Inactive (722)

Segment Number 3
Audio File corona/1638cr1c.mp3
Doctors Boyd, James B
Featured Speaker James B Boyd, MD
Guest Bio Dr. James B. Boyd specializes in emergency medicine and is a member of the medical staff at Corona Regional Medical Center.
Transcription Melanie Cole (Host): According to the Center for Disease Control, one in five Americans reported visiting an emergency room at least once in the past year. But, how do you tell when an emergency is truly an emergency that requires after hours treatment? My guest today is Dr. James Boyd. He specializes in emergency medicine, and is a member of the medical staff at Corona Regional Medical Center. Welcome to the show, Dr. Boyd. There are so many different conditions. Let’s start with the ones that we know for sure are very emergent. So, would you speak about when someone should go to the emergency room without question--stroke, heart disease--those kinds of things?

Dr. James Boyd (Guest): Yes, well, the primary one would be heart attack, and with a heart attack it’s usually new onset of chest pain that’s lasting greater than 20 minutes. It’s a pain that can radiate to the neck or to the jaw or even to the upper back. It can be associated with nausea, vomiting, shortness of breath and sweating. If you were to have these symptoms, you would immediately want to dial 911 so that you can get to the emergency room as soon as possible so we can initiate evaluation or possible clot-busting drugs that can absolutely open up that coronary artery and prevent a full heart attack.

Melanie: And what about stroke?

Dr. Boyd: Stroke is very similar. There are clot-busting drugs available for stroke symptoms. With stroke, you’re looking for sudden weakness or paralysis, especially of one side of the face or body. A stroke victim can have difficulty speaking and confusion and sometimes associated with a sudden, severe headache or dizziness. By dizziness, I mean vertigo--the type of dizziness where the room seems to be spinning. We’re also concerned about severe allergies. On occasion, people often have allergies that are pretty minor where their skin breaks out, but if they start having their throat closing or their tongue swelling, even severe weakness, then they need to be seen right away because they could be going into shock or they could have obstruction of their airway. Those three cases: heart attack, stroke, severe allergy symptoms, they really require that 911 be called so that the EMS can bring the patient to the emergency room.

Melanie: So, for parents, this can be a difficult decision, and you’ve discussed stroke and heart attack and severe allergies, but when it comes to kids, they have aches and pains and stomach aches, and all kinds of things go on with kids. What do you tell parents that ask you, “When is it okay to wait or call my pediatrician instead of calling 911 or rushing my child to the emergency room?”

Dr. Boyd: Well, a child with a stomach ache that may be chronic can be seen by the pediatrician. I would say if a child is having a constant stomach pain lasting more than two hours, then they need to be seen that day, and probably best seen in the emergency room where we have radiology and tests that can immediately discern what is going on.

Melanie: What about appendicitis? What would someone feel? And, is that an emergent situation?

Dr. Boyd: It is an emergent situation and, generally, a child, in particular, will have pain in their stomach area that subsequently will go down to their right lower abdomen, and it may be associated with vomiting or fever. That’s the child that needs to be assessed that day and best assessed in the emergency room.

Melanie: Is something like a febrile seizure--because seizures are always very, very scary--but is something like that an emergent situation and you want to get them into a trauma center or is it something that comes and goes?

Dr. Boyd: Well, a febrile seizure is--it usually occurs in a child under 6, and it’s associated with a fever. Sometimes, the parent is unaware that the child has a fever, and the first sign of the illness is that the child has the seizure. The first time a child has a febrile seizure, they need to be evaluated to the emergency room to be sure it’s not something that’s more severe. If it’s the second and third episode, they can wait for the seizure to subside as long as one or two minutes, and then call their pediatrician and get instructions. If the seizure persists and continues more than two minutes, then they need to dial 911.

Melanie: So, while we’re talking about 911, do you recommend if it is emergent, that people call 911 or try and drive their loved one to the emergency room themselves?

Dr. Boyd: It depends on how severe the situation is. Obviously, if it’s a heart attack or a stroke, a severe allergy or a long-lasting seizure that we were discussing, then 911 is the most appropriate. I would say that if the family member doesn’t feel comfortable driving the patient to the emergency room, then they should dial 911.

Melanie: That’s very good advice. Now, cuts--people cut themselves while they’re cooking, things happen, and you never quite know whether it’s something that requires stitches. What can you tell the listeners about when they can look at a cut and say, “Oh, I should probably go in and have this checked?”

Dr. Boyd: I would say that if you can pull the skin margins apart, then that needs to be closed and, obviously, if there’s persistent bleeding, then you need help with stitches. And, I would say that a very superficial cut might be well taken care of by the primary physician or by the urgent care center but if it’s a deep cut, it really does need to come to the emergency room.

Melanie: And, then, what can they expect? If people come to the emergency room, what would you like them to know about showing up at the emergency room, what would you want them to bring with?

Dr. Boyd: Well, we’d like them to bring a copy of their allergies; their medications, both what the medicine is and its dosage, and how frequently they’re taking it; and then, their past medical history. We’re interested in knowing what kind of medical problems they have, what type of surgeries they’ve had in the past. It’s wonderful that they have a typed up or a handwritten piece of paper that documents all of that stuff. It makes things so much easier for us.

Melanie: What do you want the families to know about when you guys need to do your thing and they want to stand there and watch what you’re doing? What do you want them to know about what they can expect?

Dr. Boyd: Well, it depends on what we’re doing. Sometimes it’s fine if the family stays in the treatment area, especially if they’re comfortable with it. We don’t like to be suturing someone and then have mom and dad pass out. So, there are certain things that they can observe and, then, there are certain things that are probably best have them wait in the waiting room because it sometimes interferes with the physician himself when he’s trying to perform the task.

Melanie: Dr. Boyd, when is vomiting or diarrhea considered an emergent condition?

Dr. Boyd: Well, vomiting--if the patient has had previous surgeries on their abdomen, then we’re concerned about bowel obstruction. So, we would like to see that patient within hours of the episodes occurring. In addition to that, if they’re having severe pain, obviously, we want to see them. Any patient with severe pain, we want to see immediately. Regarding diarrhea, the consideration would be more of dehydration. So, if you’ve had diarrhea for more than 24 hours, then we’d like to see you and see if we need to rehydrate you.

Melanie: So, in just the last few minutes, Dr. Boyd, what do you want people that may have to go to the emergency room to think about before they go? Is there anything that you can tell them to think about? To plan for?

Dr. Boyd: It largely depends on the time of day. If they come early in the day, there are probably fewer patients in the emergency department. It’s going to be less of a wait. If they come in the afternoon or evening when family practice offices are closed, there’s more likely to be a considerable wait. We try to take care of the most severe cases first and then take care of everybody else. The advantage of the emergency room is that we have everything on site, lab turnaround could be 90 minutes. We have x-ray, CAT scans, MRIs--everything’s available--but sometimes there’s a backup and it takes a couple or few hours to get the patient fully treated.

Melanie: And, why should they come to Corona Regional Medical Center for their care?

Dr. Boyd: Well, at Corona, we have 12 board certified emergency physicians, and just as many wonderful board certified physician assistants. They’re supported by specialists that are excellent in their field and, in turn, we have an association with UCI so that they’re available to us when we have more complex problems. Then, in June, we’re going to have a brand new emergency room available. We’re building a huge structure on the ground, and we’re going to increase our capability to see patients by about 150%.

Melanie: Wow.

Dr. Boyd: And, of course, we’re available 24/7. We’re available every day, all the time.

Melanie: Thank you so much for being with us today. You’re listening to Corona Regional Radio with Corona Regional Medical Center. For more information, you can go to www.coronaregional.com. That’s coronaregional.com. Physicians are independent practitioners who are not employees or agents of Corona Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Managing Your Loved One’s Medications

Additional Info

Segment Number 5
Audio File allina_health/1637ah3e.mp3
Doctors Kresl, Matt
Featured Speaker Matt Kresl, PharmD
Guest Bio Matt Kresl is a pharmacist practitioner with Allina Health. He started with Allina in 2004 and has worked in various patient care and administrative positions. His current practice involves working with primary care providers on improving patient symptoms, better treating chronic diseases, and removing barriers to safety and effectively taking medications.

Learn more about Matt Kresl, PharmD
Transcription Melanie Cole (Host): With over one in three adults greater than 65 years old taking more than five medications daily, understanding and managing medication use can be expensive, confusing, and sometimes harmful. Coming up with tools to help your loved ones use their medications will better ensure they get the health benefits they desire. My guest today is Dr. Matt Kresl. He’s a pharmacist practitioner with Allina Health. Welcome to the show, Dr. Kresl. Why is medication management so important nowadays?

Dr. Matt Kresl (Guest): Melanie, thank you for having me. Medications are obviously given with good intentions but oftentimes can cause more harm than good. In fact, prescription drugs rank fourth with stroke as a leading cause of death in the United States. You can imagine, a billboard outlining the risk of stroke, but you oftentimes don’t see things related to medicine and the risk of that. So, oftentimes, medication management is important because you’re ingesting things with known risks and as a pharmacist, we try to address that risk when we meet with patients.

Melanie: What are some for the most common mistakes or issues that you see when people are taking multiple medications?

Dr. Kresl: It’s interesting because oftentimes patients see multiple providers, especially elderly adults. Oftentimes when they’re seeing many different doctors, they simply just don’t understand what the medicine is for. They oftentimes just go along with whatever the provider tells them during an encounter like that and because they see so many different types of doctors, they can oftentimes leave the doctor’s office not understanding what it is they take. When we get involved, oftentimes they’re a little dumbfounded as to what their medicines are for. Then we go in and try to give them the information they need. But, in terms of practical examples, oftentimes, patients will not generally have the habits that are necessary to ensure that they’re taking them on a regular basis. That, again, is another thing as a pharmacist we do is, really try to develop the tools and habits that allow them to safely take medicines.

Melanie: So, there are other things that can affect medications and whether they work effectively or not. What are some of those supplements or vitamins? How do those work with medications?

Dr. Kresl: Well, vitamins and supplements occupy a very large part of America. It’s anywhere from a $12 to $37 billion dollar industry depending on what statistics you see. Vitamins and supplements can be used for lots of different reasons. They can sometimes complement the medicines you’re taking. So, for example, you take a vitamin D supplement because it helps your calcium be absorbed. Oftentimes, people are taking vitamins to mitigate or lessen a side-effect from a medicine. So, for example, CoQ10 is used for patients who don’t tolerate cholesterol medicines. Supplements are great in many different contexts but it’s very much a buy or beware market. Supplements are not regulated the same way that prescription drugs are and what I mean by that is, supplements aren’t mandated to prove their effectiveness. They’re really only mandated to prove that they’re not going to be unsafe when you take them. And so, it creates a situation where the barriers to entry for vitamins and supplements are very low. You get lots of different makers out there and when you have that situation, you don’t necessarily know what you’re taking as well. So, that’s my long-winded way of saying that supplements can be great. There are many good examples of that that I illustrated but it very much requires a diligent eye as to who makes it and is that company that you’re buying that supplement from, reputable.

Melanie: One of the most important things is knowing what medications you’re on. What are some of the best things people can do to set themselves up for success with their medications if they have to go to the emergency room or if a loved one is taking care of them? What do you tell people everyday about managing their medications?

Dr. Kresl: I think the biggest thing is having a list. And I go back to a point I made earlier where patients are seeing multiple different providers. As a pharmacist, what I do when I go into patients homes or see them in clinic is if they’ve seen multiple providers and they don’t even have an accurate list to present to a caregiver about what they’re taking. And, anytime there’s an omission or an incorrect dose or something like that, that can set somebody up for a potential error. So, just having a list with them, updating it on a regular basis. And I think really, a big point is just understanding the basics of what it’s for and what to expect. I don't expect my patients to know every side effect of every medicine they take, but just a basic, “This is for my blood pressure. This is for my cholesterol. This is for my COPD or asthma. This is for UTI prevention.” Just a very kind of, again, layman’s understanding can be really helpful so caregivers can get a sense of what’s going on with the patient.

Melanie: What about different pharmacies? If they use more than one pharmacy, how do they combine all of these different medications? Can they tell one pharmacy all of the things? Do you recommend that they just stick with just one?

Dr. Kresl: In general, yes. I think, anytime you can provide a consistent process for yourself, not only the pharmacy you go to but that pharmacist who is there consistently, having that relationship, I always advocate for. Unfortunately, there are times when patients need to use multiple pharmacies. For example, if they need to get a novelty drug that isn’t available at every pharmacy. Again, one place for consistency is best to help, again, with the record keeping. And then, from there, if there are multiple locations, updating that list or helping your loved one update that list can be vital.

Melanie: If someone’s taking care of an aging parent, what are some of the signs they should look for that the parent might need assistance with their medication?

Dr. Kresl: It’s a great question. When I go into patient homes or see them in clinic, the first thing I ask the patient to do is to just get all your medicines in one spot. So, if you’re a loved one and trying to figure out, is my loved one doing it right or not, gathering all the medicines is a good idea. And, if they’re in multiple places in the home, that’s a warning sign that they’re not managing it well because having them in one spot just ensures that they’re more likely to do it on a regular basis. Many patients use pill boxes and so, oftentimes, when I meet with patients, I’ll just take a peek in the box. If there are lots of slots that are still full of medicine, it gives you some confidence that they’re not taking them as they should. The other thing is just simple things like looking for medicines on the floor. I have patients who sometimes have shaky hands due to an essential tremor or Parkinson’s disease, and the medicines won't actually physically get into their mouth. So, if you see a pill on the floor, that’s another sign that things may not be as they should. If your loved one doesn’t have regular patterns, meaning eating time, sleeping time, running errands, etc., oftentimes it can be harder for them to remember to take their medicine and so that can be another sign that you could look at or a clue. It can feel little bit like you’re a detective putting a story together. And then, the last thing is just looking at the bottle, and if the dates are old and the number of pills times the number of times a day they’re taking it, don’t add up, that’s another sign they’re not taking their medicines.

Melanie: Now, with so many people on pain medications and possible opioids, do you advise children of aging parents to count these number of pills because there is an OD problem in this country with elderly and taking these pain medications at the wrong times or too close together. What do you tell them?

Dr. Kresl: Oftentimes, I tell them, these can be habit forming. I think the media nowadays is doing a much better job of outlining the risks. I hear my patients talking a lot more about the risk and they’re worried about dependency but as it relates to small children, keeping them in a locked cabinet or facility that is under lock and key. I have patients who store controlled substances literally in a safe just because of their concern about other people in the home potentially getting access to them and abusing them or misusing them. Beyond that, I think really articulating appropriate use and inappropriate use, and then just being aware of what their risks actually are. For example, with opioid medicines or benzodiazepines--those are things like Ativan or Diazepam or Oxycodone or Hydrocodone--the big risks, the life-altering risk, is respiratory depression meaning they literally stop breathing from overuse of the medicine. And just kind of making it very clear again in layman’s terms what the risk is for overuse can, I think, make a big difference as to how they go forth and use them.

Melanie: Where’s the best place to store your medications?

Dr. Kresl: Wherever you’re going to remember them the most to take them. So, when I talk to patients about adherence, I give them very frank statistics about adherence rates. So, when you go into the peer review literature and look at adherence, oftentimes patients taking their medicines half the time is what you see. And so, just being very forthright with, most people don’t remember them about half the time. So, I always tell them a central location in the house is a good place, and a lot of it is around ritual and habit formation. So, for many people, the first place they stop in the morning is the kitchen, so I tend to prefer the kitchen as a place because most medicines are taken in the morning, that’s where the day begins, and that’s where you can, again, develop the habit of taking your medicines by having them in close physical proximity. The other benefit is that they’re going to be stored under room temperature. You don’t have to worry about them overheating in the bathroom where heat and humidity can become more of an issue.

Melanie: And just wrap it up for us, Dr. Kresl, if you would. What’s your best advice when it comes to managing your own or someone else’s medication? Give the best advice and tell people what you tell them every day about remembering to take these important medications?

Dr. Kresl: Really, the only advice I give them is around looking at their rituals or daily habits. Taking medicines is no different than any other habit that you develop, if it’s a good one, and understanding how you tick, understanding what you do on a daily basis, and then, fitting your medicines into that daily routine, I think, is really, when it comes down to it, the best advice I can give. And then, beyond that developing a strategy to help you remember such as a pill timer or an alarm, I think, could be a useful tool as well.

Melanie: Thank you so much for being with us. It’s really great and very important information. You’re listening to The WELLcast with Allina Health. For more information, you can go to www.allinahealth.org. That’s www.allinahealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Celebrating 50 Years of Organ Transplantation at UVA

Additional Info

Segment Number 4
Audio File virginia_health/1639vh2d.mp3
Doctors Doyle, Alden
Featured Speaker Alden Doyle, MD
Guest Bio Dr. Alden Doyle is a transplant nephrologist and the medical director of the kidney transplant program at UVA’s Charles O. Strickler Transplant Center.

Learn more about UVA Health System
Transcription Melanie Cole (Host): In June 1967, the UVA Transplant Center transplanted its first solid organ, a kidney. My guest today is Dr. Alden Doyle. He’s a transplant nephrologist and the Medical Director of the kidney transplant program at UVA’s Charles O. Strickler Transplant Center. Welcome to the show, Dr. Doyle. Tell us a little bit about the transplant center at UVA and the 50th anniversary coming up in 2017. Give us a little background on the evolution of kidney transplantation over the years.

Dr. Alden Doyle (Guest): Sure. So, the program is a well-established one that does most of all the solid organs. So, they have a robust program in heart transplant, kidney transplant, pancreas transplant and lung transplant, and a separate one in bone marrow. So, almost all of the normal organs that are transplanted. They have been innovators in the field for years with tissue typing and different organ transplant techniques, and there’s a lot of nice overlap. So, they’ve been in the business for a long time, and recently, with a new dean who is a lung transplant specialist himself, have really put a lot of resources to make all the transplant programs go under one transplant institute, and continue to grow and be innovators in the field. In terms of history of transplant, we’ve come a long way. As you know, in the mid-50’s, the original transplant was basically reserved for very healthy folks who had living donors, and so the immunosuppression was very modest and the understanding of how the immune works to keep one healthy and to reject organs was only very rudimentary. So, it was really only available for a few folks under special circumstances. And now, with lots of medicines and a lot of greater understanding, it’s available to, not all but many, people with different kinds of organ disease and different backgrounds.

Melanie: So, there’s are many organs that you transplant now, and UVA is the only comprehensive transplant center in Virginia with more than 45 years of experience. Dr. Doyle, speak about some of the other organs that are transplanted, what people should look for when looking for a transplant center?

Dr. Doyle: So, I think there are a couple of things you can look at. There’s publicly available data. So, there’s an organization that the government funds and supervises which is called “United Network for Organ Sharing” or “UNOS”. So, they have the responsibility of maintaining oversight for transplant programs across the country and publish on the website the outcomes. So, I think one question a potential transplant recipient would ask is, “How do they do? And if I get a transplanted at the center, would I expect to survive, and how would the function of the organ work?” So, they publish one- and three-year patient and graft survival as a first test. On top of that, I think you’d want a comprehensive center that can offer the broad range of services, including overlap of disease. So often we see that patients have not just kidney disease but also liver disease, and so it’s nice to have one center that can manage the thing from soup to nuts, and even up to the unusual circumstance of requiring two organs at once.

Melanie: What do you anticipate the future holds for kidney transplantation?

Dr. Doyle: Well, our hope is a couple of things. One is, one of the biggest problems we have and we’re victims of our own success in a way. We have the one-year graft survival and patient survival that has gone steadily up and, as I mentioned before, there are a lot more folks who are potential candidates. And so, with organ donation rates being reasonably flat—they’ve grown a little bit--then there’s a bigger disparity between need for organs and availability of suitable organs. So, we hope that there’s going to be continued public advocacy for donation, different ways to do this, but to increase the supply because there’s a growing number of people who die waiting for organs even though they know that if they got transplanted, they’d be successful, but there just isn’t enough to go around. So, that’s a piece of it. Part of it is public policy so there are some things we hope Congress will do to make living donation and organ transportation even easier. They’ve been supportive but there are some important steps to make right now. There’s also a lot of science in immunology and related fields like genomics and proteomics that we hope will translate into better outcomes for transplants so we have more of an individualized medicine. We know that different people respond to medications and have different risks of rejection, but why that is in all circumstances is less clear. So, going forward, if we can make an individual plan so that this combination of medications and these organs will be the best for an individual patient, that would be a real step forward in keeping with the way--the direction--of modern medicine.

Melanie: So, can you tell us about any breakthroughs in post-transplant care?

Dr. Doyle: There’s been some. It’s been incremental. I wouldn’t call it absolute breakthrough. There have been some new medications that change the paradigm of immunosuppression. For example, there are some medications that people can get once a month by IV, that’s never been possible before. There’s been some work to try to promote tolerance where, under certain circumstances, patients would not require immunosuppression--although it’s the exception. But, it’s exciting stuff.

Melanie: Dr. Doyle, what factors are considered in organ matching and allocation? How does that matching process work?

Dr. Doyle: A number of things. It’s complicated and simple. In kidneys, unlike other organs, the primary driver for allocation of a kidneys, in other words, who gets which kidney, is based on time on the waitlist. So, recently that’s undergone a big change. So, now time counts back to when either you get listed or when you started dialysis, whichever is first, because some people used to wait years before they came in to get evaluated. So, the time is the number one thing. There are some immunologic factors and a degree of matching for the human leukocyte system, the HLA system. So, you get points for certain types of matching where, if the kidney’s a better match, you would get the equivalent of more time. And then, there are some special circumstances where your body may have immune barriers to block kidney transplants. So, it makes it harder, and so you’re given a special dispensation. So, that’s the normal thing. And then, kids get transplanted earlier because they know that kidney failure doesn’t allow them to grow normally. So, there’s couple of special circumstances, but mostly it’s driven by time.

Melanie: How does somebody get on the waiting list?

Dr. Doyle: You come into a center and you have to either be on dialysis or it should be importantly noted that you can have 20% kidney function or less. So, the best circumstance is, as soon as you hit 20% function, before you go on dialysis, which usually occurs at around 10% function, you get into a transplant center and get listed quickly because that pushes the time clock going earlier. The evaluation process always involves a multidisciplinary approach: that’s a dietician; that’s a social worker; that’s a transplant coordinator, which is a nurse or a nurse practitioner; the nephrologist like me; and a surgeon. So, we all work together in concert to try to make a decision about who’s a candidate or, more importantly, what things we need to do to get people ready so they’re the best candidate they can be.

Melanie: That is exciting. Tell us about the transplant center. Tell us about your approach to patient-centered care. What can a patient expect, because that’s a very scary thought but yet very hopeful and exciting?

Dr. Doyle: Yes. So, we try to take the broad view and that is, once upon time transplant centers were largely happy to have their success of transplant. So, the focus was always on the numbers and getting people through the operation and getting them up to a year or three years. I think as they got better, we still want--those are really obviously very important metrics but there’s more to that. So, I’m trying to push for a patient-centered approach which means yes, we want the numbers to look good but we also really want to take a person through a journey from a point of end-stage organ disease--kidney in this case--all the way through to health because kidney transplant and other organs, too, is a special case where people can really know what it’s like to be sick, sometimes deathly ill, on dialysis, and they see some people--some make it and some don’t, and you can give them the second chance. And, unlike things where people have a revelation at the end of their lives or their final days of their life and that may or may not be true for a short time, people can have--we’ve had kidney transplant patients who’ve lasted 40 years. So, you can have somebody who gets very close to being very, very sick and have the knowledge that that brings, the wisdom that that brings sometimes, and then get a second chance and be able to live that second chance for potentially decades. So, as we go forward, I’d like to continue to manage the nuts and bolts of transplant but also to increasingly focus on the human aspect which is this is really a wonderful celebration of life and a second chance.

Melanie: Wow. Such great information. Thank you for all the great work that you’re doing, Dr. Doyle. You’re listening to UVA Health Systems Radio. And for more information, you can go to www.uvahealth.com. That’s www.uvahealth.com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Midwifery for Pregnancy and Childbirth

Additional Info

Segment Number 4
Audio File allina_health/1637ah3d.mp3
Doctors Simon, Kathrine
Featured Speaker Kathrine Simon - Midwife
Guest Bio Kathrine Simon is a board-certified nurse midwife at Allina Health East Lake Street and Hopkins clinic locations. Simon’s professional interests include women's health, pregnancy, water birth, vaginal birth after cesarean (VBAC), trial of labor after cesarean (TOLAC), empowerment of women and their families and natural physiological birth.

Learn More About Kathrine Simon
Transcription Melanie Cole (Host): Certified nurse midwives care for women throughout their lives and provide holistic patient/family centered and evidence-based care. Midwives work with women and families during pregnancy, birth, routine well-woman exams, and menopause. My guest today is Catherine Simon. She’s a board certified nurse midwife at Allina Health East Lake Street and Hopkins Clinic locations. Welcome to the show, Catherine. Tell us: what is a midwife? They’ve been around for a very long time and people don’t even really know what you do.

Catherine Simon (Guest): Good morning, Melanie. Thanks for having me today. As a certified nurse midwife, I have training as a registered nurse and that I've gone beyond that to get my advance practice nurse in an emphasis with midwifery. We believe that caring for women is really a function of education, support and advocacy--support throughout their lifespan. Usually, women are finding us when they’re pregnant and they continue their care through their menopause years.

Melanie: So, how does somebody go about finding a midwife? Usually, you think of going to your gynecologist or whatever. So, how would you find a midwife?

Catherine: So, usually women find us through their friends. The web now is a great place for resources. People are becoming pregnant and finding what kind of pregnancy and birth they’re looking for and that’s how most women find us.

Melanie: So, what kind of birth and pregnancy would a woman be looking for if she was looking for a midwife? What’s different between you and, say, just going to our gynecologist?

Catherine: So, women who seek out midwifery care are looking for more of a natural physiological birth experience, they want to be empowered and be a proponent of advocacy for their birth. They’re looking for a natural experience but yet still be able to have the resources of a hospital or physician care if they would need it.

Melanie: So, that’s probably one of the biggest questions I would imagine people ask you is, can a midwife work through the hospital? And, if you are going to deliver their baby or be their pregnancy caregiver, what if something goes wrong?

Catherine: So, as a midwife, I have a team that I work with--a team that involves physicians that are obstetricians, physicians that are perinatologists, nutritionists, radiologists--a whole team of people that are able to support a pregnancy that might change from low-risk to high-risk. That care is seamless for the woman, they don’t have to find another team provider, and the communication throughout the team is very concise. It enables the woman to have that full spectrum of care.

Melanie: And, so, what does that mean? If someone is going to have a baby and they start to see you throughout their pregnancy, can you prescribe prenatal vitamins and give them good nutrition advice, and work with them though the pregnancy? And, then, what is birth like with a midwife? Does it have to be at home?

Catherine: So, there are some midwives that do birth at home. Our practice is a hospital-based practice, and we have chosen that route to be able to care for more women--women that maybe have a high-risk pregnancy but want a low-risk pregnancy experience. They can birth in a position that might feel comfortable for them, have people at their birth that are empowering for them and supportive. They can have a birth experience that puts them, their baby and their experience at the forefront. Yet, if they need expert care, they can still have that within that same birth experience.

Melanie: If you’re working with a midwife, can you have an epidural?

Catherine: Absolutely.

Melanie: Okay. So, that’s good to know because I think people think it has to be all natural childbirth. And, then, what if something goes wrong? You can get a physician onboard pretty quickly?

Catherine: Absolutely. We can have a physician there to care for you within minutes. We have a great team. We’re in communication at all times through what’s going on with the patient and the baby so that there’s that information before we would need them in the room.

Melanie: So, you also work with women in menopause. What’s that like working with a midwife as a woman goes through that change? What do you do with them?

Catherine: So, as a midwife ages, her patient population actually ages with her. There are many women I've been with through their pregnancies and now, as we’re both aging, we tend to experience those experiences together to some extent. What we do is we empower what’s natural; what’s normal. How do you navigate that pathway with having maybe medicine for support, alternative medicines, alternative therapies, and how do we embrace that change in our life?

Melanie: So, when a woman comes to you and has all of these issues and you may or may not be going through these things yourself, is this something that you work through with other forms of meditation, yoga, exercise? What do you tell women about going through that time?

Catherine: We first talk about what is your body doing--what’s normal and what’s not normal--because it’s important to differentiate a pathology which would be disease versus a normal physiological change of your body. And, then, how do we support those changes to limit the impact it is on their life. We use alternative medicines and therapies. We work with Penny George Institute to help those women as well and then we talk through nutrition support and how to embrace that change.

Melanie: And, what is the philosophy, Catherine, of a midwife, that would make it so that these things are all natural but yet still evidence-based.

Catherine: So, as midwives, we promote normal physiological birth, lifestyle choices. We want to empower women. We want to give them the support that they need through evidence, through education support to achieve whatever their health goals are.

Melanie: Can men be midwives?

Catherine: Actually, there are some male midwives--one in this state, and there are across the country.

Melanie: That’s very cool. And, do you have to be a nurse to be a midwife?

Catherine: So, there are couple tracks but nurse midwives are always a four-year nurse degree, and then an advanced practice degree which is now at doctorate level as well as a master’s level.

Melanie: So, to be a midwife, do you have to be a nurse, or can you--is there a certain certification to be a midwife?

Catherine: There are. So, there’s certifications that involve a traditional midwife or a certified nurse midwife. But, to hold the title of certified nurse midwife, you would have to be a nurse first.

Melanie: Going back to birth for a minute, people hear about all different kinds of births and you mentioned under water or with friends around so they really get to plan their own birth. What do you tell them about thinking about that and afterwards?

Catherine: So, as we meet during the prenatal course--and thankfully we get a long time to be able to develop this relationship--we talk with families, what are the emotional needs, what are the physical and spiritual needs of any family as they go into this birth? As we think about birth, it’s really the birth of a family. We want to address what are your worries and concerns, what are your hopes and aspirations so that we can facilitate that pathway. The other process is learning about how to take care of the body, how to take care for the baby so that those birth experiences can be realized and achieved.

Melanie: And after the baby is born, then do they continue to see you and what if you suspect a little postpartum depression, then what?

Catherine: You know, postpartum depression is so common and I think in our healthcare system, we have such a connected prenatal care and then after the baby comes, there’s a little bit of a change there. We still communicate with our families. We touch base with them and make sure that they’re doing well. When they come in for their postpartum visit, we encourage them to bring the baby. We have a lot of resources in this state and with Allina to help women go through that transition. Postpartum depression is first the recognizing of the symptoms but also the support that a woman would need. And that support comes through, sometimes, medication, therapy--acupuncture has been shown to be very helpful as well.

Melanie: So, wrap it up for us, then, and explain to people what you do as a midwife throughout the life of a woman and help her to start that new life as a mother.

Catherine: So, as a midwife, I think I’m very blessed. I've been invited into a very special time in a family, and at that moment of relationship building, we’re learning about each other and how to support. Birth is just part of the experience. It’s really about just becoming a woman and becoming a mother, and I think every lesson learned from each of these, we take on as we think about how we’re going to parent our children, how we’re going to support our families as our parents age and as our children get sick or need healthcare services as well. But, when I see these families come back time and time again for their subsequent births, it’s just so empowering to see them take that little moment of a message that we had during birth and to use that as they go forward in their life. And, it’s really such a wonderful relationship. I always say, a midwife, we’re not doing deliveries, we’re actually catching babies and we’re changing families.

Melanie: How lovely. Thank you very much for being with us today, Catherine. You’re listening to The WELLcast with Allina Health. for more information, you can go to www.allinahealth.org. That’s www.allinahealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Digging into Dementia

Additional Info

Segment Number 2
Audio File virginia_health/1639vh2b.mp3
Doctors Foff, Erin
Featured Speaker Erin Foff, MD, PhD
Guest Bio Erin Foff is an Assistant Professor of Neurology. She received her Ph.D. in Molecular and Human Genetics from Baylor College of Medicine (Houston, TX) and her medical degree from the Jefferson Medical College in Philadelphia, PA. Following neurology residency at the University of Virginia, she completed a research fellowship in nucleotide repeat disorder biology at the University of Virginia. She has a basic science laboratory where her team conducts research on several nucleotide repeat disorders, including frontotemporal dementia/ALS and myotonic muscular dystrophy. Dr. Foff sees patients with neurodegenerative diseases causing cognitive complaints, and she specializes clinically in early onset dementias, frontotemporal dementia and the primary progressive aphasias. She lives in Charlottesville with her husband and two children.

Learn more about Erin Foff, MD, PhD

Learn more about UVA Health System
Transcription Melanie Cole (Host): When someone hears the word dementia, they automatically think Alzheimer’s disease but there are dozens of conditions that can cause dementia, and it doesn’t just affect the elderly. My guest today is Dr. Erin Foff. She’s a neurologist and a memory disorder specialist at UVA Health Systems. Welcome to the show, Dr. Foff. As I said in the intro, when someone hears that word, they automatically think Alzheimer’s but tell us about some of the other conditions that can cause dementia.

Dr. Erin Foff (Guest): Absolutely. You know, that’s one of the most common misconceptions that patients and their families come into our clinic harboring. So, dementia is actually just a description of the severity of a cognitive problem. And many, in fact dozens, of disorders can cause dementia. Alzheimer’s is really only one of them. Other disorders--other neurodegenerative disorders that can cause dementia include such diseases as dementia with Lewy bodies which many of the listeners may be familiar with because it is the disorder that Robin Williams recently passed away from, as well as frontotemporal dementia which we’ll discuss a little bit today; vascular dementia which is even more of a problem in our society with many vascular risk factors that our patients suffer with; and then, other non-neurodegenerative diseases like autoimmune diseases that lead to cognitive complaints, and also mood disturbances.

Melanie: So, people also usually think that dementia only happens to older people but some of these conditions, as you mentioned Robin Williams, happen to younger people. So that’s true, correct? And what are some of the conditions that might happen to a younger person?

Dr. Foff: That’s exactly right. So, oftentimes in our clinic, we are stratifying people in terms of their risk of a certain type of dementia based on their age. So, Alzheimer’s dementia tends to strike mostly folks who are above age 65, most commonly in 70s and 80s, and, in fact, by the time people reach their mid-80s, they’re approaching about 50% risk of developing Alzheimer’s disease. But, some of the disorders that can strike young folks in their 40s, 50s and 60s, include diseases like the frontotemporal dementias which is a class of diseases that tends to strike young. There is a form of Alzheimer’s called “early onset Alzheimer’s disease” that strikes, again, before age 65. And, many of the non-neurodegenerative dementias, those associated with severe depression or autoimmune disease, can also strike folks that are much younger than you would typically expect for a dementing illness.

Melanie: Dr. Foff, what are some of the red flags that people--they hear about leaving their keys somewhere or not knowing where they’re going, but what are some of the ones for loved ones that they might notice in somebody that would signal the onset of one of these dementias?

Dr. Foff: That’s a really great question. So, typically, it’s actually not the patient that recognizes there may be a problem, but oftentimes their family or another one of their healthcare providers like their primary care physician. So, it’s true that we do lose some mental flexibility as we age but when family members start to indicate that somebody is repeating their sentences or questions over numerous times, if there are severe or unusual personality or mood changes, if there is any evidence of weakness or changes in the sensory system of the body, those can all be red flags--headaches, etc. So, we typically encourage people, if anybody has expressed concern that perhaps their slight memory problems seem out of proportion that they should at least have a quick screening exam with their primary care doctor, and if it looks like there may be more severe problems, having a referral to a neurologist.

Melanie: Is there a screening? I’m glad that you mentioned that because, is there a way to diagnose it for sure? Is it based just on history or would something like a CAT scan or an MRI show you anything that would tell you that that person is in cognitive decline?

Dr. Foff: So that’s great question, and that really is dependent on the reason for the cognitive decline. So, certainly, a primary care physician or a general neurologist can do the initial workup that can include some screening measures that are usually validated mostly for older patients. But, if there is a concern, we can do more in-depth cognitive testing. This is something called “neuropsychological testing” which is looking at all of the cognitive domains for evidence of abnormalities. And, in addition to standard tests like structural imaging or MRIs, looking for shrinkage of the brain or lesions in the brain, we can also do some very advanced testing, actually looking specifically for the presence of the Alzheimer’s protein or other patterns that indicate the brain is not functioning normally, and that can help a lot with diagnosis. There are now also more sophisticated biomarker tests which is where we analyze spinal fluid on patients to look for evidence that there is breakdown of brain cells and, in a particular pattern, consistent with certain diseases. So, we are much more accurate in our diagnosis now than we ever were before.

Melanie: You’re among a select group of researchers worldwide trying to find the genetic defects behind frontotemporal dementia. Tell us about the work that you’re doing in the lab, and how it might one day benefit these families.

Dr. Foff: That’s right. So, I work on a particular form of frontotemporal dementia that is associated with one underlying genetic defect, and it’s the most common cause of inherited frontotemporal dementia. It is also linked and causes many cases of familial or inherited ALS which many people know by the other name, Lou Gehrig’s disease. And so, typically in the past, people have studied mouse models or animal models in an effort to understand how these diseases progress and to develop therapies targeting those processes. We take a different approach in our lab using stem cells created directly from patients, where we are able to take patients skin cells from an adult living patient, turn them into a stem cell which is a cell that can become anything in the body, and then further make that stem cell into brain cells in a dish, and we have created very complex models of the brain in three dimensions from those patient cells so that we can study them and understand what’s going wrong, and hopefully develop drugs that can target that process.

Melanie: That’s absolutely fascinating and so well spoken. You explained that just perfectly for the listeners, Dr. Foff. Now, tell us what you tell families when they do get diagnosed--someone that they love. What do you tell them about available treatments or lack thereof or lifestyle things that they can do to at least help this person while they’re going through this?

Dr. Foff: That’s such a critical part of the process. So, many people are aware of the fact that we just don’t have a cure for any of these neurodegenerative diseases although we really hope, as a community, that we’re headed there soon. But, that doesn’t mean that our process stops at the diagnosis. So, we are very interested in pursuing what we call a “multidisciplinary approach” for every single patient. So we try to provide support along every line of the patient’s process and journey, and this includes symptom management--since many of these diseases come with lots of symptoms in terms of mood or physical symptoms--as well as providing support for the family, and access to community resources, palliative services when necessary, and then, importantly, clinical trials when patients are interested in pursuing that. For many of these disorders, we have national clinical trial networks and after we identify patients that are interested in participating in those trials, we can help direct them to the appropriate trial, which oftentimes is testing a new drug therapy that we hope will be that future wonderful drug that can slow or prevent these diseases from getting worse.

Melanie: So, tell families that are facing dementia what they should think about if they want to consider a clinical trial.

Dr. Foff: That’s right. So, the first thing is to be referred to a center that does clinical trials. That’s very, very important. And then, once there, the neurologist or the care team can help decide the appropriate diagnosis because that determines the clinical trial, and then can lead the patient and the family through their available options. Clinical trials are labor intensive for both the providers and the patients and their families and understanding fully exactly what being in a trial entails is really important. We also make a big push to make sure that patients and their families know that, in addition to the clinical trials, there are things that the patient should be doing at home to slow decline and that includes regular, vigorous exercise, a healthy diet, social engagement and good sleep. All of these things have been proven to slow decline and should be done in concert with a clinical trial as well.

Melanie: And now, to wrap up, what do you tell families, Dr. Foff, because this is, as we said, such a difficult time, not only for the person going through it, but for their loved ones, about that support for them as a caregiver, and how difficult it can be to watch somebody in cognitive decline.

Dr. Foff: That is such a crucial piece of the puzzle. So many of these caregivers take on just an incredible burden in terms of emotional output, time away from work--all of those things that. So, what I tell families is this is a marathon and not a sprint. And that keeping them healthy, well-supported emotionally and from community resources, etc, and from the clinic resources, is really critical to keeping them healthy through the entire process. And making sure that every step of the way, they understand that there’s a team that can help answer their questions, making sure they get rested when it’s needed—all of those are just so crucial to making sure that the entire family unit is supported, not just the patient alone.

Melanie: Great information. Thank you so much, Dr. Foff, for being with us today. You’re listening to UVA Health Systems Radio. And for more information, you can go to www.uvahealth.com. That’s www.uvahealth.com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Seasonal Allergy Solutions

Additional Info

Segment Number 2
Audio File florida/1630fl1b.mp3
Doctors Mazloom, Narges
Featured Speaker Narges Mazloom, DO
Guest Bio Narges Mazloom, DO specialties include Otolaryngology - Ear, Nose and Throat.

Learn more about Narges Mazloom, DO
Transcription Melanie Cole (Host): Fall can be the worst time of the year for people with seasonal allergies. According to the Asthma and Allergy Foundation, up to 40 million Americans suffer with seasonal allergies. My guest today is Dr. nargesMazloom. She’s an otolaryngologist with Florida Hospital. Welcome to the show, Dr. Mazloom. So, tell us about seasonal allergies and how would somebody know, because as the fall comes, some people think it’s a cold or they think it’s something else. How would you know if it’s allergies, seasonal allergies, as they come up?

Dr. Narges Mazloom (Guest): Well, first of all, I want to thank you, Melanie, for having me today. To answer your question, patients who do have some allergy symptoms, are going to suffer from symptoms such as itchy eyes, red eyes, watery eyes, nasal congestion, drippy, watery nose, post-nasal drainage. Sometimes they can also have a cough that goes along with it, and if they do have a history of asthma, they may also have some wheezing and tightness in the chest. Occasionally, it is difficult to distinguish between a viral upper respiratory infection versus an allergy. However, if you do not come down with a fever, muscle aches, joint aches, and otherwise are pretty much feeling okay except for those other symptoms that I listed, it’s most likely an allergy.

Melanie: Do you have to be tested for seasonal allergies? People hear about allergy testing and all the shots. Do you test for seasonal allergies or if somebody comes up with these symptoms and it isn’t a cold or a respiratory infection, you assume that’s what it is?

Dr. Mazloom: Well, the most important start to investigating the patient’s underlying condition would be a history and a physical exam. By history, if they basically have these recurrent, episodic symptoms that come on certain times of the year, then it does point towards more of an allergy as the cause of their symptoms, and then we also do an examination. There are certain things on the exam that can definitely point toward it being more of an allergic reaction. However, in order to be able to clinch that diagnosis, sometimes it is necessary to be able to do testing to confirm that allergies are actually the cause of the symptoms. And, when we do testing, there’s different forms of testing as well. The initial one is we can do a blood test which is an indirect test where we check the blood levels of specific antigens in the body, and then there’s also skin testing which we can know exactly how reactive they are to those items that we test. So, both of those are really good tools that we use to be able to confirm allergy.

Melanie: So, then, do we look for triggers? Do you want to be able to identify those triggers so they can avoid them? Because in the fall, depending where you live, it’s hard to avoid some of these triggers.

Dr. Mazloom: Oh, absolutely. When it’s a seasonal allergy, it’s basically the pollens that are in the air. You don’t have to be directly on top of the plant itself for you to be exposed to it. These pollens are carried in the air, by wind, and you inhale them. They are tiny particles and you don’t see these particles. So, avoidance is very difficult. If you are severely allergic, trying to stay indoors and use the HEPA filters to help purify the air can help. However, again, when you do go out or open the window, you’re going to get exposed to those pollens. Now, there are other allergens that are inside your home that you are, obviously, not going to be able to avoid such as dust, pet dander, mold, things like that that basically avoidance is almost impossible.

Melanie: Do things like air purifiers, dehumidifiers, any of those, work?

Dr. Mazloom: Air purifiers definitely do help. Changing your filter system within the home and using a good HEPA filter is going to be important to be able to filter out that air that’s being brought in from the outside so that it decreases the exposure load. It’s not going to eliminate it all but it will help decrease the load.

Melanie: Does an antihistamine work? What’s the medicational intervention for seasonal allergies, Dr. Mazloom?

Dr. Mazloom: Definitely antihistamines are the “go to” drug. They do block that histamine reaction which is that initial or basically the key reaction that creates the symptoms that you feel such as the runny nose and the congestion and everything. The newer medications that are over-the-counter now are the nasal sprays. There are the steroid nasal sprays that are over-the-counter which are very helpful in controlling the nasal and some of the ocular symptoms. There are prescription medications that can also be given which--one class is called a “leukotriene receptor antagonist”. One of them is called--Singulair is the brand name. And, that’s an additional medication we can use to help the patient’s symptoms.

Melanie: And, how often can you use those inhalers?

Dr. Mazloom: The nasal sprays are pretty well tolerated. Some patients need to be on them chronically, and then, they’re pretty well tolerated as long as you know how to use them properly. Some do cause side effects such as dryness in the nose and nose bleeds. Some patients may get some headaches, but there are other ones that we can switch to if they do have some symptoms like that. So, they are pretty well tolerated and safe to use.

Melanie: And, what about some of the home remedies you hear about like nasal lavage. Do you think that those help?

Dr. Mazloom: Absolutely. The nasal lavages actually help clear out the load that you’ve inhaled and it’s coating the mucosa of the nose. You can help by washing them out and decreasing that load therefore decreasing the amount the body has to fight against. So, they do help, definitely. But, again, not one thing will take care of all the symptoms.

Melanie: And, if you get those itchy eyes, are there eye drops on the market, Dr. Mazloom, that help with that or should you stay away from eye drops? Do they become, not addicting, but like an antihistamine where you use them a lot?

Dr. Mazloom: Yes, there are definitely over-the-counter antihistamine eye drops, There are prescription antihistamine eye drops as well. So, they do help. You don’t want to, obviously, have to rely on them every single day. And, if you are a patient who does suffer from allergies on a regular basis like that, then perhaps getting evaluated with allergy testing and perhaps even considering immunotherapy, which most people know as allergy shots, that maybe the better route for you so that you don’t have to be constantly on medications, and get a cure from your allergic reaction so that you don’t have to use the medications as often. Now, I don’t know if many people are aware that in addition to the more well known shots for allergies, there are also sublingual drops available by some physicians that do provide them. That would mean no shots. You just put drops underneath the tongue and have to avoid the--you don’t have to get the needle.

Melanie: How fascinating. So, wrap it up for us, Dr. Mazloom, about seasonal allergies, what you tell people every single day about identifying those triggers, and helping them to get through that season?

Dr. Mazloom: Definitely. So, patients who are suffering from those symptoms of the congestion, the runny nose, itchy eyes, watery eyes, if they have a suspicion that this could be an allergic reaction and they’re not quite certain if it’s an infection or allergies, it’s best to be seen by their physician to have that evaluated and properly started on the right medication. If they do suffer from allergies, for most ,it’s not all the year, then being tested for allergies would be an important next step and considering immunotherapy to help them become cured, in a sense, from their allergies, would be something to definitely consider. In the meantime, they can certainly try antihistamines that are over the counter, as well as nasal steroid sprays and speaking with their doctor to be able to know which medications might best help their symptoms.

Melanie: Thank you so much for being with us. It’s great information. You're listening to Health Chat by Florida Hospital. And for more information, you can go to www.hcpphysicians.org. That’s www.hcpphysicians.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Diabetes Prevention and Management at UVA Health System

Additional Info

Segment Number 3
Audio File virginia_health/1639vh2c.mp3
Doctors Kirby, Jennifer
Featured Speaker Jennifer Kirby, MD
Guest Bio Dr. Jennifer Kirby is a physician board-certified in both general internal medicine and endocrinology, diabetes and metabolism at UVA.

Learn more about Dr. Jennifer Kirby

Learn more about UVA Health System
Transcription Melanie Cole (Host): The Diabetes Education and Management program at UVA Health System offers a complete approach to diabetes care that addresses your whole body with special clinics focusing on how diabetes can affect your heart and weight. My guest today is Dr. Jennifer Kirby. She’s a board certified in other general internal medicine and endocrinology. Welcome to the show, Dr. Kirby. So, tell us about the two different types of diabetes.

Dr. Jennifer Kirby (Guest): Primarily, we think about diabetes as Type 1 or Type 2. Type 1 diabetes also known as juvenile diabetes--although I will share with you that more than 30% of the patients diagnosed with type 1 diabetes are adults--are patients who have an autoimmune disorder that causes a loss of insulin production from the pancreas. So, these patients are considered insulin dependent. The more predominant or prevalent diabetes is Type 2 diabetes. This is the one that we think about as being adult onset, and related to weight is Type 2 diabetes which is more insulin resistant. The insulin that we are making isn’t doing a good job at keeping our blood sugars normal.

Melanie: So, just for the listeners, insulin resistant--so the pancreas is making insulin but the cells of our muscles and such are just resistant to the actions of that. They just won't let them in the door, right?

Dr. Kirby: Absolutely, and the way I think about it is a key and a lock. So, if you have Type 2 diabetes, you’ve got the key, but there’s gum stuck in the lock so it’s difficult for that insulin to do its job and get the glucose to go into the cell.

Melanie: So, we used to call Type 2 diabetes “adult onset” but now we’re even seeing children coming up with this type of diabetes as a result of the obesity epidemic. Tell us about some of the risk factors that might affect children and/or adults that would predispose them to diabetes.

Dr. Kirby: That’s a great question. So, right now, we know that there are about 86 million Americans who are in the pre-diabetes category, meaning they are at risk for developing diabetes. That’s a lot of people, about 9 out of the 10 people who have pre-diabetes don’t know about it. So, risks include higher weight. So, those patients who have excess weight, patients who are sedentary, patients who have a family member--a brother, a sister, a mother, a father--who has Type 2 diabetes are at increased risk. So, those are all clues that patients may need to be clued into that they may be at risk for diabetes.

Melanie: And, you mentioned the term pre-diabetes. How would somebody know? Is this something that’s going to show up on their annual physical or would they feel something, would they notice anything that would really send them to the doctor in the first place?

Dr. Kirby: So, with pre-diabetes, they may not actually have any signs or symptoms and so it is something that we probably, as healthcare providers, need to be screening patients for, or for patients who feel that they’re a high risk, to ask about it. It could show up in blood work, so if they have an abnormal fasting blood sugar meaning that if they haven’t eaten anything but their blood sugar is slightly high, that can be a sign. There’s also other tests. Things like a hemoglobin A1C, which is a test of how your average blood sugar is over a three month period. We use that test for our patients with diabetes but it can also help diagnose pre-diabetes.

Melanie: And, because it’s not necessarily insulin dependent, when you’re talking about Type 2, what is the first thing you tell patients that are told that they either have pre-diabetes or full blown diabetes that they have to do that’s so important that they start doing to manage this condition or possibly eliminate it altogether?

Dr. Kirby: So, one of the best pieces of news that I can give patients is that diabetes and pre-diabetes are extraordinarily responsive to weight, meaning that for patients who lose even a small amount of weight, 3% to 5% of their weight, that that can make a big difference on their risk of developing diabetes or on their absolute diabetes control. There was a study called the “Diabetes Prevention Trial” that showed that a 7% weight loss prevented about 50% of patients from going from pre-diabetes to diabetes in five years. And, that’s a doable amount of weight loss for a lot of people.

Melanie: And, what about other lifestyle modifications that they can make, even if they’re small ones, that could make a big difference in this diabetes diagnosis?

Dr. Kirby: Absolutely. Part of the weight loss is being driven by changing how you eat and being more active. So, just increasing your activity level can help and getting help on eating healthy. There’s a lot of confusing information out there about what we’re supposed to be eating. What I usually tell people is, you can never go wrong with lots of vegetables, lean healthy proteins, and making sure that you’re getting up and you’re moving every single day. The American Diabetes Association recommends 150 minutes of cardiovascular exercise every week. That means that you’re doing about five days of 30 minutes where you heart rate is up and you’re feeling like you’re working hard. The good news is that doesn’t have to be all at one time, you can break it up. So, three 10 minute walks during the day can be just as powerful.

Melanie: And, when does it require some kind of medicational intervention?

Dr. Kirby: So, we usually start with our lifestyle intervention first, encouraging patients to change what they’re eating, to be more active, to try to lose weight, but Type 2 diabetes is a progressive disease and if those interventions are not successful, then we would start thinking about medications. Our first line medication for many patients is a drug that’s been around for a long time called Metformin, and it’s a very good drug because it works well, and it prevents the problems of diabetes such as the kidney and eye disease and it’s inexpensive at this point because it’s been around for such a long time.

Melanie: So then, back to foods for just a second, Dr, Kirby, because people say, “Oh well, now I can't eat that, it’s got too much sugar,” and maybe they’re talking about carrots or tomatoes or another type or vegetable or they’re worried about grains, legumes, because they’ve been told they’re pre-diabetic. Clear up that myth for us about those healthy foods that people sometimes get confused for bad carbs.

Dr. Kirby: Absolutely. There’s been a myth out there that carbohydrates are bad and the problem is that not all carbohydrates are alike. There are carbohydrates that are probably ones that people should avoid--all people should avoid--whether you have pre-diabetes or diabetes. These are your simple sugars, so the refined sugars. So, the extra sugars that get put into foods, and I will say that there’s going to be new labeling out there in the world that has--these added sugars that are going to be added to the label so it’s going to make it easier for consumers to get healthier options. But, there are complex carbohydrates, so our whole grains, our whole wheat breads and our very difficult to digest carbohydrates are more healthy and they’re less likely to make blood sugars go high if you have diabetes. And, those are important sources of nutrition that we all need to be eating. So, we talk about these low carb or no carb diets, I think, that has given carbohydrates a bad name when really we should just be getting rid of the extra sugars that are in our diet.

Melanie: Do you advocate or ask your patients to check their blood sugar on a regular basis?

Dr. Kirby: I do. It depends on their situation. So, it depends on the level of treatment they’re getting. If they’re using insulin multiple times per day--because sometimes patients with Type 2 diabetes will need insulin at some point--those patients often need to be checking their blood sugars more often. If there are patients who are on oral medications like Metformin, they may not need to be checking their blood sugars quite as often but I think for patients who check at different times, they can start to see the impact of things like the piece of cake that they had after dinner or the exercise that they did after dinner, and they can start to see the impacts of those choices on their blood sugars. So, there can be real value in that as well.

Melanie: So, wrap it up for us, Dr. Kirby, and your best advice that you tell patients every single day about lifestyle modification, controlling their diabetes or possibly preventing it altogether.

Dr. Kirby: I think every single time a patient walks into my clinic, and my patients will vouch for this, I'm talking to them about how they’re eating, how much they’re eating, what they’re eating, are they getting enough activity. Even for my patients who are not sedentary, meaning they have an active job, I still encourage them to be exercising on top of that. And, the other important piece is sleep. I think it’s the third pillar of our healthy lifestyle that we don’t focus on but patients also need to be getting sleep. So, I think those three components of your life, if you can be working on those, and we all need to be at all times, that’s the best device for all of us.

Melanie: Thank you so much, Dr. Kirby. It’s really great information. For more information on diabetes and the UVA Health System and the programs that they offer, you can go to www.uvahealth.com. That’s uvahealth.com. You’re listening to UVA Health Systems Radio. I’m Melanie Cole, and thanks so much for listening.
Hosts Melanie Cole, MS

Communicating with Your Bladder - Lifestyle Changes that Can Make a Difference

Additional Info

Segment Number 1
Audio File city_hope/1639ch5a.mp3
Doctors Cohen, Seth A.
Featured Speaker Seth A. Cohen, MD
Guest Bio Seth A. Cohen, M.D., joined City of Hope in 2016 as a urologist specializing in complex reconstruction of the pelvic floor, including fistula and pelvic organ prolapse repair. Dr. Cohen received his medical doctorate and Bachelor of Arts degrees at Northwestern University through the prestigious Honors Program in Medical Education, which allowed for direct matriculation into medical school after three years of undergraduate work. He completed his post-graduate training in California, including an internship in the Department of Surgery at University of California, San Francisco, a residency in urology at University of California, San Diego and a fellowship in Female Pelvic Medicine and Reconstructive Surgery at University of California, Los Angeles. Dr. Cohen has published in a variety of medical journals on topics including mesh-associated complications, robotic cystectomy and radiation exposure during lithotripsy.

Learn more about Seth A. Cohen, MD
Hosts Melanie Cole, MS

Melanoma: Do You Know What to Look For?

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Segment Number 4
Audio File city_hope/1637ch2d.mp3
Doctors Margolin, Kim
Featured Speaker Kim Margolin, MD
Guest Bio Kim A. Margolin, MD is a clinical professor in the department of medical oncology & therapeutics research, specializing in melanoma.

Dr. Margolin earned her undergraduate degree summa cum laude from University of California, Los Angeles, graduating Phi Beta Kappa, then went on to receive her medical degree from Stanford University School of Medicine. After internal medicine residency at Yale-New Haven Hospital in New Haven, CT, Dr. Margolin began her fellowship in hematology/oncology at the University of California, San Diego School of Medicine and completed the fellowship in medical oncology and hematology and bone marrow transplantation at City of Hope. She remained on the City of Hope faculty in both departments for 25 years prior to her recruitment to Seattle.

Learn more about Kim A. Margolin, MD
Transcription Melanie Cole (Host): Skin cancer is the most common type of cancer and it can take several forms, many of which are not life threatening and typically do not spread to other parts of the body. Melanoma, however, is a different situation. My guest today is Dr. Kim Margolin. She’s a clinical professor in the department of medical oncology and therapeutics research specializing in melanoma at City of Hope. Welcome to the show. Dr. Margolin. Tell us about melanoma. How would somebody even know if they have it?

Dr. Kim Margolin (Guest): Melanoma is generally an appearance of dark lesion either in a pre-existing mole or often in a new spot where there wasn’t previously a mole--although there is a system that the dermatologists like to use that’s called the ABCDE system. “A” for asymmetric, “B” for border irregularity, “C” for color variation, “D” for diameter larger than 6 millimeters. They’ve added an “E” for evolution, and most importantly, it’s either the evolution or change in an existing mole or the sudden appearance of a usually dark spot where there was none before. Now there are, of course, many dark spots that are not melanoma but that’s where the dermatologists need to learn how to distinguish the features between melanomas and benign other skin lesions and to biopsy anything that’s suspicious.

Melanie: And, if it’s found to be melanoma, what are some of the treatments available? People think of systemic treatments for all kinds of cancers. What do you do specifically for melanoma?

Dr. Margolin: The first line of defense for melanoma is always surgery. The first thing is to make the diagnosis which, depending on the size and the shape of the lesion and its location on the body, may be biopsied with a shave device that essentially takes off the top part of the lesion. It’s not recommended for lesions that are highly suspected to be melanoma because, indeed, it cuts through tumor, and we try not to do that. But, sometimes, it’s the most practical thing to do. What’s most important is that once the tissue diagnosis is made--the systemic diagnosis--of melanoma is made, it’s critical that the patient has the entire area of skin resected or removed, and that a margin around of what’s known to be active cancer is provided which, basically, takes into account the fact that sometimes isolated cells, cancer cells, can move from the site of the primary into the local skin, and if you can cut a wide area of no melanoma around that, you can give the patient a very reduced chance that it will recur locally. Depending on the depth or how thick the lesion is, and it’s measured in millimeters and fractions of millimeters in thickness, there may be an indication to explore the lymph nodes that are most close to the place where the melanoma was removed. For example, if it’s on the arm, it would be the lymph nodes in the corresponding armpit, and to examine them for evidence of cancer. If they have none, then that’s reassuring to the patient. If they have any cancer in them, then that often means that there’s a higher risk that the tumor may recur in the future. If that is the case, then we try to give medications that may reduce the chance of cancer coming back. Those are generally immunologically oriented interventions that stimulate the body, so white blood cells in some fashion, to recognize and kill any single circulating tumor cells they might encounter. We’re still working on the best form of immunotherapy to prevent melanoma from returning because it’s still quite difficult when it has spread.

Melanie: Is there a genetic component to melanoma?

Dr. Margolin: If you mean is there an inherited risk for melanoma, then--I’m going to assume that’s a yes--that there are families with a risk of melanoma that’s confer because they are born with gene mutations that predispose them to develop melanoma upon the exposure to some secondary routine insult like a second mutation. However, that is quite rare. The incidence of familial transmission for melanoma among all melanomas is only in the range of a couple percent, and the vast majority of melanomas are sporadic in nature.

Melanie: Are you using targeted therapy for melanoma?

Dr. Margolin: We use targeted therapies for certain types of melanoma when they’re advanced, when the melanoma has spread and there’s no longer minimal to cure, and if the patient’s melanoma demonstrates the presence of selected mutations that may lead to the hyperactivation of certain pathways in the melanoma cell. There are drugs for those pathways that block them and cause remissions in patients whose tumors are driven by those mutations. Those mutations occur in about half of patients with garden variety skin melanoma, not so much in the patients whose melanomas arise in the eye or in the mucous membranes or in the fingernails.

Melanie: If somebody is diagnosed with melanoma and you’ve tried some of these treatments, and they do go into remission, are they at risk, then, for melanoma to come back or would it come back as another type of cancer having spread or a metastatic cancer?

Dr. Margolin: A patient who’s in remission from systemic therapy of metastatic disease with immunotherapy will, of course, be at risk of relapse. It’s hard to be sure just what that risk is and how it decreases over time but, in general, we can’t guarantee that somebody stays in remission until we can look back and see that they’ve been in remission for a long time. However, the longer somebody is in remission, the higher chances that they will stay in remission, and the data that we have, most of the drugs we’re using now are so new because of the recent huge breakthroughs in therapy, that we can't really give data yet on how long remissions last, and how many patients might be actually cured. There might be a substantial proportion of patients who achieve remission with immunotherapy who are cured. There’s probably a smaller proportion of patients who achieve a remission with molecularly targeted agents who will be cured. Some people think it’s zero. Some people think it may be 10-20% depending on whose data you look at and how long the follow-up has continued. So, we’re going to have better answers to all of these with longer term follow up with all of the therapies, and then we’re going to have new therapies as well.

Melanie: And, are you doing any clinical trials for melanoma at City of Hope?

Dr. Margolin: I try to put all my patients on clinical trials as much as possible. We have clinical trials here for virtually every stage and category of melanoma with very rare exceptions, perhaps not so much for melanoma arising from the eye because that’s so rare, but for all of the other subsets. There are new clinical trials coming all the time. I’m very involved in helping to write some of those trials; I’m leading some of those trials; and, others come from a variety of groups I participate with.

Melanie: Dr. Margolin, wrap it up for us, and give your best advice and hope to those that may have been diagnosed with melanoma, and why they should come to City of Hope for their care.

Dr. Margolin: The City of Hope really specializes in providing clinical trials for patients with cancer and for those who don’t fit into a clinical trial, the best cutting edge care that we can possibly deliver. Clinical trial participation will always be, at the very worst, the best thing we can give, and at the best will be something even better. Whether you participate in a clinical trial or you do not, you’ll get the best care here. There’s very little that we cannot do here. We have access to all of the sophisticated methodologies, both medical, surgical and radiation, and we use them in all patients who need them.

Melanie: Thank you so much for being with us today, Dr. Margolin. You're listening to City of Hope Radio, and for more information, you can go to www.cityofhope.org. That's www.cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Stamping Out a Smoking Addiction

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Segment Number 1
Audio File virginia_health/1639vh2a.mp3
Doctors Clark, Connie
Featured Speaker Connie Clark
Guest Bio Connie Clark is a tobacco treatment specialist at the UVA Cancer Center.

Learn more about UVA Cancer Center
Transcription Melanie Cole (Host): The UVA Cancer Center offers free assistance to tobacco users wanting to address their addiction to tobacco. My guest today is Connie Clark. She's a tobacco treatment specialist at the UVA Cancer Center. Welcome to the show, Connie. So, what are some of the most common approaches you hear or see every day for smoking cessation?

Connie Clark (Guest): Well, I have to tell you, Melanie, it's a very individual thing. Basically, when I have someone that comes to see me, we meet for an hour in person at first because in a perfect world, it would be a one size fits all, but it's not. So, I kind of meet with them to try to figure out what their motivation is, how inspired they are to quit, and then we talk about options: medication, behavioral changes and oftentimes it's a combination of both and also coming back to see me, really up to a year. I try to check in with them to make sure that they've quit and stayed quit.

Melanie: So, how do you help individuals determine which approach is best for them? There are so many ways to quit and medications on the market. How do you help someone decide?

Connie: I do motivational interviewing and spend time with them figuring out is it--oftentimes it's habitual behavior that comes with the nicotine addiction--and figuring out what combination will work for them. If someone suffers from mental health issues, then obviously Chantix is not going to be for them. Wellbutrin is an option but oftentimes it does have its own side effects as well. So, it's kind of figuring out what will work for them. I worked with somebody this morning who is going to try acupuncture, kind of figuring out where their mindset is and what they feel comfortable with.

Melanie: What a hard thing to do--quitting smoking. So, what is the first thing you recommend for those people that want to quit? What do you tell them to do day one?

Connie: Day one: set a quit date. Because when you set a quit date, even if it's two months from now, I think that that is a commitment that they make and helps them formulate a plan. It's helping us work towards a goal and I think that that's always helpful.

Melanie: So, tell us about some resources in the Charlottesville community for those who are trying to quit smoking.

Connie: So, in the Charlottesville community, we are very fortunate that we have quite a few resources. The Health Department offers free acupuncture every Tuesday from 5.30pm - 6.30pm. We also have Quit Smoking Charlottesville, which is a support group offered also by the Health Department. They meet in the fall and then again in the spring, and offer a support group service in addition to some other strategies that people might try. There's Quit Now Virginia, which is a helpline that they can call and offers free counselling to people who want to quit and they will follow up with them as well. So, those are a few of the resources that we have.

Melanie: Connie, how long does it take for somebody to get over that nicotine dependence?

Connie: The nicotine dependence and withdrawal symptoms usually last about 3 weeks. So, if they can get through those 3 weeks of crankiness, lack of sleep, headaches--that kind of thing--it's really good. I also tell them when I meet with them that the craving for nicotine when you're trying to quit, if you can push through that 5-7 minutes and get through that craving, then you're good to go for a while. Will the craving come back? Absolutely! But, if you tell yourself, “5-7 minutes. I can do anything for 5-7 minutes”, then you're good to go for a while longer.

Melanie: So, then, there's the behavioral aspect. That's really one of the more difficult as well because people have their routines, they either go outside or they need something to do with their hands. What do you tell them about that behavioral aspect?

Connie: Well, that's another challenge that I have to personalize for each of the patients that I work with. And, that's part of that hour I spend with them trying to figure out, is it the coffee in the morning that's a trigger for you? Is it stress? Is it after every meal you're used to having something in your hands? For a female patient I work with, it is that kind of inhaling motion with her mouth and so she was able to replace that with lemon drops. I have another person that, actually, it's the reaching in his overall pocket and grabbing something and keeping it in his hands that he was missing so he replaced that with pretzel sticks and salt-free pretzel sticks, actually, because he had some teeth issues that he was coping with as well, so that he has something in his mouth and can grab something out of his pocket. Pringle sticks works for some people. I have some people with the coffee in the morning that are using the Pepperidge Farm Pirouettes. It's something in their hand and something to replace that "I have to have something with my coffee" feeling. Sometimes it can be as simple as changing the behavior. If you smoke inside, go outside. If you're an outside smoker and that's where you have your cigarette and coffee, then do it inside. Changing the habit and creating a new one.

Melanie: So, if they've planned how to deal with those urges to smoke and those behavioral issues then, how long does it take somebody? You said 3 weeks for those cravings. Is that true for behavior as well? Is it generally like a 3-week kind of time that they have to put up with?

Connie: It can be longer and I should have said from the get go, oftentimes people will try to quit 4-5 times before it sticks. When you think of nicotine, people think of it as being so acceptable socially, but the two most addictive drugs are heroin and crack. Nicotine is number 2. So, it's very difficult to quit. And I tell people I work with all the time, is it going to be in 3 weeks that you're going to feel great and not want it? Probably not. It takes a long time to change the behavior, to change habits. I was speaking with a patient this morning. I learned recently about something called a “mini-quit” that he's going to try which is try to dwindle down the 10 cigarettes he smokes but also implementing those behavioral things now so that when he gets to his quit date, those are already in place and when he gets stressed out he knows what's going to work and what to go to. So, it's kind of a process for each person and I wish there was a 'in 21 days you're going to feel great', but it's very individual.

Melanie: What about the weight gain that people associate with quitting smoking? What do you tell people that are concerned about that?

Connie: Typically, science says that on average, you might gain up to 10 lbs. And, some people don't gain any. I think it's kind of a matter of putting in place, if that's something that they are concerned about, making sure that they don't go to food and, if they do, it's something that won't cause weight gain. It's also kind of putting it into perspective in saying, “If you put on 5 or 6 lbs. while you're trying to quit, the perspective of what health concerns that is versus smoking or using tobacco on a daily basis which affects every part of your body and is the most preventable cause of cancers that we deal with.” So, kind of putting it in perspective and helping them come up with some strategies that they can use to kind of combat that.

Melanie: And, what if they have a slip? What do you tell them about those guilt feelings?

Connie: I tell them don't feel guilty. As long as you have a desire, you are never a failure. And, I remind them that it is the second most addictive drug and that it is hard to stop and people oftentimes will try 4 or 5 times before they are completely successful. But, if you have a desire, you are never a failure.

Melanie: And are there some systems like e-cigarettes or any of those kinds of things that you like or approve of? Do you like the patch? You mentioned Chantix and Wellbutrin. So, just for a minute here, speak about some of the ways to quit and the ones that you like and the ones that you don't.

Connie: So, e-cigarettes, I just will say this: I know that when they came out a few years ago, they were marketed as a method to help people quit. What we know is that e-cigarettes actually have more nicotine in them than regular cigarettes and the FDA is just getting involved, as you know, in August. There is kind of that 2-year span where people who are selling e-cigarettes have the opportunity to show them what's in them before they kind of make a final decision. But, I absolutely do not support that as a way to quit because they actually have more nicotine and they weren't regulated. So, it was really a big problem. As far as some of the other things, there's the patch, the gum, lozenges, the nasal spray, inhalers and, again, I would say it's very individual. I have people that the gum won't work for because they have dental issues that have been caused by either dipping or smoking. So, that isn't a possibility for them. Patches work. I'm a huge proponent of patches if they're used correctly. The idea isn't to put on two patches and still continue to smoke a pack of cigarettes, though. As with everything, they have to be used the way that they were designed. The inhaler and the nasal spray, they can work for some people if they're open to that idea. It's really about figuring out what each person is going to be okay with. Some people come to me very adamant about “I don't want any medication. I want to be able to do this on my own.” Okay. I respect that. And then, there are other people who are very open to that. So, it's really about doing that motivational interviewing and figuring out where they're at and what they would be okay with.

Melanie: And, how is UVA Health System helping patients quit smoking?

Connie: Well, here at the Cancer Center, they have me now as a full time person who works with all cancer patients who are dealing with cancer and also have tobacco issues. They can be referred to me. I can meet with them as many times as they want either in person or by phone, follow up with them for as long as they are open to me following up with them. They also have the early detection low dose CT scans that they do here on programs that Melissa Stanley, who is a nurse practitioner here, is helping to work with people who smoke to do some early detection so that it doesn't get to the point where it has caused any kind of cancer. I know “Hoo’s Well” has a program for employees who have a desire to quit that they have implemented here. So, I think it's something that they feel very strongly about and are really becoming very active and proactive in dealing with.

Melanie: Thank you so much for being with us today, Connie. It's great information and so important for people to hear. You're listening to UVA Health Systems Radio and for more information you can go to www.uvahealth.com. That's www.uvahealth.com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

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