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Segment Number 3
Audio File virginia_health/1609vh3c.mp3
Doctors Roeser, Mark
Featured Speaker Mark Roeser, MD
Guest Bio Dr. Mark Roeser is a board-certified surgeon whose specialties include lung transplantation.

Learn more about Dr. Mark Roeser

Learn more about UVA Children’s Hospital
Transcription Melanie Cole (Host): Ex Vivo lung perfusion is a leading edge technique designed to make lungs more suitable for transplant making it possible for more patients to receive a life-saving lung transplant. My guest today is Dr. Mark Roesser. He is a congenital heart and transplant surgeon at UVA Health System. Welcome to the show, Dr. Roesser. Briefly explain a little bit about what EVLP is to the listeners.

Dr. Mark Roesser (Guest): EVLP was designed – it came out of a lot of basic science research. It kind of hit its head in the 90’s and early 2000’s. The problem is there is a shortage of lung donors out there, especially quality lung donors. Whenever a patient is a donor they are declared brain dead. Whenever that happens to your body, it releases a lot of chemicals. Those chemicals can cause swelling in certain areas – one of those areas is the lungs. So, as they are laying there in bed, they are unable to cough because they’re brain dead. Their lungs slowly don’t do as well. So, it’s harder to get lungs from donors than it is other organs, such as livers or kidneys. What EVLP does is that it lets us take those lungs out of donors that may be questionable. It may not be the perfect lung to put into somebody. It puts it in a wait station which is a circuit with a ventilator and they perfuse and lets us see if these are actually going to be good lungs for somebody or are they, in fact, not good lungs for somebody. Instead of taking the risk of putting them into a living patient and then seeing what the results are, it is a wait station to see if these will be adequate lungs for donation.

Melanie: Is there any controversial issue with this type of procedure? Do the families of the donors question what you’re doing to get these lungs at that time?

Dr. Roesser: Everybody is informed that these will be Ex Vivo lungs and they sign off. Whenever we call them in we say, “We’re going to give you an Ex Vivo lung or we’re not” and if they refuse, even though they have written consent, if they refuse on that call in, we don’t penalize them at all. We say, “That’s not a problem.” Then we go to the next person on the list. That person won’t lose their spot in line or anything like that. It’s not allocated that way. It is allocated for the best person for that set of lungs – who’s the sickest. These lungs don’t necessarily come from high risk donors. Some people are very sick and they say, “I’ll take donor lungs from a high risk donor.” It may be somebody who has some needle marks. We test for HIV, we test for Hepatitis C but those tests aren’t 100% accurate. If you’re a healthy person, you may turn down those lungs. If you’re a sick person or you’re a person who doesn’t really care about those risks you’ll say, “Yes, I’ll take those high risk lungs.” Ex Vivo doesn’t really fall into the infection category. It falls into where the donors or the lungs weren’t doing very well. Once we take them out and we put them on the Ex Vivo circuit, we will not use those lungs if they don’t meet the standard criteria that we’d use for lungs that came straight from a donor. Even though we take lungs that are sub-par, we make sure that they are going to be adequate before we actually use them. If they are not adequate, then we don’t use them. What it does is help mitigate the risk that we would rather try to avoid.

Melanie: How has this changed the world of lung transplantation?

Dr. Roesser: It’s going to open up the donor pool quite a bit. At our center, we actually have a National Institutes of Health grant where we are actually going to give chemicals to modify these lungs. The great thing about the Ex Vivo circuit is it has no blood or blood products in it. We’re not exposing these lungs to any additional antibodies or blood-borne infections. We are just taking them out of a donor where they are in a bunch of cytokines chemicals that are making them sicker. We’re taking them out of that situation, putting them on a ventilator and a circuit that kind of separates this fluid. What that fluid does – it’s a special solution called “Steen” – it helps to take all of the free water out of these lungs and kind of dry them out. It gives us a better idea of how these lungs are going to work. I think the future of it is we’re going to be manipulating these lungs to actually make them healthier before we put them into somebody. I think that’s really going to explode lung transplantation.

Melanie: Can it reverse some previous lung injury that you might find in some of these higher risk donors?

Dr. Roesser: Exactly. That’s exactly what it will help do. Initially, this was designed to see if they were good lungs but we found out that the circuit will actually help. If you have a pulmonary edema or any extra fluid in your lung, this circuit will actually help to get that out. Let’s say there is a lot of snot or mucus and stuff. I can actually go in there and suck all that snot and stuff out and really get a good feel for how the lung is going to perform whenever I put it into a human.

Melanie: Wouldn’t that be amazing if you could do that inside a human body and reverse some of those injuries? I just wonder, do you see that is something that might be coming in the future that we might be able to do something like this for working lungs?

Dr. Roesser: Our lab is actually working on that. We have some pigs and we are injecting the pigs with this compound that makes their lungs get sick. Kind of like if you had a very bad pneumonia and you got sepsis. This compound kind of does that. What we’re trying to do is see if we can reverse those outside of the pig’s body. If those experiments work, then we’re going to go and start doing them inside while the pig – we’ll open up the pig and we’ll actually put cameras in the pig. We’ll put them on by-pass and we’ll isolate the lung and see if it will work that way. If we can show it on animal models, then my hope is that, in the future, we can use small catheters and wires in your groin. Let’s say you or your loved one or is very sick, we could actually go in and help the lungs out while they are in your own body. It wouldn’t be for a person who needed a lung transplant but it may be to prevent somebody who is very sick from needing additional procedures or it might help to rehab their lungs faster than it would otherwise.

Melanie: That is amazing, Dr. Roesser. Now, tell us about the risks for the surgery for the recipient. You said that if they are at end-stage kind of situation, they are not going to be as worried about what you’re giving them as long as you’re giving them something. But, besides rejection, are there other risks that people are concerned about?

Dr. Roesser: They actually did a national trial here. It was written up in the New England Journal of Medicine and got FDA approval or approval. There were equivalent outcomes between someone who had lungs that were placed on this machine and given to them and lungs that were just given to them. Our data shows there is no change at all in their risk of this lung. The good thing is, if you take these lungs that may not be the greatest lungs and you put them on the circuit and they look great, then you feel confident to putting them into somebody. If they don’t look great, then you just throw them away or do your research on them. All you really lose with that is money and time but you aren’t really affecting any humans or the quality of life which is really why us surgeons are very happy and excited about it. Lung transplantation, per se, may not extend your life. The average life expectancy after lung transplant is only 5.4 years. What we are really trying to do is to give people very good quality of life for the remaining time they have left. If you give them a lung that’s not very good, that quality of life is not going to improve. We’re very risk adverse. We only take very good lungs to give to people. What this will do is increase the donor pool of very good lungs to give to people.

Melanie: That’s what’s so amazing is the donor pool seems to be one of the hardest parts for any kind of transplant. Tell us a little about UVA and your team there at UVA Heath System.

Dr. Roesser: Our team consists of two pulmonologists and three surgeons. We also have four nurse practitioners and then, we also have a very predominant lab that does a lot of research. What we’re doing is using our research in the lab and helping to translate that over into our clinical activities. One of our researches is in adenosine compound. What these compounds do is, they kind of help reverse injury in the tissue. Our grant is to put this compound inside the recipients and inside lungs and see if that will help reverse any damage due to the fact that they are in a brain dead donor, due to the fact that you’re taking an organ out of somebody and putting it into somebody else. In the lab, we’ve shown that this is very helpful and now we’re ready to move into clinical trials on it.

Melanie: Wow. What an amazing job that you have. We applaud all of the great work that you are doing, Dr. Roesser. Thank you so much for being with us today. You’re listening to UVA Health Systems Radio and for more information you can go to UVAHealth.com. That’s UVAHealth.com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Open Enrollment is Over: How Do You Get Coverage if You’re Uninsured?

Now that the latest open enrollment has ended, how do you get coverage if you're uninsured?

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Segment Number 3
Audio File health_radio/1605ml5c.mp3
Featured Speaker Marianne Eterno, President of Government Relations for GTL
Guest Bio Marianne Eterno began her insurance career in 1987 at the former Golden Rule Insurance Company in Indianapolis, Indiana, and moved to Chicago in 1992, when she accepted a position with Celtic Insurance Company.

Marianne came to Guarantee Trust Life Insurance Company (GTL) in 1996, as a compliance and government relations consultant, and formally joined the company in 1997. As Assistant Vice President of Government Relations, she represents GTL in both the state and federal arenas, drives coalition development for the company, and serves as the company's media and public relations spokesperson.

In addition to sitting on committees for every major insurance trade association, Marianne serves on the Board of Directors of RetireSafe, a 400,000 member grassroots advocacy organization for senior citizens and as the Executive Director for the Council for Affordable Health Insurance.
Hosts Melanie Cole, MS

When Should You Consider a Pacemaker?

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Segment Number 2
Audio File virginia_health/1606vh4a.mp3
Doctors Mangrum, Mike
Featured Speaker Mike Mangrum, MD
Guest Bio Dr. Mike Mangrum is board-certified in internal medicine, cardiovascular disease and cardiac electrophysiology; he specializes in treatments for heart rhythm disorders.

Learn more about Dr. Mike Mangrum

Learn more about UVA Heart Rhythm Disorders
Transcription Melanie Cole (Host): Doctors recommend pacemakers for many reasons. Could a pacemaker better help you cope with a heart rhythm condition? My guest today is Dr. Mike Mangrum. He’s board certified in internal medicine, cardiovascular disease and cardiac electrophysiology at the UVA Health System. Welcome to the show, Dr. Mangrum. Tell us, what is a pacemaker? People don’t always understand what this even is intended to do.

Dr. Mike Mangrum (Guest): Yes. Well, a pacemaker is a small device that emits a low-energy electric pulse that prompts the heart to beat. Now, to fully understand what it does, you have to sort of step back and have a better understanding of the heart’s electrical system and I’ll describe that briefly. The heart has 4 chambers to it. It has the two upper chambers which are called the “atria” and the two bottom chambers are called the “ventricle.” The heartbeat actually starts in the upper chambers—the right atrium—in an area called the “sinus node.” The electrical pulse, normally, is emitted from that. It’s conducted to the middle part of the heart called the “AV node” and then down to the ventricles. So, when that happens normally, you get a nice, normal heartbeat; but, what an electrical pacemaker does is that it takes over those particular functions of the heart in which the patient may have either a slow heart rate or there’s a problem with the conduction of their electrical system.

Melanie: Okay. What a great explanation. That was fantastic. And, to think of the heart as an electrical pump really is a great way to think about it. So, what types of conditions—because when someone has something like “atrial fibrillation,” and they hear all these things--when is a pacemaker generally indicated?

Dr. Mangrum: Well, that’s a great question and how I would think about it is that a pacemaker is to treat slow heart rates. There are other devices that treat fast heart rates, but a pacemaker is used to treat slow heart rates. When I talked about the different components of the heart’s electrical system, the pacemaker really is indicated for 3 reasons. The first reason is when the electrical impulse fails to trigger. That’s called “sinus node dysfunction.” The second indication is when there is a problem with the conduction from the top to the bottom chambers of the heart and that’s called “AV node” conduction problems or “heart block.” Then, the third indication is actually there is an indication for congestive heart failure when there is, in addition to the congestive heart failure, some conduction problems below that AV node that we spoke about. So, those are really the indications for a pacemaker. It’s sinus node dysfunction, heart block and, in a subcategory, a patient with congestive heart failure that has conduction problems.

Melanie: Okay. So, if we’re talking about heart block or congestive heart failure, which you hear more and more about it. Dr. Mangrum, with the pacemaker, you insert these. How long do these last? Somebody with congestive heart failure, they confuse that with heart attacks all the time but it’s not. How long does this last? Is this something you live with for a very long time or do you have to change them or just the batteries?

Dr. Mangrum: Yes. The pacemaker—and I’ll speak about what I would say is about 99% of the pacemakers. The pacemaker has two general components to it. There are the wires that are called “leads” and then, there is the hard part of it which is called a “pulse generator.” The pulse generator is generally implanted underneath the skin below the collar bone. In that pulse generator is the battery and the circuitry for emitting the pulse. The battery lasts, on average, around 7-8 years. Now, there are some patients that it may last 10 or even 15 years. It depends a little bit on the usage of it. What would happen after that period of time is that that area would have to be opened back up underneath the skin and that pulse generator would be removed and another one placed back in there. The wires, or the leads, would be retained in the heart and it’s just a matter of replacing that pulse generator. Now, I said that that represented about 99% of the pacemakers. What I just wanted to mention is that there is an evolving pacemaker called a “leadless pacemaker.” I think, as time goes on, we will see more and more of these but these are implanted by way of a large vessel in the leg and actually inserted into the heart muscle itself and then everything is removed. So, there’s only a very small piece that is implanted inside of the heart that’s about the size of a bullet and that stays inside the heart. In that, it has all the circuitry and battery and everything is in there.

Melanie: How cool is that? That is absolutely fascinating. So, Dr. Mangrum, let’s bust up a few myths about pacemakers. People have always heard if they have a pacemaker, they can’t use a microwave oven; they can’t use, oh, cell phones; they might set off something at the airport; and, what about exercise and pacemakers? If it’s meant to maintain the pace of the heart, what if your heartbeat goes up because you’re exercising? So, answer some of those questions.

Dr. Mangrum: For most people, with a pacemaker, you would live your normal life. Most pacemakers that are implanted now are even MRI conditional, meaning that you can have an MRI with your new pacemakers. With the older pacemakers, there may be some issues with that but the new pacemakers now, most of them are what’s called “MRI conditional.” You don’t need to worry about microwave ovens any more. We recommend for cell phone usage to use the opposite hand of where the pacemaker is implanted. Remember I said the pacemaker is usually implanted underneath the collarbone? So, you would use the other hand and try not to store the cell phone in your breast pocket where the pacemaker is. Another common question is going through airports. What you would do is, you would show the security there, before the scan, that you have a pacemaker. The body scans are okay for the pacemakers. The ones that are detecting metal, you would tell the security people that you have a pacemaker and they will search you manually.

Melanie: That’s so cool. Now, it would seem that pacemakers, because they’re helping that slow pumping of the blood and helping to maintain a good, normal sinus rhythm, do they strengthen the heart, Dr. Mangrum? Do they help in someone, maybe with congestive heart failure, can they actually help to, not necessarily reverse, but maybe help a little bit with the strengthening of some of those nodes?

Dr. Mangrum: Yes. Yes. If you have conduction problems and congestive heart failure, then there is a special type of the pacemaker—it’s called a “biventricular” pacemaker, or a “CRT” which stands for “cardiac resynchronization therapy.” It’s a pacemaker that has 3 leads to it. A pacemaker can have 1 lead, 2 leads or 3 leads. In this particular one, you would have 3 leads. In about 70% of patients who have heart failure with this conduction problem--and this conduction problem is called “bundle branch block.” About 70% of those patients will have a significant improvement in their heart function and not only in their heart function, but also in their function in terms of their being able to ambulate, walk around, less shortness of breath and that sort of thing.

Melanie: In just the last few minutes, Dr. Mangrum—and it’s such really great information and so beautifully put. Why should patients come to UVA for treatment of their heart rhythm disorders? Give your best advice for people that are suffering from these.

Dr. Mangrum: Well, I’ll tell you. The University of Virginia established the first heart rhythm center in the state of Virginia. This was in 1981. Over the years, UVA has been at the forefront of technologies, both with slow heart rates and with fast heart rates. There is a very comprehensive group of physicians. We have 7 adult electrophysiologists, which are the doctors that really focus on your heart’s electrical system, and one pediatric electrophysiologist. So, I would say we have a lot of experience. Speaking of pacemakers today, we put about 500 pacemakers in per year, for instance. So, we have a large volume. We have a lot of experience and we have access to some of the newer technologies like the leadless pacemakers that are coming out. I think UVA, for those of us who live in central Virginia, I think it’s a great resource for us. Who should consider a pacemaker? I think if you have slow heart rates and there’s no reversible cause for those slow heart rates, then you may be a candidate for a pacemaker.

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

Vascular Skin Lesions: When Should You Be Concerned?

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Segment Number 4
Audio File virginia_health/1605vh4d.mp3
Doctors Zlotoff, Barrett
Featured Speaker Barrett J. Zlotoff, MD
Guest Bio Dr. Barrett Zlotoff is board certified in dermatology and pediatric dermatology; his specialties include pediatric dermatology and treating vascular lesions.

Learn more about Dr. Barrett Zlotoff

Learn more about UVA Dermatology
Transcription Melanie Cole (Host): Vascular lesions are not always harmful. Birthmarks, for instance, are a type of vascular lesion but when should you be concerned? My guest today is Dr. Barrett Zlotoff. He’s board certified in dermatology and pediatric dermatology at UVA Health Systems. Welcome to the show, Dr. Zlotoff. First, explain what vascular lesions of the skin are.

Dr. Barrett Zlotoff (Guest): Like you mentioned, vascular lesions are birthmarks that are made of blood vessels. There are many different types and that’s one of the things I find so interesting about vascular lesions. They can be made of small blood vessels called “capillaries” and they are called a “hemangioma”. If you have collections of veins, you can have venous malformations. If you have collections of lymphatics, you can have a lymphatic malformation. You can have port wine stains, arterial venous malformations and you can have various combinations of all of these types of blood vessels to make different sort of vascular lesions.

Melanie: First of all, if a child has one of these lesions is--it automatically a cause for concern? When do they run in and see a doctor?

Dr. Zlotoff: No. There are many vascular lesions that are just birthmarks that have no worrisome associations and don’t cause any problems. Some infantile hemangiomas can even go away on their own with no treatment and get better by themselves. I think that most vascular lesions should at least be discussed with your pediatrician at “well child” visits and the pediatrician can help you determine if the lesion could cause problems. Some of the issues occur when vascular lesions are near the eyes, around the mouth, on a central face or places where vascular lesions can cause issues with vision, feeding, breathing or cause disfiguring changes in the face or other areas. When vascular lesions are bleeding or have sores in them or ulcers are forming, we should also evaluate them as soon as possible or if they are growing really rapidly.

Melanie: Birthmarks was one of the first things that we mentioned and those can be anywhere on a child. If they are on their temple or anywhere around that, does a parent keep an eye on those? How does that work?

Dr. Zlotoff: I think we can definitely keep an eye on them but there are things that can be associated with different birthmarks. Birthmark, as the name suggests, can be a marker to suggest other things. So it’s really important that all kids who have birthmarks just at least have them looked at by their pediatrician in their “well child” visits and discuss them and get an idea if there should be any concern or not.

Melanie: When does somebody take their child to the doctor to have something done? What kinds of vascular lesions do you like to treat?

Dr. Zlotoff: We treat a lot of infantile hemangiomas, which are kind of the strawberry hemangiomas that are the most common vascular lesions that we see. They are so common that we see them in about 5% of kids. They are a normal thing and many kids have them. There are great new treatments for these hemangiomas. Oftentimes, we see them on the face or areas where they’re going to cause problems in the future or they could stretch out the skin and cause difficulties later on down the line; so then, we will treat them.

Melanie: What kind of treatments are available? What do you do for them?

Dr. Zlotoff: Well, this is an exciting time for vascular lesions in general and hemangiomas in particular. There are a lot of recent advances in treatment for vascular lesions that are super exciting. There are new medications. Propranolol is one of the ones that’s been in the news lately. Propranolol is a blood pressure medicine that was recently accidentally discovered in France to shrink hemangiomas down when they gave to a kid when they had high blood pressure they noticed that all their hemangiomas kind of melted away. So, we’re doing exciting things with some medications like propranolol and erythromycin. There are new ways to do sclerotherapy where medicines can actually be injected into vascular lesions to shrink them down. There are surgical techniques to remove many types of vascular lesions and there are a lot of new lasers out, too, a few of which we have here at UVA that can treat vascular lesions, even like port wine stains that can very easily be lasered now.

Melanie: Working with children with these things is there any plastic surgery involved? Is there any worry from parents about leaving scars?

Dr. Zlotoff: We work very closely with pediatric plastic surgery and plastic surgeons in general in our multi-disciplinary vascular lesions clinic and some of these lesions do require some surgery. The plastic surgeons are very good at minimizing surgical scars. A lot of times, our goal is to get at these lesions as early as possible and as early an age as possible so that we can prevent scars and we can prevent disfiguring surgeries down the line which is why I think it’s so important that they be evaluated at an early age.

Melanie: So, even when they’re little babies, that’s an okay time to look at these? You don’t wait and watch them and see if they grow with the baby?

Dr. Zlotoff: No, I think that’s the best time to get on top of them and really see what we’re dealing with so we can come up with a treatment plan. Sometimes, the plan will be do nothing and just watch the lesion but if you make that decision early, you have a lot more options for treatment and you may not be doing the treatment right away but you will at least know the treatment plan.

Melanie: Are there any, Dr. Zlotoff, that are cause for concern that you say, “We have to treat this because there could be complications”?

Dr. Zlotoff: The big ones are vascular lesions that are going to cause functional issues. So, we see vascular lesions on the tongue sometimes; we see them in the throat, in the neck, in areas that are going to push on the larynx or the breathing tube and cause issues with breathing. We see vascular lesions that are near the eyes that can cause issues with vision and that’s a big one for kids. If the eyes are in any way blocked for even a few weeks in a developing child, you can have lifelong issues with vision and blindness. So, we’re really aggressive about treating those types of lesions that are causing functional issues.

Melanie: In just the last few minutes, Dr. Zlotoff, when should patients and why should patients get their dermatology care at UVA Health Systems?

Dr. Zlotoff: I think the great thing about UVA is the number of specialists that we have that can address vascular lesions in so many different ways. We have so many tools at our disposal and now we have just started up a new multi-disciplinary vascular lesions clinic. It’s a multispecialty interdisciplinary team that works together so it includes dermatologists, radiologists, interventional radiologists, surgeons, hematologists, oncologists, ear nose and throat doctors and a variety of other specialists that all meet together to discuss complicated cases and vascular lesion cases. So, we can all work together, we literally all sit in the same room, look at the imaging together and say, “How are we going to approach this case? Maybe this case could do better with surgery; maybe it could be a good combination of sclerotherapy and surgery. Maybe we could do a little laser first and then supplement that with surgery later.” But, the plan of care is discussed together by all the providers and this is a really innovative approach and, I think, a special way to do it so that a patient doesn’t have to see ten different providers and the providers can actually communicate face to face to really come up with a plan together and I think that’s a really unusual and valuable service that UVA provides.

Melanie: Wow. That’s incredible. I applaud all the great work that you’re doing and thank you so much for being with us. You’re listening to UVA Health Systems Radio. For more information on dermatology at UVA you can go to UVAHealth.com. That’s UVAHealth.com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Prostatectomy, How to Make Informed Decisions When it Comes to Surgery?

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Segment Number 2
Audio File city_hope/1605ch4b.mp3
Doctors Zhumkhawala, Ali
Featured Speaker Ali Zhumkhawala, MD
Guest Bio Ali Zhumkhawala, M.D. is an assistant clinical professor in the Department of Surgery, specializing in urologic oncology. Dr. Zhumkhawala earned his undergraduate degree from the University of California, Los Angeles, graduating Magna Cum Laude, and received his medical doctorate from Northwestern University’s Feinberg School of Medicine in Chicago, IL. During an externship program, Dr. Zhumkhawala travelled to Layton Rahmutulla Benevolent Trust Free Eye Hospital in Korangi, Pakistan to evaluate ophthalmology patients. He continued his education by completing a general surgery internship and urology residency at Kaiser Permanente in Los Angeles, CA. In 2013, Dr. Zhumkhawala came to City of Hope and completed a fellowship in urologic oncology as well as the clinical investigator training program.

Learn more about Ali Zhumkhawala, M.D
Transcription Melanie Cole (Host): Prostate cancer is the most common cancer among men after skin cancer but it can often be treated successfully and more than two million men in the U.S. count themselves as prostate cancer survivors. My guest today is Dr. Ali Zhumkhawala. He's an assistant clinical professor in the Department of Surgery specializing in urologic oncology at City of Hope. Welcome to the show, doctor. So, tell us a little bit about prostate cancer and the treatments that we're seeing now, because the treatments seem to be changing all the time.

Dr. Ali Zhumkhawala (Guest): Well, thanks for having me. Yes, prostate cancer is one of the most common cancers in men, as you had previously said. So, there's a ton of research being done on prostate cancer and with that comes a lot of changes in the way we treat it. That's definitely to the benefit of patients. When we talk about prostate cancer treatment, our goals are really multifocal and one of the things we really want to focus on is preserving the quality of life of the patients that we're treating and really individualizing the treatment to each patient. Depending on the patient or their cancer characteristics, we need to create a treatment that's going to, not only effectively treat their cancer, but also not sacrifice their quality of life and what their personal goals are. So, all those things need to be incorporated in it.

Melanie: Are you still taking out the prostate as a form of treatment? Are we looking at more beam radiation? What are you doing, sort of, as a first line of defense?

Dr. Zhumkhawala: Well, for men with lower risk prostate cancer, that tends to be localized. What we usually recommend is actually something called "active surveillance" where it's really a cancer that we think is ultimately not going to metastasize and cause major problems for the patient, we tend to put them on a program where we just keep a very, very close eye on the cancer with repeat blood tests, repeat biopsies and if the cancer changes in any way, then we go onto a more aggressive treatment. That's called “active surveillance.” For most men with low-risk prostate cancer, that's a very good option. If they have more intermediate risk or higher-risk prostate cancer, then we lean towards some kind of treatment. The most common type of treatment men get nowadays is still removal of the prostate which is called “radical prostatectomy” and the majority of those surgeries across the country are being done through robotic surgery and, certainly, here at City of Hope, that's our mainstay of prostate cancer surgery is the robotic prostatectomy. There are other treatments that are being used frequently: radiation therapy--whether it's proton beam therapy done at a couple of specialized centers; external beam radiation therapy which we do at City of Hope or brachytherapy or radioactive seed implants also done at City of Hope, those are also options. Then, there's a different realm where we're really trying to do a lot of research on and that's called “focal therapy.” The idea behind that is that you're treating just the focus of cancer within the prostate and leaving the remainder of prostate healthy and viable. So, the thought behind that is that you're reducing the complications that come with removing the entire prostate. The different types of focal therapy are things like cryotherapy, where you're freezing the prostate, something called HIFU, or a high intensity focused ultrasound where we're using ultrasound waves that are focused on the cancer to destroy that focus the cancer; or radiofrequency oblation. Also, there are some laser therapies and there are some newer techniques that are going to be coming down the pipeline. With cryotherapy, you're just treating that focused cancer. You're not treating the entire gland, so men with multi-focal cancer or really higher-risk cancer are not good candidates for that. So, the prostatectomy, at least for now, is still really one of the mainstays of our treatment.

Melanie: So, let's speak about the robotic prostatectomy for a minute, here. What can men expect and, certainly, men are worried about those side effects, whether it's incontinence or sexual dysfunction and these are main concerns for them. So, speak about the surgery a little and some of those side effects.

Dr. Zhumkhawala: Sure, so with the surgery, the difference between the old-fashioned radical prostatectomy and what we do now with the robotic radical prostatectomies, really, one of the main things that patients notice right away is the size of the incision. So, we're doing it with smaller incisions where we're putting in robotic instruments and through that, we have a robotic camera that's three-dimensional. We can get really up close and have excellent magnification of the tissue of the prostate and the rest of the body, as well. So, it really enables us to do quite fine surgery with techniques that we couldn't do with laparoscopic or even an open surgery. We do know that there's a decrease in blood loss. That's been proven. We think that the recovery is a little bit faster because of the smaller incisions. Most surgeons that do a lot of robotic surgery think that overall, the outcomes are going to better in terms of cancer control, incontinence, and erectile function. You talked specifically about the two major concerns that most men have that are related to incontinence, or leakage of urine, after surgery and impotence, or difficulty with erections after surgery. Those are very, very common side effects from the surgery. Now, at City of Hope, we do a really good job trying to control those side effects and our continence rates are excellent. So, at about one year, 95% of our men are continent and, really, at about 6 weeks half of our men are continent. So, those are really high rates and I think there are a lot of techniques that we try to use to improve on continence in men that are undergoing robotic surgery. When you talk about sexual side effects, those are also significant and erectile dysfunction after prostate cancer surgery is very common. Probably about 70% of men are able to attain their erections after surgery, with the help of oral medications. But, even in the 30% of men that don't, there are options. So, if a man, after surgery is having trouble with erections and the pills aren't good enough, there are other medications, there are vacuum pumps, there are injections directly into the penis, and then, ultimately, if those all fail, there are surgical options to try to treat the erectile dysfunction. So, there is still a lot of hope, even if the pills are not enough. Then, we can certainly find a way to make sexual function still viable part of someone's life after prostate cancer surgery.

Melanie: Doctor, if somebody has a robotic prostatectomy, if they have the prostrate removed, can they still get prostate cancer? Can it come back?

Dr. Zhumkhawala: It can. So, there are multiple why prostate cancer can come back after the prostate is removed. One is that there's cancer left behind at the time of surgery or a positive margin where we don't cut all of the cancer out and sometimes that's something you can control for and sometimes it's not. When the cancer's invading organs next to the prostate that are really vital for life, sometimes we do have to leave a little bit of cancer behind. Usually, those patients are treated with radiation after surgery to try to eradicate the remaining prostate cancer cells. But, there are also some patients where the cancer has microscopically spread prior to surgery and the lesions that it has9 spread to are not necessarily big enough for us to pick up on imaging scans. And so, sometimes we don't find that out until later but even when patients have a recurrence after prostate cancer surgery, there are multiple lines of treatment and there are multiple clinical trials that patients can go on. So, it's a paradigm that's changing quite a bit with the new research, but there are definitely treatments out there.

Melanie: And what are you doing that's exciting there at City of Hope?

Dr. Zhumkhawala: Well, I think that a lot of the things that we do that are exciting relate to our research studies that are really aimed at treating patients throughout every step of the prostate cancer highways, so to speak, from the beginning to the end. So, we have trials that almost every patient with prostate cancer can embark on and some of the trials that we have that are unique are things like, we do have a high-intensity focused ultrasound trial--HIFU trials--for focal therapy. We do have a lot of surgical trials where we're looking at imaging techniques to try to improve our visualization of the cancer during surgery. We completed a trial using a chemical called Indocyanine Green, and we're currently doing another trial using an antibody to prostate cancer that is fluorescent and the idea is to see that intra-operatively and be able to see where the cancer is and where the prostate is and find those margins quite nicely. We also have trials for a patient that has cancer that recurs so there's imaging trials and we have some novel agents that we're using. A lot of these trials are in conjunction with other major cancer centers across the country.

Melanie: That's absolutely fascinating, doctor. Really, such great information. So, in just the last few minutes, tell us why patients should come to City of Hope for their prostate care.

Dr. Zhumkhawala: I think the main thing that we pride ourselves on is that we provide multidisciplinary care. When you come to City of Hope and you see a urologist, it's not just the urologist that's involved in treating you, there are a multitude of people that may be involved, whether it's physical therapists, whether it's nutrition and then, afterwards, there are radiation oncologists that we work closely with, there are medical oncologists that we work closely with. So, it's really a big team with a bunch of different people that can provide input and really help guide your care in a positive direction.

Melanie: Fantastic. Thank you so much for being with us, doctor. You're listening to City of Hope radio. For more information, you can go to cityofhope.org. That's cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole MS

Women’s Cardiac Health, Overall Advancements in Women’s Healthcare

Additional Info

Segment Number 1
Audio File florida/1605fl5a.mp3
Doctors Guerrero, Patricia
Featured Speaker Patricia Guerrero, MD
Guest Bio Dr. Guerrero joined Florida Heart Group in 2002 after moving from Columbia, Missouri where she was an Associate with Missouri Cardiovascular Specialists. She has written several publications and abstracts and has received many honors and awards for her work. Her main clinical interests are the evaluation of patients with arrhythmias and prevention of cardiovascular disease. She is a national speaker for Awareness of Women and Heart Disease. Her principal research interests include Device Therapy for the Management of Heart Failure and the use of Novel Agents for Arrhythmias Management.

Learn more about Dr. Guerrero

Learn more about floridaheartexperts.org
Transcription Melanie Cole (Host): You may not realize this but heart disease, not cancer, is the number one cause of death for women in America. Nearly every minute of every day each year, a woman dies of heart disease. My Guest today is Dr. Patricia Guerrero. She’s a cardiologist and the director of women and heart disease for Florida Hospital. Welcome to the show, Dr. Guerrero. Please start by telling us about what’s a little bit different for women and our heart disease than it has been, typically, for men.

Dr. Patricia Guerrero (Guest): Good morning, Melanie. Thank you. Women have different symptoms when they present with heart disease. I think most people would think of heart disease as heart attacks or that disease or symptoms that relate to an inadequate blood supply to the heart muscle. Men, customarily, would more typically, have chest pain. Women can have chest pain, if they are presenting with a heart attack but they, also, from a percentage point of view, are more likely to have symptoms that are not considered typical, meaning it is not chest pain, not the elephant sitting on the chest. It may be nausea, it might be shortness of breath, it could be jaw pain, shoulder pain or pain radiating down the arm. The presentation can be different and also the type of disease and how it affects the arteries can be different in women when compared to men, meaning that men will more typically have a focal disease, meaning that the blockage in the artery is in a discreet area versus in women it can encompass more of the entirety of the vessel. The other difference is age of presentation. Men, customarily and statistically, would have heart disease at an earlier age when they present at a later age. The outcome after a heart attack is worse for women than in men. So, it behooves women to really focus on prevention because we do fair less well after a heart attack. We have a greater percent of, in the first year, of dying and we have a greater percent in the first five years, compared to men, of having complications related to heart attacks.

Melanie: Women, we are the caregivers of society, Dr. Guerrero, and we, typically, are always treating everybody else before we take care of ourselves. So, give women your best advice about risk factors, things we should be aware of, so that we can concentrate on ourselves and then we can help the rest of society.

Dr. Guerrero: I agree with you. Women are the caregivers and so their focus is on others first before themselves. I would say, remember that you can’t care for others unless you care for yourself. The best example that you can give to your children, particularly your daughters, is showing that caring for yourself is not being selfish. It’s actually in taking care of yourself so that you can help others. The main thing that I would recommend all women to do, and this is part of the American Heart Association and the American College of Cardiology guidelines, is that as of age 18 when you reach adulthood, that you systematically have a review of what are your cardiovascular risk factors. This is a tool that is available online, even through the American Heart Association’s website but also through the Florida Hospital Women’s Heart website. It is a questionnaire, up to 50 questions and you feel uncomfortable going through those questions, you should seek help from your primary care provider. What the things that are addressed as risk factors are things like: high blood pressure, is your blood sugar high, do you not exercise routinely, is your weight above what would be considered normal, do you smoke, are you a diabetic, do you have a family history of heart attack or strokes under the age of 65? Then, there are some additional risk factors that are unique to women that also include that during pregnancy they develop diabetes or develop high blood pressure, something called eclampsia. Those are early warning signs, those are the things that should be taken as a clue that that young women will subsequently have a higher risk of developing heart disease. Routinely, reevaluating at least yearly what are your risk factor and either using the questionnaire that will help estimate what your risk factor category is or even better, seeing your primary care doctor yearly and addressing all those risk factors and what can be done to prevent disease.

Melanie: What do you like to tell people about preventing? You’ve mentioned these risk factors, some of them controllable, some of them not, but what do you tell them where diet and exercise are concerned and that’s relation to heart disease?

Dr. Guerrero: Well, in reference to that, what has been repeatedly proven is that the more you move, the healthier you will remain. So, I encourage women and men to perform at least 200 minutes of aerobic exercise per week. That boils down to about 30 minutes every day. It can be in blocks as small as ten minutes and it does not have to be formal exercise but it should involve increasing your heart rate to a point where you are slightly short of breath but can still sustain a conversation. I encourage everyone to exercise as many days of the week as possible instead of trying to just accumulate all 200 minutes in one or two days as it provides a beneficial effect on maintaining a normal blood sugar level, a normal cholesterol value, normal blood pressure and it helps with weight management. I also advise women, in particular, to do some resistance training. It doesn’t necessarily have to be with machines or weights but that at least three times a week, they do some sort of resistance training to maintain muscle mass and good posture. So, maintaining muscle mass also assists in maintaining a metabolic rate that assists you in maintaining a healthy weight as well as one ages, maintaining good posture because you have the muscle mass that may help prevent something that also occurs frequently in women which involves fractures secondary to osteoporosis. Weight training, resistance training whether it be with your own body weight or using accessory weights is beneficial.

Melanie: What about diet? Women wonder if omega-3s will help them to prevent some heart disease. They wonder about their cholesterol levels. Speak about knowing your numbers and where your diet comes in.

Dr. Guerrero: Well, knowing your numbers is critical, particularly if you have a family history of premature cardiovascular disease, these numbers should already be evaluated even when you’re still a child under a care of your pediatrician to help decrease the risk early on. At a minimum, even if your values are normal, your values should be checked at the age of 18 and at least every five years. Once you approach middle age, so you’re approaching menopause, it should probably should be checked yearly unless there are illnesses that are diagnosed early on like diabetes which would also incur a risk of elevated cholesterol values. So, the main impact of diet onto healthy lipids is that your diet should be preferably produce based. Two-thirds of what you consume should be fruits and vegetables and then a third should be a lean protein. I think when you approach the plate and you divide it in thirds, then you make sure that 2/3 of that plate is either produce and the one remaining 1/3 is a protein and all of these things should be prepared in a lean fashion and as fresh as possible in order to use food as medicine, which is the best sort of medicine there is. I also encourage my patients to be mindful of hydration. So, oftentimes, we consume more food because we are really thirsty because we aren’t attentive to enough fluid intake. By making sure that you drink adequate fluid in the form of water or non-alcoholic beverages, then you’re less likely to eat food because you’re really thirsty.

Melanie: That is great, great advice. In just the last few minutes, please continue along that line. Wrap it up with your best women and heart disease advice and why women should come to Florida Women’s Hospital for their care.

Dr. Guerrero: Well, the best advice I can give is that you should know your risk factors. Don’t be ignorant. Be involved and take charge of your health. Florida Hospital has wonderful avenues through their new women’s program but also Florida Hospital is dedicated to taking care of women and heart disease and all its manifestations. So, they can visit our website, they can also call our nurse online for directions if they need assistance, whether it be to see a cardiologist or to see a heart rhythm specialist or to help find a local primary care provider that then can help them with assessing their risk factors. The risk factor assessment tool is online and anyone is welcome to take it. We also have a bus. It is a women’s coach that is dedicated to breast cancer screening as well as screening for cardiovascular disease. You can inquire as to where the coach might be located on any given week and attend any one of its functions. So, we welcome all women to call, inquire, and seek assistance. We are there to assist and to promote good health in the community.

Melanie: Thank you so much, Dr. Guerrero. It is great information and you’re so well spoken. Thank you for being with us today. For more information on Florida Hospital for Women, you can go to FHforwomen.com. That’s FHforwomen.com. You’re listening to Health Chat by Florida Hospital. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Pelvic Floor Disorder: Treatments and Cures

Additional Info

Segment Number 1
Audio File city_hope/1605ch4a.mp3
Doctors Chung, Christopher
Featured Speaker Christopher Chung, MD
Guest Bio Christopher Chung, MD is a urogynecologist and an assistant clinical professor in the Division of Gynecologic Oncology Surgery.

Learn more about Christopher Chung, MD
Transcription Melanie Cole (Host): A gynecological cancer diagnosis can be life altering. However, as the cancer is being treated, there might be some complications with the pelvic floor that may affect your quality of life. My guest today is Dr. Christopher Chung. He is a urogynecologist specializing in female pelvic medicine and reconstructive surgery at City of Hope. Welcome to the show, Dr. Chung. Tell us what type of cancers would predispose a woman to having pelvic floor disorders?

Dr. Christopher Chung (Guest): Traditionally, any cancer that occurs in a woman’s pelvic floor, for example, GYN cancers like ovarian, uterine, cervix, or colorectal cancer, when you have surgery for these types of cancers, you damage the pelvic floor muscles and nerves. This predisposes a woman to urine incontinence, prolapse and fecal incontinence. Recently, at City of Hope, we’ve done several studies to look at other types of cancer. We found out that when you get treatment for any cancer – for example breast cancer, lymphoma, leukemia or lung cancer – the treatment that you receive such as radiation and chemotherapy can actually predispose you to have pelvic floor disorders. The best example would be the woman who receives chemotherapy for breast cancer. When a woman receives chemotherapy, the chemotherapy basically shuts down her hormone production in her body and that can predispose her to have bladder dysfunction such as frequency and urgency symptoms that she cannot make it to the bathroom in time or waking up at night to go urinate, or leaking urine. All of these problems.

Melanie: People don’t even think about that. That’s a great point, Dr. Chung. That’s something that you would think has nothing to do with the pelvic floor. When you speak about these disorders, you mentioned incontinence, fecal incontinence and prolapse, tell us what those are, what those mean.

Dr. Chung: There are several types of urine incontinence. It is a very embarrassing issue to talk about. This can be when a woman leaks urine when she coughs, sneezes or laughs or with physical activity. Then, there is another type of incontinence called “urgency incontinence” that means when a woman has urgency feelings that she cannot make it to the bathroom in time. There is another problem called “overactive bladder” that means that she has to go every hour or every two hours. She feels like she needs to go all the time or she cannot have a good night of sleep. She has to wake up every hour or every 30 minutes to go pee at night. You can imagine how detrimental that can be to a woman’s quality of life. The next topic is prolapse. This means that a woman has poor support of her pelvic floor muscles either due to vaginal deliveries, getting pregnant or tumors or surgeries of the pelvic floor, like hysterectomy or colon resection – these types of surgeries. This means that her bladder can drop down past the vaginal opening or the uterus can drop past the vaginal opening or the rectum drops down, too. When you have relaxation of the pelvic organs like the uterus, bladder or rectum, they can have the sensation that they cannot empty their bladder completely or they can have the sensation that they cannot empty their stool completely. Sometimes the woman has to push the vaginal area to help them empty urine or stool.

Melanie: As you pointed out, it is embarrassing and tough for women to talk about, Dr. Chung. How do you start that conversation when a woman is going through her cancer treatments and what treatments do you offer for some of these disorders?

Dr. Chung: The important thing is to tell your doctor about all of these symptoms. When you see your medical oncologist or your surgeon, they will ask you do you have any other issues that they can help you with. The important thing is to volunteer all of this information. I’m unique in a way that City of Hope, as a cancer center, provides pelvic floor service to our patients. If you tell your doctor, “I have bladder control issues” your doctor can refer you to see me. We can treat you either with conservative management – for example, pelvic floor physical therapy, medication, or nerve stimulation – or we can do a surgery to improve the patient’s quality of life. There are many options. Not everyone needs surgery. It depends on the diagnosis.

Melanie: Are there certain times when you can teach prevention? We hear about Kegel exercises and diet. We see so many medications on the market, too, Dr. Chung, for all of these issues. What do you tell women about those things?

Dr. Chung: First of all most women do Kegel exercise wrong.

Melanie: Really?

Dr. Chung: Yes. A lot of times, when I see a patient I ask her to contract her vaginal muscles, she actually pushes it out. When I ask them to push, she actually contract. I would say more than half of the women do Kegel exercises wrong. If they have overactive bladder symptoms or pelvic pain disorder, I can refer them to our pelvic floor physical therapists who are very specialized physical therapists who can use biofeedback. It is a method that they can teach you to do the correct Kegel exercise. They can see exactly which muscle you are contracting and teach you to do the correct Kegel exercise.

Melanie: It is important that we do that. How much does diet play a part any of this? Some women hear that they are supposed to drink more water or less water if they have urgent incontinence. Tell us about diet and its relationship to pelvic floor disorders.

Dr. Chung: Yes. When a woman is getting chemotherapy, her oncologist will tell her to drink a lot of water and you can imagine--the more water you are going to drink the more urine you are going to have. That can cause you to have frequency and urgency symptoms. But, when you are not on chemotherapy, you don’t need to drink that much water. That is a very common misconception. I always tell my patients to be moderate on the fluid intake. Drink when you are thirsty. You don’t have to drink three or four gallons of water a day. Just be moderate because the more water you drink, the more water is going to go to your bladder and that is going to cause frequency urgency symptoms and leakage of urine. In terms of diet, a lot of women experience fecal urgency and incontinence. They leak stool with diarrhea. The simplest way to treat this is to make your stool firmer so you don’t leak stool. A very good medicine to take for this is Loperamide, the stool bulking agent to make your stool firmer. You don’t need to have surgery for this.

Melanie: That’s absolutely great advice. What else would you like women to know about pelvic floor disorders that may be a complication or a side along to go with their cancer treatments , whether they are gynecological cancers or not?

Dr. Chung: I always tell my patients, “Don’t feel embarrassed about this. In the old days, your mom, your grandma learned to live with this,” but now we have many treatment options available - whether conservative management with physical therapy, medication, or surgery. The important thing is to tell your doctor about these symptoms and have an appropriate referral made to see a specialist who knows how to treat pelvic floor disorders.

Melanie: In just the last few minutes, Dr. Chung - you’re doing such great work – tell us what’s going on at City of Hope that is exciting in your department.

Dr. Chung: Traditionally, a urogynecologist doesn’t work in a cancer center so I’m unique in way that City of Hope sees the need for a specialist to treat patients with pelvic floor disorders, especially cancer patients. Here, we have come up with an innovative surgical technique to perform pelvic reconstructive surgery at the time of the patient’s initial cancer surgery. For example, if the patient has a GYN cancer and she has pelvic floor problems like leaking urine, stress incontinence or prolapse, we could do all of the reconstructive surgery at the same time of their initial cancer surgery. We believe that this is the best time to do surgery because if we don’t do the reconstructive part of the surgery as part of their initial surgery, she may need radiation and chemotherapy and she may not be a good candidate for pelvic floor reconstruction for the rest of her life. We can do a lot of things at one surgical setting. Also, we are very good at using the patient’s own tissue for reconstruction without the use of mesh. We don’t think mesh surgery is good, especially in cancer patients. You see on TV commercials that there is a lot of vaginal mesh placement issues and lawsuits. If you have a mesh placed in the vagina and you need radiation, that could be a big problem later on in your life. It could cause pain and bleeding and a lot of problems. We are very good that we can use the patient’s own tissue for reconstruction without the use of foreign materials.

Melanie: That’s excellent information. I applaud all of the great work that you are doing, Dr. Chung. Thank you so much for being with us today. You’re listening to City of Hope Radio and for more information you can go to CityofHope.org. That’s CityofHope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole MS

How Old is Your Heart?

Additional Info

Segment Number 3
Audio File virginia_health/1605vh4c.mp3
Doctors Patterson, Brandy
Featured Speaker Brandy Patterson, MD
Guest Bio Dr. Brandy Patterson is board-certified in cardiovascular medicine and internal medicine; her specialties include women’s heart health.

Learn more about Dr. Brandy Patterson

Learn more about UVA Heart & Vascular Center
Transcription Melanie Cole (Host): Do you know how old your heart is? If it’s older than you, based on conditions such as high cholesterol and high blood pressure you’re at a higher risk for heart disease and stroke. My guest today is Dr. Brandi Patterson. She’s board certified in cardiovascular medicine and internal medicine. Her specialties include women’s heart health at the UVA Health System. Welcome to the show, Dr. Patterson. Tell us a little bit about the factors that make your heart age faster.

Dr. Brandi Patterson (Guest): Thank you for having me on Melanie today. So, some of the factors that make our heart age faster are things like smoking. Smoking really tends to make plaque build-up in our arteries, not only in our hearts, but also in the carotid arteries leading to the brain as well as the arteries in our legs at a much faster rate, much more aggressively. It really leads to early onset heart attacks and strokes and peripheral arterial disease. I have actually seen this in my practice in very young women in their early to mid-twenties who have smoked a pack or two or three a day for ten years and they’ve already come in with heart attacks and they’ve already come in with strokes. So, smoking really increases the age of your heart very quickly as does diabetes, especially uncontrolled diabetes as well as high blood pressure, cholesterol that’s uncontrolled, poor diet and physical inactivity.

Melanie: How can you learn how old your heart is?

Dr. Patterson: It’s actually a great tool that ClubRedUVA.com has online. So, you can go onto ClubRedUVA.com and take the heart age calculator test. It’s designed to give you an overall idea of the health of your heart and, basically, a general idea of how your personal lifestyle related factors may have affected your heart. Now, I have to put in a disclaimer here. The calculator is meant to be used for people ages 30-74 years old who have no history of cardiovascular disease, meaning you have not had a heart attack, you have no history of a stroke, peripheral arterial disease or heart failure. It is a good method for determining if you’ve made great lifestyle choices, you can visually see this on a calculator in front of you that by making good lifestyle choices, your heart age may be the same as your chronological age or even younger. So, you may actually be younger at heart but if you’ve made poor lifestyle choices your heart may age at a much faster rate because of those lifestyle choices. It puts this on a screen for you so you can visualize it and you can see. I think it has a very powerful impact when you can see that you’re 30 years old but your heart is actually 65 or 70. The bottom line for that is that, if you’re a 30-year-old man or a 30-year-old woman and your heart age is 65 or 70, you are at higher risk for having a heart attack or stroke.

Melanie: Wow. So, if you do have that higher risk, if you have an older heart than your actual age, can you reverse the process? Can you make it young again and reduce your risk?

Dr. Patterson: Yes. You know, you can. Fortunately, it’s not impossible to turn back the hands of time when it comes to your heart. So, everyone deserves to be young at heart and you can start making changes in your lifestyle choices as soon as you can to reduce your heart age. What I advise my patients is a really simple tool – use you’re A, B, C’s – aspirin, “A” for aspirin when appropriate, “B” for blood pressure control, “C” for cholesterol management, “S” for smoking cessation. By exercising regularly, watching your diet, and not smoking, people really can do a lot to reduce their risk of heart disease and make their hearts younger. In fact, more than 75% of heart disease cases can be prevented by making the right lifestyle changes.

Melanie: Wow. So, obviously, there’s some genetic component because you always get that question, “Did anyone in your family have a stroke or heart attack before the age of something?” Dr. Patterson, what is the age when it’s considered a genetic component? Is there an age when it’s not?

Dr. Patterson: Yes. So, if you have a male relative that’s in his 60’s and a female relative in her late 50’s or mid-50’s that has a cardiac condition, then it really becomes concerning to us. While any cardiovascular disease at any age is a concern and we want to know about any family history of heart disease, the younger people are when they get their disease the more precautions or the more aggressively, we like to treat the patients that have the earlier onset heart disease in their family. So, for instance, for an example, if you have a mother that had the onset of heart failure when she was 45 years of age and a father that had a heart attack when he was 60 years of age, those two ages are very concerning to us. The fact that there are two first degree relatives involved is very important to us. That’s not to say that siblings aren’t important. Siblings are very important, too, but, really, it’s the first degree relatives that we really need to know the most information about cardiovascular disease. If you have a family history that extends beyond your mother and father, meaning your grandparents had heart failure or heart attack in their 30’s or 40’s and their grandparents had heart attacks in their 30’s and 40’s, obviously, that’s a very concerning trend that we also need to know about. The more information we can get the better.

Melanie: Well, certainly that’s true. Do you take into account if somebody says, “I had a grandfather who had a heart attack but it was 1932” and maybe they didn’t know as much. Do we still take that into effect?

Dr. Patterson: Yes. I would, personally. I would, personally, and I agree that medicine has really advanced since then and the things that we can do now for folks with heart disease is really much more advanced than we had in the past. The testing that’s used now to detect cardiovascular disease is much more advanced. However, again, I think the more knowledge that your doctor has about your family history, the better.

Melanie: Dr. Patterson, when do you feel that stress testing and testing to see if you have peripheral artery disease or any kinds of build-up, when do those come into play?

Dr. Patterson: I think it comes into play when you know what the risk factors are for the patient as well as, obviously, if the patient is having any symptoms. For example, for peripheral arterial disease a symptom would be when they are walking a block, they start to get severe cramping in the legs, the calf muscles, the thigh muscles, the buttocks, either or. When they stop, that pain gets better. If somebody came to me with that symptom and let’s just say they have a smoking history, I would be very concerned about aggressive plaque formation in the arteries in the legs. It’s really, Melanie, a combination of risk factors plus symptoms and with that, again, of course, family history, knowing when to test the patient depending on those three items – family history, risk factors and symptoms.

Melanie: Now, we certainly know women, Dr. Patterson, we are the caregivers of society and if we don’t put our own masks on first we can’t put the masks on of our loved ones. We don’t always, as you know, pay attention to our own symptoms as much as we do to everybody else’s, running around going “What did you just feel? What did you just feel?” What do you want women to know about heart disease and our risk and our different symptoms?

Dr. Patterson: Well, I think you need another segment for that! There’s a lot to talk about with that topic. I think the bottom line is that women need to know how prevalent cardiovascular disease is--it’s not just a man’s disease. Today is actually “wear red” day for women with heart disease and it’s a very important day. It increases awareness for women that heart disease is a major risk--that one in three--and some form of cardiovascular disease affects one in three women. Now, I think we all know someone in our life – a mother, a sister, a grandmother that has had some type of heart disease. While we all have these female family members--if not family members, then friends--with heart disease, and we rarely think it’s going to happen to us. I think the important part of this is that, again, it goes back to your risk factors. You need to know what your risk factors are for having cardiovascular disease. That is diabetes, smoking, high blood pressure, high cholesterol, diet, physical inactivity or physical activity and your family history. So, knowing these things about yourself, what is your risk for having heart disease? Has your mother had problems in her 30’s, 40’s, and 50’s? What was your grandmother’s cardiovascular history like? I think the more that women are knowledgeable about their own risks and understand that those risks place them at an increased chance of having not only heart attack but also potentially valve disease, rhythm disease or heart failure, I think the better we are able at recognizing symptoms in ourselves. Symptoms of heart disease can really be much different in a woman than a man. We don’t have to have the elephant sitting on the chest. I actually saw a woman the other day in the clinic who had pinpoint needle pricks in her chest – that was the symptom--prior to her stent placement. It could be as mundane as just being fatigued and that’s really difficult because, my gosh, if we don’t get a good night’s sleep and we’re fatigued the next day is our heart or the fact that we haven’t’ slept? I think having an awareness of how your body normally functions, how you normally feel, is this fatigue, is it lasting 24 hours or is it lasting a week even though you’ve gotten enough sleep the next couple of nights? If it’s lasted a week and you’ve gotten enough sleep over the last couple of nights, boy, something may be wrong and it may actually be your heart. Shortness of breath, discomfort in the stomach, abdominal pain, nausea, vomiting, numbness and tingling in the hands, the arm, the jaw. Again, I think it’s important to know your risk factors. I think it’s important to know that women’s symptoms are different than men’s and I think it’s important to know the prevalence. It’s very common for women to have some form of cardiovascular disease.

Melanie: In just the last few minutes, what great information, Dr. Patterson. We sure covered a lot in this time. Why should patients choose the UVA Heart and Vascular Center for their heart care?

Dr. Patterson: UVA has expertise in all areas in cardiovascular disease from cardiovascular disease prevention to heart replacement in both the American College of Cardiology and The Society of Thoracic Surgeons clinical data registries. UVA’s heart program actually ranks in the top 10%. This is based on measures that really matter like survival from heart attacks. I, personally, think that’s why patients should choose the UVA Heart and Vascular Center for their heart care.

Melanie: Thank you so much. What great information. For more information on Club Red and the UVA Heart and Vascular Center you can go to UVAhealth.com. That’s UVAhealth.com. You’re listening to UVA Health Systems Radio. I’m Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Alternative Treatment for Depression

Additional Info

Segment Number 2
Audio File virginia_health/1605vh4b.mp3
Doctors Hamilton, David
Featured Speaker David V. Hamilton, MD
Guest Bio Dr. David Hamilton is a board-certified psychiatrist whose specialties include TMS therapy for depression.

Learn more about Dr. David Hamilton

Learn more about UVA Psychiatry
Transcription Melanie Cole (Host): Approximately 1/3 of patients with depression don’t respond to standard treatments. When should you consider alternative treatments for depression? My guest today is Dr. David Hamilton. He’s a board certified psychiatrist whose specialties include TMS therapy for depression at UVA Health Systems. Welcome to the show, Dr. Hamilton. So, what are some of the standard therapies that you prescribe for depression that generally the population would hear about?

Dr. David Hamilton (Guest): I think the mainstay of the treatment of depression is really two-fold. It’s medication on the one hand and there are a variety of medication classes of anti-depressants and other classes of medications that we use in addition to anti-depression medications that have been shown to augment their response. The second thing would by psychotherapy. There is science showing in regards to medications and psychotherapy both are useful but, really, the whole is greater than the sum of the part. They tend to work better together.

Melanie: Okay. When does it come down to trying other treatments? How do you know that these standard course of treatments together or separately are not working for someone?

Dr. Hamilton: The patients that I see here at UVA are patients that have tried a variety of treatments, both a number of medications in different classes as well as psychotherapy and they either are not responding or they are having an incomplete response that is still leaving their lives not functioning in the way that they want to.

Melanie: So then, what? What’s the first course that you would look at as complimentary medicine?

Dr. Hamilton: Well, I think the first thing that we do is make sure that the person has tried medications that are appropriate to the symptoms that they are experiencing. Not all anti-depressants are created equal and then, not all depressions are the same. Some patients have depressions where anxiety is a huge component of their depression and other patients have depressions where just they feel like they can’t get out of bed and they have a lack of energy. Matching the appropriate anti-depressant medication to the symptoms that a person is experiencing is job number one. Now, if that’s been done and the patient has still failed to respond to a good trial of medications, then we start to look at techniques like TMS which stands for Transcranial Magnetic Stimulation.

Melanie: Tell us what that is.

Dr. Hamilton: We are beginning to understand, primarily through the advances in neuro imaging, the different parts of the brain that are in control of our mood and we know that primarily mood is something that exists very deep in the brain. So, it’s very hard to access. However, there are areas on the outside of the brain, newer parts of the brain, if you will, that are control centers for those deeper parts that we can’t access. TMS allows us to target those areas to improve their functionality and their ability to control the deeper emotional parts of the brain.

Melanie: That’s fascinating. How often does someone have to have a TMS session?

Dr. Hamilton: Well, a group of sessions is every day. One session lasts 37 minutes. It’s pretty brief but it is a commitment because it’s Monday through Friday for 4-6 weeks. Then, we do a taper for three sessions a week for a week, then two, then one. So, it is an investment in time.

Melanie: Does this work in long term doctor? Is it something that they have to keep re-doing? How does that work?

Dr. Hamilton: Well, there’s been a variety of responses. Generally, people don’t need to keep getting sessions. Sometimes, if people begin to experience symptoms of depression again then, we will do an abbreviated course – a few sessions to sort of touch them up and when they begin to respond then we’ll stop. Rarely sometimes people need a complete course again if they’re having another full blow major depressive episode.

Melanie: How do you work with patient’s doctor about other kinds of remedies for depression? Maybe mind/body therapies, cognitive behavioral therapy, exercise where do you include all those?

Dr. Hamilton: Sure. When I’m working with a patient in developing a treatment plan, I think of it as, and the metaphor I often use, is of a chair having four legs. Each leg is important. First leg is medication but I think very often people want a pill that’s going to fix everything. Very rarely is that the case in depression. Medications are an important part of treatment. The second leg of the chair, if you will, is psychotherapy and, as you mentioned, there are a variety of different kinds of therapy. Cognitive behavioral therapy, psychodynamic therapy--that’s the more sort of classic long-term insight-oriented therapy. Short term therapy that’s focused more on developing specific coping skills. The third leg or pillar of treatment plan is the things that we put into our body. That includes diet as well as substances – alcohol, drugs, both illicit and licit--in addition to things like vitamins and nutraceuticals that we know are helpful in treating depression. Finally, and certainly, last but not least is exercise. Exercise is as important as any other aspect of a full treatment plan. Of course, when somebody is in the midst of a full blown depression, it can be cruel to say, “You should start exercising.” Very often, it’s the job of the medications and therapy to get people to the point where they can start having a lifestyle consistent with recovery from depression.

Melanie: Such great information. In just the last few minutes, Dr. Hamilton, why should patients choose UVA for their psychiatric care?

Dr. Hamilton: I think at UVA, we have the advantage of being inside of a large university system and we’re able to bring all of the resources to bear. Rather than being just a TMS Clinic, we are able to really take a look at patients as individuals and decide, what is the appropriate course of treatment for this particular patient? It may be that TMS or some other kind of treatment modality is appropriate. We’re able to really customize and individualize treatment plans based on the individual needs of a patient. We’re more, I think, patient focused than focused on the clinician and what we happen to offer since we have so many different modalities to offer.

Melanie: Thank you so much. Great information. You’re listening to UVA Health Systems Radio. For more information you can go to UVAhealth.com. That’s UVAhealth.com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Treatment Options for Peripheral Arterial Disease

Additional Info

Segment Number 1
Audio File virginia_health/1605vh4a.mp3
Doctors Robinson, William
Featured Speaker William Robinson, MD
Guest Bio Dr. William Robinson is a board-certified specialist in surgery and general vascular surgery. His specialties include aneurysm repair and caring for patients with peripheral arterial disease.

Learn more about Dr. William Robinson

Learn more about UVA Heart & Vascular Center
Transcription Melanie Cole (Host): If left untreated, peripheral arterial disease can have serious long term affects. My guest today is Dr. William Robinson. He is a board certified specialist in surgery and general vascular surgery at UVA Health Systems. Welcome to the show, Dr. Robinson. Briefly explain, what is peripheral arterial disease or PAD.

Dr. William Robinson (Guest): Thanks Melanie, it’s great to be here and be on your show. Peripheral arterial disease is atherosclerotic disease that leads to obstruction of the peripheral arteries. The peripheral arteries are any artery in the body other than the coronary arteries. So, peripheral arterial disease can involve many arteries in both the limbs as well as the chest and abdominal cavities. It can be both symptomatic and actually silent.

Melanie: So, it can be silent. Who as at risk for this disease? And then, how would you even know that you have it?

Dr. Robinson: The risk factors for peripheral arterial disease are actually fairly well established and they overlap a good bit with the risk factors for heart disease. The major risk factors are: male gender, age – so with our aging population this is becoming an increasing problem. Other risk factors include smoking, hypertension, diabetes, and hyperlipidemia. Those are really the major risk factors that can lead to peripheral arterial disease.

Melanie: How is it diagnosed and what symptoms? Dr. Robinson, if you are somebody who walks on the treadmill and gets a pain in your legs – this claudication – people don’t know if it’s just muscular or if it’s something more.

Dr. Robinson: That’s exactly right. The most common area that peripheral arterial disease affects is the lower extremity. In that example that you just gave, that would be sort of a classic symptom. What we call “claudication,” that is a cramping a pain in either the calf or sometimes the thigh or buttocks due to insufficient blood supply when the patient exercises or walks. That is one way to recognize that peripheral arterial disease may be present. In that case, you would need to see either your primary care doctor or a specialist in order to differentiate that from other causes of muscular pain that might occur with activity.

Melanie: How is it diagnosed? Is this a simple procedure to diagnose whether there are arterial problems in the lower extremities?

Dr. Robinson: Actually, the diagnosis is made based on the symptoms and the examination by a physician and then sometimes supplemented with very simple testing. If you have symptoms that are consistent with peripheral arterial disease such as claudication and you are found to have abnormal pulses in the lower extremity, that would be sufficient for a diagnosis of peripheral arterial disease. In patients who are asymptomatic the diagnosis is made by measuring blood pressures in the leg, specifically at the ankle. If we see that they are reduced below a level that we would consider normal, that is sufficient for diagnosis of peripheral arterial disease.

Melanie: If somebody is diagnosed with this – and, as you say, a simple blood pressure test in the lower extremities can help you determine – then, what do you do for them?

Dr. Robinson: The treatment for peripheral arterial disease, really, first off, should be focused on prevention. The best way to treat it, as with many diseases, is to prevent it. The prevention is aimed at control of all those risk factors that I mentioned just a few minutes ago. That means having diabetes under good control, having hypertension under good control, having your fats and lipids under good control and not smoking. Those are the major things that can be done for prevention. Even after the diagnosis is made, those things remain the most important part of the treatment. Although the blockages will not be reversed by changing your diet or losing weight or getting better control of the diabetes, if those things are done, the disease will become less progressive and, therefore, less likely to lead to symptoms or complications. When we see patients with more advanced symptoms, there are definitely options for treating it. For example, in the lower extremities, if a patient has either claudication or more severe pain due to more severe peripheral arterial disease, we have a variety of options. Some of those options include endovascular therapy where we would be able to open the blockages with a combination of either ballooning or stents, for example. Other options would include surgical therapy in order to bypass around the blockage to restore blood to the lower extremity. It’s important that people realize that control of the medical risk factors and keeping a good, healthy active lifestyle is always the first line. Those treatments that I just mentioned, such as surgery--those should really be reserved for the most severe cases.

Melanie: Dr. Robinson, even if you do the endovascular stenting and ballooning and you open these back up and they still get that claudication, does this limit their physical activity because it is kind of like a vicious circle. You want them to be active and you want them to exercise and sometimes it can be quite painful.

Dr. Robinson: That is an excellent, excellent point and actually an excellent question. You are exactly right. The first line is to have people exercise as much as they can and to control their medical risk factors. However, if they are at a point where they can’t get that exercise, that is what we call “claudication which is lifestyle limiting.” That is a severe form of claudication. In that case, we would often do either endovascular therapy or surgery in order to increase the patient’s ability to walk. That can have benefits both on prevention for the future as well as preventing heart disease and other unwanted medical affects that come with inactivity. It’s really a balance. You have to sort of make sure that all of the medical conditions are under control and the patient is being as active as possible but you have to offer therapy when the claudication or the pain is extremely limiting.

Melanie: In just the last few minutes, Dr. Robinson, and it’s great advice, give your best advice for prevention of peripheral artery disease and why someone should come to UVA for their treatment.

Dr. Robinson: I think, really, the best advice for prevention, I think, is to never smoke. That is particularly important for any younger patients and older patients, too, because even if a patient has a long-standing smoking history stopping smoking even later in life will help prevent the progression to the most severe form of peripheral arterial disease which is actually what we call critical limb ischemia which can be a limb threatening condition. I can’t emphasize enough how important it is to stop smoking and to never have started smoking in the first place, actually. In terms of, if you do have advanced symptoms, I think that coming somewhere you can get comprehensive care and comprehensive options for addressing your particular PAD in the best way is why I would advise patients to come to UVA. Obviously, there are a variety of medical specialists who specialize in all of those risk factors, in controlling them and treating them as best as is possible. We have a variety of interventionists both in surgery and in other fields who can offer both endovascular therapy and surgical therapy. When you come to a place where all of the options are on the table, I think that helps a patient get a treatment plan that is best tailored to their particular disease and their particular goals.

Melanie: Thank you so much, Dr. Robinson. So, beautifully put and such great information. You’re listening to UVA Health Systems Radio. For more information, you can go to UVAHealth.com. That’s UVAHealth.com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

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