Inactive (722)

Segment Number 5
Audio File allina_health/1444ah1e.mp3
Doctors Van Valkenburg, June
Featured Speaker June Van Valkenburg, CNP – Geriatric Medicine/Internal Medicine
Guest Bio June Van Valkenburg is a certified adult-gerontology nurse practitioner at Allina Health Edina Clinic. She has a specialty in advanced diabetes management as well as professional interests in women's health, travel medicine and geriatric medicine. In her free time, June enjoys spending time with her husband and three daughters, running with her dog, biking, reading and participating in international medical missions. For the more than 10 years June has been involved with medical missions, her travels have taken her to Peru, Guatemala, Nicaragua, Rwanda, and most recently, Ecuador.
Transcription Melanie Cole (Host): Prediabetes is often called borderline diabetes, and it occurs when a person’s blood sugar levels are higher than normal but not high enough to be considered full-blown diabetes. My guest today is June Van Valkenburg. She’s a certified adult-gerontology nurse practitioner at Allina Health Edina Clinic. Welcome to the show, June. Tell us a little bit about prediabetes, and how does that differ from diabetes type one or two?

June Van Valkenburg (Guest): Well, what prediabetes is, it’s a condition where the blood sugar is a little bit elevated but it’s not elevated high enough to give you a diagnosis of type two diabetes. Type one diabetes is usually found in children and young adults, and in type one diabetes, the pancreas just stops producing insulin. People always have to go on insulin injections. Type two diabetes is the most common form of diabetes, and it’s a chronic condition which affects the way your body metabolizes glucose, and there is an insulin resistance that develops and the body doesn’t create enough insulin like it should. Prediabetes is actually a precursor to type two diabetes. There’s really no such thing as borderline diabetes anymore, but prediabetes is related to inactivity and excess weight. What it really is is a warning sign to our body that we’re going down the wrong metabolic pathway. It’s similar to a flashing yellow light when you’re driving. When the light is green, you can keep going. But when it’s turned yellow, it’s a warning that you need to stop. That’s what prediabetes is.

Melanie: Really only about one in 10 are aware that they even have prediabetes, and this is kind of staggering to me. Tell us how a listener would know that they are at risk of getting full-blown diabetes, that they’re subject to prediabetes. And how would they even know what their blood sugar levels are?

June: Well, most people don’t know what the risk factors are for prediabetes, but being overweight, a BMI higher than 25, being inactive, or a family history of diabetes, or having had gestational diabetes in pregnancy, all put you at higher risk for prediabetes. The only way to know would be to have a blood test done.

Melanie: Are there symptoms that would show up that would send someone to their doctor to get checked?

June: Oftentimes there is no symptoms of prediabetes. People might complain of a little fatigue or malaise. Sometimes there is some darkening of the skin, a skin condition called Acanthosis nigricans. Most often, people would not have any symptoms. The classic symptoms of diabetes, such as unusual thirst, unusual urination, weight loss, don’t show up in prediabetes.

Melanie: There are some factors. Certainly with diabetes there is a genetic factor involved. But what about with prediabetes? And are there certain factors that we can control?

June: There are some genetic factors, such as family history of diabetes, body type, age over 45, certain ethnic groups, such as African American, Hispanic, American Indian, Asian American, or Pacific Islander. All those genetic factors can put someone at higher risk. The factors that we can control are being overweight and inactivity. That’s the main problem in America with prediabetes.

Melanie: What would you advise as your most important information, June, for people who suspect or are told that they are prediabetic, and what would be their first step towards preventing full-blown diabetes?

June: The first thing they should do is just go into their clinic and have a fasting blood sugar and a hemoglobin A1c checked. The fasting blood sugar gives you a measure of what their blood sugar is that point in time. The hemoglobin A1c is a really nice test. It measures the amount of glucose that attaches on to a red blood cell. And since the red blood cell has a life of 90 days, it gives us a reading of what that blood sugar reading has been over the last 90 days.

Melanie: Then what if somebody gets that diagnosis? What does that mean for their future? It’s not definitive that they will get diabetes from this diagnosis, correct?

June: That’s correct, but a diagnosis of prediabetes is exactly where we want to find people. We should be diagnosing them there rather than when they become diabetic, mainly because they can make some changes. They can make some lifestyle changes that can prevent the development of diabetes. What we know now is when a person is diagnosed with type two diabetes, at that point in time, they have already lost 50 percent of their beta cell function. The beta cells are cells in the pancreas that control glucose metabolism. For about 10 years before the diagnosis of diabetes, these beta cells have been becoming less and less active. By the time that diagnosis is made, 50 percent of that function was already lost. We want to make the diagnosis 10 years earlier and make some changes. It’s a sign to assess, a time to make a U-turn when you get an elevated blood sugar in the prediabetic rate. We don’t want to keep going straight ahead. We got to turn around and make some major changes in lifestyle.

Melanie: If those beta cells are damaged or destroyed and making them resistant to the actions of insulin in the blood, then is there a way to prevent type two diabetes from coming on? It doesn’t mean that they’re going to get it, right?

June: Well, the best information we have on prevention of type two diabetes is the study that was done called the Diabetes Prevention Program that was done in 2002, and that was a randomized control trial of more than 3,000 people. What they did in that study was they put a third of the people into a lifestyle intervention group where they worked on diet, exercise, weight loss and lost around 7 to 10 percent of their body weight. A third of the group were put on a medication that’s oftentimes used to treat type two diabetes called Metformin, and then a third of the group were put in a control group. What they found was that the people in the control group ended up developing diabetes at a rate of 11 percent per year. Basically, if you do nothing, in nine years, 99 percent of those people had type two diabetes. The treatment group with the medication, the Metformin group, they decreased their risk of getting type two diabetes by 31 percent. The lifestyle intervention group and those people who lost maybe 7 to 10 percent of their body weight—so if you weighed 200 pounds and you lost 20 pounds—for most of those people in this study, they did not get down to an ideal weight, but they lost a little bit of weight, and they decreased their risk of developing type two diabetes by 58 percent.

Melanie: That’s really amazing statistics. And are there any resources you would recommend to people who are worried about prediabetes?

June: Yes, there are. There are some prediabetes classes taught at the Allina clinics by our diabetic educators. Also, the American Diabetes Association has information on prediabetes on their website at diabetes.org. One of the best resources is through the YMCA, and what they’ve done is replicated the Diabetes Prevention Program and made a 12-month program consisting of 16 one-hour weekly sessions and then monthly sessions after that and working on diet, exercise, weight loss as the goal. The interesting thing they found with the Diabetes Prevention Program was that the lifestyle intervention was effective for everyone, men and women, people of all ages and people of all ethnic groups, and that that lifestyle intervention persisted over 10 years. We have very real medications that have those kind of results, and this is something that people can do for hardly any cost and no side effects.

Melanie: That certainly is the best information as exercise has that insulin-like effect, so being physically active is certainly one of the best bits of information you’re giving here today. June, in just the last minute or so, give your best advice for someone who suspects that they might have prediabetes or has already gotten that diagnosis and how they can change that course or path thereon.

June: The best advice that I can give them is to start exercising and to work up to a goal of 150 minutes a week, so 30 minutes five days a week. Doesn’t have to be strenuous. Going out for a walk is great. Working on changing their diet so that it’s healthier. And to lose weight, they do need to eat less calories than they’re burning up. So it usually involves some calorie restriction along with healthy diet. There’s some great community-based programs out there. I think most people know what they need to do to lose weight; it’s mainly just getting going on it.

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

Holistic Heart Disease Prevention

Additional Info

Segment Number 4
Audio File allina_health/1444ah1d.mp3
Doctors Baechler, Courtney Jordan
Featured Speaker Courtney Jordan Baechler, MD - Internal Medicine
Guest Bio Courtney Jordan Baechler, MD, practices with and is vice president of the Penny George™ Institute for Health and Healing, part of Allina Health. Baechler attended the University of Minnesota, where she earned a bachelor’s degree in mathematics, a medical degree from the School of Medicine, and a master’s degree in epidemiology and public policy from the School of Public Health. Baechler is a consultant to Minnesota’s Statewide Health Improvement Plan and chair of the clinical work group for Minneapolis. She specializes in cardiology, internal medicine and integrative medicine.
Transcription Melanie Cole (Host): Heart disease is the leading killer of Americans with coronary heart disease, costing the United States nearly $109 billion each year. Yet so many of the leading causes of heart disease are preventable. My guest today is Dr. Courtney Jordan Baechler. She is the vice president of the Penny George Institute for Health and Healing, part of Allina Health. Welcome to the show, Dr. Baechler. Tell us a little bit about heart disease. What is it, and how rampant is it in the United States?

Dr. Courtney Jordan Baechler (Guest): Sure. Heart disease is quite broad. It actually affects one in three Americans, so it’s a very rampant disease. It includes everything from valve disease in our hearts, arrhythmias or abnormal heart rhythm, problems with our arteries, as well as heart failure. So, quite broad.

Melanie: What are some of the risk factors for heart disease that people need to be made aware of?

Dr. Baechler: You know the risk factors are also broad. These include high blood pressure, high cholesterol, tobacco use, stress, physical inactivity, and nutrition.

Melanie: There is a genetic component if a family member has had heart disease. Those are not so controllable. But what about the ones that we can control? What are some of the things, the best information that you would like to get out there about the controllable factors for preventing heart disease?

Dr. Baechler: Well, a couple of things. I want to emphasize that when we look at broad studies, only about 15 percent of our overall heart disease risk is genetic. We actually have upwards of 85 percent of control over our heart disease outcome. That really comes into changing our behaviors. When we look across the United States, we’re looking at folks who have a body mass index between 18 and 25 being considered healthy. Folks that get 30 minutes of exercise a day, folks that drink in moderation, and folks that avoid tobacco use. There’s only about 5 percent of the population that’s doing all four of those things. It’s critical that that’s not a drug, that’s not an intervention; that’s us feeling empowered, engaged, and able to commit to these every day of our life.

Melanie: These are great bits of information and things we should be doing every day. What is a holistic approach to heart disease prevention, and how is that different than what you just discussed?

Dr. Baechler: A holistic approach from my perspective is looking at that onion a little bit deeper. Most of us know we should be eating better. We should be exercising more. But why aren’t we doing that? Looking at things holistically, that gets into life balance, stress, sleep, things that are critical to whether or not we can engage in those healthy behaviors. Have willpower if you will, right? Well, it’s really difficult to have willpower all day long if you’re not getting enough sleep at night, if you’re feeling exhausted from either your family life or caring for ill parents or just burning the candle on both ends at work. That’s looking at things more holistically, taking a look at our social connection, the way we engage with others, the way we fuel ourselves back up. Usually that doesn’t come from a pill or intervention.

Melanie: It absolutely doesn’t and I hear what you’re saying, Dr. Baechler, and I see that everything you just mentioned kind of revolves when you say taking care of an aging parent, work, not getting enough sleep, kind of all encompasses the stresses that we deal with, and stress is such a huge factor for heart disease. And they’re learning more and more about inflammatory markers and those stressors. Tell us what we can do to manage the stress so that we bring that down a little bit and help to prevent heart disease. I think it’s one of our biggest factors.

Dr. Baechler: Absolutely, and you’ll see that we’ve been shy to approach it from a clinical perspective because it’s difficult to measure. Your stress and my stress, we’re going to measure that differently. Again, we don’t have that single-pill solution. What we do have is thousands of years of ancient wisdom and evidence-based integrative health outcomes to show we can change our body’s reaction to stress. That starts first with breathing. There’s so many times during the day where we’ll catch ourselves getting nervous about what’s coming up next and we’re breathing really shallow. Sometimes, simply shutting your door in an office and taking an opportunity to take five minutes to sit and breathe, taking big breaths in and breathing out twice as long can really, again, slow that sympathetic nervous response, tell us there’s not actually a tiger fighting or that we’re running from. So that’s huge. And there’s all sorts of things from aromatherapy to utilize our senses to help us, again, take in a different smell, like lavender, that naturally calms our bodies, to teach guided imagery. And again, for me, that’s taking myself to a beach in Hawaii and getting away from the stress of a cold Minneapolis winter, which really, again, is going to slow that sympathetic nervous system response, has been shown to decrease our heart rate, decrease our blood pressure, the exact things that we sometimes resort to medications real quickly. Acupuncture is another great way to slow that stress response as well as formal training in meditation or yoga practice. So, lots of tools that don’t have any side effects but can be very beneficial to help with that life stress response.

Melanie: If we learn to do these things, maybe we explore acupuncture for people that might be a little bit intimidated by that. We learn guided imagery. We meditate every day, along with our activity. Give us kind of a little bit of a day of practicing a holistic approach, including our nutrition. Because again, nutrition plays such a huge role in heart disease and what we eat. Give us kind of a day of what we can do including activity and meditation, whatever it is. Kind of walk us through it.

Dr. Baechler: Yeah, and I’m going to start my day in the evening, so starting it the day before, if you will, and that’s going to start with going to bed at a reasonable time. For most people, we need somewhere between six and eight hours of sleep at night, and if you’re an eight-hour sleeper, you can’t get six hours. Otherwise, you start the day off, again, not feeling rejuvenated. For me, it starts with that critical piece of sleep. Then, a way to, again, engage and empower a successful day ahead is starting in the morning rather than having that alert of the alarm clock or running to check the emails but giving your body a sense to adapt to this day. Give yourself five minutes to either do some yoga stretches in the morning, light breathing, or a very light meditation just to set the intention of that day to come. Next up is going to be having that really nourishing meal, because we know, again, as you pointed out from a nutrition standpoint, what we’re feeding our body is going to feed our mind and subsequently feed those neurotransmitters and hormones that work straight to our heart. For me, that might start with a steel-cut oatmeal with fresh fruits, almonds, some walnuts so we’re getting fats, we’re getting complex carbohydrates and we’re getting protein, all in one. For others, that’s some eggs. For some, that may be a Greek yoghurt, again, without added sugar, where we’re putting natural fruits and nuts into that. So, lots of great ways to nourish your body starting in the morning. Then, that’s going to start for me on your way into work. How are you feeding your soul at that point? Are you listening to something on the way in that’s soothing, or are you listening to something that’s getting you riled up and starting that sympathetic nervous response? I’m going to go through my morning. I’m going to start at my lunch hour. Rather than simply doing work at the office, I’m going to take 30 minutes to get out and move my body. And I’m here to tell you as someone who practices medicine, a mother of two, and married to another physician, it’s absolutely critical and we’re all capable of finding those 30 minutes in our day to get out and move our body. For me, that’s usually a light walk so I don’t have to worry about showering afterwards, but incorporating that in your day as well as then nourishing yourself at lunch with those same key elements—fruits with vegetables, lean protein, or best yet, plant-based proteins that are naturally low in fat and sugar. I might do a quinoa and some black beans and some veggies with some sesame oil that are a great anti-inflammatory diet. Going about our workday afterwards and then taking the time when we get home to separate anything that was stressful from the day. For me, that’s when I take off my clothes, that’s taking 10 minutes again to yourself to sit and breathe and get ready to move to that next phase, which for me is then being a mom at home. I think there’s lots of great ways to incorporate small chunks of time that still will allow you to do the things you love—work, being a part of your family, taking care of those loved ones, whatever it is—but nourishing ourselves with food, nourishing our mind with time, breathing small chunks of time to be able to really change what we’re doing for ourselves.

Melanie: Dr. Baechler, in just the last minute, where can people go if they want to learn more about a holistic approach to heart health or health in general?

Dr. Baechler: I would check out our website at allinahealth.org/georgeinstitute, where we have a variety of all sorts of integrated health approaches—stress, wellness, aging well, cardiovascular disease, et cetera. It’s a great website.

Melanie: Thank you so much. You’re listening to the WELLcast by 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

Cutaneous T Cell Lymphoma (CTCL)

Additional Info

Segment Number 1
Audio File city_hope/1447ch1a.mp3
Doctors Querfeld, Christiane
Featured Speaker Christiane Querfeld, MD, PhD
Guest Bio Christiane Querfeld, M.D., Ph.D., is a board-certified dermatologist and dermatopathologist with advanced fellowship training in cutaneous lymphoma. Her clinical practice focuses on the diagnosis and management of patients with cutaneous lymphoma and the care and management of patients affected by cutaneous complications of hematopoietic stem cell transplantation.
Transcription Melanie Cole (Host): If you’ve been diagnosed with cutaneous T-cell lymphoma, you might wonder what that means in terms of treatment and outcome. My guest today is Dr. Christiane Querfeld. She is the director of the cutaneous lymphoma program at City of Hope. Welcome to the show, Dr. Querfeld. Tell us a little bit about cutaneous T-cell lymphoma. What is it and how is it diagnosed? What makes it so difficult to diagnose?

Dr. Christiane Querfeld (Guest): Cutaneous T-cell lymphoma is mainly so called mycosis fungoides, and it’s really extremely difficult to diagnose because this T-cell lymphoma can mimic many other benign skin rashes such as psoriasis or eczema. Even if patients have a longstanding rash, they may not be diagnosed because the biopsy does not show features of a T-cell lymphoma and can also on the biopsy look like psoriasis or look like eczema. So you have to have a very, very low threshold as a clinician and as a pathologist to diagnose this type of lymphoma. In particular, you have to make sure that you take a good history. So if it’s a longstanding rash for many, many years, if it’s typically distributed or started in the bathing suit areas, like the buttocks, the lower back, the breasts, the inner arms, all these sun-protected areas, that’s very suspicious for mycosis fungoides. Patients have been in the past before I even see them, they have been treated with topical steroids, and it’s not helping. The rashes always come back. This is also another sign that something is not right.

Melanie: Dr. Querfeld, once it’s diagnosed, what are the first line of defense treatments for CTCL?

Dr. Querfeld: First line treatment, depending on how widespread the lymphoma is. If it’s just the skin, usually you start with so-called skin-directed treatment. And skin-directed treatments is the spectrum of phototherapy, can be PUVA, it can be narrow-band UVB or just UVB. It can be topical steroids in combination or alone before the therapy, topical nitrogen mustard, which is a topical chemotherapy, topical bexarotene, or other topical retinoids, which also affects the malignant cells in the skin, and radiation therapy. This radiation therapy is called electron beam radiation, which is very, very superficial. Electron beam radiation is not the same like phototherapy. Phototherapy is something that’s in the spectrum of the natural light treatment. It’s just filtered. It could be either UVA, UVB, or a certain spectrum from UVB, which is called narrow-band UVB. UVA is not given just as treatment. It’s given with a medication, a pill that sensitizes the body to the light, and the medication is called Psoralen and if you give this in combination with UVA, then it’s called PUVA.

Melanie: When we talk about the skin-directed therapies, Dr. Querfeld, tell us a little bit about the side effects. If we’re going to start with a topical corticosteroid or the retinoids that you discussed, what are some of the side effects, and what do people do about things like itching and the dryness that comes with these skin therapies?

Dr. Querfeld: Side effects. Of course, every treatment has its pros and cons. If you start with topical steroids, usually you give more potent steroids. If you give it for a long, long time and throughout the body, you have to make sure that you do not absorb a significant amount of steroids that can suppress your own body’s production of steroids. Steroids are very helpful and necessary, but you don’t want to suppress your own body’s production. Also, skinning can happen. It’s usually that’s why we put patients on and off to make sure that this does not happen. Certain areas cannot be treated with very strong steroids, such as the private parts or the axillary areas or skin folds, because the skin is thinner and the absorption is higher. Also on the face, you can’t really use high potent steroids. I usually start steroids as first line and give additional treatment once we have established the diagnosis. The phototherapy—in particular, PUVA—can cause skin cancer, other forms of skin cancer like basal cell, squamous cell cancer, but only if you give it for a long, long time. The best pattern or type of phototherapy would be narrow-band UVB. The risk is extremely low. Topical nitrogen mustard and topical retinoids, they can cause skin irritation that you get, like a contact allergy or, really, rashes from the medication. That’s why once we give treatment, I’d like to see my patients very closely and follow up every three to four weeks and see how the treatment works and how we can handle the side effects. One important thing is…

Melanie: What do you typically do about those side effects for people? Can they use over-the-counter creams for the itching, for these agents? What do they typically do to manage and live with this so they’re not so uncomfortable?

Dr. Querfeld: For the itching, it’s adamant to have a good care. And I have a list of eight to 10 unscented, fragrance-free moisturizing creams and ointments. I call it Dr. Q’s top 10. I want to make sure the patients do not use any lotions which are alcohol-based and can contribute to irritation. I do not like any scents in the moisturizers that can cause irritation. If the rashes are very bad, sometimes bacteria can hide in those rashes on the skin. I have implemented -- I like to use so-called bleach baths, which I have adopted from children who are treated for eczema. A quarter of a cup in a full bath once or twice a week, that works wonder. For the itching, moisturizers is the first, mild soap then moisturizing. Second, we could give systemic therapies for itching, like the spectrum of anti-itch medications. I don’t like to go into detail right now because every patient may respond differently. We have also an upcoming trial on patients who are really itchy to see if this new topical formulation can stop the itching. I do have to mention the itching is the major problem in patients who have really the itch. They’re not really bothered by the rash, it’s more the itching. If it’s really severe, such as in Sezary syndrome, it’s really disabling. So we work on it. I cannot promise really wonders, but on a continuous basis, we can decrease the itch significantly. The overall goal is to clear it, and once the patient is cleared, then the itch stops

Melanie: Now, tell us a little bit about phototherapy, the light therapy. What is it intended to do? Generally, what is the outcome for people with CTCL?

Dr. Querfeld: Phototherapy is one of the mainstay treatments, as I mentioned before, and there are experiences, probably 30 to 40 years. It was in particular discovered in the late ‘70s that patients respond very well. How does this work? In two ways. One is that the light can directly kill those atypical, those malignant cells in the skin, and they can also diminish other immune cells who live in the skin, such as dendritic cells, Langhans cells. These are the ones who actually support the growth of the lymphoma cells, and they are all affected by the light therapy. They don’t like the light therapy, and so they eventually die off. Studies have actually shown that if you treat until you clear and then you taper slowly off over months, the recurrence of the lymphoma is less compared when you just stop once the skin is clear. I like to do this, too, like tapering patients off slowly after the skin is completely clear. Usually, what you expect is that you give it about probably around three or four months. That’s the average time patients clear. And then you slowly taper from three times a week to two times a week to once a week and to once every 10 days. This is the process that goes over nine to 12 months, but that may be different. And some patients may just like to be on a maintenance treatment for a year or two every 10 days and would be fine.

Melanie: Dr. Querfeld, in just the last few minutes, please give your best advice for those living with CTCL in managing their symptoms and why they should come to City of Hope for their lymphoma care.

Dr. Querfeld: We have a dedicated multidisciplinary clinic for CTCL or for cutaneous lymphoma. It’s Dr. Zain and myself and Dr. Rosen. We have extensive experience in treating those patients. Myself, I have been involved with care for 14 years, and I’m very fortunate to do this. We have the necessary equipment here. We have the staff who can support us in treating those patients.

Melanie: Thank you so much. 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 and have a great day.
Hosts Melanie Cole MS

School Readiness: Preparing Children For a Bright Future

Additional Info

Segment Number 3
Audio File allina_health/1444ah1c.mp3
Doctors Siddiqi, Asma
Featured Speaker Asma Siddiqi, MD - Family Medicine
Guest Bio Dr. Asma Siddiqi is a board-certified family medicine doctor who practices at Allina Health East Lake Street Clinic in Minneapolis. Dr. Siddiqi has professional interests in preventive care, women's health and pediatric care. In addition to being a physician, Dr. Siddiqi is a mom to a happy little boy.
Transcription Melanie Cole (Host): Up to 90% of brain development happens by the age of five which means those fun and early years of our child’s life are so important for a bright future. Research confirms that the interactions a child has with their parents or caregivers have a big impact on a child’s emotional development, learning abilities and ultimately, their success in school and life. What can parents do to help further this along? My guest today is Dr. Asma Siddiqi. She’s a board certified family medicine doctor who practices at Allina Health East Lake Street Clinic in Minneapolis. Welcome to the show, Dr. Siddiqi. Tell us a little about school readiness. What is that?

Dr. Asma Siddiqi (Guest): Definitely. School readiness basically encompasses by preparing our children, our schools and communities to maximize educational experience of all children regardless of their developmental abilities or any health conditions they might have.

Melanie: What are some of the different elements of school readiness?

Dr. Siddiqi: There are quite a few elements, but the most important which I think we should focus on are: language development, making sure our kids are socially and emotionally ready. For example, they can sit still, make friendships. A child’s approach to learning is very important. For example, some kids learn more effectively visually while others, they’ll learn if something is written to them, general knowledge and lastly, not to ignore physical well being and motor development.

Melanie: Tell us about the importance of this well being and self-esteem and motivation as children learn to learn.

Dr. Siddiqi: Early school success or failure can affect a child’s wellbeing, self-esteem and motivation. For example, if a child is not emotionally or socially ready, he might not be able to sit still, make friendships and could be left behind in terms of not paying attention or basically missing out on what’s being taught in the class. So it’s very important to ensure that the child begins school when developmentally ready to participate in classroom activities.

Melanie: How does a parent know when their children are ready to start pre-school or some sort of pre-kindergarten class?

Dr. Siddiqi: The children should basically -- first thing which I would say would be emotionally ready in terms of that segregation which they can have from the parents. That’s very important and that’s a major milestone. If kids are still crying when the parents are going away, that’s not going to work so we have to work on that segregation. Being able to sit not for a prolonged period of time but for 10-20 minutes so they can concentrate what lessons the teacher is going to or what they are being taught. Being able to engage in friendship, being able to have some writing skills, for example holding a crayon, not mainly -- I won't expect a preschooler to write also but just some picking up the crayon properly and doing some scribbling, etcetera, stuff like that.

Melanie: What are some of the different areas of learning that determine whether or not a child is ready? You’ve mentioned the writing and scribbling, being able to make friends and are there some others that kindergarten teachers can say, you know, this child has not been ready because they couldn’t do this?

Dr. Siddiqi: I would say self-regulation. The moral awareness, that also goes into how they interact with their peers and teachers. Physical well being and motor development, sometimes, if a child is well behaved, sitting quietly, paying attention, that’s ignored by some teachers and if the school is good quality and they’re following the right curriculum, they will recognize it. For example, if a child is not pedaling well. If they’re asking him to ride a bike on a tricycle and he’s not pedaling well, that’s a concern at four years of age when they are starting pre-K. Or if they’re having some trouble while they are in the lunch room not able to feed themselves well, those are also some concerns and they can speak with the parents and parents in general can speak with the pediatrician and get appropriate help for the kid. I would also like to mention language deficiency. If the teachers are not able to make out 90% of the words or what the child is trying to say or explain, that’s also a concern.

Melanie: What are some ways that parents can incorporate learning into the daily routine so that it’s a little bit more second nature for a child to attend classes?

Dr. Siddiqi: Now, as parents, we are the first teachers to our child so we can encourage language and reading skills. For example, when we are driving, just pointing at common signs and symbols, talking about different colored cars. While you’re at home, your child can help you to cook by naming ingredients, stirring, mixing, which can help with motor skills. At grocery stores, pointing out at different vegetables, their colors, counting, for example, asking them to pick four apples. Writing skills, we can work on by asking the kid to peel a carrot, write invitations, working on cognitive skills by going to the museum to learn a bit. I do agree the best and the most effective learning does happen when incorporated into daily life rather than by being a separate activity.

Melanie: Well, speaking of daily life, there are so many screen things these days. How does that play into school readiness with TVs and Smartphones and tablets? Are these things detrimental or helpful to getting your child ready to start school?

Dr. Siddiqi: Well, the first thing to know is that there should be no screen time in the first 24 months of a child’s life. After the age of two, it’s reasonable to introduce educational programming to children. I was quite strict about no TVfor my son until he turned two, but after that, we have allowed him to watch carefully selected program. The reality is that there are many educational programs on televisions and apps on our Smartphones that foster literacy and social development. In fact, I have to admit that my son has learned a lot from these programs he watches and apps he has been allowed to use. But we do have to be careful regarding what our children are watching and be sure -- should be watched together as a family. And later after every show, we should discuss what the child saw and go over the main points with our children. I would emphasize the key is to avoid excessive screen time and to make sure the children spend enough time on other activities that promote learning and play. Also, it should be noted that a large body of research does demonstrate that watching violence even in cartoon font does lead to aggressiveness and decreased time for play in children. So everything in moderation and no TV before the age of two.

Melanie: What should we do, Dr. Siddiqi, if we think our children are not ready to go to school?

Dr. Siddiqi: The first thing is to go speak to your pediatrician or your family practice doctor. If you notice any delay in speech, for example, if by preschool, you’re not understanding 90 % what they’re trying to tell you, you have noticed some emotional or social problems that the children -- by four years of age they should be playing with other kids. Some kids do parallel play, but there is social interaction which is noted, some motor delays then speak with your pediatrician and they can refer you to other specialties like physical therapy, OT, speech therapy or community health which is available.

Melanie: An early intervention is so important, Dr. Siddiqi. In just the last minute, do you have some resources that you’d like parents to know about to help them learn more about this?

Dr. Siddiqi: Of course. I have a list of resources and I focus basically here in Minnesota, so talking about Minnesota, parents know this is State of Minnesota website designed to provide parenting information about children’s development, learning and health and parents can go on www.mnparentsknow.info. The other one which I really like is Help Me Grow. This is also State of Minnesota-designed website designed for concerns about young children’s development and learning and where to make referrals from birth to age five. A few others to name is A Parent’s Guide to Preparing Your Child for School.

Melanie: 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

Testicular Cancer: What Every Man Needs to Know

Additional Info

Segment Number 5
Audio File city_hope/1440ch4e.mp3
Doctors Yamzon, Jonathan
Featured Speaker Dr. Jonathan Yamzon
Guest Bio Dr. Yamzon is a surgical expert specializing in the treatment of urologic cancers. He joined City of Hope's surgical team following the completion of a robotic surgery fellowship within City of Hope's Division of Urology and Urologic Oncology Surgery. Dr. Yamzon received his medical doctorate from Keck School of Medicine of University of Southern California (USC). His clinical interests include the treatment of urologic cancers using robotic and open surgical techniques, benign prostatic disease, stone disease, incontinence and general urology. He speaks fluent Spanish and Tagalog.
Transcription Melanie Cole (Host): City of Hope is actively developing tomorrow’s treatment protocols today for testicular cancer. My guest today is Dr. Jonathan Yamzon. He’s a clinical assistant professor in urology and urologic oncology at City of Hope Comprehensive Cancer Center. Welcome to the show, Dr. Yamzon. What is testicular cancer?

Dr. Jonathan Yamzon (Guest): Good morning, Melanie. Thanks for having me. Testicular cancer is probably the most common solid organ tumor of young men, anywhere from puberty to age range of 45, and it develops in the testicle. You can have multiple tumors in the testicle, but testicular cancer, 95 percent of it is what we call a germ cell tumor. It develops or it is first detected upon feeling or examining the testicle, and it typically is a firm, nodular hardness to the testicle that, surprisingly, men feel and sometimes don’t get evaluated right away. It is detected upon examination, and ultrasound of the testicle can further delineate this from anything else.

Melanie: Well, I can understand how men would not get it checked right away because men typically, we’re the ones who have to shove them in to see a urologist anyway. Do you advise that men do a check, just like women, we do a self-breast exam? Do you advise men to do this check?

Dr. Yamzon: We do. In fact, this is a standard thing for men when they see their primary care physician. Their primary care physicians will routinely do a testicular exam when they’re from that age group, the young age group, that is. I do recommend that men perform self-examination and get familiar with the anatomy down there, and if there is any sort of change, then they should call this to the attention of their physician, who can then order the appropriate tests or refer them appropriately to the urologist to examine this further.

Melanie: Are there certain risk factors which would predispose a man to having testicular cancer?

Dr. Yamzon: Great question. There are. The single most notable risk factor is when a man has a history of the testicle being undescended in childhood. The descent of the testicle happens late in utero, and sometimes it fails to descend completely when children are born prematurely. That kind of history where the testicle did not make it all the way down into the scrotum or required some sort of assistance or surgical intervention, it’s those men that will have an increased risk of developing a tumor in the testicle. Sometimes, about maybe 5 percent of the time, whatever [insult] took place for one site descend, it affects the opposite or normal testes, and tumors can develop rarely on that side. There are other risk factors including what we call testicular atrophy. If the testes didn’t develop fully for some unknown reason, that testicle also has an increased risk of developing testicular cancer. Interestingly, maybe 10 to 15 percent of testes cancers are detected when men are seeking assistance with regard to infertility issues, and so it’s upon the workup of infertility that physicians recognize, hey, there’s a tumor here in your testicle and we need to further look this up.

Melanie: If a man feels a lump, goes in to see you, are there other symptoms that you want to let the listeners know about that, if they’re not feeling a lump, that might come up?

Dr. Yamzon: Usually the lump is the primary thing. On occasion, you get symptoms of disease that has already disseminated or spread. We’ve had patients present in advanced matters where they’re feeling abdominal pain, abdominal fullness, even back pain. The route of spread of testes cancer follows, for the most part, a relatively set pattern where the lymph nodes and the back of the abdomen or its retroperitoneum become involved or metastatic sites. These tumors can be quite large where they are impinging or applying pressure to the adjacent organs and musculature so that patient feels these kinds of symptoms of back pain, etcetera. Those are the kinds of symptoms that would manifest as well, beside patients present with shortness of breath because they’ve developed tumor metastases into the lungs, or even feeling palpable masses all the way up into the lymph node chain toward the neck, which were firm and they just sort of developed over time, and sometimes they are overlooked. Patients within this age group have very busy lives and they sort of just blow them off, and finally when they get evaluated, they recognize that hey, there’s a large testicle also. And finally, the imaging reveals that this is a testes cancer.

Melanie: Dr. Yamzon, once it is diagnosed, how is it treated? What are the typical treatments. Because I think this is probably the scariest but yet, most interesting part of this conversation is because men are worried about what the treatment involves.

Dr. Yamzon: Well, the treatment will depend at the stage at the time of diagnosis. In general, if men present early and the testicle is really the primary site of detection, then the testicle is removed. And then, depending on what the pathologist finds, because the testicle is removed and sent off to a pathologist and they’ll look at it under a microscope and tell us the different cellular subtypes of testes cancer and then, based on that, the treatment regimens are a little different. You can have things called seminoma, where it is very radio and chemo-sensitive. In general, if there is no evidence of spread, the removal of the testicle may be curative at usually 80 percent of the time. Part of the staging process is not only looking at or examining the testicle with the ultrasound, but also doing what we call a CT scan. The CT scan will cover the chest, the abdomen, and the pelvis and will tell us to what extent the disease has spread. The unique thing about testes cancer is that it also has tumor markers. It’s really the model of a lot of cancers in that it has specific blood detectable markers that are indicative of the subcellular subtypes and the activity, and we can use these tumor markers to monitor its response to therapies. Going back to treatment, if the tumor was confined only to the testicle, we opt to survey or watch everybody moving forward because up to 80 percent of these patients are cured with just the removal of the testicle alone. If there is disease in the retroperitoneum, and depending on the size of the disease --- but usually, if there is disease in the retroperitoneum, they move on to something like chemotherapy. If there is a very small or limited disease in the retroperitoneum, they may be eligible for radiotherapy if it’s only seminoma. But if there are multiple subtypes of testes cancer, then they’ll want to get chemotherapy. Usually these tumors respond well, for the most part, to the chemotherapy. If there are residual tumors remaining despite the chemo, then these could be surgically removed.

Melanie: Now, side effects. If you have to remove a testes, men I’m sure are worried about -- is there any involvement or sexual dysfunction that goes with that removal? I mean, if the cancer is gone, they should be happy about that, but then may worry about the side effects.

Dr. Yamzon: Good question. With regard to sexual dysfunction, upon removal of the testicle -- really the only thing that we concern ourselves about at that level is the potential for infertility, the potential compromising the natural conception of a child because it may potentially affect one’s sperm counts. Before we embark on any therapy, we encourage men to engage in sperm banking. It’s a difficult thing in today’s medical, and a lot of insurances don’t cover this. So it becomes a difficult task for those who don’t have the means to do so. We do encourage men to cryopreserve their sperm in the event that they wish to father a child in the future. The removal of testicle may affect one’s fertility, and subsequent therapy such as chemotherapy may also do that. And it’s for these reasons we have patients bank sperm when it’s feasible for them. I did mention to you the surgery earlier, which we pretty much do now after chemotherapy when there are residual masses after chemotherapy. There are a set of nerves in the area of the retroperitoneum that make the way down to the pelvis, and they’re responsible for the coordinated contractions that occur in the act of ejaculation. This is the forward propagation of semen so that it’s deposited into the vaginal vault. When some of these nerves are disrupted or if it’s infeasible to preserve them, then we have to compromise these nerves to remove the tumor. Men may have difficulty or men may not experience ejaculation appropriately. They may not propel semen in a forward direction, let alone propel any at all following a surgery like that.

Melanie: But they can still have an erection? One thing has nothing to do with the other, right?

Dr. Yamzon: Exactly. They can still have an erection. They can still experience orgasm or heightened sense of climax during intercourse, but it really becomes a conception or fertility issue at that point.

Melanie: In just the last minute if you would, Dr. Yamzon, please tell the listeners why they should come to City of Hope for their urologic cancer care.

Dr. Yamzon: Well, at City of Hope we have a very experienced team. We cover all aspects of urologic oncology, and we’re a tertiary cancer center. We specialize in treatment of these very advanced cancers, and we have got it broken down into a very set pattern. We got minimal variations. We minimize our complications, and we are contributors to the national comprehensive cancer network guidelines. And so, we find ourselves at the forefront in conjunction with other major cancer centers in developing the treatment paradigms and optimizing them.

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

Childhood Diabetes and Early Prevention

Additional Info

Segment Number 2
Audio File allina_health/1444ah1b.mp3
Doctors Meyer, Stephanie
Featured Speaker Stephanie Meyer, MD - Pediatrics
Guest Bio Dr. Stephanie Meyer is a pediatrician at Allina Health Coon Rapids Clinic. She has professional interests in well-child care, breastfeeding and children with chronic medical conditions such asthma, attention deficit hyperactivity disorder and diabetes. Dr. Meyer attended the University of Minnesota Medical School in Duluth.
Transcription Melanie Cole (Host): Every year in the United States, 13,000 children are diagnosed with Type 1 diabetes. Do you know what signs and symptoms to look for? My guest today is Dr. Stephanie Meyer. She’s a pediatrician at Allina Health Coon Rapids Clinic. Welcome to the show, Dr. Meyer. People hear about diabetes. Tell us the difference, please, between Type 1 and Type 2.

Dr. Stephanie Meyer (Guest): Well, Type 1 diabetes happens when your body doesn’t produce enough insulin. This is actually an autoimmune disorder, so this typically happens when your body’s own immune system destroys the cells that produce that insulin. It’s often thought of as a childhood-onset diabetes, although it can present in adulthood. This is different than Type 2 diabetes. Type 2 diabetes happens when your body becomes resistant to insulin. That’s often because of a poor diet and not healthy choices. And so your body is constantly pumping out insulin and thus becomes more resistant to it. This causes your blood sugar to rise and can lead to diabetes. Type two diabetes tends to be much more common in adults and is often considered an adult onset diabetes, although unfortunately we’re seeing more and more Type 2 diabetes in children just because we’re seeing more children who have problems with their weight and are making unhealthy choices as far as their diet goes.

Melanie: We certainly are. And I think that it used to be called adult onset diabetes, but more and more, as you said, they’re calling it Type 2 diabetes because we are seeing it in children. Can we prevent Type 1 diabetes in children, and what should parents look for, symptom-wise, that would make them suspect that maybe their child needs to be checked?

Dr. Meyer: Type 1 diabetes, you can’t really prevent, unfortunately. Your body has attacked your pancreas. That’s an autoimmune disorder. Type two diabetes is the type of diabetes that you can prevent, and that’s prevented with maintaining a healthy weight, getting enough physical activity, and just trying to get a healthy diet in. Signs and symptoms that you want to look for in your children that may trigger you to think your child has diabetes is if you feel like your child is excessively thirsty, so drinking a lot. They might be going to the bathroom frequently. They might be very fatigued. You might notice some weight loss. Some kids will even complain about blurred vision. These are all symptoms that can be associated with high blood sugar from diabetes.

Melanie: Now, tell us the symptoms of Type 2 diabetes, if they differ.

Dr. Meyer: The symptoms are really quite similar. Type 1 diabetes, those symptoms can present very abruptly and they can get very sick very quickly. It can be something called diabetic ketoacidosis. With Type 2 diabetes, it can be much more gradual. The symptoms can be much more subtle. With Type 2 diabetes, this has often been a long-term process where their blood sugar’s just kind of continually going up. Their body is becoming more and more resistant to insulin. So the weight loss tends to be much more pronounced with Type 1 diabetes, and those kids can get very sick, whereas Type 2 diabetes, there are other signs that your child may be having problems with their blood sugar. If you notice that they might be actually having problems with their weight and gaining weight, those are kind of the more common ones.

Melanie: Who is at risk for Type 1 diabetes?

Dr. Meyer: For Type 1 diabetes, people who are at risk are people who have a family history of diabetes, if they have a parent or a sibling. There also seems to be a genetic susceptibility. So some people have certain genes that may indicate they are at increased risk of Type 1 diabetes. Type 2 diabetes, being overweight is a really significant risk factor. Also, kids who are not very active, that definitely is a risk factor as well. Physical activity not only helps to keep you at a healthy weight, but it also helps make your body more responsive to insulin.

Melanie: What are some ways that can help prevent Type 2 diabetes?

Dr. Meyer: Like we kind of talked about a little bit before, eating a healthy diet, getting enough physical activity, maintaining a healthy weight are all ways to help prevent that. Some things that I tell my patients, kids should be trying to aim for about five servings of fruits and veggies a day. I really encourage kids to limit excess sugar intake, and sometimes sneaky ways that those sugars can enter our diet is pops and juices. And those are things kids really don’t need to be drinking on a regular basis. They should be drinking milk and water, and so saving those things for special occasions can really help.

Melanie: Now, what about exercise and activity? Sometimes it’s tough these days for parents to get their children up off the couch and away from the video games and get them the exercise that they need.

Dr. Meyer: Yes. We really try to encourage parents to limit screen time to at least two hours or less a day. That includes not just television, movies, but also tablets, iPads, phones, really try to be vigilant about limiting your child’s time spent in front of the screen, and then trying to aim for about 60 minutes a day of moderate to vigorous physical activities or getting your kids up and moving. That doesn’t have to be 60 minutes all at once, but at least in little chunks throughout the day, they should be getting up and being active.

Melanie: If children are developing more diabetes, as you say, Dr. Meyer, what are the long-term complications? If they have diabetes as a teenager because they are overweight and obese, what can happen to them in the long term?

Dr. Meyer: Diabetes can cause problems with all different systems in the body. It can cause heart disease. It can cause problems with your nerves, problems with your kidneys, problems with your eyes, foot damage. It can also cause skin infections. So really, pretty much any system in the body can be affected.

Melanie: It is very scary as we are seeing our children becoming more overweight in this country. What about pregnant women, Dr. Meyer? Is there something you want them to know about healthy eating during their pregnancy to prevent Type 2 diabetes in their children later on?

Dr. Meyer: Absolutely. Even while you’re pregnant, you want to still focus on having a very healthy, well-balanced diet. Fortunately, most OB-GYN providers and family practice physicians who are taking care of pregnant women, they do screen for gestational diabetes. Getting appropriate prenatal care is very important during pregnancy.

Melanie: In the last few minutes, Dr. Meyer, will you please wrap it up for us? Give us your best advice on diabetes prevention, both Type 1, Type 2, risk factor, symptoms. Kind of wrap it all up for us, if you would.

Dr. Meyer: Sure. I think the biggest thing that we want people to focus on preventing is really Type 2 diabetes, and the best way to prevent that is trying to maintain a healthy diet, eating all those fruits and veggies, avoiding unhealthy excess sugar in your diet, getting at least an hour of physical activity in daily, and just trying to make sure that you are focusing on maintaining a healthy weight. All of those are ways that we can kind of prevent our children and adults from getting Type 2 diabetes.

Melanie: Thank you so much, Dr. Stephanie Meyer. You are listening to the WELLcast with Allina Health. For more information, you can go to allinahealth.org. That’s allinahealth.org. This is Melanie Cole. Thanks so much for listening and have a great day.
Hosts Melanie Cole, MS

Dry Eyes – Something To Worry About?

Additional Info

Segment Number 1
Audio File allina_health/1444ah1a.mp3
Doctors Johnson, Carol
Featured Speaker Carol Johnson, OD - Optometry
Guest Bio Dr. Johnson is a licensed optometrist at Allina Health Inver Grove Heights Clinic. She has been practicing for 27 years and studied at Pacific University College of Optometry in Forest Grove, Oregon. Dr. Johnson has professional interests in ocular disease, macular degeneration, corneal ulcers, conjunctivitis and iritis. In her free time, Dr. Johnson enjoys listening to and playing music, swimming, skiing and skating.
Transcription Melanie Cole (Host): Dry eyes affect 25 million people in the United States, and you could very well be one of them. My guest today is Dr. Carol Johnson. She’s a licensed optometrist at Allina Health Inver Grove Heights Clinic. Welcome to the show, Dr. Johnson. Tell us a little bit. What exactly are dry eyes?

Dr. Carol Johnson (Guest): Dry eyes is a broad term used to include scratchy, gritty, and a bothersome feeling that can be caused by a myriad of conditions.

Melanie: What would the symptoms -- would it feel like you had something in your eye all the time? Would it feel scratchy, gritty? What would it feel like?

Dr. Johnson: The most common symptoms are a scratchy feeling in your eye, as if something’s in there that doesn’t belong. And occasionally it can interfere with the vision.

Melanie: If you rubbed your eyes when you’ve got that feeling, can that be damaging when you’ve got that feeling like there’s something gritty or something like sand in your eyes?

Dr. Johnson: The feeling of the scratchiness or the uncomfortable feeling comes from the corneal nerve. When they are being replaced, as they are weekly, sometimes scratching it just kind of fast forwards that replacement process. It often doesn’t cause a problem, but if the cornea is fragile, it can cause an abrasion.

Melanie: Nothing is more painful than a scratch on the cornea.

Dr. Johnson: Exactly.

Melanie: I’ve had one, and if you’ve ever had one of those, you even look to the left or the right, and pain shoots through your head like somebody stuck a knife in there. Who really is at risk for dry eye?

Dr. Johnson: The most common demographic is in the elderly and in women. However, people who have had LASIK surgery or have autoimmune diseases, such as thyroid disease or rheumatoid arthritis, patients on hormone therapy or antidepressants or they have some eyelid abnormalities, or contact lens patients who overwear their contact lenses can develop that corneal process that can be described as dry eye.

Melanie: Why would those hormonal changes -- and certain women of a certain age or the autoimmune disorders that you mentioned, why would those contribute to dry eye?

Dr. Johnson: There’s a few different schools of thought. Females from the age of 24 to 48 can often have some fluctuating messages from the thyroid piece, and that can cause the dry eye. The autoimmune diseases often have a predilection for females, and the answers are not really super clear as to why that happens. But they also can have issues if they are on some hormone therapy, like birth control pills or hormone replacement therapy.

Melanie: How do you diagnose somebody with dry eyes? Is there some kind of test that you can do that says, yes, this is a bit of a chronic condition with you?

Dr. Johnson: Some of the signs of dry eye are most easily diagnosed well in an eye exam under microscopic evaluation. A drop with some tint is put in to check and see if the cornea is smooth like an apple peel or if it’s dimpled like an orange peel. That dimpling can be a sign that the cornea is not lubricated enough. The best way to have that evaluated is by your eye health practitioner under the microscope in an exam room.

Melanie: You can just look under the microscope right at their eye and see and if there’s those dimpled or other signs, then you can tell. Now, Dr. Johnson, with all the computers and screen time we are in these days, is there correlation between the amount of time we spend in front of a screen and dry eyes?

Dr. Johnson: One of the studies that discuss these two concepts has shown that with prolonged screen use, there is a decrease in the blink rate. And the blink rate lubricates as well as sort of replaces some of those surface layers on the cornea. The best thing to do with excessive screen time is to take a break, remember to blink, and keep in mind that everything in moderation.

Melanie: Absolutely. You don’t want too much screen time for your eyes. Now, how do you treat it when you’ve diagnosed somebody with it? What can they then do about it?

Dr. Johnson: There are four categories, usually: artificial tears—and they can be preservative-free if people have a reaction to the preservatives—ointments, oral therapy—sometimes fish oil can be a preventative component in modulating inflammation—as well as punctal plugs. And there are some really surface surgeries that can be used in extreme circumstances.

Melanie: Dr. Johnson, how long do these treatments work if you’re talking about something topical, like artificial tears or ointments? Do you have to keep taking these things for the rest of your life? Is this something that goes away? Are you going to be one of those people? I’ve seen those people sometimes with the artificial tears, and they keep blinking them in their eye all day long. Is it something that you…?

Dr. Johnson: Yeah, it’s a very chronic condition oftentimes. The cornea is the clear window in front of the iris or the colored part of the eye, and it is perpetually replacing itself. Each week, we get a new cornea. The chronic nature of the usage is because we get a new tissue that is suffering each week, based on how the process started. If it is because there is a contact lens solution reaction, sometimes those artificial tears can be short-lived. If the reason that the dry eye exists is because of autoimmune diseases, that is a lifetime and chronic issue to pay attention to.

Melanie: I’ve heard about a prescription currently in the market called Restasis. Tell us a little bit more about it.

Dr. Johnson: Restasis is an eye drop that is prescribed two times a day for several months, usually through the life of the disease. It requires a daily commitment, and it’s about six to nine months before the maximum medical benefit is received. It’s common in patients to have underlying autoimmune disease—for instance, rheumatoid arthritis. The stem cells around the cornea that help make the cornea have a little hiccup, and so Restasis actually addresses a little bit of the hiccup on how the lacrimal system or the system that makes tears rebuilds itself. It takes several months for the maximum medical benefit to be achieved. It does require commitment as twice-a-day eye drops. It is a commitment for the patient, and it is a responsibility for the person that is trying to make that better.

Melanie: In just the last minute or two, Dr. Johnson, give us your best advice, please, on people suffering with dry eye and what they can do about it, and possibly even ways to prevent it.

Dr. Johnson: I’d like to have people know that artificial tears can be helpful for the short term. They don’t affect the distance vision to the degree that ointments can. Ointments at night can be very helpful. Taking fish oil for the long haul can help with the inflammatory piece of this process as well as in your body. Restasis is an option for folks that are having vision problems as it relates to their dry eye issue. Talk to your healthcare provider and talk to your eye doctor, because eyes should always be white and pain-free.

Melanie: Thank you. That’s great information, Dr. Carol Johnson. 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, and have a great day.
Hosts Melanie Cole, MS

What Causes Swallowing Problems?

Additional Info

Segment Number 5
Audio File virginia_health/1442vh5e.mp3
Doctors Daniero, James
Featured Speaker Dr. James Daniero
Guest Bio Dr. James Daniero is a board-certified otolaryngologist – head and neck surgeon who specializes in caring for patients with voice and swallowing conditions.

UVA Otolaryngology – Head & Neck Surgery
Transcription Melanie Cole (Host): Swallowing is complex, and a number of conditions can interfere with this process. What are the most common causes of swallowing problems, and what treatments are available to help? My guest today is Dr. James Daniero. He is a board certified otolaryngologist, head and neck surgeon, who specializes in caring for patients with voice and swallowing conditions. Welcome to the show, Dr. Daniero. What are the most common causes of swallowing problems?

Dr. James Daniero (Guest): First of all, thank you, Melanie, for having me on the show. The most common cause of swallowing problems typically happen to the elderly population, and that involves stroke, neurodegenerative diseases such as Parkinson disease, dementia, and ALS or Lou Gehrig’s disease. That can be also a consequence of radiation for treatment of other disorders, primarily head and neck cancer, as well as neck surgery or neck trauma.

Melanie: Okay. So these things that are happening in the elderly and because of diseases, you have explained to us the people that are most likely to be affected. How do swallowing problems affect the quality of life, and what might signal that this is actually happening? Because sometimes we all feel, Dr. Daniero, a little lump in our throat or we have trouble getting something down. What distinguishes this to something that would say, “Okay, you need to see the doctor about this”?

Dr. Daniero: Sure. Quality of life is a huge issue for patients with swallowing disorders, and the particular signs that this is becoming a more significant problem that needs evaluation by someone who treats swallowing disorders would be weight loss or recurrent pneumonia. Those type of things are really the most severe consequences of swallowing disorders. Now, it is very common for patients to complain of difficulty swallowing with a lump in their throat, and if that’s persistent, if that is a recurrent problem, then that would also warrant evaluation.

Melanie: How is this diagnosed? What do you do to diagnose a swallowing problem?

Dr. Daniero: I think the primary thing, the best thing I have to look at swallowing problems is talking with the patient. It’s just getting a good -- what we call a history, the onset and the type of symptoms. When I talk with patients, I ask them what kind of foods are they having trouble with and what particular situations do they describe that they’re having trouble swallowing in. That really narrows me, and primarily there’s two different types of swallowing disorders. One is swallowing disorders related to liquids, and that’s a whole different set of problems than those related to solid food, such as meats or bread that people will complain of difficulty with.

Melanie: If you’ve diagnosed somebody with one of these swallowing problems, what treatments are available out there?

Dr. Daniero: There is a number of different causes for the swallowing problems, but treatments can be broken down into a couple of main categories. One is a medical and therapy treatment, and that is why I actually work along with a speech pathologist in clinic, and we can often provide some of that treatment right in the same day as the visit. And working with the speech pathologist, there can be different maneuvers as far as swallowing that can assist them in their swallowing trouble as well as modifying the diet to different consistencies—thickened liquids or softer, pureed type food, and different conservative things. The other category, the main category and what I am typically involved in, when the speech pathologist isn’t able to make the adjustment for a safe swallow, then it becomes a surgical option. I perform endoscopic surgeries, and that’s all through the mouth without incisions in the neck and usually a faster recovery. If they’re not candidates for the endoscopic approach, then I also perform an open surgery with the incision through the neck to address some of the swallowing disorders.

Melanie: What is that surgery like? People would hear about swallow surgery and get very nervous, get scared. It sounds very scary because this is your ability to eat and to talk, and so it’s really a sensitive area. Tell us a little bit about the surgery.

Dr. Daniero: The newer approaches—and what I am actually a specialist in—is the endoscopic approaches. This is within the past 20 years, we really revolutionized the way we treat swallowing disorders and now have incision-less surgery, a minimally invasive approach. For patients, it typically involves coming into the hospital, spending a night over in the hospital, but going home the next morning, and then, generally with almost immediate relief. It’s relatively limited pain. Most patients complain they have a sore throat, like they had a strep throat or something. Then they are back on to swallowing with usually impressive results.

Melanie: Wow! Is this something that is likely to reoccur? What is the outcome from this type of surgery?

Dr. Daniero: Well, there are certain types of surgery that tend to require more interventions, and those are things such as stretching the esophagus. And many people come in saying that they have had gastroenteritis or other doctor that performed the stretching of their swallowing tube. That often will require repeated dilations, if you will, or repeated stretching in order to have a long-lasting benefit. The surgeries that I particularly specialize in are where I use a laser and I actually cut muscle fibers that produce the swallowing dysfunction tends to be a permanent result.

Melanie: Wow! That’s incredible. Now, what is then the eating outcome? Do they have to be on those thickened liquids for the rest of their life? Is there a possibility of needing a feeding tube? Or, can they resume eating certain foods and solids?

Dr. Daniero: Well, depending on the problem, the people that are generally surgical candidates from the procedure that I was talking about typically have trouble with the solid food. They’re in that category primarily. Those patients can mostly resume a normal diet, and those are my favorite patients to see after surgery because they come in and they are just so happy that they can resume a normal life. They can go out to eat again with their family members for Thanksgiving and other holidays. They now can enjoy the social interaction. And this is an at-risk population for depression, too. They are usually 65 and older. Half of this age group, half of Americans 65 and older will have swallowing trouble. Therefore, when we can restore the ability to eat, it restores a lot of their ability to have social interactions, and they are at risk for depression as a result of socialized isolation. We can cure that.

Melanie: That’s amazing. In just the last minute or so, Dr. Daniero, why should patients come to UVA for treatment of their swallowing problems?

Dr. Daniero: Well, one thing for patients to look for when they’re evaluating a place for possible treatment of their swallowing problem is to look for someone who is a fellowship-trained laryngologist. That’s some of the training that I received. That is an otolaryngologist or ear, nose, and throat doctor that specializes in voice and swallowing and has special training regarding that. There’s only a handful of providers in the state of Virginia that provides this service and have this designation, of which UVA is one of them. We also have a team approach to swallowing disorders, and I have a voice and swallowing specialized clinic, at which I work with a speech and language pathologist. We can perform some of the swallowing evaluation right in clinic on the same day. We can even perform in-office surgeries for swallowing disorders, where the patient doesn’t have to be admitted to the hospital and they can come in and out without -- they can even drive themselves to their own appointment to have these procedures because there’s no sedation or anesthesia other than just numbing the throat.

Melanie: Wow! Thank you so much, Dr. James Daniero. For more information, you can go to uvahealth.com. That’s uvahealth.com. You’re listening to UVA Health Systems Radio. This is Melanie Cole. Have a great day.
Hosts Melanie Cole, MS

Surgical Options for Stroke Patients

Additional Info

Segment Number 4
Audio File virginia_health/1442vh5d.mp3
Doctors Crowley, Webster
Featured Speaker Dr. Webster Crowley
Guest Bio Dr. Webster Crowley is a neurosurgeon whose specialties include endovascular and cerebrovascular surgical procedures for conditions such as stroke.

UVA Neurosciences: Brain & Spine Care
Transcription Melanie Cole (Host): If you or a loved one has suffered a stroke, for select patients, surgical procedures may aid in treatment and recovery. Who can benefit from these procedures? My guest is Dr. Webster Crowley. He is a neurosurgeon whose specialties include endovascular and cerebrovascular surgical procedures for conditions such as stroke. Welcome to the show, Dr. Crowley. First, can you briefly describe what is a stroke?

Dr. Webster Crowley (Guest): Sure thing. There are two types of stroke that most people think of, and the first one is something called an ischemic stroke, which is essentially a cut-off of the blood supply to a portion of the brain. That tends to be what most people think of. And then there’s also something called a hemorrhagic stroke, which effectively does the same thing, but it’s a bleed in the brain rather than a cut-off of blood to the brain. These can manifest as a number of symptoms, and it really depends on where the stroke is. So it’s difficult to determine when someone is having symptoms whether it’s a stroke caused by a cut-off of blood or by a bleed itself.

Melanie: What are the most common symptoms? Because stroke, time is absolutely essential in treatment and management of this disease. What are the main symptoms that somebody might notice that would really send them to the hospital as quickly as possible?

Dr. Crowley: The main symptoms tend to be focal neurologic deficits, such as weakness on one side of the body or speech difficulties. And again, that will depend on where it is. You also can occasionally have people with severe headache, particularly for the hemorrhagic type of stroke, and again, you can have anything you can imagine really be a symptom. But the main ones are the weakness and the speech difficulties, and sometimes someone becomes less conscious and not alert.

Melanie: Why is it so important to get to the hospital that quickly if you feel or if a loved one is suffering a stroke?

Dr. Crowley: Well, there are a number of reasons. First, for the ischemic type of stroke—again, the one where there is a cut-off of the blood vessel—time is really of the essence because we have medications that we can give intravenously, but those are only typically available within four and a half hours of the time of the symptom onset. For the surgical options that we have for the ischemic stroke, typically we need to get to it within eight hours to be able to operate safely. For the hemorrhagic stroke—again, where there’s a bleed, it could be a large bleed that needs to be evacuated surgically. It could be an aneurysm that is ruptured that needs to be treated before it re-ruptures. And so, again, a patient sitting there with thesymptoms isn’t going to know which type of stroke it is, and therefore, the sooner you get in, the more likely it is that we can treat it and hopefully reverse some of the symptoms, if not prevent new ones from occurring.

Melanie: Dr. Crowley, are there particular groups of stroke patients who may benefit from surgery?

Dr. Crowley: There are, in fact. The patients who had the cut-off of the blood vessel but usually by a clot that is clogging off the vessel. The main ones we think about are the patients that are ineligible for the intravenous treatments, which means that they are sometime between the four and a half and eight hour time window after the time of symptoms. Or, if they have another contraindication to the TPA, the tissue plasminogen activator, which is the medicine that you can give IV, those contraindications would be a recent major kind of hemorrhage or often a brain surgery, or perhaps they’re on different blood thinners, which makes giving IV tPA more risky. In those patients, certainly, the endovascular or the surgical treatment for the stroke are an option. For the other types of strokes, the hemorrhagic stroke, the things that we look for is their ability to recover in general from as large of a stroke as it is. The patients who are able to tolerate anesthesia that might need to undergo in order to get the aneurysm treated, or the blood clot removed, certainly. But in general, anyone who comes in with a head bleed is a candidate for treatment. Anyone who comes in with an ischemic stroke, one of these cut-off, is a candidate for surgical treatment if they don’t meet the qualifications for tPA, and occasionally, if they do, if the clot is quite large.

Melanie: Can you describe a little bit about the surgery that a stroke patient might undergo? What can they expect? We’ve heard a lot about heart disease and cardiac surgery. Tell us a little bit about stroke surgery.

Dr. Crowley: Yes, ma’am. When the clot is there present in the blood vessel in the brain -- again traditionally, the medicine that has been the only hope in this is try to break up the clot. We now have a number of what we call endovascular devices where we can go in through an artery in the leg and pass little tiny catheters up and try to remove the clot. Again, that typically needs to be done within eight hours of the time of onset. We are now with the newest devices. There’s one device which is essentially a stent that we open up within the clot and then capture the clot and bring it back, and we suction as well to try to bring the clot back. The latest data suggests that we can get that open between 85 and 90 percent of the time in patients if we get to it in time. Then, of course, there are going to be a small subset of patients that we’re not able to remove that clot. That will cause a stroke or complete the stroke and can cause some swelling in the brain. In that case, as a neurosurgeon, we may have to remove a large piece of the bone in order to accommodate the swelling so that someone can survive their stroke. Lastly, for the hemorrhagic stroke, there are a number of different causes. Again, it can be an aneurysm. It could be something called an AVM, which is an arteriovenous malformation and those have treatments, both endovascularly, where you go into the groin and you either treat an AVM with glue-like material or treat an aneurysm with coils or stents. And surgically, we can remove an AVM or we can put a clip across the neck of an aneurysm. There are a number of options, but again, it depends on what it was that caused the stroke, obviously.

Melanie: What is the recovery period following a surgery to treat a stroke? What are the outcomes? After they’ve had something, whether it’s stenting or something, do they have a risk of reoccurrence of a stroke then? Are they at a higher risk? What’s the recovery like?

Dr. Crowley: They often do have a higher risk. The patients who have the blood clot that is within the blood vessel, there is often something that sent that clot to clog up the blood vessel, and often it’s a narrowing in the artery in the neck. It could be narrowing in the artery of the brain. So treating the stroke itself—meaning, getting that clot out—it doesn’t often end the chance of it happening again. For those patients, they may need, again, either stents in the neck to open up the narrowing which has caused the stroke, or sometimes a surgery called a carotid endarterectomy. The aneurysm ones, recovery from a bleed hemorrhagic stroke tends to be longer because the blood itself irritates the brain. Again, if we are able to successfully remove the clot within the blood vessel, you can see a pretty rapid return of function. Some people go home within a matter of two or three days. For the patients who have a completed stroke, it’s a longer course, certainly, that often needs a rehab. Again, for an aneurysm that’s ruptured, the recovery -- we often keep patients in the hospital for two weeks just to manage other possible sequelae that they run into.

Melanie: Dr. Crowley, why should patients come to UVA for their stroke care?

Dr. Crowley: Why? I think the University of Virginia has excellent experts in pretty much anything that you can think of, and I hope that you gathered from the things I was talking about that a stroke can be caused by a number of different things. There are a number of hospitals that may have the medicine to give the tPA in order to break up a clot, but they may not have the ability to operate on aneurysm or ability to operate on a large hemorrhage. Other places may have some but not the other. At University of Virginia, we have everything possible. My medical and surgical colleague, Dr. Kenneth Liu, and I are both neurosurgeons that do both endovascular and cerebrovascular, meaning that we can do the stent or we can do the surgery, either the endarterectomy or the clipping of the aneurysm. And the old adage that if the only thing you have is a hammer, everything looks like a nail, I think being able to do both of those or all of those eliminates a great amount of bias. And at University of Virginia, we have a number of people who are trained in a lot of these different things, and so we can tailor the treatments. We have a number of radiologists, we have a number of cardiothoracic surgeons, cardiovascular surgeons, neurosurgeons, that all treat different aspects of stroke. We have a great neurology team. Again, there are other centers in the country, certainly, that have everything. There are a lot of centers that don’t. I think when you’re looking to find -- like I said, when a patient has a stroke or has symptoms of a stroke, they can’t determine whether it’s a blood clot in the artery or a large hemorrhage on the brain. They just know their symptoms, and so I think it’s best to go to a place that has a capability of treating every single one of those, no matter what it turns out to be.

Melanie: Thank you so much, Dr. Webster Crowley. For more information on UVA neurosciences, brain, and spine care, you can go to uvahealth.com. That’s uvahealth.com. This is Melanie Cole. You are listening to UVA Health System Radio. Thanks so much for listening, and have a great day.
Hosts Melanie Cole, MS

Head and Neck Cancer

Additional Info

Segment Number 3
Audio File virginia_health/1442vh5c.mp3
Doctors Jameson, Mark
Featured Speaker Dr. Mark Jameson
Guest Bio Dr. Mark Jameson is an otolaryngologist – head and neck surgeon whose specialties include head and neck cancer.

UVA Cancer Center
Transcription Melanie Cole (Host): This year, more than 55,000 Americans will develop cancer of the head and neck. Which are the most common forms of head and neck cancer and what treatment options are out there? My guest is Dr. Mark Jameson. He is an otolaryngologist, head and neck surgeon, whose specialties include head and neck cancer. Welcome to the show, Dr. Jameson. What are the most common head and neck cancers that you see?

Dr. Mark Jameson (Guest): Well, the term “head and neck cancer” is actually a very broad term. We use it to refer to all of the cancers that occur in the head and neck with the exception of brain and eye cancers. That includes cancers of the skin, salivary gland, the thyroid gland, sinuses, and the team at UVA manages all of these types of cancers. But the most common brand of head and neck cancer that we see is the squamous cell carcinoma that occurs in the mouth, that we refer to as the oral cavity, the throat or the pharynx, and the voice box or larynx. As you said, that’s a relatively small number of cancers in the United States every year, but in our practice, because it’s dedicated to head and neck cancer, that’s what we see predominantly.

Melanie: What most commonly causes these cancers, and are any of them preventable?

Dr. Jameson: Well, the biggest risk factor for head and neck squamous cell carcinoma is tobacco use. That’s been well established for a long time. That includes smoking and also chewing tobacco. And we know as well that excessive alcohol use is also a risk factor. While alcohol is not as big a risk factor as smoking, when the two are used together, they’re more than additive, so there’s a synergistic effect between those two things. Classically, our head and neck cancer patient has been a longtime smoker and someone who has used alcohol frequently. However, in the last decade, we have seen the emergence of a new form of throat cancer that is caused by the human papilloma virus or HPV, and most folks are becoming aware of this. The virus is often acquired early in adulthood and then often resides in the tonsil tissue for a long period of time, sometimes decades, before it causes cancer. What’s interesting is that while the incidence of smoking-related head and neck cancers is declining over time, actually, the incidence of HPV-related head and neck cancer is rising steadily. So we’re seeing that change in our practice.

Melanie: Dr. Jameson—because I think this is one of the scarier cancers for people because they think of their ability to talk and to eat, to swallow—what are some symptoms that might scare somebody or send them in to see you?

Dr. Jameson: You’re right. It is a scary cancer. It affects very important parts of our day-to-day life. There are a variety of symptoms, but they tend to depend on where cancer occurs. The cancer usually develops as a mass at what we call the primary site, and that mass sometimes has an ulcer or an erosion that’s very painful. Often, the presentation is, for instance, with an ulcer in the mouth that isn’t going away. Sometimes folks present with a painful or loose tooth that is sort of out of the ordinary for them. If these cancers arise in the throat, the voice box, then often, folks don’t see or feel a mass because they can’t look there. But they might notice pain when they swallow or difficulty swallowing, not being able to eat things that they could eat before. Or they might notice a change in their voice, and sometimes even difficulty breathing or shortness of breath with exertion, more so than their baseline. Cancers in the throat, interestingly, often cause ear pain just on one side because of the nerve wiring in our head and neck. There’s nothing wrong with the ear, but it’s referred pain to the ear. Sometimes we see folks that have ear pain just on one side. Then, as these cancers begin to spread, they will grow in lymph nodes in the neck. Sometimes patients just present with a lump in the neck or something. Maybe they notice when they’re shaving or doing their daily routine that there’s a lump there. Often, it doesn’t hurt, but sometimes it does. Really, any of those symptoms that linger for more than a couple of weeks are concerning to us, and those need to be evaluated.

Melanie: How is it diagnosed, Dr. Jameson?

Dr. Jameson: We diagnose by obtaining a tissue biopsy, and the way we start when they’re just concerned for a lump or a bump or some pain is we do a full physical exam. We look in the mouth and the throat. We feel the neck. And then in our clinic, we’re able to actually, with the patient awake and comfortable, pass a small camera through the nose and down into the throat so we can get an extra look around at the back of the tongue, the throat, the voice box. That allows us to see something that might be of concern. If there’s something of concern in the mouth, often in clinic, we can get a small piece of that tissue. Or if there is a lump in the neck, we can put a tiny needle into that, just with the patient awake in our clinic—a little bit of pain, but not too bad—and we can send that tissue to the pathologist and they can answer the question for us. If it’s something farther back or they’re in the voice box, then we usually have to put folks to sleep in the operating room and do a procedure where we look back there, examine everything, and also get a piece of that tissue to send to the pathologist.

Melanie: If they test positive for one of the head and neck cancers, then what treatments are available? Because again, as scary as these are, there are really innovative treatments out there that can help live this normal quality of life.

Dr. Jameson: In general, as with other cancers, there are really three big options, and those are surgery, radiation, and chemotherapy or medication. Occasionally, we can use just a surgery or just a radiation, but many of these cancers need to be treated with a combination of the two. So often we’ll do an operation to remove the cancer and follow that with some radiation or use radiation and chemotherapy together. Occasionally, we need to use all three for the more difficult cancers. We really work to provide that treatment that not only provides the best chance of a cure but also provides the best chance of preserving function, as you mentioned. Since we breathe, talk, and eat with the mouth, throat, and voice box, we really need to think about how our treatment will impact those functions. We’re really trying to optimize how a patient will function after their treatment. Now, for cancers in the mouth, the treatment of choice usually is to remove those, and often that can involve removing part of the tongue or part of the jawbone, which can be very debilitating. We have developed ways to transfer tissue from other parts of the body to reconstruct those areas. We can take bone from the leg to reconstruct the jawbone or tissue from the forearm to reconstruct the tongue and return a lot of the native function to those folks. Cancers in the throat have usually been treated in the past with radiation and chemotherapy, but a lot of these now, because of HPV, are occurring in younger folks, and radiation and chemotherapy has some downsides in terms of long-term impact on swallowing, risk of secondary cancers, and some other risks. We’re now trying to operate on these if we can. We’re using the da Vinci robot to operate through patients’ mouths and remove these surgically so that we can usually eliminate their need for chemotherapy and often reduce the dose of radiation and reduce the related side effects. For cancers in the voice box, obviously folks want to maintain their voice if they can. We try to use radiation and chemotherapy for those in very creative ways so that folks can keep their voice box, if possible. But sometimes we do have to remove the voice box, and when we do that, we have special valves that we can put in after the voice box is gone to help folks restore their voice. Part of our team specializes in restoring voice and helping folks get back their communication skills if that’s what has to happen. None of these are really a perfect scenario, but what we work at is developing an opportunity to get the patient as much back to normal as we possibly can.

Melanie: Dr. Jameson, in just the last minute or so, why should patients come to UVA Cancer Center for head and neck cancer care?

Dr. Jameson: Well, I think there’s a few big reasons. First of all, this is a fairly uncommon cancer, and yet it’s really what we spend our time doing. So we have a great experience with this illness. We have a team of experts that works in a multidisciplinary way, and we’re able to provide very complete care. We offer a comprehensive array of treatments and surgery, radiation, chemotherapy, as we mentioned, and we have all the folks that are needed to get that done in addition to surgeons and radiation oncologists and medical oncologists. We need speech and language specialists. We need dental specialists, eye care. We need nutrition and pain management, physical therapists, all those things. We have them all here and committed to caring for these patients. As we talked about, we have some exciting advanced treatment options. We have specialty reconstructive skills that really return people to great function. We have an opportunity for minimally invasive robotic surgery, and we have brand new concepts in radiation oncology that are helping us reduce side effects in addition to some new drug trials in the chemotherapy area. Lots of opportunities for folks to get the very most advanced care in the field. Then, I think finally this entire team that takes care of these patients, I know them all well. And while being some of the best docs in the country, they are also committed to a very compassionate, patient-centered care, and I’m very proud of the care that we provide to patients here.

Melanie: Thank you so much, Dr. Mark Jameson. For more information, you can go to uvahealth.com. That’s uvahealth.com for more information on the UVA Cancer Center. You’re listening to UVA Health System Radio. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

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