Inactive (722)

Segment Number 1
Audio File managing_cancer/1534ct3a.mp3
Doctors Lammersfeld, Carolyn
Featured Speaker Carolyn Lammersfeld, MS, RD
Guest Bio Carolyn Lammersfeld is the Vice President of Integrative Medicine at Cancer Treatment Centers of America® (CTCA). She oversees the Integrative Services, which are therapies aimed at minimizing side
effects and helping patients maintain quality of life. She earned a master’s degree in clinical nutrition from Rush-Presbyterian-St. Luke’s Medical Center in Chicago, where she completed a post-graduate
internship. She earned a bachelor’s degree in nutrition and dietetics from Bradley University. She is also certified in oncology nutrition and nutrition support.

Learn more about Carolyn Lammersfeld
Transcription Melanie Cole (Host): Cancer Treatment Centers of America® (CTCA) uses leading technology to aggressively treat cancer, at the same time supporting patients with nutrition and other therapies, because we know that managing the side effects of cancer treatment is half the battle. My guest today is Carolyn Lammersfeld. She’s the Vice-President of Integrative Medicine at Cancer Treatment Centers of America. Welcome to the show, Carolyn. Tell us what that means—“integrative medicine.”

Carolyn Lammersfeld (Guest): Sure. Integrative medicine is a field that can actually be used to manage many diseases. In oncology, we kind of refer to it as “integrative oncology,” and it’s an approach that combines treatments from standard medical care for cancer--chemotherapy, radiation therapy, surgical interventions-with complementary therapies like nutrition, physical therapy, acupuncture, psychosocial or mind-body support, spiritual support. So, combining them to help improve quality of life, for example, for people that are being treated for cancer.

Melanie: These things are so important. Tell us how you work as this team approach, bringing in nutrition therapy and chiropractic and mind-body medicine. How do you bring them all together for the person, the patient?

Carolyn: Absolutely. It’s interesting. Most of the literature shows us integrative oncology—integrative medicine—is very commonly used by people during cancer treatment. So, the literature shows us anywhere from 40percent, even up to 83 percent of people being treated for cancer are using these methods. Sometimes, they’re actually seeking them out on their own and may or may not even be communicating that to their oncologist, for example. So, this raises all kinds of concerns with safety, interactions and efficacy. So, knowing that patients are seeking that out and, many times, doing it separately from where they’re getting their oncology care, we actually have tried to make it easy for patients to access all of that at the same time they have their oncology care under one roof. So, we put a team around patients. We call it our “Patient-Empowered Care® team”- where every oncologist has a team of these individuals that work with them. They actually see patients together and every time patients come in to the clinic for care. So, all of these individuals will assess, in their particular area of expertise, what's going on with the patient. Of course, the patient is kind of the coach of the team. Then, they put together a plan of care as a team to address not only, for example, the chemotherapy, radiotherapy or surgery that patient is having, but all of their other needs. The nice thing is, because they are working together, seeing patients together and meeting together, everyone among the team knows what the patient's plan is. They're adding things to support that plan and to deal with, for example, side effects that the patient might be at risk for because of the treatment they are having or to deal with the emotional issues that come with adjusting to the desease like cancer and treatments that are involved.

Melanie: What role does the nutritional therapy play in dealing with some of those side effects during cancer treatment?

Carolyn: Sure. It's interesting because one of the biggest areas that nutrition is involved in is really weight management issues, and it goes from one end of the spectrum to the other. So, we will sometimes see the patient that has lost significant amount of weight—what we call “involuntary weight loss” or “unintended weight loss.” Some patients may even develop something called “cancer cachexia,” which is a wasting condition that can be caused by very complex compounds that are produced from the disease. And then, again, sometimes, the side effects can make it difficult to eat as well. So, a lot what we are doing is dealing with that. So, many of our patients come to us already malnourished. They’ve lost significant amounts of weight and muscles and so we are trying to develop a plan with diet and supplements. Actually, this is where the integrative approach is very helpful, too, because sometimes the patient may also be having difficulties eating because of depression, so we’ll deal with that. The dietitian will put a plan together from a diet supplement standpoint to try and help with weight gain and then our physical therapist will be working with patients to help them do activity to build muscles back, so they are gaining back important tissue and not necessarily adding back fat tissue or adipose tissue. So, that's one role, and again, we will be making different diet modifications using different food or other supplements to help with some of what we call "nutrition impact symptoms": loss of appetite, nausea, taste changes, maybe even bowel changes. So, that's one and then, it kind of goes across the other spectrum. Another role our nutritionists and our registered dietitians, and, really, the integrative care team, work on to help patients who maybe have extra weight. Many times, we are first trying to make sure that they don't gain weight during treatment and then working using behavior modification and trying to establish different eating and activity behaviors to help them achive and maintain a healthy weight after treament to reduce the risk of a recurrence or another chronic disease.

Melanie: Tell us about the mind-body medicine and what does that have to do with helping that patient deal with some of those side effects?

Carolyn: As you can imagine, a diagnosis of cancer is life-changing. Our mind-body team is working with patients from Day One also. So, I mentioned, even in the context of weight issues or depression, our mind-body therapists are there to establish a relationship with patients to help them work through some of the adjustment of having a disease like cancer and the treatments that are involved. With weight issues, that even goes into if somebody is trying to achieve and maintain a healthy body weight or just a healthy lifestyle in general, working with them to identify what their motivation is and any barriers that can may be making it difficult for them to eat healthy or be active, for example. They also work with families, so children whose parents are being treated for cancer. There's also a whole range of services that are designed to help with stress management, for example, and managing some of the side effects. So, we have Reiki Therapy, for example; laughter therapy; animal therapy; yoga; tai chi — anything that can really help patients manage stress and, hopefully, help with fatigue and quality of life during care. So, those are all available to patients every time they come in for treatment.

Melanie: It really is so important to treat that whole person, and in just few last minutes, Carolyn, what should people be thinking about when considering integrative approaches to cancer treatment?

Carolyn: Well, I think one of the things is, obviously, get as much information as you can. Always get a second opinion, particularly if you are looking for an integrative approach and not getting it. Our website at cancercenter.com may be helpful. The Society for Integrative Oncology is another great resource to get information. And then, there are different models for integrative oncology. Primarily, make sure whatever you're doing, you communicate with your attending oncologist and there is communication between those providers and the attending oncologist. There can be interactions, if you are taking supplements, for example, or chiropractic care and you want to make sure your chiropractor knows whether it's safe to do an adjustment based on what type of cancer you may have or are being treated for. Ideally, if you can find a place where it's being provided under one roof and the providers are communicating one with another, I think that's critical for safety.

Melanie: Thank you so much. You are listening to Managing Cancer with Cancer Treatment Centers of America. For more information, you can go to cancercenter.com. This is Melanie Cole. Thank you for listening.
Hosts Melanie Cole, MS

The Future of Lymphoma

Additional Info

Segment Number 1
Audio File city_hope/1534ch2a.mp3
Doctors Kwak, Larry W.
Featured Speaker Larry W. Kwak, M.D., Ph. D.
Guest Bio Larry W. Kwak, M.D., Ph.D., is the director for developmental therapeutics and translational research, director of the Toni Stephenson Lymphoma Center within the Hematologic Malignancies and Stem Cell Transplantation Institute and is endowed with the title of the Dr. Michael Friedman Professor in Translational Medicine. Dr. Kwak earned his undergraduate degree, medical doctorate and PhD from Northwestern University while also completing a research fellowship in tumor cell biology. Dr. Kwak’s postgraduate training also includes an internship and residency in internal medicine, followed by a clinical and research fellowship in medical oncology at Stanford University Medical Center.

Learn more about Larry W. Kwak, M.D
Transcription Melanie Cole (Host): For people who are diagnosed with lymphoma, the Tony Stevenson Lymphoma Center at City of Hope is one of the biggest and most successful treatment centers in the nation. Because of our vast experience in treating patients with lymphoma, the specialists lead the field in hematopoietic cell transplantation with excellent outcomes. My guest today is Dr. Larry Kwak. He’s the Director of the Tony Stevenson Lymphoma Center at City of Hope. Welcome to the show, Dr. Kwak. Tell us a little bit about lymphoma. People hear Non-Hodgkin’s and Hodgkin’s they don’t know what these mean. Give us a little working definition.

Dr. Larry Kwak (Guest): Certainly, I would be glad to Melanie. So, there are many different kinds of cancers that spread to lymph nodes but what lymphomas are, are cancers that actually arrive in the lymph nodes as the primary organ. So, when a patient comes to us with lymphoma this is a disease that is also different from more common solid cancers in that these are highly treatable. They’re very sensitive to most types of therapy--the conventional types including chemotherapy and radiation—and, in addition, now we have newer therapies and these lymphomas are proving to be very sensitive to these new therapies as well.

Melanie: So, this type of blood cancer, are there certain things that predispose us to these kinds of things? People hear about bone marrow transplants for blood cancers; for lymphoma. Are there certain risk factors for this?

Dr. Kwak: That’s a very good question. There are certain professions that have a higher risk for developing lymphoma such as farmers in the Midwest. We think that that’s due to pesticide exposures. Individuals in the hair dressing industry also have a slightly higher incidence of lymphoma probably due to the exposure to hair dyes. The majority of times, we actually have no idea what caused the lymphoma. It’s an active area of research and we’re trying to find out what hereditary, as well as exposure factors, might be involved.

Melanie: How would someone even know? Are there some symptoms that might arise that would tell you’ve got something going on systemically in your body that isn’t just affecting one organ? How would you know?

Dr. Kwak: Usually, lymphomas are primary tumors of the lymph glands and it’s quite common when there’s a small infection to have lymph node, say in your neck or in groin area enlarged. That’s the normal function of a lymph node. If a lymph node enlarges and it stays enlarged for more than just a few weeks, that’s how someone might know that they need to seek additional consultation to make sure it’s not a tumorous growth.

Melanie: Tell us about some of the treatments for lymphoma. Are these very aggressive? Are there a lot of side effects that go with lymphoma? What are some of the outcomes like?

Dr. Kwak: So, lymphomas are one of the real triumphs of medical oncology in this decade and what I mean by that is that virtually any type of lymphoma can be treated. There are actually several different types of lymphomas--some more aggressive than others. But, even the most aggressive types can now be addressed successfully with chemotherapy and, in some cases, stem cell transplantation. What’s particularly exciting is that we are developing a very robust pipeline of new drugs that are replacing chemotherapy in some cases with what we call targeted agents which are pills now. Just in the last couple years, there have been already three or four pills like this that have been approved by the FDA for treatment of lymphoma patients. These are, as I said, in some places replacing chemotherapy.

Melanie: That’s very exciting. Where do you see the future of lymphoma going? People hear these types of cancers, it’s very scary to get that diagnosis, Dr. Kwak. So, what do you want to say to give them hope from City of Hope about the future? What are you doing research-wise?

Dr. Kwak: Well, I’m really pleased to have joined City of Hope just in the last five months and one of the things I find most exciting here is the very focused research going on, particularly in blood cancers including lymphomas. Particularly, the new areas here, in addition to those targeted agents and the pills that I just described, is what we call immune therapies. These are a new class of therapies or drugs that are designed to harness the patient’s own immune system. This idea has been around for 20 or 30 years but it’s just now that we at City of Hope and, actually, around the country are also beginning to see successes with these types of immune therapies. One example of this success is what we call CAR T-Cells. The term “CAR” refers to chimeric antigen receptor. What that means is that we’re able to take the immune cells, the T-Cells from the patient’s own body, and to genetically modify them, manipulate them, in the test tube to be more specific for the cancer cell; for the lymphoma cell in this case. After that manipulation, which only take a couple weeks, then we infuse them back into the patient and they seek out and destroy lymphoma cells. This is a therapy that clearly works. It has now graduated from academic laboratories such as at City of Hope and have now made their way into pharmaceutical companies. This is a therapy that everyone is very excited about. Again, some of the very early work started here at City of Hope and is the basis for some of the companies out there. This is an approach that I think is going to revolutionize the treatment of lymphoma. Again, moving to a softer biologic approach rather than toxic chemotherapy with all its side effects.

Melanie: What do you want people to know about those side effects and treatments and things that are going on as far as how long? I know it’s individual with each patient, Dr. Kwak. I know that. But when they think of something that is systemic, they don’t think you can go in and target one single spot, what do you tell them about Non-Hodgkin’s and Hodgkin’s Lymphoma to help give them some hope that this can be dealt with?

Dr. Kwak: Particularly for what we call “low-grade lymphomas” which make up about half of all lymphomas, what I tell my patients is that our therapy has progressed to such a stage that we can actually just keep the tumor at bay. I tell my patients to think about these low-grade lymphomas as more like chronic diseases like high blood pressure which we can’t actually cure either but we can manage high blood pressure quite effectively with pills. Low-grade lymphoma is evolving very rapidly into that same strategy where we can periodically treat patients with the pills when they need it and then the disease goes back into remission. While many types of common cancers like breast cancer or colon cancer, it’s a very serious situation once the tumor has escaped outside of the organ of origin, in the case of the lymphomas, these are tumors that are often in multiple lymph nodes in multiple parts of the body but they can be managed quite successfully, as I just described, treating them as a chronic disease. So, even now, there are many patients with low-grade lymphomas who will die of something else and not the lymphoma.

Melanie: Why should patients come to City of Hope for their care?

Dr. Kwak: I believe City of Hope has a really unique ingredient of what we call research driven patient care. What that means is that we are not only practicing the standard of care here but we’re also inventing it. For this reason, patients get early exposure to the idealist treatments which will one day become standard of care.

Melanie: It’s great information. Thank you so much, Dr. Kwak. 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

Out With The Cold and In With The Flu: Facts You Should Know Before Flu Season

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Segment Number 1
Audio File allina_health/1534ah1a.mp3
Doctors Mohrbacher, Katelyn
Featured Speaker Katelyn Mohrbacher, MD - Family Medicine with OB
Guest Bio Dr. Katelyn Mohrbacher is a board-certified family medicine with obstetrics/gynecology physician at Allina Health Hastings First Street Clinic. Dr. Mohrbacher has professional interests in cesarean sections, women's health, pediatrics, geriatrics, mental health and integrative medicine.

Learn more about Dr. Katelyn Mohrbacher
Transcription Melanie Cole (Host): Can the flu shot give you the flu? Is the flu just like a bad cold? Do you need to get a flu shot every year? These questions and so many more really get in the minds of people as colds and flu seasons start to come in. My guest today is Dr. Katlyn Mohrbacher. She’s Board Certified Family Medicine with Obstetrics and Gynecology Physician at Allina Health Hastings First Street Clinic. Welcome to the show, Dr. Mohrbacher. Let’s start right off the bat with the flu vaccine. Some people think it’s not safe. Some people think that if you get the mist, you’re going to get the flu. Tell us about the flu vaccine and what you really want listeners to know.

Dr. Katelyn Mohrbacher (Guest): So, the flu vaccine is very safe. In children, the only time you have to be worried about having something that is unsafe is if they have an egg allergy where they can’t even eat eggs themselves or they have an outbreak throughout their entire body. Otherwise, even in people who’ve had that before, there’s only been a 1.3% chance of ever having an egg allergy outbreak when you get the flu vaccine. Otherwise, you will not get influenza from the vaccine itself because most parts of it are inactivated. In the live vaccine, the nasal vaccine, they are attenuated which means weakened, which means it cannot form or grow within your body. It just allows your body to mount an immune response to it and then fight off the flu if you are exposed.

Melanie: So, this is a very safe vaccine, yes?

Dr. Mohrbacher: Yes. It’s very safe.

Melanie: Now, people don’t know if they get the flu or a cold. How do we know the difference?

Dr. Mohrbacher: It’s true, they do kind of have similar symptoms. They both have fever, body aches, kind of feeling tired and a dry cough. However, with the flu, usually these symptoms are much worse. So, much higher fever, the tiredness is much longer, the cough can be transferred into developing other worsening breathing symptoms where the kid cannot catch his breath and may even get other source of pneumonias on top of it. So, it’s really they’re very similar it’s just the severity of the symptoms that makes it more the flu then a bad cold.

Melanie: If you get the flu vaccine, can you still get the flu?

Dr. Mohrbacher: Yes, if you get the flu vaccine, you can definitely still get the flu. Part of that is when you get the flu vaccine, it takes about two weeks for the flu vaccine to work for you to protect you against getting the influenza. So, let’s say you had exposure to the flu right after you get the vaccine. You still could get the flu. You can also still get the flu but, usually, is not as severe symptoms because you already have some antibodies in your body fighting off the flu that you just got but usually it’s to a lesser degree. You don’t have to go to the hospital. You don’t end up getting pneumonia or having breathing problems and things like that. Then lastly, every year there’s different flu viruses that drift and change, so sometimes there’s a new virus that evolves and you can get the flu if that is not in the vaccine that year.

Melanie: Can you get the flu even if you’ve gotten the vaccine?

Dr. Mohrbacher: Yes, you can get the flu even if you’ve gotten the vaccine.

Melanie: So then, people would say, “Well, I got vaccinated so why do I have the flu?” Just explain a little bit about, not necessarily percentages, but how that vaccine works and that sometimes it doesn’t work for every strain.

Dr. Mohrbacher: Right. So, this year and most years there are four different flu strains that are put into the immunizations. So, every year the CDC and other organizations look to kind of see what kind of virus is going to be in our area and then they pick those viruses and make a vaccine against those. But every year, the flu virus can adapt and makes some changes on its own because viruses are always evolving and changing. So, sometimes there may be a newer virus that comes out that is not in the vaccine that we are given. So then, that is one way that you can end up getting the flu even though you’ve received the flu vaccine.

Melanie: Are there some people that should not get the flu vaccine?

Dr. Mohrbacher: There are some people who should not get the live flu vaccine, particularly. Those are people like pregnant people, young children, children with asthma, people who are immunocompromised and that means people that have a lot of chronic disease or are really ill, like receiving chemotherapy, or are on other medications and then people who, obviously, have had a severe egg allergy in the past. Otherwise, flu vaccines are very safe. The other people that sometimes will be told by their doctor not to get the flu vaccine is if they’ve ever had Guillain-Barre Syndrome.

Melanie: So, tell us a little more about prevention, Dr. Mohrbacher, because that seems to be what everybody wants to know. Is there any way to prevent, besides the vaccination, getting flus and/or colds because they can just be miserable as the fall approaches? What do you want us to know that we should be doing?

Dr. Mohrbacher: The most important thing is covering your mouth when you cough. If you yourself are sick or have the flu, I would not recommend going to work or school because you can spread it to other people. And then, washing your hands because it is a respiratory illness, so if you cough or sneeze on something and then touch that and/or breathe it in, then you could get sick. The best thing is washing your hands, covering your mouth and staying home if you are sick.

Melanie: So, I’d like to get into a few myths, Dr. Mohrbacher. Can stress increase your chances of getting the flu or a cold?

Dr. Mohrbacher: No, it cannot.

Melanie: What about lingering around in wet clothes or you go out after a shower into the winter and your hair is wet?

Dr. Mohrbacher: Nope, that can’t either. You have to be exposed to it for it to cause the infection. Being cold or having wet hair will not cause it.

Melanie: What about some of the products that are on the market? Do some of those help to prevent them? Echinacea, Airborne, Cold-eze, all of these things. What do you think about them?

Dr. Mohrbacher: Some people will find that taking echinacea before you’re sick, so not even when you’re exposed, can help build up your immune system. But, in general, just being healthy, eating a balanced diet, taking care of yourself, getting rest, all of those things can help you have a strong immune system but, again, they will not if you don’t have those lead to getting influenza.

Melanie: Well, speaking about diet, are there any foods that you particularly like people to eat to help keep their immune system healthy? What about that myth: “feed a cold starve a fever; starve a cold feed a fever”? Does any of that make sense?

Dr. Mohrbacher: Again, some people will talk about taking vitamin C and things like that. They are getting plenty of oranges and those type of things. The most important thing, though, is just to eat a balanced diet. Once you are sick with the influenza those things will not treat it or prevent it or make it any better.

Melanie: In just the last minute, your best advice about if we do come down with a cold or the flu, how we should help ourselves get past it as quickly as possible.

Dr. Mohrbacher: I would stay home. If you work, I would not go to work. Try to get plenty of rest, drink lots of fluids and, again, just try to eat a balanced diet during that time. Let your body rest and improve.

Melanie: And make sure to get our vaccines every year.

Dr. Mohrbacher: Yes, every year because every year they change a little and when we get the vaccine, we only have the immunity for approximately 7-8 months to about a year. So, we need to be re-immunized every year so we have that little army to fight off the influenza.

Melanie: Thank you so much. You’re listening to the WELLcast with Allina Health. For more information, you can go to allinahealth.org. That’s allinahealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Chronic Sinus Infections: Not Just In Your Head

Additional Info

Segment Number 5
Audio File allina_health/1528ah2e.mp3
Doctors Dennison, Bruce
Featured Speaker Bruce Dennison, MD
Guest Bio Bruce Dennison, MD, is board-certified in Ear, Nose and Throat (Otolaryngology). He enjoys travel, and participates in outdoor activities such as hunting, fishing and scuba diving.

Learn more about Bruce Dennison, MD
Transcription Melanie Cole (Host): It seems that for some people every time they get a cold a sinus infection follows. Seasonal allergies also get the blame sometimes for causing sinus headaches and infections. Are some people just more prone to getting sinus infections and is there anything that they can do to prevent them? My guest today is Dr. Bruce Dennison. He’s board certified in ear, nose and throat otolaryngology at Allina Medical Clinic in Woodbury, Minnesota. Welcome to the show, Dr. Dennison. So, tell us a little bit about the sinuses and what they do and how they get, for some people, so easily infected.

Dr. Bruce Dennison (Guest): Well, that’s an interesting question. First of all, with the sinuses, there are four separate sinus areas--that would be the frontal, maxillary, sphenoid and ethmoid sinuses. Because one’s infected doesn’t necessarily mean that the other one can be infected. It can be rather complicated in terms of which sinus is a problem but, eventually, that would be something we could discuss further in this conversation. Frequently, patients will ask the question, “Doctor, what do the sinuses do?” and to be honest we don’t quite know why they exist. Some anthropologists might suggest that it’s for phonation related to our earlier ancestors, if you believe in evolution. Others might suggest that it actually lightens the head but we really don’t know why sinuses exist. They certainly can cause problems as they have a tendency to become infected in certain categories where we describe patients that would be prone to sinus infections.

Melanie: So, tell us a little bit about the infection itself. People, Dr. Dennison, think every time that if they blow their nose and there’s yellow or green, they right away assume that they’ve got a sinus infection. That’s not necessarily the case, yes?

Dr. Dennison: You’re absolutely correct. Most individuals will assume they have a sinus infection and, in fact, what they probably are suffering from is an acute viral infection. In general, we’d like to think of a sinus infection as being caused by, in many cases, a viral infection but time becomes a factor. Usually, most colds or viral infections will resolve within a week to 10 days. If your symptoms of purulent drainage, facial pressure, pain, dental pain, post-nasal drip, and cough persists or actually gets worse at the tail end of a cold, it’s likely that you’ve handed off that virus to a bacterial infection and that, officially, would be a sinus infection. The other issue is why do certain people, certain individuals, more prone to sinus infections? That, frequently, is where an ear, nose and throat physician can play a role in managing and trying to minimize the number of infections or the complications or symptoms related to sinus infections. So, when I’m seeing someone for the first time, it’s typical they’ve been seen by their primary care physician on a number of occasions, been provided with antibiotics and maybe a saline wash with the hopes that their symptoms will go away. I think it’s imperative on the physician’s part to look at the issue of not do they have a sinus infection but why is this individual prone to sinus infection. So, in my practice, I will typically look at more common causes such as underlying allergies and immunosuppression. Is there an anatomical issue that may be predisposing the individual to infections? Typically, the investigation will involve an excellent or in-depth nasal exam or sinus exam coupled with possibly a sinus CT and, if symptoms suggest, having the patient undergo allergy testing. At least in my view, if you do a good job controlling allergies, you’re less likely to become infected over and over and over again. One issue that can come up during the exam can be the presence of polyps. If there’s polyps, that generally suggests there may be underlying allergies but it’s a different issue because the polyps will predispose you to recurring sinus infections simply by obstructing the sinus openings. So, I look at that scenario like how can we control polyp formation or do we need, at some point, to remove the polyps? Again a lot of that is based on our physical exam, assessment radiographically and, if need be, getting our allergy colleagues to take a look at the patient.

Melanie: Dr. Dennison, what’s the first line of defense? If you determine somebody does have a sinus infection, are antibiotics the first thing and why do they sometimes not work as well?

Dr. Dennison: There can be several reasons why they don’t work but let me touch first upon the first part of your question—antibiotic. I think more recently, at least, the data and the sense is that antibiotics should be something that you hold in reserve and waiting for that 10-day period is a reasonably good first approach, using a saline wash – not necessarily jumping to an antibiotic. But, if you choose an antibiotic and you assume that there’s a bacterial infection, there’s always a possibility that they type of organism that resides in the sinuses is not sensitive to the antibiotic that’s been prescribed, i.e. resistance. Frequently that’s the case when individuals have received multiple courses of antibiotics in their past because you will select out for more resistant organisms. So, the idea that an antibiotic will work every time would mimic or would suggest that the model for sinus infection is overgrowth of bacteria, antibiotic, resolution of infection and that really may not be the correct model. The model might be better promoted as follows: This patient has a sinus infection because… and it can be poorly controlled allergies, nasal polyps, septal deviation. If we can eliminate or control that underlying cause, we’re more likely to have a more positive outcome rather than repeating antibiotic after antibiotic after antibiotic. In many cases, in my practice, I will find that if we look at a sinus CT, the poor patients receive three or four antibiotics and yet the sinus film looks entirely normal and what we’ve been treating is poorly controlled allergies. That both is a disservice to the patient and prolongs the level of symptoms or the time the symptoms have been inadequately treated. So, I like to get a baseline and, again, going back to my original comments. Let’s figure out why this patient is having a problem rather than just always assume it’s bacterial and that an antibiotic would be the first choice. I don’t necessarily find that to be the case.

Melanie: Are there certain things that you like to recommend that people can do at home? Giving your sinuses a bath, as it were, nasal lavage, any over the counter products that you like?

Dr. Dennison: Absolutely. The idea of using a saline wash and frequently that’s done under the guise of a Neti pot. The Neti pot assumes that you are going to create a vacuum to pull mucus and debris out of the sinus. That actually would be incorrect on an individual whose sinuses haven’t been opened surgically. If they’ve been opened surgically, a Neti pot is fantastic way to flush the sinuses. Also, if you’re using a Neti pot or a saline wash, essentially, what you’re doing is facilitating the movement of mucus out of the nose, you’re eliminating bacteria, and you’re also flushing out pollen--all of which will help the hygiene of the nose which indirectly can help the sinuses. So, the idea of using a saline wash is a great idea. Absolutely great idea. Of course, if you live in the cold climates up in the Twin Cities in the middle of winter, any moisture in the nose when it’s cold and dry out certainly can benefit the function of the nose and indirectly the sinuses and may actually help to prevent viral infections or colds. So, saline wash you can’t go wrong. It’s cheap, it’s easy to use and it has very little side effects, so I would be a proponent of that.

Melanie: We don’t have a lot of time, Dr. Dennison, but is there any truth to the myth that some of the over-the-counter, Sudaphedrine and nasal sprays can actually exacerbate a sinus infection?

Dr. Dennison: I’m not so sure. Assuming when you say over the counter spray, you’re talking about decongestant spray, that would be a separate condition that may be the result of the spray and, unfortunately for many individuals, they use a decongestant spray and often it results in just the opposite condition that the patient is trying to treat. In fact, it will eventually lead to swelling inside the nose. Sudafed, at least in my view, I try not to use a great deal of it. I think its side effects of increasing the viscosity of mucus may actually predispose one to lack of drainage of the sinus but if you’re complaint is the inability to breathe through your nose, Sudafed acts by shrinking the lining of the nose--not the sinuses. It may help to facilitate the opening of the sinus but I’m not a big fan of Sudafed. Unless you have severe allergies, I don’t think I would use it on a regular basis to treat a chronic sinus condition. I would tend to shy away from that but that’s my opinion. I think others in my field would have a different viewpoint but Sudafed increases your heart rate, can make you jittery, keep you up at night and if you tend to be a little bit older, it may actually have some ill effects on your cardiovascular systems. Again, I tend to shy away from it.

Melanie: No, that was a great answer and great information. In just the last minute, please give your best advice for those that suffer from chronic sinus infections and what they can do about them or possibly prevent them.

Dr. Dennison: In general, I think if it gets to the point where it’s adversely affecting the quality of your life, you’ve seen a number of primary care physicians or you’ve sought the counseling of providers who treat sinus infections, at some point rather than treat the symptoms, try to determine what the underlying cause is. I think, in the long run you’d be well served to take that approach. Really, you’re dealing with the root cause rather than treating the symptoms as they occur. You’re being proactive and in the long run, it will serve the patient better.

Melanie: Thank you so much for great information. You’re listening to the WELLcast with Allina Health. And for more information you can go to allinahealth.org. That’s allinahealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Seasonal Fall Allergies: Don’t Let the Fall Bring You Down

Additional Info

Segment Number 4
Audio File allina_health/1528ah2d.mp3
Doctors Johns, Kenneth
Featured Speaker Kenneth Johns, MD – Allergy and Immunology
Guest Bio Dr. Kenneth Johns specializes in allergy and immunology and practices at Allina Health Coon Rapids Clinic and Allina Health Maple Grove Clinic. His professional interests include child and adult asthma, seasonal allergies, hives and skin rashes.

Learn more about Dr. Kenneth Johns
Transcription Melanie Cole (Host): Autumn is arriving soon which means the change in season can bring an onset of sneezing and sniffles. My guest today is Dr. Kenneth Johns. He specializes in allergy and immunology and practices at Allina Health Coon Rapids Clinic and Allina Health Maple Grove Clinic. Welcome to the show, Dr. Johns. What kind of allergies are we seeing most in the fall? Up to 30 million people suffer from these.

Dr. Kenneth Johns (Guest): The biggest problem in our falls is the fall wheat pollens with ragweed probably being the most important. Sometimes, a little later in the fall it could be outdoor mold but our ragweed is probably our worst. There’s a very predictable season. It starts about August 15^th every year until there’s a hard frost and that usually ends it. Those outdoor molds can start a little earlier and last a little longer than that.

Melanie: In the fall, people also come up with colds at the end of the summer. How do we tell the difference between the sniffling and the sneezing that we’re getting and maybe what’s just turning out be a fall cold?

Dr. Johns: It can be really hard to tell them apart. In general, when it’s allergy it itches more--there’s more itching of the eyes and nose. Basically, it’s the duration. A cold, a viral upper respiratory infection, it might last a week or ten days whereas an allergy, for example, if you’re allergic to that ragweed, that can go on for weeks or even a month or so. So, really, it’s the duration that helps you tell them apart. It can be tough.

Melanie: How do you test a child or an adult for allergies? Are we still doing--because people think of allergy tests as being a ton of little shots--and what are you doing now?

Dr. Johns: We have two basic ways that we test for allergies. There’s the traditional skin testing which, I think, we’ve fine-tuned over the years. Mostly epicutaneous is the technical term for what’s sometimes called “scratch tests” or “skin tests.” Drops of materials that you might be allergic to are put on the skin and then scratched and we look for a welt to develop that would indicate a positive skin test. They are not as painful, not as uncomfortable, as you might think. Our second option is the blood tests that are done. It’s a way to measure sensitivity to specific allergens using blood, which there are different types, but they are, basically, equally accurate. In most cases, they are the same accuracy as the skin test. Sometimes there are patient preferences over one type of test or the other but, again, I’m going to say they are equally accurate. So, either method is fine.

Melanie: People go outside in the fall and they rake leaves and it’s such a beautiful time of year. How do we treat those fall allergies aside from staying inside? We want to be out in it but there’s those triggers. So, what are the treatments for fall allergies?

Dr. Johns: Well, we, most of the time, really discourage people from staying indoors but we have good treatments for seasonal allergies. Medication-wise, we have a variety of antihistamines, both prescription and over the counter, which help a lot with the sneezing and the itching. I would say the gold standard for medication is the topical steroid nasal sprays which are extremely effective for most of the allergy symptoms. They are a little bit tricky to use. You have to use them daily and they may take a couple of weeks to have full effect. So, you do want to anticipate and start them early in the season. They can be very effective and with good medication, people can participate in outdoor activities fully. When medications fail, we have the traditional allergy shots. They are a type of allergic desensitization where very small amounts of the allergen, let’s say the ragweed, for example, is given as a shot to desensitize a person against the ragweed pollen when they encounter it. This is a very time consuming treatment and, basically, the shots are given year round for four or five years to give tolerance to the allergen. The newest wrinkle in immunotherapy or inducing tolerance is oral immunotherapy. I’m going to quote Lauren Michaels here and say, “Not quite ready for prime time.” The oral immunotherapy is really only good for a couple of our allergens including the ragweed and we’re not quite sure where that’s going. It’s been sort of a tricky type of treatment to study. It is approved and it is available. We’ll see where that one goes.

Melanie: Are there any all-natural remedies that you recommend to treat allergies? Do you like nasal lavage, doing Neti pots? Anything? Do you believe in air filters or certain allergy reducing pillows? Or, is there anything that you like to tell your patients to do for behavior modification and lifestyle?

Dr. Johns: Well, there are certainly a lot of things that have been discussed and certainly a lot of treatments that are suggested but the data is not great for a lot of those things. For example, air filters and air cleaners, it stands to reason that you should be able to remove the pollen from the air indoors and I’m going to say that it’s not clear if we can really do that with air cleaners and air filters. A Neti pot--a saline lavage--is very helpful for other conditions. For example, a viral illness or sinusitis, but for allergy, not so much. Obviously, you can have a combination of the two problems but my allergy patients are not as impressed with saline lavage or Neti pot as my sinusitis patients are. The other treatments that you alluded to, again, some people find some improvement but the data isn’t really there to support them, for the most part.

Melanie: Are allergies something that you are going to take with you for your whole life? If you’ve got them as a child and you’re allergic to things in the fall is this something that you’re ever going to outgrow or is it something that you can look forward to every year?

Dr. Johns: Most people do outgrow their pollen allergies. The most common natural history is where they sort of come on in the late teens early 20s and peak in the 20s and 30s and then just sort of just gradually fade away, so most people will outgrow them. Sometimes, those specific allergies can be replaced by other conditions that sort of sound like allergy, vasomotor rhinitis or the other non-allergic nasal conditions can sometimes worsen over time and kind of sound like allergies but really aren’t and do respond to different treatments which is very frustrating to patients and doctors alike. But, I’m going to say that most of us will outgrow our pollen allergies.

Melanie: In just the last minute, Dr. Johns, if you would, give us your best advice on how to reduce fall seasonal allergies or treat them if we just must endure them.

Dr. Johns: Again, our medication options are quite good. We can significantly reduce symptoms and, again, my goal is to get people outdoors and doing whatever activities they want to do outdoors. We have good treatments for that. Again, immunotherapy allergy shots are sort of our last resort and for the right patient with the right allergy they can be very helpful.

Melanie: Thank you so much. You’re listening to the WELLcast with Allina Health and for more information you can go to allinahealth.org. That’s allinahealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Treating Hip Injuries

Additional Info

Segment Number 5
Audio File virginia_health/1525vh5e.mp3
Doctors Gwathmey, Winston
Featured Speaker Winston Gwathmey, MD
Guest Bio Dr. Winston Gwathmey is an orthopedic surgeon whose specialties include arthroscopic hip surgery and sports medicine.

Learn more about UVA Orthopedics
Transcription Melanie Cole (Host): Are there certain sports or activities where hip injuries would be more likely and be more common? What are those most common hip injuries and how do you prevent them? That’s the most important thing. My guest today is Dr. Winston Gwathmey. He’s an orthopedic surgeon with UVA whose specialties include arthroscopic hip surgery and sports medicine. Welcome to the show, Dr. Gwathmey. Tell us a little bit about sports or activities where our hips seem to be more at risk for injuries.

Dr. Winston Gwathmey (Guest): Thank you. The hip is sort of the new frontier of sports medicine in that injuries that, 20 years ago were really unrecognized or we just really didn’t understand the pathology behind it, we are starting to recognize a lot more often now. To be honest, it’s sort of an exciting topic to discuss. So, your question about what sports predispose you to injury, really any sport where you’re moving at a high speed, pivoting, changing direction, where you are loading the joint, the hip can be at risk. I think that what athletes need to understand is that sports that may injuries, there’s also elements of the human body that may predispose injury as well. I think it’s an important concept to understand when you are dealing with hip injuries.

Melanie: Well, we are even seeing more of these which we never would have seen in younger people. As soccer becomes more prevalent and these, as you say, the stopping and turning, and those kinds of sports are becoming more common. People are playing weekend soccer and injuring their hips. What about the things that don’t involve sports? Things that we could do that would injure our hips that are just functional things every day.

Dr. Gwathmey: I think I need to back track just a touch and that it’s not that the hip injuries are more common now; I think we are starting to recognize sort of what’s causing them. It’s a combination of two things really that make it pretty simple. One is the way you’re shaped and two, is what you expose your hip to. The normal hip is pretty tolerant to most activities but there are certain elements to the way the pelvis might be shaped that might make you at risk for having a hip injury with sports or even with just routine activities. What I mean by that is, sometimes the ball and socket of the hip joint just don’t fit together that well and it’s either a developmental things or it’s sort of built into your genetics--sort of the same reason why some people go on to have arthritis and some people don’t. I think that what we are starting to recognize is, there are certain elements of the skeletal morphology that might make you at risk for having hip injuries.

Melanie: When do we know that it’s actually a strain or an injury? When would we go see a doctor?

Dr. Gwathmey: So, normally hip injuries will be pain localizable to the groin. The hip joint is actually directly in the groin. It’s not out in the side. It’s not really in the back. Most people who have hip injuries recognize discomfort in the groin and it’s usually worse with the loading the hip. So, if you are putting impact onto the hip or when you are sitting for a long period of time with your hip flexed, sometimes you will feel some discomfort. Sometimes standing up from a long car trip, you’ll feel pain from the hip or sometimes when you’re playing a specific sport and you to a certain twist or turn, you’ll feel that pain. That’s when really we start thinking more and more about the hip joint as being part of the problem.

Melanie: What do you do about it? What’s the first line of defense? Icing the hip or resting? You know, you think about the knees are easier, but what do you do about the hip?

Dr. Gwathmey: The hip, like you say, the knee is right there, the hip is deep down within the body so even putting a bag of ice on it, it takes a while for that cold to get down to the hip joint. I think rest really is the first thing I would try. Just try to calm things down. Ice is very helpful for some of the inflammation that might be around the hip. Anti-inflammatories are always very helpful because there’s usually an inflammatory component to it. Hip pain that’s real localizable to the groin that doesn’t get better after a couple of weeks, you probably ought to at least see somebody to try to make sure that you don’t have something more sinister going on.

Melanie: What if you do? When you go see a doctor, what is it you’re going to do? Can an x-ray show things or do you have to have an MRI?

Dr. Gwathmey: I think that’s a very good question. I think, and this is sort of my gestalt, if you will, that the x-ray is really the gold standard for diagnosing hip pathology. What I mean by that is, going back to what I said previously, is that the way that your body and your pelvis is shaped is very important when you’re trying to understand hip injuries. There’s a term that’s kind of a complicated term. It’s called femoroacetabular impingement or FAI. The femur is the thigh bone, acetabular is the socket and, basically, it’s when the ball and the socket don’t fit together that great. That’s recognized really on x-ray really to be honest. You can see sort of the way the ball and the socket is shaped and see if there’s going to be a risk factor for having a hip injury. Let’s just say that you do have that shape to your pelvis, an MRI can be very helpful to make sure the labrum, which is basically the seal, the lip around the hip joint, the cartilage, the soft surface of the hip, to see if there’s damage there or the muscles around the hip.

Melanie: I’m even hearing about some younger people requiring hip replacements, Dr. Gwathmey. When does it come to that and especially we hear about that in our older patients all the time. Hip replacement being one of the easier to recover from, certainly more than a shoulder or a knee, but when does it come with the younger people to something so drastic?

Dr. Gwathmey: So, let me tell you, my goal--my specialty--is to avoid hip replacement. I’m a hip preservation specialist so I try to do everything I possibly can to prevent the progression of arthritis, to address injuries in a minimally invasive manner to avoid the ultimate salvage which is the hip replacement. All that being said, a hip replacement is an outstanding surgery. It has got probably the best positive track record of any orthopedic surgery that we offer but it is metal inside the body. If you can maintain your own anatomy and your own tissue, you’re a lot better off in the long run. So, what I would try to do is recognize the pathology that might predispose you to having arthritis and do what I can to either correct it or at least ameliorate it to a point where you can put off getting a hip replacement much, much later in your life.

Melanie: Dr. Gwathmey, when I hear people complain of hip pain and right away they want to do something about it or, as you say, look into replacement, sometimes there’s a simple solution. As a hip preservationist, how important do you think shoes or heel lift or orthotics play that role if we find out our hips are uneven or something’s going on in our spine that’s causing pain that we think is in our hips. How important do you think it is?

Dr. Gwathmey: My first line for all hips is trying to address the environment in which the hip is. So, whether it be a misbalance of the pelvic stabilizers, whether there be a spine issue like you’re saying, whether it be shoe wear, limb length discrepancy, a lot of times I’ll start with a therapy routine to try to get a functional assessment. So, a therapist can take a look at you and see how you walk, see if there is something just in the way you do things that might put your hip at risk. That really is a first line for all people with hip problems just to make sure that you correct what can be corrected before you go forward with something like surgery. To be honest, most people get better without surgery. As far as hip preservation, that’s where I come in and I do arthroscopic surgery of the hip and so if the therapy doesn’t work or if there’s pathology that can’t be addressed from an external standpoint, that’s where I come in and do what I can do to try to make the hip feel better.

Melanie: I agree completely and I see so many people and have myself had hip problems that were solved very simply with a better pair of shoes or an orthotic or a heel lift. So, these kinds of solutions are something that people really can look to. What role do you think that exercise plays in keeping those good strong hip muscles? What are your favorite exercises to recommend to people to strengthen up their pelvis and all around their hip muscles?

Dr. Gwathmey: I start with the core, typically. I think the core is really where the foundation for the entire gait cycle, the way your hips move, the spinal stabilizers, the pelvic stabilizers and things like that. The hip abductors and adductors are very critical as far as keeping the pelvis balanced. But, again, you have to have your range of motion first before you can imagine strengthening stuff so I work on symmetry. Whatever’s going on good with the hip that’s working, I try to make the bad hip match that one.

Melanie: That’s great information. In just the last minute, why should patients that are suffering from hip pain come to see you at UVA for their care?

Dr. Gwathmey: Again, I am a surgeon that specializes in arthroscopic hip surgery. So, let’s just say that all the stuff we throw at your hip, it’s still not getting any better and we get an MRI and you have a labral tear or you have FAI--this impingement thing that we’re talking about--what I can do and what I think that sort of sets me apart as a surgeon is, I can address those elements with a video camera and two tiny holes in your hip. Now, it sounds simple but it’s actually a very challenging procedure and it’s actually pretty challenging to come back from but it is a technique that we can utilize here that gives a minimally invasive approach to hip pathology. So, I do think that there is a role for trying to do everything we can to get the hip better without surgery but when it comes to surgery, I think I can provide a pretty good tool bag as far as things that I can do to help the hip.

Melanie: Thank you so much. 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

Caregiver’s Guide Through Hospice

Additional Info

Segment Number 3
Audio File allina_health/1528ah2c.mp3
Doctors Amberg, Joseph
Featured Speaker Joseph (Joe) Amberg, MD - Hospice and Palliative Care
Guest Bio Dr. Joseph (Joe) Amberg is a board-certified physician and medical director of Allina Health Palliative Care, where he leads the palliative care teams at all Allina Health hospitals and provides medical care, including home visits.

Learn more about Dr. Joseph (Joe) Amberg
Transcription Melanie Cole (Host): Being a caregiver for someone who is terminally ill can, at times, be stressful and exhausting but there is help. My guest today is Allina Health Hospice and Palliative Care physician and medical director, Dr. Joe Amberg. Welcome to the show, Dr. Amberg. What is hospice care and does it mean that this person is now terminally ill once they have entered hospice care?

Dr. Joe Amberg (Guest): Hospice care is a special kind of medical care provided by nurses, doctors, chaplains, social workers, volunteers – a whole team of people--specially designed for people who do have terminal illness. It provides the necessary care for the person living with that illness and their family as they deal with this difficult time.

Melanie: People get hospice and palliative care confused all the time. Please explain the difference between those two.

Dr. Amberg: The important difference is that palliative care is the same kind of attention to comfort care and personal care and social needs but it can be provided for people who are not terminally ill. It can be provided for anyone with a chronic illness who needs extra attention to comfort.

Melanie: So, palliative care involves medication and, as you say comfort, sort of all the same things, it’s just that someone can be in palliative care for a long time. Correct?

Dr. Amberg: That’s right. We like for people to get palliative care early in the course of any chronic illness. It gives them the power to direct their care according to what’s important to them. We have staff who are specially trained in communication, listening, and getting to know the people who are living with this illness.

Melanie: So, putting somebody into hospice care, calling in docs such as yourself, is a big decision and not easily made. It’s very emotional. What is your advice on starting that conversation with the person that you love and getting them involved in this kind of care?

Dr. Amberg: It’s a very big decision. It’s a tough time for people and family who are living with a possibly terminal illness. So many people feel like choosing hospice is giving up because they will not be receiving any more treatment to prolong their life. In fact, when people choose hospice care they will continue to live their life as they naturally would. They may even live longer and better than with usual care. The important thing is to ask your doctor, or any other healthcare provider that you know, questions about hospice so they can direct you to the right people and be sure to talk to your family. It is very important that once you have made this difficult decision that everyone in the family supports you, too.

Melanie: So, what are some things that you want the family and their loved one to think about before going into hospice? How do they think about what their goals are for care? As you said, people think that it means giving up but it really doesn’t. So, what do you want them to think about as the goal of care? Whether it’s for comfort, feeding – what’s involved?

Dr. Amberg: That’s right. I want everyone in the family to know what is important to the person living with this illness. It is very normal at this time in life for people to want to spend time with their loved ones doing things that are meaningful to them. The other important thing to understand from a technical point of view is that the person would probably not want to return to the hospital, have tests or procedures any more. That can be a difficult transition when people living with illness become so accustomed to that as part of their routine healthcare. In fact, they get a lot of their emotional support from their healthcare team in that way. So, it feels like giving something up. What hospice provides instead is a lot of attention directed to the less technical aspect of care.

Melanie: What services are involved in hospice care?

Dr. Amberg: The most important aspect of the hospice care is the hospice nurse. This is a healthcare program where we really elevate the nurse to a responsible role to get to know the person and assess the medical needs. There is a large team supporting the nurse case manager: a physician, like myself, who is medical director for the hospice team, a social worker, a chaplain – we always inquire and support the spiritual needs of our patients. We have volunteers. They are a core participant in our hospice care team. Then, we have a lot of integrative therapy specialists: music therapy, massage therapy. Some of our teams even provide pet therapy. We all work together. We meet every week to talk about the people we are taking care of, so it is a coordinated effort. People who see us come to their home to visit and provide this care sense that they are part of a team.

Melanie: Do you still be involved with your primary care provider when you’ve entered a hospice program?

Dr. Amberg: Yes, absolutely. It is very important to know that the hospice team is not taking away any of the contact that you have with your primary care provider. For most of my career, I was a primary care internal medicine doctor and it was important to me to maintain contact with my patients until the very end of life. I did not want to lose that because they were getting hospice. So, it is important to know that they stay involved. They still approve all of the treatment that we recommend and stay involved throughout the course of time in hospice.

Melanie: So, let’s speak just a little bit about the caregivers themselves because this is such a difficult thing but hospice provides that extra support when you’re caring for someone who is terminally ill. Does the caregiver then get a bit of a break? Do they get pushed to the side? What happens to the caregiver that has been caring for this person once hospice gets involved?

Dr. Amberg: The caregiver has a key role in hospice care. I’m talking about a spouse or a daughter, or a sibling, or even a close friend who provides this care at home. Hospice does not provide 24 hours of care. We are not there round the clock to meet the day-to-day care needs for people who are living with a terminal illness so we rely on family members or others to do the basic care of keeping a person clean and fed and comfortable and receiving their medication on time. There are times where that can be overwhelming and the hospice team can provide care temporarily in a facility that is called “respite care”. That is a well defined benefit of hospice care and this gives families a break so that they can get their energy back until the person returns home. Sometimes families can’t maintain this care at home; it can be too exhausting and that is when our social worker helps to arrange for care in another setting.

Melanie: Some common misconceptions and myths about hospice. I’d like to cover one, Dr. Amberg. Hospice care is all about how you die. Please explain how that is really a myth.

Dr. Amberg: It is. Hospice care is all about how you live. We recognize that people coming to hospice have a serious illness that may end their life. The care that we provide helps to make that life as meaningful and as comfortable as possible during that time. None of the treatment that we provide either hastens death or changes the natural outcome. We really like focusing on the positive aspects of living well. That is why the success we have had with hospice has led to the specialty in the field of palliative care because providing what seems like a simple attention to social needs and comfort really helps people live better. We should be doing this not just at the end of life but throughout the person’s life.

Melanie: I agree completely. Give your best tips to the caregivers at this emotionally difficult time. What tips can you give them to make it a little bit more bearable?

Dr. Amberg: One is to be willing to ask for help. So many people that we know are fiercely independent and value their ability to take care of themselves and it is a loss when they can’t do that. The caregivers, too, can become overwhelmed in that role. So, be willing to ask for help. Take advantage of this time to really open your heart and say things that are important to the people that you love. I am from Minnesota and we are famous here for hiding our feelings and not speaking openly. So, we encourage you to say, “I love you,” share memories, say all the things that are important at this time of life. It can make this whole experience very positive.

Melanie: In just the last minute, Dr. Amberg, how does somebody get that involved in hospice? What is the first step they should take if they feel like their loved one may be ready for hospice care?

Dr. Amberg: You need to talk to your healthcare provider and they can help connect you to a hospice program in your community. So, that is the first step. You need to talk to a nurse, a care manager or a healthcare provider like a physician. When you feel you need hospice care, it is important to talk to your healthcare provider–that can be a physician, or a nurse, or a case manager that you are working with--and if they aren’t able to connect you directly with a hospice program, you can call Allina Hospice directly at 651-635-9173 or check the internet at AllinaHealth.org/hospice and you can make a quick connection and we will help to get you the treatment that you need.

Melanie: Hospice is such a wonderful program for someone that you love. You can call Allina Health Hospice at 651-635-9173 and for more information you can go to allinahealth.org/hospice. That's allinahealth.org/hospice. You’re listening to The WELLcast with Allina Health. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Living with Metastatic Breast Cancer

Additional Info

Segment Number 5
Audio File city_hope/1528ch2e.mp3
Doctors Waisman, James
Featured Speaker James Waisman, MD
Guest Bio James Waisman, M.D., a highly respected and well known expert on breast cancer, is a clinical professor in the Department of Medical Oncology & Therapeutics Research. He joined City of Hope from the Breastlink Medical Group, Inc., a network of breast centers in Southern California, where he served as Medical Director of the Research Group. He was an Associate Clinical Professor of Medicine at Keck School of Medicine, USC, prior to joining Breastlink, and served as Vice President of the Medical Staff at USC/Norris, as well as the Chair of the Practice Operations and Development Committee. Prior to his time at USC, Dr. Waisman was an Assistant Professor of Medicine at UCLA and the Medical Director of Cedars-Sinai’s hospice program.

Learn more about James Waisman, MD
Transcription Melanie Cole (Host): A woman confronting metastatic breast cancer faces challenges that, at the outset, seem really overwhelming. These patients are especially vulnerable to anxiety and depression while at the same time they are facing very complicated choices about their medical care. My guest today is Dr. James Weisman. He’s a highly respected and well-known expert on breast cancer and clinical professor in the department of medical oncology and therapeutic research at City of Hope. Welcome to the show, Dr. Waisman. So, tell us what does that mean when we hear the term “metastatic” breast cancer?

Dr. James Waisman (Guest): First of all, good morning. It means that the cancer has spread from the breast to another organ in the body. Early breast cancer is defined as cancer in the breast and the lymph node under the armpit but metastatic disease can be anywhere in the body. There are certain areas, like the brain, liver, lung and bone that are more likely to be areas where it spreads, but it can literally spread anywhere.

Melanie: Okay. So, you hear the word “spread” and right away a woman freaks out. When you hear that it’s contained, then there are lumpectomies and treatments and things that you can do but when you hear that it spreads, right away that would cause a woman to sort of lose hope. People are living with metastatic breast cancer, yes?

Dr. Waisman: Absolutely. I’ve been practicing for a couple of decades and the changes we are seeing really make us say that this is now considered a chronic disease. Something like diabetes or heart disease, where people live and live productive lives and we have to keep treating them, but the drugs we have and the treatment we have are not only extending life but making people have lives that are completely livable.

Melanie: So, what kinds of treatments are available? Right away people think of losing their hair and getting very sick from chemotherapy. All of that, that’s involved, especially if the cancer is systemic. What are the treatments that are involved and how are you getting women to live longer with this?

Dr. Waisman: Well, the thing that has to be understood is that it’s not one disease. Actually breast cancer and other cancers are newly defined by molecular characteristics, by the biology of the tumor and it can be different. Really, we look at three main different kinds of metastatic breast cancer; one, whether it’s hormone sensitive and is responsive to things that block estrogen, for example. That’s usually pills or very low side effect related medications. Patients live without hair loss, without the side effects of chemotherapy and do very well for a long time. Then, there’s a second kind of breast cancer where a protein called the HER2/neu is on the cancer cell. We have incredible new therapies for that based on antibodies and, again, avoid a lot of the side effects of chemotherapy. The third kind of breast cancer metastatic disease is what we call “triple negative” meaning it doesn’t have any protein receptors that can be used to target the cancer cell and for that we do use chemotherapy but often low side effect related. We use the term “toxicity chemotherapy.” So, the old image of women sick and ill and vomiting is much less the common experience.

Melanie: If a woman has metastatic breast cancer is there any way she knows? Would that be something that because her breast cancer initially was undetected? Is that why it becomes metastatic? Or, is it something that, that’s where it was going to go anyway?

Dr. Waisman: That’s a great question and we don’t exactly know the reasons that women who have breast cancer develop metastatic disease. We know it is related to how large the cancer is; how far it has spread initially into lymph nodes; how aggressive it is as we see it under the microscope. What I tell women because they have breast cancer and they ask me, “Well, how do I know if I have metastatic disease?” The answer is, it’s not an experience that you will have ever had in your life, as a general rule. So, people who have mild headaches and coughs and backaches and skin rashes; that is very rarely metastatic disease. I do a lot of reassuring of women with breast cancer, that they are adults and they go through life like the rest of us and only if they have something really unexpected, like shortness of breath or not able to get up and take a shower. Then, that’s something they have to be concerned about.

Melanie: So, then what kinds of things do they look to deal with? This has got to be a very multi-disciplinary approach, correct, Dr. Waisman? Because it’s a chronic disease, because it affects other organs and such, what is that multidisciplinary approach to help these women go through something so scary?

Dr. Waisman: It’s a great question and, frankly, it’s the main reason that I left private practice to come to the City of Hope. The team, now, really is been expanded to include immune-directed scientists and doctors with expertise in removing tumors with robotic equipment using fine surgical approaches. We do use surgery now for resecting areas of metastatic disease. There are scientists who are interested in these concepts of targets, so you have to examine the tissue with a molecular analysis, which can be very complex. So, yes, we need the multidisciplinary teams and that includes nutritionists, physical therapists, and psychologists because, really, it’s a situation where we want women to feel a sense of well-being as they are living with--and I like that term, “living with”--metastatic disease.

Melanie: You use that term “living with.” Are there certain factors that will determine that? Women say, or anybody with cancer says, “How long do I have?” That’s been around for so many years, so is there a certain factor that determines that you can say, “Yes. We’re going to get you to live a nice long life.”

Dr. Waisman: Well, I mean, we are concerned about if a vital organ is involved. Obviously, things like the liver or brain or lung, that’s different than the skin or lymph node or bone. So, yes, we are more concerned when the metastasis is in those organs. Having said that, I have, and my colleagues have, many patients with disease in the liver or lung that years ago would have been a fatal illness. It no longer is the case. We can treat them with medications and not only extend their life but extend the quality of their life. I actually keep a list of all my patients with metastatic disease, so I know exactly how they are doing and for how long they have been dealing with this. Many of those patients are living more than a decade. So, things like using the average length of life, is just simply not a real concept anymore.

Melanie: In just the last few minutes, Dr. Waisman, give us your best advice for women that might be newly diagnosed with metastatic breast cancer. What’s going on in the horizon and what’s exciting in the research and why they should come to see you at City of Hope for their care? You sound to me like a caring and amazing doctor, so give women kind of that little encouragement that I can hear from you, so that they know that there is hope out there.

Dr. Waisman: First of all, it’s a new day. So, what women heard from their relatives and their friends from even three years ago, is changed. All those different cancers have new targets. The concept of target means, you can identify something in the cancer cell that makes that cell vulnerable to treatment. We just have more treatment, less side effects from that treatment and what happens at a place like the City of Hope is that the technology and the science is moving together so rapidly that you really have to stay current with what is going on. By reading, by listening to programs like yours, by being a participant in educational settings. So, to me, the most important thing is to be involved and engaged in the future of your life and to see yourself with a future. I think that is probably the major change that we’ve seen over the last several years: that women can see a future. That means working; that means traveling; that means being with their family and the old model of this is an end of life conversation is no longer operative and no longer the norm. Yes, bad things can happen, but we don’t look at patients like that--not when we have the options that we now have.

Melanie: Thank you, so much, Dr. Waisman, for such great information. You are listening to City of Hope Radio. For more information you can go to cityof hope.org. That’s cityofhope.org. This is Melanie Cole. Thank you so much for listening.
Hosts Melanie Cole MS

Inflammation: The Hidden Health Threat

Additional Info

Segment Number 2
Audio File allina_health/1528ah2b.mp3
Doctors Van Sloun, Nancy
Featured Speaker Nancy Van Sloun, MD – Integrative Medicine
Guest Bio Nancy Van Sloun is an integrative medicine doctor at Penny George™ Institute for Health and Healing – WestHealth. Outside the clinic, Van Sloun tries to follow the advice she gives her patients. She enjoys taking walks with her dog or human companions, finding and cooking new recipes, and spending time with her family on the Gunflint Trail.

Learn more about Nancy Van Sloun
Transcription Melanie Cole (Host): Inflammation is your body’s way of fighting infections and coping with injuries but there’s a growing evidence that another kind of inflammation – low level chronic inflammation -- can contribute to many diseases in chronic health conditions from arthritis and Alzheimer’s to heart disease and cancer. My guest today is Dr. Nancy Van Sloun. She’s an integrative medicine doctor at Penny George Institute for Health and Healing, WestHealth. Welcome to the show Dr. Van Sloun. Tell us a little bit about inflammation. People hear about inflammation in their hands or in their knees and they think arthritis but we’re talking about all kinds of inflammation here, aren’t we?

Dr. Nancy Van Sloun (Guest): Yes, we are and I like to distinguish between what we call acute inflammation which is something that is short-lived. It occurs in response to injury or infection. When that occurs, say you sprain your ankle, there are different mediators that are released into the bloodstream that create this inflammatory response. In this setting where inflammation is occurring in response to an injury, it actually is part of how the body responds to the injury and how the body heals. With acute inflammation, it is a good thing. It’s part of how the body heals and gets better. That is contrasted with chronic low-grade inflammation. The difference with that is that it’s not really occurring in response to any event. It is something that can be related more to different lifestyle factors. In contrast with acute inflammation that is healing and helpful, this chronic low-grade inflammation actually can cause tissue destruction. We’ve finally begun to realize how much it plays a role in many of our chronic diseases and conditions.

Melanie: That was an excellent explanation of that because people really do hear this term and now we’re hearing it more in line with heart disease and cholesterol levels and all of these things. If we have arthritis in our knuckles, we can see it’s inflamed. That’s chronic and that’s the acute inflammation. But how do we know if we have this low-level chronic inflammation? Is there a test?

Dr. Van Sloun: There are blood tests that doctors can do that measure inflammation and we call them “inflammatory markers”. One that’s commonly used is called CRP. That stands for C-reactive protein. There’s another test we sometimes do when we are looking at joint inflammation and trying to decide how much of that is truly an inflammatory response. That test is called a “sedimentation rate”. So, those are some tests that are done at the doctor’s office. The CRP is probably the one that people hear about most commonly in terms of testing that can be done. When research is done and they are trying to assess inflammation, they sometimes use other tests that a different mediator is involved in inflammatory pathways but that is probably more research tools as opposed to something that somebody would get at the doctor’s office.

Melanie: Are there some causes that we can look to? Is there anything we can do to try to prevent or reduce this type of inflammation?

Dr. Van Sloun: Absolutely. The interesting thing is that many of the contributing factors to inflammation are related to lifestyle. So, I’ll give you a list of them and diet is one of the most important. I’ll leave that for last. Physical activity is one. Studies have looked at how active people are and if people are more physical active, they have lower markers of inflammation whereas if they are sedentary, they have higher markers of inflammation in the blood. Simply getting moving and being active can reduce inflammation. Another factor is stress. I think of stress as not necessarily the events in our lives but how we are reacting to them and handling them. If people feel like they can just tell from their body that they are feeling stressed much of the time, that chronic stress can be a factor that increases inflammation. So, chronic stress is another thing that plays a role in low-grade inflammation. There can be environmental factors such as cigarette smoke, whether a person individually is smoking or is exposed to cigarette smoke. Another factor is being overweight or obese. We know that being obese, particularly if people are carrying weight around their abdomen, that creates a chronic low-grade of inflammation. So, paying attention to weight and trying to keep weight within a healthy zone is important. Lastly, diet is a big factor in terms to this chronic low-grade inflammation. We know that over the past 50 plus years that the diet in the United States has really changed a lot. It’s changed in a way that’s made our diet more pro-inflammatory in terms of the foods we’re eating.

Melanie: What are some of those foods that we are eating that could be contributing to this?

Dr. Van Sloun: The foods we know that are associated with increased inflammation, one category is trans fats and that’s the type of fat that was manufactured and created because it extends the shelf-life of food. That is still in fast food preparation often times. It can be in bakery goods that are at the grocery stores. It can be in some snack foods. It’s in refrigerated doughs. You can check the ingredient label on foods to look for trans fats. If you want to look at an ingredient list, you look for partially hydrogenated oils. We know the trans fats really are a big contributor to inflammation, so that’s a key one to watch for. Another category is saturated fats and those are fats that are found in dairy products or meats. They are associated with increased inflammatory markers. Lastly, we think about foods that create higher increases in blood sugar and subsequently higher increases in insulin levels. That is going to include foods that we know have added sugar. There’s a lot more sugar in our diets. So, sugar, soda or candies or other foods where you can see that there’s a lot of sugar added. In addition, it includes more processed carbohydrates because carbohydrates are all broken down into blood sugar eventually or sugar in your bloodstream and if those foods are more processed, meaning they are made with white flour, they can be turned into sugar and digested into sugar much more quickly which creates a higher blood sugar level and an increased insulin response. Those things--increased blood sugar and increased insulin response--contribute to inflammation.

Melanie: I know there are certain foods that have an anti-inflammatory effect on us, pineapple being one of them. Tell us some foods that can reduce inflammation and what that diet would look like.

Dr. Van Sloun: There are several categories here. Fruits and vegetables is one. Fruits and vegetables have antioxidants that help with inflammation. They also have fiber and that helps with inflammation. So, thinking about getting lots of fruits and vegetables, different kinds, different colors is important. High fiber foods, which is going to include fruits and vegetables but also whole grains like barley or other intact grains, steel cut oats, things like that. High fiber foods also help to reduce inflammation. Within that category also are legumes. Some of those plant-based foods that are high in fiber are important. Omega-3 fatty acids are a big category that reduces inflammation. That includes fish, particularly cold water, fatty fish like salmon, sardines, and herring. There are also some plant-based sources of Omega-3 fatty acids like walnuts, flaxseeds, leafy greens that also help to reduce inflammation. The last category we think of are monounsaturated fats. That includes things like olive oil, olives, nuts and seeds and avocados.

Melanie: Avocados is really one of nature’s most perfect foods. People hear about the words “the Mediterranean Diet”. We don’t have a lot of time Dr. Van Sloun, but if you could tell us about the Mediterranean Diet and please give us your best advice for reducing this chronic inflammation.

Dr. Van Sloun: Mediterranean Diet is going to be plant based. Lots of fruits and vegetables, nuts, whole grains, legumes. Olive oil is a primary fat source. It’s going to include some low fat dairy. Fish with those Omega-3 fatty acids. Some poultry and eggs but limiting red meat, processed foods, and refined sugar. That’s a Mediterranean-style diet and that is an anti-inflammatory diet. Overall, if we are trying to reduce inflammation, the more closely you can adhere to a Mediterranean-style diet, that’s going to be in your favor. In addition, being physically active, controlling weight, not smoking and managing stress – all those things are very powerful in terms of reducing inflammation and reducing risk for diseases.

Melanie: Thank you so much for such great information. You’re listening to The Wellcast with Allina Health. For more information you can go to allinahealth.org. That’s allinahealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Latest Treatments and Research for Metabolic Disease

Additional Info

Segment Number 4
Audio File city_hope/1528ch2d.mp3
Doctors Awasthi, Sanjay
Featured Speaker Sanjay Awasthi, MD
Guest Bio Sanjay Awasthi, MD is a Professor, Department of Diabetes and Metabolic Diseases Research.
A Professor, Department of Medical Oncology & Therapeutics Research.
A Professor, Division of Development and Translational Diabetes and Endocrine Research.
A Member, Developmental Cancer Therapeutics Program, Comprehensive Cancer Center.

Learn more about Sanjay Awasthi, MD
Transcription Melanie Cole (Host): City of Hope has one of the most influential metabolic disease research programs in the world. Our scientists’ work has revolutionized the understanding and treatment of these diseases and continues today with exciting developments. My guest today is Dr. Sanjay Awasthi. He’s a professor in the Department of Diabetes and Metabolic Disease Research and a professor in the Department of Medical Oncology and Therapeutics Research at City of Hope. Welcome to the show, Dr. Awasthi. Tell us a little bit about metabolism and the metabolic disorders in general.

Dr. Sanjay Awasthi (Guest): Well, the condition metabolic syndrome is a very common condition across the world. It has increased in incidence very significantly as our population here and across the world, really, has grown more obese. It is characterized by elevated blood pressure and insulin resistance. Insulin resistance is a condition where insulin doesn’t have as good an effect on the liver or muscles or the fat as it should. As a result, multiple abnormalities occur. These include either an elevated blood sugar or abnormal glucose tolerance tests and it’s very frequently associated with hypercholesterolemia that is elevated cholesterol, elevated triglycerides, high levels of LDL—the bad levels of cholesterol--and low levels of HDL, which is the good cholesterol and a variety of other things that we can measure. People with metabolic syndrome often have increase in size of their abdominal girth. They have high levels of fat in the abdomen that surrounds their intestines, which is one of the best ways of knowing that the patient may have metabolic syndrome. They have high levels of fat sometimes in the liver. Often we find patient’s who have had a CAT scan for another reason that have a fatty liver. These are pretty good markers of patients having insulin resistance. Probably an underlying cause, if you will, is the presence of excess inflammation. It’s not clear whether the inflammation is a cause or the result of the metabolic syndrome but it’s certainly associated with it. Metabolic syndrome often transitions into type-2 diabetes. The reason why it’s important is it increases your risk of cardiovascular death very significantly and probably also increases your risk for certain kinds of cancers. It often is associated with a variety of other inflammatory disorders like joint inflammation, or tendon or muscle inflammation and a variety of other inflammatory conditions that either are caused by or a cause of the metabolic syndrome.

Melanie: So, with the obesity epidemic that we’ve got going on in this country, Dr. Awasthi, who is most at risk? What do you want them to know about metabolic diseases, such as diabetes and thyroid disorders and things? Is any prevention available or lifestyle modification behaviors? What are things you want them to know?

Dr. Awasthi: The most important this is control of caloric intake. Eating too much is probably the most important and modifiable variable. The second is, of course, exercise. Many studies have shown that eating less and doing more exercise causes improvement in overall condition of metabolic syndrome. It can lower your blood pressure; it can lower your total cholesterol; it can increase your HDL cholesterol and lower your LDL cholesterol. There are other lifestyle modifications that are less important but can play a role in many people. Things such as eating while you’re stressed, eating while you’re standing, eating excessive amounts of omega-6 fatty acid containing foods, having a large amount of fat in the diet, these are also factors that patients can modify. Certainly one of the most important, really, is stopping smoking. Smoking is associated with something called “oxidative stress,” which is an underlying factor in insulin resistance and the inflammation that occurs in metabolic syndrome.

Melanie: So, when we are talking about metabolic diseases, can they lead to cancer? Is there a link between metabolic diseases and cancer?

Dr. Awasthi: Well, epidemiologically across populations, yes. The cancers such as breast cancer, colon cancer and prostate cancer have been clearly linked to the presence of metabolic syndrome. Again, it’s not exactly clear whether tendency to malignancy caused by, let’s say smoking, leads to metabolic disease or whether a metabolic disease or metabolic syndrome actually increases the risk of cancer. One thing is quite clear and that is that many of the same factors that predispose metabolic syndrome are also things the predispose cancer.

Melanie: So, they do tend to go together. So, tell us a little bit about thyroid disorders and how they can lead to obesity and what can be done about those? Is this a lifestyle thing or does this generally need treatment?

Dr. Awasthi: Thyroid disorders can affect the entire metabolism. It can increase or decrease metabolism and may be a contributor, although probably relatively minor in terms of the sort of etiology of metabolic syndrome. Recently, there’s been a lot of interest in a variety of small proteins called “peptides” that control your appetite and control satiety, the feeling of being full after eating. These are revolutionary findings over the last couple of decades that have implicated the brain or the hypothalamus and the connection between the intestines. The hypothalamus and intestine connection is particularly important, and is going to be increasingly important, as we realize how certain bacteria that live in your intestines are a cause of inflammation that can lead to metabolic syndrome. Thyroid disease itself is likely not a direct cause of metabolic syndrome.

Melanie: In just the last few minutes, Dr. Awasthi, if you would, please give us one of your horizon picture. Tell us what’s going on in the world of metabolic disease and what do you see happening for the future? What kind of research are you doing at City of Hope?

Dr. Awasthi: My research is involving metabolic pathways that metabolize poisons or toxins, particularly those that generate from omega-6 fatty acids. I’ve been working on this for the last 30 years and have worked on a variety of enzymes in these pathways and discovered a few years ago that one of the proteins of this pathway that’s present on the cell membrane, on the outside of the cell, has a crucial role in both cancer as well as conditions such as obesity and metabolic syndrome. So, the protein I work on is called RALBP-1 and we have shown that blocking this protein has beneficial effects in metabolic syndrome and blocking it actually causes a regression or disappearance of cancers in a variety of animal models of cancer. I made some mice, they’re called “knock out mice” that don’t have the gene and they are very resistant to diabetes and metabolic syndrome and are extremely resistant to cancer and so we have seen in recent studies that we can have beneficial effects on both cancer and metabolic syndrome, simultaneously that are involved in this as well.

Melanie: That is so exciting. What exciting research you’re doing. Thank you so much, Dr. Awasthi. You are listening to City of Hope Radio. For more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thank you so much for listening.
Hosts Melanie Cole MS

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