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Segment Number 2
Audio File virginia_health/1525vh5b.mp3
Doctors Singh, Kanwar
Featured Speaker Kanwar Singh, MD
Guest Bio Dr. Kanwar Singh is a board-certified physician in interventional cardiology, cardiovascular disease and internal medicine whose specialties include critical limb ischemia and peripheral arterial disease.

Learn more about UVA Heart & Vascular Center
Transcription Melanie Cole (Host): If left untreated, critical limb ischemia can lead to amputations. My guest today is Dr. Kanwar Singh. He’s a board certified physician in Interventional Cardiology, Cardiovascular Disease, and Internal Medicine whose specialties include critical limb ischemia and peripheral artery disease at UVA Heart and Vascular Center. Welcome to the show, Dr. Singh. Tell us a little bit about what critical limb ischemia is.

Dr. Kanwar Singh (Guest): Good morning, and thank you so much for the opportunity to share some thoughts about critical limb ischemia. Critical limb ischemia is defined as breath pain, tissue alteration, or gangrene as the function of abnormal circulation to the leg.

Melanie: Wow! What would cause this? Why would somebody even have these kinds of problems? Is it associated with certain diseases, diabetes, peripheral artery disease?

Dr. Singh: Absolutely. I tell patients all the time that artery disease is artery disease, meaning people who have coronary artery disease in their heart’s arteries or carotid artery disease in their neck’s arteries are the same types of patients who develop the same sort of blockages in their leg artery. If a person has eczema, a rash on their elbows or a rash on their knees and a rash on their neck, we don’t describe them as having neck eczema, knee eczema. We describe them as having eczema. It’s a total body condition. It’s a rash. And an artery disease is much the same way. The same things that cause the blockages in other important parts of the body contribute to the development of blockages in the legs. Namely, tobacco smoke is the number one risk factor. People who are smokers are at a substantially increased risk of developing clogs in their arteries that threaten the very existence of their legs. They lose their toes, they lose their ankles, they lose their knees, or even higher up. Diabetes is another major contributor. It tends to affect the smaller artery, typically of the lower legs, meaning the calf and below down into the feet, and it’s a major cause of amputation in this population. And then certainly, the other traditional risk factors, such as high cholesterol or high blood pressure, can also be contributors. But really, it’s the smokers and the diabetic folks who suffer the most at the hands of this condition.

Melanie: The risk factors—smoking, diabetes—is this a hereditary thing in peripheral vascular disease, just arterial lower limb disease? Is this something that’s hereditary?

Dr. Singh: It certainly can be, and we certainly know families where artery disease runs rampant among parents, uncles, aunts, relatives, et cetera. There aren’t so much genetic predictors that we’re looking at in terms of doing screening or blood testing or things like that to identify people at particular risk. It’s not as if it’s an inherited condition that is so classically or elegantly associated with a gene deletion on such and such a chromosome. It’s more of an overall risk factor that can run in families. Frankly, I think a lot of families who share risk factors genetically also share risk factors socially, namely self-injurious behaviors, like smoking to excess or even being around excess amounts of smoking, even if you’re not the primary tobacco user yourself.

Melanie: And even being overweight can run in families. Obesity can contribute to this. What about sedentary lifestyle? And what role does exercise play? I’m an exercise physiologist, Dr. Singh, so to me, keeping that blood flow in the legs, keeping your body moving gets that blood and keeps it from pooling. Does that contribute to this?

Dr. Singh: That’s such an excellent point. I’m so glad you brought it up. Exercise, exercise, exercise in the form of low level walking. It needn’t be necessarily going out for a trail-busting run. It need not be necessarily getting one’s heart rate up over 150 beats per minute. In fact, that may not be necessarily the most helpful thing to do. But plain, good old-fashioned walking, walking, walking is a tremendously valuable tool in the armamentarium of patients to help prevent developing peripheral artery disease, and more importantly the symptoms that peripheral artery disease can lead to. So even if one has blockages in the legs, the more active you remain, the less likely you are to develop a sore or an ulcer that thereby leads to an infection and that thereby increases your risk of developing an amputation.

Melanie: Women especially get concerned when they start to feel pains in their calves if they’re walking or if they’re exercising and they’re busy around the house. They always think right away blood clots or constrictions in their legs. Are there certain symptoms, red flags? Do they have to look for certain things to worry about lower limb clots or blockages?

Dr. Singh: That’s another great question. It’s important to distinguish what I call the northbound and the southbound traffic of blood flow. The southbound traffic would be blood that’s flowing from your heart down toward the leg, muscles, and the skin of your lower extremity. And that’s of course being pumped by your heart through our artery. The blood then gets to our lower legs, and it then pools in the venous circulation, and then it’s transported back up the leg towards the heart in veins that are responsible for the venous return of circulation. And believe it or not, the conditions that affect the veins and that affect the arteries are very, very different and completely unrelated. There are lots of young folks under the age of 35 who might have venous problems, either varicose veins or incompetent valves of their veins that result in leg swelling or spiders or varicose veins that folks can see and might identify. Those sorts of things, those vein problems can actually cause symptoms in the calf muscles or thigh muscles or a sense of leg fullness simply because there’s this sort of soggy leg with lots of blood that’s not getting great blood return out of it back up towards the heart. That’s very different from the southbound traffic problem, where there’s a constriction of blood flow because of a clog or some sort of blockage in the arterial blood flow that’s going down the leg. The symptoms to be aware of, classically speaking, are things like leg heaviness, leg fullness, cramping, pain, or occasionally tingling that is most present with exertion. That is the typical hallmark pattern symptom complex of arterial insufficiency, arterial blockage. It’s pain that develops in the calves or in the thighs or occasionally, in the buttocks muscles—because they need blood flow too—on exertion that is relieved by rest.

Melanie: Then what do you do for them? Does it always require surgery? Is it something with blood thinners, something that can be taken care of with medication? What’s the first line of defense?

Dr. Singh: I tend to think of this as two separate buckets of treatment. The first bucket of treatment is to deal with the symptoms that the patient is experiencing. Those symptoms can be thought broadly into categories also. The person who has leg symptoms when they walk and is relieved by rest, that is more commonly a very stable situation. In other words, it’s unlikely to rapidly progress and deteriorate. Those folks will say, “Gosh, doc. I walked a city block or I walked out of my driveway to my mailbox and back, and my calf muscles are burning. But by the time I get back inside, I rest, I feel fine and I’m okay.” Those patients who have symptomatic, what we call claudication or muscle pain on exertion, they will most often respond to a prescribed exercise regimen and don’t at all necessarily require treatment, either with balloons, and catheters and stent, the kind of work that I do, or with surgery, bypass surgery or clog opening surgery called endarterectomy or bypass that my surgical teammates and colleagues do at UVA. That’s sort of one category of symptoms, the stable claudicate, “my legs hurt when I walk.” The second category of symptoms are the critical limb patients. Those are the ones who have pain at rest or tissue ulceration or gangrene at rest. In other words, there’s just not enough blood flow getting down the leg to keep the very skin alive on the outside of their leg, and that’s an emergency. That’s something that needs attention in the next one to two days to be seen by someone and then a plan made for how to get that circulation back and relieve the symptom of pain or the risk of amputation. Overall, that’s sort of one bucket. It does not at all necessarily require surgery, although many times what is recommended are minimally invasive procedure with balloons and catheters and stents to relieve the blockages, restore blood flow, and optimize the benefits of healing and getting that skin back to be intact. That’s the first bucket, treating the symptomatic leg. The second bucket is recognizing that these patients who have leg artery blockages, the most likely reason that they’re going to end up getting sick enough to be at risk of death is something like heart attack or stroke. And so, in addition to treating the leg symptom, we also have to make sure that these patients are being monitored and treated for the presence of coronary artery disease or carotid artery disease that that would take their life in the form of heart attack or stroke. Those patients need to be at appropriate blood pressure control, medication, diabetes control medication, cholesterol control medication, and have to be living an overall healthy lifestyle to the best of their ability to reduce their overall cardiovascular morbidity and mortality.

Melanie: Wow, very well put. Such great information. In just the last minute, give your best advice to people suffering from this claudication, what you really want them to know, and why they should come to the UVA Heart and Vascular Center for their care.

Dr. Singh: Well, I’m very fortunate to work at one of the absolutely best centers in the country, if not the world, for the treatment of patients with lower leg artery disease. And I say that because we have a unique group of surgeons, intervention radiologists, as well as cardiologists, including myself, who take care of this condition holistically and don’t just think of this as a plumbing problem that needs relief. We think of the whole patient who need to have their risk factors modified, their symptoms treated, and their overall health optimized. The patient with claudication needs to recognize that they have this problem to have to talk carefully with their providers about it and make sure that their overall risk profile is minimized. If they’re symptomatic enough that it’s lifestyle limiting—they’re a postal carrier and they can’t get around or do their job, or they’re a line dancer and they can’t get out and dance with their partner—if it’s affecting their lifestyle, then they warrant an intervention, a balloon treatment or a stent treatment or surgery—rarely, but if indicated. For those patients, the primary to think about is getting out of trouble and preventing the downstream complication that leads to limb loss.

Melanie: Thank you so much, Dr. Singh. 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

Muscle Weakness and Rashes in Kids: Could It Be Dermatomyositis?

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Segment Number 1
Audio File virginia_health/1525vh5a.mp3
Doctors Patel, Aarat
Featured Speaker Aarat Patel, MD
Guest Bio Dr. Aarat Patel is a board-certified specialist in pediatric rheumatology, pediatrics and internal medicine.

Learn more about UVA Children’s Hospital
Transcription Melanie Cole (Host): If your child is suffering from muscle weakness and an unexplained rash, dermatomiositis could be the cause. My guest today is Dr. Araat Patel. He’s a board certified specialist in Pediatric Rheumatology, Pediatrics in Internal Medicine at UVA Children’s Hospital. Welcome to the show, Dr. Patel. Tell us a little about muscle weakness and unexplained rash and what would send the parent to the doctor. How do you diagnose this?

Dr. Araat Patel (Guest): Thank you for having me on the show. Well, dermatomiositis is an inflammatory disease of the muscle, skin, and blood vessel. The symptoms are very nonspecific, but for someone who’s seen many patients with dermatomiositis, usually an adult rheumatologist or pediatric rheumatologist, it’s fairly easy. But for someone such as a pediatrician who has to see diseases from a vast majority of specialties, it’s a little difficult because of the nonspecific symptoms. Once we see a patient with that classic rash, we usually know what the diagnosis is.

Melanie: So do we know the causes, you know why. Is this an autoimmune disease?

Dr. Patel: Right. So we do not know the cause, but it is an autoimmune disease, meaning your immune system is revved up and attacking parts your body that it should not.

Melanie: So what groups of children are most likely to be affected by that?

Dr. Patel: So all ages of groups, all ethnics groups, but most cases in children occur between ages of 5 and 10 and about twice as often in female.

Melanie: Is it hereditary, Dr. Patel?

Dr. Patel: It is not hereditary, but a lot of the autoimmune diseases, such as lupus, rheumatoid arthritis, dermatomiositis come in batches. So there’ll be a family history of another autoimmune disease, possibly.

Melanie: So how scary for a parent, especially when there’s muscle weakness involved -- a parent’s mind goes in all different directions. Once they’ve come to see you and you have diagnosed this, what treatments are available, and is this something that the child will have to live with now for the rest of their life?

Dr. Patel: So we say that you will have this for the rest of your life, and our goal of treatment is remission. And we can achieve remission fairly quickly. We usually use corticosteroids, which are prednisone, Solu-Medrol. We use that for a brief period of time, and then we use the same medications that we use for rheumatoid arthritis. And one of them is methotrexate, and another medication for those children that are little more sick is something that we give in the hospital through an IV for about 24 hours every month called IVIG. The treatments are really good, and we can control the majority of cases and put them into remission, and they stay on medication for a few years, and then sometimes they come off of medication. So technically they’re cured, but we never say that they’re actually cured, just in case they flare up in the future.

Melanie: What would happen if this is left untreated?

Dr. Patel: Usually the child would get very sick, and it will start affecting the muscles which control breathing and swallowing. So they will end up in some sort of emergency room, urgent care center, or sometimes even in intensive care unit because they can’t breathe or can’t swallow, and their secretion, their spit and their food is going down the wrong tube, into their lungs. So usually they’ll end up sick and someone will figure out the diagnosis.

Melanie: For some children, Dr. Patel, is there a need for physical therapy? What’s their daily life like? And can they mainstream in school, or is this something that’s going to affect their normal living?

Dr. Patel: So it does depend on the severity. Once we diagnose it, we are very aggressive with treatment. We try to get their muscles functioning normal as soon as possible. They may have already suffered some muscle atrophy, so physical therapy is very important. Sometimes we send them to aquatic therapy in a pool; sometimes we send them to physical therapy in an inpatient unit, depending how sick they are. But once we start treating them, they usually will live a normal life with some restrictions, such us the sun. So, where I live in Virginia, it’s pretty sunny, so some of these children have to make sure they apply sun block on every day because that could make their disease flare. The majority them live a normal life as long as we can control the disease.

Melanie: Now you mentioned steroids and the methotrexate. These medications begin to work, and then the parents and the child will see some results. They’ll see them getting better. Do they stay on steroids, and does that have its own side effects?

Dr. Patel: So steroids have a lot of side effects so we try not to use as much steroids as some of the pediatric rheumatologists 20, 30, 40 years ago had to because they didn’t have some of the good medications we have now. So I try to keep patients on steroids for a minimum of one month and a maximum of maybe three months, if anything, depending on how bad their disease is. And then the other medication such us methotrexate, IVIG, Imuran, they sound scary when you read the prescribing information, but in fact they’re very well tolerated and even better tolerated in children compared to adults.

Melanie: Are there any comorbidities that go with this? Is there anything that parents should look out for as the child approaches their teenage years and on? Is this going to put them at risk for other autoimmune diseases—lupus or Crohn’s or MS or any of these others?

Dr. Patel: So once you have one autoimmune disease, you have a higher risk of acquiring another autoimmune disease, such as thyroid disease, psoriasis, lupus. But usually they’ll just have this one disease. The comorbidities come in from the disease severity. So, some of these children, especially teenagers, when they can’t keep up with their peers, there is sometimes depression, sometimes anxiety. Other things are occurring at the same time in their life that should be occurring normally in a child’s life. So, the multidisciplinary approach is usually physical therapy, sometimes psychology, sometimes a counselor just to get them through feeling abnormal because they will probably be the only person with this disease because of how rare it is.

Melanie: So what about dietary needs? If chewing or swallowing or muscular weakness can be an issue, are there certain foods you like to recommend to parents that they feed this child? Is it going to affect their eating habits for a long time?

Dr. Patel: Not for a long time, only in the beginning. If they truly have some problems swallowing, we are aggressive with the steroid dose, and we usually try to fix that in a few days to weeks. So maybe for a few days, you can’t go to a steakhouse and eat some hearty meat that gives you trouble swallowing. But most of the time there are no foods that are going to make this better and there are no foods to really avoid, just the normal foods that everyone should avoid, such as processed food and fast foods, but nothing out of the ordinary.

Melanie: So in just the last few minutes, Dr. Patel, if you would, give your listeners best advice and why they should come to UVA Children’s Hospital for their care.

Dr. Patel: So like I said, unfortunately, dermatomiositis can cause nonspecific lab abnormalities, nonspecific symptoms. So if you are in a position where you’re going from one specialist to another specialist to another specialist, sometimes you have to think about rheumatology—“maybe I should go see a rheumatologist”—especially if there’s fever and rashes, muscle weakness and joint pain and joint swelling. So at UVA, we use a multidisciplinary approach. We are aggressive with our treatments, and we try to get these children back on their feet. We have excellent physical therapy there. We have excellent ancillary services, and most of the families in Virginia are very happy when they come to UVA for their care.

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

Managing ADHD Without Medication

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Segment Number 4
Audio File allina_health/1522ah5d.mp3
Doctors Paper, Sarah
Featured Speaker Sarah Paper, RDT, PsyD, LP - Psychology
Guest Bio Sarah Paper is a board-certified psychologist with professional interests in children and adolescents, ADHD, parenting, pregnancy, trauma, body image/eating disorders, self-harm, mood symptoms, delinquency and psychological evaluations.
Transcription Melanie Cole (Host): A diagnosis of ADHD can be difficult, not only for the child diagnosed but also for the parents who need to learn how to manage this condition. There are many side effects identified with the various medications that are typically prescribed to treat ADHD, and that can even add a little bit more stress and additional issues to an already stressful situation. Are there some alternative ways to cope with this? My guest today is Dr. Sarah Paper. She’s a board certified psychologist with professional interests in children, adolescents, and ADHD at Allina Health. Welcome to the show, Dr. Paper. Tell us a little bit about how is ADHD diagnosed, because sometimes that seems to be the sticking point is actually making that diagnosis.

Dr. Sarah Paper (Guest): Right. ADHD can be diagnosed by a primary care physician, the child’s pediatrician, but most often and especially recently, those doctors have been making referrals for psychologists to assess the child. That assessment includes a good clinical interview, oftentimes measures for teachers and parents to complete because we want to make sure that the child is presenting those symptoms at home and at school and even outside the school. We want to see it in multiple settings. Then also, sometimes, cognitive assessment is done to see if there are learning issues that might be impacting concentration and ruling out other diagnoses like depression and anxiety that can look like ADHD.

Melanie: Sometimes you hear a parent say, “Well, he’s just being a kid.” What are some red flags? You mentioned that the symptoms have to occur both in school and outside of school and all the different areas of the child’s life, but what are some red flags that might pop up that would say to the parent, “No, this is more than just kid energy”?

Dr. Paper: I think the most important thing is the teacher feedback because they’re dealing with multiple children and they’ve seen kids over time, and so they’re going to be the ones to notice impairment. An impairment is the most important part of recognizing ADHD versus an active child versus just your typical daydreamer, and all of us have qualities of different diagnoses. Some of us might wander off in our mind or tend to have more energy than others, but when it causes functional impairment, that’s when we start looking at a disorder. Teachers can notice this kid is daydreaming more than other kids and the daydreaming is affecting his or her learning, his or her relationships, behavior. The hyperactivity is causing problems in the classroom, problems on the playground. Oftentimes, I ask if the kid’s in trouble, if they even have difficulty at home sitting still for a meal and watching movies or reading books. Because some parents don’t have a good sense or they haven’t been around enough kids to know what normal kid activity even is. The kid feels active to them, but that might be typical energy or manageable energy.

Melanie: We hear about so many of the medications on the market. When a child is actually then diagnosed with ADHD, attention deficit hyperactivity disorder, what do you do first? Do you start with behavioral therapy? Do you start with medications? What is sort of the first line of defense?

Dr. Paper: What I do is first talk with the parent and the child present. I think that’s an important component of it, to make sure that the child is included in the discussion so that they don’t feel as if something is terribly wrong with them or that they should be ashamed of. I like to have a nice, open conversation, and I really feel like it’s up to the parents to make the decision. And I give them information on the different options, but you want the parents to buy into it, believe in it, trust in it. You want the kid to have some input if they’re old enough about what they think would be helpful. I talk to them about school accommodations that can be helpful versus medication, both things happening at the same time—looking at therapy as far as teaching skills to manage their distractibility, manage their hyperactivity, focus on what they’re doing, taking breaks often so that they don’t fatigue because it does take more energy for them to concentrate. Medication does tend to be the first line of treatment, but it’s not the only line of treatment.

Melanie: Tell us about some of the other lines of treatment, behavioral therapy. How does that work with the hyperactive child who is easily distracted or gets in trouble at school? How does this therapy help them to control those emotions that can sometimes get them to do things that they otherwise would be able to control?

Dr. Paper: There are skills that we teach in the office that they can then practice and then use in the classroom, ways to do things that come maybe more naturally for other kids. Some things I’ve done is teach kids to sit on their hands during circle time or find ways to fiddle with their shoes. Keep their energy contained as small as possible so that they can release it and not draw attention to themselves, not get in trouble. Talk to them about fidgets. Sometimes they bring gum to school so that they can chew on it and get that sensory input into their body. Do things like playing games, even at home. I encourage the parents with them things like “Red Light, Green Light,” “Mother, May I?” games that they have to freeze and be a statue. Sometimes I’ve done things where I have the kid maybe hold a bat or a ball and then have them wait, wait, wait and then time to go so that they’re working on that impulse control. So having them do things and then stop doing things and then try not to do things even when they want to so that they can build up that ability and then talk to them and teach them about how to apply that into the classroom. Another game some therapists use is called Pop and Stop, where they fill the room with bubbles and the kid has to pop them for a certain amount of time and then stop while there are still bubbles that they want to pop. Because that’s a hard thing, as silly as that sounds. For kids with ADHD, wanting to do something and stopping themselves from doing it is quite difficult. So that plays out in a classroom. Same thing, they’re poking their friend or tapping their pencil or making jokes.

Melanie: Will those impulse control issues that children tend to have that have ADHD, how long in these kinds of therapy should it take to start seeing results, maybe hearing some positive feedback from the teachers at school or caregivers or any of those? How long should this take to start seeing some of those results?

Dr. Paper: It depends on the severity of the ADHD and the other environmental issues, social issues. Some of it can be quite challenging. Or sometimes the kids do well in the office and then have trouble translating that out into a more stimulating environment like home and school. Other times I’ve seen kids pretty early on show a great deal of progress, but then they’re not able to sustain it for very long, almost like they run out of steam or it takes so much effort that they can’t maintain it. Over time, they make progress but then they develop and they have new challenges that they face with each grade. It’s a persistent disorder that’s going to affect them for quite a while, most of their life. Some people do tend to grow out of it, but a good percentage of people continue that symptom well into adulthood.

Melanie: How important do you find, Dr. Paper, sleep and diet to be in managing ADHD?

Dr. Paper: The research on that is questionable. There are some people who say it works really well. There are some theories out there that are being researched right now related to sugar sensitivity and that some kids seem to be more sensitive to sugar, some kids seem to be more sensitive to additives, and other kids, that’s not contributing to their symptoms at all. So parents are often encouraged to explore those things, if that’s something that they feel that they can do. There are issues with resources there, too. There are a lot of parents who aren’t able to provide that or even themselves have ADHD and can’t manage that type of diet and that type of structure in their day, and then financial limitations. So I think if parents are willing and able to try that, it’s something that is worth trying and some kids gain the benefit. There’s a good percentage of kids who that doesn’t seem to help.

Melanie: What about sleep?

Dr. Paper: Sleep is very important. There have been some kids who have come in for ADHD assessment, and I just work with them on sleep and said, “Once you’re sleeping, come back if you’re still having symptoms.” Because kids can’t concentrate. Adults can’t concentrate if their brain is not well rested. That can affect your objective functioning, the parts of your brain that are struggling with ADHD. It can look that way. Think about when you haven’t had enough sleep in that day, how well you concentrate or how well you self-regulate. I think that’s the first thing to look at if that hasn’t been addressed yet by the pediatrician is how to improve the sleep so that we can see their brain at its maximum potential and then decide how much impairment is there.

Melanie: In just the last minute, Dr. Paper, give your best advice to frustrated parents listening about ADHD and managing it, yes, with medications but sometimes without medications and the behavioral therapy that’s involved. Your best advice, please.

Dr. Paper: I think the most important advice is to remember that your kid is not doing this on purpose. This is not their fault and they don’t want to be acting this way—they don’t want to have these problems either—and to be patient and compassionate in validating and to talk to professionals if you’re really feeling frustrated. Kids with ADHD often experience adults as being frustrated with them and annoyed with them, and that can really damage a child’s self-esteem and create additional problems in addition to the ADHD.

Melanie: Thank you for such good advice. You are 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 for listening.
Hosts Melanie Cole, MS

Interventional Pain Management for Cancer Pain

Additional Info

Segment Number 1
Audio File city_hope/1524ch1a.mp3
Doctors Leitner, Andrew T
Featured Speaker Andrew T Leitner, MD
Guest Bio Dr. Leitner is an assistant clinical professor of anesthesia and interventional pain in the Department of Anesthesiology. He earned his undergraduate degree magna cum laude in biology from Tufts University in Medford, MA. He went on to receive his medical doctorate from the Washington University School of Medicine in St. Louis, MO. He completed his residency in the Department of Anesthesiology at the University of California, Los Angeles (UCLA), where he also pursued a fellowship in interventional pain management.

Board certified in both anesthesiology and pain management, Dr. Leitner is fluent in Spanish, Hebrew and Hungarian. He is an active member in numerous professional associations including the American Society of Anesthesiology, the American Society of Regional Anesthesia, the California Society of Anesthesiologists, and the North American Neuromodulation Society. He has also written several articles and abstracts.
Transcription Melanie Cole (Host): There’s more to cancer care than simply helping patients survive. There’s more to cancer treatment than simple survival. Constant pain should not be a part of conquering cancer or any quality of life, for that matter. My guest today is Dr. Andrew Leitner. He’s an assistant clinical professor of anesthesia and in interventional pain in the Department of Anesthesiology at City of Hope. Welcome to the show, Dr. Leitner. Tell us a little bit about pain management, this field of pain management, interventional pain management. What is its role in cancer?

Dr. Andrew Leitner (Guest): Thank you, Melanie. It’s good to be here. Pain management is a relatively recent field within medicine and it comes in different flavors, but ultimately, all of its adherents and specialists are looking to approach pain from a symptom standpoint and help patients return to functioning life. The interventional pain specialists have a few extra tools at their disposal, but ultimately, all pain specialists are looking at the most effective ways of treating pain symptoms, whether it’s a combination of medication, physical rehabilitation, nerve blocks or some combination of the above. With an interventional pain specialist, there is extra training in specifically those procedures that can help alleviate pain symptoms both in the short and long term.

Melanie: Is this just for cancer patients, or can this really benefit a whole variety of people suffering from chronic pain?

Dr. Leitner: Well, the field was developed for the treatment of pain of all types, and we typically categorize pain as malignant or non-malignant pain. But as cancer treatment has improved and as patients are surviving longer with cancer, that line becomes blurred. And ultimately, we treat all types of pain. The separation that we typically approach our patients with is is this pain from cancer, is this pain from cancer treatment, or is this pain from a patient who may have cancer, may be in remission, but ultimately develops the types of pains that everybody else does—from aging, arthritis, degeneration, inflammation?

Melanie: Tell us about it. I know it’s certainly specific to each patient and where their pain is located, what they’re suffering from, but tell us a little bit about pain management. What kinds of pain management options are out there?

Dr. Leitner: The options for our patients really depend on what the source of pain is. In many cases, the referral to pain management comes after discussion with a primary treating team. In many cases for our cancer patients, cancer directly from either a physical mass or involvement with nerves becomes referred to an oncologist or a surgeon, where the primary treatment is really directed at the tumor itself. But in cases where treatment has already taken place and pain persists, that tends to be the time when they are referred to a pain specialist. Now, in many cases, we also like to see these patients early on so that we can help guide approach to pain if it develops or if it progresses. And what we have at our disposal, as I have mentioned, are various types of medications, and these are always evolving in addition to a specific guidance on physical rehabilitation, whether it’s working with a physical therapist or other professionals. And then the final one is specifically directed treatment at nerve and the nerve signaling pathway, whether it’s an injection, an ablation technique, or placement of special devices that help decrease the signal through the spinal cord.

Melanie: What’s going on in the world of pain management? What’s exciting on the horizon? What can people look forward to in this burgeoning field?

Dr. Leitner: Ultimately, pain management becomes more effective when teams are built around it. That’s one of the unique attributes here at City of Hope. We’re not working in isolation. We are a strong unit with both our patients’ primary oncologists and other treating services such as radiation oncology or interventional radiology. Each one of these specialties may have special tools specifically to offer for our parents who are suffering from pain, and it would be a disservice to our patients to only offer the tools that we specifically have. So this multidisciplinary model is probably the most effective resource that we have for our patients. Of course, there are always new technologies that are developing and some of them are very exciting, and one of these technologies is neuromodulation, where we can, in a sense, trick the body’s nerve signaling pathways into believing that a pain signal is not transmitting up the spinal cord so that it can be processed in the brain, which is where all pain is experienced ultimately through higher levels and higher channels through the brain. This neuromodulation technology is still in development, but it has been used for a good couple of decades but is evolving, and this includes spinal cord stimulators or peripheral nerve stimulators at the site of either injury or a chronic nerve irritation.

Melanie: What do patients say to you, Dr. Leitner, when you’re discussing treatment and if you’re looking at nerve blocks or spinal cord stimulators? What are some of the questions that they ask you?

Dr. Leitner: The first question most patients ask is how will this affect my current quality of life, my functioning, and then I usually ask the question back. The most important priority for how we approach care is really an honest and open discussion with my patients about what their goals of care are. This is not the same for everybody. Just as cancer is a highly personal and unique experience, pain and other symptoms can be a highly personal and unique circumstance. I have patients for whom maintaining their physical functioning, the activities that they crave and they need to continue to feel whole, that may be their number one priority. For other patients, maintaining their cognitive function, being fully alert so they can interact with loved ones, that is a treatment priority. For other patients, it’s pain relief is most significant so they would be able to tolerate some reduction in either physical function or cognitive function so they would not be in as much suffering. Most patients would like obviously some combination of those. That’s really the first question, they ask, how is my quality of life going to be affected by these different treatment options.

Melanie: That’s a great answer, too, because you think some of the treatments might affect your ability to think clearly and some of them won’t. So that’s a really great answer, good, succinct answer for that. Tell us a little bit how City of Hope’s approach to cancer pain treatment is different from other places and why patients should come to City of Hope for their care.

Dr. Leitner: Well, there are a few ways in which City of Hope stands out. The first is we as pain specialists and as a supportive care team and multidisciplinary team in general is involved early with the care of our patients. This is somewhat unique. As opposed to going through weeks and months of working with a primary oncology team, patients always have the opportunity to see a pain specialist early in their care. And we are working on different methods of making that point of contact even earlier, even if it’s just to provide information for patients that they can use later prior to starting chemotherapy, prior to starting radiation treatments, prior to surgery. And this is well integrated with our various departments. For instance, the anesthesia department will do specific clinic interviews with our patients before they’re undergoing major surgery so that any concerns or questions can be addressed. And if needed, we can put into place a plan for how specifically to address pain after the surgery and weeks and months after that as well. That opportunity to be involved early is one thing that is quite unique about City of Hope. And then of course the other aspect, as patients are well aware, our oncology research here is top of the line, and patients have opportunities to be administered treatments that are developed in our lab bench-side and then administered here in our clinics or in hospital. And the same can go for pain treatment. If we’ve decided that a patient has a unique circumstance and have shown benefit from an experimental treatment, we are able to offer them that treatment earlier, more readily with fewer steps in between, because this is ultimately a smaller institution with great communication between the services and we can get involved early.

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

Breastfeeding 101

Additional Info

Segment Number 3
Audio File allina_health/1522ah5c.mp3
Doctors Fulwider, Kathleen
Featured Speaker Kathleen Fulwider, RN, Lactation Consultant
Guest Bio Kathleen Fulwider, registered nurse and board-certified lactation consultant, is part of Unity and Hospital and also serves patients for home lactation consultants. She leads the weekly Baby Cafes at Unity Hospital and Allina Health Maple Grove Clinic and enjoys educating and supporting moms to help them have a positive breastfeeding experience with their newborn.
Transcription Melanie Cole (Host): Breastfeeding is a personal choice for every new mom to make. And despite how natural breastfeeding is supposed to be, it’s actually just like many other learned things in life. It calls for a bit of patience and practice and perseverance, for sure. My guest today is Kathleen Fulwider. She’s a registered nurse and board certified lactation consultant at Allina Health. She’s here to give us breastfeeding 101 for new moms. Welcome to the show, Kathleen. When does a new mom begin to produce milk for her newborn?

Kathleen Fulwider (Guest): Well, thank you, Melanie. Women start to produce colostrum, that early milk, right about in the mid trimester, the mid, second trimester of her pregnancy. Some women may even leak colostrum towards the end of their pregnancy, which can be very reassuring.

Melanie: Okay, so right at the beginning, the colostrum. What are those first few hours and days, like with feeding a baby, teaching that baby to latch on, is this difficult for most people, some of the people? Is it difficult at all?

Kathleen: It can be challenging for some. Not all babies slide down the chute and know how to breastfeed, so there is a learning process that takes time for both mom and baby together. The first hour after delivery, we encourage mothers in an ideal situation to hold their baby skin to skin. Within that first hour or two of life, a baby goes through nine little stages, the eighth stage being feeding. So it’s encouraging if a baby has his or her first feeding within that first hour or two post-delivery.

Melanie: What are some of the challenges that a new mother may face within those first few days and even first few hours?

Kathleen: Well, we do know that the first 24 hours of life for this new baby is a time for transition and recovery. That little baby has been working just as hard to be born as the mother is working to birth her baby. In that first 24 hours, we need to still awaken baby, hold skin to skin, and encourage frequent feedings. We encourage baby to go to breast at least every three hours in that first 24 hours. On the second day of life, they kind of perk up and realize that they’re not inside anymore, and then they start to keep you cluster feeding. Cluster feeding is when a baby feeds more frequently. It has nothing to do with a woman’s milk supply. They often tend to feel that their babies are still hungry, that they’re not providing enough. Cluster feeding is a normal developmental activity that a baby does to help tell the mom’s body through his sucking to make more milk.

Melanie: Why is breastfeeding so important and recommended by the American Academy of Pediatrics?

Kathleen: That is a very good question. Breastfeeding is no longer a lifestyle choice. That has become a public health priority in terms of disease prevention. Through all of the research over the last decade or two, we have learned how breastfeeding one’s baby prevents disease in both the mother and the baby. So it’s very, very important that that occur. The American Academy of Pediatrics recommends that a baby be exclusively breastfed for the first the first six months—exclusive meaning no water, food, juice, et cetera—while solids are then introduced at about sixth months while the mother continues to breastfeed for that first year of life. The baby’s main source of nutrition in that first year of his or her life is the breast milk.

Melanie: So, what equipment should a new mom have who choose to breastfeed? What should they have before the baby arrives?

Kathleen: Well, I don’t necessarily think anything needs to be purchased beforehand. That’s the beauty of breastfeeding. Your milk is always available, always the right temperature and always perfect at any given time or day or month of your baby’s life. If a woman is returning back to work, like many of us do, most insurance companies are now covering the cost of the breast pump and lactation consultation through the Affordable Care Act.

Melanie: That’s great for new moms to hear. What are some of the best positions you’re recommending? You want the mom to be comfortable, especially if she’s feeding quite often. So what are some of the best positions for mom and baby while feeding?

Kathleen: Well, there’s no really one right way. Mom has to be comfortable and relaxed in order for her milk to let down, and flow if you will. A baby needs to be facing mother, nipple to nose and tummy to tummy. If you keep those two little guidelines in mind, mom and babies should be doing fine.

Melanie: Do we have to keep track? Because even back in the formula-popular days, women kept track of how much their babies ate and then how much they had bowel movements. Do you still recommend keeping track? How do we know that baby is getting enough milk?

Kathleen: Absolutely. Keeping track, keeping a look of baby’s feedings and diaper output is really one of the best ways to reassure a mother that feedings are going well. If baby has the required amounts of feedings and stool and urine output within 24 hours, you can be pretty assured that her milk supply is just fine and that her baby is getting what he or she needs. Allina has an excellent tool called the Breastfeeding Guide and Diaper Diary, which shows daily minimums for each day of life, just to have a visual reassurance to the mama.

Melanie: That’s so cool. Now, how long should each feeding last? Is there a limit to how often she should feed or how long it should take? Should we worry if the baby is falling asleep during feedings?

Kathleen: A breastfed baby needs abare-bone minimum of 8 feedings in 24 hours for the first couple months of life. Feedings should really last as long as the baby is wanting to suckle. In the early days of breastfeeding, the first couple of weeks, the more nipple stimulation a mother gets by her hungry baby, that will determine how quickly more milk is available and how long she will physically be able to make milk for that baby. So if a mother has a goal to breastfeed her baby for the first year, what she does in the early days when she’s most tired and exhausted will have an impact on her overall breastfeeding experience.

Melanie: Well, speaking of having an impact on breastfeeding, are there certain foods that you would recommend new moms stay away from while they’re breastfeeding or certain foods you would like them to fill up on?

Kathleen: That’s a good question. Lots of moms have that question in mind. We want moms that are breastfeeding to eat a healthy, well-balanced diet and to drink to thirst. We want her also to continue taking her prenatal vitamins or supplements to ensure that she has enough calories to keep up her energy level. So the baby will always get the goods from the mama’s body. If she’s choosing to eat poorly, her milk will always be perfect at any given time for her baby. Her body will suffer, and she may become ill from not eating properly, but her baby always gets the best from her.

Melanie: We only have a few minutes left, Kathleen. It’s great information. What advice do you have for new mothers, your best advice if they’re feeling frustrated by breastfeeding and being a new mom and feeling overwhelmed by the whole process?

Kathleen: Sometimes it can be reassuring for a mother to go to a support group for breastfeeding. Allina Health Hospital has three baby cafés throughout this city: United Hospital has one in St. Paul, Unity Hospital in Fridley, and Maple Grove Allina Clinic has a baby café. Now, a baby café is a drop-in support group that is free to all expectant and breastfeeding mothers. It’s a good follow-up plan from discharge. It’s just a great place to get free information. All Allina Hospitals also offer outpatient lactation appointments for moms to meet their lactation consultants, whichever one is convenient to their location of where she lives. Those visits are typically covered by insurance, and it’s a one-on-one visit with the mom and the baby to kind of come up with a plan and to get all of mom’s needs and questions answered. There’s a lot of support available to a breastfeeding family.

Melanie: It sounds like a great support system. 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 for listening.
Hosts Melanie Cole, MS

Healthy Tips for Grocery Shopping

Additional Info

Segment Number 2
Audio File allina_health/1522ah5b.mp3
Doctors Vander Laan, Elizabeth
Featured Speaker Elizabeth Vander Laan, MS, RD
Guest Bio Elizabeth Vander Laan, MS, RD, LD is a bariatric dietitian at Abbott Northwestern Hospital’s Bariatric Center. What she likes most about her job is seeing patients transform their lives using healthy methods for weight loss. In her free time, Vander Laan enjoys camping and hiking with her husband and two young children, practicing yoga and training for races and triathlons.
Transcription Melanie Cole (Host): You may have heard thatto make the healthiest choices at the grocery store, you really should shop the perimeter of the store. But is everything in those areas really healthy? My guest today is Elizabeth Vander Laan. She’s a dietician with the Bariatric Center at Abbott Northwestern Hospital. Welcome to the show, Elizabeth. Why is it that we’re told to shop the perimeter of the grocery store?

Elizabeth Vander Laan (Guest): I think the reason we’re told to shop the perimeter is because it does tend to be more of the healthy, fresh foods. But of course there’s exemptions to every rule. Of course, the bakery and the deli, there’s certainly less healthy options in those areas. But I also think in the middle, there are some healthy options as well, such as beans or whole grains, or whole grain bread that’s not at the bakery, that type of thing.

Melanie: Let’s first then talk about the produce section. Very few things in this area have nutrition labels, so what should we be looking for? There are some things that have labels. I’ve seen prepackaged beets in that department and they have a label on them. What should we be looking for?

Elizabeth: I always recommend eating foods the closer to nature as possible. Those are plentiful in the produce section. There are some other more processed products that sometimes find their way into that area. I guess what I think of is caramel dip sometimes to go with the apples and ranch dressing to go with the vegetables. It’s not cut and dry, but in general, you want to try to stick to things, like you said, that don’t have the label on them. I’m not going to say that there’s any one food such as potatoes or whatever that you shouldn’t eat. It’s just in moderation. You can’t eat everything unlimited. But in general, those are great options if they’re fresh produce.

Melanie: Sometimes even nuts and seeds and such are in the produce department, and those come in bags and boxes, too.

Elizabeth: That is true. And I would recommend that, of course, in moderation. Typically, a quarter cup serving is all you need on those. And I would watch to make sure that they’re not adding a lot of sodium to those things, as well.

Melanie: So the deli is another area where there aren’t always visible food labels. If we buy our deli meat or cheese in this area, what should we be mindful for and should we look? They have them in big bulk. Do we get to look at that label to see if there is added nitrite or too much sodium?

Elizabeth: You certainly could ask to see the label. I have asked myself, and they typically don’t have a problem with that. Yes, I would avoid nitrate. The less processed that is, the better. In general, I still would recommend you’d go over to the fresh meat, and you can make those quite convenient as well. If you get a family pack of chicken and just cook it on the crock-pot, it’s just as convenient when you do that as the deli meat, really, other than that one step. I usually recommend that if you want some chicken or whatever; use that to make a sandwich.

Melanie: Now, we’re moving around the store, Elizabeth, the milk and cheese and yogurt in the dairy department. There’s a lot more dairy-free options these days. Is it healthier to be drinking almond or soymilk or eating dairy-free cheese? Should we be looking for caseinon the labels? What should we be looking for?

Elizabeth: In my opinion, I think that dairy clearly wins nutritionally. There’s a lot of people out there that are suggesting otherwise. I do think that there are intolerances that people have, and certainly, that is real. But I think a mainstream person that doesn’t have that issue, such as lactose intolerance, I certainly think doing plain dairy gives the best nutrition, best bang for your buck. The way I compare it, it’s kind of like breast milk. What they’re trying to do is make almond milk similar to dairy by adding some protein to it. I’ve seen ones that are fortified to be like that. It’s best to do the more natural thing, but they’re making those other food products similar, if that makes sense.

Melanie: Well, it does, and that’s a good answer. So we can really try the more natural. Stick with milks and yogurts and cheese unless we have some insensitivity.

Elizabeth: Right. And there is some nutritional benefits to those other things. But again, it’s kind of like breast milk versus formula. They’re trying to make them like those things, but in general, I think nature does better than humans do at making food.

Melanie: Well, I know we’re supposed to be talking about the perimeter of the store, but we have those busy nights, and sometimes we like to throw in a frozen dinner. Are there any frozen foods, Elizabeth, that are healthier than others? Because sometimes I walk by those bags of prepackaged chicken and vegetables and they say, “You throw them in a pan and cook them and you’ve got this voila dinner.” But then I think to myself, “I can buy chicken and vegetables and throw them in a pan, too.” But sometimes it is faster to use those bags. What do we do about that?

Elizabeth: I think there are some healthier options. Of course, if you did it yourself, it is better. But yes, everyone does have some busy nights sometimes. If it’s chicken or meat or something in there, I’d try to make it so they’re not breaded ideally, because then there’s more processing going on there and more unnecessary carbohydrates, typically not healthy. If you’re doing a frozen meal, I’d maybe look for ones that are low fat, try to have less than 3 grams of fat per hundred calories. I would look for ones that have whole grains in them if they’re starches; try to have them mostly meat and vegetables and maybe a little bit of whole grain. They have come a long way. They used to be less healthy options, but I think you have to be smart about it. Look at the ingredients. Try to have the least amount of ingredients as possible.

Melanie: So it’s still all about reading those labels and knowing what you’re getting. What about frozen or canned vegetables? We’ve talked about certainly fresh fruits and vegetables are always going to be the best. But do they have the same properties if we get canned vegetables, peas or corn or asparagus or something in a can?

Elizabeth: You do lose some nutritional benefits while they can. However, it’s all relative. I’d rather have you snack on that or eat that than a processed junky cheese puff or something like that. And I’ve had some patients that have food allergies and such that can only tolerate really well-cooked or canned. And there is still some nutritional benefits. If given the option, it’s better to have fresh or frozen. In fact, frozen, they’re pausing the degradation process of those fruits or vegetables, and so they actually have higher nutritional benefit when they are frozen. But you do lose a little bit in cooking if you’re choosing to cook vegetables today. I would just say in general, the more fruits and vegetables you have, the better, and try to keep it fresh or frozen if you can.

Melanie: So the bakery is definitely one that’s on the perimeter of the stores. It’s usually somewhere around the produce. Does that give us permission to buy cake and cookies, or what should we be looking for in the bread department? If they’re selling fresh bread, fresh-made bread with seeds and things on them, what should we be looking for?

Elizabeth: I often hear this with my patients that they think it’s a good bread if there’s all those little seeds in it, I often hear people say. What matters more than if there’s seeds in it is if the actual flour itself is a whole grain. And you might not be able to know that unless you look at the label. I always tell people the important word is the word “whole,” whether it’s whole rye, whole wheat. If you’re talking bread, the best would be if you bought whole grain bread from a bakery. There’s maybe five ingredients in it. The next best thing if you got a hundred percent whole grain from the grocery store, that’s going to be have a little bit more on the preservatives. Then you won’t have to put it on the freezer like you would on processed bread. And then, the next test would be a partially whole grain, and then I wouldn’t even bother with the white, to tell you the truth.

Melanie: So if our listeners take one thing away from this podcast, Elizabeth, what’s your best advice for making healthy choices at the grocery store?

Elizabeth: I would say the more whole, minimally processed food that you can do and try to make things yourself. There are shortcuts that we don’t have enough time to talk about today, but I gave a few along the way. We’re all busy, but it’s worth our health.

Melanie: Well, it certainly is, and you’ve really given us some good tips and workable information so the next time we go to the grocery store, we can really shop smart. 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. Thank you so much of listening.
Hosts Melanie Cole, MS

ADHD: How Can I Help My Child Concentrate In School?

Additional Info

Segment Number 1
Audio File allina_health/1522ah5a.mp3
Doctors Bishop, Lisa
Featured Speaker Lisa Bishop, MD – Pediatrics
Guest Bio Dr. Lisa Bishop is board-certified in pediatrics and sees pediatric patients at Allina Health Maple Grove Clinic. She has professional interests in adolescent health, ADHD, NICU graduates, autism, heart diseases and metabolic disorders.
Transcription Melanie Cole (Host): ADHD can be especially challenging for children at school. How can you help your child be their most successful? My guest today is Dr. Lisa Bishop. She’s board certified in Pediatrics and sees pediatric patients at Allina Health Maple Grove Clinic. Welcome to the show, Dr. Bishop. Tell us a little bit about ADHD. How would you summarize it, and how is it diagnosed?

Dr. Lisa Bishop (Guest): ADHD is Attention Deficit Hyperactivity Disorder, but it can also be attention deficit disorder without the hyperactivity. It is a disorder of attention and focus, but it’s also a disorder of other things like executive function, processing information, filtering out unwanted information. So it is attention, but it also extends into other areas which affect learning, affect interactions with other people at a social level. Its diagnosis, there’s no single-sstep process to say this is how we diagnose ADHD. However, it’s generally diagnosed based on defined symptoms—symptoms of poor impulse control, symptoms of poor attention, often poor organization. So it’s defined by the American Psychiatric Association Diagnostic and Statistical Manual. These criteria which were set out, you’re looking at a questionnaire, usually the Conners questionnaire, which is given to schools and the parents. The symptoms of ADHD must be present in more than one environment. So if it was just present at school, we will look for something related to maybe something specific with that school. So it must occur at home and in school or at home and at work, so in at least two environments.

Melanie: At what age might parents start to notice some symptoms? What should they look for? Because a lot of parents, Dr. Bishop, say, “Oh, he’s just a boy,” or, “He’s all boy,” or something like that. What might they notice at what age that would signal something is wrong or a red flag?

Dr. Bishop: Often, parents will pick up something is different even by age two, because a child may be a little bit more active, may have more impulse control, although most children at that age will have more impulse control and focus. But they may just be more distractable. They may need to be told more times than a child without attention deficit disorder, which can be very frustrating for parents. But usually, most of the data that we have is based on school-age children, so children who are six and up. But parents will often notice it first. Parents who send their children to things like preschool, they’ll often get reports saying your child wasn’t listening, we had to tell them it’s not time, or they forgot their shoes, they forgot their papers. Parents will often get information from other people and won't be aware themselves earlier than school age. But the biggest things that parents will notice or that they will hear from other people will be that the child loses things, they have to tell them several times, and evidence of poor impulse control, such as hitting another child or throwing things or having poor emotional modulation. So they may be more upset and maybe more excited. If a child is having those types of behavior and it’s affecting how they’re learning or it’s affecting interactions with others, those can be red flags.

Melanie: What help can a child with ADHD diagnosis get at school? Because if they’re disrupting the classroom or they can't follow in the mainstream line of thinking, what do they do? What can a parent do to work with the schools to get their child the best education to ensure that success?

Dr. Bishop: With ADHD, first thing that should be done is getting a diagnosis. Actually having a diagnosis is very helpful so that you can say, “Look, my child has a neuropsychiatric diagnosis,” so that it’s not just because they’re willfully not paying attention or they’re willfully letting their minds wander during class, which often is helpful because one of the first things as their parents to understand what this process is. Because if parents understand that this is not a willful disorder, that the child is not just wanting to not pay attention or that they’re just ignoring instructions on purpose but very often they’re missing a lot of that information. So if parents can understand that this is a neuropsychiatric disorder and that there are certain things that are going to be difficult for them, it’s like if a child is in a wheelchair, there’s certain accommodations which can help that child to have the same access to things as their peer. And it’s the same with ADHD. Or someone has described it as getting glasses. So if you have your child who doesn’t have glasses and they’re wandering around and bumping into things, there’s certain accommodations. One of them is getting glasses. But just helping them to have the same access as their peers. That’s the first thing is for parents to understand the disorder. The second thing is to help teachers understand the disorder as well and, again, that it’s not just willful, that the child is lazy or that they just don't want to pay attention. So helping them to understand is a really helpful thing as well. And then working as a partnership. So there are several things in legislation that can help children with attention deficit disorder have access to an environment with greater accommodation. And there’s two processes. One is the 504, which is based on the Rehabilitation Act and it’s actually an employment law. And that is designed to level the playing field, so to provide some accommodation for children with ADHD, things like maybe having a check-in at the end of the day at school or in the morning. But it doesn’t provide as much protection or as much accommodation. There’s not funding attached to 504 through the ideal legislation, which can offer further help from the Department of Special Education. And that actually has a very similar criteria. So the diagnosis is the first thing, and then having that diagnosis impair aspects of learning for the child so that because they have this diagnosis, they’re unable to learn as well or they’re disorganized, which prevents them from learning as well as their peers. And so, getting those things started out. And organizations like [Pacer] or looking at a website like CHAD. There’s place for attitude and ADD that can actually help parents navigate the system. But for parents who just want the initial “let’s try to help these symptoms without taking it further,” one of the things is the understanding, and then also for that particular child. Because not all children with ADHD are the same, just like not all children are the same. So if that child has a real problem of forgetting things, again, that check-in in the morning and check-in at the end of the day is a very helpful thing. Kids with ADHD are often visual learners, and so when you have them at home, you can have a very colorful chart for them to actually tick a box if they’ve done or completed a task. If between the homework to have a place, the same place, same timing every day and having it as clutter-free as possible so they can have that quiet in getting their homework done and then having it very structured. The other thing is having frequent breaks, because kids, they will have their focus, but after a period of time, kids with ADD are really going to struggle. And at that point you’re not going to get good information or good learning until they can have a break and just move around physically. The other thing is sometime stress balls, where that can help them to actually focus. Because kids with ADD, they use something called the basal ganglia, which is part of our brains associated with movement. And that helps them to encode information. So often when they’re wandering about and they’re walking about and they’re learning something, that can be helping them actually learn that subject matter. And that’s where the stress ballscan be helpful. Or sometimes they can have the balls to sit on to provide extra sensation or texture while they’re trying to learn a material.

Melanie: Dr. Bishop, in just the last minute—we’ve run out of time now, and I’m sorry because it’s such great information—please give the listeners your best advice on ADHD and their children to assure a successful outcome in their school-age years.

Dr. Bishop: First of all, understand what the disorder is, that your child is not a bad child. The second thing is to work as a partner with the school and plan early. So talk to your teachers before you start the year, to plan, to try to avoid possible issues that you know that may come for your child, like the organization or self-esteem issues. So, to plan and to partner early.

Melanie: Thank you so much. It’s great information. More resources for additional information about ADHD can be found from your child’s pediatrician at allinahealth.org, at the Centers for Disease Control and Prevention at cdc.gov, and the National Institute of Mental Health, nihm.com. 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

Urologic Cancer and Urinary Stones

Additional Info

Segment Number 5
Audio File city_hope/1516ch5e.mp3
Doctors Hannoun, Donald
Featured Speaker Donald Hannoun, MD
Guest Bio Dr. Hannoun attended medical school and completed both an internship and residency at the Keck School of Medicine, University of Southern California, where he was elected to membership in the Alpha Omega Alpha Honorary Medical Society. He is the recipient of multiple awards and honors including the Dean’s Recognition Award from Keck and was recognized as Intern of the Year, by Keck’s Department of General Surgery. In addition, he was awarded Resident Teacher of the Year from Keck’s Department of Urology in 2009.
Dr. Hannoun is an active member in several professional organizations including the American Urological Association and the Los Angeles Urological Society. He has presented several abstracts for the Proceedings of the Western Section of the American Urological Association and has written several articles, abstracts and book chapters.

Learn more about Dr. Hannoun
Transcription Melanie Cole (Host): At City of Hope, our physicians are leading experts in treating patients with all type of urologic cancers. Just as no two patients are alike, cancer requires a unique treatment plan tailored to each individual to attain the best possible outcomes. My guest today is Dr. Donald Hannoun. He’s a urologist at City of Hope. Welcome to the show, Dr. Hannoun. Tell us what constitutes urologic cancers.

Dr. Donald Hannoun (Guest): Yes. So, urologic cancers are cancers that take place anywhere along the tract of the urinary system. This starts at the level of the kidneys, and there’s these long tubes that connect the kidneys down to the bladder called the ureters. And then obviously, urine is stored in the urinary bladder until it’s a safe and appropriate time to empty the bladder, and then the urine goes down through the prostate in males down out the urethra, or in females, right out the urethra. So a urologic cancer is a cancer that arises anywhere along that flow of urine.

Melanie: There are some other conditions besides cancer, such as urinary stones. What are they, and who is at risk for them?

Dr. Hannoun: Urinary stones are precipitations or substances that are oversaturated in the urine and then can precipitate out of solution into a solid substance. For example, if calcium is present in really high concentrations in the urine, especially in somebody who is relatively dehydrated, these calcifications can form with other substances to make solid substances within the urine, and this can then grow. And this is what forms urinary stones. While there are multiple, multiple risk factors for kidney stones, the number one risk factor really is dehydration. And then the other risk factors are underlying predispositions based on how a patient’s kidney handles calcium and other substances, and these can also lead to precipitations or urinary stones.

Melanie: What’s the difference between urinary stones and kidney stones?

Dr. Hannoun: You know, they’re really same things. It’s just based on the locations. Just like how we mentioned urologic cancer is a cancer that can take place anywhere in the urinary system, stones are very similar. Stones will form in the kidney usually, and then if they’re in the kidney, they’re called kidney stones. If they try to make their way down those long tubes that we discussed, sometimes they can get stuck along the way, then they’re considered urethral stones. If they make their way into the bladder, then they would be considered bladder stones. So a urinary stone is a very nondescript term for a stone that could be anywhere along the urinary system. A kidney stone, you’re typically describing a stone that’s still in the kidney itself.

Melanie: So after they’ve developed, how would you know? Because we’ve heard that kidney stones, for example, can be quite painful to pass. How would you even know that you have them?

Dr. Hannoun: That’s an excellent question. What’s scary is that sometimes, if you have a kidney stone that had not made its way down yet, it can actually be completely silent, and you will never know you have one unless you had an imaging study done for another reason, or let’s say you saw some blood in your urine, this would often prompt a physician to order some radiologic studies, and this could find the stone. Otherwise, if you begin to experience symptoms, it would typically be on either the left or right side, depending on where the kidney stone is. And if it makes its way down, typically, you would feel pain on that one side and what we call the flank or the side or the upper back area—not in the middle of your back, but really more on the side. And then as that stone makes its way down closer to the bladder, that pain can actually do what we call radiate. It can actually move down towards the groin area, and then once it gets into the bladder, if it does make its way into the bladder, you can begin to experience more urinary symptoms, so maybe not so much pain but rather urinary frequency and urgency or feeling like when you need to go to the bathroom, you need to go to the bathroom much quicker.

Melanie: So what’s the treatment for these? Are they something that you just have to wait until they go away, or is there something that can speed the process along a little bit?

Dr. Hannoun: Yes, that’s a very good question. And that really depends on multiple factors. The biggest factor that dictates the treatment of a stone is the size of the stone. Smaller stones obviously have a much higher chance of passing on their own; larger stones do not. Sometimes, getting an idea, if the patient has previously passed stones, this will tempt you one way or another whether or not these stones can be observed and allowed to pass on its own. For example, a patient who has previously passed stones, they can pass the stones on their own. Patients that have never passed a stone before may have a tougher time, so it really depends on the size, the patient’s history, its location. Stones that are located closer to the kidney have a harder time passing. Stones that present closer to the bladder, meaning they’re further down in the urinary system, have a much higher chance of passing on their own. So that’s another thing. And then also time. Typically, if a stone has been stuck there for anywhere from two to four weeks and has not moved, then in that case, typically, you need to act on it. There are some medications that can help stones pass, some medications that are similar to Flomax, which we give for older men with prostate problems. These can help the stones pass. But typically, if either of those treatment plans fail, then typically you’ll have to move to surgery.

Melanie: Is this more common in men or women? Do men seem to come up with kidney stones or urologic stones more often than women? And do urinary tract infections, which women seem to come up with, do they contribute to this at all?

Dr. Hannoun: That’s another very good question. If you went back about 15 years ago and prior to that, the incidence of kidney stones in men outnumbered women about 8:1. Now, if you look at those numbers, that gap has narrowed, and it’s narrowed down to about 3:2—meaning now, for every three men that develop kidney stones, about two women will develop kidney stones. And the reason for that change has been because of the epidemic of obesity in our country. So obesity turns out it’s actually a risk factor for certain types of kidney stones. Now, as far as your second question, whether or not women who have a higher risk of urinary tract infections, can they get more kidney stones? Urinary tract infections can contribute to kidney stone formation, but it has to be from a specific bacteria that causes the infection, and the infection has to be in the kidney. In those patients, yes, urinary tract infection can be a predisposition for certain types of kidney stones.

Melanie: You mentioned at the beginning dehydration. Are there any other sort of behavioral modifications, lifestyle, things you’d like to recommend to the listeners for prevention?

Dr. Hannoun: Yes. For patients that are known kidney stone formers, the general recommendations for the best diet to try to prevent future kidney stones development or the growth of a present kidney stone is to maintain a low-sodium diet, which is typically less than two grams. There’s been a lot published in the literature whether patients who develop kidney stones, should they cut out calcium from their diet or do they not need to, and it turns out it’s actually neither. They neither should take calcium nor should they cut out calcium. But rather, they should continue taking the normal recommended daily elemental calcium intake, which is anywhere from 800 to 1,200 mg of calcium a day, and then the last recommendation is to try to not overconsume a lot of animal protein. So this is overconsumption of chicken, red meat, fish, not overconsuming these substances because these can also contribute to kidney stones. To summarize, low sodium, low animal protein but to continue the normal recommended calcium intake.

Melanie: That’s great information. Thank you so much, Dr. Hannoun. 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

Could Your Food Be Making You Sick?

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Segment Number 5
Audio File allina_health/1518ah3e.mp3
Doctors Bell, Debra
Featured Speaker Debra Bell, MD – Integrative, Complementary Medicine
Guest Bio Debra Bell has more than 25 years of experience in conventional medicine, and complementary and alternative medicine. As part of her practice, she is skilled in the use of vitamin, nutritional and dietary supplements, and diet and lifestyle changes. She tells family and friends that the key to good health is paying attention to how you feel physically and emotionally, what you eat, and what gives you joy and meaning. In her spare time, she enjoys gardening, cooking, cycling, kayaking and being with family and friends.
Transcription Melanie Cole (Host): Food allergies and food intolerant and sensitivities can affect how you feel and lead to chronic symptoms like stomachaches, fatigue, or joint pain. But it can be a challenge to determining exactly which foods aren’t sitting right with you. My guest today is Dr. Debra Bell. She’s an integrative medicine family physician at Allina Health Penny George Institute for Health and Healing. Welcome to the show, Dr. Bell. Tell us a little bit about food allergies. Is it pretty common these days? Is it getting more common?

Dr. Debra Bell (Guest): Well, the answer to that is that food allergy is a big word. In general, food allergies are specifically that a person has a reaction soon after eating a certain food, and that would be something that your immune system is overreacting. Those are becoming more common. People hear about people having peanut allergies or children having severe allergies, and those are more common. There are also things that many people call food allergies that are not the same as those kinds of food allergies where you would have a specific reaction right after eating, like trouble breathing or swelling or hives or something like that. So it’s a big category in terms of what people think of when they hear “food allergy.” But technically, we’re talking about immediate hypersensitivity reaction from the immune system is technically what a food allergy is.

Melanie: What are some of the most common causes of food allergies?

Dr. Bell: The most common causes would be things like nuts and certain fruits are the most common that people have. Some people will have food allergies also to dairy, and of course celiac disease is actually an immune sensitivity to gluten, which is what’s in certain grains.

Melanie: And we hear a lot more about as people get older they develop food allergies that they didn’t have when they were younger, or is that an intolerance to fish or shellfish, things like that?

Dr. Bell: Yes. There is what’s called the delayed hypersensitivity response food allergy, and that would be the kind of thing that would develop later in life. That would be the kind of thing that somebody might develop over time. For instance, celiac disease is actually a delayed hypersensitivity response. And so that can happen as we get older that basically, our immune system, there’s something else that’s going on in our body, other exposures or other things that are increasing inflammation that sort of turn the dial up so that we begin to have more reactions. Our immune system becomes more reactive. And then in the same way, there are food intolerances which are still creating an immune response but is a different kind of immune response than from specific food allergies, and those also can develop as we get older based on all the other things that are happening in terms of exposures and our digestion and things like that.

Melanie: You mentioned food allergies and it being an urgent situation. It can be. What kind of symptoms would someone have if they have a food intolerance or a sensitivity?

Dr. Bell: That can be very broad. One of the most common things for food intolerance or a food sensitivity would be gastrointestinal complaints. And so people might have bloating or nausea or abdominal pain or diarrhea. Those would be the most common. But people can also have broader things like skin rashes. They can have joint achiness. People can have depression or difficulty concentrating or what people might call brain fog. And also, people can have fatigue. Those are symptoms that can be associated with food intolerance.

Melanie: When we’re talking about food sensitivities, you mentioned celiac, and we hear about gluten so much in the media. Are people reacting to this? Is this an overreaction, or are we truly getting oversensitive to gluten?

Dr. Bell: Well, I think both. I think that people are overreacting. Anytime anybody has anything wrong with them, people will always say, “Oh, it’s from gluten.” But the fact is that most people tolerate gluten quite well. There are many complicating factors though. What is in our grain now in the American agricultural realm is actually quite different than what we might have had 50 years ago, and so some people speculate that some of the sensitivity and intolerance is not actually the gluten but is to the modified grains and the various chemicals and pesticides that are used to grow those grains. That’s something that sometimes causes people intolerance. And then again, because we have so many different kinds of exposures and our food chain is not as great as it used to be, there are people who are sensitive to gluten. And gluten is a protein that is in certain grains, and so there are more people who have celiac disease that they’re used to, but it’s a small number. And now there’s a group of people who have what would be called non-celiac gluten intolerant. There are many more people with that than there were 50 years ago, but it’s not nearly as many as you might hear in the media or the public that blames just about everything on glutens.

Melanie: If you have some of those symptoms you’ve described, Dr. Bell, if they suspect that their eating might be what’s causing this bloating or nausea or any of these symptoms, what’s the first thing they should do?

Dr. Bell: I actually think that if people are having symptoms, it’s not a bad idea actually to seek professional help and make sure that you don't have celiac and that everything else with your digestion is normal. And then under guidance of a professional, consider doing an elimination diet. And whether you’re just doing elimination diet with gluten or you’re doing elimination diet with gluten and dairy or you do a more extensive elimination diet would be something that you would work out with the professional that you are working with, and that would be a skilled nutritionist or an integrative medicine practitioner. Because I think that one thing that I'm finding is that there are some people now who are eating extremely restrictive diets and actually are not having the right nutrients that they need—they’re losing weight, they don't feel well, and it’s because they’re not getting nutrients from being too restrictive. So you really want to do it under guidance in a very systematic way. We have people eliminate just for two to four weeks and then do a very systematic re-challenge so that we can gather information about whether or not someone really does have the food intolerance.

Melanie: What else would you do if they have that food intolerance? How would you treat it if you find out that this is really something that they’re intolerant now? Do they have to stay away from that food permanently? Is reading labels going to be a big part of this, or can they gradually reintroduce that food?

Dr. Bell: Well, again, it depends on the person and the situation. Most people do need to eliminate it for one to three months. Now, again, in integrative medicine, we often think that sometimes somebody’s food intolerances have to do with the health of the digestive tract and the general health of immune health. And so we do many other things to improve that. We improve other aspects of the diet to avoid exposures of excess—excess sugars, excess fats, excess processed foods, which can also just heal the gut over time. We try and avoid unnecessary antibiotics. We pay attention to making sure people are having enough sleep, stress reduction, and then we sometimes will use probiotic capsules of very specific kinds of bacteria to help to rebalance the environment of the gut. So there are a lot of things that we do for gut health, immune health, stress reduction and general healthy nutrition that then help to improve things so that people may be able to tolerate the substance either in moderation, which would be once or twice a week, or gradually be able to reintroduce it back in their diet over a four- to twelve-month period.

Melanie: In just the last few minutes, Dr. Bell, if you would, what’s your best advice for people that might think that they’ve got food allergies or intolerance or sensitivities? And you can even include prophylactic probiotics, taking those. Just give us your best advice.

Dr. Bell: Sure. The first thing that I would recommend to people is to eat real food. I recommend that people read labels. If they can't pronounce a word on the ingredients or they don't recognize that word as a food, then they should put that back on the shelf. And they should attempt to really eat as much whole food as possible, shopping the perimeter of the grocery store and trying not to eat out of the box. That’s the first thing. Many people will eliminate all the processed foods and eat more of a whole food diet and their symptoms improve just from that. Then after that, taking a good quality refrigerated probiotic. And one way to know that it’s good quality is that it actually says on the label, “guaranteed until the time of expiration,” not just at the time of manufacture. And that’s also something that’s acceptable for people to do. The final thing is to try and keep a bit of a food and symptom diary and see if you do notice any direct associations of when you’re eating something and when you’re having a symptom. That’s a good beginning of just beginning to observe and watch and paying attention to our body. It can give us a quite a lot of information right from the start.

Melanie: Thank you so much. It’s really 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

Pancreatic Cancer: Diagnoses, Treatments and What's New in Research

A timely and accurate detection of pancreatic cancer is essential to planning the best course of treatment.

Since it is usually diagnosed at a later and more advanced stage, pancreatic cancer can be a difficult disease to treat.

Thus, therapy needs to be rapid and aggressive — requiring the expertise of experienced specialists — to ensure optimal results and best chance at a cure.

Laleh G Melstrom, MD is here to discuss pancreatic cancer and all City of Hope's research, diagnoses and treatments.

Additional Info

Segment Number 4
Audio File city_hope/1516ch5d.mp3
Doctors Melstrom, Laleh G
Featured Speaker Laleh G Melstrom, MD
Guest Bio Laleh G. Melstrom, M.D., M.S is an assistant clinical professor in the department of surgery, specializing in hepato-pancreato-biliary (HPB) surgery and melanoma surgery. Dr. Melstrom earned her undergraduate degree from Johns Hopkins University in Baltimore, MD, then went on to receive her medical doctorate from Weill Cornell Medical College in New York. Dr. Melstrom then completed her residency in general surgery at Northwestern Memorial Hospital in Chicago, and also completed a research fellowship in a pancreas lab at the Robert H. Lurie Cancer Center of Northwestern (2005 – 2007). She was awarded a Master of Science degree in Clinical Investigation from Northwestern Feinberg School of Medicine. Dr. Melstrom then went on to Memorial Sloan-Kettering Cancer Center (2010 – 2012), where she completed a Surgical Oncology Fellowship.
Transcription Melanie Cole (Host): Pancreatic cancer is one of the most challenging diseases to treat since it rarely shows symptoms in its early stages. However, aggressive therapies and specialized care can significantly improve outcomes and increase the likelihood of a cure. City of Hope has one of the most experienced pancreatic cancer programs in the United States with a multidisciplinary team that takes an integrated approach to fighting cancers of the pancreas. My guest today is Dr. Laleh Melstrom. She’s an assistant clinical professor in the department of surgery specializing in liver and pancreatic surgery at City of Hope. Welcome to the show, Dr. Melstrom. Tell us a little bit about pancreatic cancer. What’s the difference? People hear exocrine tumors, eyelet cell tumors. Tell us some of the differences that we might hear so that we can better understand the difficulty and challenge that goes with this disease.

Dr. Laleh Melstrom (Guest): Thank you, Melanie, for having me. Pancreatic cancer comes in several different varieties. The pancreas gland, its job is multifactorial. One, its job is to make hormones like insulin to help you regulate your blood sugar. There are other cells in the gland that make other types of hormones to help regulate blood sugar, and based on that, there are tumors that can arise from those cells. Those are termed neuroendocrine tumors. You can have functional or non-functional neuroendocrine tumors. If they’re functional, they secrete hormones and patients may have symptoms. But those tumors, neuroendocrine tumors, are not what we traditionally consider pancreatic cancer or pancreatic adenocarcinoma. The other job of the pancreas is to make the enzymes to help you digest your food. The cells that make those enzymes are what we call the exocrine function of the pancreas and those cells are the cells that lead or that can develop the traditional pancreatic adenocarcinoma that we so often hear about. The challenge with the disease, pancreatic adenocarcinoma, is that it can be quite insidious, so by the time patients have symptoms, the disease has progressed relatively to the lymph nodes or to other distant sites, particularly that patients often present with pain and abdominal bloating.
On the other hand, occasionally patients will present with jaundice where the tumor is right at the head of the gland, blocking the outflow of bile from the liver. Very, very small tumors can present in this way. So I always encourage patients if you are told you have pancreas cancer, it does not mean that it’s not resectable, it does not mean that it’s late stage. Additional workup and evaluation can better tell us if you could be a candidate for an operation, which truly a 2015 surgery is really the only chance at cure and it’s always not surgery alone. It’s in conjunction with multidisciplinary care, specifically chemotherapy and sometimes radiation.

Melanie: Since it’s so difficult to catch early, is there anything that we might notice or in a loved one? Besides jaundice which means it’s already getting there, what might we notice? Is there any way to tell? Are there any signs and symptoms?

Dr. Melstrom: Well, really, with any malignancy you say, “Listen to your body.” If something is not right and it’s persistently not right, you need to get it evaluated. Sometimes it may take several trips to the physician or potentially to gastroenterology if you’re having abdominal bloating, weight loss, early satiety or getting full very quickly, reflux that’s not alleviated by normal acid blockers. These are all potentially signs that something is not right. I’m not saying that those are definitive signs of potential pancreatic cancer, but if your body’s biology and physiology is not behaving as it has for many, many years, something has changed, I would persist on getting that evaluated. Sometimes, it takes several tries, or sometimes it takes several physicians to sort out that, sure, a CAT scan is warranted to see potentially what’s going on.

Melanie: Are there certain risk factors? Is there a genetic component to pancreatic cancer?

Dr. Melstrom: Sure. Familial or the genetic pancreatic adenocarcinoma is comprised of very, very small proportion of all pancreas cancer, but there are certain known mutations that increase your risk of developing it, specifically the BRCA mutations that we often associate with breast cancer. Those folks have an increased risk of developing pancreatic cancer and perhaps could be offered surveillance CT scan. That’s number one. Number two, there is something called the p16 mutation. Those folks are also at risk of developing pancreatic adenocarcinoma. When you first meet a patient, as a physician or as an intern, if you do their family history, if they have an extensive history of gastrointestinal cancers, melanoma, and breast cancer, those should all be signals in your mind that potentially this patient could be at risk of developing pancreatic cancer, and imaging or more careful monitoring is warranted.

Melanie: Tell us about the treatments. You mentioned that surgery is definitely something you have to do now along with other multidisciplinary approaches. What is going on in the world of pancreatic cancer? What’s exciting in the research and surgery? Because we hear, Dr. Melstrom, about the Whipple procedure, this big, huge procedure, what’s going on in your world?

Dr. Melstrom: It has been, over decades and decades and decades, where we don’t necessarily change the complications associated with that operation. It’s quite a large operation. We cut a piece of the stomach, we cut a piece of the bile duct, we cut a piece of the pancreas and then we reconstruct all those three areas of division. The operation is certainly safer than it was, 20 to 30 years ago, but the potential complications still occur. We have made great advances in addressing those potential complications with interventional radiology, CAT scan, certain procedures we do in the operating room to minimize the severity of the complication. Now just like pancreas cancer, colon cancer, stomach cancer, the overall care is multidiscipline. So the sooner you can get patients recovered from their operation, the faster they can receive their adjuvant chemotherapy and the more effective it is, because the theory of chemo is you’ve taken out the macroscopic lesion and now the chemotherapy is to kill off the microscopic cell that you cannot see by eye and therefore minimize the risk of the cancer coming back. So for us, minimally invasive surgery is really the next horizon to improving the functional ability of the patient after an operation like a Whipple or a distal pancreatectomy. Whipple is what we do for a cancer in the head of the pancreas, the front part of the pancreas. A distal pancreatectomy is what we do for the tail of the pancreas. The gland itself span from the right side of the abdomen, underneath the rib cage, all the way to the left side of the abdomen. On the left side, it’s immediately adjacent to the spleen and on the right side, it’s at the base of the liver, small intestines, and stomach, so it’s really kind of a very delicate location where a lot of things in the gastrointestinal tract come together. Minimally invasive surgery is what I was getting at. Currently, we’re able to offer distal pancreatectomy and splenectomy either using the da Vinci robot, which is a tool that is, in my mind, far superior than laparoscopy because the da Vinci has the ability to move the instrument in the abdominal cavity like a human wrist so that you have that fine motor capability comparable to your own hand. Actually, the da Vinci is able to correct for any tremor in the surgeon’s hand so it’s almost a super fine detail piece of equipment. Again, we always emphasize that it is a tool; it’s not necessarily kind of an over-reaching technology. You still have to have the basic skill set and familiarity with the anatomy and the disease to do this operation.
At City of Hope, we’re able to offer robotic distal pancreatectomy, laparoscopic distal pancreatectomy and we are progressing to offer robotic pancreaticoduodenectomy or Whipple operation. The operation typically takes about four hours and the length of stay in the hospital is about seven days for a Whipple. Over time, we’ve been able to shorten the time, the duration of the operation and the length of stay, and hasten the recovery so patients can receive their adjuvant chemotherapy faster.

Melanie: Dr. Melstrom, in just the last minute or so, give your best advice on hope for the future of pancreatic cancer for people listening and why they should come to City of Hope for their care.

Dr. Melstrom: Number one, hope in that this disease, I would say after melanoma, has the greatest amount of effort and technological advancement on a molecular level. There are multiple therapies in line currently being evaluated in phase one and phase two trials for patients with specifically metastatic pancreas cancer, several of which are led by City of Hope, that are essentially the next step in care for patients with pancreatic cancer.
In City of Hope, we have three senior pancreatic surgeons; we have two medical oncologists, one radiation oncologist, and two interventional radiologists whose primary effort and goal is the care of GI malignancies. Two of us have very intensive lab effort including myself, where in every spectrum, both in activism through a pancreatic cancer network, through our research by my lab, and through our clinical care in the full spectrum, we are wholly dedicated to this disease and improving the survival of these patients.

Melanie: Thank you so much for such great information. 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. Thanks so much for listening.
Hosts Melanie Cole MS

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