a bit more expensive as you're going through those different areas. So those would be good things to plan for from a budgeting standpoint.   Host: Yeah, sure. Besides the plane, were there any other activities that you guys did indulge in while you were there?   Guest: No, yes, there wasn't. Frankly, we were on a budget on our trip last summer, and you know, some of that was because we didn't know or realize how expensive gas would be, how expensive food would be. So we didn't really necessarily plan for that, which meant we had less money to spend doing things. But there's tons of activities that you could do if you wanted to. Go whitewater rafting, or if you wanted to go on a boat ride, or if you wanted to go fishing, there are a lot of things that you could do up there. I was going to say, our boat ride, that's why I said no, yes. We did do a boat ride from Skagway to Juno through the Inside Passage. Oh my gosh, it was beautiful. And thanks to my mother-in-law, Chad's mom, that was our birthday gift, I believe, or Christmas... yeah, birthday gift. So yeah, we had some... we were definitely budgeting, and there was... we had a couple of friends that did the plane ride to Katmai, I think it's called, and we would love to do that this summer because that's a place where you can go fly another small plane, beautiful experience. And then there's tons of grizzly bears that are enjoying salmon right in the river, and it's all... there's electric fences, I believe, to just kind of keep you safe. I mean, the grizzlies are super focused on the fish, so everyone's pretty much safe, but it's a beautiful, really cool experience. And honestly, the only way I think I'd want to see a grizzly, but so yeah, there's that trip that people can look forward to. And then I would love to do the whitewater rafting, but so maybe this summer we'll be able to do that. But yeah, all we did last time was the plane ride and the boat trip. I highly recommend that.   Host: For sure, that's awesome. And I mean, you're in Alaska, so especially in the summer, like, put your hiking boots on and start walking.   Guest: Like, that's an adventure in itself. And I think that's the thing, is that you don't necessarily... all of those things are options. I'm sure we didn't get to do many of them, but they would be incredible experiences. And every day, you can just walk out of your van door or whatever your rig is, and there's just natural beauty all around you. And there's tons of free activities and places to explore, so we never found ourselves running out of things to do.   Host: Very cool. Now, obviously, you were there in the summer, so you have a little bit more sunlight than we might be used to, but what was there to do at night?   Guest: Stay outside, because it's light out. One of my favorite memories is we were in Alaska with DJ and Garen, and we were all sitting around a campfire, and Chad was basically falling asleep in his chair. He's like, "I'm ready to go to bed." And I said, "Why?" And it was because it was almost midnight, but it was super light out. So, I mean, at night, you just... you stay outside and hang out, or try to catch the Northern Lights. I mean, those are a huge thing up there, but it honestly didn't get dark enough where we were, so to the point where you could start a four-hour hike at 6 p.m. and you would still finish it with daylight, and you would be fine. So, the answer to what you can do at night is pretty much everything that you could do during the day, which is a very unique experience.   Host: I love that. Normally, we ask, where is a good sunrise or sunset spot? But I mean, those happen so quickly and all together. Probably that... did you even see a real sunrise or sunset when you were there?   Guest: That's a good point. I'm trying to think... I mean, we may... well, we may have seen a couple, but the thing about the daylight, so it is like 20 hours of daylight. So, technically, that means that for four hours, the sun has gone below the horizon. However, it doesn't ever get fully dark. So, I think, like Eileen might have mentioned at one point or maybe in the past episode, there was one night where we tried to see the Northern Lights. We stayed up till about 2:30 a.m. and went to bed realizing that it was never going to get dark enough that wasn't going to be possible. So, um, yeah, starting to get brighter.   Host: That's got to be a weird thing to get used to. How long did it take you to just get used to it being bright all the time? And at what point did it start getting dark?   Guest: It's a very weird thing to get used to. Your internal clock just gets very thrown off. So, I would say for the first probably two or three weeks, it took us a long time to acclimate to it. And your body doesn't feel tired. It'll be 10:00 and it's still very bright out. And so, your body's like, "Well, I don't think it's time to go to bed." So, back to trying to force yourself into some semblance of a routine, we found that that helped, trying to go to bed at 10:30 or 11 o'clock every night. We would definitely recommend having blackout curtains or magnetic shades that you can put on your van or your rig or using something like an eye mask or an eye pillow so that you need to create darkness because it won't be there like you're used to. It's weird.   Host: That's good tips, though, because I mean, everyone knows that in the summer, Alaska's bright, but actually hearing from someone who stayed there for an extended time, like, yeah, no, it really is bright, and you need to bring that eye mask or something. I think that's a really good tip and just something to be prepared for.   Guest: Yeah. And I remember even driving at 8:00 p.m. or 9:00 p.m., right, and the sun was still in your eye. So, 100% bring sunglasses, um, because it's just wild. It's always out, which is beautiful, but it's really... it's weird, for sure. And so then what's kind of odd is, since there's such a huge swing going from 20 hours of daylight in the summer and then 20 hours of darkness in the winter, around late August and September, you start experiencing the difference, and it starts changing. And if you're from the lower 48, you're used to maybe the sunset changes two, three minutes per day, and up in Alaska, it was changing as much as like 8 to 9 minutes per day. So, all of a sudden, a week goes by and it's getting dark an hour earlier. So, when we left in September, I think it was getting dark by like 8:30 or 9:00 p.m. So, it is amazing how it starts to swing. But if you're going there in June, July, early August, it's still going to be pretty bright up.   Host: Wow, that's fascinating. Yeah, and I can't even imagine going there in the wintertime when it's the exact opposite. It would drive you crazy.   Guest: We did meet a couple of those people that can handle it. Actually, his cousin Greg who lives there, he leaves in the winter because yeah, it's just... it's too dark. And we talked to a couple of folks that do stay the whole year, and they say that they never go anywhere without their headlamp. And some of them try to convince us that it's beautiful, which I'm sure it is in its own way, but that would be so hard, I think.   Host: Yeah, yeah. I don't know how it could be beautiful if it's pitch black the whole time.   Guest: The moonlight's... well, the Northern Lights.   Host: Yeah, you can probably see the Northern Lights all day, right?   Guest: Basically. That's funny.   Host: So transitioning now into food, did you guys stop at grocery stores, cook in your van a lot? Just cost-wise, were there any spots that you stopped or found along the way that were great?   Guest: We definitely cooked in our van a lot. For periods of that trip, our meals in the van became very simple things like ramen or things like cereal or whatever it may be that didn't involve a lot of cooking or things that could stay fresh for a long period of time. So, we relied on a lot more boxed things or canned goods just because sometimes we didn't know when we were going to have availability to a grocery store. So, we did a lot of camping or a lot of cooking in our van. There was one restaurant in particular that was outside of Denali National Park called Carston's Public House that we really liked, and we recommend that people go check that out. And there's another brewery that we went to in Anchorage, but I'm drawing a blank on the name of it.   Host: So, Anchorage is actually home to quite a few breweries and distilleries, so if craft brews are your thing, you might want to check it out. I'll put a link in the show notes for more.   Host: I know we talked about quite a bit of things. Are there any things you're doing differently to prepare yourself for this next trip now that you've already been there for six weeks?   Guest: That's a good question. Relaxing, yes, relaxing. I was freaked out about the bear situation, truly. And it's not as bad as you would think. People say you have to be more afraid of moose. But I pictured in my mind that there would be bears everywhere you look, and there wasn't. So, relaxing, that's a good answer. Yeah, I mean, just relaxing from the standpoint of knowing that it's not going to be as intense or as extreme as we thought it was going to be. Relaxing and knowing that when you get there, a city like Anchorage is a very big city. It's going to have all of the big box stores that you're used to. It has all the things that you're used to in the lower 48. So, you're not traveling to like a third world country or something like that. You can find the things that you are used to. If you need to get packages or we navigated all of those things while we were in Alaska. And so, relaxing, I think we'll just approach the whole thing with a little more ease, and that'll feel really good. Awesome, that's a good point. Yeah, just kind of relaxing, taking it easy, and then also budgeting. You've been there once. You're preparing more to spend one and a half times what somebody might expect to have to pay if they hadn't gone before.   Host: So great, we can transition to the 3-2-1 Countdown, the final three questions of the podcast. We might have brought up a few things here, but what are three things people are bringing when they're going to Alaska?   Guest: Bug spray or bug protectant as a whole is what we want to recommend. So, bug spray, fly swatter, and bug nets. We're actually getting some of those soon because there are a lot of mosquitoes, and they're huge. Yeah, we'll say it again, the blackout curtains and eye mask. You've got to have some kind of plan for making your rig dark. So, whatever that's going to look like for you, you'll want to think about that, or else you're going to have a really difficult time sleeping, and that will be a challenge. And then, our last thing is binoculars, which the cool people in Alaska call them "binos." And that's so you can see hopefully some wildlife from afar and at a safe distance, right? So, binoculars for sure.   Host: Cool. Did you get to see it all your last time out? I mean, the big... the grizzly bears, the moose, the wolves?   Guest: Yeah, we did not see a grizzly bear in Alaska, which was disappointing. We did see one on our trip back, actually once we got back into the US, in Montana. But otherwise, we saw tons of black bears, we saw quite a bit of moose, we did see wolves. So, we saw a good mix of things but not a grizzly when we were in Alaska. So, hopefully this summer will be different. Really? I don't know, we don't have to hope, a grizzly, maybe from afar through the electric fence, right? Through the binos.   Host: What are two complaints or things people wish they had prepared more for when venturing to Alaska?   Guest: We probably talked about a few of them. Yeah, so we're going to go back to the bugs. That is something that you want to be aware of. They are everywhere. There's nowhere that you can go that you're going to be able to get away from them. The mosquitoes are huge, they are nasty, they are persistent. And so, having tons and tons of bug spray on you, having solutions to try to keep them out of the van is very helpful. But that's just, I think, one of the most common complaints. And if you go on any social media and just look up videos of the mosquitoes in Alaska, you'll see some pretty crazy stuff. But that is something that you are going to want to be aware of. It's worth it, though. I mean, and I think there were days or locations where they were worse or if it was windy, I feel like they weren't out as much. But I remember, I was cutting his hair in the middle of nowhere, and I was getting eaten alive, and thankfully, the haircut wasn't too bad, but the mosquitoes are really distracting and annoying. But bug spray does work, so definitely just bring a lot of that bug spray. And then the second thing is bears, again, for sure. Definitely just think about safety and peace of mind. So, having something like bear spray was something that we had with us at all times. Anytime, you know, if you're parked off the road somewhere and if you've got animals around or dogs, since you do have food in your van that you can't always keep airtight, you just want to always be bear-conscious and animal-conscious in general. So, that's something that I guess could be a sort of complaint or something that at least you'll want to think a lot about and be very conscious of. Hiking in groups is really great, and just talking a lot is good too. Those were some of the tips. So, we would always just say "hi bear" or talk or sing, and that was in the beginning when we were really anxious, I'm talking about myself, I just always talking. But just doing those things helps. And then having the bear spray just helps you feel a little more safe.   Host: How are the roads? I had heard people, they've said if you go to Alaska, have a spare tire, and if you have room, bring a second spare tire. But there's... you said there were two main roads to kind of get through. Were they rough or how did you maneuver that?   Guest: They're not great. So, a spare tire would definitely be a good idea. Also, plan for your windshield taking some pretty serious dents from rocks. We probably picked up ten different dents in our windshield of all different sizes, and one of them led to a pretty big crack in our windshield. So, yes, having a spare tire is a great idea. And not that there's a whole lot that you can do about your windshield, but that's something to just think about and probably going to be a reality as well. So, the roads are not great, especially... there are sections of them that are very, I'm going to call them bouncy. I mean, there's like really big hills. It's a roller coaster, to the point where there's moments where our van was like two wheels would go off the ground, and then you'd slam back down. So, yeah, the roads are not great, so that's something to just be aware of. You will need to at points drive slow, even though you're in the middle of nowhere and there's nothing around. But spare tires are definitely a good idea.   Host: Do you have 4x4?   Guest: No, we don't, and we were fine. I mean, you have to know some of your limitations with that, but there weren't any roads... the main roads getting to and from Alaska, you don't need four-wheel drive. After everything we just mentioned, it's like... you have to know that it's stunning, right? There are bears, there are mosquitoes, there's all this stuff, the roads are terrible. But it goes to show you how epic it is. So, it's worth it.   Host: Yeah, no, there's bears, mosquitoes, the roads, but yet not only did you guys do that, you're going back for another three, four months. Clearly, it's worth it. All right, guys, one last question: what is one thing you cannot leave Alaska without doing?   Guest: The plane ride, for sure. You have to get up in the air and see Denali National Park from a plane. It's stunning. You will not believe your eyes, and highly, highly recommend it. The other thing I'm going to say is go jump in a lake or a river. I think you've got to go out and just experience the nature, and I mean, those are some of the lakes and rivers are about as fresh as it gets up there. So, go jump in one. It's a great experience.   Host: Nice, awesome. And we'll have to have you guys back on after you guys do your six-month or your summer adventure up there, and we'll talk about what you guys did that time. So, yeah, well, great. Guys, thanks again for coming on. One last question, where can our audience find out more about you?   Guest: We are @TheMilesVanLife on Instagram, and I'm @EileenRoseMiles. That's my personal Instagram. And then I am ChadMMiles on Instagram, and I have a podcast that is called "A Level Deeper."   Host: All right, sweet. Everybody go check them out. Chad and Eileen, thanks again.   Guest: Thanks, guys.   Host: Thank you.   Guest: Appreciate you both.

In 6 AM Hour: Larry O'Connor and Patrice Onwuka discussed:  HOST: What about the millions of illegal immigrants already in the country? MAYORKAS: Amnesty Education chief mercilessly mocked for misstating Reagan's famous government ‘here to help' line 6:35 AM - INTERVIEW - NATE HURTO - founder of Save Del Ray (Alexandria) – discussed Alexandria City Council is proposing a bill to create more attainable, affordable housing in the city. Members of the community who have mixed opinions about the proposal. Vote is tonight.  Facebook group: Save Del Ray https://www.facebook.com/profile.php?id=100080291265071 Mitt Romney Names The 2 Republican Presidential Candidates He Won't Vote For Where to find more about WMAL's morning show:  Follow the Show Podcasts on Apple podcasts, Audible and Spotify. Follow WMAL's "O'Connor and Company" on X: @WMALDC, @LarryOConnor,  @Jgunlock,  @patricepinkfile and @heatherhunterdc.  Facebook: WMALDC and Larry O'Connor Instagram: WMALDC Show Website: https://www.wmal.com/oconnor-company/ How to listen live weekdays from 5 to 9 AM: https://www.wmal.com/listenlive/ Episode: Tuesday, November 28 2023 / 6 AM HourSee omnystudio.com/listener for privacy information.

A billionaire who supported Trump in 2020 says he talks to Joe Manchin every week and urges him to ‘stay tough.' Arizona State Police are recommending charges for the protesters that followed Sen Sinema into the bathroom. Five Veterans quit Kyrsten Sinema's advisory council in protest. Bernie Sanders to Host “What's in the Damn Bill” online panel discussion about Democrats' package. AOC warns that Corporate Lobbyists would love people to ‘Give Up Before the Deal Is Done.' ‘You Are WEAK!' Don Lemon ERUPTS on Biden, Democrats: ‘It's Not Our Job to Sell Your Agenda for You!'Hosts: Ana Kasparian and Cenk Uygur See acast.com/privacy for privacy and opt-out information.

The introduction of your podcast is probably the most critical part of your show. A typical listener will give you between 90 seconds and a few minutes to entice them to stick around. Don't blow it. You can't catch up to a slow start. Today, we are going to break down six different podcast intros. I will show you which parts of the introduction are effective and which are not. When you create your podcast introduction, you need to put yourself in the shoes of your listener. What is in it for them? That is what they will be asking. How will they be better by the end of the episode? If you are going to use a clip from the episode at the beginning, you need to open a conversation loop. Tease the content to come by creating some intrigue. Make your listener want to stick around. If you can't do this, don't use a clip. The voiceover intro should tell your listener who you help, what you help them do and why. You do not need to structure it in those exact words. However, your intro should answer those questions. As an example, our first sample episode opens with, "Do you love your work? Do you think it's possible? You're about to find out." Do you know what this show is all about? It sounds like a show about finding a career that you love. I don't even need to tell you the name of the podcast. Edit your intro. Keep it short. Let it give your episode momentum. Don't coast and wander your way into the show. Start quickly. Capture the attention of your listener and get them excited about the content. If you would like help with your introduction, grab my Podcast Introduction template at www.PodcastTalentCoach.com/intro. Ok, let's jump into the intros. First up is "48 Days to the Work You Love" with Dan Miller. 48 DAYS TO THE WORK YOU LOVE WITH DAN MILLER Host: Well, a listener says, "Hey Dan … all this talk about setting goals and getting things done sounds great but, I’m a thinker. Not a doer." (VO over music bed) Do you love your work? Do you think it’s possible? Well, you’re about to find out. It’s time for 48 Days to the Work You Love with Dan Miller on the 48 Days online radio show. Whether you need a professional tune up, or a work overhaul, this is the program for you. Now here’s your host, Dan Miller. Host: Well, what do you think? Do you need a tune up or a complete overhaul? You know, we’re still here at the beginning of the year. A great time to be looking at that. Just gonna have some little kind of subtle realignment to what you’re gonna do? Or, are you gonna really make a break and head off in a new direction? We’re hearing from lots of you who are doing both of those things. Delighted to hear the plans you’re making. You know, last week, the lead in was, "I know what to do, but can’t make myself do it." We had a whole lot of you that that apparently kind of struck a nerve, and you commented on that. I’m delighted to have you do so. We’re gonna talk some more about that. What is it that keeps us from doing? There may be some unique kind of built-in traits that we have that make us more a thinker than a doer. Well, we’ll look at that. So, questions … "I know what I need to do, but I’m easily turned back to wonder and invention." Somebody asked, "How can I make some money off the land I just inherited?" "Where do you find customers who aren’t broke?" Love that question. We’re gonna dig in. ANALYSIS First, the title of the episode doesn't get too cute. It let's you know what the podcast is all about. "48 Days To The Work You Love" sounds like a career search podcast. The name isn't too clever or too cool for the room. The tease to open the podcast is effective. It is short and to the point, while creating anticipation of what is to come. The tease gets you guessing what the quote is all about. It makes you want to stick around to close the circle. The voiceover introduction starts with the listener point of view. "Do you love your work? Do you think it's possible? Well, you're about to find out." These three sentences reinforce exactly what this podcast is all about. The intro makes it relevant to you. We don't waste a lot of time with information you don't need. Dan comes in after that with the overview of this particular episode. We know what the podcast is all about. He now tells us how this particular episode is special. What makes this one different than the others. Again, he begins in the shoes of the listener with, "Well, what do you think? Do you need a tune up or a complete overhaul?" He gets the listener invested in the content. Dan does a nice job creating social proof. He uses phrases like, "We’re hearing from lots of you", "Delighted to hear the plans you’re making", "and you commented on that", and "So, questions …" All of these statements show listeners exactly what he wants them to do. Finally, Dan gives an outline of the questions he will address on this episode. This is sort of a table of contents. Overall, this is a solid intro. BUSINESS UNUSUAL The next intro is “Business Unusual” with Barbara Corcoran from Shark Tank. (Host) Hey this is Barbara Corcoran you are now tuned in to "Business Unusual". And, everything you ever learned about business, throw it out the window. I’m gonna tell you the real deal. Listen in. Today, I’m gonna answer all your burning question about work, life, starting a company, getting on track, and much much more. Be sure to call into the "Business Unusual hotline" with your question at 888-BARBARA. That’s 888- BARBARA. But first today we’re gonna be talking about moms getting back in the workforce. What do you do when you put your life on pause, or at least your career on pause, to raise a bunch of kids and you want to get back? Listen in. I’m going to give you great advice. ANALYSIS This is a solid intro. It doesn't start with your typical sample clip from the episode. Barbara gets right into it. A sample clip isn't necessary. If you plan to use a clip to tease the episode, you need to do it properly. A teaser clip should create some anticipation. It should open the loop that needs to be closed by listening to the show. Pulling a random clip doesn't accomplish either of those. Barbara tells us exactly what the podcast is all about. You know she tells it like it is. Her intro is focused on you. She says, "I’m gonna answer all your burning question about work, life, starting a company, getting on track, and much much more." She also gives you the phone number to participate. She effectively tells you what the podcast is about, so you know it is right for you. Barbara then says, "Today we’re gonna be talking about moms getting back in the workforce. What do you do when you put your life on pause, or at least your career on pause, to raise a bunch of kids and you want to get back? Listen in." She sets up the content for today to keep you around for the entire episode. This whole intro is short and sweet. I love the momentum it creates. FLIPPED LIFESTYLE Next is the "Flipped Lifestyle" podcast with Shane and Jocelyn Sams. (Host) Hey y’all! On today’s podcast we welcome back Brooke Butcher. Last time Brooke was on the show, she was just starting out and growing her online nursing community. On this episode we get to celebrate Brooke's growing membership and her incredible milestone. Brooke just quit her job and works full-time online. On today’s podcast Shane is helping Brooke get used to her new, self-employed, location independent lifestyle as well as growing her nursing membership. You’ll learn how to balance your time between business and life while working at home, promotions to help grow your membership site and how to know when it’s time to go full-time online. You are going to love today’s podcast. Enjoy the show. (Voiceover) Welcome to the "Flipped Lifestyle" podcast, where life always comes before work. We're your hosts, Shane and Jocelyn Sams. We are a real family who figured out how to make our entire living online. Now we help other families do the same. Are you ready to flip your life? Alright. Let’s get started. (Host) What’s going on everybody? Welcome back to the "Flipped Lifestyle" podcast. It is great to be back with you today and I am super excited because not only is this an amazing member of the Flip Your Life community on the show, it is a repeat guest. It is someone we know and love and we are going to be celebrating some major, major wins in her online business and her membership world today. Welcome back to the program Brooke Butcher. ANALYSIS This intro is solid, but could be cleaned up a bit. The opening bit delivered by Jocelyn before the voiceover says much the same thing Shane says after the intro. Jocelyn's part could have been cut in half. This portion is intended to get you to listen to the rest of the episode. We don't need a full guest introduction here. This portion would have been sufficient: "On today’s podcast Shane is helping Brooke get used to her new self-employed, location independent lifestyle as well as growing her nursing membership. You’ll learn how to balance your time between business and life while working at home, promotions to help grow your membership site and how to know when it’s time to go full-time online. You are going to love today’s podcast. Enjoy the show." After this part, Jocelyn says Brooke is self-employed, location independent and the owner of a nursing membership site. We're going to learn about time management and how to promote our site. Shane then comes on and again tells us that Brooke has a membership site. We got that in Jocelyn's portion. He says she is a repeat guest. We know that, too. Finally, he tells us we are going to celebrate some major wins in her membership. Jocelyn told us that as well. I do like the voiceover intro. We know what the show is about. It is focused on us. "Welcome to the 'Flipped Lifestyle' podcast, where life always comes before work. We're your hosts, Shane and Jocelyn Sams. We are a real family who figured out how to make our entire living online. Now we help other families do the same. Are you ready to flip your life? Alright. Let’s get started." With this intro, we know exactly what the show is all about and what we are getting. We know how we will be better off when the episode is over. I also like the way Shane doesn't waste much time before he jumps into the interview. Tell us what we need to know to understand this interview is applicable to my situation. SPEAK UP The next podcast is "Speak Up" with Matthew and Elysha Dicks. (Host) Welcome to "Speak Up", a podcast about telling better stories. This is episode 103. I’m Elysha Dicks. I’m the Executive Director of Speak Up. We are a Hartford-based storytelling organization. We produce shows, teach workshops, and help people find and tell better stories. And I am Matthew Dicks. I am the husband of Elysha Dicks. I am also the Artistic Director of Speak Up. I’m a storyteller myself. I’m an author of several novels. And the non-fiction title "Storyworthy: Engage, Teach and Persuade and Change Your Life Through the Power of Storytelling". A book that will help you become a better story teller. How are you doing today, honey? I am fine. Excellent. How are you? I am great. I am happy to be podcasting again with you. Yes. It’s a glorious summer day. We only have two weeks left of our summer vacation before we have to return to school, but we are trying to suck the marrow out of every minute we have. That sounds gross. No, it’s a phrase. I know it’s a phrase. That doesn’t mean it’s good. Alright. It’s poetry. You’re supposed to suck the marrow out of life. I know I’ve heard it before. This one I’m going to pass on. Alright I’m going to be sucking the marrow over here. Suck it by yourself. Do you have any follow up for us honey? Not that I can think of today, how about you? ANALYSIS "Welcome to 'Speak Up', a podcast about telling better stories." This is probably the shortest intro that tells us exactly what the show is all about. I like this a lot. No questions here. However, they follow it with "episode 103". Is that important? Not really. That doesn't have anything to do with anything. Leave it out. Elysha then gives us their pedigree. I usually suggest podcasters start in the shoes of the listener. However, this is effective in giving the audience a reason to believe what they have to say. This intro gives them credibility. We also know they teach workshops and produce shows. We know they know what they are doing. We also know we can get more of what they have to offer if we choose. The intro is followed by some chit chat. I love the way the play off each other. It gives us a sense of their style and sense of humor. However, it gives us no reason to stick around. You can't catch up to a slow start. If Elysha and Matthew took some of their story teachings, they would realize they need to start strong. Set the stage. Suck me in. Give me a reason to care. "How are you? Fine. Glad to be podcasting. Have two weeks left in summer break." I'm getting fidgety listening to this. I'm inclined to find something more compelling. They need to hook me sooner. Most people give themselves anywhere between 90 seconds and a few minutes to decide if they will stick with an episode or find something else. Make it count. INSPIRED MONEY This one is "Inspired Money" with Andy Wang. (Clip) Today on "Inspired Money" … Take this year, what a crazy year we’ve been in. So if I think that nobody’s hiring, there’s no opportunity for a small businesses, they’re all shutting down, that we’re all going to get sick and then it’s going to kill a whole lot of us, well, there’s some pieces of reality in there. If that’s what is dominant in my mind, I’m dead in the water. I’m not going to start a profitable business. I’m not going to see new opportunities. But if I think wow, this is a challenging time. With every challenge there’s the equal seeds of opportunity. If I believe that, then I look at this, ok, i didn’t expect this to happen. Yes, it closed this door. What am I going to find if I just re-direct a little bit in terms of a new opportunity? This is episode 163 with career coach and author of "48 Days To The Work You Love", Dan Miller. (Voiceover) Welcome to "Inspired Money". My name is Andy Wang. A managing partner at Runnymede Capital Management. Each week we bring you an interesting person to help you get inspired, shift your perspectives on money and achieve incredible things. From making it to giving it away, inspired money means making a difference, creating something bigger than oneself, and maybe, just maybe, making the world a better place. Thank you for joining me. (Host) Hey inspired money maker, welcome back. If this is your first time listening welcome. Are you happy in your career? Do you feel like you found your calling? So many people aren’t quite sure and experience midlife crisis. I want to open with a quote from our guest. "Success is never an accident. It typically starts with imagination, becomes a dream, stimulates a goal, grows into a plan of action, which then inevitably meets with opportunity. Don’t get stuck along the way." That’s Dan Miller. He’s author of the New York Times best-selling books "48 Days To The Work You Love", "No More Dreaded Mondays", and "Wisdom Meets Passion". He also hosts the top ranked career podcast "48 Days to the Work You Love Internet Radio Show". ANALYSIS The clip at the beginning of this episode sets up the interview. We get inspired with just a few sentences. We also end with a question, which opens the loop. The guest ends with, "What am I going to find if I just re-direct a little bit in terms of a new opportunity?" That's what the episode is all about. The voiceover part of the intro tells us what the podcast is all about. "Each week we bring you an interesting person to help you get inspired, shift your perspectives on money and achieve incredible things. From making it to giving it away, inspired money means making a difference, creating something bigger than oneself, and maybe, just maybe, making the world a better place." We know what we're going to get. When you create your intro, tell your listener how they will be better after listening to an episode. What's in it for me? This intro does exactly that. Andy then introduces Dan. He gives us just enough to find his guest credible. He has written a few New York Times bestselling books and he hosts an online radio show. I'm good with that. I'll listen. The introduction of your guest only needs to provide your listener with enough information to make them care and want to stick around for more. It doesn't matter that Dan is a career coach or that he has started multiple businesses. Just give us enough to want more. SCREW THE NINE TO FIVE The next show is "Screw The Nine To Five" with Jill and Josh Stanton. (Clip) Your mission is to pay back how much you spent on ads. I’m getting all these customers coming in. Now, I’m building a customer list. And then you have a flagship program or one-on-one coaching and it’s so much easier to upgrade an already existing customer than it is the first acquiring of them. Yeah. Right? Once you get them in the door and you rock their world they’re going to be like, "This guy is awesome. I wonder what else they have." (Voiceover) Warning. This podcast may cause you to quit your job, and start a business. What’s up? We're Jill and Josh Stanton. And we help people quit their jobs. Right now you’re joined by tens of thousands of up-and-coming entrepreneurs all around the world who are using their commute to redefine their lives and build a business online. So if you’re ready to create the financial freedom, time freedom, location freedom and personal freedom you crave so you can do what you want when you want, then turn up the volume and let’s do this thing. This is the "Screw the 9 to 5" podcast. (Host) Hey! Welcome back to another episode of the "Screw The Nine to Five" podcast. Today we are jammin' on if we were to start all over again ... no audience, no revenue, none of the things ... how would we build this business from scratch? ANALYSIS The clip at the beginning of this show does very little for me. At the end of the full opening, we know the episode is about "if we had to do it all over again, what would we do?" The intro clip is all about, "Your mission is to pay back how much you spent on ads" or "getting a customer is harder than keeping a customer." What does that have to do with anything? It doesn't open a loop or create any intrigue. Be sure to tease effectively. Now, I do love their voiceover intro. "Warning" is a great way to start. "You are joined by tens of thousands" shows social proof. They talk all about the life I want to create. This is all perfect. They are in my shoes and telling me the benefit. When Jill comes back in with "Today we're jammin' on starting over again", you get a sense of how she rolls. She jumps right into the content. The momentum is great. The intro overall is nice and short. It would be much stronger if they had just used a more effective clip at the beginning. TEMPLATE If you need help creating your intro, get my intro template at www.PodcastTalentCoach.com/intro. This will help you shape the opening of your podcast. Do you need help with your podcast? E-mail me any time at Coach@PodcastTalentCoach.com. Let's see what we can do. Let's turn your information into engaging entertainment.

About this Trailblazer:  Juan is a Gallup Strengthsfinder Coach who specializes in the development of Leadership Professionals and Their Teams. He is US Army Veteran, A Husband, Father, and Entrepreneur.  What drives Juan? His goal is to help individuals to work in their purpose on purpose towards their purpose.  How can you stay connected with Juan?  Visit Juan at http://www.weraizethebar.com (www.weraizethebar.com) to book a coaching session.  Follow Juan on Instagram: http://instagram.com/raizethebarCEO (@raizethebarCEO ) Grab the free book here: https://linktr.ee/raizethebarceo (https://linktr.ee/raizethebarceo) About the Host:  What gets my blood pumping? Projects! I thrive off projects (big or small), mission-oriented tasks, and love the details in between. There is nothing more exciting than helping people organize their ideas to achieve success. My motto is no short-cuts. If you want to achieve sustainability and add impact to your community, you must have a process in place. With a background in project management, operations, policy, email, and content marketing, I focus on finding the sweet spots in your business so you can operate more efficiently! Connect with #AskAsh  Instagram: http://www.instagram.com/ashleyshuler_ (@ashleyshuler_) Linkedin: http://www.linkedin.com/in/ashleyshuler (www.linkedin.com/in/ashleyshuler) Sign Up for the Systems Lab: http://bit.ly/SystemsLabSignUp (http://bit.ly/SystemsLabSignUp) Be sure to subscribe and share this podcast with 3 friends. Don't forget to DM me on instagram @ashleyshuler_ to tell me what you learned from this episode. 

Dodge Data and Analytics Chief Economist Richard Branch joined the Engineering Influence podcast to discuss his 2021 economic and construction market forecast. Host: Welcome to the Engineering Influence podcast sponsored by the ACC Life/Health Trust. With us today is Richard Branch, chief economist for Dodge Data and Analytics. A couple of weeks ago, Richard released Dodge's 2021 economic and construction market forecast. And he's joined us to delve into the numbers. Richard, welcome to the podcast. Click here to purchase the  Dodge Construction Outlook 2021.Branch: Thanks. Great to be here.Host: To start, can you give us a broad sense of what the engineering industry can expect in 2021?Branch: Sure. I think the simplest thing to say is that we do expect construction activity to improve next year. We do expect it to grow, but that pace of growth is going to be fairly modest. It's going to be fairly moderate. Of course, given everything that the industry and we as individuals have been through in 2020, that is certainly good news. But we need to keep in mind here that there are significant headwinds at play as we move into 2021 that make this recovery much more tenuous.Host: In your forecast, you mentioned several times that it depends on the widespread adoption of a vaccine by the middle of the year and the passage of a substantial stimulus package in the range of $1.5 trillion in the first quarter of the year. Have you ever had a forecast that faced such stark deal-breakers and how stark are they?Branch: Pretty unique, I'll say that. I think the closest parallel that I can think of is if we go back to 2009 during the Great Recession as Congress was weighing passage of the American Recovery and Reinvestment Act. If we think back to that time, it passed both the House and the Senate pretty much along party lines, but getting it to that point, it was touch and go and it was unclear right up until the last couple of days of how much sacrifice would need to be made in terms of the overall amount in the ARRA funding to get the support needed to get through Congress. Obviously, it ended up passing and it had a tremendously positive influence on the economy in the wake of passage.Branch: So now we've got not only the uncertainty regarding the passage of further fiscal stimulus, but I would offer it's happening in a much more sensitive political environment. We're currently in a transition period between two administrations and between two congresses because there will be changes in the house and the Senate as well,. Then we need to layer on top of that when we can expect not just the vaccine to be ready, but when we see it adopted widely across the country. Of course, there's been a lot of good news recently with regards to efficacy rates of the vaccines as they make their way through trials. So that certainly good news. And I think at least that knowledge does or should provide a sense of stability in terms of the underpinning of the forecast.Host: What are your thoughts on that stimulus package? Do you see it going through in the first part of the year?Branch: So when we did our forecast, we assumed that $1.5 trillion would be adopted in the first quarter. And we were using that 1.5 trillion as I'll call it a median. It could have been a little bit higher, could have been a little bit lower depending upon what the final makeup of Congress was going to be. The Democrats lost a good chunk of their majority in the House. It looks like they're on track to lose about 10 seats of their majority, if not more--there are still a few races where they're counting--and the Senate is still up for grabs. We've got those two run-offs in Georgia to get through, but if you look at just how much split-ticket voting there was in this election, it's probably reasonable to assume that the Republicans will maintain control of the Senate, but it could go either way. Short story long, given that reduced majority in the House, though, I think we can probably expect that $1.5 trillion is a maximum dollar amount instead of a median. That's good news and bad news, right? The good news is a lower dollar value means it's probably going to get through Congress much quicker. So we might see it sooner rather than later. The bad side is the reduced dollar value means less support for individuals for businesses and of course, state and local governments.Host: Looking at the specific sectors, the warehouse sector is thriving. You mentioned in your forecast that there were 38 warehouses over 1-million-square-feet built in the first nine months of 2020. And then looking at 2021, you forecast a strong market for this sector. How resilient is the warehouse sector?Branch: Backing up to 2019 in terms of warehouse construction, it set a record in terms of our data, both in dollar value and square footage, and our data goes back to 1967. We do expect it to break a record again this year and next. So over the short term, through 2021and even into 2022, I think this market's fairly resilient. Online shopping is going to continue to gain market share over bricks-and-mortar. And then we layer onto that consumer behavior and consumer attitudes towards shopping and our expectations on delivery--I don't want to wait a week, I want my stuff now. So we're seeing the build-out of these large facilities, and there have been several this year that have been in the 3 to 4 million-square-foot range.Branch: But I think you get to a point where, within the next handful of years, the market gets a little bit saturated in the sense that you're going to get to a point where the buildup of those large facilities has occurred along most major transportation routes and within a short drive to the major metropolitan areas in the country. So what happens after that? I think the market starts to shift into a more spoke-and-hub approach and you get more suburban/urban development of warehouses. These are smaller facilities, for Amazon and these other distributors, to help them satisfy that last mile of delivery.Host: Is the data center market a similar type of market or does it have more long-term potential?Branch: We capture data centers under the office market, so they're not part of the warehouse market, but it's a very similar dynamic except the upside potential in terms of longevity is more powerful on that data center side. As companies and as individuals, our data use increases exponentially, with virtually no limit on the amount we want to stream and the amount of data that gets transferred on a minute-by-minute basis across the U.S. economy. So over the longer term, the data center market is much more resilient.Host: The situation for public construction is dire in your forecast. You quoted a Kroll Bond Ratings Agency report that projects $690 billion in state and local government revenue losses in the coming fiscal year. Yet you only project a 1% drop in the value of public building starts. So how do those jive?Branch: Our public building category includes prisons, courthouses, local police and fire stations, armories and military buildings, and whatnot. So as part of our forecast process, we include large projects that we expect to break ground. We include those explicitly in the forecast years, and as we look into 2021, there are several that we expect to break ground. There's a $300 million courthouse that we expect to break ground in Norristown, Pennsylvania, and a handful of similarly sized projects across the country. And when you look at the entire category of all the 22 that we forecast, this is on the smaller side. It's around a $9 to $11 billion per year market. So those large projects have much more of an outsized influence in terms of the direction of the forecast.Host: I noticed that also in airports. I don't remember the numbers, but there was the projection for the entire market, and the work at JFK was going to account for about 60% of that.Branch: That's pretty much it. If you look at our transportation building forecast in 2021, it's an 11% gain, which is a pretty bold prediction to make given where transportation is headed currently. But as you said, we do expect those early stages of JFK to break ground in New York City in 2021. That's going to be a multi-year multi-billion dollar project. But it goes without saying that if that project were to be delayed or canceled or scaled back, that could very easily take that 11% gain and shift it to the negative. It's a very similar story with the public construction in that it's about a $10 to $11 billion per year market. So if you take out a billion or two from JFK, if that were to be delayed, scaled back or, or canceled, that would shift that entire market to the negative.Host: The streets and bridges construction sector is looking at a slight increase in activity. I think it was about 1% or so. How much of that is due to the FAST Act extension and how important is getting a five-year transportation program in place to the resilience of the sector.Branch: In a word critical. If we recall the FAST Act expired at the end of September 2020,. As part of the continuing resolution that's keeping the government open through December 11th, they extended the FAST Act through the end of September 2021. So that's good news. It did keep however funding flat, so the funding level for fiscal year 2021 is the same as the funding level for fiscal year 2020. That's why our forecast for streets and bridges is showing a fairly tepid gain. In terms of the importance of getting that reauthorized, it's critical given that the dire need of infrastructure in this country in terms of road and bridge work.Branch: The good news, though, is we're optimistic that the reauthorization of the FAST Act will occur in the summer of 2021. Congress made good progress on it before the election. the Senate Public Works Committee released a plan in the spring or summer that was unanimously... Let me say that again, the Senate Public Works Committee unanimously approved their plan to reauthorize it at around $320 billion. The House, as part of HR-2, or the Moving Forward Act also authorized a five-year plan that would have been an excess of the FAST Act. So the good news is the underlying support for an increase in transportation funding is there and once we get into the new Congressional year, the inauguration takes place, and everybody has a chance to sit back and breathe, we think that goes forward. In our forecast, we've built in $300 billion for the core highway portion or highway bridge portion. That's more than what's under the FAST Act, but that's not going to help us until we get into 2022.Host: Not surprisingly given the state of the nation's water and wastewater infrastructure, you project a healthy increase in this sector. How do you see that being funded?Branch: I don't know if I'd use the word healthy. When we look at our environmental public works category--that's the summation of sewer systems, water systems, as well as dams and reclamation projects--we're looking at a 1% gain for that entire sector. In terms of what drives that funding, it's usually through that the Corps of Engineers, the EPA construction budget, as well as state revolving funds. And in general, the appropriation process has been fairly positive to those budgets. And when we look at what the House and the Senate were saying just before the election, we're looking at funding being fairly flat to a slight positive overall for the EPA, for the Corps, and for the State Revolving Funds budget. So that gives us that just a little bit of an increase. We're also looking at the two-year update to the Water Resource Development Act. Again, there was broad bipartisan support for that before the election in both the House and the Senate, so we think that in short order, once we get into 2021, that we'll get that authorized by Congress. And that's likely to be an $8 to $9 billion program over two years.Host: The power market is remarkably volatile. Going back a few years, the value of starts was up 123% in 2019, then down 48% in 2020, and you forecast a 35% jump in 2021. Why is it so volatile?Branch: It's essentially the presence, or the absence, of these large LNG import and export facilities. Those projects are measured in the billions of dollars, between $1 and $5 billion per project. So having one of those start in a year, skews the data, because it's not there the next year and pushes it down. When we look at the forecast for 2021, the Federal Energy Regulatory Committee has approved 15 LNG facilities all in the Gulf coast, except for one that's up in Portland, Oregon. Again, multi-billion dollar facilities. So they've approved 15, we're expecting one or two of those will break ground in 2021. And again, at a billion or a couple billion dollars, they certainly will cause that 35% gain.Branch: But I think if you go broader than just that LNG import and export facility, renewables is also a growth market in the electric power sector. If you look at all electric generation starts over the past 10 years--coal, natural gas, nuclear, utility-grade solar, and utility-grade wind--wind and solar combined have accounted for about 60% of the total. As those technologies come closer and closer to grid parity, where a kilowatt-hour from one is the same as a kilowatt-hour from the other, they're just going to keep ramping up.Host: What about the transmission line market within the power market? What do you see there?Branch: I think they go in lockstep. If you think about where these wind and solar projects are, they're not in midtown Manhattan or downtown Boston. They're in Wyoming and Texas and out Wes and generally not in populated areas. As part of building up that renewable infrastructure, you need to build the high-speed transmission lines to get them from Wyoming or Texas into the major markets across the country. So they absolutely move in lockstep.Host: Finally, you reported in your forecast that the office vacancy rate moved higher in 55 of the 63 metropolitan markets in the third quarter, yet you expect the market to grow in 2021. What's behind your optimism.Branch: I think there are three reasons here. Despite the fact that vacancy rates are moving higher, and despite the fact that COVID has pushed us all out of our offices and into our living rooms and whatnot, there will still be projects that move forward. I'm not 100% on board with the office-market-is-dead storyline. I think companies will continue to invest in office space. Amazon has been very upfront about that. There is actually a $2 billion office project that broke ground in New York just within the last couple of weeks. So those projects will continue to move ahead, not to the same pace as they've done in previous years, but the office market will continue to move forward. Second, we include renovation dollars in our office data. So if you think about maybe an open space office, cubes and whatnot and converting that back to traditional offices and improving air handling and HVAC that boosts the dollar value as well. And as we previously discussed, we include data centers in our office market. Over the past couple of years, it's ranged between 15% to 20% of total office construction. And I think that's an incredible growth market over the next several years,Host: If I may just tag onto that. One of the other things besides the death of the office that people have talked about has been the movement of people from living in cities to moving to the suburbs. Do you see that as a continuing trend?Branch: Absolutely. When you look at our residential data by county and you look outside of the large central metros, like downtown Phoenix and downtown New York, and out in the fringe metro or fringe areas, which are basically the suburbs or even beyond that into micropolitan areas or rural areas, we are starting to see residential activity pick up significantly there. Of course, that creates incredible spinoffs. It'll pull some commercial construction with it, although it'll be a different kind of commercial construction than we've seen, with fewer urban towers and maybe more flat flexible space. It'll pull institutional construction with it, schools and healthcare, and it'll pull infrastructure construction with it. You need roads, you need bridges, and new water. So I think that movement is definitely a silver lining for the construction sector in 2021.Host: Great. Well, thanks so much for sharing your expertise with us today.Branch: Happy to do it. Anytime. 

Ashley provides her Power Four Identifiers for evaluating the right technology tool: Features: a distinctive attribute or aspect of product. Benefits:  the outcomes or results that users will experience by using the product Pricing: the cost of the technology tool Integrations: connecting technology tools to perform automation tasks. Homework Reflection Questions:When evaluating the next technology tool in your business, ask yourself, where are you growing to?  Once your done, send me a message on IG @ashleyshuler_ Recommended Resources:Email Marketing: https://www.activecampaign.com/ (ActiveCampaign) (#AskAsh Preferred) and http://convertkit.com (Convertkit). Customer Relationship Management System: https://www.dubsado.com/ (Dubsado) (#AskAsh Preferred) and https://www.honeybook.com/ (Honeybook) Membership/All-In-One Website: http://katra.com (Kartra) or https://kajabi.com/ (Kajabi) Project Management Software: https://clickup.com?fp_ref=3b474 (ClickUp) or https://asana.grsm.io/ashleyshuler1964 (Asana) Connect with #AskAsh Instagram: http://www.instagram.com/ashleyshuler_ (@ashleyshuler_) Linkedin: http://www.linkedin.com/in/ashleyshuler (www.linkedin.com/in/ashleyshuler) Sign Up for the Systems Lab: https://shulerstrategiesgroup.activehosted.com/f/1 (http://bit.ly/SystemsLabSignUp) Be sure to subscribe and share this podcast with 3 friends. Don't forget to DM me on instagram @ashleyshuler_ to tell me what you learned from this episode.  About the Host:What gets my blood pumping? Projects! I thrive off projects (big or small), mission-oriented tasks, and love the details in between. There is nothing more exciting than helping people organize their ideas to achieve success. My motto is no short-cuts. If you want to achieve sustainability and add impact to your community, you must have a process in place. With a background in project management, operations, policy, email, and content marketing, I focus on finding the sweet spots in your business so you can operate more efficiently!

 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. 

 Mick Morrissey, managing partner of Morrissey Goodale, visits the Engineering Influence podcast to analyze the current state of the M&A market and offer insights and advice to engineering firm owners who may be contemplating selling their firms. Sponsor Message:The ACAC Life Health Trust is offering free insurance comparison quotes for all ACEC Engineering Influence listeners. During these uncertain times, every dollar counts. And we want all our listeners to take advantage of this special offer. Typically our firm medical plans offer your employees lower insurance costs, better coverage, and complementary health and wellness benefits above our competitors. Visit our website at acclifehealthtrust.com or call our sales team at (844) 247-0020.Host:Welcome to the ACEC Engineering Influence podcast brought to you by the ACEC Life Health Trust. The mergers and acquisitions market has been very strong in the engineering industry in recent years with Baby Boom generation owners, looking to sell their firms and buyers looking for strategic purchases. Not surprisingly the COVID-19 pandemic had an impact on the M&A market due both to the initial, rapid deceleration of the economy and now the uncertainty that pervades the market as it recovers. To find out where the M&A market stands right now and where it may be going, especially for owners who are looking to sell., we have invited Mick Morrissey, managing partner of Morrissey Goodale onto the podcast. Morrissey Goodale is a specialized management consulting firm that exclusively serves the AA and government contract consulting industries and is one of the go-to advisors for buyers and sellers.Host:Welcome, Mick. Thanks for joining us,Morrissey:Thanks for having me on great to be here. All of us at Morrissey Goodale are big fans of the podcast.Host:So the M&A market for engineering firms took a dip in the spring when the pandemic hit, but it has gradually worked its way back up right now. Year-over-year deals in the U.S. are off about 10%. What do you expect to see in the market over the coming months?Morrissey:Let me put some context on that. It's a great question. 2019 was a record year for deals in our industry, 317 deals, almost one per workday, a pretty torrid pace of activity and, really speaking to how fast our industry was consolidating. January and February of 2020 were ahead of that pace, then COVID hit and the M&A market froze in the spring, March through May deals were down about 50% year over year. We were back to 2017 levels. Things started heating up a little bit in June and July, but still way behind last year. And then boom, in August of this year, M&A just started right up again. And indeed, we're going to have one of the strongest August on record for deals in the United States. Based upon everything that we're seeing in terms of interest from buyers, based upon the fact that the consulting engineering industry and the engineering industry writ large has been remarkably resilient through this pandemic, and then given that we anticipate some sort of stimulus package benefiting the industry after the election, we would anticipate that we're going to see lots more M&A activity and an uptick in M&A activity as we head into the back end of the year here in Q3 and Q4. I wouldn't be surprised if we end up the year very similar to where we were in 2019, which was a record year for deals, or maybe 5% or so beneath that level.Host:You mentioned, that the engineering industry has not suffered as badly as many other industries did. A guy who owns a firm and is looking to sell, is now a good time to sell?Morrissey:It depends. It depends on what markets your firm is in. Buyers are looking for quality. They're looking for growth in the acquisitions that they make. They were before the pandemic and that's certainly where they're focused now. So if a firm is serving, for example, the federal market, or if a firm has particular expertise, let's say in warehouse and distribution centers, both of those markets are doing well in 2020 and are anticipated to do well into 2021. This could indeed be a very, very good time in terms of valuation and deal structure for a seller that serves those markets. On the other hand, if you're a firm that is seeing a decline in backlog or weakening in earnings, and oftentimes today, those are firms that are serving, for example, the retail market or the commercial markets, this may not be the best time to go to market. It may not be the best time to seek a buyer.Host:What about size? Is this a good time if you own a smaller engineering firm or a larger engineering firm? Does That have any impact on the decision?Morrissey:Well, it's a really interesting question, because the trend we're seeing in acquisitions for consulting engineers is that the median-size deal has continued to fall over the last several years. Now the median-size deal is something like 15 to 17 employees with somewhere between $2 and $3 million in revenues. And that's a direct result of it being so hard to find talent in this industry and that challenge hasn't gone away with respect to COVID. While there may be 9% to 10% unemployment nationally, that unemployment level is not being felt in our industry. By and large, quality people in our industry aren't getting hired at the same rate that they were before, although maybe it's a little different in terms of onboarding and hiring now with most of it being done remotely, or a lot have been done remotely, but still, talent is very hard to find and that's what's driving acquisitions of smaller firms in our industry.Morrissey:And that's why the median deal size continues to fall because small acquisitions are a way to get talent on board fast, instead of going through a three-month to six-month to one-year cycle of picking up the equivalent number of employees. So I'm not sure that that size is a determinant with respect to whether it's a good time or a bad time to sell. I do think though that size and we saw this pre-pandemic and we're seeing it still that size correlates with valuation. So the larger a firm is, the greater the probability that it will achieve a higher valuation when it sells than a smaller firm.Morrissey:If you look back a decade or so ago, right after the last recession, about one-quarter of all deals in the United States were being done by publicly traded firms, the Jacobs and AECOMs. The brand names. Since the Great Recession, the percentage of deals being done by the publicly traded firms has dwindled to about 5% of all of the deals. Over the same time period, private equity-backed firms and private equity recapitalizations of firms engineering firms in the ENR 500 have grown significantly to the point where now about a quarter of all the deals. Now, what does that mean with respect to size? Those private equity groups typically are looking to make acquisitions of firms that are generating at least $1 million in EBITDA and more commonly $3 to 5 million in EBITDA. And that speaks to firms that are generating about $10 million to $50 million in revenues, which would speak to the larger firms in the membership of ACEC.Morrissey:So, um, I think the market is fairly agnostic believe it or not with respect to size. I think there's a market for each size segment with different types of buyers. Again, I come back to the determinant, particularly in 2020: What is the outlook for the markets that the selling firm is serving? Are the selling firms are serving markets that are being impacted by the shift in what's happening in the larger economy? If the firms are serving commercial real estate, or they're serving bricks and mortar retail, or they're serving, for example, the cruise industry or the hospitality industry, those firms, by and large, are seeing some significant or moderate impact to their backlog into their earnings. And they're just not attractive to buyers right now because buyers are looking for quality. But for firms that are serving the federal market, which is still going strong, for firms that are subject-matter experts in particular facility types where there's great demand, such as warehouse and distribution centers being driven by the Targets and the Amazons of the world, those firms are seeing demand. And particularly for firms that have figured out how to incorporate technology and big data management, or have developed proprietary software applications to wrap into their traditional engineering business model, those firms are seeing demand.Host:So if I were the owner of a firm and I was not in warehouses or data centers, what would be my strategy to make myself appealingMorrissey:That depends on what sort of runway you've got. From our perspective at Morrissey Goodale, the industry has entered the first phase of a new reality, and most firms have got about a year we believe to figure out that new reality because we believe there's going to be a lot of pain in 2021 as state and local governments face some real holes in their budgets. That'll put real downward pressure on the market for engineering services and put downward pressure on pricing and fees. So, firms need to reposition themselves from our perspective over the balance of 2020 and beyond. If you have a backlog to do that, then the way for firms to make themselves more attractive over the next year or so is to get into the markets that are more attractive.Morrissey:They either do that by making key hires or making acquisitions to do so, or they need to figure out how to deploy technology. And that's either generating it internally, leasing it, or buying it off the shelf, and then customizing it to adjust their business model, to really improve their technology game. Neither of those strategies are immediate strategies that can happen in a three to six-month period, so firms need to start making those investments now. For firms that only have 30 to 90-days worth of backlog, to make themselves more attractive for a buyer, they need to really cut out all extraneous costs, need to get themselves profitable, need to connect with their clients, and need to get as much backlog as they can in place.Morrissey:Those are the things that they need to do to position themselves for a sale, but even in that situation, and even if they do find a buyer, firms that are serving clients or markets that are being challenged are going to find it hard to find a buyer. Again, I come back to buyers being focused on quality. They're focused on the long term. And so they're planning to allocate their M&A resources to, to quality firms.Host:What about selling to insiders? Is that market slow right now? Has it stopped or is it continuing?Morrissey:It's continuing, although we believe it's going to run into headwinds into 2020 and 2021. If you look at 9 to 10% unemployment in the nation, there's a greater chance that, somebody's spouse or partner has either been furloughed, um, or has lost their job. So, if you're a potential owner in an engineering firm and your partner has lost their job, your kid is graduating from college and can't get a job because of a 9% unemployment rate and is stuck at home with you, then it's harder to have that kitchen table conversation and say, "Hey, I need to invest a hundred thousand dollars in my company to support the ownership, transition plan," because the money just may not be there.Morrissey:This is what we saw in the last recession. Ownership transition plans broke down in the industry, and we saw a spike of M&A activity 12 to 24 months after the recession as firms realized that they just weren't having the capital inflows from their employees and potential owners to support the plans while they were digging out from, uh, the wreckage of the recession. So we expect to see internal ownership transition plans be challenged again over the next 24 to 36 months as we come out of whatever we're in the middle of. And in particular, when we come out of the challenges after 2021, because again, we think that 2021 is going to be a real challenge for the industry.Host:So in this situation with, with the uncertainty, with the potential for a bad year coming up, how do you value a company? Are they the standard valuation techniques or is there some sort of percentage allocation for uncertainty?Morrissey:Yeah, that's a great question. And actually there should be some sort of percentage allocation for uncertainty, Valuation is one of those professions that has a hard time in pivoting to a new reality and it is pretty much stuck on the axiom that valuations of a firm are based upon forward-looking cash flows for the entity. In a time of great uncertainty, however, forward-looking cash flows become hard to forecast. Most firms in our industry have a hard time forecasting a year anyway and beyond a year becomes challenging. So when you look at valuations done in the industry, and you look at the projections that are used for those valuations, they make you scratch your head sometimes. And also when you consider that in the middle of the year, the publicly traded firms in our industry withdrew their guidance, meaning that they weren't going to provide estimates as to what was going to happen going forward.Morrissey:You can see how it makes it much harder for smaller privately held firms, which are the majority of the ACEC membership to do so. The way that valuation adjusts is, the valuation folks assign a higher discount rate, which just means they put more risk into the model, and that tends to drive down valuations. So that's sort of a theoretical perspective, but that's not necessarily what we have seen in the marketplace. My contention to our team was if deals are falling 50% in the spring, then let's figure out if valuations have also fallen 50%. And what we found was it wasn't the case. In the data set of deals that were done in the spring and the data set of deals that were done in the summer, the valuations are not that dissimilar from the valuations that we saw pre-pandemic, in January and February or in 2019.Morrissey:So what really happened was, instead of buyers beating up on sellers and looking for lower valuations as the pandemic played out, in the first stages, buyers just kind of withdrew. And so those valuations in theory went to zero, but in reality, they kind of stayed put, because many of those deals came back online in the summer. Also, when you're buying an engineering firm, the last thing you want to do is start with an evaluation and then if things change, try to beat up on the seller and say, "Things have changed, We're only going to buy it for 50% of what we said." That's just a lousy way to start a relationship and it really doesn't help integration.Morrissey:So what happened was the deals where buyers felt that there was quality, they stuck with those valuations through the deal-making process. Where there was uncertainty, about half of the deals in the U.S. stopped. They just stopped. Now the deals are coming back. What we've seen in the late summer, what we're seeing in August is those valuations are pretty much picking up where they left off prior to the pandemic. So, I urge everybody listening to the podcast to take these metrics with a grain of salt and don't apply them specifically to your individual firm, but what we saw at the high end and what we're still seeing at the high end, in the upper quartile, is multiples of EBITDA in and around the seven range, seven times trailing 12 months; EBITDA multiples in the medium range of about five or north of five; and multiples in the lower quartile of a little under four and a half. So we haven't seen the valuations change that much from a real-life perspective in the marketplace.Host:What do you think might happen to valuations if the market does struggle next year? Do you expect to see a gradual tailing off or do you think this trend will continue?Morrissey:So I think what we'll see is a bifurcation of the market, actually a continued bifurcation of the market. Quality firms--firms that have got really strong backlog, firms that have got something special about them, firms that serve attractive clientele, firms that are located in a great part of the world in terms of the outlook for engineering services, firms that have proprietary offerings that they have developed and where there is demand--those firms will continue to see strong demand and strong multiples and high multiples. Generic firms--firms that are vanilla firms that don't have anything special about them, firms that are followers rather than not leaders, firms that have to sell--they're either going to find lower multiples await them with not very attractive terms or they are going to find that there's no buyer for them. That's where I think we're headed and that's where that's the market that we're in now.Morrissey:In 2019, there were 317 deals. Not all of those firms were getting the higher multiple. Smaller firms tend to get the lower multiples. Smaller firms tend to have fewer options and may need to sell rather than choose to sell. And when you need to sell, when you have to sell that's when the deals that are in front of you generally are less attractive. And that gets to the interesting nature of selling your consulting engineering firm. The best time to sell is when the economy is doing well, when your market you're doing well, when your firm is doing well from a financial perspective, and to do it before you're 60, because then typically a buyer is going to lock you up for three years. And so at 63, which is still relatively young given all of the advances in healthcare and science, you've got two great decades ahead of you to decide if you want to work or consult or go and sail the Caribbean. Most owners don't figure that out. And most owners end up looking to sell when the economy is not good when their markets are not good, when their firm's financial performance is weak, and when they're 65 plus, and they have lost all of the leverage that they could have had in any negotiations,Host:That's a great lesson, right there, I'd say for people to listen to it because that seems to me to cut right to the heart of it. But just one more question and then we'll let you go. What kind of financial arrangements are you seeing as far as how the deals are structured?Morrissey:We're seeing the same basic packages as pre-pandemic. So cash, notes paid over one, two, or three years, stock, and earn-outs. Pre-pandemic we were seeing more cash, more notes, more stock, less earn-outs. Post pandemic, what we've seen is buyers moving more consideration to the earn-out component and moving it away from the guaranteed components of either cash or note payments over one, two, or three years. And that I think is just an acknowledgment that, the market is less certain for both buyers and sellers, and buyers are looking to hedge their bets with the amount of money that they guarantee in a deal.Host:Which, given the pandemic, sort of makes sense.Morrissey:Yeah, I think it does, but I also think, and this is what we saw again in the last recession, there's a whole bunch of received wisdom and conventional wisdom in our industry, and that has played out in the fact that M&A has declined over last year, which is not unusual. In general, when there's a recession or a pullback in the economy, M&A does decline, and indeed, M&A was down 19% in May and June year-over-year, but now it's back to just down 10% or so. But I think, when you dig into the details, once again more and more deals are being done by these private groups. So while employee-owned firms and ESOP firms have pulled back from the marketplace, the private equity firms are still buying because that's what they do. And if you consider a mantra of buy low and sell high, while the marketplace in general recognizes the pandemic and acts appropriately, and most of the ACEC membership acts conservatively, a number of these private equity groups, who are very, very skilled buyers, are seeing this as a buying opportunity and a way to position themselves ahead of the market recovery. And I think that's something for the membership and the listeners to be aware of.Host:It's a good place to end. I appreciate your taking the time to talk to us about the market. Thanks so much,Morrissey:Thanks for having me on, I really enjoyed it. Great to be with you. 

             John Carrato and Michael Carragher, the Chair and Vice Chair of the ACEC Research Institute joined Engineering Influence to talk about the organization's mission, vision and future.  Transcript:Host:Welcome to another edition of Engineering Influence, a podcast by the American Council of Engineering Companies. One of the really exciting things that was announced over the past was the development of the ACEC Research Institute, which would be the research arm of the Council. Something that really wasn't there before. While we do now have an impressive advocacy program. While we have a lot of talent on education and even some market research staff, we've never really had a dedicated organization that actually took an analytical look at the industry and trends that are guiding the engineering industry as we move forward into really a world that is based on data technology and, and really just a rapid change in the overall marketplace. And the ACEC Research Institute, which was officially launched at the board of directors meeting just this last month on a virtual platform.Host:We wanted to be able to do it personally, but unfortunately in the world we live in right now of COVID, we had to go virtual and we and we released the first promotional effort to announce the ACEC Research Institute. We want to talk about that today. And we're very pleased to be joined by two leaders of the Institute. John Carrato. He is the Chair of the Research Institute. He is also president and CEO of Benesch, a multi-disciplined professional services firm providing civil structural, electrical, mechanical, geo-technical landscape architecture and environmental services. And also we're joined by the Vice Chair, Michael Carragher. Michael is president, CEO of VHB, a multidisciplinary civil engineering consulting and design firm headquartered in Watertown, Massachusetts. John and Michael both welcome to the program.John Carrato:Thanks Jeff, we're really excited to get the, get the opportunity to talk about these two today.Yeah, it's a great thing. And I wanted to kind of go over the mission here. I cause it's, it's, it's really poignant. The Institute's mission is to deliver knowledge and business strategies that guide and elevate the engineering industry. And it's been tasked with identifying funding and providing industry wide research forecasts and trend analysis that will help capitalize on the rapidly changing nature of technology and society to ensure a sustainable engineering industry, to promote the engineering industries, professions the professions in a central value to society and to inspire future generations to solve the world's most challenging problems through engineering. Not at all an easy task.John Carrato:Well, it came to fruition as part of developing the ACEC strategic plan. It was pretty clear that we want to be an influential thought leader in the industry. So the Institute will help accomplish this by being the leading source of injury industry-wide research forecasts and cleanse analysis. So repurposing the existing foundation, which solely focused on scholarships was a great way to stand up the Institute. So that's really what we've done. We've changed the bylaws, we'll still be giving out the scholarships, but primary focus now will be positioning us as a thought leader.Host:And I, it's, it's important because as an industry you need to have some kind of framework. You need to have some kind of system in place to be able to actually gather the data about the impact of the industry. Because it's, it's large both in the public sphere and the private market.Host:In your, in your opinion I guess we'll start with John and then toss the mic. Why is having the Institute in place and developing research so important both for ACEC as the organization that's trying to get the word out about the importance and the impact of the industry, but also to individual farm executives who are doing the day to day work to maintain and expand their own businesses?John Carrato:Well, I, I think you know, things are changing rapidly in our industry, in the world. Whether it be climate change and the need for a more resilient infrastructure or staying ahead of the frenetic pace of emerging technologies. Engineers need to be at the forefront. So one of our goals is to demonstrate that the engineering profession by essential value to society, which kind of lifts all of our boats. If, if we're at the forefront of these things as they come about, it positions our firms to compete for that work as well.Mike Carragher:You know, it's interesting, Jeff, our our member firms are sometimes challenged with finding time to contemplate future trends and opportunities and look out there on the horizon and we see the research Institute really having the opportunity to step back to look across that horizon of the possible and kind of organize the broad array of influencing elements and trends and provide some focused insight into which are the key opportunity areas or key areas for research that we should all be thinking about. And in doing so, we'll be able to really be seen and to provide guidance as thought leaders to not only our industry and our industry's leaders, but really to our nation's leaders as they help shape the course of our future together.Host:That's a really good point. I mean you're both leaders in the industry leading your own firms and a lot of we hear from our executives, you know, they're so busy on the day to day that it's not so easy to kind of step aside and look at you know, prognosticate about what's happening next, especially in this market. There's a lot of challenge, but there's a lot of opportunity for both of you. What do you think is the biggest threat to the industry right now and what do you think is the best kind of an untapped opportunity?Mike Carragher:You know, Jeff, as we look out there, there, you know, the, the pace of change as always has continued to increase and it just continues at an ever increasing pace. And I think one of the things that is influencing that pace of change and the array of possible on the horizon is the advancement of technologies, which is exponentially increasing in its pace. And we at the Institute are working hard to think about how to help make that understandable and how to kind of bring that within the grasp of our member firms. So that we can help shape the the opportunities that come out of these, you know, emerging and, and developing technologies as really additional tools to help us solve our client's challenges. The broad array of things from you know, climate change and the need for resiliency and how that plays into sustainability and all those things, you know, the ability to understand them and to address them in a way that helps improve, you know, society and all the way down to people's communities and their daily lives are aided by our ability to embrace and understand how to use these technologies to solve those problems in more thoughtful and creative ways that that really intertwine with a successful, sustainable environment.John Carrato:And I would just add that I think Mike said it very well that, you know, you can look at these as threats or you can look at them as opportunities and we believe part of our mission as the Institute is to help the industry turn threats into opportunities.Host:Absolutely. And I think there's on the other side of the world where you're trying to talk about both the changing nature of the marketplace, the, the threats that we all experience in, in climate change disruptive weather patterns or the need for resiliency. These are all things that are part of that larger national conversation. And the best way to try to get a handle on exactly these larger issues is by putting numbers behind them. And you're able to really tell a story and you're able to demonstrate that essential value if you're to actually put numbers behind the statements that you're making from a media standpoint. Of course, you know, that's, that's the world I come in and it's, it's, it's very important to be able to talk to a reporter or talk to a member of the media and be able to say, well, the engineering industry's impact is x and actually back up with a number or talk about different trends or requirements in, in, in what we're advocating for based off of actual statistics. And that's, that's really an important piece of the puzzle.Mike Carragher:It's interesting, Jeff, as you talk about that and you, you talk about being able to convert that into numbers, that again plays into the array of information that's generating the array of data that's generated and now able to be collected, sorted through and made sense of by some of these emerging technologies. Create the opportunity for us to take that all into account and to organize it, you know, synthesize it and with it come out with more definitive guidance, more definitive elements to convert those thoughts and ideas about how we address the issues across the horizon into, you know, real digestible elements with sound backing so that we can share that with, you know, society at large and with the leadership in Congress as well.Host:What do you think the industry does well as a whole in terms of advancing really our overall business interests? And where do you think we fall short?John Carrato:ACEC does a great job, excuse me, of advocating for the industry, whether it be for investment in infrastructure fighting onerous legislation, but unfortunately we're not, we don't always have a seat at the table. And we've seen that Linda and her team are working hard to change, that the Institute can help by being at the forefront of issues such as climate change and technology by producing research positions so ACEC is an intellectual thought leader. So we will, we will be needed at the table. And that's really our goal is we want people to want to sit at the table to implement those decisions.Mike Carragher:And we see that opportunity to, to be at the table is reinforced when you're providing not reactionary, you know, day to day responses. But when you're really helping to paint the picture of the future and how we navigate the uncertainty of the future, the more that the Institute can provide that type of guidance and insight to our people who are sitting at that table, I think the more influential the conversation that ACEC can bring will be recognized by the broader markets at large.Host:Absolutely. I mean you, you saw that immediately with the waves of surveys that are being put out by the Institute on business impacts related to coronavirus. Being able to come out and say with certainty. This is how the industry is reacting to the paycheck, protect the paycheck protection program. You know, this is how many firms have taken advantage of the programs as so many firms are, are looking to take advantage of the program. Being able to use that and, and take that not only to the press, which immediately sees numbers and wants to use them, but then also being able to take that to policymakers who were working on those programs. That gives them insight, which is of, of critical need and importance. And if you develop those numbers, people will seek you out. That's, that's a good example of research that's being done. Now I know that there are a lot of projects in the pipeline. What are some of the short term goals for the Institute? And, and long-term. What do you hope to accomplish with some, your research? What's in the pipeline right now?John Carrato:Well, we as you started the podcast, we didn't get the start leading up to you know, having an in person meeting at the annual conference, but our goal upfront is to really demonstrate the value that the Institute can bring to our members because that will help us stand up our fundraising efforts, which will allow us to reach our, our long-term goals by immediately what we're looking at is over the next three months, we will be hosting three webinars that look towards the future. The topics will be the buildings we live and work in and pack the technology on engineering and funding and the new normal. And these will be conversational style panels. They won't be presentations and they will be leading experts both in their, in our industry and industries that are aligned with us for the long-term. We'll be standing up research advisory council that will help ensure that we have a robust research agenda for the long-term. And we're currently in talks with multiple organizations about teaming to do research.Mike Carragher:So right now, Jeff, we're, we're starting out, you know, again, we're starting to walk before we can run and, but already we're partnering with FMI on an ownership transfer and management succession survey. The results can be found on our website that was recently completed and shared and it's generated some good conversation in our industry from that. We've also just launched a study kind of a new updated, refreshed look at quality-based selection and you know, that result in kind of a really state-of-the-art report and brings advances that discussion, which has been ongoing for quite a while, but I think gives it a little more depth and currentness and we'll also be looking to provide that to our member organizations is they use that in each state to bring that into the conversation necessarily each of our States. We're also intending to fund study on kind of, again, a new refresh look at what is really the impacts of design build delivery across our industry on the quality of the built project, the treatment of all the members of the design build team and how that works out for each of them. And what's important to know and what is important that legislatures should understand before they go down the path of design, build delivery and also an economic impact of engineering in the United States. We see that, again, getting to your point of trying to put some numbers to categories and to be able to convey the impact and kind of a multiplier impact of the work that, that we as engineers do as it contributes to the overall economy. You know, as we look out on the horizon, we've been developing a longer list that we help to, to work and to refine with a research advisory council that we're looking to work and put that together. But some of the items out there in the horizon, we've touched on today, you know, elements of climate change and resiliency in engineering sustainability the impact of rapid technology change on the engineering industry and what that means for us, the opportunities it opens.Mike Carragher:And I mean, even if you think of how that plays out with the additional types of expertise that we need to, to bring it into our organizations and how to meld those elements together. We're also looking at you know, a broader perspective around innovation and how do we really encourage and create the environments of innovation within, you know, our engineering firms now and moving forward as things continue to proliferate. We hope to be able to look at a broad array of viable options for infrastructure funding is something that has perplexed and challenged society at large for years and the case only grows in its importance. We're also have a topic looking at women, minorities and the case for inclusion, equity and diversity in the engineering industry. So as you can see, there's kind of a broad array of things that we're looking at and we're hoping to get input and guidance from a kind of wide casted research council to help us narrow those downs and prioritize the projects that we undertake.Host:Yeah. Each, each and every one of those is a critical area of focus from diversity to innovation technology. It's all really rich ground to mine for not just a good numbers, but then also just that thought leadership. And I've seen some of the details on those, on those round tables. And I gotta tell you it's, heavy hitters. I mean, the people who are, are lining up for, are participating in these roundtables are, are leaders in their field - are recognized names. And, and one of the things that's been said about thought leadership is, is it's not just getting information out there, but it's also being able to convene thought leaders and leading voices in the world to sit down and, and be the organizer to bring these people together to start talking about these issues. And it really does look like the Institute is on a solid firm footing. One of the questions I do have is, is kind of tied into that last point, which is getting involved in the Institute. There's a lot of work that has to be done. And how can ACEC members, how can members of the engineering industry get involved to help the Institute with its mission?John Carrato:Well, as you know, we're, we're still standing up the Institute, but we would really appreciate any members that have ideas for research to pass those along to us. And we talked about the research advisory council. If anybody's interested in being a member, we would appreciate them reaching out to Daphne Bryant. It's not an open council but we will certainly consider anyone that expresses an interest. And finally we would greatly appreciate any level of contribution. Members are willing to make the support the Institute. Charitable contributions will determine how much research we can perform going forward. And we're just starting to ramp up our fundraising institutes. But it's essential that we have a wide network of supporters in order to accomplish our goals as an Institute.Mike Carragher:Yeah. That support is going to be critical. And I think when you look at, you know, our, our member firms and their focus and their, their mission statements of what they're trying to do and not just create a successful company but really have a strong impact on the future, I think those things weave together. And this is an opportunity to kind of direct, you know, financial support into the research and study of elements that are going to help broaden the perspective of our industry, of how to, you know, provide a, you know, a safe and sustainable future in the built environment. And that element of understanding that this really, it comes down to - Jeff, you have made the point about being able to convey a numbers and that's important, you know, but everything we do in our industry results in the impact on humanity and the built environment and our ability to kind of not only have the numbers, but to convey the stories down to the human and personal level of how it helps improve the quality of life on this. Something that's very important to us. And as we look to people to be on the, the research advisory council, bring that broad array of perspectives will be, will be important to us and it's also going to be important on our storytelling as we go forward to, to share our perspectives.Host:Absolutely. Well for those who want to get involved immediately I encourage everyone to take a look at the institutes website. It's ACEC Research Institute, all one word, dot org. They also have links to their social channels. They're on Twitter, Facebook, LinkedIn and Instagram. Follow them because all the research that they're putting out will be posted to those channels. But then also on the, on the website, you go over there right now and you'll see the first few waves of that coronavirus impact survey as well as the FMI ownership transfer management succession survey. It's all there for you to take a look at, download and and review. John and Mike, thank you very much for taking the time today. On a, I guess a pre-holiday Thursday. We're all working from home so the holidays kind of blur. I keep forgetting that it was Memorial Day weekend coming up. But for both of you stay, stay healthy, stay safe and I really want to have you on back on the show as the Institute really gets into full swing. Maybe during those round tables we can kind of reconvene and talk about some of the topics that were discussed and of course with your next big survey going out. We definitely want to have you back on the show.John Carrato:Thank you very much Jeff. We're really excited about the potential of the Institute. Greatly appreciate the opportunity to talk about it.Mike Carragher:Yeah, thanks Jeff. This has been a great conversation. I appreciate the opportunity and you know, just to our listeners you know, John and I are always looking for good and supportive people throughout our industry. So we look forward to continuing the conversation.Host:Absolutely. So again, go to www.acecresearchinstitute.org and check out the research that's already been posted. And again, this has been Engineering Influence, a podcast from the American Council of Engineering Companies. We'll see you on the next episode. 

Co-chair Helen Jansen was on Real Radio 104 and talked about what a Geopark is and its great opportunities for the community. Missed it? No problem, you can listen to it here. Transcript: Host:Right, time to talk about Geopark. And we are joined by Helen Jansen, one of the trustees of the Whitestone Waitaki Geopark project. How are you doing? Helen: Absolutely splendid. It's a great day. Absolutely. Thank you for coming in. It's an opportunity for Waitaki to take advantage of a framework. That is a globally recognized framework based on the geology of the areas. It's got to be unique. And in Waitaki we've got unique geology. We tell a story about incredibly ancient Geo-tectonic movements right through to the present. It is about telling the story of the people, of the animals and the plants that have taken advantage of this sort of geology right up to the present day and going into the future because the land that we live and work in sculpts the things that have happened and that do happen and can happen in the future. Host:What's the potential as far as tourism is concerned here? Helen:If we have a Geopark in the world that has increased their visitor numbers and increased their local economy many times, so it's an opportunity which we have had scoped which shows that there will be enormous benefits to the district, depending, of course, on what level of investment you prepare to put into it. Host:There's been a lot of talk about the money that goes into it but the amount that we are investing as far as Waitaki district is concerned versus the amount of potential investment from external forces that we're only putting in a small portion, potentially, aren't we? Helen:Absolutely. And we broke it down into small stages so at the district plan has ongoing support for it for ten years. We've taken the annual amounts for the last couple of years and we have just being granted money from the surplus of this year by the council in order to get us to the point where the UNESCO Geopark application can be completed and assessed. And we are in a very good space to be accredited as a Geopark. We cannot count our chickens, but we will in a very good place to do that. Host:So why should people get behind the idea of a Geopark? Helen:Because it's going to unify the district. It's going to give opportunity to all sorts of, initially tourists opportunities from flags worn through the east coast and up through Oamaru and right up through Ohau. We've already seen excitement through the culinary world and the producers of food in the Geogastronomy group that just started. They are championing at the bit to get this going so this would be really a great opportunity. We've got investors lined up already ready to sign contracts now that we've got this assurance that we can get this through to June. We will have those investors joining up so it's a huge opportunities for this district and for every man. That it depends very much on the energy and enthusiasm the district generates as to how much investment we will be able to bring . Host:Thanks, Helen. We'll catch up again soon. Helen:Thanks very much!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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