Inactive (722)

Segment Number 4
Audio File virginia_health/1412vh5d.mp3
Doctors Darby, Andrew
Featured Speaker Dr. Andrew Darby
Guest Bio Dr. Andrew Darby is board-certified in internal medicine, cardiovascular disease and cardiac electrophysiology. He specializes in treating patients with heart rhythm disorders.

Organization: UVA Heart and Vascular Center
Transcription Melanie Cole (Host): What are heart rhythm disorders and what are some of the new exciting treatment advances for heart rhythm disorders. My guest is Dr. Andrew Darby. He is board certified in internal medicine, cardiovascular disease, and cardiac electrophysiology. Welcome to the show, Dr. Darby. Tell us what are heart rhythm disorders?

Dr. Andrew Darby (Guest): Hi. Good morning. Thank you. Heart rhythm disorders are essentially electrical abnormalities of the heart which affect the timing of the heart rate and heart rhythm and they can either make the heart beat too quickly or too slowly. Some are completely benign, but they can cause bothersome symptoms whereas others can increase the risk of stroke and that’s primarily a rhythm called atrial fibrillation which is a very common heart rhythm disorder in adults and still other heart arrhythmias can actually be life-threatening and these are the ventricular arrhythmias which are abnormal rhythms that arise from the lower chambers of the heart and these arrhythmias include ventricular tachycardia and ventricular fibrillation.

Melanie: Typically doctor, treatment for, you know atrial fibrillation as you said is becoming more common. People go on Coumadin and blood thinners, all of these things. What is after that, if those things are not working for them? Tell us about some of the new treatment advances for heart rhythm disorders.

Dr. Darby: Sure, so for atrial fibrillation, there are actually a lot of exciting therapies for the patients who have symptomatic atrial fibrillation meaning they feel their heart racing, they feel their heart beating irregularly. We have medications we can use to try to control the heart rhythm to try to keep patients in normal rhythm. We also have procedures that we can do called catheter ablation where we can minimally invasively insert catheters into the heart to identify the areas where the arrhythmia is coming from and basically burn those areas out and eliminate them to try to maintain a normal rhythm. You mentioned Coumadin which is a blood thinner. One of the main risks with atrial fibrillation is that it can increase the risk of stroke. Over the past few years, a number of new medications have been developed as alternative to Coumadin. These medications are nice in that they don't involve any blood testing which Coumadin requires. They tend to be very reliable on how they work that can be very effective and relatively safe. For patients who can't take blood thinners, there are number of new exciting alternatives to protect patients from a stroke. There are procedures that we can do to essentially seal off the part of the heart where clots tend to form and one of those procedures can be done through by inserting catheters into their veins in the leg and one of the procedures can be done actually by accessing the space around the heart and actually sealing off the place where the clots form, so for the patients who can't take blood thinners, those therapies are nice alternative. For other arrhythmias such as the ventricular arrhythmias like ventricular tachycardia, we have a lot of exciting new therapies to treat those as well. There is catheter ablation just like I mentioned for atrial fibrillation. There is a catheter ablation procedure, we could do to treat that as well as implantable defibrillators which are heart rhythm devices that monitor the heart rhythm and restore normal heart rhythm should patients develop one of these life-threatening heart arrhythmias.

Melanie: So, Dr. Darby speak about the subcutaneous implantable cardioverter defibrillator that's a lot to say, but this is a new exciting treatment, so tell the listeners what that is?

Dr. Darby: Sure, so let me first start by talking about the standard defibrillator which up until now has been the only version available, so the previously available defibrillators are systems that we call transvenous defibrillators and what that means is there's not only a defibrillator unit which is something that we implant under the skin in the chest, but there's a wire that we place into the heart to monitor the heart rhythm, so standard defibrillators as we have had available involve inserting one or more wires into the heart and in the way, we implant these devices as we make a incision in the upper part of the chest. The defibrillator device, the actual defibrillator unit, is placed under the skin and then more and more wires are placed into a vein in the upper part of the chest and through that vein, we are able to pass these wires into the heart and traditionally, the wires have been the weakest link or the weakest part of the defibrillator system, so the wires are actually secured to the heart muscle and so they move with each heartbeat and you can imagine if someone has an average heart rate of 70 or 80 beats per minute that's about hundred thousand heartbeats in a day and these devices are supposed to last for years and years and years and decade and that’s a lot of wear and tear and lot of stress on these wires over time and one problem with the standard defibrillator is that the wire can sometimes fracture, can break which can lead to other issues for the patient and so the subcutaneous defibrillator has been developed as an alternative to this and hopefully will be a more durable device and so the biggest differences I would say between the subcutaneous device and the defibrillators that we have traditionally had are that the subcutaneous device is as the name implies, completely subcutaneous, so it does not involve placing anything inside the bloodstream or anything inside the heart. The way we implant it is we make a small incision on the side of the chest for the defibrillator unit to fit in and then two smaller incisions are made along the left side of the breastbone and those smaller incisions are what we use to actually implant the wire that’s attached to the defibrillator, so there is a wire just like we have with standard defibrillators, but this wire is just subcutaneous, it’s just under the skin. That wire essentially is the antenna for the device. That’s how the device monitors the heart rhythm and helps to detect whether the patient is going into a dangerous heart arrhythmia.

Melanie: That is so cool Dr. Darby. Who is a candidate for this?

Dr. Darby: It’s a good question. I think anyone being considered for a defibrillator is a potential candidate for subcutaneous device. I think anyone who has had, has blood vessel problems where we might have difficulty accessing the heart or placing the standard transvenous leads into the heart, it would be a good candidate for subcutaneous device. Patients with infectious issues, if the patients have had bloodstream infections or have had recurrent bloodstream infections, we don't want to implant something in the body that could potentially become infected, so the subcutaneous device is out of the bloodstream, so it's nice in that regard. I think especially for young patients, patients who might have the device for years and years and years for decades, with them the subcutaneous device is going to be much more durable because we don't run to the issues with the lead or the wire or the antenna fracturing. I think one thing that should be emphasized is who might not be a candidate for the subcutaneous device, so one limitation of the subcutaneous device is that it cannot function as a pacemaker, so the standard defibrillators that involve the wire going into the heart like I mentioned, those devices can also be pacemaker, so for patients who have a slow heart rate, who also require cardiac pacing, meaning they require some assistance to the device to maintain a normal heart rate to speed their heart rate up, that cannot be done with the subcutaneous device, so the patients who require both a defibrillator which would protect them from life-threatening arrhythmias and the patients who require a pacemaker, patients who require both would be better served by the standard defibrillator. Patients who don't require any pacing assistance would be perfectly fine with the subcutaneous device.

Melanie: Dr. Darby and just the last minute please, why should patients come to UVA for heart rhythm diagnosis and treatment?

Dr. Darby: Very good question. I think every patient should come to UVA, but I'm biased. I think we have very well-trained, highly experienced staff both as far as physicians as well as our non-physician staff to support us in these procedures. The University of Virginia was actually the first hospital in the State of Virginia to have an electrophysiologist about 30 years ago, Dr. John DiMarco and we have grown and grown and grown our program over the past few decades and we have the most experience of any program in the state. We have done thousands and thousands and thousands of catheter ablation procedures and device implants and I think that experience matters and another nice thing about being a University Academic Medical Center is that we often have exposure and are given access to these new technologies sooner than other hospitals are and so, we will be the first hospital in Central Virginia to be implanting the subcutaneous defibrillator and we will all have access and do have access to other ablation technologies and other device technologies that other hospitals don't have and so I think for those reasons the experience and the access to new better technologies, I think these are some of the big reasons to come to the University of Virginia.

Melanie: Thank you so much. That's great information. You are listening to UVA Health System Radio. For more information, you can go to uvahealth.com. This is Melanie Cole. Thanks for listening.
Hosts Melanie Cole, MS

Providing Cancer Care for Older Patients

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Segment Number 3
Audio File virginia_health/1412vh5c.mp3
Doctors Ramsdale, Erica
Featured Speaker Dr. Erika Ramsdale
Guest Bio Dr. Erika Ramsdale is a board-certified specialist in internal medicine and geriatric medicine who specializes in geriatric cancer care.

Organization: UVA Cancer Center
Transcription Melanie Cole (Host): For patients aged 65 and older with cancer, there are some unique challenges these patients and their caregivers face. My guest is Dr. Erika Ramsdale, she is a board-certified specialist in internal medicine and geriatric medicine who specializes in geriatric cancer care. Welcome to the show, Dr. Ramsdale. What is geriatric oncology?

Dr. Erika Ramsdale (Guest): Well, thank you very much for having me on, so geriatric oncology is a pretty new field and it combines two different specialties focusing on the care of older adults with a diagnosis of cancer, so geriatric oncologist like myself often have training and certification in both geriatric medicine and oncology.

Melanie: So, what are some of the unique challenges that an older patient with cancer might face different than their younger counterparts.

Dr. Ramsdale: Sure so, as we know, you know, as we age, our physiology changes. I tell patients you don't have the same body at 80 as you did at 20, so we become susceptible to more health problems and that includes cancer. Older adults can be more at risk also for complications from their cancer and from their treatment compared to younger patients, so some are more risk for side effects or they may have other complex health problems affecting them, for example, they may have a mobility issue that makes getting back and forth to the clinic difficult, so I think determining the right treatment plan is sometimes not easy and really requires thinking about the whole person, not just the cancer. On the other hand, I would say aging doesn't happen at the same rate in everyone, so age really is just a number, some healthy and fit older adults are not offered treatment for their cancer because of their age and this is unfortunate because some might really benefit.

Melanie: Well and as you mentioned that they might have other medical problems in addition to cancer, whether it's mobility issues, arthritis, or you know any of these things, they also might not have as easily access to transportation and social support, that sort of thing, so what are some important things that caregivers of these geriatric and elderly patients need to know.

Dr. Ramsdale: The caregivers are critical parts of the cancer care for older adults. They are really important to all patients going through cancer treatment, though maybe especially for older adults and especially as you mentioned for those with complex health problems, mobility problems, memory loss, and things like that, there's a lot of accumulating data that our social support structure is really critical for these patients and does affect the outcomes of treatment in older patients to a very significant degree. On the other hand, caregiving can be really tough on the caregiver and so I would say, he or she needs to know how to access health, so I always encourage patients to have their caregivers present at clinic appointment, so that they can ask questions about what to expect. I also strongly encourage all my patients really at any age to talk about their wishes and goals with their primary caregivers and to also designate a power of attorney for healthcare in case they become unable at some point to make decisions for their healthcare. This really helps the caregivers be better advocates for the patient and especially for older patients if something unexpected happens or the end of life.

Melanie: I think it's also important that the caregivers help with that advocacy because a lot of time, you know, the hearing is even an issue, so that the elderly patient can't even hear the doctor’s instructions or hear their prognosis, you know, those are the kinds of things that that advocate, that caregiver is so important. Now, where do emotions come in Dr. Ramsdale, can depression for example affect treatment and outcomes?

Dr. Ramsdale: Yes, most definitely. There is a lot of data that problems with mood including depression can significantly impact outcomes for cancer patients.

Melanie: And what about the risk factors for elderly patients like their susceptibility to falling maybe if treatment gives them a little bit of nausea, something that they're not that used to. What do you tell them and their caregivers to watch out for?

Dr. Ramsdale: Well, I think you point out that it's true that, you know, older adults have less what we call reserve, so things that might not bother younger patient or might not push them into a serious situation can be sometimes very serious for older adults, so I tell them to speak up and the caregivers to speak up if they experience any side effects because we need to react quickly in many cases to prevent complications like falls which can obviously be very devastating.

Melanie: Where does nutrition play a part in treatment for cancer care for older patients?

Dr. Ramsdale: Well, as you are going through cancer treatment, I always encourage my patients to maintain their weight as much as possible. Often patients have weight loss and then in older patient, they predominantly lose muscle mass when they lose weight and this actually increases the risk of mobility problems, and to falling, and other, you know, adverse health outcomes, so the role of nutrition is particularly important for older adults.

Melanie: Do you like to, you know, recommend some of the nutritional supplements, cans and things that are out there to help them keep up that nutrition while they are going through treatment?

Dr. Ramsdale: I do. I think a lot of patients are obviously scared by a diagnosis of cancer, so they really want to make some changes in their diet, but I tell people the most important thing going through cancer treatment is to again maintain your weight, so that is calories and that is protein, so certainly I often recommend shakes like, you know, Ensure Boost, some of the calories supplementing shakes because these are sometimes easier especially when someone has a lower appetite because of their treatment or because of the cancer, so yes this is something I often recommend.

Melanie: Now doctor, one of the things that kind of goes along with being older and then also having cancer is that you are on so many medications for these other things. How do you work with the patients and the medications that they are on for blood pressure or diabetes or their arthritis or any number of things and what they're going through for their cancer care?

Dr. Ramsdale: Yes, so you are right, older adults are often on many medication for other health problems and also older adults metabolize drugs differently, so I always do a very detailed review of their medication list, what they're taking and how they're taking it and look at potential interactions between those medications and also potential interaction with the cancer treatment itself, so these are very important things to be aware of and their actually criteria out there to help us look at these medications and decide how we should be tailoring therapy.

Melanie: Well, it's such a wonderful field that you're in, this new burgeoning field and tell the listeners why geriatric cancer patients should choose UVA for their care.

Dr. Ramsdale: Well, at UVA, we just started the Geriatric Oncology Clinic, it’s located in the Emily Couric Clinical Cancer Center where the cancer patients receive most of their care, so in that clinic, I am the physician there and we see patients on the request of their treating physician and so the patients can get referred to the clinic for a variety of reasons, not just advanced age because, you know, they have additional concerns about some other conditions we have been talking about and so we do a comprehensive assessment of the older person's functioning, not just their physical functioning, but some of the domains that we have talked about like cognitive status or social functioning, emotional functioning, how their nutrition is. We look at their other health problems in depth and we review their medications as I mentioned and their potential interactions with cancer treatment that allows me to give an individualized summary and recommendation back to the treating physician and this helps with decision making for the patient. For example, what's the right cancer therapy for them, are they likely to tolerate this therapy, what’s likelihood of significant side effects, you know, how will the cancer impact other health problems and these are obviously very important questions in an older adult, so I would say UVA contributes, this is not a clinic that is available at a lot of other sites. Obviously, a diagnosis of cancer requires really multidisciplinary expertise with experts from different fields working together for the patient and UVA, I have really seen how successful the experts are in individualizing care and I've been really impressed by how motivated my colleagues are to work together to find the best plan for the patient because this is what really leads to excellent care, so we have not only the geriatric oncology clinic, but excellent supportive care services, palliative care experts, social workers, nutritionists, physical therapy and I think we really offer comprehensive care for older patients and this is really what we need to ensure the best outcome.

Melanie: Thank you so much Dr. Erika Ramsdale. You are listening to UVA Health Systems Radio. For more information, you can go to uvahealth.com. This is Melanie Cole. Thanks for listening.
Hosts Melanie Cole, MS

The Benefits of Breastfeeding

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Segment Number 2
Audio File virginia_health/1412vh5b.mp3
Doctors Kellams, Ann
Featured Speaker Dr. Ann Kellams
Guest Bio Dr. Ann Kellams is a board-certified pediatrician and director of UVA’s Breastfeeding Medicine Program.

Organization: UVA Children’s Hospital
Transcription Melanie Cole (Host): Breastfeeding has been shown to be the best option for both newborn and their moms. My guest is Dr. Ann Kellams, she is a board certified pediatrician and director of UVA’s breastfeeding medicine program. Welcome to the show, Dr. Kellams, tell us a little bit for newborns, what are the health benefits of breastfeeding.

Dr. Ann Kellams (Guest): Thank you for having me. I think the first thing to know is that human milk is really perfectly designed for human babies, it is different than cow’s milk or goat’s milk or squirrel’s milk, any other mammal and so there is no question that a baby getting its mother milk has added health benefits or may be that is the norm and may be wish to think about that what are the risks of not using breast milk. Babies who breastfeed tend to have lower infections and that is because their mother as they are exposed to the environment or making antibodies specific to what the baby sees, they also have lower rates of sudden infant death syndrome, probably because babies are supposed to be close to their moms, feeding frequently but that elegant cueing system where the baby shows a little sign and the mother responds, they sleep differently, there is even long term effects such as lower rates of diabetes type 1 and type 2 later in childhood, all kinds of good stuff.

Melanie: So, Dr. Kellams, other than the bonding which is so wonderful for mom and baby, what are some of the benefits of breastfeeding for the new mom.

Dr. Kellams: Yeah, so for the new moms, it has been shown that if you breastfeed, your rates of breast cancer are lower, your rates of ovarian cancer are lower and then there are some immediate postpartum effects such as lower rates of postpartum depression which you mentioned, less blood loss, so less of that bleeding after delivery and moms do get down to their normal size more quickly after delivery.

Melanie: In your role with UVA’s breastfeeding medicine program, what are the most common issues new moms face with breastfeeding because some women, this is not as much as they would like to think, a natural process and for some women Dr. Kellams, it is not always that natural of a feeling right off the bat, is it.

Dr. Kellams: I agree with you. I think that when I think about that breastfeeding is natural, I have to remind myself that a lot of things that we do in the hospital as part of our routines for, you know, preserving safety and health during the birthing process are not natural and so, it used to be routine that you would have your baby and then it would be whisked off to a warmer or to a room down the hall called the newborn nursery where they were supposed to live but they can come out and visit mom and so all of these kinds of separations and interventions, medications that mom get, IV fluids serve for the purpose and have helped us to make the birthing process safer but on the backend, it can make the establishment of this natural feeding patterns unresponsive, a little more tricky so. One of the things we do in the clinic is meet with women prenatally, particularly if they have had trouble breastfeeding another child or they are worried or they have a particular medical condition or medication they are taking that might put them at more risk of having trouble right away. We see a lot of moms for reassurance about supply, so we do a full exam of the baby, we look at the weight pattern, we look at that output pattern and try to come up with a plan for her to either increase her milk supply or reassure her that things are going well because it is really hard to know would you have not done this before. We work on latch and sometimes the baby is doing something funny with its tongue or with its lips or not get on deeply enough, really trying to make sure that both mom and baby are comfortable because generally, a painful latch which you hear so much about seems so common, really is an indicator generally that the baby is doing something on the front or shallow or the angle is such that the nipple is really rubbing the tongue that we try to help fix that because really a deep comfortable latch is what we are going for. The other thing we do is work with moms either when the baby has been premature or may be ill in the hospital, so there has been a separation or a medical condition that prevented them from getting it going and so then we can help them to, on the backend, get the baby back to the breast. Sometimes, that takes a couple of days and depending on the issue, sometimes it takes a couple of weeks but usually its possible.

Melanie: So, Dr. Kellams, as you address all of these issues with new moms, how do you help them set up a breastfeeding routine because that becomes something that does help them adjust much more easily getting into that routine, looking forward to it.

Dr. Kellams: Yeah, well and I think that part of helping them is helping them to realize that if you don’t feel like you are pro at this until it has been a few weeks because newborns are sloppy and sleepy and they forget what they are doing and they move their arm in the way and so, you kind of need the no going into it that it is going to feel very hit or miss and for women in our society are used to kind of having it altogether and that can be really tough, it is the first time for many in years that they have not been able to call the shots about their life and so we really focus on the interaction between the mom and the baby and getting teaching the mom what the little subtle feeding cues are or how to maximize the effectiveness of a certain feeding if the baby thinks they are done and you do a little hand expression and then they kind of wake up and get more interested or may be it is time to burp or change the diaper and finish that diet or something like that, so a lot of paying attention to what the baby is showing and paying attention to mom’s body because moms can get used to telling oh wait, I’m empty, that was a great feeling, you know, versus ha, this is then go very well, so I am going to be watching you and the next time you stir, we have got to finish that, so we do a lot of kind of getting to know that baby and seeing how they interact and seeing how we can help them get into a groove.

Melanie: And how do you help the family and even the father get involved with this bonding, how can the father and the family be involved as well.

Dr. Kellams: Yeah, that is a great question because so many women will say something like well, I do want to breastfeed but I want the dad to be involved. There are so many things that dads, partners, grandparents, helpers can do. In the first few weeks, the baby is going to have Brazilian diapers, mom is going to need to rest when the baby is resting, so that means anything like laundry, cooking, cleaning, answering all the myriad of phone calls that are coming in, can all sort of handled by them and then right after a feeding when moms kind of get in back together and may be needs to go to the bathroom or something, the baby will often be sleepy and that is a great time for grandma or dad to hold and snuggle the baby and other really great thing for newborns is that as I mentioned they do sometimes fall asleep at the breast but they are not quite done so that is a great time to hand the baby off to one of those people that kind of be like, hey what are you doing and may be burp or may be change the diaper to kind of make them stir a little bit and then hand them back to mom to finish the feeding, so it is definitely a team effort. Mamma has the good, good milk that her body is making but that only happens for, you know, if you add it up an hour or two out of the 24 hours of the day, so lots of ways for people to get involved.

Melanie: So, there are so many ways and it is so helpful to the mom and to the baby if everybody else is involved in just the less 30 or 40 seconds if you would Dr. Kellams, tell us why families should choose UVA for their pediatric care.

Dr. Kellams: Well, I think UVA has come a long way in the past seven years in terms of really looking at the evidence of what helps moms successfully achieve their feeding plans and implementing those changes, so babies that are born at UVA go right to mom’s chest and they stay there until the first feeding is accomplished. We do not have a room called the newborn nursery anymore and only would separate mom and baby for a medical procedure or indication and now for the past two years, we have had a breastfeeding medicine program whether you are in the surgical ICU as a mom with a baby at home or your baby is readmitted to the pediatric floor or you are just home and having trouble, we have a way for you to see a lactation and a consultant pediatrician for help and so kind of comprehensive from prenatal all the way through to being home and at work, we have designed a program to help and we have not really advertised and it is all word of mouth and people are coming because this is feeling a need that previously was not addressed.

Melanie: Thank you so much Dr. Ann Kellams, sounds like a wonderful support system. You are listening to UVA Health Systems Radio. For more information, you can go to UVAHealth.com. This is Melanie Cole, thanks so much for listening.
Hosts Melanie Cole, MS

How Does a Living Donor Liver Transplant Work?

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Segment Number 1
Audio File virginia_health/1412vh5a.mp3
Doctors Pelletier, Shawn
Featured Speaker Dr. Shawn Pelletier
Guest Bio Dr. Shawn Pelletier is a board-certified surgeon and surgical director of liver transplantation at UVA.

Organization: UVA Transplant Center
Transcription Melanie Cole (Host): For patients in need of a liver transplant, a shortage of livers available for transplant has long been an issue. One solution for helping address this issue and this shortage is living donor liver transplants. My guest is Dr. Shawn Pelletier, he is a board certified surgeon and surgical director of liver transplantation at UVA. Welcome to the show Dr. Pelletier. How does a living liver donation work?

Dr. Pelletier (Guest): Well Melanie, we start first by identifying a candidate who needs a liver transplant. So, for the most part, people will come forward who have liver disease, if their symptoms are severe enough, we will work towards getting them on the waiting list for a liver transplant, and at that point, we will talk to the candidate about how the waiting list works and their options and whether or not finding a friend or relative to donate part of their liver would be the right step for them. Once we get to that step, then we would bring in the living donor and meet them and talk to them, it sounds like that is going to lead into your next question.

Melanie: So, what are the benefits for the patient first to a living donor versus, you know, another type of donor.

Dr. Pelletier: Right, there are several benefits to the transplant candidate. First of all, the waiting list works pretty well. We are able to get a liver for about 80% of people on the list, what that means is that there’s somewhere close to one in five people who we see who needs a liver transplant never gets one in time and either gets too sick to the point where they are not a candidate anymore or they might die waiting. So, if you have a living donor, you can avoid that risk in a sense you are bringing your own liver, so you are almost, you know, you increase your chances of getting a liver transplant in time. The other is that the way the system works right now is that the sickest person who’s on the list that’s most likely to get the next liver available. So, you have to wait not only until you are sick enough to need a liver transplant but then to the point where you are sicker than everyone else who is on the list before liver comes to you. So, if you have a living donor, we can wait, we can evaluate the candidate, wait till there, at their best that they are healthiest and do it rather than waiting until they are so sick that it’s kind of at the last minute and saving their life at the last minute.

Melanie: And what is this like for the donor and what eligibility requirements do they have to fulfil.

Dr. Pelletier: For the donor, it really starts out with us asking the candidates to talk to the potential donors. If they are interested, they can either call or they can go to a website and give some basic information. For the most part, people who can be potential donors have to be pretty healthy, they have to be an adult less than 55 years old and if they fit and then also be blood type compatible, so as far as matching the organs, matching a liver is one of the easier organs that do as long as their blood types are similar or compatible then we are able to do it. At that point, we would have the donor coming to meet our team, we talk to them about the different risks and the benefits, what’s involved, there is a number of different tests we have to do to make sure that if we could do the surgery safely for the donor and it includes getting a CT scan and an MRI looking at the blood vessels going to the liver, essentially looking to see if we can put the liver into two pieces and that both pieces will work okay.

Melanie: So, what should a potential donor know before making this decision. What is the recovery and the surgery like for the donor?

Dr. Pelletier: For the most part, the donors do relatively well. There is some information that they have to know and part of what we want them to know is the risk to the recipient and why anyone would consider doing this and you know really it’s a pretty big benefit that the recipient is getting that we talked about little bit earlier as far as not having beyond the waiting list and die waiting. The other part though is the risks for them. We can do the donor surgery safely and we can get donors through it somewhere around 99.5 to 99.7% of the time. So, some people come and say, you know, the odds are way in my favour, it won’t happen to me. Obviously, we take even that small risk whenever we operate on someone who’s healthy and doesn’t need that surgery very seriously. So, we let them know that we would only do the surgery if we thought that we could do it safely and that they agree that the benefit to helping their friend or relative is enough for them to get through it. Usually, the recovery is that would come in on the same day of surgery. The surgery itself takes somewhere around five hours for the donor. We watch them in the ICU for one night assuming that everything is going okay, they are usually in the hospital for five or seven days and then somewhere around four weeks, six weeks after the surgery, they come in and say, wow that was kind of a big surgery, but I’m starting to feel better and then somewhere around six to eight weeks after the surgery, they can get back into their normal life. So, in a sense what we are asking a living donor to do is to take two months out of their life to potentially save the life of their friend or loved one.

Melanie: And what happens to the liver of the donor. Does this grow back, people always want to know if now that donor is liver deficient, the liver itself grows back.

Dr. Pelletier: Yeah, it’s an amazing process. So, if you are removing part of a liver for a different reason for cancer or something like that, you can remove up to 80% of a healthy person’s liver and they can survive that and the liver will regenerate and come back. When we do the process for the living donor, we remove up to about 65% of the liver, so really we might take even a little bit more than half of the donor’s liver and give to the recipient. As fast as four or six weeks down the road, both sides of those liver, one in the donor and the one in the recipient will both be somewhere around 90 to 100% normal size again. So, the donor and the recipient don’t grow, if you get the right side of the liver, you don’t grow a left side, it’s just that the right side grows bigger, so you make up the difference, but it’s a pretty amazing thing and then for the most part, donors have normal liver function for the rest of their life.

Melanie: And what are you seeing for the patient when they get a living liver donation, is the recovery process for them a little bit quicker.

Dr. Pelletier: It’s varied a little bit, so that is a part of this. For liver transplant, when you get a whole liver from the waiting list, the liver is little bit bigger, the blood vessels are bigger, so in a sense, the surgery for the surgeon is a little bit easier to do. So, if we had a whole liver that is our preference, when we get a living donor liver, we only get a part of the liver, so the piece is smaller, the blood vessels are smaller, so the chance of having a complication is little bit higher, but on the other hand, we can do it when the patient is not at their sickest and when, you know, they are relatively at their strongest. So, it kind of forms a little bit of a mixture where the surgery is a little bit more difficult to do, but the patient is in better condition. So, for the most part, we do the same as someone who got a liver from the waiting list and what that means is the average person in the hospital somewhere around 10 days, their recovery is, you know, little bit slow for the first two or three months, somewhere around three months, they come in and they say they feel better and then somewhere between six months to a year down the road, they come in and they come in and they booed and even realize how sick I was, I have not felt this good in 10 years, and most of those people who receive a liver are able to go back to living and enjoying their life.

Melanie: In just the last minute Dr. Pelletier, tell us why patients should come to UVA for their transplant care.

Dr. Pelletier: I can tell you the strongest reason is the team approach that we take, that if someone comes in with liver disease or kidney disease, the first approach is to help them to maintain their own organs and to keep those functioning and we really take an approach from the entire patient including, you know, from a social perspective and all those different reasons along with medical and surgical approaches. If it’s needed, we help people get on the list, maintain them on the list until an organ becomes available and then as a team, we really get them through the whole process and back to, you know, normal life.

Melanie: Thank you so much Dr. Shawn Pelletier. You are listening to UVA Health System Radio. For more information, you can go to UVAhealth.com. This is Melanie Cole, thanks for listening.
Hosts Melanie Cole, MS

How to Prevent and Treat Polycystic Ovary Syndrome

Additional Info

Segment Number 4
Audio File virginia_health/1408vh5d.mp3
Doctors Burt-Solorzano, Christine
Featured Speaker Dr. Christine Burt-Solorzano
Guest Bio Dr. Christine Burt Solorzano is a pediatric endocrinologist at UVA Children's Hospital whose specialties include polycystic ovary syndrome.

Organization: UVA Children's Hospital
Transcription Melanie Cole (Host): Polycystic ovary syndrome is a health problem that can affect a woman’s menstrual cycle, hormones, blood vessels and more. My guest is Dr. Christine Burt Solorzano. She’s a pediatric endocrinologist at UVA Children’s Hospital whose specialties include polycystic ovary syndrome. Welcome to the show, Dr. Burt Solorzano. Tell us a little bit about polycystic ovary syndrome.

Dr. Christine Burt Solorzano (Guest): Thank you. Polycystic ovary syndrome or PCOS is disorder where the ovaries of a woman make too much male hormone. It leads to acne, facial hair, and other male pattern hair growth, and also to irregular menstrual cycles. The irregular menstrual cycles mean that women can have trouble with infertility later when they want to start a family. And in fact, polycystic ovary syndrome is the leading cause of inovulatory infertility in women, affecting 46 percent of all reproductive-age women.

Melanie: What are some of the risk factors for PCOS?

Dr. Solorzano: One of the biggest risk factors for PCOS is excess weight, and this is likely related to insulin resistance. Insulin resistance is where your body has trouble using the insulin that it makes and therefore makes more insulin to help keep blood sugars normal. Girls and women with insulin resistance often have dark skin around their necks. That’s when you can tell if you might be at risk for it. And in research studies here at UVA, we found that about 60 percent of girls with obesity already have elevated male hormone levels. This group of girls are at very high risk to go on to develop full-blown PCOS during or shortly after puberty. Other groups of girls and women may have insulin resistance without obesity—those born small or prematurely, daughters of women with PCOS or girls who get early body odor or pubic hair.

Melanie: Are there some symptoms that would send up a red flag and send them to see you?

Dr. Solorzano: The main symptoms of PCOS are signs of male hormone excess, so bad acne or facial hair, especially if they’re having trouble with their periods, very irregular menstrual cycles or missing menstrual cycles.

Melanie: What happens if they are diagnosed with PCOS? What treatments are available?

Dr. Solorzano: The gold standard treatment, even with all our medications that are available, is still diet and exercise, and that’s even if a girl’s weight is normal. That’s because this helps with the insulin resistance that we were talking about. But medications containing progesterone like birth control pills can be helpful because they quiet the ovaries so they don’t make too much male hormone. And also, Metformin is commonly used, especially in girls, because it helps with insulin resistance. And it may be used for women or girls with early signs of PCOS when they’re early in the progression or later if they’re considering pregnancy.

Melanie: Because insulin resistance is such a big part of this, doctor, do we assume, or does this put them at a higher risk to diabetes?

Dr. Solorzano: Yes. Girls and women with PCOS are at higher risk of diabetes, both type 2 and gestational diabetes. And also, other metabolic syndrome kind of problems related to insulin resistance, like high blood pressure, cardiovascular, and problems including heart attack and stroke.

Melanie: And then what about fertility? You mentioned it was one of the leading causes of infertility. How does it affect fertility?

Dr. Solorzano: The reason it affects fertility is because you don’t ovulate during your cycle. So if you don’t ovulate, there’s no egg there to be fertilized. And it can be very hard to get the body to ovulate regularly with PCOS. So Metformin or diet and exercise can help the cycles be more ovulatory, have eggs produced each cycle. But if you’re having trouble and you want to become pregnant, then fertility stimulation treatments, which basically induce ovulation, can also be used.

Melanie: And what if a woman does get pregnant and she’s got PCOS? How does this affect her pregnancy?

Dr. Solorzano: PCOS can affect the pregnancy in that they’re at higher risk for gestational diabetes. They’re also at a higher risk for premature birth or for problems with preeclampsia. So it puts the woman at a slightly higher risk during the pregnancy. It also exposes the baby to higher male hormone levels, and we’re still learning what that means. But we do know that daughters of women with PCOS are at a higher risk of PCOS themselves.

Melanie: What about the emotional effects of PCOS, doctor? Because the appearance factor, you mentioned acne and male hormones and hair on the face. What are the emotional aspects of this?

Dr. Solorzano: Yes. These things can be very hard for girls and women to talk about, but especially teenage girls. You know, to have a teen, it’s hard enough to have normal puberty developing, but to be getting facial hair on top of it can really create a lot of problems with self-esteem, which eventually can lead to depression or anxiety or other problems like that.

Melanie: So what do you do? If it’s your child and they’re exhibiting these symptoms, do you also include a multidisciplinary approach and have them see someone for those emotional effects?

Dr. Solorzano: Yes. So the best treatment for the whole variety of problems that occur with PCOS is to see an endocrinologist or a gynecologist to help with the symptoms of PCOS. But that person should also partner with a primary care provider to help connect the girl into resources for counseling and other support. And also here at UVA, we have a program called Go Girls, which is where girls who have problems with insulin resistance or PCOS or diabetes get together and we exercise. We do Zumba together, and we talk about healthy topics and we also talk about self-empowerment ideas as a support for these girls.

Melanie: Really, what are the most important steps that a woman can take to prevent PCOS?

Dr. Solorzano: The important things to do to prevent PCOS are to keep a normal weight, eat a balanced diet, avoiding fast foods, get lots of fruits and veggies, plenty of water, no sugary beverages, make sure to get at least 30 minutes of exercise every day. Just a 20-minute walk after eating can really help your body use insulin better. Those are the most important things to prevent PCOS.

Melanie: What’s on the horizon? Are there some more advanced treatments, things that we can look for and advances in PCOS?

Dr. Solorzano: At UVA, we’re doing ongoing research to help understand exactly why PCOS starts. We believe that it starts during puberty. And so, by learning more about what causes PCOS, where it starts and how it affects the brain and how it communicates with the ovaries, we’re hopeful that we will be able to pinpoint exactly what and in which girls different treatments can be helpful.

Melanie: Is there an increased risk of cancer, Doctor, if you have PCOS with ovarian cyst, or is that something to be worried about?

Dr. Solorzano: Actually, ovarian cyst and irregular menstrual cycles put you at a slightly lower risk of ovarian cancer, but it puts you at a higher risk of uterine cancer, because the uterus needs an endometrial lining to shed at least a couple of times of year. And if you’re not having that menstrual bleeding, then it can put you theoretically at a higher risk of uterine cancer.

Melanie: Which makes your yearly exams and your visits with your physician even that much more important, correct?

Dr. Solorzano: That’s right.

Melanie: So why should women come to UVA for help with their PCOS and other endocrine conditions?

Dr. Solorzano: UVA has a team of endocrinologists and gynecologists who specialize in PCOS and other endocrine disorders for both children and adults. I think the other important thing is that we use the experiences with our patients to identify which areas of PCOS we don’t understand, and we use those questions to conduct ongoing research to help us understand how to treat girls with PCOS better. And then the other thing that I mentioned is the Go Girls Program. I think it has helped me connect with my patients in a way that I couldn’t in an exam room and has really provided valuable support to lots of girls in our local community.

Melanie: And your best advice, Dr. Christine Burt Solorzano, for women with PCOS, your best advice for dealing with this?

Dr. Solorzano: The best advice for dealing with it is to talk about it with your healthcare providers so that if you’re having bothersome symptoms, you can be referred for treatment. And then the other thing is to know that you’re not alone—it affects a lot of women—and that lifestyle changes, even the small ones can make a big difference in the long-term progression of this disease.

Melanie: Thank you so much. You’re listening to UVA Health System Radio. For more information, you can go to uvahealth.com. This is Melanie Cole. Thanks so much for listening, and have a great day.
Hosts Melanie Cole, MS

Treating Concussions in Children

Additional Info

Segment Number 3
Audio File virginia_health/1408vh5c.mp3
Doctors Jaffee, Michael
Featured Speaker Dr. Michael Jaffee
Guest Bio Dr. Michael Jaffee is a retired U.S. Air Force colonel who joined UVA as a neurologist specializing in concussions and traumatic brain injury following a military career that included service as national director of the Defense and Veterans Brain Injury Center.

Organization: UVA Brain Injury and Sports Concussion Clinic
Transcription Melanie Cole (Host): What are the signs of a concussion, and what should you do
if your child has suffered from one? My guest is Dr. Michael Jaffee. He’s a neurologist specializing in concussions and traumatic brain injury, and he was prior the National Director of Defense in Veteran Brain Injury Center. Welcome to the show, Dr. Jaffee. What is a concussion?

Dr. Michael Jaffee (Guest): Thanks. It’s great to be here. Concussion has been really getting a lot of attention lately. We used to think that concussions require a loss of consciousness following a blow to the head, but we know a lot more now, and we realize that a concussion can be caused by any attack to the head or any force that is transmitted to the brain. And what we see can not only be a loss of consciousness but what we call an alteration of consciousness, and that could be something as simple as seeing stars or feeling dazed and confused for a couple of minutes following such an impact. What we’re really looking at is on the outside of what’s happening on the inside, a transient surge or release of chemicals in the brain caused by that force.

Melanie: What are the most common concussion symptoms? I wonder this both for parents, for the coaches, and even for other athletes that might be, including the buddy system out on the field, that can keep an eye on each other. What is it we’re looking for?

Dr. Jaffee: That’s a great question. The way we think about that is we kind of divide the offenses to three different symptom types or symptom clusters. You can have physical symptoms, cognitive symptoms, or behavioral symptoms. Some of the most common physical symptoms include headaches, dizziness, sensitivity to light, and difficulty with your sleep. Some of the most cognitive symptoms include difficulties with attention or difficulty with short-term memory, and then some of the most common behavioral symptoms may include things like irritability or changes in mood. And people can have one or two of any of these symptoms or different combinations, and people present the symptoms of their concussion differently. But I would say that those are probably the most common types of symptoms that people are going to be causing people problems.

Melanie: Dr. Jaffee, with the equipment today, are we seeing a decrease in the incidence of concussion as we’re hearing more about them? But in sports such as football, they’ve got helmets on. Are these protective? Can parents rest a little easier, or no, not so much?

Dr. Jaffee: I think there’s a combination of things that’s happening, one of which is improvements in equipments, in helmets, and things like that. But I think the most important thing is the awareness that’s going on, and there’s a lot more recognition of this. There’s now more guidance for parents and coaches and teachers and doctors to provide appropriate management for when a concussion does occur to a child or anyone, and a lot of states now have requirements. There’s baseline testing done before season, in some of the organized sports and a whole protocol that’s being done, and we’re seeing that mirrored from the professional level to the NCAA down to the high school and other recreational sports levels, that increased awareness. And so we’re better able to recognize what’s happening and manage it, and by doing that, we’re really preventing long-term problems and really promoting quick recoveries.

Melanie: If you suspect that your child has a concussion, what are the treatments? How is it treated? Do we give Ibuprofen or Tylenol at home, keep a close watch? Do we keep them home from school?

Dr. Jaffee: Well, that’s a great question. First thing we want to do is protect the child from having any other concussions. So if they suffered a concussion in a sports event, we want to remove them from play at that point in time and not send them back to the game that same day. Give them a chance to recover. So what we’ve come up with is really a combination of refresh at least the full day, and then a form of active recovery. And that active recovery is going to be done in a graduated manner. At first, when we see that the symptoms are resolved at rest, we know that sometimes, if you start exerting yourself, that can bring about a headache or dizziness or some of the symptoms you were suffering from. And as part of the recovery process though, to keep that going and prevent recovery from plateauing we come up with an active program in that we sort of return them to activity gradually to see if they can tolerate that, and then we move them up. And we don't really get back to contact activities until they’ve gone through aerobics and other types of exertion showing that they’ve recovered from that. The other aspect you ask about is school, and there’s a similar approach to that, and that should be initially brief, like a day. But then it’s active. So rather than keep someone from school, we want to get someone the benefit of education if they can, start gradually exercising their brains, just as you was gradually exercise your body, and give them accommodations initially that they need a little bit of extra time to take a test or delayed taking exam. But we want them to not stay out of the classroom for too long and start figuring out ways to keep going, because we want to exercise that brain, and that helps promote recovery.

Melanie: When you say exercise the brain, what about things like video games and television? On the day right after a concussion, do you let your child sit there and play video games? Is there any risk to this?

Dr. Jaffee: I think that’s part of the brief rest component, where right away we would want to do things to reduce the stimuli. A couple of things is, especially with the light sensitivity that can happen with concussion and the multiple stimulation that happens with video games, it might be a little bit too much right initially. So I would say for the first day or so to not do that. And then with everything else, we would go with a graduated return, and that starts with watching videos or work on the computer, seeing how that goes, making sure that doesn’t produce a headache or dizziness, and if they can tolerate that for the day, then gradually on up until you get all the way back up to those full video games with all the stimulation that’s involved. So that’s part of the whole model of brief rest and active recovery.

Melanie: During active recovery, when do you know that your child can return to play? If they sustain this concussion during football or even soccer, any of these sports, when do you know they’re safe to return?

Dr. Jaffee: One of the things we do now is we look at a couple of things with that, one of which is if the symptoms that they were having resolved, have those gone away? And if we put them to physical activity, do they stay at bay. They haven’t come back because you’re running or increasing your heart rate. That’s just the one part of the self-report symptom aspect. And then with a healthcare professional who has some training in this, they can do an examination, make sure there’s no subtle signs of any residual injury or damage to the individual. In some cases, we may do some additional diagnostic assessments using some form of cognitive testing looking at how well you perform with your memory, making sure that that looks well and tested well and all those things together really combine to make an informed decision for returning to play and returning to activities.

Melanie: How is the UVA Brain Injury and Sports Concussion Clinic working to improve concussion care, doctor?

Dr. Jaffee: Well, there’s this really an exciting initiative we have at the University of Virginia because it’s truly multidisciplinary. What we’ve done is we brought together a number of different professionals together to provide individualized and tailored care for people who may be having problems in recovering from their concussion. So under one roof, we have adult neurology, child and adolescent neurology, physical therapy, occupational therapy, physical medicine rehabilitation, neuropsychology with ready access to other specialties such as pain management, neurosurgery, sports medicine. We actually have with us in the clinic experts in psychiatry and sleep medicine. And so for people who are having challenges where all of us together can evaluate the individual and come up with an individualized and coordinated plan of care. And the other exciting aspect of this is recovering all forms of injury, not just sports injury, and every severity of injuries—concussion on up through the moderate to severe injuries. So we really cover the entire spectrum and the entire patient population in a coordinated way, and we actually have members of our team who are helping with the inpatient care for those who have more severe injuries and helping to provide a system of care as they go through the medical system, as they are leaving the hospital making sure they have good tracking and appropriate follow-up. Our individuals are very much involved with outreach and education in the community, working with local school systems, making sure they’re up to date on the latest innovations in concussion care, and we’re very well ingrained with the UVA athletic department. And so it’s really exciting to have this synergy and cooperation with all of these people together.

Melanie: In just the last 30 seconds or so, Dr. Jaffee, give us your best advice regarding concussion prevention, your best advice for parents.

Dr. Jaffee: Kids want to do the sports they love, so our job is to try and make sure they find the safest way to do it, and that involves taking care of the appropriate practices, using the appropriate policies, appropriate equipment, and appropriate management. So I would just make sure to ask the school what their policy is. Most schools now are required to have one, and if they don’t, we can certainly link them to a professional to help with that education because our goal is to promote the activities that people love but to do it in a safe way.

Melanie: Thank you so much, Dr. Michael Jaffee. You’re listening to UVA Health System Radio. For more information, you can go to uvahealth.com. This is Melanie Cole. Thanks for listening. Have a great day.
Hosts Melanie Cole, MS

Minimally Invasive Surgery for Rectal Cancer

Additional Info

Segment Number 2
Audio File virginia_health/1408vh5b.mp3
Doctors Hedrick, Traci
Guest Bio Dr. Traci Hedrick is a colorectal surgeon at UVA Cancer Center who specializes in minimally invasive colon and rectal surgery.

Organization: UVA Cancer Center
Transcription Melanie Cole (Host): For patients with rectal cancer, there’s a minimally invasive surgery that is an option. My guest is Dr. Traci Hedrick. She’s a colorectal surgeon at UVA Cancer Center who specializes in minimally invasive colon and rectal surgery. Welcome to the show, Dr. Hedrick. Tell us a little bit about what would send up red flags. What are some symptoms of rectal cancer?

Dr. Traci Hedrick (Guest): Thank you, Melanie, for having me. The main symptoms that most people have with rectal cancer are rectal bleeding. A lot of times, patients mistake that for hemorrhoids in the beginning. But rectal bleeding that particularly is mixed in with the stool should be evaluated and can be a sign of rectal cancer.

Melanie: You said mixed in with the stool. So if you see bright red blood -- because people get terrified. They could eat beets and see bright red blood when they go to the bathroom. So this has got to be something a little bit different that’s mixed in. That’s what would send them to see you.

Dr. Hedrick: That’s the most worrisome. But certainly, even if it is bright red blood, any bleeding, if it persists, should be evaluated by a physician. But certainly, most bright, red bleeding is from hemorrhoids. But an older person with any kind of bleeding should be evaluated.

Melanie: If they are diagnosed with rectal cancer, what is the standard treatment?

Dr. Hedrick: Well, the treatment depends largely on the stage of the cancer, and that includes how deep the cancer has faded into the rectum, but also whether or not it spread anywhere. For cancers that have spread into the wall of the rectum or have spread to the lymph nodes, the treatment usually includes chemotherapy and radiation for about five weeks, followed by a very large operation, but oftentimes can include at least a temporary, if not permanent, colostomy, and then more chemotherapy. For smaller tumors that haven’t spread quite so extensively, in most cases, the patients still require a very large operation for the earliest of cancer. So if they’re caught in time, the minimally invasive approach through the bottom may be an option.

Melanie: So you use this minimally invasive approach, the trans-anal endoscopic microsurgery. How is that different than the standard approach?

Dr. Hedrick: It is quite different. Unlike the standard approach, where we’re making an incision in the abdomen to completely remove the rectum, trans-anal endoscopic microsurgery or TEM, as we refer to it, is a lot like laparoscopy, and that’s the way that most patients have their gallbladders removed, with the long instruments and the scope and the high-definition camera. We’re using all that same equipment except for that we’re doing this surgery through the actual rectum itself, and it allows us to take out tumors within the rectum that we are unable to reach otherwise.

Melanie: So what are some advantages to patients for this type of surgery?

Dr. Hedrick: Well, the surgery itself is very well tolerated because we’re not making any incision in the skin. In many cases, patients don’t have any pain at all. That’s a relatively minor surgery. The patients usually go home either the same day or early the following morning, and there really is a very low complication rate with the surgery itself. That’s compared to a very large operation if we have to completely remove the rectum, which can forever change a patient’s quality of life and can be associated with high complication rates. This surgery is not right for everybody. It’s only effective for patients with very early cancers, but it’s something that certainly can be an option in that situation.

Melanie: And what about something like bowel obstructions after surgery? Is that an increased risk with this or less?

Dr. Hedrick: Much less because we’re not making incisions into the abdomen. There is a risk of scar tissue in the rectum itself from the surgery, but that chance is very low.

Melanie: In addition to rectal cancer, can endoscopic microsurgery be used for other conditions?

Dr. Hedrick: It can be used for other conditions. It’s highly effective for treating polyps, which are what we know are the precursors to cancer. There are a lot of patients out there that have very large polyps in the rectum that can be very difficult to treat and are at risk of turning into cancer. Without TEM many times, these patients have to go undergo repeated procedures to try to keep these polyps at bay from turning into cancers, and they have a tendency of coming back. Or the alternative in that case as well is to have a very large operation to have the rectum removed. However, with TEM, I'm able to completely remove the polyp with a very low chance of it ever coming back or turning into a cancer. And in fact, I'm getting ready to do one for that reason right now. That’s the main other indication. It has been described for treating other conditions such as fistula, which are connections that can occur between the rectum and other structures. But for the most part, TEM is really used to either prevent cancer by getting rid of a polyp or to treat early rectal cancers.

Melanie: What are some advances, Dr. Hedrick, in rectal cancer? What are some of the new things going on today?

Dr. Hedrick: Well, rectal cancer, like many other cancers, is really becoming an individualized condition. Here at UVA, whenever a patient is diagnosed with rectal cancer, we have a multidisciplinary group, and we get together and we discuss that patient. There really are several different options. One is this minimally invasive approach through the bottom. If it’s too extensive to be taken up that way, either there are minimally invasive approaches to doing the larger operation as well, which we’re doing here at UVA. We actually have a couple of clinical trials that are available to patients with rectal cancer here. One of the large cooperative national trial that looks at whether or not we can avoid radiation in some patients that have rectal cancer. I actually have a clinical trial that I'm doing as well where we’re looking at potentially being able to sample the lymph nodes with TEM to try to be able to expand this minimally invasive procedure to patients with even more advanced rectal cancers. There’s really a lot on the horizon with rectal cancer, as there is with many other cancers as well.

Melanie: Thank you so much, Dr. Hedrick. In just the last minute, please, why should patients come to UVA for their cancer care?

Dr. Hedrick: Well, unlike many other centers, at UVA, we have physicians and nurses in every specialty that are dedicated to specializing in colorectal cancer. Like I mentioned before, we have these weekly multidisciplinary meetings where we focus and individualize the care for each patient. With regard to surgery, my partner and I specialize in colorectal surgery. It’s all we do, and we do hundreds of these complex operations every year as opposed to only a handful. We have these various innovative ways for dealing with patients with rectal cancer. Certainly, for rectal cancer, it’s been shown that patients do better and they live longer if their surgery is done by a specialist in colorectal surgery. So I think for all those reasons, we are top-notch at colorectal cancer care.

Melanie: Thank you so much, Dr. Traci Hedrick. You’re listening to UVA Healthsystem Radio. For more information, you can go to uvahealth.com. This is Melanie Cole. Thanks for listening, and have a great day.
Hosts Melanie Cole, MS

What You Need to Know Before Your Imaging Exam

Additional Info

Segment Number 1
Audio File virginia_health/1408vh5a.mp3
Doctors Matsumoto, Alan
Featured Speaker Dr. Alan Matsumoto
Guest Bio Dr. Alan Matsumoto is an interventional radiologist and chair of the Department of Radiology and Medical Imaging at UVA Health System.

Organization: UVA Department of Radiology and Medical Imaging
Transcription Melanie Cole (Host): What does a radiologist do? And why is it so important to have your imaging done by a radiologist who specializes in the area of the body that you need examined?  My guest is Dr. Allan Matsumoto. He’s an Interventional Radiologist and Chair of the Department of Radiology and Medical Imaging at UVA Health System. Welcome to the show Dr. Matsumoto.  Tell us what is a radiologist and what role do they play in diagnosing and treating medical conditions?

Dr. Allan Matsumoto (Guest): Melanie, a radiologist is a medical doctor; a physician. We’ve gone to medical school and we spend four years of training after our internship just to learn anatomy and physiology, and the technology of how images are obtained with an ultrasound, a CAT Scan, an MRI or a PET Scan, so we can look at the pictures that are obtained to tell a patient and the referring provider what is normal, what is abnormal, what is an incidental finding, and more importantly, based upon the findings, direct the provider and the patients to the best treatment options, if it needs treatment or further diagnostic tests that needs to be provided. In addition to providing diagnostic imaging interpretation, radiologists also use imaging technology to look inside someone’s body, to figure out what a problem is and to either decide: does it need to be biopsied? And then, perform the biopsy to get a diagnosis, or to treat it like there’s an abnormal fluid collection, like an infection. They can go in and drain the infection, or identify an abnormal site of bleeding and stop the bleeding.

Melanie: You know there are many types of imaging exams now, Dr. Matsumoto and people do worry about risks. Are there any risks to the general types of imaging that radiologists perform and diagnose and look at?

Dr. Matsumoto: With any imaging test that you undergo, or any procedure you undergo, there will be risks and benefits. One risk is the cost, but the thing you’re referring to probably most prominent now is the risk for radiation exposure. That’s why it’s very important to have a trained and subspecialized and board certified radiologist involved with obtaining the examination to minimize the amount of radiation exposure and making sure that the right exam is done for the right reason, at the right time. So, with risk benefit analysis, the radiologist can have a significant impact in optimizing the benefit for the minimum amount of risk.

Melanie: Why is it so important to have your imaging done by a radiologist who specializes in the area of the body that you need examined?

Dr. Matsumoto: Melanie, much like you might take your child to see a pediatrician, or a sports injury to an orthopedic surgeon, radiologists specialize in those areas as well. So the advantage of a subspecialty radiologist is that they interpret the area of their specialty. So, a breast imaging specialist, that’s all they do day in and day out. They look at breast images, mammography, MRI of the breast. A neuroradiologist look at studies of the brain and spine. A musculoskeletal radiologist looks at knee joints, hip joints, muscles, tendons. A cardiovascular radiologist looks at the heart. So it’s very important, just like you’d want someone in your family to get the specialty care, the specialized radiologist does make a difference as compared to a generalized radiologist.

Melanie: So really it parallels the medical or surgical specialty. You want somebody that knows that part of the body really inside and out because those pictures, we see them, Dr. Matsumoto, you know we look as we kind of exit the room and really most of us don’t know what we’re looking at. How do you know what you’re looking at?

Dr. Matsumoto: With years of training and the additional specialty experience all of our faculty have done what are called fellowships. And these are extra one to three years of training to learn in specific, more detail, about the information on these images, specific to the questions that are being asked. So even though a primary care physician may order a brain MRI, when our neuroradiologists look at it, and based upon the symptoms and what the patient is complaining about, we can oftentimes direct the primary care physicians or the provider to the appropriate referrals going forward for the patient. So, clearly, a subspecialty-trained radiologist can have a significant impact on the well-being of a patient.

Melanie: How might a patient come in contact with a radiologist, Dr. Matsumoto?

Dr. Matsumoto: As we talked about, there’re really two different types of radiologists – those that do procedures and those that look at images for diagnosis. Those that do procedures come in to patients on a daily basis. Those that breast biopsy, they meet the radiologist. They talk with them. The radiologist explains what is being done. Myself, I’m an interventional radiologist. I have a clinic. I see patients there, but I also do minimally-invasive, image guided procedures and we interact with patients at the level, much like a surgeon or cardiologist interacts with a patient. The diagnostic radiologist oftentimes work with the technologists who are then performing the procedures for getting the CAT Scan and the MRIs, in conjunction with the radiologist. In those situations, the radiologist does not typically come in contact with the patient, but they will be glad to see a patient. The radiologist oftentimes interacts with the provider to ensure that the patient gets the appropriate the care and that the information is communicated to the referring provider.

Melanie: That’s a great distinction between an interventional radiologist and a diagnostic radiologist, Dr. Matsumoto. With an interventional radiologist, such as yourself, do we expect our results while you’re doing procedures, or is it we wait until your done and then you say, “Okay, it will be a day or two,” or you can give us the results pretty quickly?

Dr. Matsumoto: If it is the biopsy procedure there’s often at time period because we submit the specimen to pathologists who then look at it. And depending upon the nature of the question being asked, it can take anywhere from 48 hours to 96 hours for the pathologist to be able to look at the information. So oftentimes with a biopsy it takes a little bit of a time to get the result back. If you’re undergoing a procedure, for instance if you have an aneurism, or if you have a place of bleeding and the interventional radiologist goes in and treats the aneurism or treats the bleeding, then we often, much like a surgeon, would talk to a patient. The interventional radiologist says, “We found the site of bleeding. We believe we stopped it. We’ll know over the next few hours whether the bleeding has stopped.” So it depends upon the specific circumstance.

Melanie: Dr. Matsumoto, we have a few minutes left. Would you tell us why a patient should choose UVA for their imaging services?

Dr. Matsumoto: Well, at UVA our radiologists consider it to be a privilege to be involved in the patient’s care and we really take pride in performing the right imaging tests, or the right procedure for the right reason, at the right time. It’s very important for us to have the technology available to us, and at University of Virginia all our equipment is state-of-the-art. In addition, all the images that are interpreted and all the procedures performed are done by sub-specialists that are in that area of interest. So, they are all subspecialty radiologist. So again, a pediatric X-ray is read by a pediatric radiologist. A heart MRI is read by a cardiac MR. That makes a huge difference for the patient’s well-being. Plus the technology makes the difference. Not all equipment is the same. Those of you that have a laptop, you have a smartphone, you have a television, you know that it’s important for the state-of-the-art equipment. If your camera only takes 4 megapixel pictures, you’re not going to be able to see the level of detail to see if there’s a subtle cartilage there. So, not only are our radiologists specialized, they’re working on state-of-the-art equipment, but they’re also physically here on campus and live in the Charlottesville community.  Lastly many of our radiologists have developed the technology so once it becomes widespread we have been using it for five years. And not only that, we’re teaching other radiologists how to do this. So we are, in many instances, the expert.  A couple of other bonus points about being at UVA is we’re at multiple locations, whether it’s at the main campus, Northridge, Zion Crossroads, Fontaine, we have accessed imaging studies at night and weekends at multiple sites with all state-of-the-art equipment. And lastly patients access their reports and their images through our electronic medical record through something called MyChart and MyView. So, you put that all together, we provide the entire package; the subspecialty physicians who care, the technology that cares, the specially-trained technologists that take the images, the multiple locations patients can access and access to the information. And lastly, our radiologists are often leading the way. So we have experienced interpreting and utilizing the state-of-the-art equipment that many other institutions around us don’t have that luxury.

Melanie: That is great information, Dr. Allan Matsumoto. Thank you so much.  You’re listening to UVA HealthSystem Radio. And for more information, you can go to uvahealth.com. That’s uvahealth.com. This is Melanie Cole. Thanks so much for listening. Have a great day.
Hosts Melanie Cole, MS

Advanced Imaging Options for Heart Disease

Additional Info

Segment Number 5
Audio File virginia_health/1403vh5e.mp3
Doctors Bourque, Jamie
Featured Speaker Dr. Jamie Bourque
Guest Bio Dr. Jamieson Bourque is a cardiologist at UVA Health System specializing in heart imaging.

Organization: UVA Heart and Vascular Center
Transcription Melanie Cole (Host): New advances in heart imaging can help doctors better identify heart disease. My guest is Dr. Jamie Bourque. He's a cardiologist at UVA Health System. Welcome to the show, Dr. Borque. Tell us what are some of the advanced imaging options available at UVA to identify heart disease.

Dr. Jamie Bourque (Guest): Well, thank you very much for having me. We have several advanced imaging options available now, including Cardiac Magnetic Resonance Imaging or Cardiac MRI, which gives very detailed images of the structure and function of the heart and has some additional features, such as scar imaging that is particularly useful; Cardiac Computed Tomography which allows us to look at the coronary arteries in a non-invasive fashion, without actually having to put a catheter in the body. But the one that I'm particularly excited about and that we recently started using is an advanced form of stress-test imaging called Cardiac Positron Emission Tomography, or Cardiac PET for short.

Melanie: And what exactly is that? How does it differ from the standard imaging?

Dr. Bourque: Cardiac PET stress testing allows us to more accurately diagnose chest pain that we think is due to coronary artery disease more quickly that our standard stress imaging and also with less radiation. Those are all advantages, but the most exciting feature is its ability to image the microvasculature—that is, the small blood vessels that supply the heart. Using this technique, we can identify the cause of chest pain in patients with convincing symptom but who have a negative workup, including a cardiac cauterization. These patients have previously been told there is nothing wrong with their heart, but we now know that sometimes that is not the case. They may have coronary microvascular dysfunction, and this test allows us to look for that.

Melanie: So it gives you a better view of those micro-vessels that we didn't have before.

Dr. Bourque: Yeah. Previously, there was no way to actually assess those vessels, and this is now an option that is available to us.

Melanie: So who benefits most from these new imaging techniques?

Dr. Bourque: Again, patients who have a negative cardiac workup previously but may have continued symptoms, or who had a stress test that was previously equivocal, as in they weren't quite sure whether it was positive or negative, which can sometimes happen with our stress testing. Those sorts of patients particularly benefit from Cardiac PET Imaging. However, because of its improved diagnostic accuracy in patients who have multi-vessel disease, it's also very useful in patients who have diabetes and kidney disease, as well as patients who may carry a little more weight.

Melanie: So in the Cardiac PET stress test, are there limiting factors as in a regular stress test, where maybe the quadriceps start to burn early, or the person can't keep up with the treadmill? Are there those limiting factors, or have those been removed?

Dr. Bourque: It's a good question. Unfortunately, the current tracers available don't allow us to use exercise for stress. By the time the patient got on the table after exercising, the tracer would already be gone, which is good because it means low radiation for the patient, but it's unfortunate we can't use exercise. There are some imaging tracers in the research pipeline that will allow exercise stress, but for the moment, what we do is we give a medication that dilates the blood vessels, and that simulates stress on the heart. It's very safe but also allows us to stress the heart without actually having them walk on a treadmill.

Melanie: So Dr. Bourque, what would you recommend for heart imaging exams that patients should undergo routinely, and how often?

Dr. Bourque: It turns out that most of our cardiac imaging really should only be done when a patient is symptomatic. So they may have chest pain or shortness of breath. There are very specific instances where noninvasive imaging may be helpful, such as someone with a very significant family history in multiple cardiac risk factors, or someone who is particularly high risk and plans to undergo non-cardiac surgery. But for most patients, we actually would wait to do any imaging until they had symptoms. This has really been an advance in our field. Cardiac imaging is something that has been overused to the significant expense of patients and insurance companies, and then, also, significant expenditures to patient time and effort. For the most part, patients should really be symptomatic before undergoing these tests.

Melanie: Are there different rules for men versus women?

Dr. Bourque: Basically, men do have a higher risk of coronary disease. However, that difference has been shrinking, partly due to the sort of rise of obesity, increased tobacco use in women. While that might have been the case in the past, it's less true now.

Melanie: If someone is experiencing chest pain, shortness of breath, how do you determine? Do you go right into testing? How do you determine whether this is anxiety? Because we're a very stressed out society these days, Dr. Bourque, and sometimes those symptoms can be associated with a number of different other conditions.

Dr. Bourque: Absolutely. There's no question that both chest pain and shortness of breath can be due to non-cardiac reasons, or even to cardiac reasons other than decreased blood flow to the heart. The initial screen that we do is with a careful history in physical. And oftentimes, in talking with patients and finding out when they have their symptoms and the quality of their symptoms we're able to make a determination, "Well, that chest pain that you get when you're just sitting still on the couch and it's worse after a fatty meal, that's probably not coronary disease, whereas chest pain or shortness of breath that comes on three minutes or every time you go up a flight of stairs, or every time you walk up a hill, causing you to sweat and pant and have to stop at the top and resting makes it better, that's very concerning symptomatology."

Melanie: What about other imaging tests that have been used previously, like carotid ultrasounds or looking at cholesterol levels, plaques in arteries? Are we still using these, even CRP?

Dr. Bourque: Those are all good methods for risk stratification for patients. Again, those sorts of testing are probably better, as you were saying before, for the asymptomatic patient, where we may want to look at someone who has a family history, or who has multiple cardiovascular risk factors and do plaque imaging. Or actually, the most effective method we have right now is calcium scoring, which is a non-invasive cardiovascular imaging test, relatively inexpensive. We do offer that at UVA. But usually, looking at blood pressure, blood glucose, cholesterol, all of the standard cardiac risk factors gives us a pretty good idea of who to test. CRP can be used in patients where you sort of have a borderline, "Should we treat this patient or not?" after looking at their risk factors? The CRP, Calcium Scoring, which we do offer, Carotid Intima-Medial Thickness Measurement, but calcium scoring is probably a better method.

Melanie: Why should patients choose patients choose UVA for their heart care?

Dr. Bourque: I'm biased, but I do believe that UVA is an excellent choice for anyone who's looking for compassionate care and for a comprehensive evaluation of their heart by highly trained physicians using the latest tools that are available anywhere. I believe that our up-to-date knowledge and our cutting-edge diagnostic testing and the treatments that we have available make us the clear choice for cardiac care.

Melanie: Dr. Bourque, give us your best advice in the last minute for preventing heart disease, and maybe then, we don't have to come see you.

Dr. Bourque: Absolutely. I think that the best thing that folks can do to prevent heart disease are to watch their risk factors. Get an annual physical, monitor the blood pressure, monitor cholesterol, watch your diet. A Mediterranean diet, we know now, is probably the best way to go. Keep one's weight down, keep from becoming overweight. And probably, most importantly—and I know you like to hear this as an exercise physiologist—we need to get out and exercise more. And I think if patients do all of those things...

Melanie: Thank you so much. If they do all of those things, then maybe they can help to prevent heart disease in this Heart Health Month. You're listening to UVA Health System Radio. For more information, you can go to uvahealth.com. This is Melanie Cole. Thank you so much for listening.
Hosts Melanie Cole, MS

Neurocutaneous Disorders: Tumors Caused by Genetic Factors

Additional Info

Segment Number 4
Audio File virginia_health/1403vh5d.mp3
Doctors Asthagiri, Ashok
Featured Speaker Dr. Ashok Asthagiri
Guest Bio Dr. Ashok Asthagiri is a neurosurgeon at UVA Health System, where he leads a multidisciplinary team in treating neurocutaneous disorders.

Organization: UVA Health System Neurosciences
Transcription Melanie Cole (Host): While most people associate tumors with cancers, they can also be caused by genetic factors. Today we're talking about neurocutaneous disorders and their treatment options.My guest is Dr. Ashok Asthagiri. He's a neurosurgeon at UVA Health System, where he leads a multi-disciplinary team in treating neurocutaneous disorders. Welcome to the show. So tell the listeners or people who aren't familiar, what are neurocutaneous disorders?

Ashok Asthagiri (Guest): Great. Neurocutaneous disorders are a constellation of different disorders that have been grouped together because of certain components that are very similar. The folks with any type of neurocutaneous disorder will have neurologic problems—that's where the neuro part comes—and oftentimes also have cutaneous signs or skin alterations that can be readily apparent on physical examination. That's how these groups of disorders have been clustered together.In addition to that, this group of disorders also carries what you had mentioned earlier, a genetic component, that we understand that many of them are actually caused by known mutations in DNA and can be inherited from parent to child. So we've lumped all these together because they sort of fall under the same category of common symptoms that may cluster together, and that's why they've been historically grouped together.

Melanie: Do we know what causes them? How common are they, really?

Dr. Asthagiri: Well, the reason that we're still talking about neurocutaneous disorders and that it's not widespread knowledge what they are is because of their relative rarity. If we cluster them all together as a group, they occur at about one in every 1,000 persons living in the United States. When we think about that, that's a pretty small number. In fact, they are actually covered under the terminology of rare disease by the Office of Rare Diseases in the National Institute of Health. Having said that, that's also what has propelled them to the forefront of research and investigation and actually has really gone into why we are able to definitively say what causes these types of syndromes.The mainstay of what causes them are genetic mutations. So for example, there are several of them that are quite common. There are the neurofibromatosis, Von Hippel-Lindau Syndrome, and tuberous sclerosis. And we know that genes that are involved that actually cause these, and we can actually do genetic testing to identify that there are these genetic mutations that are present.

Melanie: Now, if somebody does have these genetic mutations, are there certain treatments? Is this something that is a chronic situation in their lives? Tell us about treatments.

Dr. Asthagiri: Yeah. Even though it is oftentimes passed from parent to child, it is not just a pediatric disorder that folks grow out of—as you mentioned, chronic condition, a lifelong condition. For many of these syndromes, the adult aspect is equally, if not more, important to their chronic care as their pediatric years are. It's really a lifelong process of continual surveillance and treatment that's really needed in order to manage patients with these types of disorders effectively.As research and investigation of these disorders have developed, the treatments have been really ratified over the last 20 years. Let me give you a few examples of how things have changed. And there, I think it epitomizes what medicine is evolving too in many conditions. Thirty, 40 years ago, what happened with all of these types of patients is you wait until you get a problem, you see the doctor, and we might identify a tumor in the nervous system that's causing a problem, and then it gets taken out. For some conditions now, we have actually developed certain types of alternatives: surgical therapy and also the use of radiosurgery, which is focused radiation, to manage some of the tumors. In other situations, it also progressed to very efficacious types of medical therapies that can absolutely control some of the symptoms that developed, such as hearing loss and some of the condition, and also, tumors that are growing, they can cause seizures. Some very effective medications exists or that and are under clinical investigation, clinical trials. So epitomizes the transition from a reactive type of treatment—when you have a problem, we take care of it.In general, medicine has evolved such that we're not trying to react to problems that develop, but rather, be proactive, be able to figure out problems, where they come on, number one. And number two, try to treat them in a more holistic approach and try to treat things in a less morbid, even less surgical approach. That's where things are moving to, and that's what we're trying to evolve to and create new treatments for them.

Melanie: You're focusing more on preventing or maximizing the person's capabilities at home and in the community, correct?

Dr. Asthagiri: Absolutely, because folks with neurocutaneous disorders oftentimes develop multiple nervous system tumors. If you have three brain tumors, two spinal tumors, and one or two tumors on the peripheral nerve, there's no way to get rid of all of the tumors. We don't operate on all of the tumors just because they're there. Instead, we follow them very closely. And if they develop symptoms, naturally, we would have to treat, but part of the issue is trying to figure out a way to optimize their ability to work and function in the community, and then also try to delay or prevent symptom evolution. That's where things are headed. That's where we would like to be in 10, 15, 20 years, and we're getting there. I think we're making our steps into those types of advances.

Melanie: Doctor, you lead a multi-disciplinary team in treating neurocutaneous disorders. What does that mean, and why should patients come to UVA for their care?

Dr. Asthagiri: Well, one of the reasons that I actually came back to the University of Virginia is because of this commitment to the multi-disciplinary aspect of these patients. Patients with neurocutaneous disorders not only have problems with tumors in their nervous system and from skin changes. They also have, at times, cardiac abnormality and brain tumors that can cause high blood pressure. They also can develop renal cell cancer and many other types of organs that can be involved. So for each of the subtypes of neurocutaneous disorders, we've developed a multi-disciplinary first point of contact team that has agreed to help manage patients with these specific types and conditions. For a long time, folks with neurocutaneous disorders would have to go to a center, one center, or get an appointment in to go see a neurosurgeon and then three weeks later, have a disjointed appointment with another doctor who may not know about the neurosurgeon, that wasn't very coordinated.

Melanie: Now, we don't have much time, so what you're saying here, doctor, is that you can provide all of those different aspects in one place, yes?

Dr. Asthagiri: That's right, yeah. That's what the University of Virginia has to offer for folks with neurocutaneous disorders. That's right.

Melanie: Well, thank you so very much. You're listening to UVA Health System Radio. For more information, you can go to uvahealth.com. You've been listening to our discussion on neurocutaneous disorders and the multi-disciplinary approach at University of Virginia Health System. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

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