Inactive (722)

Audio File allina_health/ah137.mp3
Doctors Voye, Erin
Featured Speaker Erin Voye, audiologist, Woodbury clinic
Guest Bio Erin Voye is a licensed audiologist with professional interests in hearing loss, hearing aids, hearing conservation, aural rehabilitation and communication strategies.

Learn more about Erin Voye
Transcription Melanie Cole (Host): After a lifetime of listening you might find that your hearing doesn’t seem as sharp as it used to be. Our hearing tends to change gradually over time. However, there are some steps you can take to protect your precious hearing. My guest today is Dr. Erin Voye. She’s a Doctor of Audiology at the Allina Health Woodbury Clinic. Welcome to the show, Dr. Voye. What’s the prevalence of hearing loss? Is this something that’s an automatically assumed thing -- that we’re all going to lose our hearing as we get older?

Dr. Erin Voye (Guest): Well, for the most part, there is some hearing loss as we age. Usually – there are studies that show 1 in 4 over the age of 65 have hearing loss, so I think it is more prevalent than some people are willing to admit.

Melanie: What are some signs that it’s happening because I find, Dr. Voye, that people are much more patient with someone who is blind than someone who is going deaf or losing their hearing. They get very impatient, and they say, “Well, why can’t you hear me?” What are some of the signs we should be looking for, and red flags that signal that this loved one of ours is starting to – or ourselves – starting to lose some of that hearing and that maybe there’s a way to alert people so that they would be more patient with them?

Dr. Voye: Yeah, definitely. I think sometimes it’s more of a funny thing as we start to lose our hearing, but asking people to repeat themselves more often, or noticing that the volume on the TV or the radio is maybe louder than others prefer or louder than you used to have it, experiencing even ringing in the ears can be a sign of some hearing loss. Complaining that people mumble, “It’s not my fault. Everyone’s trailing off,” is another thing that we hear often. But yeah, usually it is those family members that start to notice somebody is having trouble before they actually have concerns themselves.

Melanie: How often should we get our hearing checked?

Dr. Voye: There’s nothing that is regulated, but I always think it’s a good idea to – at Medicare age, 65, why don’t we just get a baseline hearing test and check things out? But also, people who have a family history of hearing loss you would want to get your hearing checked sooner. If they have been working in noisy environments – factory workers, farmers, construction workers, people who are exposed to those loud noises throughout their career, we tend to see hearing loss as well. Just the first sign -- but even getting a baseline hearing test -- so that we can see if there is any progression as things get worse or as we age.

Melanie: So then let’s talk about treatments. If you start to notice that somebody is starting to lose their hearing, or they come in for that baseline hearing test, right away do you go towards using a hearing aid – and I’d also like to talk about the advances in hearing aid equipment these days, but what is the first thing you do with somebody when you notice that there’s some slight loss?

Dr. Voye: Number one, we want to make sure that there’s no simple wax buildup, and so we check to make sure there’s no wax buildup. Sometimes, just getting a hearing test – and even if there’s a mild hearing loss, we don’t necessarily jump to hearing aids right away. It may just be different communication strategies like making sure that if you’re trying to have a conversation with somebody, turn down the radio, or TV, or distracting noises. Putting yourself in better listening situations, so if you’re out at a restaurant if you can sit in a booth with high backs, or with your back against a wall, that’s going to help to decrease background noise coming in. There’s simple things that way, but then the next step could be hearing aids, and whether one or two is better, everybody is a little bit different, so depending on their needs --

Melanie: So tell us what’s going on in the world of hearing aids today, because they seem so small, and so tiny, and some of them are invisible, and yet, some of the tiny ones have battery issues for older people – they can barely grab the tiny batteries and tiny little – I know because I’ve done this with so many people. Tell us what’s going on and what are some of the cool advancements in the world of hearing loss?

Dr. Voye: Yeah, there’s definitely a stigma of hearing aids – people see these big, beige bananas that their great-grandfather used to wear and they’re much sleeker and smaller than that. They have gotten very, very small. They are these very sophisticated computers that you can wear, and so that is something that people are often surprised by is the size. They like that – “Oh, that’s what it looks like?” That’s kind of fun to see.

And then the batteries? Yes, they’re definitely an issue, so that’s something we keep in mind for each different person, so some of the older people who may have dexterity issues or vision issues we may go with a different style, or maybe a bigger battery for those certain people. And there are hearing aids that are rechargeable now. They are the behind-the-ear style, but that is something that is kind of nice as well. You do have to put them on a charger at night, but there’s no fumbling with those fingers to get those batteries in and change them frequently, like once a week or so.

The other exciting thing for hearing aids is that there are several manufacturers that have hearing aids that will connect directly to an iPhone and some android phones via Bluetooth, so you are able to use your cellphone as a remote control to turn the hearing aids up and down, volume-wise, or change different settings. In the iPhones, they also will stream the phone calls directly to your hearing aids, so it’s this hands-free, cool benefit to the hearing aids that instead of having to make adjustments to the hearing aids, it looks like you’re maybe just texting somebody on your phone, but really, you’re adjusting your hearing aids. That’s designed to some of those younger, maybe 40s, 50s, 60s patients who aren’t quite ready to talk about their hearing aids, but it gets them in the door a little bit sooner.

Melanie: And wrap it up for us with your best advice. Is there any way to prevent this hearing loss – this age-related hearing loss? And give us your best advice, Dr. Voye, about things we can do in our younger years that may help to protect our hearing?

Dr. Voye: Yes, my rule of thumb is it’s never too late to protect your hearing from loud noises, so wearing hearing protection when you’re around loud noises, like mowing the lawn, power tools, chainsaws. Even at concerts – I know it’s not the cool thing to do, but rock concerts, really noisy places like that, wearing hearing protection. When you are listening to headphones or music through headphones, keeping the volume at a safe level, at about 60% or less volume is usually a safe volume to listen to for extended periods of time. Take control of your hearing loss. Be an advocate. If you know somebody who is experiencing hearing loss or that’s maybe having trouble, have them get a hearing evaluation. And again, all it is is a baseline. We’ll go over results and then go through those recommendations of either communication strategies or talking about the hearing aids if we need to.

Melanie: Thank you, so much. That’s really great information, and so important for people to hear. Thank you, Dr. Voye, for being with us today. You’re listening to The Well Cast with Allina Health, and for more information, you can go to AllinaHealth.org, that’s AllinaHealth.org. This is Melanie Cole. Thanks, so much for listening.
Hosts Melanie Cole, MS

What is Sports Medicine?

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Audio File florida/fl018.mp3
Doctors Millan, Sonia
Featured Speaker Sonia Millan, MD
Guest Bio Sonia Millan, MD is a board-certified physician that specializes in Sports Medicine. She obtained her Doctorate of Medicine (MD) from the Quillen College of Medicine at East Tennessee State University. After successfully completing her Family Medicine residency in Tennessee, she decided to follow her passion for Sports Medicine by completing a fellowship in Daytona Beach, Florida at Halifax Health.

Learn more about Sonia Millan, MD
Transcription Melanie Cole (Host): From weekend warriors to professional players, spanning multiple medical disciplines, the diverse teams of physicians and specialists at Florida Hospital are highly experienced in addressing a wide array of sports and rehabilitation issues. My guest today is Dr. Sonja Millan. She's a board certified physician that specializes in sports medicine at Florida Hospital. Welcome to the show, Dr. Millan. What is sports medicine? What is this field all about today?

Dr. Sonja Millan (Guest): So, sports medicine is an area of medicine concerned with the treatment of musculoskeletal injuries. Of course, the definition of sports medicine implies that they're athletic injuries but really not necessarily. It's any musculoskeletal injury sustained during the participation of physical activity as well as life activities. You just twisted your knee or you twisted your ankle just walking, not necessarily participating in a sport. So, that's what the field is.

Melanie: So, they're basic orthopedic type injuries that don't necessarily only happen to athletes? What kind of doctor can become a sports medicine physician?

Dr. Millan: That's a good question. There are a number of ways that you ultimately can be considered a specialist in sports medicine. You do need to have a board certification in either family medicine, emergency medicine, pediatrics, internal medicine or physical medicine. Rehab has a specialty in sports medicine as well. So, what that means is for example, myself, I have a primary board in family medicine and then I did a one-year fellowship in sports medicine. So, each of these fields that I mentioned, you do a primary board in that field, and then you go on to additional training, fellowship training, in sports medicine. Orthopedic surgery has its own brand of sports medicine. However, that has been a surgical field, whereas the fields that I listed prior--ER, family medicine, peds, internal medicine, physical medicine and rehab--are all non-surgical specialties who have a sports medicine fellowship.

Melanie: Dr. Millan, if a parent has a child--we hear so much emphasis today on sports injuries and even things like concussion, ACL in soccer players--who do they go to first? Do they call their pediatrician or do they look to a sports medicine physician when they sense an injury with their child?

Dr. Millan: Well, ultimately, a parent does not have to go to the pediatrician first. However, I will say the caveat to that is, there are many insurance companies that require you to see your primary care person before they give a referral to a specialist such as a sports medicine specialist. So, theoretically though, no, you wouldn't have to start at your pediatrician, although there's certainly nothing wrong with that.

Melanie: What can you expect with a sports medicine physician? How does that differ from, say, a physical therapist or somebody that we might see along those lines?

Dr. Millan: So, to see a physical therapist, you have to have a prescription from a physician. So, that differentiates. They do the rehab of the injury that has been diagnosed by the physician. So, that would be the difference there. You'd have to see a physician to get your prescription for physical therapy.

Melanie: Then, what can they expect from a sports medicine physician?

Dr. Millan: So, you would come in and let us know what's going on and we would run you through a series of questions because with a lot of information that I gather related to an injury, I get a lot of good clues from how you sustained the injury. What are your normal activities? Are you going to tell me "Well, I was like standing there and got tackled from the side"? So, I can get a lot of information just from you telling me about how you sustained the injury. And then, of course, we run through a series of tests known as a physical exam, so then there's that. And then, after that, once we figure out what the issue is, a lot of times, actually knowing what the issue is is the least of it and the more complicated aspect is figuring out how you got there, especially when we're talking about chronic injuries. You know, a knee injury you didn't necessarily get knocked down, but over time running a certain way maybe has caused a knee injury. So, you can expect to come in, talk about how you sustained the injury, a full physical exam related to that part of your body, I guess, and then from there, we talk about the plan of how we're going to treat it. So, that can take on a number of different aspects. It could be we start with conservative stuff like your regular ICE, your elevation, putting a compression band on it. Then, we move into “does it need physical therapy?” Then, do we move in, is it a little bit beyond that? Do we need to offer some kind of injection, like a steroid injection or something called gel-shots, viscosupplementation? So, from there, we just move along the line of things that might help get you over the injury.

Melanie: Speak about orthopedic injuries for a minute, Dr. Millan, if you would. What is the difference between an acute injury and a chronic injury?

Dr. Millan: So, an acute injury is just something that you have sustained recently and it's been going on basically less than 4-6 weeks. You get into chronic once, when you know the injury is sustained. In other words, "I fell and I sprained my wrist." So, that's a known kind of mechanism to what you did to your wrist but sometimes, it can be like people come in and they're like "Well, my wrist has been hurting for two years." We don't know how it happened but it's chronic. It's been well over 6 weeks, so we call those “chronic injuries”.

Melanie: What are some of the most common chronic injuries that you see?

Dr. Millan: That really varies. So, for example, I see a lot of chronic injuries related to peoples’ work. So, let's just say, for example, a hairstylist with elbow pain or a letter carrier with knee pain. Those are different kinds of chronic injuries that I see quite a number of. Or, it could be, you know, not related to work. It could be "I've been a runner for many years and now my shins are really hurting or my hamstrings," or "I've been a swimmer and I have a shoulder pain." So, there are a number of different things I would see related to acute and chronic injuries.

Melanie: So, give us your best advice in the last few minutes here for, hopefully, preventing acute or chronic orthopedic injuries. Why listeners should come to Florida Hospital for their care?

Dr. Millan: So, for prevention of injuries, the best thing to do is if you know you've been hurt and your usual care that you give yourself, like ice and maybe taking an ibuprofen or something like that, if you know it's been going on for a long time, it would be best to get it evaluated sooner than later. And the reason for this is that if you let an acute injury get chronic, then you start compensating for this injury. For example, your left ankle's been hurting you because you twisted it and now you're going on to two months and it's not gotten really that much better. You start throwing your weight, let's say, onto your right foot or your right ankle. Then, what you may be coming in to me for is like the injury on the other side, like your ankle, your knee, or your hip, when really, it all started with your left ankle. So, I encourage people, if you know it's been going on two, four, and certainly nothing past six weeks, if you know it's been going on for quite some time, I encourage people to get it looked at, simply to avoid further injury. I guess a good reason to come to Florida Hospital Flagler Orthopedics and Sports Medicine for musculoskeletal care is that we offer a wide variety of treatments, all the way from conservative things to more invasive treatments like surgeries or injections. And then, we have a wide range of specialists within orthopedics. So, for example, our group has upper extremity specialists, lower extremity specialists, foot and ankle specialists, non-operative specialists--that would be myself--and then, we also have a gentleman that does it all. He's a general orthopedics person. So, you'd be in good hands.

Melanie: Thank you so much for being with us today. It's great information. You're listening to Health Chats by Florida Hospital. For more information, you can go to www.fhfortho.com. That's www.fhfortho.com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Your Brain 101: The Process Of The Teenage Brain

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Audio File allina_health/ah134.mp3
Doctors Corry, Jesse
Featured Speaker Jesse Corry, MD
Guest Bio Jesse Corry, MD, is board certified in critical care and neurology, and serves as a neurologist at Allina Health’s United Hospital in St. Paul. His clinical interest is in the stroke continuum of care.

Learn more about Jesse Corry, MD
Transcription Melanie Cole (Host): Scientists have known for some time that the teen brain is wired to produce reward signals in response to irresponsible or dangerous behaviors and while parents may not like these risky behaviors, a new study says it’s the same brain process that also helps teens be better learners. My guest today is Dr. Jesse Corry. He’s a neurologist with Allina Health’s United Hospital in Saint Paul. Welcome to the show, Dr. Corry. The teen brain, still under construction as the NIH says. Tell us about this study. Tell us about what is going on with this unfinished brain that our teens have.

Dr. Jesse Corry (Guest): Thanks for having me, Melanie. This is a great study. We’ve all seen – from our own personal experience, from other studies -- that teens engage in a lot of risky behavior. What the folks in this study here did, they looked actually at how the brain – what were the parts of the brain that were interacting during a memory process. They wanted to see what parts of the brain are interacting and what mechanisms really excite those parts of the brain. What they found is that teens brains are really geared towards the outcome. For the teens, it’s the destination, not necessarily the journey that’s important.

When you look at -- how do we want to reinforce – what reinforces those pathways, those behaviors, it’s getting positive feedback. The teen brain really isn’t so keen to remembering negative feedback. It doesn’t necessarily just look at the risks of doing things; it’s looking at the outcome and the more positive feedback the brain gets, the more it’s going to remember these things. What they were looking at was a type of memory called episodic memory, or that autobiographical memory we have. This is kind of like the – think of it as the memory that’s always with us, that story of our lives. If they’re always getting positive feedback, that’s what they’re really going to respond to.

Melanie: It is absolutely a fascinating topic. The electrical business that’s going on in those teen brains, Dr. Corry, is that different than adults because I’ve heard – especially like when you’re teaching your teens to drive -- that you cannot be yelling at them, “Hey, look out! Look out for this!” Those electrical conductions actually make it uncomfortable for them to hear you yelling and try to concentrate on driving at the same time.

Dr. Corry: I completely agree with that. There’s a story – my folks took me to a cemetery to learn to drive. When I was driving in there, yeah, the negative feedback, “See what happens if you do dumb things?” didn’t really help. It just made me more nervous. When we look at how the teen brain is wired, the connections between the parts of the brain called the striatum that helps with reward, and the parts of the brain that help with memory, the hippocampus, these are really strongly interconnected in the teenage brain. They’re connected in the adult brain, but not as much. In the adult brain, we see – again, we tend to have more of an understanding of both the carrot and the stick. We like a reward, we like the outcome, but also like not having bad things happen to us, so our brains learn by trial-and-error, by appreciating the negative consequences and the positive consequences. The teen brain is very heavily wired for a new experience, for learning on the positive feedback, the positive reward they get. The danger in that, though, is that the teens may not be savvy enough to know if that quote-unquote positive reward – is it really a good thing or a bad thing?

Melanie: So what are we supposed to do as parents? All of this comes down to – because there’s also certain instances with teen brain and substance abuse, where it actually has more of an effect than it would on say a thirty-something who’s smoking marijuana or drinking versus a 15- or 16-year-old that’s doing these things. What are parents supposed to do about this teen brain? We can’t just keep giving positive reinforcement all of the time?

Dr. Corry: No, no --

Melanie: Sometimes they need to hear shame and discipline and boundaries.

Dr. Corry: Yeah, and this study is great. It gives us the neuroanatomy of what’s going on here, but they don’t necessarily address what to do with this. I think as physicians we have to start putting this into a bigger context – okay, what can we learn? I think you’re absolutely right. First of all, kids need to learn about the negative consequences. Eventually, that teenage brain will become an adult brain, so they’ll need to be exposed to there’s a good and a bad to things. A lot of this research is really applicable to addiction studies and to addiction medicine. One of the things that I take when I read this is that, okay, the teenagers are going to look for that positive reinforcement. Where do they get it from? Yeah, it’s important that we give a nurturing environment for kids, that we expose them to positive behaviors for positive things. What I also take away from this is that it’s important to really provide new experiences for the teens, to give them – you always remember when you were younger, your parents would say, “We need to get you into sports, get you a job, keep you out of trouble,” and I think that’s actually really sagely advice. I think if teens are given more new experiences they’re going to seek rewards in those new experiences, no necessarily seek a reward or they may find it where it may not be a healthy behavior.

Melanie: That’s absolutely true. As a parent of a gymnast, I see that, and I know that – I’ve heard before bored teenagers are the ones that tend to get into drugs and alcohol?

Dr. Corry: Absolutely.

Melanie: So we’ve learned that we do need to watch – get them involved, keep them involved in teams and sports and things so that they are focusing on these other things. What else can we do about this teen brain to keep them from – I mean even if we do have to discipline them, Dr. Corry, sometimes they shut down. You can see it.

Dr. Corry: Yeah, absolutely. When I read this, I was thinking, “Okay, what are things I can do with my kids – and my kids are just a little before teens -- but things like trying to keep things – surprise the kids. Keep things new and exciting. I think that what we’ve seen is that the parts of the brain that help with reward and memory -- especially when we were younger, but even as we get older -- are very tightly linked. I think doing positive things, positive rewards for your kids that may surprise them, that’s a good way to keep their focus on good things, like things like family and sports and stuff, and less have their minds wander to oh, let me try this thing, or that thing, which may not be good for them.

I think definitely parents should still say, “We definitely need to have discipline. There definitely needs to be consequences.” Again, as a parent, you try to mold that adolescent brain into a sound adult brain, so it may be one of those things where it’s not fun -- the kids may not be early on necessarily listening to those [LAUGHS] consequences, but over time hopefully, this will start to reinforce the development of a more well-rounded ability to take in information, a more well-rounded learning style.

Melanie: So Dr. Corry, things that we should watch out for, because I’ve also read that mental disorders, many of them, the symptoms first emerge during adolescence and young adulthood, so as parents while this brain is growing and we’re trying to be positive and surprise them and get them involved in things, and not overwhelm that teenage brain, we also need to watch out for some of these red flags, yes?

Dr. Corry: Yeah, especially things like schizophrenia and bipolar disorder, some of these things you typically do see start at later adolescence, particularly in men, so I think it’s really important for family members to start to notice if there’s sudden changes in the behavior of their teen. A teen who is normally really gregarious and outgoing, now becomes more isolated, if they start having irregular thoughts, starting to have really repetitive behaviors – putting their shoes a certain way all the time, or doing certain stereotype movements before an activity, or what have you, these are things a family should look for. I think, always look to about the culture around that son or daughter. If you notice that the people around that son and daughter are changing, or the clothes on that son or daughter are changing, that should be another red flag that something here may be amiss. Either the child potentially could be having problems with their own psychiatric health, or maybe running in with a different crowd.

Melanie: Okay so we need to definitely keep our eye on all of these things, so wrap it up for us, Dr. Corry, because this is such an interesting topic for parents to hear because sometimes as parents – and you and I both know this – that you don’t always understand why your kid is shutting down, or you don’t always understand why they scream back at you, or can’t handle when you’re screaming at them because you feel like you want to scream at them because you’re a parent, and they don’t understand it, and that goes back and forth and creates that lack of communication. So wrap this up for us with your best advice about dealing with that teen brain as it’s part of the body of our beloved little teenagers.

Dr. Corry: Yes, what I take from the study here is this. The young brain is geared towards the outcome and that it likes positive reinforcement so when I want to reinforce good behaviors in my kid, I remind them of the good outcome. I reward the positive actions and tend to turn a blind eye to some of those negative things. When it comes to – they have to learn consequences, and so I think always being mindful of that when there are examples of bad behavior or examples of bad choice, discussing with my kid, keeping the lines of communication open. They may not listen now. They may not listen the tenth time, but maybe the hundredth time they’ll start listening. My hope is that while this study teaches me how to teach my kid better, I hope just by being an aggressive, nosey parent [LAUGHS], that my child will, over time, become a really wise and well-rounded adult.

Melanie: Great information and such great advice. Thank you, so much, Dr. Corry. I love this series that we’re doing about the human brain. Absolutely fascinating. You’re listening to The Well Cast with Allina Health, and for more information, you can go to AllinaHealth.org, that’s AllinaHealth.org. This is Melanie Cole. Thanks, so much, for listening.
Hosts Melanie Cole, MS

What is a "Normal" Menstrual Cycle?

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Audio File allina_health/ah133.mp3
Doctors Ackermann, Sara
Featured Speaker Sara Ackermann, DO
Guest Bio Sara Ackermann, DO is a board-certified obstetrician and gynecologist with professional interests in abnormal bleeding, contraception and menopause.

Learn more about Sara Ackermann, DO
Transcription Melanie Cole (Host): In the United States, the average age of a woman’s first period is about 12 years-old, which means most women have menstrual cycles a significant portion of their lives. My guest today is Dr. Sara Ackerman. She’s an obstetrician/gynecologist with Allina Health. Welcome to the show, Dr. Ackerman. What are the characteristics of a normal period? When a young girl gets her first period, does it look like a 25-year-old girl’s period, or do they look a little bit different?

Dr. Sara Ackerman (Guest): When a female gets her first period, in the beginning, it tends to be a little bit lighter, and maybe a little bit more irregular. It can take maybe a year or so for things to get into that regular 28- to 30-day cycle.

Melanie: So if you see a little bit of spotting – if a young girl, 12, 13, 14 years-old – does that mean that they’ve now started their menstrual cycle?

Dr. Ackerman: It can. A first period often can just be a little bit of light spotting as you mentioned.

Melanie: What should women look out for in their teen years and into their twenties? What do your patients ask you most about, and what’s normal with a period?

Dr. Ackerman: Well, first of all, a normal period tends to be about 2 to 7 days, and then the cycle is usually about 28 days. Typically blood flow is heavier in the beginning, or the first two days of the menstrual cycle, and then tends to lighten up a little bit before the period is over. Things that we would want to look out for would be if you were changing your tampon or pad pretty often, though bleeding that is requiring a change every hour or two might be considered a little bit too heavy.

Melanie: And if that’s the case, is there anything that can be done about that?

Dr. Ackerman: Well, I would definitely come in and talk to your provider. There are things that we would want to do some evaluation for, fibroids, or wanting to know if you were having a lot more pain or cramping with periods, and then certainly things like contraceptive medications can help lighten and regulate bleeding.

Melanie: So sometimes in a girl’s period they see what looks like a big clot, or a big clump of blood. Is that normal?

Dr. Ackerman: I would say that some clotting can happen, especially in the beginning of the menstrual cycle, but you shouldn’t be passing blood clots that are larger than a quarter consistently.

Melanie: What about your overall health, Dr. Ackerman? How much does that affect, or impact your monthly cycle?

Dr. Ackerman: Yeah, I think – definitely being healthy and active, exercising, and being in a normal weight category can help make periods regular and lighter. Women who tend to be a little overweight, sometimes have irregular menstrual cycles where they don’t have bleeding for a while and then when they do get a period, it can be really, really heavy. Conversely, if you’re underweight, or very malnourished, you may not be experiencing regular menstrual cycles either.

Melanie: And how much of a role does genetics play in when you start your first menstrual period and when maybe you start menopause?

Dr. Ackerman: You can talk to your female relatives, especially your mother about when she began menstruation and when she ended. As you mentioned, the typical age to begin a period is about 12-years-old and then interestingly, if you’re on the shorter side, you might end up getting your period closer to that age 12. Taller girls tend to get their period a little bit later, and that’s sort of to do with growth and development and the effects of estrogen in terms of final height, and that can have a genetic component. And then we know that women often experience menopause or the cessation of periods around the same time as their mother. That average age to end periods is around 51 in the United States, but if your mother ended her periods earlier, you might expect, or anticipate that you will also end your periods a little bit earlier.

Melanie: Now, periods have side effects, Dr. Ackerman, sometimes cramps, sometimes a little bit of headaches, there’s a lot of things that could go on. What do you tell your patients about dealing with some of those side-effects?

Dr. Ackerman: I like to have patients track their menstrual cycles, especially if they’re not on a contraceptive method that allows them to predict when a period is going to happen. I think it helps to know before hand when the period is going to occur so you can do things like start taking an NSAID, so something like Aleve or Ibuprofen, maybe the day before your menstrual cycle is going to start. I think that can be very helpful for reducing blood flow and also helping to eliminate cramping that can occur with your menstrual cycle.

Melanie: What about stress? What role, if any, does it play in our menstrual cycle? Can it make it heavier, can it make it lighter, can it change the regularity of it? What about stress?

Dr. Ackerman: I think stress definitely plays a role in how our bodies function and a lot of times what we’ll notice is that irregularity in cycling. Many women notice that they have a very predictable period, that it’s every 28-days as the normal, but when you’re under a lot of stress, not eating well, not exercising, and not taking good care of yourself, sometimes that can get disrupted.

Melanie: And are there some things you’d like to tell women – you mentioned heavy bleeding before – but are there some things you’d like to mention to them that would signal a trip to their doctor, something that isn’t quite normal – if their bleeding patterns have changed, or the color has changed – are any of those things that we should be watching out for?

Dr. Ackerman: I think if there is a change in the menstruation – in the flow, in the regularity, in timing, and especially in the severity of cramping, then it is a good reason to come in and talk to your ob/gyn.

Melanie: Would any of those things signal things such as endometriosis -- and you mentioned fibroids before – do we worry about those when those changes might occur?

Dr. Ackerman: Absolutely. Heavy bleeding can be a signal of something going on with the uterus itself, and that does include fibroids as the most common thing that can lead towards heavy bleeding. Definitely, if cramping is very severe, that can be a signal of endometriosis.

Melanie: Now, I know some young girls, and even their mothers, think about birth control not as necessarily – the pill – not as necessarily something only to prevent pregnancy, but also to regulate periods. Speak to that just a minute.

Dr. Ackerman: I think that’s an extra added benefit of using birth control methods. Many of them regulate the cycle, cause the bleeding to be a lot lighter. It’s very normal on a birth control pill to have maybe a 2- or a 3-day very, very light menstrual cycle and I think that’s very beneficial for women. If you’re busy and have an active lifestyle, it’s nice to not have a really prolonged period and have it be shorter.

Melanie: And now a question that I’m sure you get often – as a mother with a teenager that’s getting her first period, do you recommend using tampons right away? Should they be using pads? What do you recommend for controlling those periods, especially in the teenage years?

Dr. Ackerman: I think that for teenagers, it takes a lot of patience and teaching and familiarity with using tampons. There’s no reason that an adolescent female who is just starting menstruation shouldn’t use a tampon, but had mentioned before that a lot of times adolescence have very light bleeding and irregular bleeding and so they might feel more comfortable with using a pad, to begin with.

Melanie: So wrap it up for us, with your best advice -- what women, what young girls and their mothers ask you every day about normal menstrual cycles -- and give us your best advice about how to deal with that, discussing it with your daughter and how – really what you want people to know.

Dr. Ackerman: I think it is a good idea to always have a conversation with your provider about expectations of what is going to happen when the period begins and certainly just to know that there are definitely things that we can offer and do that can help regulate the menstrual cycle and also makes the cramping and the other side-effects a little more tolerable.

Melanie: Thank you, so much, Dr. Ackerman, for being with us today. That’s such great information for women and young girls to hear. You’re listening to The Well Cast with Allina Health, and for more information, you can go to AllinaHealth.org, that’s AllinaHealth.org. This is Melanie Cole. Thanks, so much, for listening.
Hosts Melanie Cole, MS

The Importance of Adult Vaccinations

Additional Info

Audio File allina_health/ah132.mp3
Doctors Swartz-Williams, Leslie
Featured Speaker Leslie Swartz-Williams, MD
Guest Bio Leslie Swartz-Williams, MD is a board-certified internal medicine physician with professional interests in preventive medicine, total care of complex patients and geriatric care.

Learn more about Leslie Swartz-Williams, MD
Transcription Melanie Cole (Host): You never outgrow the need for vaccines. The specific immunizations you need as an adult are determined by factors such as your age, lifestyle, high-risk conditions, type and locations of travel, and previous immunizations. My guest today is Dr. Leslie Swartz-Williams. She’s a board certified Internal Medicine Physician at Allina Health. Welcome to the show, Dr. Swartz-Williams. What specific vaccines do adults need to think about as they’re getting older? And you can even start with what we consider legal adults in the 21-year-old area and then work your way up.

Dr. Leslie Swartz-Williams (Guest): Okay, well at the youngest age, we will be looking at all the childhood vaccinations to make sure that the person has had the childhood vaccinations that we expect – Measles, Mumps, Rubella, or the MMR, and what’s called a Tetanus, or a TDAP, which is Tetanus, Diphtheria, Pertussis. Most people have had the vaccinations that they need by the time they reach my office at age 18, but if they haven’t, we can get them caught up on those basic vaccinations. The other thing that we recommend for 18 and above, and younger and older both is the flu vaccination every year. We used to recommend only for the very young and the very old and then it became apparent that that didn’t provide enough protection and there were viruses out there that would be actually more dangerous to the healthier person, and we determined that getting everybody vaccinated was the safest route for the influenza vaccination.

As one gets older, there is usually spell where we don’t have to worry about vaccinations other than the annual flu until people hit about the age of 50. Then we start looking at Herpes Zoster vaccination, or what’s known as the Shingles vaccination. We can start thinking about that at age 50, although we tend to hold off on recommending it until age 60.

Melanie: So Doctor, when we’re sending our kids off to college, we’ve heard that we’re supposed to maybe think about the Meningitis vaccine. Is that true?

Dr. Swartz-Williams: Yes, for people who are going to be in dormitory situations, which includes military situations or college with dorms, we do recommend the Meningitis vaccination. There are two that can be considered. Which one is the most beneficial can be discussed with the individual’s physician, but those are ones that are very, very beneficial because meningitis is so, very serious.

Melanie: So for adults, and specifically older adults, and you mentioned the Shingles vaccine, and you mentioned the Flu vaccine, what about the pneumonia shot? Are we supposed to get that, too?

Dr. Swartz-Williams: Yes, there are two pneumonia vaccinations now – for years there was only one, but now we have two. If the person has chronic lung disease, we’ll be recommending that they get pneumonia vaccinations sooner than age 65, but everybody should have a series of two pneumonia vaccinations after the age of 65. We start with one at the physical at age 65, and then the following year we give the second vaccination.

Melanie: And when you mentioned the TDAP vaccination, then tetanus – how often should people get a booster of this?

Dr. Swartz-Williams: We’re looking to booster that once very ten years. TDAP, which is a booster that contains the pertussis vaccination that is a one-time booster vaccination. It contains both Tetanus and Pertussis. After the TDAP has been received, then we go back to doing just straight Tetanus, and we recommend that every ten years.

Melanie: So then wrap it up for us with your best advice and information about, again, what we should ask our providers about vaccinations as adults.

Dr. Swartz-Williams: People will come to me, and they’ll say, “Well, what do I need?” And then I’ll determine that if they’re very, very healthy, we need to have a Flu vaccination every year. If they’re a healthy person over the age of 60, we start talking about the Shingles vaccination, and over 65, we start talking about the pneumonia vaccination. People who have chronic illnesses, we’ll start some of those vaccinations a little earlier.

Melanie: And the importance of getting those vaccinations, Doctor?

Dr. Swartz-Williams: They are really, very critical. We have thousands, and thousands of people who die every year because they didn’t get a vaccination, and that’s very, very preventable. The vaccinations have very few side-effects, and people tolerate them extremely well, so it’s a very simple way to prevent very, very serious illnesses.

Melanie: Thank you, so much, for being with us today. It’s such important information for listeners to hear. You’re listening to the Well Cast with Allina Health, and for more information, you can go to AllinaHealth.org, that’s AllinaHealth.org. This is Melanie Cole. Thanks, so much, for listening.
Hosts Melanie Cole, MS

Annual Physicals: What You Need to Know

Additional Info

Audio File allina_health/ah131.mp3
Doctors Swartz-Williams, Leslie
Featured Speaker Leslie Swartz-Williams, MD
Guest Bio Leslie Swartz-Williams, MD is a board-certified internal medicine physician with professional interests in preventive medicine, total care of complex patients and geriatric care.

Learn more about Leslie Swartz-Williams, MD
Transcription Melanie Cole (Host): Your health is your most important asset. That’s why at Allina Health, we recommend regular physical exams for adults. My guest today is Dr. Leslie Swartz-Williams. She’s a board certified Internal Medicine Physician at Allina Health. Welcome to the show, Dr. Swartz-Williams. So let’s speak about these regular physical exams for adults because we hear with children we bring them in every year for their well-visits, but adults don’t always think that they need to go in. What’s your best advice and most important information to start out with about getting those annual physicals?

Dr. Leslie Swartz-Williams (Guest): Well, for adults we recommend that blood pressure and weight be monitored. If blood pressure and weight are doing well, then people can get by with a general physical a couple of times in their twenties, with the exception being that women should have a pelvic examination every three years or so. If everything is going very well, then a person should be seen two, three times in their twenties, about three times in their thirties, probably about the same number in their forties, and then annually after 50. It’s more important that we see people annually after the age of 50, a little bit less frequently -- provided they’re in very good health – in the younger years.

Melanie: So then let’s start with when we do get that physical we always see that they’re going to take a blood test and get a blood sample for many different things that they’d like to check. What should we be sure is in that chemistry panel and complete blood count?

Dr. Swartz-Williams: The two primary labs that we will follow when we’re doing physical examination is an evaluation of cholesterol, and if there is any indication that the patient is at risk for diabetes, then we’ll check a fasting blood sugar. The majority of the other tests that are ordered are based on indications of some potential problem that we’d be looking for.

Melanie: So when you say fasting blood sugar, and also people hear A1c, and we know diabetes is such a problem in this country today and obesity is actually an epidemic in the country, so do you recommend taking the A1c and who, if you do, would you recommend getting that?

Dr. Swartz-Williams: I would do an A1c if the patient was at high risk and for some reason, we didn’t think that a fasting blood sugar would give us an adequate reading. There are three ways of defining diabetes; an A1c is one of them. A fasting blood sugar is the second one, and then we can do what’s called a two-hour glucose tolerance test. Any one of those can give us a diagnosis of diabetes. However, any one of them can also be an error and over-diagnose diabetes, so you have to choose your tests carefully, and it really depends on the entire circumstances of the patients, their exercise, their height, weight, family history, and a variety of things along those lines.

Melanie: So sticking with blood lab tests for a minute, as we get older and our risk for certain things increases, there are some predictors of heart disease that people have questions about – homocysteine, CRP – do you take these as a regular, or is it based on a family history or health history of that patient?

Dr. Swartz-Williams: No they’re not recommended to be taken on a regular basis. There’s very weak data that these provide additional information beyond what we can ascertain by smoking history, the risk for heart disease based on diabetes, family history, the basic cholesterol testing. Those tests provide additional information, but they rarely, rarely will throw you from, “I don’t think this patient needs to be treated,” into “Gosh, we’ve got to start treatment right away.”

Melanie: Speak about cholesterol and the blood work there, what do those numbers mean for the listeners?

Dr. Swartz-Williams: The total cholesterol is what most people focus on, but it’s really not the most important number. What we are shifting our focus to is the ratio of the total cholesterol to the good cholesterol with an eye toward what does the bad cholesterol or LDL, look like? We use a ratio to compare all of these numbers. The total cholesterol can be very high, and that’s okay if the good cholesterol is very high. If the good cholesterol is low and the bad cholesterol is high, then the ratio is going to be very poor and will determine that the patient is at some degree of increased risk for heart disease. We have algorithms that we use that help to guide us to what is a low-risk, moderate-risk, and high-risk, and for people who are in the moderate-risk, that would be where we might consider additional testing.

Melanie: And what about for men specifically, do they need a PSA, and if so, when?

Dr. Swartz-Williams: PSAs are even more controversial than probably any other test out there right now. If there’s a family history of prostate cancer, or with African Americans, we can start screening as early as 50, otherwise we can consider screening with the PSA blood test after age 50. It is very controversial because there are not any good studies that show benefit from screening men with a PSA in preventing the rate at which men die from prostate cancer.

The American Urology Association has continued to lean toward recommending the PSA, but other organizations think that the risk of falsely positive test results and the anxiety of further testing, and complications from those tests outweigh the benefits. That is a test that definitely needs to be individualized to the patient with their concern and their family history.

Melanie: And what about a Hepatitis C? Should people be checked for that at some point in their lives?

Dr. Swartz-Williams: There is a recommendation now that people between the ages of – people who were born between the year 1945 and 1965 be checked once for Hepatitis C. That disease is more prevalent than Hepatitis B and is a significant contributor to both cirrhosis and liver cancer, so a one-time screening test is recommended.

Melanie: And for women, what do you recommend that they do yearly as far as mammograms or self-exams – we’re talking about the annual physical, but that does include certain women-specific things.

Dr. Swartz-Williams: Mammograms are something that we’ve been backing away from recommending them quite as frequently as we used to. That’s due to some recent studies that came out and indicated that most cancers are not as fast and aggressive as they were all presumed to be, so, between the ages of 50 and 65, women are usually okay to have a mammogram every other year unless they are at high risk. Mammogram is between 40 and 50 need to be individualized to the patient’s individual risk and mammograms after 75 are definitely something that needs to be individualized to the person’s risk and life-expectancy and individual desires.

Melanie: And Dr. Swartz-Williams, do you recommend at this annual physical – and mainly speak about the over-50 crowd – that they get an EKG or a chest X-ray at their annual physical?

Dr. Swartz-Williams: We do not recommend annual chest X-rays for anybody. They have been proven to not provide us any useful information. The EKG can be done as a baseline, but that’s also something we will do on more of an as-needed basis.

Melanie: And what about lifestyle? Do you discuss with your patient’s lifestyle modifications? Wrap it up for us, what you would like listeners to know about discussing things, partnering with their healthcare provider to be their own best health advocate.

Dr. Swartz-Williams: Lifestyle and exercise and diet modifications are one of my favorite areas to get into because that’s something where people have a lot of misconceptions, or they’ve tried things, and they’ve failed, and they don’t know what they can do next, or what to try alternatively. There’s a lot of good information out on the internet, and there’s a lot of misinformation, so talking with the person about what their weight goals are, what their exercise goals are, what they’ve tried and what they want to do. How we can move forward with maximizing one’s health using diet and exercise is something that is really a very, very good topic for a general physical or wellness examination.

Melanie: And what would you like people to ask their providers at that annual physical?

Dr. Swartz-Williams: That’s an excellent question. There are so many different people that have different concerns, but it is very good to discuss the benefits of screening tests, the risks involved in the screening tests, and what else can we do to live long, healthy lives where we’re not feeling decrepit and old and always be trying to maintain what we have today for as long as possible.

Melanie: Thank you, so much, for being with us today. That’s great information and so important for listeners to hear. You’re listening to the Well Cast with Allina Health, and for more information, you can go to AllinaHealth.org, that’s AllinaHealth.org. This is Melanie Cole. Thanks, so much, for listening.
Hosts Melanie Cole, MS

Multiple Myeloma

Additional Info

Audio File city_hope/ch103.mp3
Doctors Upadhyaya, Gargi
Featured Speaker Gargi Upadhyaya, MD, FACP
Guest Bio Specializing in hematology and medical oncology, Dr. Upadhyaya is board certified in internal medicine. She received her medical degree from Government Medical College, Surat, India. Her residency and hematology and oncology fellowships were completed at Los Angeles County USC Medical Center and City of Hope National Medical Center. She also served as a research fellow in the Hematology and Oncology Division of the Internal Medicine Department of the University of Michigan Medical Center. Dr. Upadhyaya has published articles in the Journal of Clinical Investigation, Blood, and Leukemia and is an active member of the American Society of Clinical Oncology (ASCO).

Learn more about Dr. Upadhyaya
Transcription Melanie Cole (Host): Myeloma is the second most common type of blood cancer accounting for around 1% of blood cancer cases. This year, more than 30,000 people in the United States will be diagnosed with myeloma according to the American Cancer Society. My guest today is Dr. Gargi Upadhyaya. She’s an assistant clinical professor and specializing in hematology and medical oncology at City of Hope. Welcome to the show, Dr. Upadhyaya. Let’s talk about multiple myeloma and this debilitating malignancy. Explain what it is as a part of the spectrum of diseases.

Dr. Gargi Upadhyaya (Guest): Multiple myeloma is a diagnosis involving the bone marrow. The patient presents with pain, weight loss, shortness of breath, and fatigue.

Melanie: Okay, so if somebody is experiencing this – first of all, who is at risk for this type of myeloma?

Dr. Upadhyaya: Most of the time it’s an older patient in their 60s are at risk, but we’ve seen 3 to 5% of younger aged patients ranging from 30 to 50 years old also.

Melanie: So is there--

Dr. Upadhyaya: The majority of our patients are between 60 and 65 years old.

Melanie: And is there a genetic component to it?

Dr. Upadhyaya: There are no genetic components to the cancer itself that it doesn’t get given from one parent to the other or from parent to children. However, there are certain genetic tests that we do for myeloma to evaluate the aggressiveness of the disease.

Melanie: So who would get that genetic test and who would – you mentioned a few symptoms, but some of those symptoms sound very vague and like they could be many different things. What would send somebody to the doctor to get checked?

Dr. Upadhyaya: When a primary care physician finds a patient who has lost more than 10% of their body weight without trying, or they find – if you have anemia with a hemoglobin of less than 10 grams, their white count has gone down, or they are experiencing night sweats – night sweats as described being drenching sweats where they have to change their sheets, or their T-shirt while they’re sleeping – are common symptoms. There are people who also will get recurrent infections, so they would have either an upper respiratory infection, two months later they could have a sinus infection, the third month they could have a urinary tract infection, that’s when the primary care will say, “Something’s going on with this patient. We need to send them to a specialist.”

Melanie: So then, how is it diagnosed?

Dr. Upadhyaya: It’s diagnosed with a blood test, so when we see a patient, and we see they have anemia – white count is down, and they have the symptoms that I’ve just described – we order what we call a serum protein electrophoresis, and we also measure their immunoglobulin levels. Once we know and find out if their immunoglobulin level is high -- one of them would be high. There are four kinds of immunoglobulins – actually, there are five kinds, but we look at the three main. One is called IgG, the second one is IgA, and the third is IgE and IgM. We pay attention mainly to the G, A, and M part of the immunoglobulins. If one is very high and the others are low, it increases the suspicion for multiple myeloma. On the protein electrophoresis, we’ll see an abnormal quote-unquote band of protein, which tells us that this doesn’t belong here and this is why the person is having symptoms.

The other thing we look for is whether the person has kidney failure and/or if they are anemic. If that is what we get on the preliminary blood tests, then we move onto further testing, which includes doing a bone marrow biopsy and we do further blood tests with certain genetic tests and also request genetic tests on the bone marrow, which are called the CD38 mutation, p53 mutation, and other deletions of certain chromosomes, which, depending on what the person has will tell us how severe the myeloma is and whether or not we should treat them aggressively or with standard treatments versus going for a transplant. It gives us an indication of how to go about with the treatment.

We also order X-rays of the whole body, which is from skull to toe because multiple myeloma tends to cause what we call pathological lytic fractures in the bone, especially in the long bone and on the skull. If the patients have that, that also confirms the diagnosis. We don’t need to biopsy the bone, but with the blood picture and the X-ray picture, we’ll get a confirmation.

Melanie: So if you get a confirmation from all of these tests, is this cancer that is curable? Is it cancer that requires as you mentioned, possibly aggressive treatment? What does the prognosis look like and what does the treatment look like?

Dr. Upadhyaya: At this time, multiple myeloma is very, very treatable. Unfortunately, it’s not curable. However, the treatment is not very aggressive. We can treat them with a medication called Velcade -- which is an injection that’s given under the skin -- twice a week for two weeks, and then we give them a week off. We do that for four times and repeat the bone marrow biopsy. If the patient has any lesions in the bone, then we will give them a medicine called Zometa to strengthen the bone. Zometa is given once a month. If they go into remission depending on the patient’s age, if they are older – older meaning older than 70 years old, which is the cutoff for transplant – we will put them on maintenance therapy of Velcade or a pill called Revlimid for maintenance. If they are younger – younger than 70 -- and they’ve gone into what we call a complete remission, that means that the bone marrow now has less than 5% of the myeloma cells, then we send them for evaluation for a bone marrow transplant.

Bone marrow transplant doesn’t mean that it is taking their bone marrow – I’m sorry, not giving bone marrow from somebody else. However, it is taking the stem cells from the patient himself, or herself, freezing these cells, then giving more extensive chemotherapy, reinfusing the stem cells and allowing the healthy stem cells to grow in a person’s body. This is called an autologous transplant, and the chances of survival with an autologous transplant are much higher, and the patients have less side-effects because it is not somebody else’s marrow. In younger than 70-year-old patients we recommend doing a transplant after they achieve remission so they can stay in remission for more than ten years.

Melanie: That’s fascinating Dr. Gargi, and what about things that you’re doing there at City of Hope in terms of immunotherapy or targeted therapies? Are any of these useful for multiple myeloma?

Dr. Upadhyaya: At this point, there’s not targeted therapy for multiple myeloma, but we will eventually have them. We have some clinical trials going on. The results are not out yet, but we try to give our patients the option of enrolling into trials as soon as we think they are eligible for it. It gives them a second option. These are not experimental medicines. We know that these medicines work in myeloma, but we need to sometimes prove that this medicine is better than the standard of care is one purpose of doing the trial. The second would be to see if the medicine is helpful with fewer side-effects than the standard therapy. There are many reasons for doing the trial, and we’ve had a lot of success with the clinical trials, and unofficially I can say we have seen a lot of people living longer, but the trials have not been published yet, so we will have a better idea as soon as the trials get published.

Melanie: So wrap it up for us, with people who may have been diagnosed with multiple myeloma and living with it, what would you like them to know, Dr. Gargi, about managing side-effects, or pain management, or just staying healthy and active while they go through these types of treatments.

Dr. Upadhyaya: The one thing I tell my patients about multiple myeloma is you keep moving. The more you move, the myeloma will not catch up with you. It is a treatable disease. You live a long, normal life. It’s almost like a chronic disease, which is less debilitating than diabetes, or hypertension, or arthritis, so a person who can exercise should exercise. Stay away from sick people – not that you don’t go near them, but just use common sense. Wash your hands when you touch somebody who is sick, don’t share a drink. It’s common sense stuff that you do.

And once you’re in remission and you’re not on any therapy, you live a normal life. You live your life and just get checked every three months, and there are very few chances that this comes back in the first couple of years. Usually, I’ve seen them come back after five, ten years. I’ve had patients living for 20, 25 years and a healthy lifestyle and a healthy life, good quality of life, traveling around the world, doing everything with their kids and grandkids. Even though this is a diagnosis of cancer, it’s not a dismal prognosis. People live a good life. They live a normal life. Yes, while they are on treatment, it may be a little difficult, but these treatments are very tolerable. Side effects are very manageable, especially if you exercise and keep moving.

Melanie: Thank you, so much, Dr. Gargi, that’s really great information and so important and hopeful for listeners to hear. 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

Hematologic Malignancies and Stem Cell Transplantation

Additional Info

Audio File virginia_health/vh178.mp3
Doctors Ballen, Karen K.
Featured Speaker Karen K. Ballen, MD
Guest Bio Karen K. Ballen, MD is the Director of Stem Cell Transplantation at UVA Cancer Center and Professor of Medicine at UVA School of Medicine.

Learn more about Karen K. Ballen, MD

Learn more about UVA Cancer Center
Transcription Melanie Cole (Host): UVA Cancer Center has a team of dedicated physicians who specialize in the diagnosis and treatment of blood disorders. The hematology physicians and nurses offer superior care for patients in whom blood disorders have been diagnosed. My guest today is Dr. Karen Ballen. She's the Director of Stem Cell Transplantation and Hematologic Malignancies at UVA Cancer Center. Welcome to the show, Dr. Ballen. So, what conditions would be associated with hematologic malignancies? Explain what that is to the listeners.

Dr. Karen Ballen (Guest): Well, thank you so much for having me on. My mother asked me the same question. So, hematologic malignancies refer to cancers of the blood and most of patients that we see have either leukemia, a type of blood cancer, lymphoma, Hodgkin's Disease, or multiple myeloma. It would also encompass patients who have what we call “myo-proliferative diseases”. Some of those are diseases such as chronic myeloid leukemia or myelofibrosis. So, these are all cancers of the blood.

Melanie: First of all, who's at risk for blood type cancers?

Dr. Ballen: Well, unfortunately, we all are at risk, and as we get older, the risk of having a blood cancer goes up. Blood cancers aren't necessarily related to any lifestyle choices such as smoking or alcohol or where you live. We are still really learning about why people get them. So, we actually all are at risk for developing a blood cancer.

Melanie: Are there any genetic components to them?

Dr. Ballen: There are genetic components in that there are different genetic mutations that can contribute to blood cancers, but most of these are not passed down in families.

Melanie: So, what symptoms would somebody experience that would send them to somebody to get checked in the first place?

Dr. Ballen: Well, you know, often the symptoms are very mild. It might be fatigue or a headache, or sometimes easy bruising, and sometimes it is difficult. Some patients do see several doctors or maybe have gone to the emergency room before the diagnosis is made, but certainly, a fatigue that seems out of proportion to what one usually has, easy bruising, fevers and infections that don't go away would all be signs that people should get blood counts checked and get further care to make sure that there's no problem.

Melanie: So, if you do the blood counts and you diagnose with lymphoma or Non-Hodgkin's, or one of these things you've mentioned, what is the next step for that person?

Dr. Ballen: Right. So, these diseases are usually diagnosed either on a bone marrow test or on a biopsy of a lymph node, and then once a diagnosis is made, we'll evaluate the patient here at UVA and often, will work with our colleagues in other specialties such as radiation, or surgery, to give the patient the best care possible. Fortunately, most of these diseases are curable and patients will then start on a treatment plan often involving chemotherapy. The good news is that our chemotherapy these days is a lot easier to take. We have many medicines for nausea to make patients more comfortable. So, in many cases, we will have an excellent outcome.

Melanie: You mentioned radiation. Can you use radiation therapies for blood cancers when blood is moving and it's not in a specific spot?

Dr. Ballen: Well, that's a great question. So, for some of the blood cancers like leukemia, we don't usually use radiation, but for others such as lymphoma, or Hodgkin's disease, particularly if the disease is localized in a specific spot, then sometimes radiation can be very successful and sometimes it's given by itself, or maybe in combination or after chemotherapy.

Melanie: So, Dr. Ballen, speak about stem cell transplantation and how that works. Give the listener a little working definition of what that is and hematopoietic cell transplantation.

Dr. Ballen: Right. So, we all have stem cells in our bodies. These are the cells that make all of our blood cells. Our red cells that carry oxygen and white cells that fight infection and platelets that help to clot the blood. When someone has a stem cell or bone marrow or hematopoietic cell transplant, we're all talking about the same thing. It's basically taking someone who has a bone marrow disease and replacing their abnormal bone marrow with a normal bone marrow from a donor. That donor could be a brother or sister. Nowadays almost everyone has a donor, either in their family, through the only related registry, or through something through what we call umbilical cord blood. Blood that normally just gets thrown out when a woman has a baby, can also be used to save someone's life in a transplant.

Melanie: How does that work, then, and then just explain a little bit for the listeners about transplant related morbidity and what they can expect as far as rejection of the marrow or the stem cells? How does that all work?

Dr. Ballen: Right. Well, for the donor, the donor usually has the easy part. The donation is usually done as an outpatient and usually takes several hours. For the patient, it is a long process. The patient may be hospitalized for several weeks here at UVA. During that time, they're receiving intensive chemotherapy and what we call supportive care--antibiotics and transfusions and medicines to make them feel more comfortable. So, it is an intensive procedure but, fortunately, it's something that we're getting better and better at and making it safer and easier for the patient to get through.

Melanie: You mentioned that some of these are curable. What does that mean for the patient and how do you know?

Dr. Ballen: Right. So, when we say curable, it means that the patient has no evidence of their disease and often, you know, to be honest, that means that they're living 15, 20, or 25 years later and maybe getting hit by a bus or some other event happens but unrelated to the cancer. So, for many of these cancers, if the disease has not come back in a five-year interval, it's very unlikely that it would and so that's also an important landmark in many of these diseases.

Melanie: Are there any current clinical trials at UVA?

Dr. Ballen: Yes. So, we have many clinical trials at UVA. Some of them relate to choosing the best donor for a patient who is undergoing a stem cell transplant, that's a very large, national study. We're also looking at using different types of chemotherapy and immunotherapy to help fight cancers. That's a new way of treating blood cancers by using the immune system to help fight the cancer. That's the focus of many of our clinical trials at UVA.

Melanie: Dr. Ballen, if somebody is interested in being a bone marrow or stem cell donor, what should they know? What do you want them to do?

Dr. Ballen: Well, the best way to find information is through the international registry which is called “Be the Match” and they can find that information online. And to become a donor, all it takes nowadays is just a cheek swab that puts the DNA sample into the registry.

Melanie: So, tell us about your team at the UVA Stem Cell Transplant program.

Dr. Ballen: Right. So, we have an excellent team. It certainly does take a village to care for these patients in the best manner possible and we're fortunate to have an excellent team of physicians, nurses, coordinators, physical therapists, dieticians, social workers all really working to help in the care of the patient. It's the people sometimes they don't see who are most important for their care, that includes everyone that keeps the hospital running from an administrative and facilities standpoint; it's the people in pathology reading the slides; people reading their X-rays, that often also have a big impact on a successful outcome.

Melanie: So, wrap it up for us, if you would, Dr. Ballen, with your best advice for people that are concerned about blood cancers and what you want them to know about the UVA Cancer Center.

Dr. Ballen: Yes. Well, I think unfortunately cancer affects all of us. We've almost all had a friend or family member that's affected by cancers. I think the good news is that the majority of these patients are curable, while the treatment is not easy, it is often successful and, therefore, patients should be hopeful and we're certainly happy to work with the patient on their journey through this.

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

The Pathology of Breast Cancer

Additional Info

Audio File city_hope/ch102.mp3
Doctors Apple, Sophia
Featured Speaker Sophia Apple, MD
Guest Bio Born in Korea, Sophia Apple, M.D. survived a childhood bout with polio which left her with a slight limp and a determination to become a physician. In her second year of medical school she became fascinated with pathology, which she calls “the brain of medicine.”

After more than 20 years at UCLA (15 as director of breast pathology), Dr. Apple came to City of Hope to expand her clinical and research work with breast cancer, in search of better treatments for her patients.

Dr. Apple studied biochemistry at New York University, received her medical degree from Wright State University in Dayton, Ohio, and completed her pathology residency and fellowship at UCLA.

Dr. Apple literally “wrote the book” on combining breast imaging and pathology, co-authoring a definitive textbook on the subject and published more than 70 peer-reviewed journal articles related to breast diseases.

She’s grateful and loves America for the opportunities given for her to fulfill her dreams.

Learn more about Sophia Apple, MD
Transcription Melanie Cole (Host): Led by pathologist renowned for diagnostic excellence, the Department of Pathology at City of Hope combined state of the art laboratories equipped with the latest diagnostic techniques and advanced instrumentation with superior investigative skills to accurately and rapidly identify even the rarest and most complex diseases. My guest today is Dr. Sophia Apple. She's a clinical professor in the division of anatomic pathology in the Department of Pathology at City of Hope. Welcome to the show, Dr. Apple. Today we're going to talk about breast cancer and specifically combining breast imaging and pathology. So, will you first start by please explaining what a pathologist even does?

Dr. Sophia Apple (Guest): Pathologists are subspecialty people who are mostly responsible for providing final diagnosis on any diseases, either benign or malignancy.

Melanie Cole: So, if we're talking specifically about breast cancer, when would you be brought into a woman's diagnosis?

Dr. Apple: A woman with any breast abnormality or even after age 40, when the diagnostic screening mammogram is done then they will get the mammogram or ultrasound or sometimes the MRI, and if the radiologist finds any abnormality or any concerns or suspected lesion they would target that with the core needle biopsy. Those core needle biopsy gets into the pathology department and we fix the tissue and make a slide and then we look at the slide and provide a final diagnosis.

Melanie Cole: Is a pathologist somebody that the patient would actually meet?

Dr. Apple: No, we are behind a curtain but I would say that we are the brain of the entire medicine because if we provide the diagnosis wrong, then everybody will go into the wrong route. So, we're critically important because we provide the final diagnosis of any diseases. We are behind the scene and sometimes the patients’ mention, “Who are these pathologist who gave us the bills and what are they doing?” but we actually are the critical doctors, medical doctors, who provide the diagnosis for individual patients.

Melanie Cole: You're kind of steering the ship as it was. So, please speak about the benefits of a collaborative working relationship between pathologists and the radiologists that have done the stereotactic or whichever kind of biopsy they did?

Dr. Apple: Yes. So, the radiologist and pathologist they both provide diagnoses but the radiologists look at the shadow of the disease whereas a pathologist actually look at the tissue of the material that they've provided. We have to work together. If the radiologist thought that the lesion was very suspicious and the pathologist called it “benign” then it doesn't match. So, we do like to do correlation between clinical imaging, clinical findings, and a pathologist findings. That's called “triple test” because clinical is one, imaging is another, and the pathologist are third. They all have to match together to provide an accurate diagnosis. For instance, if clinically or imagingly suspicious lesion was targeted and the core needle biopsy was performed but if I called it benign that means there's a probability or possibility that radiologist did not get the lesion. So, if the triple test failed then the radiologist would have to bring the patient back, either redo the core needle biopsy or wait for three months or six months and then retarget that lesion again.

Melanie Cole: Speak about some of the critical components of a radiology/pathology integration and how that for the patient as you're the one sort of steering the ship and really making that final diagnosis and giving the histologic type pictures, then what would be some of the most critical components that you would want the patient to know about the importance of this relationship.

Dr. Apple: Let's say the patient is worried about a mass lesion and she goes to imaging or radiologist and the radiologist targeted that lesion and perform the core needle biopsy and if I called it benign or the benign entity explains the mass that the woman is experiencing, then since the final diagnosis was benign, she does not have to worry about it; whereas, on the other side of the coin, if the radiologist looked at the mass lesion and if the pathologist called it “malignant”, she has a diagnosis and she has to act on it, such as surgical removal and if the surgical removal is a breast cancer with hormonal findings, the estrogen receptor, the progesterone receptors, if those are positive, then the oncologist will treat the patient with endocrine therapy. If HER2 is positive, then the receptor therapy is generated. So, pathology provides an incredibly significant role in diagnosing women with cancer.

Melanie Cole: Do you think that the widespread adoption of electronic health records or improving health information technology is going to help to remove some of the barriers between pathology and radiology?

Dr. Apple: Yes, I really hope so. In the future, I hope to see patients because the pathologist does provide incredible critical information to the patient and, therefore, I hope that one day the curtain will be removed and we have a face to face interaction because once they see the slides of their own cancer cells and they can picture that in their mind what that tumor cells look like, then they could target that in their brain image. It's a very powerful way to look at your own cancer and think about that and fight over that emotionally. I've seen a patient a couple of times when they came to a pathology office and they wanted to actually see the visual image of their own tumor and it really helped them to fight emotionally. So, I think in the future maybe pathologist perhaps should come out of the curtain and actually see the patient and help them.

Melanie Cole: And, you think that this can really add value to improve patient outcomes and that's the main goal, isn't it?

Dr. Apple: Yes. Many people do not see pathologists and they don't really see their slides. It's a visually very different image if you have a malignancy versus a benign. It's actually not that difficult to identify which one is abnormal and which one is normal. So, when a patient gets to see that I think it will be helpful for them, as sometimes they are suspicious of whether “Do I really have a breast cancer or can anybody else say that it's not cancer?”. They do have that speculation sometimes but when they see the actual image of a pathology slide they may be able to trust medical professionals a little more.

Melanie Cole: Do they get to see the actual image of the slides?

Dr. Apple: No, they don't. Sometimes the radiologist will show them ultrasound findings and mammogram findings, and they can show there is a mass lesion or there's this speculation, suspicious calcification. They have opportunities to show it to patients but not pathologists.

Melanie Cole: Would you like to see that change?

Dr. Apple: I do.

Melanie Cole: Where do you see it going in the future in the field of pathology and wrap it up for us, Dr. Apple, and what you would like to see, in your own opinion, happen in the field of pathology with this integration with radiology?

Dr. Apple: First of all, pathologist and radiologists have to work together very well to serve the patients with the most accurate diagnoses together. Radiologists cannot work independently and pathologists also cannot work independently because of possible sampling error and sampling issues. For the benefit of the patient, for the best patient care we can possibly provide in City of Hope. I like to have a pathology and the radiologist work together and go over all the core needle biopsies that they ever perform, first of all. And the second thing, I would like to have a pathologist come out of the curtain and see the patients so the patient can see the pathologist is actually a medical doctor who provides the final diagnosis. In the future, I'd really like to see patients with pathologists and, hopefully, get reimbursement for the time that we're spending with the patient in explaining what the disease actually is. So, that's what I'd like to see happening in the future.

Melanie Cole: Thank you so much, it's a really fascinating topic. Thank you so much, Dr. Apple, for being with us today. You're listening to City of Hope Radio. For more information you can go to www.cityofhope.org. That's www.cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Can You Prevent Colon Cancer?

Additional Info

Segment Number 1
Audio File texoma/tm005.mp3
Doctors Saltz, Richard K.
Featured Speaker Richard K. Saltz, MD
Guest Bio Richard K. Saltz, MD is a Gastroenterologist and a member of the Medical Staff at Texoma Medical Center.

Learn more about Richard K. Saltz, MD
Transcription Melanie Cole (Host): According to the American College of Gastroenterology, colorectal cancer is the number two cancer killer in the United States, yet it is one of the most preventable types of cancer. My guest today is Dr. Richard Saltz. He’s a Gastroenterologist and a member of the medical staff at Texoma Medical Center. Welcome to the show, Dr. Saltz. Who is at risk for colon cancer? Is there a genetic component to it?

Dr. Richard K. Saltz (Guest): There is a genetic component, but the major genetic risks produce the cancer in only about 10% of people. Most people are susceptible to this problem based upon age with genetics being a smaller factor.

Melanie: So, we know that there is a screening for colon cancer -- It’s one of the very few out there that’s actually been touted as a prevention type of screening -- tell us who should get a colonoscopy and when should they start them?

Dr. Saltz: Well, the simplest number to remember is age 50 where most people for an average risk. We should qualify that by saying that African Americans should be tested at age 45 and some people think possibly even younger than that for that subgroup. But the average risk group begins at age 50. That’s not to say that some cancers don’t occur before then, but most of the cancers that occur in young people – teens, twenties, thirties – are the genetic ones, which represent only 10% of the total cancer occurrences.

Melanie: So if you’re supposed to begin at age 50, how often thereafter?

Dr. Saltz: Well, it depends on whether you remain in the average risk category. If you have a completely normal exam, that is no precancerous polyps are proven on biopsy; then you continue with average risk screening, which is a ten-year interval – 50, 60, 70, sometimes 80. There are some societies that suggest that we’re not obligated to do the screening after 75, but the main rule of thumb that we use for the older age group is that if we think someone has a ten-year lifespan potential, then we keep offering the screening, even at age 75 to 85.

Melanie: So let’s discuss the screening colonoscopy. People tend to be afraid of it just because of the prep; they hear about, so explain how a colonoscopy works and what’s going on with the prep these days?

Dr. Saltz: Well, the prep is a very, very important part of the exam. In order for the doctor to do a high-quality exam, a very good prep must be completed, that is the bowel has to be cleansed so that it’s virtually empty in the large intestine and rectum. To accomplish this, we have most people start one day before with a clear liquid diet – jello, broth, tea, coffee is also included as a clear liquid, but no milk or creams. Patients are then advised to do a lavage laxative-type prep. The most effective type prep is called the split dose prep, one where they’ll take half of the laxative the evening before and half early in the morning on the day of the exam. In the past, most people have used a large volume jug of prep, which they sometimes find difficult to complete. There are, however, in recent years, several newer, small volume, better tasting preps that are much better tolerated and people say, “If I had known that this was available, I wouldn’t have put off getting my exam.”

Melanie: So the prep notwithstanding -- and I personally, in my own opinion, do not feel it’s that big of a deal, and I’ve had quite a few colonoscopies -- but once the prep is done, then what can they expect on the day of the procedure? What is that like?

Dr. Saltz: The day of the procedure, it’s preferred to have the exam in the morning hours, although some are scheduled in the early afternoon. The patient comes in to be registered. They change, sign consent forms – they receive an intravenous needle in the vein of the arm to administer the sedative anesthetic. The anesthetic is not given until the doctor comes in the room and addresses the patient.
The only discomfort that patient might experience is from the initial injection of the anesthetic. In a few people, not everyone, there could be a burning in the arm where the sedative is given. Typically if they put it in the small vein in the wrist or hand, that’s more likely to occur. But for most people, there’s no discomfort, and there’s no discomfort at all throughout the remainder of the procedure.
The medication that we use at Texoma Medical Center is called Propofol, and it’s a drug that produces a deep level of sedation. We don’t use the conscious sedation, which was done for many, many years, and is still done in some parts of the country, but in our experience, patients greatly prefer the deeper sedation, so they have no recall, no experience of any bad effects or feeling from the examination, no pain.

Melanie: So then they wake up, and they ask you, “Dr. Saltz, when are you going to start?” And you say, “I’ve already finished—“

Dr. Saltz: Exactly.

Melanie: [LAUGHS] -- and you give them pretty little pictures. What is a polyp? If you happen to find one while you’re in there, what is it that you’ve taken out?

Dr. Saltz: Anything that we identify as a bump or that appears to be a possible thickening of the lining or growth, we will call it a polyp, and we will take a biopsy of it. Polyps range in size from very small, tiny, to almost an inch in size and they can be cut off, or they can be simply biopsied without any discomfort to the patient.

Melanie: So what do those polyps show? What are they all about?

Dr. Saltz: Well, the tiny, tiny ones sometimes are insignificant, and they’re just a thickening of normal tissue. Those people we say we thought there was a polyp, but it turned out it was insignificant. The technical medical term is usually hyperplastic or normal tissue. We tell them, “You’re okay, you come back in ten years,” but there are growths that are true polyps, that is they have the potential to get bigger and bigger and eventually a risk developing cancer within the. There are different types of those polyps that we distinguish under the microscope that tells us a little bit about that risk. Some of them, the most common, are called tubular. Others, more significant that tend to grow a little more rapidly are called villous, and then there’s a special type that’s called sessile serrated, which can occur on the right side of the colon, and that’s particularly important because those are often flat and hard to see and covered by mucous. The mucous seems to attach there, and if they haven’t done the good prep, that can be missed. I get particularly concerned about that type of polyp because it’s the type that the endoscopists who are not extensively trained to look for subtleties, often miss. It’s those misses that could produce the development of cancer within one or two years after an exam, and then people say, “Well, how is that possible that I developed cancer within one or two years after an exam?” Because it was an unusual, difficult to identify the type of polyp that only an experienced endoscopist can truly find.

Melanie: So after the procedure and you’ve discussed the polyps with them, and then they maybe have their follow-up in however many years based on the results, what else do you tell them about maybe nutrition – is that myth that nutrition and fiber can help with colon cancer prevention?

Dr. Saltz: Well, I think the horse is out of the barn at the point in your life that you have the polyps. That’s probably a little bit late, but when we think about younger generations clearly obesity, which is an epidemic in this country, and sedentary lifestyle, lack of activity – is considered a risk factor, so we do find more cancers in those people. There are other nutritional issues, but you can’t just adjust your diet and think you’re going to reduce your risk of cancer starting at the age of 50. You really have to start much younger.

Melanie: So why don’t you wrap it up for us? Give your great advice about colon cancer prevention and what you want people to know who are at risk for colon cancer are of the screening age, what would you like them to be aware of?

Dr. Saltz: They must do some type of screening examination. Colonoscopy is the gold standard. It finds the most polyps, the most cancers, and it is both diagnostic in finding it and therapeutic in treating it. By removing a polyp, you prevent it from becoming cancer. There are other screening options that are available to individuals who, for a variety of reasons, might be hesitant, and particularly in the older age group, if they have reasons to be concerned about other medical problems, there are several other screenings that could be done, although they’re not preferred. Anyone age 50 who’s in good health, that’s absolutely no excuse for not having the screening colonoscopy. It is so sad when I see people several times a year coming in in their 60s who skipped the first exam, and I have to tell them I just found cancer.

Melanie: And why should they come to Texoma Medical Center for their care?

Dr. Saltz: Well, we are highly skilled endoscopists with advanced training, and we are paying attention to all of the factors that are important in finding small, hard to find polyps, particularly of the type that I discussed. We have equipment that allows us to do the job very effectively.

Melanie: Thank you, so much, for being with us today, Dr. Saltz. You’re listening to TMC Health Talk with Texoma Medical Center, and for more information, you can go to TexomaMedicalCenter.net, that’s TexomaMedicalCenter.net. Physicians are independent practitioners who are not employees or agents of Texoma Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks, so much, for listening.
Hosts Melanie Cole, MS

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