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Segment Number 4
Audio File virginia_health/1351vh5d.mp3
Doctors Shimer, Adam
Featured Speaker Dr. Adam Shimer
Guest Bio Dr. Adam Shimer is an orthopaedic surgeon at the UVA Spine Center. He provides comprehensive spinal care, specializing in complex cervical spine surgery, adult spinal deformities and minimally invasive treatment of spinal conditions.

Organization: UVA Spine Center
Transcription Melanie Cole (Host): Low back pain is one of the most common ailments that we face, and how can you tell when low back pain signals something that might be more serious. My guest is Dr. Adam Shimer. He's an orthopedic surgeon at the UVA Spine Center. Welcome to the show, Dr. Shimer.What are the most common causes of low back pain? Everyone suffers from it, and it also keeps millions of people home from work. It is one of the main reasons people lose work time, too. What are the main causes that you see?

Dr. Tim Showalter (Guest): Well, I'd like to first thank you, Melanie and Radio MD for having me on. I think you touched on many important points of low back pain. It is the second most common cause of missed work, secondary only to the common colds. It is also one of the leading causes of disability for those at working age. It has not only an impact to the individual but also significant societal and economic impact.
I think the most common causes of low back pain are those that are not concerning from an emergency standpoint. Those can be simple muscle strains, tendon pulls. One of the more common reasons is what we call degenerative disc disease. Those discs are the cushions in between the bones of the spine. Those, over time, much like you can get arthritis of the hip and knee, can lose some of their mechanical properties and begin to collapse. You may have heard the term "black discs" or "degenerative discs" or "slip discs." Unfortunately, we have a bunch of terms describing more or less the same thing.

Melanie: Now, is there something we can do, Dr. Shimer, to reduce our risk for low back pain? I mean proper lifting techniques, or if you know that maybe you're subject to arthritis, osteoarthritis or something, that you can keep yourself strong and healthier? Is that going to help?

Dr. Shimer: Yeah. I tells folks that it seems cliché, but really doing what your mom told you to do: eating right, getting good sleep. Losing weight is one of the key ones that is difficult to talk with patients or folks about. But if you can take off 10 percent of your overall weight, you decrease the strain on your back a considerable amount. Also, smoking. It's not commonly known that smoking is one of the leading causes of increasing the rate of disc degeneration, and folks who smoke have an increased rate of back pain. So I tell people they really need to increase the healthiness of their lifestyle: better eating habits, get good sleep, stop smoking, lose weight, and exercise, cardiovascular, low-impact exercise. These are all really the hallmarks of decreasing your chance of having back pain.
Melanie: Are there any signs or symptoms that might signal that it's a more serious condition?

Dr. Shimer: Absolutely. There are conditions such as kidney stones. There are conditions such as aortic aneurisms. These can be more significant things, and you really want to look for any other concerning symptoms, such as recent, unintended weight loss, fevers, chills, rapidly progressing back pains. It's not bothering you one day, and then, three hours later, it's incapacitating. Any weakness of the legs or any change in the ability for you to control your bladder. I think that those examples are really kind of the basic spectrum of things that should be what I call red flags. If either the patients themselves or the primary care physicians, in their assessment of the low back pain, hear those, they really need to be a little bit more concerned and maybe increase the acuity of their evaluation.

Melanie: Dr. Shimer, if a patient is experiencing low back pain, what is the first line of defense if they come to see you? Do we start with anti-inflammatory medications? Surgery would seem to be -- of late, people would like to make that the very last option, for if it is something serious, disc-related. But what do you do first for low back pain?

Dr. Shimer: Surgery should absolutely be the last option. I think that, as you have been going since starting me off, handed me the ball and allow me run, but I think anti-inflammatory medications, and that's as tolerated. Certainly, people's stomach can get upset on those. Or if they high blood pressure, those can be some relative contraindications. But as their medical condition allows anti-inflammatories, and those can even be over the counter, such as naproxen or ibuprofen. Also, some good low-impact cardiovascular aerobic exercise. What we want to try to get people to do is strengthen their core. That should really be a flexion-based protocol, so not a whole lot of back extension or stretching your back up, because that puts more strain on the spine. So things to really strengthen the abdominal muscles help back pain quite a bit. And then, really the number one thing is time. This is what I tell patients: patience. I tell patients patience. But they just need to give it a little bit of time. And 95 percent of back pains spontaneously resolves within a week or two. The olden days of recommending prolonged bed rest, so, "Go home and lay in bed for a week," are gone. That is the worst thing to do. You really want to keep patients up and active and sit and decreasing the inflammation associated with back pain with simple, over-the-counter medication.

Melanie: What about decompression exercises? There's kind of a movement towards almost back to the old school of traction, but this decompression, sort of lengthening out those discs so they're not compressing on each other so much.

Dr. Shimer: Yeah. There's a few. Not only manual manipulation, it can be done by osteopathic doctors and chiropractors, which I'm never against. I think alternative, non-surgical interventions, if they work, are fabulous. And if people feel better, it works. There's also some more machine-based intervention, such as [VACS-D], that are traction-based devices, but they can charge patients quite a bit out of pocket. And from what I know, the evidence behind them, the peer-reviewed literature is pretty limited. I usually lean my patients more towards physical therapy, core strengthening. If they want to have some sort of manipulation, more doctor-based manipulations instead of being placed on a machine. But that's just my opinion.

Melanie: If they do have to have surgery, what treatment options are available? We don't have a lot of time, Dr. Shimer, but what kinds of surgery are we seeing now?

Dr. Shimer: I really try to limit surgery for the end of the line. We predominantly as spine surgeons focus on leg pain from sciatica, or disc problems that are pushing on nerves. Back pain itself from degenerative disc disease is really usually poorly responsive to surgery. For that reason, we do all of the things that we talked about in the previous nine minutes or so to really get patients better.I always say the most minimally invasive surgery is no surgery at all, try to get them better without surgery.

Melanie: Which is certainly the best option. Now, there are some minimally invasive things that you can do that might give some temporary relief?

Dr. Shimer: Well, hopefully we choose a procedure that leaves the lowest surgical footprints, so the least damage to the muscle and surrounding tissues. But achieving this surgical goal, and the goal is to get people lasting relief. So if someone has a disc that's bulging and pushing on a nerve, giving them intractable leg pain, we can go in with very small instruments in a microscope and very expertly remove that small piece of disc that's pushing on the nerves. Patients about 85 to 90 percent of the time get good to excellent durable results. I'd like to think that a well-chosen spine surgery that's well-performed, patients get really nice relief, pretty predictably.

Melanie: Now, in just the last 30 seconds or so, Dr. Shimer, explain to patients why they should choose UVA Spine Center for their care.

Dr. Shimer: I think it's a combination of things. I believe that UVA itself as an institution has really topnotch academic physicians and surgeons that are up to date not only on the newest technology that may be pushed through advertisements but really the most up-to-date evidence-based, peer-reviewed medical care. So what you're going to get is care that is based on science, not based on advertisement, not based on the shiniest new implant. But really, we can look you in the eye and say, "This is the best care."

Melanie: Care based on science. I love that. You're listening to UVA Health System Radio. For more information, you can go to uvahealth.com. That's uvahealth.com. This is Melanie Cole. Thanks for listening.
Hosts Melanie Cole, MS

Reducing Breast Cancer Treatment to a Single Day

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Segment Number 3
Audio File virginia_health/1351vh5c.mp3
Doctors Showalter, Timothy
Featured Speaker Dr.Timothy Showalter
Guest Bio Dr. Timothy Showalter is a radiation oncologist at the UVA Cancer Center. In addition to caring for patients with breast cancer, he also treats children with cancer as well as patients with prostate cancer, digestive cancers and gynecologic cancers.

Organization: UVA Cancer Center
Transcription Melanie Cole (Host): For patients with breast cancer, the treatment can often take several weeks. But at UVA Cancer Center, it's among the first centers in the US to offer a new breast cancer treatment that can reduce treatment time to a single day. My guest is Dr. Tim Showalter. He's a radiation oncologist at the UVA Cancer Center. Welcome to this show, Dr. Showalter. Incredible. Tell us about this treatment for breast cancer that can reduce the treatment to a single day. Really?

Dr. Tim Showalter (Guest): Well, thanks for having me. It's very exciting. One of the recent trends in breast cancer care in general is that there has been this development of intra-operative radiation therapy. Rather than having selected patients come in for a six-or-more-week course of daily radiation therapy, we can actually get their treatment done in a single day right at the time of lumpectomy. So when they get their surgery, they also walk out that day having had their radiation therapy.
The very exciting component of the IORT program at the University of Virginia is that we're actually doing it quite differently than other places. We have an image-guided intra-operative radiation therapy approach, where we actually use a different style of treatment and different equipment to deliver the IORT. We can actually visualize what we need to treat and visualize the normal tissues and deliver a highly-conformal image-guided radiation therapy plan, all at the same time as the surgery.

Melanie: How does it work? Is it something different than we've seen with typical radiation therapy?

Dr. Showalter: It is. We actually use a type of radiation treatment that's called high-dose rate brachytherapy. What's unique about the setup at the University of Virginia is that we have, within the brachytherapy procedure room, we have what's called a CT on rails. It's actually a diagnostic, quality CAT scan that can slide across the floor. The surgeons come in here. The anesthesiologist comes in. The surgeons do the surgical procedure, remove the breast tumor, verify that at least in terms of an early assessment that the margins are negative. They're still staring at the lumpectomy cavity. They can easily visualize what they need to treat. They place a brachytherapy catheter in the lumpectomy cavity, which basically looks like a balloon with a tubing attached to it, and they close the lumpectomy cavity.
And then we're able to do a CT image right there. Without moving the patient, we acquire the image. We do detailed radiation treatment planning with that patient's CT scan, with the balloon in place. We connect everything and deliver the treatment. The whole time, the patients are being monitored by the anesthesiologist and the breast surgeon. We're able to get the treatment done in time. When the brachytherapy is finished, the surgeons go in and finish closing the wound, remove the catheter, and the patient's on their way.

Melanie: That's fantastic. What are some of the other advantages to doing this IORT? Shorter treatment time is, obviously, but what about tissues', organs' effect of this?

Dr. Showalter: Well, inter-operative radiation therapy, in general, as an overall trend, is really exciting, both for the convenience factor but also because you have the ability to actually visualize what you need to treat at the time of surgery. It gives us a lot more information and control, and we're treating a smaller amount of tissue. We expose less normal tissues to radiation therapy. That's important because standard forms of radiation can expose significant volumes of the heart, if it's a left-sided breast cancer, or the lungs and ribs as well. What's very exciting about the UVA version is that for most inter-operative radiation therapy approaches, it's being done in an operating room without benefit of imaging or the ability to scalp the dose. So we end up with a radiation treatment plan that looks like a simple sphere, and it's something that we can't control or adjust with a misguided planning or any sort of computer modeling. With our approach, we actually take the tools that we use in other situations for breast cancer care and really distill it down into a brief, hour-long procedure that's done at the time of lumpectomy. We use all of our CT scanning and computer planning. We use the ability to use a radiation source in multiple passageways within the applicators so that we can really carve a specialized and highly-conformal radiation plan for that individual patient.

Melanie: Now, are there some particular groups of breast cancer patients who would most benefit from this treatment?

Dr. Showalter: Yeah. This type of treatment is really only appropriate for women who have a relatively small—so generally less than 3 centimeters—breast cancers that are low grade and considered favorable. Part of the rationale is that we're not treating the entire breast. This isn't for women who have more advanced tumors or who are extremely high risk of recurrence. That would be the case overall for anytime we're using what's called accelerated partial breast radiation, which we're just treating part of the breast, or when we're using inter-operative radiation therapy.

Melanie: Are there any side effects? And what are your outcomes, generally?

Dr. Showalter: Well, this is relatively new program for us. This type of treatment, in terms of the inter-operative radiation therapy, is a brand new program for us. While we have a clinical trial that's helping us keep track of outcomes for this, so far, things have gone well, and we can also look at the data from the clinical trials of the other forms of inter-operative radiation, which don't use image-guided planning but do treat a similar volume of tissue. Those have been very large studies with hundreds of women who have agreed to participate in them, and the outcomes look excellent from those studies. It's considered a safe and effective treatment option, and we think that our version has some additional advantages even beyond that.

Melanie: Well, additional advantages. If the patient has to undergo a mastectomy, or something along those lines, is it going to give them options to make this a little bit less drastic or dramatic, like nipple-sparing surgery, such like that?

Dr. Showalter: We're not sure. Just to be clear, this type of radiation is only added to lumpectomy. So it wouldn't be helpful for women who have chosen to undergo a mastectomy or have a medical reason based on their tumor stage that they're going to undergo mastectomy. We think certainly that when women have a partial breast radiation, in general, the future options are less difficult than if they have their whole breast treated. But that's a very individualized scenario that may vary from patient to patient.

Melanie: It's very exciting. Dr. Showalter, what are you seeing on the horizon for this type of radiation therapy?

Dr. Showalter: Well, UVA's unique, currently in terms of the particular layout of our equipment, and we're very fortunate that we're able to offer this for our patients and to be the leaders in developing this type of inter-operative radiation therapy. I think in the future, the next stage for us is going to be working with our colleagues at other institutions. Once we've gained more experience with this, they try to bring them on board and to do larger scale studies. One of the exciting things from an oncology perspective about this version of breast inter-operative radiation therapy, because we have some added advantages in terms of the technique, you can actually deliver a higher dose than what's delivered in other forms of inter-operative radiation therapy. We think that may be helpful for patients in terms of reducing risk of recurrence. I think our next step, I'd like to see this expand to other centers. And I've heard rumors that other facilities across the country are looking at getting brachytherapy procedure areas set up like this with in-room CT imaging. I think that would be the next step.Moving forward, the other approach is that there are other centers that are currently working on extremely short course brachytherapy for breast cancer that is not done at the time of surgery. I think that our results will help inform those trials and may help those centers move their studies forward and help deliver another convenient alternative for patients.

Melanie: In the last just 20 seconds or so, Dr. Showalter, tell us why patients should consider UVA Cancer Center for their breast cancer treatment.

Dr. Showalter: Well, I think this a great example of UVA really pushing forward all of the shared missions. First and foremost, we're a cutting-edge medical center that serves its community. I think this is an example of a clinical program that lots of us, a very large team of folks, have worked hard on to bring forward. It's an excellent program that uses our most advanced technologies and does something that's convenient and I think beneficial for patients. But it also demonstrates our role as a national leader.

Melanie: Thank you so much for listening to UVA Health System Radio. I'm Melanie Cole. Thanks for listening.
Hosts Melanie Cole, MS

Understanding a Common Prenatal Condition

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Segment Number 2
Audio File virginia_health/1351vh5b.mp3
Doctors Herndon, C.D. Anthony
Featured Speaker Dr. C.D. Anthony Herndon
Guest Bio Dr. C.D. Anthony Herndon is a specialist in pediatric urology who serves as Director of the Division of Pediatric Urology at UVA Children's Hospital.

Organization: UVA Children's Hospital
Transcription Melanie Cole (Host): Prenatal hydronephrosis is the most common condition identified in babies during prenatal ultrasounds. My guest is Dr. Tony Herndon. He's a specialist in pediatric urology, who serves as the Director of the Division of Pediatric Urology at UVA Children's Hospital. Welcome to the show, Dr. Herndon. Tell us a little bit about this prenatal condition that most people have not even heard of.

Dr. Tony Herndon (Guest): Thanks for having me on today. Prenatal hydronephrosis is the identification during the maternal fetal or the obstetrician ultrasound of the mother, where the baby inside of the mother has fluid on the kidney or dilation of the kidney. There are varying grades of this. The most common is grade one, which is very minimal fluid on the kidney, and the most severe is grade four, and that's less common. That's where the fluid causes tension to the point where it compresses the normal kidney tissue, and that can be seen fairly readily with an ultrasound because the fluid is actually urine. That's very easy to discern. That's one of the reasons it's the most common condition diagnosed. It's easy to pick up.

Melanie: What causes it, Dr. Herndon? If urine is putting pressure on his kidney, pregnant women have enough pressure going on in all sorts of places anyway. So you spot this on an ultrasound, what is the cause?

Dr. Herndon: Well, I have a discussion with the families directed at that. The most common cause is transient, actually. There's fluid that builds up on the kidney, and if you follow the kidneys throughout pregnancy, in about two-thirds to 70 percent, most of those kidneys normalize within the first six months postnatally. Almost all of these kids, as a whole, you can assure the families that everything's going to be okay. There's a subset of kids that have a specific diagnosis that puts them at a little bit higher risk of an infection, the need for surgery, or kidney damage. The issue though is you can't always sort those kids out prenatally, and that's done based on postnatal testing. We have a risk stratification that we use that puts them in kind of a low, medium or high risk, and depending on the risk, that prompts things such as the need for preventative antibiotics postnatally, invasive testing, where we would actually put a little tube in the bladder and inject dye to look at the bladder anatomy, or do further imaging of the kidneys to look at drainage and function.

Melanie: So this is what happens during pregnancy. How does it affect the newborn?

Dr. Herndon: Well, the newborn, during pregnancy, the mother is providing kidney functions. So in terms of the kidney functions, it's very uncommon for us to do anything or have the need to do anything prenatally because the mother is providing the kidney function. In a very select subset, the baby is not urinating, and the urine, during pregnancy, allows fluid to go around the baby and the lungs to develop. That's the only condition that we actually do something prenatally. That's the first thing that we tell the families. Then we check off the list that there's plenty of fluid, amniotic fluid, around the baby that we can safely follow the baby postnatally. When the baby is born, we need to do a kidney ultrasound of the baby, very similar to what the mom had, an ultrasound, and that's done before the baby leaves the hospital. That sets the tone for further testing. Some kids need to be followed very, very closely, and some kids, as I mentioned previously, might resolve or significantly downgrade their kidney dilation.

Melanie: After the baby is born, you do an ultrasound of the baby's bladder, kidneys, and then you kind of keep a watch on them. What could happen, Dr. Herndon? Could they reflex back up into the system? Could they sort of be toxic, a little bit?

Dr. Herndon: Well, the kids—and that's where this risk stratification comes into play—as a group, as a whole, pediatric urologists have tried to get away from using preventative antibiotics. It's developed this risk stratification [I have] to try and classify kids into groups that are at low risk of infection, and that's based on the degree of kidney dilation that we see prenatally. Kids who are at moderate risk and high risk, those kids, if they do have urine that backs up, which is one of the [ideologies], they're at high risk of having kidney infection and toxic, like you said. If they're at low risk of infection, even if they do have urine that backs up, they're probably not going to get infected, hence not become toxic. That's the tricky part is we don't study every child. If we did, we would pick up disease in kids that might not necessarily have an issue with it. They keep up with this disease. One of these conditions is reflux, where the urine backs up. Those kids are managed with long-term antibiotics. We're trying to get away from that.
The other ideology is kidney obstruction. But luckily, those kids predominantly have severe kidney dilation, grades three and four, so those kids, we kind of know based on that ultrasound. The kids that tend to get that trouble, we kind of have a lead on that, because of the severity of the kidney dilation in terms of the kidney blockage. Kids that have urine that back up to the system reflux, the ultrasound helps us classify the risk of infection, and that's what directs the intervention with the invasive testing to diagnose the urine that backs up to the kidney.

Melanie: For the most part, are they able to filter this out when you see? Of course, you can't study every baby, but are they able to filter this out? If they're not, is there surgery required? Are there other certain other interventions besides the long-term antibiotics?

Dr. Herndon: Sure. Going back to the ideologies, the most common is transient, meaning it does go away. That takes care of 70 percent. The urine that backs up the reflux, those kids typically do well that are picked up prenatally. If you look at that group, they get infected, but at a much lower rate than kids that present later in life with reflux and infections. Infections, when you're dealing with urine that backs up to the kidney, that drives surgical intervention, not necessarily the presence of urine backing up. Some of those kids will have surgery, probably about 20 percent because of infections, but a little bit depends on the severity of urine backing up. Kids that have the same volume that's in the bladder backing up to their kidneys, those kids are more likely to have surgery. Kids that have minimal urine backing up from bladder to the kidneys are less likely to have surgery. That group of refluxing patients, that's what we call that Vesicoureteral reflux. Those kids, they're a spectrum; most kids will not need surgery, but a subset will, and those are the same kids that are getting infected or have very high-grade reflux.

Melanie: Dr. Herndon, these babies in the prenatal NICU, are they, when they're born, they've got this condition?

Dr. Herndon: No. Most babies are not. Most babies are born on the regular ward, and a small subset will be delivered in the NICU, but that's very uncommon. Most of these babies are delivered at community hospitals, or they might be delivered at UVA. They have an ultrasound after the baby's born. Most of this work up is done as ambulatory, so in the clinic. They would come back and see me at one month, and we would repeat the ultrasound. If the patient is one of those moderate- to high-risk stratifications, then we would have the invasive testing, where we slip a little catheter in the bladder and use contrast to determine if urine backs up to the kidney, or if there's an abnormality with the urethra, the tube that leads from the bladder.

Melanie: Dr. Herndon, in the last 20 seconds or so, explain to the listeners why they should choose UVA Children's Hospital for care for this condition.

Dr. Herndon: One of the reasons is we offer a multi-specialty approach. I run a prenatal clinic with maternal-fetal specialist, Chris Chisolm and his group here at UVA. That gives us the opportunity to meet the families prenatally and to meet the mother and to explain to her what the risk stratification is for her baby. And then that allows one, for education; and two, for her to know what to expect postnatally.

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 for listening.
Hosts Melanie Cole, MS

What Are the Signs of Huntington’s Disease?

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Segment Number 1
Audio File virginia_health/1351vh5a.mp3
Doctors Harrison, Madaline
Featured Speaker Dr. Madaline Harrison
Guest Bio Dr. Madaline Harrison is the director of the UVA Huntington's Disease Program, recognized as a Center of Excellence by the Huntington's Disease Society of America. In addition to Huntington's disease, she cares for patients with a range of movement disorders, including Parkinson's disease, tremor, dystonia and Tourette's syndrome.

Organization: UVA Huntington's Disease Program
Transcription Melanie Cole (Host): Huntington's disease is one of the most common genetic disorders in the United States affecting more than 250,000 Americans. My guest is Dr. Madeline Harrison. She is the Director of the UVA Huntington's Disease Program, recognized as a center of excellence by the Huntington's Disease Society of America. Welcome to the show, Dr. Harrison.
Tell us, what is Huntington's disease?

Dr. Madeline Harrison (Guest): Huntington's disease is a hereditary neurodegenerative disorder, meaning that it is inherited and causes loss of brain cells that results in a number of symptoms that progress over time.

Melanie: What age do you typically see the onset?

Dr. Harrison: It's more variable than we originally thought, but most typically, the symptoms become apparent somewhere between the ages of 35 and 55.

Melanie: So what causes it? Is there a genetic component? Are there certain risk factors people can be aware of?

Dr. Harrison: It is a genetic disorder, so that the principal risk factor is coming from a family with Huntington's disease. When they've identified the specific change in the gene that causes the disorder, it's a specific expansion, and it's passed from parent to child so that each child of an affected individual has a 50 percent chance of inheriting the genes.

Melanie: So if a parent had that, do you recommend a genetic test? Do they need a genetic test to say whether they have that gene or not?

Dr. Harrison: Well, the genetic test is highly specific and will certainly indicate if they have the genes. About 95 percent of the time, the mutation is very specific and has specific features. That's called a CAG repeat expansion. There's a certain of repeat sequences that will result in the disease. Deciding to have genetic testing is a very individual decision, because you have the genes on birth. But the symptoms may not appear into midlife, as we discussed. So, for diagnostic purposes, it's very helpful. But the clinical symptoms are what actually indicate that the disease has begun.

Melanie: What are the symptoms of Huntington's disease? When do they appear? What do you notice?

Dr. Harrison: It's variable, but there are three areas that are affected in the majority of the individuals at some point along the course of the disease. Often, the first changes are subtle changes in cognitive efficiency—ability to organize information. Sometimes, there are mood and personality changes early on. The most characteristic symptoms are changes in motor function. People develop extra involuntary movement called chorea. It's the most common. And also, difficulty coordinating movements necessary for simple tasks, for walking, for performing coordinated tasks with your hands. Those are the symptoms that are the most definite indications that the disease has started.

Melanie: These are movement disorders. What about cognitive disorders, or psychiatric? Are there any others that go along with these?

Dr. Harrison: Yes, there certainly are. There's a very high incidence of psychiatric disorders that can really take any form. Most common are what we call mood disorders. People maybe come in depressed. There's a high rate of serious depression, even suicide, in the illness. Often, people who are very even-tempered can become irritable unexpectedly and unpredictably. But these are fortunately very treatable symptoms. The cognitive changes are not. They are really organization and information handling. It's not as much of a memory problem as, say, something like Alzheimer's that people are more familiar with. But it certainly can create difficulties at home and at work, particularly with complex tasks.

Melanie: What treatments are available for Huntington's disease? If you start to notice some of these symptoms, cognitive disorders, movement disorders, can there be something done to slow the progression, or is it symptom management? What kinds of treatments are available?

Dr. Harrison: Currently, what we have available are treatments for symptom management. Fortunately, we can generally very effectively management the mood or psychiatric symptoms using the same treatments that are successful in other settings—the same antidepressants that are useful in a wide range of conditions are helpful here, for example, and similarly for some of the other symptoms. We can also help suppress the extra movements if they're causing problems. Sometimes they're very visible, but not limiting the person. But we do have treatments, and the only FDA-approved treatment for Huntington's disease is actually directed at the chorea component of the disease. For the cognitive, we don't have specific treatments, but there's a lot of workaround and strategies that we work closely with physical and occupational therapy to help people manage effectively in spite of some of these limitations. What we don't have yet is neuroprotective diseases therapies, or what we call disease-modifying therapies, which could slow the progression of the disease. But there's very active research going on worldwide into promising treatments that would actually give us the ability to slow down or, one day, we hope, prevent the development of the symptoms.

Melanie: Tell us a little bit about what UVA does to help patients with Huntington's disease, Dr. Harrison. Are the family members involved? Because I would imagine this is a difficult disease both for the patient and for the family members involved.

Dr. Harrison: Well, that's absolutely correct. Family members are very much involved. It's really a team approach between the professional team and the affected individual and their family or caregivers. We have a monthly clinic with participation by , myself and a nurse practitioner and another neurologist. We now recently have a psychiatrist who has joined us. There's a physical therapist, occupational therapist, speech language pathologist. Our genetic counselor is there, and we have neuropsychology services available as well, for both counselling and for cognitive assessments. In the monthly clinic, the patient and family arrive, and they're seen by each of the professionals in the course of a morning or afternoon visit. They help assess where they are functioning, what they need for safety, what medications they may need to help manage their symptoms and to assist them with planning and resource utilization. And I've neglected to mention, a very important member is our social worker, who works with families before and after clinic to get the kind of help they need.We have all these in one visit at one place. I'm fortunate to have a team that many of them have been working together close to 15 years doing this now.

Melanie: It sounds like a very multidisciplinary approach and really very complementary and would help the families. Give us your best advice for patients with Huntington's disease or someone that they love might be suffering from this disease.

Dr. Harrison: Well, I think the most important advice I would give you would be to see someone who has experience with Huntington's disease. Although, there are estimates of, as you mentioned, close to 200,000 people with or at risk for Huntington's disease, it's still not a disorder that most physicians are familiar with, and certainly not in terms of the day-to-day management. So I think it's very important to get advice from someone who has specialized experience with Huntington's disease. And many movement disorders physicians are in a position to offer good advice. There are centers around the country with specialized teams, both the HDSA centers and other specialty clinics. I think that there are more and more available to patients and families, and the HDSA also has a network of support groups which can be critically important, particularly for the caregivers. And then, I think working with the team and partnering with the local physicians to make use of that expertise can make it a big difference in how well people manage with the disorder.

Melanie: Thank you so much, Dr. Madeline Harrison, the Director of the UVA Huntington's Disease Program. For more information, you can go to uvahealth.com. You're listening to UVA Health System radio. I'm Melanie Cole. Have a great day.
Hosts Melanie Cole, MS

The UVA Health System NICU

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Segment Number 5
Audio File virginia_health/1346vh5e.mp3
Doctors Kaufman, David
Featured Speaker Dr. David Kaufman
Guest Bio David Kaufman is a neonatologist at UVA Children's Hospital. He's board certified in pediatrics as well as neonatal-perinatal medicine.

Organization: UVA Neonatal Intensive Care Unit
Transcription Melanie Cole (Host): Hi. My guest is Dr. David Kauffman. He is a neonatologist at UVA Children's Hospital. Welcome to the show, Dr. Kauffman. Let's talk about the NICU at the University of Virginia Health System. What type of patients do you typically see there?

Dr. David Kauffman (Guest): Well probably most people think of a NICU as a place for pre-term babies, and we take care of some of the most immature babies born at 22, 23 weeks of gestation, when pregnancies are complicated by preterm labor or need to deliver early. But we also take care of a lot of term infants. For some families, unfortunately, there may be a child with a birth defect or there's a difficult delivery, and the babies need additional care after it's born.

Melanie: So, term infants and premature babies are there. Now, what types of conditions might make a baby be in the NICU, and in such a scary place for the parents, too? So first, speak about the conditions a little bit. What are you doing for them?

Dr. Kauffman: Some of the most difficult situations is when someone is expecting a normal, healthy child, and something happens around the time of delivery and the baby needs additional support, whether it's a ventilator or some oxygen. But oftentimes, these babies might be at risk for brain injury because of the difficulties at delivery. So one thing we have at UVA is a cooling protocol, in which kids who may be at risk for brain injury get cooled from normal temperature, 98.6 degrees to 92 degrees for three days. This helps prevent some of the cells that might be in shock from what happened at delivery to recover and improve outcomes for those families and those kids.

Melanie: You mentioned that one of the more difficult is when you're expecting a healthy delivery, and all of a sudden, something does go wrong. Now, are many of the things that you see things that have been predicted so the parents kind of have a little bit of an expectation that they're going to deliver a baby that's going to be in the NICU?

Dr. Kauffman: Yes. Sometimes, with birth defects, families will be referred to UVA, our perinatologists who help take care of them while they're pregnant. We as the neonatologists take care of the baby and the family after delivery. One of those defects is called the congenital diaphragmatic hernia. For example, these patients would be referred here. We have an excellent team that includes pediatric surgeons, the neonatologist. Everyone in the NICU is specialized in neonatology, from the nurses, neonatal nurse practitioners, and all the care partners. These babies, their diaphragm of their lung has a hole, and the intestines migrate into the chest, preventing normal lung development. So they can be very sick at birth and need sort of general ventilation. At times, they may be very, very sick and need to be put on a heart lung bypass machine for several days. With this team and this approach, we have great outcomes similar to major centers elsewhere, and it's good that those patients can get that care right here in Charlottesville.

Melanie: Speak about the team approach. Who is involved in the NICU? What is the team that really works with the babies and with the parents? Because as I said before, how scary for parents. They've been expecting this very happy time, and all of a sudden, it's turned into something that could be very serious and scary. How does your team deal with both the parents and the baby, and who is involved?

Dr. Kauffman: Well, initially, there are a lot of people from just getting greeted at the desk when they come in by our health care coordinators, and then, at the bedside, the nurse plays an invaluable role in just meeting the family, orienting them to everything that is happening to the baby, and the physicians and neonatal nurse practitioners as well. I think the biggest thing when we've looked at what families need is they need to feel they can trust us and they sort of know what's going to happen the next 24 hours. So I think them getting to know us and us communicating openly, talking about everything that happened and what's going to happen the next hour or the next 24 hours, it helps families give trust. Obviously, we want and they want to be with their baby at home, and to give up that care to the NICU is challenging. So I think establishing a good relationship and communicating what's going on really helps ease families through this roller coaster in the NICU.

Melanie: Dr. Kauffman, what makes them so specialized, the nurse practitioners and doctors such as yourself? I mean, this specialty, you have to really be trained to do this, correct?

Dr. Kauffman: Yes. So for the physicians, they go through a three-year pediatric residency and then additional three years of neonatal medicine. The nurses, in addition to nursing school, get special training when they first get to the NICU for about half a year to a year, and then their years of experience. Similarly, the nurse practitioners are nurses who then go through a two-year training to become neonatal nurse practitioners.

Melanie: It takes a lot extra training and a certain amount of empathy for what these parents are going through. So speak about how you deal with the parents, because some are probably more difficult to deal with than others. How do you calm their fears?

Dr. Kauffman: Well, I think listening to families really helps us know what each family needs. Sometimes they just need to know what's going on. Sometimes they just need to know how much the team cares about their baby who's in the NICU. And I think just listening to their questions and trying to guide them to what's happening. They're worried if the baby will survive or not come home or not come home this week versus a week from now. You know, it's really about trying to figure out what they need to know to help. The other thing we try to do is get them involved in the care, even if it's the littlest thing of touching their baby. Like at 24 weeks, the baby is so small. Their wrist is as big as a wedding band ring, and people are afraid. They don't know if they can touch their own babies. So just helping them know they can do that, they can read to their child, and they can still care for the baby, they know we're doing it together with them.

Melanie: That's really great to hear, Dr. Kauffman. We've all seen those little babies in there and what they look like, and they're just so small and so helpless, and so I can only imagine what parents are going through, and I certainly applaud all the work that you do. Now, what about outcomes? The real positive stuff, give us some of the hope that you've seen going on.

Dr. Kauffman: Well, through the years, it would be unthinkable for certain babies to survive, but even at pregnancy where someone has to deliver at 23 or 24 weeks, the majority of those babies can now survive where 20 years ago, almost all of those babies would not be able to go home with their families. Every week makes a big difference as far as how the babies do. All have some risks of developmental delay, and that's something we work and follow the kids once they leave the hospital. But for example, at 24 weeks, about 80 percent of the kids survive now, and about 70 percent have normal outcomes. Then once you get to 28 or 29 weeks, 90, 95 percent of the kids are surviving with good outcomes.

Melanie: That's great information for parents that are scared and that the UVA Health System in the NICU, these doctors are specially trained, as are the nurse practitioners. They're sensitive to what you're going through and have such positive outcomes that there is really a lot of hope that things are going to go well. You're 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

Options for Treating Heart Failure

Additional Info

Segment Number 4
Audio File virginia_health/1346vh5d.mp3
Doctors Kennedy, Jamie
Featured Speaker Dr. Jamie Kennedy
Guest Bio Dr. Jamie Kennedy is a fellowship-trained specialist in heart failure who is board-certified in both internal medicine and cardiovascular disease.

Organization: UVA Heart Failure and Transplant Center
Transcription Melanie Cole (Host): More than 5 million Americans have heart failure. The treatment advances that are providing new hope to patients with this often serious condition are out there. My guest is Dr. Jamie Kennedy. She's a fellowship-trained specialist in heart failure who is board certified in both internal medicine and cardiovascular disease. Welcome to the show, Dr. Kennedy. Please explain for the listeners: what is heart failure? They hear heart failure, they think heart attack, stroke, but it's different. It's a condition and can be a chronic condition. Explain a little bit about heart failure for us.

Dr. Jaime Kennedy (Guest): Heart failure describes a whole host of different disease processes that all have similar symptoms. That's namely fluid retention, so swelling in the legs and in other body parts as well. The other key symptom is exercise intolerance. Patients may be comfortable sitting still, but when they do more strenuous activities as far as climbing stairs or walking up a hill, they develop shortness of breath and fatigue to the point where they're not able to do those activities anymore.

Melanie: Heart failure, Dr. Kennedy, can develop over time as the heart's pumping action grows a little bit weaker. So it's not pumping that fluid out of the lungs, around the lungs, and up from the legs, correct?

Dr. Kennedy: It's a combination of inability of the heart to pump efficient blood to the rest of the body and then the body's compensatory mechanism that cause fluid retention in the legs, in the lung, everywhere.

Melanie: If you notice this fluid retention, you notice this edema in your legs, in your ankles, around your abdomen, or you're coughing, you're having exercise intolerances, you say, which is not just normal exercise intolerance but a little bit more severe, and they come to see you, what can they expect? How is this diagnosed?

Dr. Kennedy: We use a lot of different tools. One of the most important is just talking with the patient to explore their symptoms and then examining the patient to look for signs that we see in patients with heart failure. As far as more specific testing, what's called an EKG is very helpful. It just looks at the electrical activity of the heart, and that helps us to know if abnormal heart rhythms are part of the problem. The other test we rely on a lot is that called an echocardiogram. That's basically an ultrasound of the heart. It's very much used to look at pregnant women, the babies that they're developing in the uterus. But we're using the same technology to look at the function of the heart that helps us to know if the heart muscle is weak, if there's heart valve problems, either leaking or not opening well, a whole host of problems in the heart that can lead to the heart failure syndrome.

Melanie: Now, how is this treated? If there are underlying causes such as coronary heart disease, blood pressure problems, diabetes, anything that might contribute to congestive heart failure, what do you do for treatment?

Dr. Kennedy: That goes back to the wide range of different disease processes that can lead to heart failure, and then we have to look into each one of those processes and treat it appropriately. Like you said, if a patient has high blood pressure, then we need to get that blood pressure under control. If a patient has coronary artery disease narrowing their blockages and heart arteries, then we consider whether bypass surgery or stents in those arteries would be helpful. If patients have valvular heart disease—one of their valves is too tight, it doesn't open enough or if it's open [wide too well] it leaks—then we consider whether repairing or replacing the valve in some way would be helpful. If the heart muscle itself it weak, unfortunately, there's no perfect fix for that, but we do have medications which can help the heart to recover in some cases, and in many, many cases can, help a heart to be as efficient as possible despite its weakened state. All of these things, the goal, of course, is to keep people feeling well, as active as they possibly can be, keep them out of the hospital, and obviously, keep them alive.

Melanie: When you're talking about treatments—and you mentioned medications, making sure to get the blood pressure down to reduce the strain on your heart—what about things like diuretics? If fluid does start to build up, is this something that you're on permanently now for the rest of your life?

Dr. Kennedy: It really depends. We use diuretics, of course, or medications to help people get rid of extra fluid. Some patients will need them forever. Some patients, as we treat the other processes involved, their need for diuretics can be reduced or even, at times, eliminated. Diuretics, we really use as we need to. It's not mandatory necessarily. The patient will need a diuretic only when fluid retention is a problem.

Melanie: What about lifestyle changes, Dr. Kennedy? Do you work with patients in lifestyle changes so that the workload of their heart is reduced? What are those lifestyle changes you might work with them about?

Dr. Kennedy: Yes. Absolutely. Lifestyle modifications are a huge component as well. We do encourage patients to exercise, though I ask them to try to be smart about it. I ask them not to push themselves to the point of gasping for breath. I also ask them to avoid any really heavy lifting type activities to where they're straining. Then, obviously, if they are feeling profoundly short of breath, chest pain, lightheaded or dizzy, or passing out, they need to stop whatever exercise they're doing and rest and recover. Dietary changes are also a big part of heart failure care. Especially in patients who tend to retain fluid, keeping the amount of sodium in your diet to a reasonable level can help with that problem because sodium, where sodium goes, water tends to follow. In general, Americans eat a colossal amount of sodium every day, at least 4 to 5 grams in the average American diet. We ask patients with heart failure to try to keep that closer to 2 grams of sodium a day. Obviously, sodium is necessary for your body's processes and you cannot eliminate it completely because that is equally harmful. But trying to keep it to a moderate level can be helpful. Also in patients who tend to retain fluid, we ask them to limit the amount of fluid that they take in to minimize the fluid retention problem. Again, you do need some fluid. You can't eliminate that completely. But we ask folks to keep it to about two liters of fluid a day.

Melanie: What about alcohol?

Dr. Kennedy: Alcohol actually can cause heart failure in itself in patients who drink to excess. There are some people who have a very difficult time controlling their alcohol intake. And those individuals, I tell them that they need to eliminate it completely. In patients who enjoy a drink once a week, I think that's a reasonable thing to continue. There's a little bit of data that red wine can be somewhat helpful for heart function. If you're going to drink something, red wine might be something to drink.

Melanie: Okay. You've talked about fluid intake. You've talked about alcohol and lifestyle changes and exercise, and I do want to just bring out that you mentioned about heavy lifting, that Valsalva maneuver, that holding your breath and pushing really hard, that can actually worsen congestive heart failure, correct? It can aggravate it.

Dr. Kennedy: Patients just tend to not tolerate that sort of activity very well. They tend to get profoundly short of breath and also extremely lightheaded and can pass out.

Melanie: If you would just sort of wrap it up for us, heart failure patients coming to UVA for care, what can they expect, and what are the most recent advances that you can tell them about?

Dr. Kennedy: I think it's a very tailored treatment plan because it does depend so much on the individual's characteristics as far as our disease process as well as the rest of their life. But we can promise it's a very individualized treatment plan depending on what the individual needs.

Melanie: It's an individualized treatment plan, and there's lifestyle changes, medication, and it's symptom management and getting that heart failure under control, and all of the things that might go along with it. You're 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

House Calls for Your Children

Additional Info

Segment Number 3
Audio File virginia_health/1346vh5c.mp3
Doctors Brown, Amy
Featured Speaker Dr. Amy Brown
Guest Bio Dr. Amy Brown is a pediatrician who runs the pediatric home visit program out of the UVA Health System Primary Care Center.

Organization: UVA General Pediatrics at the Primary Care Center
Transcription Melanie Cole (Host): Some doctors still do make house calls. Do you have one that does? Pediatric Home Visit Programs from UVA Health System Pediatrics are something you should look into. My guest is Dr. Amy Brown. She's a pediatrician who runs the Pediatric Home Visit Program out of the UVA Health System Primary Care Center. Welcome to the show, Dr. Brown. Why are home visits so important? What is the difference between getting parents to bring their kids in for their well visits, for their appointments to the doctor's office, and the advantages of having your doctor come to you?

Dr. Amy Brown (Guest): Yes. Thanks so much for having me on the show today. Home visits are an incredibly useful tool for pediatricians, and really, all of the auxiliary services that are involved in child health in the community. Somebody said, "A picture is worth a thousand words." That is definitely true. When you go to a child's home, apart from a 10- or 15-minute visit in the office, you gain so much more information about the child's circumstances, the family dynamics, safety issues. You are able to better assess a child's development in their own natural environment. It helps pediatricians, I think, guide services for these children and plug them into community resources that prepare them for school readiness, and catch kids that are falling by the wayside.

Melanie: Now, Dr. Brown, this is not necessarily for underserved population, is it?

Dr. Brown: No, absolutely not. The Department of Health and Human Services is really taking a look at this, especially with the authorization of the Affordable Care Act. It's primarily focused on early interventions targeting prenatal, postnatal visits, and infants and young children. Doctors have been doing house calls for generations. Decades ago, this was the standard. Your doctor came to your home. They knew your family. They knew where you lived. I think that's an art of medicine that we have really lost in our generation, in our current healthcare system, because doctors have lost the ability to know their patients that way.

Melanie: Do you all have enough time in your day? Because I see pediatric offices, and I applaud all of you pediatricians, because what a field you have entered. But do you have enough hours in your day to see as many patients as you could if you have to go house to house?

Dr. Brown: It's certainly difficult, especially with current reimbursement structures with health insurance companies. But what we've tried to do at UVA, we train a lot of future pediatricians here. We have a well-developed residency program. Back in 1995, one of our attending physicians really had the forethought to say, "You know, this is important for young physicians to understand where their families come from and the neighborhoods in which they live and to get outside of the hospital." What we've done is we've incorporated that into part of the residency training, where once a month, we take a team of physicians, small group of physicians, and we're able to spend an entire day going and visiting our primary care patient from our pediatric center here at UVA. It's been effective, and I hope that the community also sees the services for them that they don't have to fight the traffic and drive four kids into the clinic. We make it actually useful for them to stay at home, and we bring everything to them.

Melanie: I think it's awesome. I would absolutely love a pediatric home visit because fighting the traffic, waiting for the other kids to finish. Pediatric offices are well-known to be germ infested.

Dr. Brown: Yes, definitely.

Melanie: It's like you go in there for a well visit and you're worried, you're looking around and all the kids that are in there being sick. I think it's incredible that you're doing this, and certainly at UVA Health System. Now, early intervention. You can catch children with any kinds of needs for early intervention. Also, as you stated, looking at the home environment. Are there effects that you can look at maybe decreasing child abuse, possibly, or smoking in the home, educating the entire family as opposed to just what you do with the child?

Dr. Brown: Absolutely. Some of that never comes out in an office visit. But when you're in a home, you see such a better picture of what's going. It's a great opportunity to sit there and say, "You know, I noticed such and such about your house. I noticed you have stairs but you don't have a gate on, and you have a toddler." Then we are able to discuss the risks of fall hazards or other safety issues in the home that we would have never been able to know in the office. That's something that is really coming down the pipeline when we look at the outcome measures of home visiting programs for young children and infants. But they're really trying to improve prevention of child injuries, prevention of child neglect, child abuse, addressing early developmental skills and school readiness. I think we're going to see that there's some great research that comes out of that.

Melanie: In the high-risk populations, I would suspect that this is even doubled in its long-term effects that you can be looking at things like child abuse, as you say, and neglect, and even possible criminal behavior of the parents. You can get a handle on all of it, and you're the expert, so you can help the family as a unit.

Dr. Brown: Absolutely. There have been some studies that have shown kids or young children with families that received home visits were able to keep their well child checks 3 to 10 times higher than families who didn't. That just ties them back into the medical system where they actually have a medical home. For us, we see it as we're our patients medical home but we're out in their communities. We're out in their houses, and we know their neighbors. For us, that's a great benefit. That's why many of us went into medicine in the first place.

Melanie: Is there a different type of care you provide at the home visit? You're still doing blood pressure. You're carrying around your sphygmomanometer with you. You're still doing vaccinations. Are you carrying all these things with you?

Dr. Brown: Yes, absolutely. We actually take everything into the home so we can do the head circumference, the weight, the height. We bring vaccines on our visits. Many times, we're doing more extensive developmental assessments than we would be able to do in the clinic. I think another benefit of the home visits for us is to really plug those kids in that have chronic medical illnesses. We're not sure what the compliance is at home with their therapies, and so we're able to address kids with chronic asthma or chronic eczema, ADHD. We do really a full spectrum of visits in the home.

Melanie: Plus, you're making sure that these kids are getting vaccinated, where maybe parents say, "It's just a well visit. I'll blow it off this year. We'll do it in a couple of months." This way kids are getting their flu shots and their vaccinations on time because you're coming to them.

Dr. Brown: Yes, absolutely. There are a lot of kids that have missed well child checks, so it's an opportunity for us to really call those families and say, "You know what? How about we come to you?" Because sometimes transportation is an issue or missing work for a parent is a big issue. To be able to go to the house and take care of that and catch up on their vaccines and really assess how this child is doing after not having seen them for a couple of months, it's very helpful for us, and important.

Melanie: Now, with UVA's Child Care In-Home Pediatric Visits, tell us a little bit about how you go about getting involved in this program.

Dr. Brown: Sure. We offer home visits typically on the third Friday of every month, then we try to stack the whole day with families that we're going to see within up to an hour of our academic center here in Charlottesville. Well child checks, it's fixed visits, it's follow-up visits from the ER, newborn follow-up visits from the new born nursery, and anybody who considers the Pediatric Primary Care Center their medical home are eligible to participate in the program.

Melanie: Do you have to sign up? Do you have to meet special requirements? Or if you're just part of this pediatric care program, you can get in on that? It's third Friday of every month, correct?

Dr. Brown: Mm-hmm. Yes. Usually, we consider everybody eligible. Obviously, we try to save some appointments for some of those kids that have been lost to the medical system, so can really pull them back in and then get them caught up in the vaccines or whatever. But anybody is eligible that considers us their primary care or clinic or medical home.

Melanie: What a great reason to use UVA Health System's Primary Care Center Pediatric Home Visits. You're 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

What Are Your Options for Preventing Colorectal Cancer?

Additional Info

Segment Number 2
Audio File virginia_health/1346vh5b.mp3
Doctors Friel, Charles
Featured Speaker Dr. Charles Friel
Guest Bio Dr. Charles Friel is the Chief of Colon and Rectal Surgery at UVA Health System. His specialties include surgical treatments for colorectal cancer and inflammatory bowel disease.

Organization: UVA Colorectal Surgery and UVA Cancer Center
Transcription Melanie Cole (Host): Colorectal cancer is preventable. You can learn more here about the symptoms and the best screenings and options to protect yourself. My guest is Dr. Charles Friel. He's the Chief of Colon and Rectal Surgery at UVA Health System. Welcome to the show, Dr. Friel. Let's first talk about commons signs and symptoms of colorectal cancer. Then we're going to move on to the screening process.

Dr. Charles Friel (Guest): The first thing to really understand is that a lot of times, there are really no signs and symptoms of colorectal cancer. I think the most important kind of risk factor is age. As we get older, this is something we need to think about. Fifty is the key age to remember. Having said that, certainly, if you have any kind of changes in your bowel habits, if you see blood in your stool, if you see a change in constipation, perhaps your stool becomes a little bit smaller or thinner, or you have crampy abdominal pain or chronic anemia, all those things can be symptoms of colon cancer. If you have any of those things, then you should be evaluated by your doctor, and your doctor may suggest a test such as a colonoscopy. But not all people have symptoms, so just keep that in mind.

Melanie: Dr. Friel, you mentioned blood in your stool. Hemorrhoids cause blood. People freak out. They see blood. They run to a guy like you and say, "Oh my god." Is there a difference that you can tell when you see blood like that?

Dr. Friel: There can be. There are classic findings of hemorrhoids where there's a little blood on your toilet paper. But I think a common mistake is that people just dismiss blood in the stool as being hemorrhoids. While it's most common, especially if you're young, that you have a little blood from hemorrhoids, it really should be evaluated. Unfortunately, I've even seen very young people with colon cancer. Just don't dismiss your bleeding as your hemorrhoids, and get it evaluated, because it could be a sign of colon cancer.

Melanie: You mentioned 50. When should people start getting screened? I get my colonoscopies every three years. Because things run in my family, I started younger. But what time should people typically start getting their colonoscopies?

Dr. Friel: Now, you raise a very important point. The first risk factor, as I talked about, is age. We screen people who are considered to be moderate risk for colon cancer. All of us, by definition, become moderate risk at age 50. I think for the general population, you should remember age 50. You should be getting your first screening test. Most of the time, that involves colonoscopy, but there are other options, and you can talk to your doctor about those other options. However, some people are at higher risk. Family history can be significant. If you have a family member who has colon cancer, your doctor may recommend that you begin screening earlier. That could be typically at age 40. Other risk factors are some genetic disorders that are associated with colon cancer. If you have any genetic disorders, you might be getting a screening earlier. Certain diseases like ulcerative colitis can put you at risk factor for colon cancer. There are other higher risk factor groups, and you just discuss these with your doctor and they would make recommendations. But 50 is the key age to remember.

Melanie: Let's give a quick running definition of the colonoscopy. It's not nearly as bad as people think. The prep is really only the bad part. You're not even awake for most of it. They say bye-bye and you're out, and when you wake back up, it's already done. Tell people how easy this great preventive screening test is, Dr. Friel.

Dr. Friel: Absolutely right. It's a pretty straightforward test. I have had one myself. As you pointed out, I think even the prep, people can tolerate pretty well. But I think that's the most difficult part for people. It is critically important though that you work hard at your prep because we need a nice, clean colon to get a good look at your colon. If you don't do a good prep, then you will have a poor test. If you have a poor test, it really is not as effective for you. So work hard on your prep. But once you get to the procedure room, we do give you some medications which make you nice and sleepy. Most people don't remember anything. The next thing they do is they wake up and the first thing they ask me is, "Have you started yet?" and by then, the test is over.

Melanie: It's so easy. It really is. Now, what if you tell them that you've found polyps? Is that something to be scared of?

Dr. Friel: Actually, we don't want to have polyps if we can avoid it. But if there is a polyp in your colon, you want it removed. One of the real advantages of colonoscopy is not only are we looking for an early cancer. Hopefully, if you have polyps, we'll find your polyps and we can remove your polyps. Polyps are not cancers, but we do consider them to be pre-cancerous. If you remove the polyp, we can in fact potentially prevent a cancer from forming in you over time. While none of us want to have polyps, you shouldn't be afraid of them. If they're in you, we want to remove them, and we can do that easily with a colonoscopy.

Melanie: Then you test the polyps, make sure that these are benign, nothing that we should be scared of. What if, God forbid, they're malignant?

Dr. Friel: As you just pointed out, polyps, by definition, are considered to be benign. They're considered to be pre-cancerous. A malignant polyp just has a little bit of cancer in it. By definition, then you actually technically have colon cancer. Most of the time, that may involve an operation, but sometimes not. But most of the time, that's going to involve an operation, and that is something that I do on a regular basis. We can cure many, many people with colon cancer. It's not something to be afraid of. It's a treatable disease. You just need to consult your doctors, and they can help you with that.

Melanie: Treatments. You can have surgery to remove any of the cancers that you see. What else? Is there chemotherapy involved? Radiation? People are scared of this cancer, Dr. Friel, and you're giving us a lot of hope and positive messages. Continue that. Speak about the treatments.

Dr. Friel: I think it's really important to understand that getting a cancer diagnosis is extremely difficult, and it can be quite scary. But colon cancer is a very treatable disease. It almost always involves an operation where we remove the colon cancer itself. Most of the time, we can put your colon back together so you don't have to have any bag—the other thing that people are really quite frightened about. Is that the case all the time? Unfortunately, it's not. But for most patients, we can take the piece of the colon out and do this without any significant long-term problems. As far as other treatments are concerned, it really depends on the stage of your colon cancer. If you have a little bit more advanced disease, which is still curable, we will frequently use chemotherapy. As for radiation therapy, it usually revolves around people who have what we call rectal cancer, which is just a slightly different version of colon cancer. But oftentimes, we will use radiation for rectal cancer.

Melanie: Are there drugs that, like with breast cancer, maybe you go on tamoxifen for five years or something? And then what's the follow up?

Dr. Friel: Yes. We don't typically leave you on long-term medications for colon cancer, but it is important that you have continued follow-up. Some cancers can come back, but we actually have pretty good treatment for that too. The most common place that a colon cancer will come back is in your liver. Here at University of Virginia, we've got several specialists who are liver surgeons who can remove these cancers from your liver, and you can still have a very good long-term result. It is important that we do frequent surveillance of your entire body, which will probably include a CT scan. The other thing that's important is, as just you pointed out, you get your colonoscopies every three years. If you've had a previous colon cancer, you are at risk to develop another colon cancer in the future or another polyp. We probably would put you on a schedule. We would be doing more frequent colonoscopies for the rest your life.

Melanie: When patients are choosing UVA for their colorectal cancer screenings and treatment, what can they expect?

Dr. Friel: I think what you can expect is a comprehensive team of doctors that's thinking about you personally. We try to look at your case individually. We have a multidisciplinary tumor board that will include doctors that are gastroenterologists; it will include surgeons like myself, who operate almost exclusively on the colon; and we have liver specialists; an oncologist who will be looking at your case and thinking about you and thinking about all the options that are available to you. We try to treat you in a comprehensive manner with all doctors that are really thinking about this disease, that are specialists in their area.

Melanie: In the last 20 seconds, Dr. Friel, best advice on colorectal cancer screening and prevention.

Dr. Friel: Probably the most important thing is that you do get your screening. Remember, age 50 is the year. When you get your 50th birthday, that's your birthday present: a colonoscopy.

Melanie: I love that advice. That's great advice. Give yourself a 50th birthday present that's going to give you many more birthdays. Get your colonoscopy. It's easy. It's not as difficult as you might think. It could save your life. You're 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

Is it Normal Aging or Alzheimer’s Disease?

Additional Info

Segment Number 1
Audio File virginia_health/1346vh5a.mp3
Doctors Fernandez-Romero, Roberto
Featured Speaker Dr. Roberto Fernandez-Romero
Guest Bio Dr. Roberto Fernandez-Romero is a neurologist at UVA Health System's Memory and Aging Care Clinic. He specializes in treating patients with Alzheimer's disease and dementia.

Organization: UVA Memory and Aging Care Clinic
Transcription Melanie Cole (Host):Is the memory loss you're experiencing a common part of aging, or could it be a sign of a memory disorder like Alzheimer's disease? My guest is Dr. Roberto Fernandez Romero. He's a neurologist at UVA Health System's Memory and Aging Care Clinic. Welcome to the show, Dr. Fernandez. What are some of the normal changes to your brain's function that you can expect? We have age-related dementia, and sometimes we forget little things, but what are some of the things that we can expect to happen as a normal part of aging?

Dr.Roberto Romero (Guest): Just like the rest of our body, our brains experience significant changes as we get older. However, not all of these changes have to be negative. Actually, there are many brain functions that can benefit from life experiences and the things that we tend to practice and do on a regular basis so they can actually improve with age. Things like vocabulary, for example, or just general knowledge can be better or get better with age because we tend to accumulate those memories and experiences over time. They can also shape the way we react in certain situations, and so we sometimes tend to be better at responding in certain circumstances. That's something that many people call wisdom, which is something that comes with age. However, there are many other brain functions that do get affected negatively with age. These are cognitive functions that typically rely on things like quick thinking or fast reaction or mental flexibility, and also things like attention, which can be sustained attention, just keeping focused on something in particular, or divided attention, which is focusing on different things at the same time. These are things that require a lot of brain activity and require sharp connections between different parts of the brain, and those can get affected with age. It is not uncommon for older individuals to have more difficulty with things like multitasking, for example, that requires the ability to divide our attention between different tasks or problem solving or quick decision making, which are things that are not so much dependent on our life experience and practice but, rather, our ability to respond quickly. Likewise, the reaction times that require, for example, a motor action in response to a stimulus are things that we see typically that tend to decline with age. Perhaps the best example of this would be driving a vehicle, which requires your ability to respond quickly in certain circumstances.

Melanie: We do notice, Dr. Fernandez, that older people, their response time in driving gets a little bit less. We worry about them having their licenses longer, and that's part of that brain function. But what are some of the signs? If you lose where your keys are, that's one thing. What are some of the red flags that might signal that somebody is sort of entering that first phase of Alzheimer's that might send them to see someone such as yourself?

Dr.Romero: Yes. The important thing to keep in mind is that there are subtle things that happen with age, with memory, like you mentioned just losing your keys every once in a while or things like forgetting a word now and then. But when these things become frequent enough that they are actually interfering with the way you do things, or when family members or friends or caregivers start noticing that these memory lapses or these changes in behavior are affecting your day-to-day activities, that's when you should start getting concerned. Things like difficulty, other than memory problems is the first thing we would think about with Alzheimer's disease. This can be having trouble remembering recent conversations, or if people start repeating themselves or asking the same questions over and over again. That should always be a red flag. Misplacing things around the house every now and then is okay. But if you're constantly misplacing your glasses or your keys and have to search for them and cannot find them, then that can be also concerning. But there are other signs that are not necessarily related to memory that is important to keep in mind because we typically don't tend to associate those with Alzheimer's but they are actually very frequent, and those are things like getting lost or disoriented in familiar places when driving, having trouble finding their way around, or things like having difficulties finding words in casual conversation all the time, or even things like having trouble balancing the checkbook. Those are the things that are concerning and we should keep in mind.

Melanie: Are there personality changes that go along with this that we might notice mood changes, personality changes?

Dr.Romero: Yes. There are personality changes. It is not uncommon actually to see patients with early dementia who also have depression. However, depression by itself can mimic dementia. It's always a fine line between which one is causing the symptoms. But we also have to keep in mind, particularly with younger people—so people below the age of 65—there are other types of dementia that have more significant behavioral problems as opposed to memory problems. Even though these are less common or rather rare conditions, they still happen, and they can often be misdiagnosed because people are not looking for dementias in that age.

Melanie: In younger people. That's true. Now, what can UVA's Memory and Aging Care Clinic do to help patients? What's the treatment? If you bring somebody in, they've got mild Alzheimer's, they're in their first stages and you've noticed those personality changes—getting lost, trouble paying bills and handling money, normal daily tasks, any of these things that you've said signal a red flag that would send them in to see you—there's no cure, right? There's nothing we can do to stop the progression? But can we slow it? What can we do about it, Dr. Fernandez?

Dr.Romero: Yes, you're absolutely right in the sense that we currently and unfortunately don't have a cure. There's not necessarily even a medication that we can give to significantly slow down the progression. However, there are advances coming up all the time and there are new therapeutic experimental treatments that are promising. So, making an early diagnosis is still very important. But also, you have to realize that the treatment and care of patients with dementia doesn't just stop with medications and treatments like that, but it also involves giving the support to the families and caregivers and the patients. That includes education so that people know how to cope with the condition and also are aware of how to plan ahead for the future. For the University of Virginia, we are very fortunate. We have the Memory and Aging Care Center, which has a highly specialized multidisciplinary of team of professionals, and that includes neurologists, neuropsychologists, nurses, nurse practitioners, social worker, and even a representative from the Alzheimer's Association. We all work together as a team to give a more comprehensive care to these patients. Also, as an academic center, we have, aside from the expertise to make a diagnosis and begin the appropriate treatment, a significant amount of cutting-edge diagnostic tools that can be particularly helpful in those rare dementias and disorders that I mentioned briefly before.

Melanie: In just the last 30 seconds, Dr. Fernandez, wrap it up. Give hope to the people listening and your best advice about Alzheimer's disease.

Dr.Romero: The best advice is to, first of all, to seek treatment early because, again, there are medications that can help with the symptoms. Also, there's support that can be given to caregivers and families, and also to understand that most of the time, Alzheimer's is a condition that progresses slowly over time. Since we're not necessarily all about memory, there are still many brain functions and qualities that will be preserved for a long time, and so it's important to keep an open mind and be optimistic about the future.

Melanie: Thank you so much. You're listening to UVA Health System Radio. This is Melanie Cole. Thanks for listening.
Hosts Melanie Cole, MS

Helping Children with Cerebral Palsy

Additional Info

Segment Number 5
Audio File virginia_health/1342vh5e.mp3
Doctors Romness, Mark
Featured Speaker Dr. Mark Romness
Guest Bio Dr. Mark Romness is a pediatric orthopedic surgeon at UVA Children's Hospital. He specializes in treating children with special needs, including children with cerebral palsy and spina bifida; gait abnormalities, pediatric lower extremity problems and trauma; and osteogenesis imperfecta.

Organization: Pediatric orthopedics at UVA Children's Hospital
Transcription Melanie Cole (Host): Thousands of children are diagnosed each year with cerebral palsy. What treatments can help improve the quality of life for these children? My guest is Dr. Mark Romness. He's a Pediatric Orthopedic Surgeon at UVA Children's Hospital. Welcome to the show, Dr. Romness. Describe a little bit about what cerebral palsy is and how common it is these days.

Dr. Mark Romness (Guest): Cerebral palsy or CP, as we often call it, is actually a group of conditions, sometimes called an umbrella term. It's where there's abnormal development of movement and posture, type of activities, and that causes limitations in their activity. About two to three children out of every thousand born have cerebral palsy, and about 10,000 babies are born each year that will develop cerebral palsy. There are different types of cerebral palsy and sort of a spectrum involvement. The most common type is what's called spastic cerebral palsy, where the child has muscle spasticity or tightness, most commonly of the extremities, sometimes, the trunk. The spectrum itself is very broad—very mild involvement and very few limitations to much more severe involvement and extensive involvement, where the child requires full assistance for all activities.

Melanie: Now, what about risk factors during pregnancy? Is there anything that you can do, and is this something that's spotted on ultrasound or amnio early?

Dr. Romness: Not usually. It is caused by an injury to the developing fetal or infant brain, so there is something related to the brain injury itself that can occur intrauterine, but there's no specific known causes during pregnancy that can be addressed.

Melanie: Women worry about things like this. Is it something you'll know right when you have that baby? Is it something that you can diagnose, Dr. Romness, pretty much right after the baby is born, or is it something that you start to see with developmental and motor delays?

Dr. Romness: It's not usually completely obvious at birth because it takes some time for the brain and the child and the peripheral nerves to develop before you actually start to see lack of development. That's usually how the diagnosis is made.

Melanie: Okay. So once you start to notice these sorts of things -- and I imagine, for parents, it's pretty scary. So, Dr. Romness, explain a little bit about the progression of this disease, of this condition or set of conditions. Really, starting from the very early age of diagnosis, even six months to a year old, what are parents doing? What are doctors such as yourself doing and even working with early intervention in their school systems? Take us right through.

Dr. Romness: Right. First, the entry to the brain itself is considered permanent but non-progressive, meaning that the brain injury doesn't get worse. But the symptoms that you see in the child can be progressive with time, especially during growth. So they will start to develop problems as they get older. That's why it is a progressive condition, but the injury to the brain is not necessarily progressive. What's done is you sort of monitor those things initially as diagnosis, and again, they are developing ways to diagnose it at earlier ages. People have been coming up with different ways of assessing that and finding things in children that suggest that the child will develop more issues down the road. Your other question was related to treatment something?

Melanie: Treatment plan. As you map out a treatment plan and the parents are thinking long-term of what they're going to do for this child as they grow and what -- physical therapy, occupational therapy, speech and language, how does that all tie together?

Dr. Romness: As you mentioned, it does start early. Really, as soon as diagnosis is made, it's been found that intervention with therapies and treatments like that are helpful. In most of the states, they even have what's called an early intervention program, or it's also sometimes a birth to three where they will evaluate the child, and it'll determine which therapies will be best for the child to keep them progressing and get them going. From a medical standpoint, most of the treatments are individualized, because each kid has a unique pattern that there's no standard protocol for treatment. But the treatments tend to be individualized specifically for that patient. Most common treatments used, like you mentioned, are physical, occupational, and speech therapy. Other things we tend to use are [bracing], or sometimes called orthotics or orthoses, and those are used to help position the limb. Sometimes, as they get older, we'll get into equipment issues such as walkers, crutches, wheelchairs, and then there's also some medications to help with some of the conditions, like the spasticity. There are some medications available to try and treat spasticity. Then, surgically, which I'm involved with as an orthopedic surgeon, tends to deal with things like joints and fractures, foot position, hip issues, spine and scoliosis.

Melanie: Okay. So these types of surgeries that you would be involved in, what are they intended to do?

Dr. Romness: The main goal is probably function. You're trying to maximize their function, both short-term and long-term. Surgeries are usually sort of restoring or repositioning the hip, the leg into a more functional position.

Melanie: Now, does that stay? Is that permanent? If you do that and you restore that hip into a more functional position, is that something that then will -- the muscles will get lax again and retreat back to where it was, or is this something that would last for the child's life?

Dr. Romness: Again, it's somewhat age-dependent. There are some surgeries that are better done at a young age, and then they will help the child down the road. But there are some procedures that we actually wait until the child is a little bit older because if we do it at a young age, the recurrence is pretty high. So some of the bone procedures where we turn the bone or correct the foot position, we found that it's better to wait until they're older and it's less likely that they're going to need another surgery for that.

Melanie: Now, how is UVA equipped? How are you helping children with cerebral palsy? In your department, Dr. Romness, braces and things, working with all of that, what are you doing there?

Dr. Romness: As part of the Department of Orthopedics, we do have these orthotics and prosthetics, which is the brace place, and so they're involved with us in terms of a lot of bracing issues. My approach is what we call family-focused approach. We don't just look at the child. We look at the child in their family setting because we find that all that works together. What I do is I kind of assess each child for the unique aspects, determine what I can do to help them now, things that I need to worry about for the future, and then I sort of say, "What I can do to prevent future problems and keep them going?" I then determine which treatment is best, both for now and the future, and then discuss that with the family.

Melanie: In the last minute, Dr. Romness, wrap it up for us about CP and working with the families and giving the best quality of life to children with this.

Dr. Romness: Right. Like I said, this is family-focused. I will say that UVA is one of the leaders in that kind of treatment because we have such a diverse field of specialists who are not only competent but they're comfortable and excited about taking care of kids with special needs. We have the therapist, we have a dietary and feeding specialist, behavior and developmental specialist, dental, ENT, gastroenterology or GI, orthopedist, neurosurgeons, to name a few. One of our developmental pediatricians, Richard Stevenson, he was just elected President of the American Academy for Cerebral Palsy in Developmental Medicine, which is the main organization for practitioners. Probably you could say that we're at the forefront of the field with that.

Melanie: That is great. Such good news. Thank you so much, Dr. Mark Romness. You're 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

More...

Treatment Options for Adults with Spinal Deformities

Treatment Options for Parkinson's Disease

Identifying Patients at High Risk for Pancreatic Cancer

Identifying and Managing Fibromuscular Dysplasia

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