Inactive (722)

Segment Number 1
Audio File allina_health/1518ah3a.mp3
Doctors London, Arnold
Featured Speaker Arnold London, MD, Pediatrician
Guest Bio Arnold London, MD is a Board-certified pediatric physician with professional interests in health counseling, vaccine promotion and circumcision.
Transcription Melanie Cole (Host): Something that parents of baby boys need to decide is if they want their baby to be circumcised. Some parents circumcise their sons because of religious or cultural or social reasons. Other parents decide not to circumcise because it may not be medically necessary. But the decision is certainly up to each family. My guest today is Dr. Arnold London. He is a pediatrician at Allina Health Bandana Square Clinic in St. Paul. Welcome to the show, Dr. London. Tell us a little bit about circumcision. Is it as routinely done as maybe it used to be? What are the benefits and/or side effects from it?

Dr. Arnold London (Guest): Well, circumcision is a procedure that’s been done since they were building the pyramids. It was a way to mark slaves indelibly at that time, and more recently, it’s done for religious or ethnic purposes. It has benefits and risks. The benefits are primarily in the first 12 months of life, babies who are circumcised are only 10 percent as likely to get a urinary tract infection as if they are uncircumcised. About 10 percent of babies who are not circumcised in the newborn period later in life requires circumcision for medical problems related to the foreskin, such as related to diabetes and infections. Finally, getting a circumcision protects adults against contracting HIV infection—about 50 percent compared to not being circumcised—so it’s better than any vaccine that’s being developed. The risks are mainly bleeding and infection. Bleeding is most common on the mother’s side if the family there is hemophilia, which is a genetic bleeding disorder where you don’t make clotting factors and the mother carries one defective X chromosome that can be given to the baby boy. And if that happens, then the baby boy can’t clot well after incisions or injuries. In general, most babies with hemophilia have a positive family history where the mother’s male relatives have bleeding disorders. The other risk is infection. Infection is very rare, as is significant bleeding after circumcision. I’ve been doing them for about 40 years, and I’ve never seen a significant infection that was in any way life-threatening.

Melanie: Tell us a little bit about the actual medical procedure of a circumcision that takes place at a clinic rather than at the hospital following the birth of the baby. Is there an advantage to one over the other?

Dr. London: The procedures are identical. Just the timing is different. There are some proponents of breastfeeding who recommend delaying circumcision until after the breastfeeding is well established at five to 10 days of age. That’s certainly debatable, and a lot of babies still are circumcised in the nursery. The procedure itself is fairly brief. Initially, the baby has oral Tylenol given for pain control, and some sugar solution is usually given to the baby to drink, which helps with pain control as well. Then an injection of lidocaine is used to block pain in the penis area. It’s given under the skin. That’s allowed to work for a minute or two before the procedure. During the procedure, the foreskin is removed using several different devices. A clamp or a Mogen clamp can be used, or a Plastibell can be used. In the clamp procedures, there is nothing left on the penis after the procedure and the skin edges are fairly well approximated. In a Plastibell procedure, a plastic ring is left on the foreskin with a ligature around the outside of it. It causes the skin downstream from the ligature to fall off, and the entire ring falls off at about five to 10 days after the procedure. After circumcision, with the clamp devices where there is nothing left on the penis, the parents have to apply Vaseline every diaper change for about five days until the incision is healed. During that time, they watch for signs of complications, such as infection or bleeding. Bleeding is pretty self-evident when it happens but very rare. Infection can be noted by babies who, for example, stop eating well, start having fever, or have redness go up the shaft of the penis from the incision. Something that is sometimes confused with infection is the fact that the head of the penis frequently becomes mattery and yellow, like a scraped knee, because of the procedure causing a little abrasion at the head of the penis. That’s totally normal and doesn’t need any special treatment other than the routine application of Vaseline every diaper change for five days.

Melanie: After the circumcision and parents are caring for the baby, just as you say, what is the difference for parents who choose not to circumcise and how they care for this new little baby’s penis and teaching the baby on down the line what to do?

Dr. London: Well, the foreskin does not retract back behind the head of the penis in most children until they’re five to 10 years of age. Until that time, when it’s easy to pull it back, nothing need be done at all about the underlying head of the penis. The foreskin is just treated like the rest of the body and washed with soap and water when needed, and no special care need be done. Only when it gets quite lose and it’s easy to see the head of the penis through the pulled back foreskin is that the time when one would recommend starting routine retraction and cleaning underneath the head of the penis.

Melanie: When somebody asks you for your advice on whether or not they should circumcise—is this painful for the baby, will it create a stigma in their later life if we don’t circumcise—what do you tell them? What is your best advice?

Dr. London: Well, every 10 years or so, the American Academy of Pediatrics reevaluates the risks-benefit ratio of circumcision, whether it’s worth doing or not. More recently, about a year ago, the last reassessment emphasized that the risks are much less significant than the benefits. It’s a good idea to consider it, although it’s totally up to the parents. We don’t try to talk anybody into it. We just try to give them the facts of the benefits and the risks. If the father is circumcised and he wants his son to look like him, then that’s a factor. I think it’s a good idea. Some of the insurance payers such as medical assistance has stopped paying for circumcision about eight to 10 years ago because they didn’t consider it medically necessary, but I think they are going to reconsider that over the next few years as more and more evidence of HIV prevention is presented.

Melanie: Wow, that really is amazing. In just the last minute, if you would, just tell parents what you want them to know about circumcision and making that decision.

Dr. London: Well, for some people, it’s not much of a decision to make because their ethnic groups don’t routinely circumcise, and that’s fine. If you’re wondering about the risks and the benefits, that’s really what drives the decision for most parents these days who are willing to consider it. And I believe that the benefits outweigh the risks. Preventing HIV is a pretty cool benefit. Preventing urinary tract infections is desirable. There is more risk at doing circumcisions later in life. I do them up to two months of age, while most pediatricians do them up to two to four weeks of age. Doing them after a year of age has more complications, so it’s better if you’re going to do it to do it in the first month or two of life.

Melanie: If you have any questions about whether or not to circumcise your baby, speak to your pediatrician. Get the facts. Get the information, and then make your decision as a family. Thank you so much, Dr. London. 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 so much for listening.
Hosts Melanie Cole, MS

Low Testosterone in Men

Additional Info

Segment Number 3
Audio File yakima_valley/1511yv3c.mp3
Doctors Shively, Norm
Featured Speaker Dr. Norm Shively, Yakima Urology Associates
Guest Bio Dr. Norm Shively is a board certified urologist for Yakima Urology Associates. Dr. Shively received a bachelor’s degree at Whittier College, a medical degree at Oregon Health Science and continued his education with a surgical/urology internship at the University of New Mexico. Dr. Shively completed a medical mission in South Africa before completing his urology residency in 1988. He is active in several professional organizations and previously served three years as Chief of Surgery.
Transcription Melanie Cole (Host): Testosterone is the hormone that puts hair on a man’s chest and is the force behind his sex drive. It’s the hormone that builds a man physically, building his muscles, strengthening bones, and deepening the voice. It’s normal for men to experience a gradual decline in testosterone after age 30, but the symptoms of low testosterone can mirror those of other conditions and may be quite alarming. My guest today is Dr. Norm Shively. He is a board-certified urologist for Yakima Urology Associates. Welcome to the show, Dr. Shively. Tell us a little bit about what is low testosterone and things that we hear in the media about low T and what symptoms should men be on the lookout for.

Dr. Norm Shively (Guest): Well, thank you. Yeah, low testosterone is getting a lot of press these days and we’re certainly seeing a lot of it in the office, people having questions about it. When we decide to treat low testosterone, really, it’s based on a couple of things. You alluded to a fact that with low testosterone there may be the loss of energy, loss of sex drive or libido, maybe some loss of muscle mass, gaining weight, these sorts of things. Those are sort of signs and symptoms, but also, we base treatment on documenting a low serum testosterone, which is a blood test.

Melanie: When would a man or his wife or his spouse send him in to the doctor? Because really, we women are who send our men to the doctor in the first place. Is this something you think that the women would notice first or that the men would notice and try and ignore for a while?

Dr. Shively: I would have to say I think men are worried about it. At least, when they come to see me, it’s not that they were sent in by their wife. It’s usually that they’re complaining of some things that are kind of parts of the normal aging process where they may be run down, feeling tired, and just not as strong as they used to be. Part of that is just normal parts of life. They often come in with the complaints that they’re just not strong enough and they can’t do the things they want to do. Another part of it is testosterone has quite an effect on the mind. These fellows may be a little bit depressed, may lack gumption to get up and go. They may have some kind of self-esteem or self-confidence issues. Testosterone is an amazing compound in the body and affects so many things that there are often psychological issues that will bring them in. And with all the press testosterone is getting now, we’re a society who like the quick fix. It’s like, “Oh, gee, I’m tired. I’m run down. I must have low testosterone.” We’re seeing advertising now. We’ve got these great preparations now for replacing testosterone. That’s generated by the industry. Guys are just more aware it and kind of wondering now, “Could this be low testosterone for me in why I’m so tired?”

Melanie: Tell us about the mainstream treatments. When you do actually test someone, blood test and you diagnose them with low testosterone and they’ve had all these symptoms, what are some of the treatments? And then we will start with some of those media things and maybe some natural treatments.

Dr. Shively: Well, let me back up by just saying that there’s not a pill. We don’t like to give testosterone or testosterone supplement orally because they can have some very serious liver consequences. Basically, we want to give it parenterally, which means any way but oral. There’s some transdermal preparations. There is a patch that can be worn. There are several lotions or creams that are applied usually over the shoulders or upper body. There’s even a little patch that you stick inside your gums and put a couple of little patches a day there to secrete testosterone. Those are absorbed by the bloodstream across the oral mucosa. But basically, it has to be done parenterally. Those preparations are really pretty expensive, and insurance reimbursement is kind of iffy on those. The insurance companies really don’t like to pay for this, so they’re expensive treatments. Probably the cheapest is actually getting a shot, and we have a preparation that lasts several weeks to about every three weeks. A fellow may come in and get a shot, or sometimes we teach them how to give it to themselves or their spouse give it at home.

Melanie: How often and how long does it last? Is this something that now if they have low testosterone that they’re going to have to keep a watch on for the rest of their life, or is it something that will just build itself back up once you start this therapy?

Dr. Shively: Well, that is an excellent question because it really is sort of a trap. Because once you’re on testosterone therapy, your body’s production of testosterone—that is, the testicular production of testosterone—is stopped. You’re committed to use testosterone really forever. Even if you stop it, your testosterone production will start again, but it may not reach the same level. It really is a commitment. It’s not just like, “Okay, we’ll use it for six months, boost things up, cure the problem, and that’s it.” Because once you stop it, there will be zero testosterone in your bloodstream because it’s not being produced and it takes a while for that to build up, so the symptoms will return. As good as it sounds to get started on testosterone and get the beneficial effects with increased energy and libido and drive and all that, it can be really a lifelong proposition. I think men need to know that, and I tell them that right from the get go. That’s one of the little bit controversial parts of supplementing testosterone. It’s really not just a quick fix.

Melanie: Are there other risks that might include prostate issues or BPH? Do men have to be aware of some of these before they consider starting this?

Dr. Shively: Well, I like to have a thorough discussion with the patient and discuss these things with them. The ones that I find the most satisfying to treat are guys who are profoundly hypogonadic. They have some syndrome or some cause where they come in and their testosterone is way, way down. They’re having the signs and symptoms. They have hot flashes. They have this profound fatigue, depression, all sorts of things. Then you can document the low testosterone, then it’s a no brainer. Let’s give you the stuff. But for the fellows who are just tired, it’s a little bit tougher because there are some issues supplementing testosterone. One is -- they’ll get back at me. I’ve had a few fellows or their spouse come in and say, “You know, this testosterone is not working so good because he’s now aggressive and he’s just kind of hyper.” I’ve had some wives actually ask me not to give it. You mentioned prostatic enlargement. Prostate is an organ that’s dependent on testosterone for its growth and can be stimulated to grow and cause some urinary obstructive symptoms, like a little bit more difficult to urinate. And prostate cancer is associated with testosterone. Now, supplementing testosterone and the presence of testosterone in the body does not cause prostate cancer. But the prostate itself, including prostate cancer cells, are stimulated by testosterone. So if a fellow has some occult prostate cancer, we give testosterone, those cancer cells are going to be stimulated to grow. Part of starting it is screening for prostate cancer with a PSA, and of course, feeling the prostate on digital rectal exam.

Melanie: In just the last few minutes, Dr. Shively, if you would, give us some natural treatments, maybe some behavioral or lifestyle modifications, things you might like men to do to increase their levels of testosterone naturally and why they should come to Yakima Memorial Family of Services for their care.

Dr. Shively: Well, I’m not sure that we can necessarily raise testosterone levels except one thing that seems to interfere with testosterone metabolism and availability is obesity. Certainly, weight loss, getting rid of excess fat stores, which tends to absorb or break down or make less available testosterone in the body is one of it. Certainly exercise, low-fat diet, weight loss are things that fellows have to do. Exercise program. Of course, they should feel better anyway. A lot of these signs and symptoms that we wish testosterone will take care really are kind of a lifestyle thing. A healthy lifestyle with good diet, exercise, weight loss, those are probably going to have more benefits and less cost associated than getting a shot, getting a preparation to supplement testosterone.

Melanie: Thank you so much. For more information on Yakima Memorial Family of Services, you can go to yakimamemorial.org. That’s yakimamemorial.org. You’re listening to Healthy Yakima. I’m Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Could Your Child Be The Bully?

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Segment Number 5
Audio File allina_health/1512ah1e.mp3
Doctors Roby, Myriam
Featured Speaker Myriam Roby, CNP – Family medicine
Guest Bio Myriam Roby is a certified nurse practitioner. Her professional interests include pediatric and geriatric care. Also a mother, Myriam uses her own experiences as a mother to understand and help children and families overcome issues at school or at home.
Transcription Melanie Cole (Host): Most parents are always on the lookout for bullies. They’re looking for other kids who might be bullying their child. What if your child is the bully? Would you be able to admit this to yourself and do something about it? It might be tougher than you think. My guest is Myriam Roby. She’s a certified nurse practitioner. Welcome to the show, Myriam. If your child has behavioral issues that you know about or they’re easily angered, they’re easily flying off the handle, are these some red flags that your child either may be getting bullied or may be the bully himself?

Myriam Roby (Guest): Yes, there are many different signs that you can look for to see if your child is a bully or may be bullied. Some of the signs you look for is being impulsive, for instance, or easily frustrated or angered when they are talking to their peers or family members or even their teachers at school. Those are some of the things you can look for.

Melanie: If your child’s always been a child that’s easily frustrated, if their homework isn’t going well or they don’t play well in sports or they’re not as popular as they’d like to be, could this be something that could lead them towards it, or are there risk factors, things that predispose a child to actually being the bully?

Myriam: Absolutely. There are always predispositions that will lead a child to possible bullying, such as if they have had trouble sleeping and going to school sleep-deprived. That usually heightens their anger, frustrations. If they’ve seen it in the home, maybe there are different things that have been going on in the home that they have experienced that could lead them to feel that they’re frustrated and don’t know how to verbalize their feelings, they act out in different mannerisms.

Melanie: You mentioned trouble sleeping. So many young kids and teenagers today just don’t get enough sleep with all the electronics and the temptations and distractions. What about the sleep issues and this bullying issue? Is there a tie in there?

Myriam: Absolutely. Actually, the University of Michigan conducted a study of 341 children, and it was found that children who have sleep problems are actually more prone to having bullying tendencies or maybe acting out in frustrating mannerisms or anger or not able to contain their frustration.

Melanie: Now you notice these things may be in your own child. Parents kind of go into denial. Always just having a rough patch or we don’t have an abusive home. Nobody’s ever been a bully around here. How do you get the parents to see this, Myriam? Because I think that’s the hardest thing. Parents are blind when it comes to their children’s faults.

Myriam: Yes. Unfortunately, parents believe that their children could not possibly be the bully and so they usually turn a blind eye to it. What we’re asking parents is to become a little bit more involved with your children. Talk to them. Have them open up. Discuss things with them and maybe during conversations, there may be some red flags, you know, noticing that they’re short-tempered. Maybe they may express that they’ve been having nightmares at night and hasn’t been sleeping very well. Maybe even talking to the teacher and finding out that the teacher has noticed that their child has shown some discipline problems that could indicate that they possibly may be bullying others.

Melanie: Is it time for counseling or is this something that a parent tries to do themselves first?

Myriam: Initially, the parent can try to see if it’s something that they can manage on their own, but we don’t want parents to feel that it’s just on their shoulders alone. There are many different individuals that are out there to help. Schools are very, very keen on bullying and they have placed many things in place to try to help parents with this, as far as school counselors, as far as the principals are willing to guide and help with that. Even if the parents have a spiritual adviser, that’s something that they can always have their children talk to, if they are unable to be open to them.

Melanie: I think one reason why parents may be hesitant to accept this, acknowledge it, is because they feel that people would blame them for their child being a bully. What about that relationship between parent and child and that dynamic? Are children that bully always a product of their parents?

Myriam: Not always. We always want to continually let parents know. It’s not always the reason that the child is a bully is a product of the home. There may be different things that the child is being exposed to in different scenes as far as at school, outside in the public, TV. You mentioned video games. Some video games have different things in there that may not be appropriate for children. They’re absorbing all of these, and as they’re growing, they’re putting their own perception on it. We want parents to know that we want them to be open with their children and be open to us and/or their school so that we can get the help that the child may need.

Melanie: Give parents some advice on how to talk to their children about their behavior in a non-threatening way so the child doesn’t get defensive, pull back, blame the parents. Give us some tips for speaking with our children.

Myriam: What you can do is usually take the child to an environment that they like. If you do date night with your child at the local ice cream parlor or if you go and do activities where you walk around the park, take them somewhere where they feel that they’re not going to be judged. Slowly just start talking to them, getting them to open up. Trust is the key. When they feel that they can talk to you and trust that you’re not going to be judgmental or you’re not going to get angry with them, they will feel that they can open up to you a little bit more and that’s how the communication starts between you and your child. Try to get them to get better.

Melanie: What about their friends? I always call them OPCs, other people’s children. If you notice that your child is hanging out—and we’re not necessarily blaming the other children for behavior of your own child—but if you notice that they’re hanging out with kids that you don’t trust or that seem to be someone you would peg as a bully, what do you say to your children about those kids? Do you start forbidding them to hang out with them? Do you say that child may not be the best choice for you? What do you do?

Myriam: I wouldn’t outright say that their friend is someone that they absolutely cannot hang out with. What you would want to do is let them understand that the different mannerisms that their friends may be expressing, such as aggressive tendencies, such as easily frustrated to other individuals, those are different tendencies that you don’t want them to display to others. This would be something that you want to let your child know. You want them to stay away from that and maybe explain to them how it can make others feel. Books are very good as far as giving different pictures and making the child understand why it would be good to stay away from some of the children. Outright saying not to associate with these children, especially if they’re in a classroom, it’s a little difficult. You just try to make them understand your reasoning to why you feel that they should not adhere or adopt the tendencies that the children have.

Melanie: In the last few minutes, Myriam, if you would, give your best advice to children dealing with bullies and to parents who may suspect that their child might actually be the bully.

Myriam: First, I want to encourage the parents and the children to really seek outside help. Your school is paramount in trying to help motivate bullying and they have counselors, teachers, other school officials that are very prepared to help with the concern with bullying, and that’s for both parents and children alike. Secondly, I would advise to speak up to anyone you trust: to your parents, to your spiritual adviser, to your teacher, to your best friend, even law enforcement, who are trustworthy individuals who can help you in your time of need. Bullying only works when the victim remains silent, so you have to make sure that you speak up as much as you can. If one person isn’t open to hearing what you have to say, go to the next person. That person may be more receptive to what you have to say. Speaking up is the key.

Melanie: That’s great advice, Myriam. Thank you so much for being with us today. 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 so much for listening.
Hosts Melanie Cole, MS

Cancer Causes and Risk Factors

Additional Info

Segment Number 1
Audio File city_hope/1516ch5a.mp3
Doctors Lacey, James V. Jr.,
Featured Speaker James V. Lacey, Jr., Ph.D.
Guest Bio Dr. Lacey is associate professor at City of Hope's Division of Cancer Etiology and a member of the cancer control and population sciences program.

To learn more about Dr. Lacey.
Transcription Melanie Cole (Host): Researchers in the Department of Population Sciences at City of Hope are working to better understand the causes of cancer, including hereditary, genetic and environmental factors that may influence a person's risk of developing cancer. My guest today is Dr. James Lacey. He's an Associate Professor at City of Hope's Division of Cancer Etiology and a member of the Cancer Control and Population Sciences Program. Welcome to the show, Dr. Lacey. Tell us a little bit about what actually –we hear about a million different types of cancer—what is cancer?

Dr. James Lacey (Guest): What is cancer? It's a good question. Cancer is abnormal growth of the normal cells in our body. What is supposed to happen as we go through life is our cells, organs, or systems are naturally growing and dying and there's an order process to that. If the cells continue to grow uncontrolled, then that becomes cancer, and that uncontrolled growth is what causes the problems we associate with cancer.

Melanie: We hear about many different causes, risk factors, things out there that can cause cancer. Tell us what you, studying etiology for a living and an expert, find as some of the most main causes and most main risk factors for cancer.

Dr. Lacey: When we refer to cancer, we're really talking about a collection of different cancers. Each cancer that occurs in a different tissue of the body, for example, breast cancer versus lung cancer is slightly different. Nonetheless, there are two common risk factors that tend to affect a lot of cancers. One that most people have heard about is smoking. Even though fewer people are smoking today, smoking is still a major cause of lung cancer and other cancers. Two other ones that people hear about for a good reason are exercise and obesity. We're learning more and more about how obesity can increase the risk of a whole range of cancers. And exercise as well, both because of its ability to maintain a healthy body weight and because of some of the mechanisms of the body, exercise seems to reduce some risks of cancer.

Melanie: What role does genetics play? People always want to know family history, and if somebody in your family has lung cancer, or lymphoma, or breast cancer, does that mean that you are at higher risk for most of these cancers? Do most of them follow a genetic line?

Dr. Lacey: We've known for years that almost every cancer is a combination of genetics and environment. And what's been really exciting in research for the last 20, 30 years is we've got much better tools now to measure the genetic component of it. Family history is one thing that captures some of that genetic risk. If a woman has a mother who had breast cancer and an aunt who had ovarian cancer, those combinations of the same types of cancers within a family in two or three generations tell us as researchers that there are some strong genetic influences on those cancers. Now on the whole, genetics are really I would say the primary cause for a subset of all cancers. For the majority of cancers that occur among older adults, it's really a combination of genes and environment, and that's where some of the work we're doing is trying to tease out the specific effect of, say, genetics plus smoking, or genetics plus obesity, to determine what's going on there.

Melanie: We hear so much about diet, nutrition. These foods are carcinogenic, these foods cause cancer, these foods don't; these foods cause, you know, fight cancer, help fight cancer. Tell us a little bit about diet, nutrition. Where are we going in the field of diet and nutrition toward cancer?

Dr. Lacey: It's been a fascinating part of our research to watch. At the broad level, if you compare populations with certain kinds of diet to populations that tend to eat different kinds of diet, you can see some distinct and real differences in the risk of cancer. So, it appears that some of those differences are real and they can turn into significant differences in cancer risk. We also know that the purpose of diet is to give our body and ourselves the energy that it need to keep living and dividing and growing. At a simplistic level, the better food we eat, the better energy those cells have. And there's a third level as well. Particular nutrients; micronutrients, macronutrients, vitamins can have specific effects on some of those mechanisms in the body, how well can our cells pick up, repair and fix little changes that might turn into cancer. So, what we see in diet is there's an attempt both to understand what does a specific vitamin or mineral or type of food do, and also at the broader level, what do patterns or types of activities mean for a person with cancer risk?

Melanie: So then when we're looking at all of those and we're thinking about carcinogens that are just part of our environment, so obviously other places you see less cancer based on their environment or what they eat or how much activity that they get in a day, but if you live in a city and you're taking the bus and you're standing by the train, are you exposing your body to more of these carcinogens, Dr. Lacey, and thereby increasing your risk?

Dr. Lacey: Yes and no, and that's where we get into the issue of how do we balance these risks to understand the risk and the benefit? We're exposed to those types of risks every day in our normal activities. Not everything we eat at breakfast is good for us, not everything we eat at breakfast is bad for us. The body is very good at both utilizing the energy we give it and also controlling those risks that you talked about. So even if we breathe in a little bit of exhaust from a bus that passes us on our walk to work in the morning, the lungs and the immune system have a very good way of taking those pollutants, so to speak, and wrapping them up in the immune system and kicking them out so that they don't affect our body. Think of the body as having a very good defense mechanism. What we see though is that sometimes either the volume of the risks that impact our body—and the tobacco smoking is a good example of this—if someone is smoking cigarette for 10 years, it overwhelms the body's ability to manage and control and get rid of those pollutants. So that's one of the ways that can increase the person's risk of cancer.

Melanie: So then if we're exposed to all of these things and our body's immune system is able to generally fight it off—I mean that must be true because the whole entire population doesn’t have cancer—what about things like radiation, naturally occurring radiation, or the radiation that we're getting from a mammogram or some of these annual exams and the X-ray? Do any of those contribute?

Dr. Lacey: When you say "contribute", we can answer at a theoretical level and say yes. But I think it's much more useful to then take that theoretical "yes" and turn it into specific information that people can use. What we're seeing in the radiation field, and take mammogram for breast cancer for example, is an ability to quantify those risks and then we can tell the public, we can tell individual patients, “This is a very small risk and we think the benefits outweigh the risks,” or we can say, “This is maybe a risk that should lead to some differences in behavior.” For mammogram, the benefits of early detection of cancer, and that's really what a mammogram is supposed to do, find those breast cancers before we would be able to diagnose them in a clinical setting, so early detection leads to better outcomes. It reduces a person's risk of dying of cancer and it tends to detect the cancer at a stage when it's still treatable. For mammograms, there is a small amount of radiation involved with those mammograms, and a wealth of research has shown that if mammograms are given to the right population at the right frequency that increases the ability to achieve early detection, then the overall radiation that that group is exposed to is small and it's an acceptable risk because the benefits outweigh that risk.

Melanie: Dr. Lacey in just the last few minutes if you would, give the listeners your best advice for where you think the horizon of cancer control, prevention, diagnosis, where that's going and why they should come to City of Hope for cancer care.

Dr. Lacey: Control, prevention and diagnosis, if we could control all of those things we'd be in good shape, but we're making real progress on each of those. Prevention still comes down to a lot of individual decisions and the things we've all heard of: don’t smoke, eat a healthy diet, exercise regularly, get cancer screening, don't be out in the sun too much without sunscreen, and know your family history. The goal of all that information is to help people prevent cancers that might otherwise occur. If we're consistently engaging in those healthy behaviors, consistently getting recommended screening exams, are good ways to prevent cancer from appearing too late. On the diagnostic front, a lot of the work at the City of Hope is targeted at trying to detect those cancers earlier. And then once we know what those cancers are, find their specific types. What at the cellular level is driving those cancers? That's where a lot of the focus then is taking that knowledge about the nuts and bolts of cancer and then using that to develop targeted therapies. We're seeing that work in a number of cancers and that's a whole lot of excitement on the field right now that this approach can be expanded to a number of other cancers and improve cancer control of the population.

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

The Future of Multiple Myeloma

Additional Info

Segment Number 5
Audio File city_hope/1512ch2e.mp3
Doctors Krishnan, Amrita Y.
Featured Speaker Amrita Y. Krishnan, M.D., F.A.C.P.
Guest Bio Amrita Y. Krishnan, M.D., F.A.C.P. is the director of the Multiple Myeloma Program at City of Hope. She is also a professor and associate director of Medical Education & Training, Hematology & Hematopoietic Cell Transplantation

More on Dr. Krishnan
Transcription Melanie Cole (Host): Myeloma is a cancer for plasma cells which normally produces antibodies to help fight infection. Left untreated, myeloma can interfere with production of normal blood cells and cause serious complications in bones and kidneys. City of Hope is the only Southern California member of the Multiple Myeloma Research Consortium, a collaboration of research organizations focused on rapidly bringing the most promising multiple myeloma treatments directly to patients. My guest today is Dr. Amrita Krishnan. She is the Director of the Multiple Myeloma program at City of Hope. Welcome to the show, Dr. Krishnan. So tell us a little bit about what multiple myeloma is, and are there any symptoms that would signal a red flag and get someone in to see you?

Dr. Amrita Krishnan (Guest): Well, thank you again very much for the opportunity to speak to you and your audience. So, myeloma is actually the second most common hematologic blood cancer in the United States. There are about 20,000 cases every year, and it’s a disease generally of older people, a median age of 72. Now, symptoms can vary. Some people in fact are completely asymptomatic and their myeloma is found often on routine blood work. Often they’re anemic or they have an elevated protein in their blood, or their kidney function may be abnormal. Other people sometimes presents more dramatically with severe bone pain, what we call a pathologic fracture—meaning a fracture that occurs just outside of normal trauma. Certainly, fractures in the back, what we call compression fractures, are often a presenting sign. Other people sometimes present with symptoms of kidney failure, fluid retention, severe nausea, vomiting, and severe blood chemistry abnormality.

Melanie: So how do you diagnose multiple myeloma if someone is experiencing some of these symptoms? Or if they’re not, is this something that would be found on a routine physical, on a blood test?

Dr. Krishnan: Well, a routine physical can certainly give you those hints, if a person is anemic or they have elevated protein. So a routine set of blood always looks at a total protein, and if that’s high, that may be a clue. Usually, that’s when patients are referred to hematologists or blood doctors to further figure this out. And then we do more specialized tests. We do something called the serum electrophoresis, which is a fancy way of saying we look at the protein and try and figure out is it an abnormal protein or is it just normal protein that your body makes, as you mentioned earlier, to fight infections. We then do I guess the hematologist’s favorite test, the bone marrow biopsy, where we look to see if the plasma cells that you have in your bone marrow are abnormally high in number. Because everyone actually has plasma cells that you also mentioned, but in myeloma you have too many, and the ones you have are abnormal. They make abnormal immunoglobulin, and often even just looking at them under the microscope they may in fact look more immature or more abnormal. Then we do a bunch of X-rays, something they call a skeletal survey, looking at the bones to see in fact if there are subtle changes in the bone, even before people have symptoms. That can also be suggestive of myeloma. And then we often collect urine samples as well to look for protein in the urine.

Melanie: So what are some of the newest developments in treating multiple myeloma? What is the typical standard of treatment, and what is changing today?

Dr. Krishnan: So that’s certainly a challenge in regards to the question of what is the standard of treatment. Because often, as patients will find, certainly they go out see a physician and they also get a second opinion, sometimes a third opinion. Many of the times, with active myeloma, those opinions may not agree. And what I tell patients is that doesn’t mean there’s a wrong answer. It just speaks to the multitude of choices to patients with myeloma now. And that’s patients from the beginning of their diagnosis to patients who have relapsed disease. So the general paradigm for patients who can tolerate it, the patients who are fit enough but we say they don’t have other what we call comorbidities, other factors playing into their health, we try and give three drugs for their initial therapy. And those three drugs generally fall into category: a category called a proteasome inhibitor, another category called the immunomodulatory agents, and then steroids.

Melanie: And now, what is changing? Is there different research going on for multiple myeloma, things that are changing? Cancer seems to be changing all the time, Dr. Krishnan. So what’s changing for myeloma?

Dr. Krishnan: So that’s the great thing and the exciting thing for those of us in the myeloma field is that change, as you mentioned, is happening, and it’s happening so quickly. In cancer, this has been an incredible couple of years. For myeloma, several things—even this year, I think, we’re going to see—that are very exciting to us in the field. For example, use of what we call targeted therapy. So, monoclonal antibodies to myeloma are probably the newest thing on the block, where we target specific antigens on the myeloma cells so that the antibodies can attack those myeloma cells specifically. We’ve shown some very encouraging results with a different variety of antibodies for patients. The other thing that’s certainly moving forward and City of Hope is one of the leaders in this is this whole concept of immunotherapy. So, using your own immune system, but re-engineering it to make it smarter to fight myeloma. And we’re looking at a variety of ways, certainly T-cell therapy probably being one of the areas where we’ve been a big leader of research. We’ve now started to explore that in myeloma as well.

Melanie: What advice do you have, Dr. Krishnan, for patients that are recently diagnosed with multiple myeloma? It’s a scary diagnosis. What do you tell them as the first thing that they should do?

Dr. Krishnan: So I agree with you. Any cancer diagnosis is frightening, and myeloma I think even more so because when patients get on the Internet, they read that the disease is incurable, they read the median survival. And sometimes it can be shorter than certainly than what they ever thought. So I would first of all caution them to take it all into context that, as we talked about, the field is changing so quickly. So in fact, some of that stats in terms of survival is certainly also changing and for the better, very much so. The other thing I would say is, really, myeloma, while it is in the hematologic cancers as one of the top ones, it’s still a relatively rare cancer compared to breast cancer, lung cancer. So I would encourage them to come and see a myeloma specialist. Now, I reckon,especially California is a huge state, not everyone lives close to a myeloma center. But also, what we do is we work with physicians in the community. The patients come to see us and we sort of recommend a treatment algorithm, and then they go back to their treating physicians in their community and we work with them, follow along their progress, and we’re available for questions, et cetera. But I think that’s probably a very important part because certainly, part of the treatment of myeloma, for example, is stem cell transplant and figuring out where to put that into a patient. Treatment is part of our expertise. We have multiple clinical trials for patients who have relapsed disease as well, and in fact we also have clinical trials now for patients who have newly diagnosed myeloma. So I really would encourage them to come to a center, at least for a second opinion to see what their options are.

Melanie: How does multiple myeloma affect bone health, and are these effects permanent? Do you give advice on building to maintain healthy bones during treatment?

Dr. Krishnan: Myeloma certainly affects bones in the sense that the plasma cells send signals to the cells in the bone that leads to what we call abnormal bone turnover. So we’re constantly turning over our bones—building it up, breaking it down, building it up, breaking it down. But in myeloma, you break it down too much and you don’t build it up. And so, certainly the best way to prevent that is treat the myeloma, so get those plasma cells to stop sending those signals to the bone. But we have other what we call bone strengthening agents, the bisphosphonates you may have heard of zometa aredia, that we use in conjunction with our anti-myeloma therapy. And then other supportive care measures: vitamin D, calcium. Exercise is tolerated, certainly. All those things together are important in terms of bone health.

Melanie: In just the last minute, if you would, Dr. Krishnan, give your best advice to the listeners about multiple myeloma, what you would really like them to know and why they should come to City of Hope for their cancer care.

Dr. Krishnan: Certainly, we have been at the forefront of a lot of some of the new drugs for myeloma, and those drugs have had a huge impact in improving survival for people with myeloma. And we also are the leader and expert in stem cell transplantation, and we are certainly one of the leaders in myeloma for that as well. So we really offer the patients this comprehensive range of care. And that really starts from the newly diagnosed myeloma patients through patients undergoing transplants through patients with relapsed disease and patients with multiple relapses in advanced myeloma. So, we can offer all those treatments for a variety of patients. The nice thing is also our doctors are integrated, so the same doctor who you see at the beginning of your journey is the same doctor who will be your doctor if you need a stem cell transplant, the same doctor if your myeloma comes back. So that’s also very nice for patients. And I think the biggest issue is obviously our expertise and our access to many, many new drugs for myeloma that have clearly markedly improved survival for patients. And ultimately, I hope that someday we’re going to be able to use that word “cure,” and I strongly believe we’re getting closer and closer to that.

Melanie: Thank you so much for such great information. You’re listening to City of Hope Radio, and for more information, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole MS

Helping Patients Recover from a Heart Attack

Additional Info

Segment Number 5
Audio File virginia_health/1516vh5e.mp3
Doctors Keeley, Ellen
Featured Speaker Ellen Keeley, MD
Guest Bio Dr. Ellen Keeley is board-certified in cardiovascular medicine and interventional cardiology; her specialties include helping patients with their post-heart attack recovery.

Learn more about UVA Heart & Vascular Center
Transcription Melanie Cole (Host): If you or a loved one suffered a heart attack, what can help you speed your recovery? What things do you need to do so that you can get back to living a normal high quality form of life? My guest today is Dr. Helen Keeley. She’s an interventional cardiologist. Her specialties include helping patients with their post heart attack recovery. Welcome to the show Dr. Keeley. So once someone suffers a heart attack, what is the typical timetable for recovery? When can they get back to normal life?

Dr. Helen Keeley (Guest): It usually takes several weeks. It depends, of course, on the type of heart attack and the severity of the heart attack. But in general it takes about two to three weeks for them to really start feeling back to their normal self, and then depending on the pumping function of their heart and how they’re doing in general, it might take another couple of weeks before they really feel as though they can get back into, say for instance, their exercise program.

Melanie: Dr. Keely, back in the day, if someone would have a heart attack, they’d be in bed for three weeks. Now with the cardiac rehab and phase one, you’re really getting people up pretty quickly, aren’t you?

Dr. Keeley: That’s right, exactly. In fact, even with some of our large heart attacks, the patient is up and around within about two days and on the floor out of the unit around that time. We encourage them to walk around with the physical therapist, and usually by day three or four, at least by day three or four, they’re discharged from the hospital, even with some of our larger heart attacks. Most of the recovery actually does happen at home and that’s why it’s still important, we believe, to really have a program set for patients when they do go home because this when all the hard work really starts for them.

Melanie: So speak about that multidisciplinary approach for as, if you would. What are some of the key elements of that post heart attack care that your healthcare team provides?

Dr. Keeley: Well, what we realized is that, again, a lot of the work for the patient and the patient’s family starts after discharge. We thought that maybe if we were to develop a clinic that where we would see the patient very early after discharge, within about a week to 10 days after discharge, that we would be able to really answer any questions that they had that they weren’t able to ask during the hospitalization or that they were unclear about during hospitalization. We are able to check their medications, make sure they’re on the correct medication and really get them referred properly to cardiac rehab, help them with their smoking cessation and do all this early on, because we find that when patients run into trouble after heart attack and they get readmitted to the hospital, this actually does occur, the majority of it, within about the first two weeks. So we feel though if we’re able to see them quickly after discharge, we’ll be able to catch anything that might be brewing and kind of nip it in the bud so that they do not get readmitted to the hospital.

Melanie: Tell us a little bit about the new clinic that you’ve helped establish for patients recovering from heart attacks.

Dr. Keeley: Well, we’re really excited about this. It is a multidisciplinary clinic. In our clinic we have an exercise physiologist, we also have a dietician and we have a pharmacist who not only specializes in arranging the patient’s medications so it’s easy to take and affordable but who also is very interested in helping patients stop smoking, and then myself. So we’re able to really, in one clinic, answer a lot of questions for the patients and, more importantly, make sure that their medications are correct, answer questions according to their medication problems that they may be having, and then also get them referred to cardiac rehab that’s close to their home. And if they, for whatever reason, cannot go to cardiac rehab which we feel though is extremely important, we try to arrange a bit of an exercise program for them to get started at least at home.

Melanie: And how do you engage them in that lifestyle management, behavioral changes that are so important after a heart attack so that hopefully to prevent another one?

Dr. Keeley: The last several weeks in the clinic, we have found that patients are really enjoying the clinic. A lot of them have brought their family members, they have lots of questions, they’re very motivated at this stage of the game to make some changes in their lifestyle, whether it be smoking cessation, starting an exercise program, and also monitoring their diet more closely to a heart healthy diet. They seem to be very motivated because they were just discharged from the hospital and, you know, it’s a scary thing to have a heart attack and a lot of things happen during the hospitalization. So when they come in, they’re a little bit more relaxed they’re able to focus on themselves, we give them personalized attention because each patient is obviously different and their needs are different, and we found that we’ve been able to really hopefully make some changes early on. The patients seem to be more motivated and more relaxed than when you’re trying to discuss these types of things while they’re still in the hospital.

Melanie: What nutritional advice do you like to give them? Is there any dietary restriction or are there things that you want them to learn about nutrition after heart attack?

Dr. Keeley: Well, our dietician Carter Buxbaum, who works with us in the clinic, is really fantastic and she has a handout about healthy heart diet. She also goes over portion control with the patients; she goes into lots of details about their specific issue. Say, for example, if someone has hypertension and she feels as though that they have too much sodium intake, she teaches them how to read the labels about the amount of sodium in their food. So truly, it’s very personalized. Some patients she recommends the Mediterranean diet for, other patients she feels as though they’re doing the right thing but gives them some little tips here and there. So in general we do teach them a heart healthy diet, but you will see that a lot of them are doing some things correctly, some things maybe not so correctly, and she monitors that and adjust it accordingly to each patient.

Melanie: And what about exercising on their own, walking, getting a bike in their home, doing any of that sort of thing? Do you encourage that or do you like them at least at the beginning to be monitored?

Dr. Keeley: We very much like them to be monitored at the beginning. We’re very much a pro-cardiac rehab. The problem is that not all patients are able to attend to cardiac rehab because it is something that you have to go several times a week and the reality of it is that some patients are not able to do it, even though we very much encourage it and any patient who can we certainly enroll them into a cardiac rehab program close to their home.
But short of that, we have found that our exercise physiologist Mitchell Adams and Courtney Connors are able to sit down with the patients and at least get them started. They have several handouts showing how to exercise safely in the first couple of weeks after a heart attack, and safety tips of exercise. They also have some very interesting applications that can be used on smartphones to help people be motivated to try to start an exercise program.
So in general, yes, we do like them to be monitored and we do advocate them to be enrolled in a cardiac rehab program. The reality is it’s not always possible, and when is not possible, then Courtney and Mitchell do their very best to start them on an exercise program that they can do at home.

Melanie: When generally can people return to work and some of those activities? What about lifting and strength training?

Dr. Keeley: Usually we ask them to wait ideally until after cardiac rehab is finished because during cardiac rehab the exercise physiologist is really able to see how they’re doing in general, especially in patients who, for example, has had a large heart attack and the pumping function of the heart is not normal any more. So we would really encourage patients to be monitored while they’re exercising, kind of do what the exercise physiologist sets out for them to do. In terms of people who have had smaller heart attacks and kind of activities of daily living, usually within the first couple of weeks, again, we advocate that patient can start walking and usually start lifting at that point probably no more than 10 pounds or so. A big exercise program involving weight probably would be something we would defer for probably a month to six weeks, again depending on the size and severity of the heart attack.

Melanie: Dr. Keeley, in just last minute if you would, give listeners your best advice about those who have just had a heart attack or whose loved one has just had a heart attack and what you really want them to know and why they should come to UVA for their heart care.

Dr. Keeley: Well, I think UVA provides just topnotch health care. Especially in our division, cardiology division, we advocate patients to come early whenever they have a sign or symptom of anything consistent with a heart attack. And remember, it’s not always classic chest pain; it can be any symptom. If the patient is concerned about it, they need to to call 911 and come early. So the earlier someone comes to the hospital, the earlier we’re able to take them to the cardiac cath lab, the quicker we’re able to open up the artery and establish normal blood flow and the smaller the heart attack will be. So the key is to come early. Once it happens and the patient does have a heart attack, then the next important thing is to modify any risk factor possible that the patient may have, including smoking cessation, control of their diabetes if they have diabetes, control of their cholesterol if they have high cholesterol, and control of their blood pressure, staying on a heart healthy diet and starting an exercise program. These are all extremely important things. So, the first thing is to come early and have the heart attack stopped as quickly as possible. The next important thing is to make important changes to decrease the chance of you having a second heart attack.

Melanie: Thank you so much for 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

Enhanced Recovery After Surgery

Additional Info

Segment Number 4
Audio File virginia_health/1516vh5d.mp3
Doctors Hedrick, Traci
Featured Speaker Traci Hedrick, MD
Guest Bio Dr. Traci Hedrick is a colorectal surgeon who specializes in caring for patients with colorectal cancer and other colorectal conditions with minimally invasive surgery.

Learn more about UVA Cancer Center
Transcription Melanie Cole (Host): A new recovery program for surgical patients at the University of Virginia Health System is helping patients to go home sooner while making them more comfortable both before and after surgery. My guest today is Dr. Tracy Hedrick. She is a colorectal surgeon who specializes in caring for patients with colorectal cancer and other colorectal conditions with minimally invasive surgery. Welcome to the show, Dr. Hedrick. So tell us a little bit about some of the typical challenges that are faced by patients when they are recovering from colorectal surgery.

Dr. Tracy Hedrick (Guest): Yes, thank you. So, colorectal surgery itself can be quite complex and patients typically after surgery, you know, as from any surgery, can have pain after surgery but also can have problems with their bowel becoming awake after surgery, so it’s oftentimes that patients are in the hospital four to five days waiting for their bowel function to return. What enhanced recovery does is allow that process occur much more quickly.

Melanie: Wow. So what can people expect? I know you doctors, you want the bowels to return, you want to make sure that they are passing gas and having a bowel movement, whatever it is that they have had done, before you let them even think about leaving the hospital. When do they get up and start moving around? Does that help speed the process?

Dr. Hedrick: Yes, absolutely. So, with this new protocol, in fact, we get them up and moving around in the recovery room because we know that that stimulates the bowel to function. So we get them up in the recovery room and then once they get to the hospital ward, we get them up again and we get them up two and three times on the day after surgery. That is very important.

Melanie: What about eating? Do they start eating solid food pretty quick? Do they have to take laxatives, stool softeners for quite a while afterward, or is this just initially?

Dr. Hedrick: Before, we used to wait until the patients were passing gas to actually feed them, but with the new protocol they get liquids the night of surgery, jello and that type of thing, and then the next day they are started on solid food. You know, patients are very good at regulating themselves. Since they are nauseated, they don’t take the food but most patients are able to tolerate soft food the day after surgery.

Melanie: You’ve helped pioneer some of the changes in the recovery process for abdominal surgeries. Can you explain how the enhanced recovery after surgery process works a little bit for us?

Dr. Hedrick: Yes. You know, each protocol is a bit different at each institution, but it’s basically based on several tenets,and that is, one is avoiding the use of opioids such as morphine which can slow the bowel down after surgery, so we use different types of pain medicines to control pain such as ibuprofen and Tylenol and gabapentin and things like that. It’s also based on avoiding giving the patients a lot of intravenous fluids, saline, through their veins, so we let the patients drink up until two hours prior to surgery and then we allow them to drink in the recovery room to keep themselves hydrated. It’s also based on, as we discussed, getting up and walking right after surgery and also eating right after surgery. Finally, it’s really based on allowing the patients and their family to be an active participant in their care, so we tell them exactly what is going to happen, we give them a checklist so that they know what is going to happen, and they help us to remind the nurses to get them up after surgery, and really make them the star player of their care.

Melanie: What are some of the benefits for the patients of this enhanced recovery process? Does it help them to go home quicker? Does it help their families care for them post-surgery?

Dr. Hedrick: Yes. So it helps them, on average, go home two days sooner; it helps them be prepared to go home sooner. It actually controls their pain better and it allows them really to get back to their normal selves much quicker.

Melanie: What do their families and loved ones need to know about post-surgical care and taking their loved one home? Are their certain things you like to teach them about their incisions or about things they should be looking for, red flags?

Dr. Hedrick: Yes. So, you know, a lot of times families want to keep their loved ones in bed and do everything for them. I personally think it’s better for the patient to be up and active as much as possible after surgery. There are red flags: We want to know anytime the patients have a fever, anytime they start to develop flu-like symptoms, things like that. But outside of that, we want them to be up and active, taking walks and doing the likes, because that really does speed up the recovery process.

Melanie: And so if they have these red flags, obviously they call you right away. Are there certain candidates, certain patients that you have that have surgery that are not candidates for this enhanced recovery program?

Dr. Hedrick: No. Really we do put everybody on the protocol, even the sickest of patients that have certain medical conditions. We monitor them very closely; we don’t send them home before they are ready. The key is not to discharge patients before they are ready. It’s to get them to the process where they feel like being discharged sooner than before, and so if they are not quite ready, we don’t send them home. But, you know, the key is standardizing the care process and we do it for the young 19-year-old patients to the 90-year-old patient. We do customize it to each individual person that everyone benefits from the protocol.

Melanie: So tell us in just the last few minutes your best advice for people that are considering having surgery, what to expect afterward and why patients should come to UVA for their surgical care.

Dr. Hedrick: Well, I think we pride on ourselves on providing the most up-to-date quality care. You know, this protocol has been proven to be effective, in not only reducing the link to stay but also reducing complications, and we are becoming a center now for teaching other institutions how to do this protocol. I think for all those reasons, patients should choose UVA for their health care needs.

Melanie: Thank you so much, what 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

Repetitive Stress Injuries in Athletes

Additional Info

Segment Number 3
Audio File virginia_health/1516vh5c.mp3
Doctors Brockmeier, Stephen
Featured Speaker Stephen Brockmeier, MD
Guest Bio Dr. Stephen Brockmeier is a board-certified orthopedic surgeon who specializes in sports medicine and shoulder surgery.

Learn more about UVA Orthopedics
Transcription Melanie Cole (Host): Repeatedly performing the same athletic task, such as throwing a baseball, can lead to injuries. What steps can athletes take to reduce their risk for these repetitive stress injuries? My guest today is Dr. Stephen Brockmeier. He is a board-certified orthopedic surgeon who specializes in sports medicine and shoulder surgery at UVA. Welcome to the show, Dr. Brockmeier. So tell us a little about some of the more common stress injuries that you see.

Dr. Stephen BrockMeier (Guest): Thanks, Melanie. Thanks for having me. So each sport kind of has its own subset of repetitive or we like to call overuse injuries. The ones that we see most commonly or certainly get the most attention are associated with the overhead athletes, as you mentioned in the introduction of this topic, something you hear very commonly associated with either baseball players or racket sport players like tennis, where you have some overuse injuries that are pretty common involving the elbow and the shoulder, and these are pretty common things that we see.

Melanie: So in sports, in our little athletes, in our high school and collegiate athletes, and I'm sure in professional sports, Dr. Brockmeier, they have you know throwing limits. There are people that put it out there that, you know, can't have your little athlete out there for more than a few innings. So what are they doing to hopefully reduce this?

Dr. BrockMeier: Yeah, so there is a lot of research going on in this area, specifically the baseball player population. And really what they are looking at is, is there a pitch count and is there a better pitch count given the age of the athlete? There is a subset of this that we see in youth athletes that really can be very problematic. And so you are either looking at pitch counts. I think one of the major mistakes that are made, especially with those of us who are parents with our children, is underestimating the rest that these children will need. So it's not only pitch counts in one given outing but it's also sometime for the arm to kind of rest and recover from a repetitive stress type sport. So oftentimes these kids will pitch and then they will go and play in the outfield or go play in a different position and there is really not a lot of down time to let the arm accommodate it. That's I think one of the common mistakes that we see.

Melanie: With all sports and even with, you know, exercisers running and people that do certain exercises repetitively, these overuse injuries are becoming more and more common. Do you recommend cross training? What do you recommend as a way to sort of prevent some of these overuse injuries?

Dr. BrockMeier: Yeah. I mean I think you mentioned one of the key areas of prevention is a good healthy conditioning. You know, I preach moderation to my patients. I think youth sports in particular have directed over to being kind of a specialist. So a kid is a baseball player or a soccer player or a basketball player. It used to be back when I was a child that, you know, the three-sport athletes were the true athletes. I think some of the better athletes you’ll see are the ones who really develop their athleticism through a lot of different sports. And so one of the traps obviously is doing the same sport repetitively. If that’s something that you are doing, I think it's really critical to train in different ways to improve on your endurance and your muscle memory and all those various things without doing the same exact thing over and over and over again.

Melanie: What do you do if you do start to suffer an overuse injury or a repetitive stress injury? Do you like your patients to ice, elevate, rest, wrap? What is it you want people to do to give this some relief?

Dr. BrockMeier: Yeah. I mean the good news is with a lot of these injuries, the majority of times, this is something that gets better without any type of intervention, And the key component almost always is going to be rest, meaning that the athlete needs to take a period of time, and normally it's not just a day or two, away from their sport to let their body try to recover. You know, the majority of these can get better if you just give your body a chance to help. So icing can be helpful; rest is critical. There are certain rehabilitation exercises that are specific to each type of injury that we will often institute. Things of that nature are the initial steps that we’ll take, and that normally gets this better in the majority of athletes.

Melanie: And what about those people that are just your exercisers? I mean, they don't want to stop running, right, Dr. Brockmeier? They don't want to stop going to the gym doing the things that they are doing. How do you get those people to settle down a little bit, cross train, do some other things?

Dr. BrockMeier: Yeah. I think to really answer that question, you may want to have a psychotherapist on the line here because this is really a way of life. I mean, you know, people don't generally get these types of injuries sitting on the couch. And so it's really hard for some of these people to take a break. So what I tend to try to do is I try to find a different area that they can maintain some of the stress relief and some of the other aspects of sports or of fitness that these people really use this for and focus them on that area while they are letting their body recover. So if it's a runner, for example, maybe they try swimming or other type of cross training type activities. You know if it’s a baseball player if it's somebody playing a specific sport, maybe you focus on some of the training aspects of things. And sometimes these people actually really get into the rehab portion of the treatment for these types of injuries. So you can kind of try and focus their energy and their attention and, you know, kind of their obsessions, so to speak, on rehabilitating from the injury. And they tend to be pretty dedicated to that.

Melanie: Dr. Brockmeier, what we are seeing now something sort of new in the sports medicine field, and it's not even necessarily in sports medicine now, are occupational repetitive stress injuries, I mean everything from using a computer to texting, these things, these overuse injuries. Are you seeing that now?

Dr. BrockMeier: Yeah, you do. You know, occupational injuries account for a good percentage of the patients that we see for a variety of things, both overuse injuries as well as structural things that may require surgery. This is something that can be particularly challenging because it's not like this is a hobby or kind of a recreational pursuit. This is how somebody makes their living so that's a real challenging thing because oftentimes it requires at least a period of time to allow the body to recover from whatever the treatment’s going to be and it can have major impact and ramification for this individual as far as how they make a living.

Melanie: Are you looking at ergonomics? Are you helping them to decide different positional ways that maybe whatever it is they are doing can, you know, not cause some of these repetitive injuries that you might be seeing?

Dr. BrockMeier: Yeah, certainly ergonomics from the standpoint of the elbow and wrist type of injuries that we see commonly, very important. Low back, you know, is something that obviously all of us will get from time to time. But the way that you lift for those that do labor is really critical. And then some of the stuff that I see in the shoulder or in the knee, a lot of these things are related to repetitive stress as well, so maybe limiting overhead positioning of the arm to kind of let the shoulder maybe not be quite as symptomatic or positional things with relation to the lower extremity. All of these things are really things that you have to consider to try to get these people healthy and pain-free and to be able to continue to do their job.

Melanie: So really, you know, a burgeoning field and a burgeoning topic, this occupational frozen shoulder, from your desk, being at improper height and such, so what do you tell people when they've got this kind of situation? Do you ask them to assess their work situation and then go from there?

Dr. BrockMeier: You know, it's funny; a lot of people have already done that. People are always looking for why “it shouldn't be that all of a sudden my shoulder starts hurting,” so what happened? And sometimes it is something related to either repetitive things that thy are doing at work that initially they don't seem to pick up on but then do, and other times they are just trying to find a reason. Some things we see will come on just with age-related changes or just with use over time. But these are questions that we'll often ask when we are first meeting a patient: How did this happen? What are some things that may be contributing? How can we address those things to try to minimize symptoms for you? So, yeah, all of these things are very critical.

Melanie: In just the last few minutes, Dr. Brockmeier, if you would, give listeners your very best advice, and those that may be suffering from sports-related repetitive stress injuries, overuse injuries, and why they should come to UVA Orthopedics for their sports medicine care.

Dr. BrockMeier: Sure. Well, I think what I would tell them is obviously this is something that is really common, so you are very much not alone. And a lot of times it can be managed very efficiently just by recognizing what the problem is and taking some simple steps to try to address it and correct it. The body can correct a lot of these problems if just given the opportunity to do so. Our group, we really have a multi specialty group. I have four partners who are board certified and some specialty trained orthopedic surgeons for those patients who do require more specialized care. But we have primary care sports medicine doctors, specialists in running athletes and other conditioning type sports, exercise physiologists, things of that nature, and all of us work together to treat kind of the entire spectrum essentially of bone and joint problems and try to get people to be active and to be healthy and fit and enjoy their lives and their jobs and their other pursuits.

Melanie: Thank you so much for being with us. Absolutely great information. You are 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

The Latest Research on Brain Tumor Treatments

Additional Info

Segment Number 2
Audio File virginia_health/1516vh5b.mp3
Doctors Purow, Benjamin
Featured Speaker Benjamin Purow, MD
Guest Bio Dr. Benjamin Purow is a neurologist who specializes in researching new brain tumor treatments and caring for patients with brain tumors.

Learn more about UVA Neuro-Oncology Center
Transcription Melanie Cole (Host): Recent media coverage has focused on possible new treatments for brain tumors. My guest today is Dr. Benjamin Purow. He is a neurologist who specializes in researching new brain tumor treatments and caring for patients with brain tumors. Welcome to the show, Dr. Purow. So there has been some coverage recently about new potential treatments for brain tumor, so talk about some of those recent developments.

Dr. Benjamin Purow (Guest): Certainly, certainly, and thank you for having me. You know, there is really growing excitement in this field, as I would say, there is a cross oncology, but there is lot of it focused in neuro-oncology and brain tumors. We had a big brain tumor meeting back in November several months back and there were few exciting developments there which, you know, I have to say is all too unusual at this meeting.
You know, one of these was combining very unusual new treatment which actually involves electrical currents to the skull to the region of the brain tumor, combining that electrical treatment with radiation and a chemotherapy we use a lot called temozolomide and this combination for patients that had recently been diagnosed with glioblastoma, the most common and aggressive brain cancer that’s out there, led to some exciting results in the clinical trial.
There was another positive clinical trial that was announced at this meeting, which combined in immunotherapy essentially a vaccine against a mutation only found in about a third of glioblastoma patients but only in those cells in the body, that particular mutation combining that vaccine with a drug called avastin which attacks the blood supply but may also have some good effects on the immune system which prompted that clinical trial which again had positive results which is also super. You know, there is a bit of other positive results announced at this trial using this avastin medication in a subset of patients with glioblastoma, but a lot of enthusiasm at the meeting was focused on new immunotherapy treatments that rev up the immune response against the cancer, and there are different ways to do this. A couple of exciting presentations with the meeting involved a polio virus treatment which is being pioneered at Duke University. They use polio, basically a weakened and attenuated polio virus, and inject it right into a piece of a location of recurrent glioblastoma cancer. Another couple of things: they’re trying to directly kill the cancer cells there in the brain but it also seems to attract the immune system’s attention because of the polio virus infection. An immune system then turns around and attacks the tumor. They have a couple of patients who have done great for a long time with this treatment. There was another viral therapy being pioneered at MD Anderson Cancer Center in Texas that also looks very promising, but there are a number of other immunotherapy that are looking great now too. There are some other cancer vaccines which are starting to show some exciting results. On top of that, there are some therapies that are already out there and FDA-approved for melanoma that people are increasingly excited about for glioblastoma, other brain tumors and cancers across the board. These are treatments that can be given IV every couple of weeks and they rev up the immune system, somewhat nonspecific so there are some risks to these drugs like autoimmune diseases. But they seem to be a great way to get the immune system engaged in fighting the cancer, and everyone is awfully excited about these drugs and some of the combinations that we’ll be doing.

Melanie: So most of these immunotherapies and vaccines and really exciting new treatments that you are describing, they are in clinical trial phase. When do you, in your opinion, see some of these coming to the forefront where they might actually benefit some patients?

Dr. Purow: Sure, sure. So for some other cancers, as I said, for melanoma and actually one of these for lung cancer are already FDA approved. Insurance won’t cover this but a few patients are trying to get some doses of this paid for out of pocket. So a few patients are already accessing this immune system boosters we call check point inhibitors and drugs like nivolumab or [pembrolizumab] but the trials I think will move fairly fast, and [recurring] patients certainly fast too, so it may just be a matter of couple of years, few years, before there is evidence of the fact and FDA approval will hopefully come pretty quickly, especially since these are drugs where they are already FDA-approved for certain settings, patients with melanoma, or already lung cancer has been added to melanoma.

Melanie: Now patients with glioblastoma, you mentioned earlier electrical fields and I know your colleague Dr. David Schiff was involved in this wearable device, tell us a little bit about that trial.

Dr. Purow: Sure, sure. So, you know, the great results from that trial I have to say came as a bit of a surprise to the field in a way. It stems from, you know, this is a very unusual treatment, as I started mentioning before. It essentially involves putting electrode patches up on the skull in the region roughly over where the brain tumor is. These electrode patches are wired to a battery pack you carry around that applies alternating electrical current to that region of the head. We have some good research that led into this, mostly out of Israel, that show that these electrical currents can actually lead to killing of glioblastoma cells especially if the current hits the dividing cell, dividing cancer cell, at the right orientation. There had been trials of these electrical treatments in patients that had recurrent glioblastoma when the cancer came back again, and this actually prompted FDA approval of the device in this setting, although the effectiveness of this in that setting, you know, glioblastoma coming back wasn’t traumatic. But, you know, there is a hint that it was about as much as some chemotherapies we use that can have some marginal benefit but very safe; it only seems to cause a little bit of skin irritation. But in this new trial, this was combined with the upfront radiation and chemotherapy that we use, a drug called temozolomide, and then the effects seem much more dramatic. You know, it really led to a significant lengthening of people’s lives. This sort of hit like a bit of a bombshell and there may be an extension of the FDA indication for two patients who, you know, were recently diagnosed and just got the radiation and using this alongside the upfront chemotherapy. So, you know, this another exciting new development in the field.

Melanie: Dr. Purow, I know you are very excited about the immunotherapies and all of these trials, since we last talked you’ve been on the show with us before, what are some new areas of research that you are focused on?

Dr. Purow: Sure, sure. So I spend about a quarter of my time seeing patients and then three-quarters of the time in my laboratory and we are trying to figure out some new and creative ways to attack these diseases. We focus mostly on glioblastoma in the laboratory and we are attacking glioblastoma at multiple levels. We are also finding the several of our projects seem to have potential for other cancers as well. One of the things we’ve been doing is repurposing existing drugs or recycling some abandoned drugs, you know, not only to block an exciting new target called DGK Alpha or diacylglycerol kinase alpha. You know, it’s one that we think hits the cancer at multiple levels, directly killing cancer cells, attacking the blood supply, but there is also potential to rev up the immune system against the cancer. So I think this may be a great combination with some of these hot new immunotherapies.
You know, we are also repurposing existing drugs to suppress some promising known targets. There are drugs out there that are in light use that have some anti-cancer properties that haven’t even been really figured out. We think we are nailing down the important effects for at least one of these drug classes out there. We’re also looking at some new projects where we think we figured out new vulnerability of subtypes of glioblastoma and other cancers.
There are some subgroups within glioblastoma that you see similar general types in other cancers as well, so we are trying to figure out some Achilles’ heels for those and have some new ideas there. You know, we are also trying ways to maximize the effects from existing drugs, combinations and ways to sensitize to some of the existing armamentarium against cancer. Some of those things are starting to look promising as well.

Melanie: It’s absolutely fascinating, Dr. Purow. You can hear the passion in your voice. What an amazing doctor you are! In just the last minute, why should families come to the UVA Neuro-oncology Center for their care?

Dr. Purow: Sure. You know, we hope that we can provide a lot of reasons for patients to come here. We’re not only giving patients state-of-the-art care including a number of exciting clinical trials that are ongoing, but we add to that compassion and also 24/7 access to our doctors on our team. We also have wonderful other members of the team. Our nurses, physician assistant, even our administrators, you know, are just a terrific group and I think we all come to mean a lot to the patients hopefully. This entire team approach and all the members of the team really bring a lot to our patients and giving them this great access. We really try to treat every patient uniquely as we would our own family member or loved one. We emphasize not only length of life that we really fight to extend as much as possible but also quality of life. So, you know, hopefully we just bring all of that to the patients in a unique way.

Melanie: Thank you so much for joining us today. You are 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

Concussions Outside the Playing Field

Additional Info

Segment Number 1
Audio File virginia_health/1516vh5a.mp3
Doctors Heinan, Kristen
Featured Speaker Kristen Heinan, MD
Guest Bio Dr. Kristen Heinan is a pediatric neurologist who specializes in caring for children with concussions.

Learn more about UVA Neurosciences
Transcription Melanie Cole. (Host): While concussions are most commonly associated with sports, they can happen in a variety of other settings. My guest today is Dr. Kristen Heinan. She’s a pediatric neurologist who specializes in caring for children with concussions. Welcome to the show, Dr. Heinan. So tell us a little bit about concussions. They are most commonly associated with sports but there are other settings; I mean kids can bump their head in a variety of ways.

Dr. Heinan (Guest): Yes, absolutely. We see a lot of different mechanisms for concussion in the clinic. For some of the older teenagers, car accidents are quite common, cars versus trees, or rollovers. For the younger kids, playground accidents, or this winter, a lot of flooding mishaps were causes of concussion that brought people in.

Melanie: You know, these are things you don’t always really realize and think about, but now that you say that sliding playgrounds, kids fall off of the equipment, what’s a parent to do? You know, in sports we are looking to the helmets, to teams, to coaches to help us with this. What do you do on the playground or the sliding hill?

Dr. Heinan: We have this conversation with parents a lot particularly if they’ve had a child with one concussion. They are especially sensitive to the risks and are hoping to prevent future injuries. You can’t wrap your kids in bubblewrap, you have to let them go out into the world, but common sense things, if you are sliding on a hill, probably a well-travelled hill not in the forest but a bunch of trees on the playground with a good soft surface and again parental or teacher supervision. But accidents and things will happen. And that’s what we are here for if something does.

Melanie: So what are some signs that a child has gotten a concussion? If we see them fall off the monkey bars, or bump into a table, what are some signs we might notice?

Dr. Heinan: Sure. So a lot of times, sometimes kids are afraid to say that they have gotten hurt practising gymnastics in their room without permission. So, a parent, or teachers even, might notice that the child seems more fatigued. A lot of times they might be grumpier; appetite can be decreased. They may not directly complain of a headache but you can notice changes like not being as active as usual, being more quiet, not wanting to do all the fun things that they usually want to do. And sometimes obviously they’ll say, “My head hurts, it hurts for me to read, I don’t want to play the video games or watch the TV.” Parents are just really good at picking up when their child just doesn’t seem right, and so those are kind of the big key features of concern.

Melanie: Dr. Heinan, when children, little babies, are learning to walk, we worry about them falling and hitting things. Can little babies get concussions too?

Dr. Heinan: They can. It helps that toddlers are closer to the ground. Usually you hear the thump and they end up with a bruise on the outside that looks terrible but they are typically okay. They sure can though; I mean we’ve seen young kids who have fallen or been involved in car accidents and they’ll do the same thing. They’ll be sleepier, they might be fussier, not wanting to eat as much; they seem out of sort just like they are getting sick almost.

Melanie: If you do suspect that your child has a concussion, should you always take them to the doctor? Do you go to the emergency room? What do you do?

Dr. Heinan: Nobody would ever fault a parent for bringing their child to the doctor or the emergency room if they were concerned. A lot of times what we do is offer reassurance that, yes, this is a concussion and it’s going to be uncomfortable and nerve-wracking for a while but then the child will be fine. It’s difficult to tell the severity of a concussion oftentimes, but certainly you should definitely seek medical attention if there is loss of consciousness involved, if the child is not making a lot of sense when they return, when they wake up. If there is any weakness on one side of the body or both sides, if they are complaining of really excruciating headache, if there is a lot of confusion, those are some major warning signs. Also a lot of vomiting, some is okay, some is pretty common but we can worry about more severe head injuries if there is a lot of vomiting or if there is any physical abnormalities that are going along with the concussion like weakness or…

Melanie: And what do you do for a concussion? Is there anything for a parent to do or you as a physician? What about things like, you know, for the headache or symptom management, Tylenol? Are any of these things okay, ice? What do we even do?

Dr. Heinan: Yeah, we are still working on that one. Unfortunately, there is no silver bullet for how to make the brain heal faster at this point aside from rest. It is very okay to treat the headache. Oftentimes there is associated neck pain too. If you think about hitting your head, your neck is attached, so they can have head and neck pain.
Tylenol is fine. Typically recommendations are, for the first 48 hours or so, to give Tylenol rather than ibuprofen or naproxen which is Aleve, because it has less of a chance of contributing to bleeding, in case there is a more significant injury. But after the first couple of days, your pain medication of choice is fine. We caution people to not rely on that so heavily after the first couple of weeks but initially that’s fine. And then the brain really just needs to rest. For the first 24, 48 hours, even three days, we say treat it like you have the flu. You are not going to feel good, let them rest; it’s kind of very symptom-guided, it’s very patient-specific. So whatever they indicate that they are up to doing, they should be allowed to do, but rest is key for those first couple of days.

Melanie: Is there any truth to the video game, television, reading, to keep them out of those things for that first day or so, to allow your brain not to, you know, work so hard?

Dr. Heinan: That’s a great question. We get that question a lot. There is nothing magic about the TV, video games, and reading. It is, as you said, just a cognitive exercise, if you will, that those things tend to require; that is the problem. So, if they are feeling well enough to want to email a friend and say, you know, “Hey, I have a concussion, I’m resting but I’m doing okay,” that’s fine. A lot of times the bright light of the computer screen or the TV screen are really exacerbating and the kids really don’t want to do that anyway. So there is, you know, there is no magic in what you can or cannot do; it’s just whatever symptoms tend to be exacerbated. The noise, the light, is what they should avoid. And the reading is great if your child loves to be read to; sometimes that’s easier. There is a lot of visual symptoms that go along with concussion that conversionsinsufficiency, difficulty sort of coordinating the eyes, and reading can sometimes be really annoying. So, if they try it for a little bit and it’s okay, no problem; if they try it for a little bit and they just feel terrible, then stop.

Melanie: So in just the last minute, Dr. Heinan, why should families come to UVA brain injury and sports concussion clinic for their care?

Dr. Heinan: It’s a really great clinic. It’s very interdisciplinary. So we have physicians that are there, we have occupational therapy who does a lot of work with the visual symptoms, there is physical therapy, education no consultants, are available and then we can set people up with neurocognitive testing or neuropsychiatric testing if they are having trouble with school, memory, things like that. So it’s a really great, very whole-person-oriented, family-oriented, inclusive clinic.

Melanie: Thank you so muh for joining us today. You are listening to UVA Health Systems radio. For more information, you can go to uvahealth.com; that’s uvahealth.com. This is Melanie Cole, thanks so much for listening.
Hosts Melanie Cole, MS

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