Inactive (722)

Segment Number 3
Audio File city_hope/1509ch1c.mp3
Doctors Kruper, Laura L.
Featured Speaker Laura L. Kruper, MD
Guest Bio Dr. Kruper’s long-term academic and research objectives are to optimize the management of breast cancer through better clinical trials. She believes one way to work toward this objective is to translate current scientific research findings from basic bench research into clinical studies and eventually clinical practice.
Transcription Melanie Cole (Host): City of Hope offers the latest advances in the surgical management of breast cancer provided by specialized surgeons. For patients with small tumors and early stage breast cancer, breast conserving surgery is a treatment option providing optimal cancer surgery while achieving excellent cosmetic outcomes. My guest today is Dr. Laura Kruper. She’s the co-director of the breast cancer program at City of Hope. Welcome to the show, Dr. Kruper. Tell us a little bit about what’s going on in breast cancer surgery now and this trend towards immediate reconstruction after a mastectomy.

Dr. Laura Kruper (Guest): Okay. At our center and at many centers across the United States, we are able to offer many women nipple-sparing mastectomies. That is a procedure in which we can preserve the whole envelop of the breast—so all of the skin and the nipple—and the patient can have small scars so that we can remove the entire breast through that incision and then the patient could have immediate reconstruction afterwards straight to implant so that the patient can have all their surgery in one day and preserve the whole appearance of their breast. For many women, it’s difficult to even tell that they’ve had surgery, period.

Melanie: What are the advantages to the nipple-sparing mastectomy aside from the cosmetic advantages? Are there any other physiological advantages?

Dr. Kruper: It’s interesting that you ask that. They actually have done studies. There is a great questionnaire evaluating women and their satisfaction with the procedures that they have. Although women may feel that their preserved nipples actually feel the same pretty much as or have the same satisfaction as a woman who has had a nipple reconstruction, the benefits are actually seen in their physiological mood and their sexual well-being. That is the benefit to preserving the nipple for most…

Melanie: How much sensation does it have after this kind of surgery?

Dr. Kruper: For many women, it doesn’t have much sensation, which is why I think many women say that the satisfaction level is about the same as a woman who has a reconstructed nipple. We always tell women that they most likely will not have sensation, but some women actually do regain some sensation to their nipple.

Melanie: Who would be a good candidate for this type of surgery?

Dr. Kruper: The best candidates are people who have smaller tumors, not very large tumors, or tumors close to the nipple. Or there’s something called ductal carcinoma in situ, which is cancer within the ducts. So if a woman has DCIS, which is spread throughout the breast, they are not a very good candidate for nipple sparing. But more and more, we are seeing many patients are eligible for nipple sparing.

Melanie: What’s the healing process with this type of surgery? Is it any different than a full mastectomy without the reconstruction done right at that time? Is it a faster healing process?

Dr. Kruper: It’s actually somewhat longer because if someone had a regular mastectomy without any reconstruction, that recovery time is normally two to three weeks. When you add in reconstruction, that doubles the recovery time anywhere from three to six weeks because of the reconstruction. Then there are really no other further surgeries, and most women are much more satisfied when they have reconstruction. For many women, the prolonged recovery is worth it.

Melanie: Is there any risk, Dr. Kruper, of recurring cancer of the nipple after this?

Dr. Kruper: That’s a good question. Several studies have shown, or if you look at retrospective studies, that if a woman has cancer in the breast, the overall rate of developing another cancer in the nipple would be about 5 percent. And that rate might depend also on the size of the tumor and whether the lymph nodes are involved and what type of systemic therapy the patient receives. In a prophylactic surgery—so women who are genetic mutation carriers and have nipple sparing mastectomies prophylactically—the risk of developing a cancer in a breast that has had no cancer is less than 1 percent. So, a safe procedure.

Melanie: There’s been a lot of news in the media of double mastectomies even if there is not breast cancer in both breasts. Can you tell us about this rise in this trend? And what does it mean? Why are women doing this?

Dr. Kruper: That’s a very good question. Yes, there has been a very large increase in the number of women who are requesting contralateral prophylactic mastectomies. We call them CPM, when there’s no cancer in the other breast. The majority of these women who are requesting CPMs are not people who have either familial risk factors or genetic mutation. There are multiple reasons behind this increase. One is there have been studies that have shown that genetic testing—not even a positive genetic test, just actually being sent to a genetic counselor to have testing—will increase the rate of a woman requesting contralateral prophylactic mastectomy. Obviously, a strong family history of breast or ovarian cancer increases that rate. Also, women who undergo an MRI. One of the problems with MRI is although they are a very good tool for detecting cancer, they do have a high false positive rate. And for a lot of women, if they are being worked up for a breast cancer with an MRI and there are other findings, that makes them pretty concerned about cancer in the other breast. Then other factors that are associated with a higher rate of CPMs are higher education and a woman’s baseline anxiety or worry about recurrence. We have noticed that there is a trend. There have been several papers that came out last year looking at the increased rate of bilateral mastectomies, so mastectomy for the cancer side and then the other side. We certainly see that trend is very high in women who are young—and young being defined as age 40 or below—and you could understand why that would be because a woman who is diagnosed under the age 40 is going to live a very long time and obviously is going to be very concerned about another cancer. What’s interesting is that other studies have shown that the rate of developing what’s called a contralateral breast cancer is actually very low, but many women will foresee that that risk is higher. There are so many factors for why we are seeing this increased rate. Then another reason is, quite honestly, the reconstruction. The reconstruction nowadays that plastic surgeons are doing are really beautiful, and the different kind of techniques that they use. A lot of women know a friend who has had both the breasts removed, and soI think there are a lot of factors coming in to play.

Melanie: When you have a mastectomy or a bilateral mastectomy prophylactically, can you get cancer in the breast?

Dr Kruper: Yes, you can. That rate is very low and unfortunately for a patient who’s had cancer and we do a mastectomy, I always tell them that we can’t get down to zero. There are such things as called chest wall recurrences. That means anywhere along the muscle but also within the skin flap. As hard as we try as surgeons to remove all the breast tissue when we are doing surgery, sometimes you can’t tell the difference between a fat cell and a breast cell. It’s true that cancers can come back. In the prophylactic side, that risk is very, very, very low.

Melanie: Dr. Kruper, what advice would you have for women who have either previously had breast cancer or have a family history about getting that genetic test and that risk that you discussed about, the anxiety, and then considering a bilateral mastectomy?

Dr. Kruper: I think especially since Angelina Jolie came out saying she was a genetic mutation carrier, that really has increased the rate of people asking about genetic testing. The reality is that most breast cancers are spontaneous and they are not related to family history or a genetic mutation. Genetic mutations make up approximately 10 percent of all breast cancer cases, and there are certain things to look for that make some women more at high risk than others. Multiple generations of women with breast cancer in a family, other kinds of cancer as well such as colon cancer, prostate cancer, a young age. Any woman under the age of 45 qualifies for genetic testing. So I do try to counsel patients because a woman who has no family history of breast cancer is the first one in her family and presents at age 65 with a breast cancer, I am going to reassure her that she most likely does not have a genetic mutation and does not really qualify for genetic testing. But if she wants, we could send her to a genetic counselor. A lot of people, I think everybody now or many people think that if they have breast cancer, they have a genetic mutation, whereas it’s actually the reverse. I do try to reassure people. The decision to have a contralateral prophylactic mastectomy is one that really should be a shared decision between the physician and the patient. I really try to counsel my patients that all the studies have shown that if you remove a contralateral breast that’s unaffected, it actually does not improve survival. I tell this to my patients. And for most patients with breast cancer, the risk of distinct cancer or cancer coming back somewhere else in the body, like the bone or liver, is higher than developing a breast cancer in the other breast. But even giving all of those facts, many women will make up their mind one way or another based on whether they have friends who have done this, their own personal concerns. I try to talk them through the whole process.

Melanie: In just the last minute or so, Dr. Kruper, tell listeners why they should come to City of Hope when they are considering breast cancer reconstruction surgery.

Dr. Kruper: I think there are many great centers, but I think one of the benefits of our center is that we are a cancer center. All of our doctors here, we only focus on cancer. We have a multidisciplinary team. A medical oncologist, the surgical oncologist which is me, and then our plastic surgeon. Our plastic surgeons here pretty much only do breast reconstruction. They do beautiful work and they can offer different types of reconstruction for different patients. When a patient comes here, they’re going to get all of their care, and we can offer many state-of-the-art therapies given that we are a national comprehensive network cancer.

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

Barrett's Esophagus and the Risk for Esophageal Cancer

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Segment Number 2
Audio File city_hope/1509ch1b.mp3
Doctors Lin, James L.
Featured Speaker James L. Lin, MD
Guest Bio Dr. Lin is highly experienced in the field of endoscopic ultrasound (EUS), ERCP, and other advanced endoscopy services.

Learn more about Dr. Lin
Transcription Melanie Cole (Host): Barrett esophagus can be a serious complication of GERD and can lead to esophageal cancer. My guest today is Dr. James Lin. He is highly experienced in the field of endoscopic ultrasound at City of Hope. Welcome to the show, Dr. Lin. Tell us a little bit about Barrett esophagus. What is it, and how does it relate to GERD?

Dr. James Lin (Guest): Well, Barrett esophagus is the condition where the normal cells in the lining of the distal esophagus are replaced by a different type of cell, almost look like intestinal cells. This process usually occurs as a result of repetitive damage to the distal esophagus from longstanding acid reflux or gastroesophageal reflux disease, GERD. This repetitive exposure to the acid damages lining of the esophagus and yet it changes in the lining from squamous mucosa of the normal esophagus to columnar epithelial, where the cells look more intestinal-like.

Melanie: Okay. So what is that relationship between Barrett esophagus and cancer? If we hear about this precancerous lesions or you’ve got reflux disease, what is that link?

Dr. Lin: What is that link? Like we discussed, Barrett esophagus, in the esophagus, it’s squamous epithelium. And when you get chronic acid damage from GERD, the lining changes. It becomes a metaplastic, and it turns into this columnar epithelium, and it’s this change to the columnar epithelium that predisposes to cancer. The lining can progress to a thing called dysplasia, and there’s a progression of dysplasia from low-grade dysplasia to high-grade dysplasia to cancer.

Melanie: Wow. What can people do about it, and how is it diagnosed? Do you do endoscopic ultrasound? What are you looking for?

Dr. Lin: Well, the first thing to diagnose the Barrett esophagus is you have to get an upper endoscopy. This is a procedure where we put a flexible camera down into the esophagus and we look for these changes in the lining and we do biopsies to confirm whether there is Barrett esophagus or not. That will be the first step.

Melanie: Then what do you do after that?

Dr. Lin: Well, if it’s just Barrett esophagus with no evidence of dysplasia, then we do a surveillance where we would do endoscopy every three to five years to check up and see if there’s any new changes. If we do the endoscopy and we actually discover dysplasia, low-grade or high-grade dysplasia, then we need to talk about how we’re going to manage this.

Melanie: Who is most at risk, if it’s people that just have the gastroesophageal reflux disease, or is there other things that contribute—coffee, drinking, spicy foods—any of these things contribute to Barrett esophagus?

Dr. Lin: Yes. Well, the main thing is the chronic acid reflux, the GERD. Other risk factors for Barrett esophagus include older age—greater than 50. It’s more common in males, 2:1 male to female ratio. Caucasians are at more risk of developing compared to other ethnicities. Obesity and also having a hiatal hernia, which predisposes to having more reflux symptoms. These are the risk factors for Barrett’s.

Melanie: How often should somebody who has these precancerous lesions or Barrett’s or you think that there are risks for Barrett’s, how often should they have an endoscopy?

Dr. Lin: Once the diagnosis of Barrett’s is established, what we want to know is if there’s any dysplasia. If there’s no dysplasia, then the recommendation is to have upper endoscopy every three to five years for checkup. If you have a low-grade dysplasia, it already has some precancerous changes, then recommendation is to have an endoscopy either 6 to 12 months. Or if you have high-grade dysplasia, once this is established that you have high-grade dysplasia, then we really talk about treatment. If treatment is not an option, then we do surveillance every three months for the endoscopy.

Melanie: Before we talk about treatment, Dr. Lin, do you see that like colonoscopy, which is now covered under insurance as a well thing to prevent colon cancer, that endoscopy will now be something that can help prevent esophageal cancer if caught early enough and it might be something that’s also considered under insurance?

Dr. Lin: That’s a great question. Once you have Barrett’s or established the diagnosis of Barrett’s esophagus, I think the screening and surveillance is indicated and covered. The question becomes should everyone who has acid reflux be screened for Barrett’s esophagus. That question is still up to debate. Right now, it’s managing the chronic acid reflux, we would try medications first. And then if symptoms don’t improve, then we talk about doing an upper endoscopy for further evaluation.

Melanie: What kind of treatments do you do? You try and manage the acid reflux. If someone doesn’t even know that they have acid reflux, that could be going on silently for quite a long time. What do you do besides managing the acid reflux? Is there something to calm the esophagus? Is there something to help heal those lesions?

Dr. Lin: The main form of treatment for Barrett’s esophagus is aggressive control of the reflux symptoms. A lot of the times with the Barrett’s esophagus is once you have the changing of the lining from squamous to a columnar epithelium, the columnar epithelium is more resistant to the acid in the stomach. That’s why you may not feel it as much as before. That’s one of the challenges why the people with Barrett’s, they may tell you that they don’t even have reflux symptoms.

Melanie: Then what other things can you do?

Dr. Lin: Other things that you can do is really a lot of behavior and lifestyle modification. Certain foods can actually cause worsening of the reflux. Coffee, tea, chocolate, alcohol, fatty foods can make the acid reflux worse. Diet and lifestyle modification is a huge part of the treatment for the reflux.

Melanie: Dr. Lin, in just the last few minutes, please give the listeners your very best advice about people suffering from GERD that risk for Barrett’s esophagus and what you really want them to know about Barrett’s esophagus and its link to cancer and why they should come to City of Hope for their ultrasound and endoscopies.

Dr. Lin: Barrett’s esophagus is a precancerous condition of the esophagus. Most patients with Barrett’s esophagus will not progress to esophageal cancer, but if you develop a condition called dysplasia, which is a precancerous change, then you’re progressing towards esophageal cancer. And that you need more of a workup. And there’s a lot of different treatment options for dysplasia. One of the treatment options, the new thing that we have at City of Hope is radiofrequency ablation. Radiofrequency ablation is the treatment where it’s essentially a thermal type ablation of the tissue. So we destroy the Barrett’s esophagus and allow it to heal and you’ve got a new squamous lining. It treats the Barrett’s esophagus with dysplasia. This radiofrequency ablation treatment currently is indicated for patients with high-grade dysplasia. There are treatment options for patients who do have Barrett’s esophagus with dysplasia.

Melanie: That’s fascinating. Thank you so much for such 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

Spinal Surgery Without Losing Mobility

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Segment Number 4
Audio File valley_pres/1506vp4d.mp3
Doctors Mouw, Graham
Featured Speaker Graham Mouw, MD
Guest Bio An outpatient clinic of Valley Presbyterian Hospital, The Neurospine Surgery Center was founded by Graham Mouw, MD, FAANS, FACS. A board-certified neurosurgeon, Dr. Mouw employs advanced, minimally invasive tools and techniques to resolve conditions in all areas of the spine. Dr. Mouw graduated from the University of Southern California Keck School of Medicine and conducted his surgery and neurosurgery residencies at Case Western Reserve University. He completed a complex spinal neurosurgery fellowship at the University of California, San Francisco before practicing at Cedars-Sinai Medical Center, Kaiser Permanente Medical Group, Cleveland Clinic and now Valley Presbyterian Hospital. Dr. Mouw was also Florida Sports Team Consultant for professional athletes while at Cleveland Clinic.
Transcription Melanie Cole (Host): Your health and safety is the top priority of Valley Presbyterian Hospital, and those factors are especially important in the operating room. Many procedures performed at VPH involve minimally invasive techniques with smaller incisions which can help minimize pain and speed your recovery time. We’re talking today with board-certified neurosurgeon with VPH, Dr. Graham Mouw. Welcome to the show, Dr. Mouw. Tell us a little bit about spinal surgery. What conditions would require somebody to seek out a neurosurgeon and say, “I think I have some issues with my back, and it’s pretty severe”?

Dr. Graham Mouw (Guest): Hi, nice to speak with you. The conditions that I normally treat involve people who have either a pain in their arms or hands or numbness in their arms or hands or sometimes weakness in their arms or hands. Similar symptoms with legs, the pain shooting down a leg or any numbness and/or possible weakness. I even treat people who have difficulty walking which is stemming from the nerves from the spinal cord.

Melanie: If people are experiencing these symptoms and they come to see you, is there something you do with them first? Do you try medications? Or at this point, have medications already been tried and now it’s time to discuss procedures?

Dr. Mouw: Well, I think the most important part of the analysis is that a patient has to start off with the MRI imaging, most likely, depending if it’s up the neck or the lower back. I think that’s usually a good start. Usually by the time people come to see me, they’ve had some sort of imaging study.Aand if they haven’t, then certainly that’s something that I can order for them.

Melanie: Okay. Once they’ve gotten that and you’ve looked at it and you’ve said, “Okay, this is the situation,” whether you’ve got stenosis or severe arthritis or some cervical issue, then what? What kinds of procedures are we talking about that can not work on reducing mobility and that are not fusion involved?

Dr. Mouw: One should always take a conservative approach to the spine, and sometimes we use medications or sometimes I’ll send them to a pain specialist. Very often, surgery is actually needed, and we’re moving into the realm of very high success rates with spinal surgery. I think a lot of that success is coming from what I call motion-sparing surgery, surgery where you maintain the normal motion of the spine as well as what I also call less invasive surgery, which is surgery that doesn’t require a long hospital stay and people can return very quickly to their normal function of life. The success rates are very high today with these newer techniques that are available.

Melanie: People always want to know. I myself am an exercise physiologist and people ask me this question all the time, Dr. Mouw. Do you go to an orthopedist when you’ve got a back issue, or do you go see a neurosurgeon?

Dr. Mouw: Well, that’s an excellent question. I’m a board-certified neurosurgeon with fairly extensive experience with spinal surgery. I come from the Cleveland Clinic and have come to Valley Presbyterian because of the excellent services that are offered. The advantage of a neurosurgeon is oftentimes you can get smaller surgeries. My particular expertise is in motion sparing. I’ve helped develop some techniques, particularly in the neck, that allow a patient to have a surgery and not have what we call spinal fusion, where the bones are fused together. That’s a very common procedure at America. But in other parts of the world, there are procedures that have been developed that allow full motion of the spine. I’ve developed those techniques in my practice, and that’s something that’s now available at Valley Presbyterian Hospital.

Melanie: People get very afraid of anything having to do with their neck, Dr. Mouw, and even for their spine. What is recovery like? Are they able to start physical therapy pretty quickly? How soon can they resume some activity?

Dr. Mouw: That’s the really nice thing about motion sparing surgeries is that people can resume activity very quickly and have a very normal and natural feeling to their neck because it’s motion sparing. Just to give you an idea, the two types of a motion sparing surgery, one is disk replacement surgery in the neck. In that particular case, people usually go home the next morning and can usually within a week have a fairly normal activity level. The other procedure that I’m an expert at probably more than just about anybody in the United States is what we call cervical laminoplasty, where I actually reconstruct the back of the spine, what we call the lamina, and I expand it, I make it wider. Those people similarly can return to fairly normal activity level usually within two to three weeks, and by about four to six weeks, there are really no restrictions at all. I’ve performed that procedure on NFL players. I’ve also performed that procedure on a wide range of people ranging from 40 to 80 years old, and that’s an incredibly successful surgery.

Melanie: Are there certain people that are not candidates for the cervical laminoplasty?

Dr. Mouw: The most important thing when you have the symptoms that we talked about at the beginning of the interview, symptoms down the arms or hands, weakness, numbness or symptoms in the legs, is to meet with a spine surgeon who can perform most, if not all, aspects of spinal surgery. There’s absolutely certain indications where I would choose, for instance, to do a disk replacement or a patient who I would choose to do a laminoplasty. That’s for the neck. In the lower back, there’s also a less invasive procedure similarly, where I could decide to do a micro nerve root decompression versus a standard open laminectomy, where you remove the whole lamina of the back part of the spine. I can do a very selective surgery called nerve root decompression. These are almost outpatient procedures where people certainly would be home by the next morning. There’s also procedures in the back where I can preserve motion where there’s some weakness in the back, some devices that are available. But really, in order to be able to tell what is the best option from you, you need to meet with a surgeon such as myself who is trained in all of these procedures and even pioneered some of these procedures so that you get the exact procedure or the best fit for you and your spine. Very often a surgeon may only know how to, for instance, do a fusion and you’re going to go meet with them and that’s what you’re going to be offered. A surgeon you meet with such as myself should be able to do just about everything so that you get the best fit for you.

Melanie: That’s great information. In the last few minutes, if you would, Dr. Mouw, please give us your best advice for people suffering from cervical or spinal pain and what you really want them to know about this type of pain and what procedures and help there is out there for them.

Dr. Mouw: Well, I think that as we are all experiencing these sorts of symptoms at some point in our life, I think people need to know that spinal surgery has improved significantly, and relief is certainly quite possible now. I quote people very, very high success rates, well over 90 percent for the relief of these symptoms. However, it’s very important to seek out a surgeon who has specialized training, such as a neurosurgeon with spinal fellowship training such as myself and somebody who can try and do the least invasive surgery and always try and preserving the motion of the spine. What I can tell people is that they don’t need to suffer and that certainly, if you’re a good candidate for surgery, the surgical success rates today in the right hands are extremely high. I quote people, like I said, well over 90 percent success rate if I sign them up for surgery.

Melanie: Thank you so much. That’s absolutely fascinating and gives hope to a lot of people who are suffering from cervical and spinal pain. You are listening to VPH Med with Valley Presbyterian Hospital. For more information, you can go to valleypres.org. That’s valleypres.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Preventing Spring Allergies

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Segment Number 4
Audio File allina_health/1508ah2d.mp3
Doctors Johns, Kenneth
Featured Speaker Kenneth Johns, MD – Allergy and Immunology
Guest Bio Dr. Kenneth Johns specializes in allergy and immunology and practices at Allina Health Coon Rapids Clinic and Allina Health Maple Grove Clinic. His professional interests include child and adult asthma, seasonal allergies, hives and skin rashes.
Transcription Melanie Cole (Host): Spring brings warmer temperature, sunshine, and flowering buds. But for many people, it can mean bouts of spring allergies that can be downright miserable. My guest today is Dr. Kenneth Johns. He specializes in allergy and immunology and practices at Allina Health Coon Rapids Clinic and Allina Health Maple Grove Clinic. Welcome to the show, Dr. Johns. Tell us about the spring allergies. What do you see most when spring comes around?

Dr. Kenneth Johns (Guest): Well, quite a few things show up in the spring. Some of those are allergies. Some of those are things that sort of sound like allergies, but as it turns out aren’t. In terms of allergens, we start to see some outdoor mold early in the spring. Those mold spores are not a real common allergen, but they can be a particularly difficult one to treat. A little later in the spring, when the trees pollinate, we have the tree pollen allergy. And that season is really very variable. Some years it’s early. Some years it’s late, depending on weather. Towards the end of spring, we start to see some grass pollen. Those would be the major allergens. Again, sometimes in the spring, we have problems. We have symptoms that are caused more by irritants, and sometimes we have problems that are more viral. Respiratory viruses can cause symptoms that really sound like allergy but aren’t.

Melanie: As you say, the respiratory viruses are going around at this time of the year. People have colds and things and runny noses. How do you know whether you have just a common cold or some kind of virus or whether it’s a seasonal allergy?

Dr. Johns: It can be really hard to tell them apart. In general, allergy symptoms are going to go on quite a bit longer. Your basic respiratory virus, you can have symptoms that go on for a week or 10 days, sometimes it will drag out to two weeks, whereas the allergy symptoms can go on for weeks or months. There is usually more itching with allergies than there is with respiratory infection. Otherwise, they can be hard to tell apart. We actually do tests for specific allergies. There are several different ways to do that. We do have the traditional skin test, where there are minute quantities of the pollen or the mold or what have you introduced underneath the skin, causing a welt if there’s a positive. And then we can do a blood test. There are various types of the blood test which have about the same accuracy, and sometimes we’ll do the blood test if we can’t do the skin test. But we have several different testing methods to diagnose a specific inhalant or allergy.

Melanie: Once you’ve diagnosed these as an allergy versus a virus or something else, then what is your first line of defense for treatment?

Dr. Johns: Well, we have basically three treatments for allergies: avoidance and then medications and then allergy shots or desensitization. I would say there really isn’t a first line. We have these options and we try to figure out what would be the best approach. Avoidance of springtime allergens is tough. Our springs in Minnesota are short enough as it is. I really discourage people from staying indoors. Beyond that, there’s not a whole lot you can do in terms of avoidance of those allergens. In terms of medication, we have lots of options. One by one, these options are gradually going over-the-counter, which makes things a lot easier. Sometimes we’re using antihistamine. Sometimes we’re using topical steroids in the nose. Sometimes we’re using different nose sprays. Sometimes we’re using eye drops and any combination thereof. We actually have quite a few options of very safe medications in different combinations for patients of any age, really. Then we have our traditional immunotherapy allergy shots. There are different types, but the consensus is that immunotherapy -- we call it subcutaneous, where you get an allergy shot weekly to begin with. Then they get spaced out as time goes by. This is a type of desensitization. We’re actually giving you very small amounts of that pollen, for example, that desensitizes you to the pollen when you inhale it or encounter it. These allergy shots, we’ve had them for about 100 years. I want to say allergy shots have been given for almost a century now, and they can be very effective for the right patient with the right allergy. The newest wrinkle in desensitization, as of this year, we have desensitization that’s a sublingual pill or drop. It’s something that’s been used successfully overseas for many, many years, and they’re just recently approved in the United States. We really don’t know how popular these are going to be. They’re only available for a few allergens, basically grass and ragweed. In terms of comparisons, we really don’t know how well they work compared to traditional allergy shots or medications. I’m going to say the jury is still out on the sublingual desensitization. There are options in some combination of those.

Melanie: If avoidance is impossible because you want people getting outside and such, are there things that they can do inside when they are? Do air filters work? Do dehumidifiers work? Does changing their pillowcase or using these anti-allergic pillows/ Any of these kinds of things you read about, do any of those work?

Dr. Johns: Air cleaners and air filters are a real popular approach, but the data, the studies really aren’t there to show that they actually make patients feel better. It isn’t a real common recommendation. The best that you can say is if you’re indoors and the doors and windows are shut and the air conditioners are running, that’s probably as good as it can get. A specific filter or HEPA system or what have you, like I said, we really don’t have good evidence that those are terribly helpful. The other avoidance measures that you are referring to really have to do with the dust mite allergy, which is more of a perennial, year-round allergy. If people are allergic to dust mites, there are things that can be done to reduce their exposure, but they really wouldn’t be helpful for the spring pollen allergy or mold allergy.

Melanie: Can you develop these kinds of spring allergies as you age, or do you get them as a child and keep them all through your life?

Dr. Johns: There are different patterns. There are some kids that seem to get them very young. But the most common pattern would be that late teens, early 20s who, over a course of years develop seasonal allergies, seasonal allergic rhinitis. They may sort of peak in the 20s and plateau in the 30s and 40s and then sort of gradually fade away. There definitely is a natural history for the main group of people with seasonal allergic rhinitis. Adult onset, someone in their 30s, 40s, 50s who just sort of develops pollen allergies, that’s not real common. That wouldn’t be a real common pattern. I think that it probably does occasionally happen. But more commonly, other things, other conditions that have some similar symptoms of allergies, those can show up as an adult. For example, people that are having more difficulty tolerating irritants like smoker dust, that’s something that can really show up in any age and will sort of fool you because it can sound like seasonal allergies but isn’t, and certainly has different treatment.

Melanie: In just the last minute, Dr. Johns, can you please give the listeners your best advice on how to reduce spring allergies, as it’s coming right around the corner?

Dr. Johns: Well, as they say, I think it would be cruel and unusual to stay indoors, so I think you should stay outdoors and enjoy the weather while you can. Medication-wise, it’s reasonable to start with over-the-counter antihistamine or nose sprays, specifically topical nasal steroid sprays, which are now over-the-counter. If those fail, it’s probably time to talk to somebody like me. We have some options for you.

Melanie: Thank you so much. It’s great information to try and nip those spring allergies in the bud. You’re listening to the WELLcast with Allina Health. For more information, you can go to allinahealth.org. That’s allinahealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Focus on Graft-versus-Host-Disease

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Segment Number 4
Audio File city_hope/1509ch1d.mp3
Doctors Cotliar, Jonathan
Featured Speaker Jonathan Cotliar, MD
Guest Bio Jonathan Cotliar, MD Primary Specialties are Plastic Surgery. His Clinical Area / Sub-specialties are Dermatology and his Departments/Division/Program is Surgery/Dermatology.

Learn more about Jonathan Cotliar, MD
Transcription Melanie Cole (Host): Graft-versus-host disease is a complication that can occur after a stem cell or a bone marrow transplant With GVHD, the newly transplanted donor cells can attack the transplant recipient’s body. To learn more about this today, we’re talking with Dr. Jonathan Cotliar. He’s associate clinical professor within the division of dermatology at City of Hope. Welcome to the show, Dr. Cotliar. Explain a little bit about a stem cell or bone marrow transplant and what this complication called graft-versus-host disease is.

Dr. Jonathan Cotliar (Guest): Well, thanks for having me. Bone marrow transplantation is something that sort of developed or came to fruition in the ‘70s and ever since has been exponentially growing and is emerging as the treatment option for a lot of patients, primarily with hematologic diseases, whereby donors, either related or unrelated, are donating their stem cells to a recipient whose immune system is deficient and by accommodating these stem cells from a donor, it allows them to sort of reconstitute an immune system that can go on and fight cancer. Problem is that for a lot of patients, despite intensive immunosuppressive medications, they still develop something called graft-versus-host disease whereby cells that are originating from the donor recognize this new recipient as foreign and these white blood cells that are usually used to fighting infection sort of turn on this new recipient and say, “Hey, we don’t recognize this new body. We need to fight this off.” As a result, there are complications, primarily in the skin, the liver, and the gut, which we, as sort of proponents of graft-versus-host disease treatment providers struggle with from early after transplant, sometimes even years after transplant.

Melanie: What are the first signs and symptoms? If someone has had a bone marrow or stem cell transplant and they’ve been on these immunosuppressive medications, are there something you tell them specifically, “I want you to make sure to call right away if…”?

Dr. Cotliar: Yes. Well, the good thing is that early after transplant, while patients are hospitalized as their immune system sort of recovers, for those of us who take care of stem cell transplantation, we are very accessible because we know that in terms of rates of graft-versus-host disease, depending on the studies you read, it can be anywhere from one-third to two-thirds of patients who do get bone marrow transplant. Early on, one of the more common manifestations is diffuse skin rash and while the morphology or the characteristics of these skin lesions can be challenging for doctors, it’s usually up to a dermatologist who has experience in this area to make an assessment, a form of skin biopsy if needed, whereby we can confirm a suspicion of graft-versus-host disease. The skin tends to be one of the chief early presentation of acute graft-versus-host disease, and that can occur either in isolation or concurrently with diarrhea, which is a manifestation of intestinal acute graft-versus-host disease, and finally some inflammation of the liver that can be picked up on surveillance laboratory draws is also one of the key components. So, all of these features, either in isolation or in combination, makes us suspicious and allows us to make a diagnosis of graft-versus-host disease which can occur sometimes even a week after transplantation.

Melanie: Can it be prevented or are there certain people that are more at risk than others?

Dr. Cotliar: We know in terms of risk factors, there are few sort of chief key risk factors for developing graft-versus-host disease. That includes the older the patient, the degree of mismatch between donor and recipient, the new, I should say, host or recipient of the stem cell, depending on the amount of blood products they’ve received. All of these risk factors can confer to a given patient a higher risk of graft-versus-host disease. The sort of chief way we treat this is actually prevention, whereby patients receive prophylactic immunosuppressive medications usually a few days prior to infusion of the stem cells in the new recipient up until weeks to months thereafter to try to prevent either the occurrence of graft-versus-host disease or minimize the severity of graft-versus-host disease.

Melanie: If you determine that they do have GVHD, what then is the treatment? What do you do for them?

Dr. Cotliar: In order to answer that question, we need to make a distinction between acute and chronic graft-versus-host disease. Formerly, acute graft-versus-host disease is only differentiated from the chronic from by this sort of arbitrary delineation of a hundred days. We now know that the pathophysiology of GVHD is far more complex and with the advent of what we call mini transplantation or stem cell transplant that don’t require full ablation of one’s own bone marrow to allow for donor stem cells to take hold, we know that relative levels of immunosuppression can alter somebody’s likelihood of developing graft-versus-host disease. So, the distinction is less of one chronologically and more of clinical presentation. I already alluded to the fact that acute graft-versus-host disease does tend to occur earlier after transplant. It’s characterized by inflammation in the gut and then the liver and has very non-specific findings in the skin. We contrast that with chronic graft-versus-host disease where patients may develop sclerotic skin lesions that may sort of limit their range of motion that may lead them to profound weakness. It may lead to ulcerations of the skin. It may lead to problems with the eyes or the oral mucosa, some of the deeper skin structures such as the fascia or even the muscle. So, those are the distinctions we make.

Melanie: If it’s chronic and you’re treating them with something that suppresses the immune system, even something like prednisone, Dr. Cotliar, you know there are always side effects, and so do they then have to worry about the side effects for something you’re really trying to treat them for to help with what you originally did? I mean, how do you, as a doctor, balance all of these different things?

Dr. Cotliar: That’s a great question, and again, I wanted to answer your previous question as well. Systemic steroids are typically first-line therapies for both acute and chronic graft-versus-host disease. Systemic steroids are great for short periods of time especially in high doses because they provide a level of anti-inflammation that is unparalleled. The problem is if they are chronically administered, they lead to things such as diabetes, osteoporosis, cataracts, among others, and so the sort of the push has been to try to find steroid-sparing agents both for the treatment of acute and chronic graft-versus-host disease. The problem is that if you look at their literature, if somebody is either dependent on systemic steroids, meaning we cannot sort of effectively taper down a given effective dose, or if they are resistant to treatment with systemic steroids, no single line second agent has been shown to be more effective than any other. What this leads us, both in the acute and chronic forms and we’re trying to treat either one of those, is that a lot of it is trial and error and that may be based on a given institution’s sort of protocol with respect to how they like to treat graft-versus-host disease with second line agents that may be related to a patient’s underlying comorbidities, whereby they may not be candidates for treatment with one immunosuppressive medication over another, that may be a function of a patient’s ability to get to the medical center in a timely fashion or with the type of frequency that may be required for certain systemic treatments that we can’t otherwise give if they live quite a distance away. All of these are major factors, and unfortunately, there is not one formula that fits all.

Melanie: Tell us what’s on the horizon. We don’t have a lot of time, so in just the last few minutes, what’s on the horizon for graft-versus-host disease research and treatment and what advice would you have for listeners why they should come to City of Hope for their treatment and care?

Dr. Cotliar: Well, I think anytime that a patient is able to be seen by a team of multidisciplinary doctors or be seen in the context of a multidisciplinary clinic where there is cross-collaboration among different specialties, meaning I, as a dermatologist, can share clinical space with the transplant doctor and I may have really good access to an ophthalmologist or a medicine person or a physical therapist, anytime you can see all these people under one roof like we’re fortunate enough to have at City of Hope, and certainly this type of setup exists elsewhere, this kind of a setup certainly benefits patients. Specifically at City of Hope, we are offering a multidisciplinary chronic graft-versus-host disease clinic, which we do once a week and the benefit of that is we’re able to assess patients in a room together, both the dermatologist and the transplant oncologist.In terms of what’s on the horizon, there was a groundbreaking paper on the New England Journal of Medicine last year showing that low-dose interleukin-2, which is the chemical that our bodies make naturally but given in low doses, may provide extreme benefit to patients specifically with the most severe form of chronic graft-versus-host disease which is the sclerotic form. In addition, there are a number of emerging biologic therapies such as agents that target interleukin-6 and interleukin-17 that may very well play a role in not just effectively treating graft-versus-host disease, but perhaps even as part of a prophylactic regimen to try to preempt the development of graft-versus-host disease.

Melanie: That’s very exciting and it’s a great multidisciplinary approach that you have, Dr. Cotliar. Thank you so much for joining us. You are listening to City of Hope Radio. For more information, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole MS

Is My Morning Sickness Normal?

Additional Info

Segment Number 3
Audio File allina_health/1508ah2c.mp3
Doctors McGillis, Gail
Featured Speaker Gail McGillis, RN – OB nurse
Guest Bio Gail McGillis is a Home Health – Mother & Newborn nurse.
Transcription Melanie Cole (Host): As many as 80 percent of all pregnant women can experience some degree of nausea or vomiting during pregnancy, but how do you know if it’s just morning sickness or something more serious like hyperemesis gravidarum? Today, my guest is Gail McGillis. She’s a nurse with Allina Home Health, mother of a newborn, who will provide us with the signs and symptoms of the difference between the hyperemesis and normal morning sickness. Welcome to the show, Gail. So tell us a little bit about what is the difference between morning sickness and HG or hyperemesis gravidarum.

C McGillis (Guest): Well, the biggest thing is the intensity and often the length of time. Morning sickness occurs in many of the pregnancies. It tends to be sometimes just nausea. People can eat off and on, snack throughout the day, and still gain weight and stay hydrated. They can drink fluids. They don’t usually get very dehydrated and they just can keep more down. But with the hyperemesis, it’s a smaller percentage. The patients that I talk with are so sick that I see some of the extremes and they almost always have severe vomiting. Many of them are dehydrated, needing IV hydration to help with that. For some reason, it’s harder to drink fluids than it is to eat food, but the nausea can be just overwhelming and constant all day long.

Melanie: Do we know what causes this?

C McGillis: No. There are various theories but there is no one “this is what causes it.” There are just too many things. A lot of people feel that the biggest part is just the hormone balance that’s so different in someone’s body.

Melanie: So does hyperemesis get better as the trimesters go along? Like usually with morning sickness, Gail, the first trimester, that’s kind of when it hits you and then it seems to taper off. Tell us a little bit about some of the symptoms and if they taper off as you’re more and more pregnant.

C McGillis: That’s really more individual. Some people do seem to get at times when a normal pregnancy, they would have hormone surges. If hormones especially are some of the reason they’re sick, they’re going to find that they’re much more intense. And I found over the years talking to people that we’re hitting a point where there’s more growth in baby and so now they’re feeling sicker again. Some just stay sick all the way through, there’s ebbing and flowing of that, but it’s so different for everybody it’s hard to tell. I’ve seen some that feel well enough to stop taking anything and then the other pregnancy, they kind of get hit again with the nausea and vomiting and not being able to drink. Others are on throughout their pregnancy, and depending on how they can handle the medication, they’ll do well and better and back and forth. So there’s somebody who’s doing well for a while. All of a sudden, they have that hit where they’re down again. You’re just not feeling great. There’s just not always reasons; it’s an ebb and flow for some people all the way through.

Melanie: So Gail, how does somebody know that they have HG? If they’re experiencing an increased heart rate, shivering, throwing up, they might think right away they have the flu.

C McGillis: And I think that does happen a lot. Typically, we see a lot of people with repeat pregnancies who will know right away “this is what it is.” Otherwise, they’re going in because they think they’ve got the flu. If it’s lasting any length of time longer than normal flu, their doctors are thinking, “Well, they’re pregnant. This might be the reason.” The shivering, I don’t see as much because I think that’s more of an early stage, but it’s the fact that they can’t keep fluids especially down, the food just tastes differently, or as soon as they’re eating, they are throwing up. The other thing is the weight loss. If they’re losing a percentage of their weight, that’s a real clue that this is hyperemesis, and after so much weight loss, you need to get in there and get them back up because you don’t want it to affect the baby’s growth.

Melanie: So can it affect the baby’s growth? Does this have any effect on the pregnancy?

C McGillis: It’s not something that I’ve seen a lot of because we try to check with patients after they have delivered and most of them do fine. The babies pretty much get what they need, but you find moms that feel that it’s difficult to be the mom they want to be while they’re pregnant to the baby that they’re growing, just like they feel that they’re not being able to spend the time thinking about what they can do for baby. It’s tough to be pregnant and feel that sick and enjoy being pregnant.

Melanie: Well, it certainly can make pregnancy very uncomfortable and difficult. So what can we do to really get some relief from HG?

C McGillis: Oh, one of the first things is to be hydrated. We found out that any medication that’s out there to be used works better if you’re hydrated. One of the first-line things that we often do is helping them out by letting them run IVs at home. And if they don’t have that option, if there’s not an agency where they are, a lot of times it’s going into an infusion center, maybe at the hospital. Or sometimes the freestanding urgent cares can do fluids for people – or even their clinic sometimes. But it’s routine, regular fluids every day. And then for a lot of people, for the food piece, it’s just grazing, eating something all the time. Many people say, “If I have something in my stomach, I do better.” And then the other thing is talking with their doctor. Sometimes people get very dizzy and lightheaded and if they can take a medication for that, that takes away some of the symptoms. Some people have excessive salivation. They are just always having a lot of saliva in their mouth and they’re spitting and they’re losing a lot of fluids by doing that. There are some things that can be done for that. They can always talk to their doctor about things. So it’s trying to take care of the symptoms. That’s really the best way to help people through this.

Melanie: And what about some alternative therapies? People think of chewing mint leaves or ginger tea or any of these things that are known to help with nausea.

C McGillis: Those are always good things to try. There are so many cases where there’s not just one therapy that works. There are several medications that are out there to use because one acts a different way than the other, so they work well together. It’s the same thing with some of those therapies. A lot of people, by the time I’m talking to my patients, they’ve already tried those things. But it’s sometimes a reminder that even on those days when it’s a little more tough to just maybe increase some of that to have it help out. The ginger tea is good. There are just so many things out that they can try. Some people just tell me what they’ve learned and I say then if that works, keep doing that food or that kind of thing if it’s something that their doctors have approved.

Melanie: When should you worry? When do you call your healthcare provider and say, “Okay, this is a little bit more severe than I thought”?

C McGillis: The biggest thing is when you are putting out urine, if it gets a strong odor or a strong, darker color, that’s the biggest sign that you’re dehydrated. It’s hard sometimes to gather how you feel and realize, “Oh, I’m not getting enough fluid.” You’re just thinking, “I am so sick.” But when you see that, that’s a sign you need to get in and get fluids or talk to your doctor about getting fluids. So it’s that. It’s just feeling you’re too weak to do anything and we see that a lot. People who are severely ill just don’t feel like they can even get out of bed and make it to the bathroom sometimes, or fix a meal. If they are needing help with these things, that’s a good time to say to the doctor, “I need to come in, be seen, what else can be done?”

Melanie: Does everybody get morning sick, Gail? There’s an old wives’ tale that if you’re morning sick, you’re having a girl, and if you’re not, you’re having a boy. Is there any truth to any of those kinds of things?

C McGillis: I don’t think there is. I think there’s always been a thought that having a girl increases hormones. I have talked with as many patients who were having boys that have morning sickness but not with their girls. So there are so many different reasons to have morning sickness or the hyperemesis. So it’s hard to tell that. For some people, it does seem to be that way but there are just enough differences out there that I don’t think you can say that. I’ve heard that maybe it means twins. Well, we don’t take care of that many people with twins but they are quite sick. So I think it’s one of those things that people always thought it would be nice to say that, especially someone who’s got three boys who’s hoping to have a girl. This is the reason but you never can be sure.

Melanie: No, you certainly can’t. And in just the last few minutes, Gail, would you give us some additional resources for women experiencing hyperemesis and your best advice for women that are newly pregnant and are starting to feel nauseous or sick and really what would you tell them if they came to see you?

C McGillis: If they were to call me, I would be saying, “Get in to see your physician.” Many of the physicians have nurses, nurse practitioners in the office who seem to have a lot of information at their disposal to be talking to people about that. Getting in to be seen, getting a baseline weight so people know if you’re losing or gaining, being very open to trying the different medications and things and seeing what will work, getting your family and friends to help you out. That’s a big issue for some people, getting help from people, being able to say, “I need help,” and “Can you do this or that for me?” Because that’s a very big thing, to tell your community to help you out with whatever you need.

Melanie: Thank you so much, Gail. It’s really great information for pregnant women, new mothers to be, and what an exciting time. For more information, you can go to allinahealth.org/homehealth or you can call (612)863-4478. You’re listening to the WELLcast with Allina Health. And as I said, for more information, you can go to allinahealth.org. That’s allinahealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Treating Pulmonary Hypertension

Additional Info

Segment Number 3
Audio File virginia_health/1508vh5c.mp3
Doctors Mazimba, Sula
Featured Speaker Sula Mazimba, MD
Guest Bio Dr. Sula Mazimba is board certified in internal medicine and cardiovascular disease and specializes in caring for patients with pulmonary hypertension and heart failure.

Learn more about UVA Heart & Vascular Center
Transcription Melanie Cole (Host): What is pulmonary hypertension and how is it linked to heart failure? My guest today is Dr. Sula Mazimba. He is board certified in internal medicine and cardiovascular disease and he specializes in caring for patients with pulmonary hypertension and heart failure. Welcome to the show, Dr. Mazimba. Tell us a little bit about pulmonary hypertension. What is it and how does it differ from hypertension that we might have heard about?

Dr. Sula Mazimba (Guest): Thank you so much for having me on the show. Pulmonary hypertension is a type of blood pressure that affects the arteries in the lungs and ultimately the right side of the heart. In order to be able to sort of understand the disease, it’s important to understand that we have two sides of the heart, the circulation. There is the left side and the right side. In order for blood to pump around the body, it has to pump from the left side which has a higher pressure to the rest of the body and ultimately to the right side which takes blood to the lungs. The right side of the heart has fairly low pressure. It’s a low pressure system. In some situations where you start having elevation in blood pressure in their right side of the heart or the lungs, what happens is that the circulation is impaired, meaning that the blood going to the lungs is not able to adequately get oxygenated, and so it affects the circulation around the heart. That’s kind of, in a nutshell, what pulmonary hypertension really is.

Melanie: What symptoms might somebody experience if they think that they might have this?

Dr. Mazimba: The symptoms for pulmonary hypertension are actually very nonspecific, and because of this, sometimes patients present very late. Typical symptoms include shortness of breath, which as you know is very nonspecific. Patients really just feel short of breath and very tired, dizzy, occasionally they may have some chest pains or racing heart, and so they tend to be very nonspecific.

Melanie: Okay, so what would send somebody in to see you to even get tested for pulmonary hypertension? Would it have anything to do with if they have been suffering from regular hypertension before or if they have a family history of this situation?

Dr. Mazimba: In some cases, patients do have family history of pulmonary hypertension, and sometimes they come testing for the disease, but those are very few situations. Oftentimes, patients who have presented at their primary care physician, they may have been trying to find out why they are very short of breath and very tired. Ultimately, an echocardiogram is ordered and that kind of shows that the pressures on the right side of the heart are high and that’s how they end up oftentimes coming to see us.

Melanie: If you diagnosed someone with pulmonary hypertension, then what do you do for them?

Dr. Mazimba: Well, in some cases, pulmonary hypertension is related to other disease conditions, and so when we are treating pulmonary hypertension, we often treat also the underlying disease condition. The treatments are often very complex. The medications, they are sometimes very complex, and so we oftentimes have to make combination therapies. There are also what we call supportive therapies, where we essentially, not necessarily, altering the disease process, but we are kind of helping patients deal with the symptoms, like for instance, giving them some diuretics, oxygen, blood thinners. In some situations, we resort to surgery. We may have to sometimes recommend lung transplant or heart and lung transplant, depending on the situation.

Melanie: What are some of the complications that could happen if… they can go into heart failure if this isn’t treated? How long can it go on before those complications might start to set in?

Dr. Mazimba: That’s a very good question. Pulmonary hypertension is, like I said, associated with other disease conditions, and so it depends on the company it keeps. There are some situations where, for instance, it may be connected with rheumatoid arthritis or other connective tissue disease, and so depending on the company it keeps, the prognosis also varies according to the type of pulmonary hypertension. There are various types. We often categorize pulmonary hypertension in five major groups. Each of those groups may have different prognostic type over the long haul. In general, without treatment, pulmonary hypertension can be very fatal and so this is why it’s critically important for patients to present early so that we can institute some of these medical advances including therapy treatments and sometimes surgeries.

Melanie: Dr. Mazimba, how does your expertise in hypertension relate to your work with heart failure patients?

Dr. Mazimba: As you know, when pulmonary hypertension is severe enough, it impairs the contractility of the right ventricle, meaning that the right ventricle will have to struggle to push blood to the lungs. Ultimately, heart failure is the leading cause of death in patients with severe pulmonary hypertension. There is that link between pulmonary hypertension and advanced heart failure.

Melanie: Wow, it’s really very interesting. Tell the listeners why should someone come to UVA for heart failure and pulmonary hypertension care and give your best advice for people that might be suffering some of these nonspecific symptoms and what you would tell them.

Dr. Mazimba: One of the reasons why patients should really look at UVA as a place where they need to seek their care is that pulmonary hypertension and heart failure are very complex disease conditions, especially heart failure when it’s advanced. They are best served in medical teams that specialize in these disorders. At UVA, we see patients from within the state and outside the state. We have a lot of experience when we’re talking about pulmonary hypertension and advanced heart failure. That is one of the strong points, advantages of care at UVA. It’s multidisciplinary and we see a lot of very complex patients. One of the things I advise patients who are having these nonspecific symptoms is, of course, talk to your doctor about this and don’t blow away the symptoms and say, “Well, it’s maybe I’m just tired.” Indeed, you may be tired, but if the symptoms persist, it’s important to seek medical advice.

Melanie: That’s very good 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

New Studies Highlight Breakthrough Stroke Treatment

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Segment Number 2
Audio File virginia_health/1508vh5b.mp3
Doctors Gaughen, John
Featured Speaker Dr. John Gaughen
Guest Bio Dr. John Gaughen is a board-certified radiologist who specializes in interventional neuroradiology procedures to treat strokes and other brain conditions.

Learn more about UVA Neurosciences
Transcription Melanie Cole (Host): An innovative method of removing blood clots significantly reduces stroke patient’s chances of being disabled, new studies suggest. My guest today is Dr. John Gaughen. He’s a board-certified radiologist who specializes in interventional neuroradiology procedures to treat strokes and other brain conditions at UVA Health Systems. Welcome to the show, Dr. Gaughen. Tell us a little bit about these studies, the recently published studies that examined the type of stroke treatment. What is this treatment?

Dr. John Gaughen (Guest): Well, Melanie, first of all, thank you for having me on. I’m very excited to be here. Yes, last week, at the International Stroke Conference in Nashville, Tennessee, there were two—really three studies—two that have already been published that has demonstrated very exciting news for the stroke world. Many of the listeners may know there has been a treatment around for about a decade now to help treating certain patients with stroke called mechanical thrombectomy. Simply, what that is, is taking the tube into the blood vessels of the brain, finding the blood clot in the blood vessel of the brain that is causing the stroke and mechanically pulling that blood clot out and restoring blood flow to that part of the brain. Now, we’ve always known that this is a very time-sensitive treatment and only works for patients that have brains that have not completely stroke, so within the first several hours after the stroke onset. It doesn’t apply to all patients. But one of the things that we’ve had a very difficult time in the past doing is demonstrating that this approach to stroke treatment actually provided benefit to patient. What these studies last week showed is they basically confirmed another study that came out over the last fall that showed that in certain patients that have clots in large blood vessels of their brain removed in a timely fashion, those patients showed a much lower rate of disability, a much lower rate of death, than patients treated with our typical conservative treatments, which are blood clot medicines through the vein and other conservative measures. Basically, in a nut shell, what these pieces of literature have done is overnight, made a gigantic paradigm shift in how we’re going to approach strokes in this patient population, which is patients that come in with stroke symptoms that have large clots in large blood vessels of the brain. It is going to change, I think, the way that patients are evaluated and the way patients are treated once they get to the emergency room when they do have an acute stroke. So it’s very exciting information.

Melanie: It is very exciting information. Dr. Gaughen, when a patient is admitted and they’re evaluated for stroke situation, how fast can this procedure be evaluated for and then done?

Dr. Gaughen: Well, the interesting thing, all of these different studies looked at this disease process in a little bit different way. One study was done in Netherlands, one study was done in Australia, and two of the studies are multinational studies and they all had a little bit different criteria for how they evaluated these patients and determine who was eligible for the treatment. But one thing that they all found was that the faster these patients were identified and the faster they got on to the operating room table to have the clot removed, the better they did. One of the big focuses in the coming months and years are going to be to standardize ways to streamline patients who come to the emergency room to get this treatment as quickly as possible.

Melanie: Streamlining that would make it so because with stroke, we know that time is brain and the speed at which you’re cared for really determines that amount of disability you could possibly suffer. As an interventional neuroradiologist, would you be one of the first people in line to see this person and say, “Let’s get them up. Let’s do the mechanical stent.” How does that process work?

Dr. Gaughen: Well, the process starts with the first responders. One of the things that we have been doing and we will continue to do is to educate the EMS, Emergency Medical Services, the population in general, that when you identify the symptoms of a stroke, that that is a very time-sensitive issue. When a patient comes in the emergency room, either from family members themselves or from the EMS, we want to know right away if we think that that patient is having a stroke. Typically, at the University of Virginia, we have a stroke neurology service that’s in-house 24 hours a day, seven days a week, and as soon as anybody in the hospital, whether they’re admitted to the hospital or showed up in the emergency department with stroke symptoms, a pathway is begun where the stroke neurologist sees that patient immediately to determine whether they truly think that patient is having a stroke and how bad that stroke is, and how long they’ve been having the symptoms. Once we determine that, we can determine what type of treatment we think that patient is eligible for. If they’re eligible for this type of treatment, meaning they have been having the symptoms for less than eight hours, their stroke symptoms are bad enough that we think that a large blood vessel is blocked and that’s causing the symptoms, that patient will go immediately to the CAT scanner where we do some imaging tests, a CAT scan and a CT angiogram, to look at the brain to make sure that there isn’t something that’s causing the stroke that’s different than what we think, like a big brain bleed or tumor or something that can mimic a blood clot. Then we’d do the CT angiogram which looks at the blood vessels of the brain to see if there is a clot in the location that we can remove. That imaging takes no more than a couple of minutes. Once that patient has got that imaging, we have already, as interventionalists and as radiologists, have already been alerted that there is a patient that potentially has this blood clot. We are looking at those images as they are being processed immediately after they’re taken to make the decision about whether or not that patient is a candidate. If that patient is a candidate, the goal is to get that patient directly from the CAT scanner to the angiography table, where we can place the patient on the table and remove the clot. It is a very time-sensitive procedure, and there are a lot of moving parts between the emergency room physicians, the first responders, the neurologists, the radiologists, and the interventionalists and it takes a very coordinated effort to get that system as streamlined as possible to help patients. What we see is that if you can do that in a quick fashion, we see very good outcomes. We see patients that have significantly reduced mortality and significantly improved functional outcomes when they recover from strokes. It is something that we’re going to see dramatically change, I think, the face of stroke as we know it today.

Melanie: Now, in just the last few minutes, Dr. Gaughen, tell us about the risk of this type of thrombectomy and why patients should come to UVA for their stroke care.

Dr. Gaughen: Well, like I just said, having a multidisciplinary approach, having physicians that are available in the hospital 24 hours a day, seven days a week, having dedicated critical care team members that are specifically trained in neurological disorders, are all very, very important because the speed with which we treat this disease and the expertise with which we have to treat this disease is very important in this very complex disease process. UVA has all of these. UVA has one of the most experienced stroke neurology services and one of the most acclaimed neuro intensive care units in the state, if not the country. As neuro interventionalists, we have over 50 years of experience in treating all sorts of complex neurovascular diseases and a great degree of expertise in the ischemic and hemorrhagic stroke. What was the first part of the question?

Melanie: I just wanted you to tell the listeners how safe this procedure is and really how exciting. What’s on the horizon for this now?

Dr. Gaughen: What these studies have done actually is very interesting. The disease itself is a very bad disease. Stroke is the third or fourth, depending on what you read, the third or fourth leading cause of death in America and the number one cause of adult disability in the United States. The major complication with the treatment is bleeding. When we remove that clot and the blood gets back to the brain, if the brain has already been damaged, it may not be able to accommodate that blood or deal with that blood and that causes bleeding into that area. The interesting thing about this study is that in the time frames that these studies were able to get blood clot out, which is quicker than older studies, we find that that risk of bleeding is very low. In a couple of these studies, that risk of bleeding is even lower than the risk of bleeding when we give the clot buster medicine through the vein. It turns out that it is a very safe procedure compared to what we have historically seen with stroke treatment and very effective. We’re very excited about it. I think this is only going to lead to a better understanding of our ability to treat this disease in the future and I think we’re going to continue to see improved outcomes with this treatment modality. This is certainly not the end. I think it’s the beginning of a wonderful road ahead that’s going to give us a lot of information on ways to treat a disease that has been a very difficult disease to treat in the past.

Melanie: Thank you so much, Dr. John Gaughen, absolutely fascinating 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

When Should Your Child See a Pediatric Geneticist?

Additional Info

Segment Number 1
Audio File virginia_health/1508vh5a.mp3
Doctors Wilson, William
Featured Speaker William Wilson, MD
Guest Bio Dr. William Wilson is board certified in pediatrics and medical genetics and specializes in caring for children with genetic conditions.

Learn more about UVA Children’s Hospital
Transcription Melanie Cole (Host): Fortunately, most children are born healthy with no medical problems or birth defects. However, there are some instances where your family might consider bringing their child to see a medical geneticist. When might that occur? My guest is Dr. William Wilson. He’s board certified in pediatrics and medical genetics and specializes in caring for children with genetic conditions. Welcome to the show Dr. Wilson. Tell us a little bit about what a pediatric geneticist does.

Dr. William Wilson (Guest): Pediatric geneticists see a wide range of patients. Actually, most geneticists are in fact pediatricians, but we also see adults because our training is both in genetic conditions in children and in adults. We diagnose patients. We see patients who are referred because of family histories, because of findings of biochemical disorders, or newborn screening or in subsequent testing. Frequently we see patients whose families just have questions about what is going on with their children, what the diagnosis might be, what they might expect and what this might imply for other family members and potentially future children.

Melanie: Tell us, Dr. Wilson, what types of conditions do you help evaluate?

Dr. Wilson: We see a wide range of children and adults. Again, we see primarily children, but we also see adults, as medical geneticists are trained in both pediatric and adult genetics. We see children with birth defects, growth issues, sometimes learning issues, problems like autism, suspected biochemical disorders, abnormalities on newborn screening test that all children in Virginia get. We also see adults with similar sorts of issues or with positive family histories or findings that might suggest a genetic disease that may have some more specific diagnostic testing available.

Melanie: What would make somebody decide to come to see you for this evaluation? In some of the things that you’re talking about, yes, testing, that sort of thing with a child, we go to our pediatrician and then they say, “Well, you might want to go see a pediatric geneticist.” When an adult would see you, what would make them decide that “this is time, I need this evaluation”?

Dr. Wilson: One of the problems with genetics is that the knowledge base is expanding so rapidly right now. It’s very difficult for excellent primary care physicians and even excellent specialists who aren’t specifically geneticists to keep abreast of the changes in diagnosis and testing availability. We see about half of our patients who are referred by other physicians, either their primary care physician or other medical specialists, and about half come from initial family referrals because of something that they’ve heard about other family members, something they have read in the newspaper, seen on the Internet or television, and we are here primarily to make diagnosis and to share information with families.

Melanie: What do they do with the information that you then give them after an evaluation?

Dr. Wilson: Well, it depends on what the specific situation is. Sometimes, we make diagnosis of conditions that have some complicated medical implications or perhaps involving other organ systems that may not have been considered, and somehow, if we can help with case management, we can help the primary physicians in terms of other specialty referrals that might be appropriate. We’re primarily involved in making diagnosis and giving the information. What we don’t is usually tell people what to do, because sometimes these are very difficult situations in terms of deciding who gets tested, what people want to do with the information, if in fact, they don’t what to have that information, and so we try not to force anything on our patients, but really give them information and try to help them make informed decisions.

Melanie: Dr. Wilson, as you stated earlier, the field of genetics is exploding right now. It is huge. People are looking for genetic markers and everything from family risk of breast cancer and congenital heart disease, hypercholesterolemia, all of these things with genetic markers. What do you tell people about that decision to even see a geneticist, to even find out what they might possibly be at risk for? As you say, some people don’t know if they even want that information. What do you say to people questioning this?

Dr. Wilson: Sometimes, before we do the testing, we actually discuss the test results before they come out, before we even start the testing process actually, and talk about the implications. Many tests are not perfect. Most tests are not perfect. There are certainly genetic conditions for which we do not have a reliable genetic marker, and then there are other genetic conditions where we have genetic markers and yet the implication of finding that particular change may vary from one patient or even one family member to another. We try to give people a notion of what they’re getting in for, in terms of information and what kinds of issues, even having the testing information right there for them.

Melanie: Is the testing information public? If somebody gets some kind of genetic information, is that now something that insurance companies can look up and find out?

Dr. Wilson: You’ve asked a very good question. There is a federal law called the Genetics Information Nondiscrimination Act that is supposed to protect the patient’s use of genetic testing information. Genetic testing information is part of the medical record, like any other physical finding or any other piece of laboratory information. Thus far, I’m not aware of patients who have problems with having the genetic information per se, but it is a concern that sometimes having that piece of information might be disadvantageous to certain individuals in certain situations.

Melanie: What else would you like to tell families, in just the last few minutes, Dr. Wilson, about genetic testing and specifically, pediatric genetics, if their children have some issue that they would like to get tested for, and why should families come to UVA for evaluation of pediatric genetic conditions?

Dr. Wilson: I think the most important thing is to discuss the possibility of seeing a geneticist with your primary care physician because sometimes that physician can provide us with some information in pediatric cases, like growth charts or medical information, etcetera, that might help us in seeing the patient and make the visit more efficient for the family and make the use of the patient’s time much more productive. Some families see us primarily without referral from physicians because of family history and concerns, and I think it’s important to try to get as much family information before you come because then that’s more going to be helpful for us in trying to figure out if there’s a pattern in the family, if there are clues that might lead us to a specific diagnosis or might help guide us in what we might suggest to the family for testing. Why come to UVA? One of the great things I like about being at UVA, and I’ve been here for over 35 years, is we work together very well. We have excellent pediatric and adult specialists and subspecialists and we really work in a collaborative, cooperative fashion. I think this really makes the care of patients much more efficient, much more streamlined, and much more effective for the families.

Melanie: Thank you so much. It’s an absolutely fascinating field of study and field of medicine. Thank you so much for being with 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 day.
Hosts Melanie Cole, MS

Using Robotic Surgery to Treat Urologic Cancers

Additional Info

Segment Number 1
Audio File city_hope/1509ch1a.mp3
Doctors Lau, Clayton S.
Featured Speaker Clayton S. Lau, MD
Guest Bio Dr. Lau is an Associate Clinical Professor in the Department of Urology and Urologic Oncology at City of Hope. His expertise and interests are in minimally invasive approaches to urologic oncology and reconstructive urology. He has lectured and taught numerous surgeons robotic surgery throughout the nation and is the Director of the Fellowship in Urologic Oncology/Robotic Surgery at City of Hope.

Learn more about Dr. Lau
Transcription Melanie Cole (Host): At City of Hope, our physicians are leading experts in treating patients with all type of urologic cancers. Just as no two patients are alike, cancer requires a unique treatment plan, tailored to each individual to attain the best possible outcomes. My guest today is Dr. Clayton Lau. He’s an associate clinical professor in the Department of Urology and Urologic Oncology at City of Hope. Welcome to the show, Dr. Lau. So tell us a little bit about robotic-assisted surgery. What is that? It sounds very new space age, but really, what is it?

Dr. Clayton Lau (Guest): Good morning, Melanie. Thank you. Robotic surgeries have been around for over a decade now and it’s taking laparoscopic surgery, which is a minimally invasive operation, where one, instead of making a big incision, fills up the abdomen with a gas, makes tiny incisions, puts ports in, and puts small instruments to do the operation that we would do just like an open operation. With robotic surgery, what we’re doing is taking it further by connecting the laparoscopic ports to a robotic interface, where one can use advanced cameras, where we can use magnification 12 times the human eye. We can use wristed instruments and different instruments, just like in doing the open operations. We do much more fine dissection and more complex operations.

Melanie: So the difference between that robotic-assisted surgery and the laparoscopic surgeries are…?

Dr. Lau: The biggest distinction is using the robotic interface. With the laparoscopic surgery, one would have to just use their hands. With the robot, you sit behind what appears to be a robotic console. It’s like a video game console, in a sense, where one surgeon will sit comfortably and use all the advantages of the robot with the visual optics and the instruments themselves. In addition, the instruments, if even one were to shake while we’re doing the insert, it cancels it out, so it will make a surgeon almost a better surgeon.

Melanie: Wow, that’s really neat. And the way that you guys have been trained to use this robotic surgery, how is the training for this? Does it take a lot of practice to use this equipment?

Dr. Lau: It certainly does. The company that makes the robot is called Intuitive Surgical. It is intuitive but it takes quite a bit of training and there certainly is a learning curve where it takes hundreds of cases to get facile at it. In addition, what we found with having done over thousands of procedures, we’re still getting better. I think that we’re actually getting more efficient and better and finding more uses in different procedures and doing the operations.

Melanie: So what type of urologic procedures can be done using these robotic-assisted techniques?

Dr. Lau: The most common procedures that we’ll do is a radical prostatectomy for prostate cancer. Also, it’s very commonly done for nephrectomies or kidney removals, partials and radicals, and also for cystectomies which are bladder removals, and they’re all for specific cancers – prostate cancer, kidney cancer, and also bladder cancer. We can also use it for less common cancers such as adrenal cancers. But the robot can be used in a multidisciplinary fashion where you can use it for lung cancer, for colon cancer. So if a person actually has a colon cancer and a kidney cancer, you can do the operation at the same time and use the robot.

Melanie: Are there some people, Dr. Lau, that are not candidates for using this robotic type equipment?

Dr. Lau: I think there are some candidates where the disease is widely metastatic, where an open operation is needed. But frankly speaking, even at the Cancer Center at City of Hope, I would say in urology, about 95 percent of our cancer operations are done robotically.

Melanie: Dr. Lau, I’m sure this is a question that many patients have: What if the equipment fails during the operation? What happens then?

Dr. Lau: Well, typically, the surgeons that are trained to do robotics are trained to do conventional operations so they’ll just switch over to the conventional operation. But at the City of Hope, we actually have the luxury of having more robots. So when it happens, and it’s really uncommon to happen where a robot has a breakdown where it’s non-recoverable, in other words, it can’t restart back up, sometimes they’re like any electronic device. You can just turn it off and turn it back on. Usually, it works again. But if that happens, and maybe it happens once every two or three years, we’ll just bring another robot in the room. Other than that, we can just do the old standard approach or the open approach or even just laparoscopic and just complete the operation.

Melanie: So does this make it less recovery time? Is there any advantage to using the robot for prostate cancer or kidney or bladder cancer? If you’re using the robot for these types of surgeries, are there any advantages in recovery time?

Dr. Lau: There certainly are. I mean, most patients, what we found is that they’re actually in the hospital in much less time, less chance of a complication or infections. So they can get back to their life sooner – back to work, back to working out, just getting back to their normal routines. So there’s huge advantages. Also, blood loss is much less common with these sort of operations.

Melanie: So then what happens afterwards? You’re using the robotic surgery, then there’s recovery time. Is this something that needs rechecking? Do you go back in ever and look? How does that work?

Dr. Lau: Even after an open operation, most patients with cancer have a specific followup and that might entail blood work or CT scans afterwards. And depending on the type of cancer or the extent of the cancer, we would put them on a protocol to survey them afterwards to make sure that the cancer doesn’t come back. And if it does, we would apply the appropriate adjuvant or salvage therapies if needed.

Melanie: Tell us about the horizon. What’s going on with robotic surgery that’s very exciting at City of Hope, Dr. Lau?

Dr. Lau: We have the latest and greatest of the newest robots. We use special cameras, special lights to help determine margins or edges. Instead of just using fluorescent lights. We’re also developing our own proprietary camera to help determine the edges of where the tumor begins and the normal tissue begins also. In addition, we do quite a bit of training for many physicians worldwide. We have so much experience that many physicians come here to learn. It’s an exciting place, and I would tell you that it seems like every 6 months or 12 months, we always have new devices to make the operations even easier. Before, we can only do a few operations with robotics, but now, sky is the limit. We can do most major operations robotically.

Melanie: Now, Dr. Lau, in just the last few minutes, please give the listeners your best advice on considering different urologic cancers and those that might need surgery, and really give them some comfort in knowing that the robots are going to be really their best option.

Dr. Lau: I think robotics a decade ago was deemed to be experimental. But nowadays, it’s commonplace for most hospitals including larger community hospitals to academic hospitals to VAs. It’s commonly used even for benign conditions, just for hysterectomies or whatnot. So it has actually become a standard instrument for many surgeons out there, and the benefits are incredible for most patients that undergo surgery, especially with the recovery time and less blood loss. It is the standard, and with experience, surgeons are getting better and we’re seeing a lot of the benefits. I think the most important thing for a patient when they’re choosing their surgeon is to make sure that their surgeon has the experience doing this specific technique before proceeding.

Melanie: Thank you so much, Dr. Lau. 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

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