Medical Intel

Colorectal cancer is expected to affect about 146,000 Americans in 2019. Dr. Jennifer Ayscue discusses the advanced techniques we use to diagnose and treat this disease.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We're speaking with Dr. Jennifer Ayscue, section director of colorectal surgery at MedStar Washington Hospital Center. Thank you for joining us today, Dr. Asycue.

Dr. Ayscue: Thank you so much for having me.

Host: We're discussing colorectal cancer and the minimally invasive techniques now used for the procedure. Dr. Asycue, could you start by discussing what colorectal cancer is?

Dr. Ayscue: So, colorectal cancer is a cancer of the large bowel or large intestine, which includes the colon, whose job is mainly to absorb water, among other things, and the rectum, which holds stool until it's ready to be expelled. Cancer occurs when the inner lining of the colon or rectum develops abnormal cells which have the ability to then invade through the bowel wall and even spread to other parts of the body, like the lungs or the liver.

Host: Recent studies have suggested that colorectal cancer has increased in young adults. Could you explain why this is, plus other groups of people who are most susceptible?

Dr. Ayscue: Yeah, we've been patting ourselves on the back because for a number of years we've been noticing that the rates of colorectal cancer have been decreasing and this is, we think, in large part due to widespread colorectal cancer screening. However, unfortunately, as we've taken a closer look, we've found that the number of cancers diagnosed in young people, even in their 20s or 30s or 40s, has actually been rising and now they actually have a higher risk of colorectal cancer, in some cases, than people over the age of 50. We're not really sure the reason of this but it may have something to do with increasing rates of obesity, sedentary lifestyle, drinking more alcohol - especially in men, smoking, eating processed food or red meats, and all of these really increase our risk for getting colorectal cancer. Or it could just be some other environmental factor that we have yet to figure out.

Host: Are there symptoms people can experience with colorectal cancer?

Dr. Ayscue: The most common signs or symptoms that I see are people who have rectal bleeding or urgency, meaning they need to get to the bathroom quickly but even after they use the restroom, they still feel this urgency. They may also have some mucous, maybe even mixed with the blood that we talked about before. They may have a persistent change in their bowel habits, which usually lasts for more than a few days or weeks. They may have abdominal pain or rectal pain. So, these are pretty non-specific and don't always result in a diagnosis of colorectal cancer but should raise suspicion.

Host: In what ways do you typically diagnose colorectal cancer?

Dr. Ayscue: So, we offer many options. And some of the less invasive options for colorectal cancer screening include tests that may just test for blood in our home tests. Unfortunately, these do require some dietary restrictions and multiple stool samples, but it's a cheap test and it's only performed on a yearly basis. The ability for that to detect polyps and some cancers using that method are just limited. Another more sensitive test is called the fecal immunochemical test, or the FIT test, as it's more widely known. This test tests for blood products as well, but it's more sensitive and detects blood that definitely comes from the rectum and colon. It's not great for smaller polyps but it's a little more expensive than the guaiac test but not overly expensive so that it's able to be used by a pretty large population. It's offered for free, actually, through our community program for patients who qualify in certain wards in DC. And it's usually covered by insurance for those who do have insurance. The last fecal test is fecal DNA test which may also test for blood but like the FIT test, and it's very good, but it also tests for the fecal DNA which makes it more sensitive and is able to find over 90% of colorectal cancer and more polyps than the FIT test can. It's only required every 3 years instead of yearly like the other two. However, it is more expensive and can be a limitation if someone is uninsured or if the insurance doesn't cover it.

Another option is to perform a CT colonography or what's known as a virtual colonoscopy. This is recommended every 5 years and up to 94% of larger polyps and cancers can be found with this. But it generally requires a bowel prep, similar to colonoscopy, and no biopsy can be formed at the same time. Also, other findings on CT may prompt further workup on those findings - sometimes, unnecessarily. So, I should also mention that if any of these minimally invasive tests are positive, then that person has to proceed on to colonoscopy, where the colon can be evaluated and either lesions biopsied or even removed, if anything's found. Unfortunately, sometimes these tests can be positive and then no lesion is found on colonoscopy, and this is pretty stressful and frustrating for the patient.

Host: Could you discuss some of the minimally invasive techniques your team uses to treat colorectal cancer?

Dr. Ayscue: We offer a range of colorectal cancer treatments that are minimally invasive, but probably the most common would be the laparoscopic route. And, that would be when a colon cancer or a rectal cancer has to be removed. This is usually in conjunction with, sometimes, radiation or chemotherapy. So then, we can remove it either laparoscopically where we place instruments through very small incisions into the abdomen and then remove the colon through a relatively small incision as well. We can also use robotic techniques where the small incisions are also used but these instruments are connected to robotic arms which are controlled by the surgeon who is in the room at the same time but also allows us to have more fine control of the instruments and get in to spaces that we might not otherwise be able to get in to so that we can remove cancers more efficiently and with less post-operative pain and sometimes better outcomes overall.

Host: Can you discuss the importance of why getting screened early can help your treatment?

Dr. Ayscue: So, the newer recommendations are actually to get screened at 45, whereas it used to be 50 years old, because of patients having a higher risk of colorectal cancer in younger ages. If we're able to get to people early and get them screened, meaning that they don't really have any symptoms of colorectal cancer and we're just looking to see if they have anything like a polyp or an early cancer, then we think by treating the polyp and removing the polyp that we can help prevent that polyp from becoming a cancer, which will hopefully decrease the risk of them ever getting a cancer. If we do find a cancer and it's in an early stage, it's much more curable.

Host: What does recovery typically consist of after surgery?

Dr. Ayscue: Well, most patients are in the hospital for anywhere from 1 to 4 days after surgery and most patients are treated with a very specialized program to help avoid narcotic usage and uses a lot of non-narcotic medications. And, with the combination of the minimally invasive surgery and this protocol, we're able to get patients on their feet very quickly, eating diets within a day of surgery and home, usually, within the 1-4 days with minimal pain medications when they go home.

Host: How do the minimally invasive treatment and diagnostic techniques today compared to techniques used 10, 20, 30 years ago?

Dr. Ayscue: Well, the diagnostic techniques are getting better and better with each year and are able to diagnose now smaller lesions at earlier stages than they have in the past. And I suspect that they'll become the primary tests of the future with colonoscopy reserved only for positive results in all patients, even high-risk patients. As for the treatment techniques, some of these didn't even exist or were in the very early research stages 30 years ago, and have become better and better each year and...I suspect that laparoscopic and robotic techniques will merge and we will basically have robotic techniques that allow us to do almost anything in the abdomen without the need for an open incision.

Host: Could you share a story of a patient who had a successful outcome with minimally invasive surgery at MedStar Washington Hospital Center?

Dr. Ayscue: I had a mid-50s female who hadn't been screened yet and she decided to get a FIT test and it came back positive. She saw me, and we did a colonoscopy at that time. And, I found a large polyp which I couldn't remove using the colonoscope and I found several other polyps that actually could be removed. She then needed to have a robotic-assisted colon and rectal resection. And, I'm happy to say her pathology revealed a benign polyp which had some pre-cancerous cells. She was cured by that surgery and will just get regular surveillance to avoid needing any surgery in the future. But, if she'd waited another year or two, she might have had a cancer that would have required more treatment. So, we were very happy with this outcome.

Host: Why is MedStar Washington Hospital Center the best place to seek care for colorectal cancer?

Dr. Ayscue: So, our hospital has a significant focus on colorectal cancer, and this starts with the robust screening program that we have, with a nurse navigator who can help patients get the right screening for them and assist with any concerns. We also have a really strong team of gastroenterologists, surgeons, radiologists, and, if needed, cancer treatment doctors who are all very dedicated to the prevention and treatment of colorectal cancer. We definitely have the newest technology and we're in the process of getting accreditation as one of the first hospitals in the nation for a multidisciplinary treatment of cancer.

Host: Thanks for joining us today, Dr. Ayscue.

Dr. Ayscue: Thank you for having me.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

From 2017 to 2018, vaping increased by nearly 80 percent among high schoolers and 50 percent among middle schoolers. Dr. Jonathan Giurintano discusses the short-term effects vaping can have on dental health and the lungs.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We're speaking with Dr. Jonathan Giurintano, a head and neck cancer surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Giurintano.

Dr. Giurintano: Thank you so much for having me.

Host: Today we're discussing how vaping affects oral health. Typically, when doctors talk about the effects of vaping, the concern is for patients' lungs. Dr. Giurintano, what are some of the more common oral health side effects of vaping?

Dr. Giurintano: So, of the more common health side effects, simple general irritation of the oral mucosa is probably the most common side effect that we see. However, there have been recently published studies that show that there are higher rates of colonization of the oral cavity mucosa with a fungal organism called Candida albicans in patients who vape or who use e-cigarettes regularly compared to patients who do not use vape devices. The importance of this fungal organism is that if there is an overgrowth of the fungal organism in the mouth, patients can experience what is called oral candidiasis or more commonly known as oral thrush. This can be an inflammatory and very uncomfortable situation to have when it is located on the tongue or on the inner cheeks and can require the use of an antifungal medication in order to resolve the infection.

Host: What concerns you the most about vaping?

Dr. Giurintano: The thing that concerns me the most about vaping or e-cigarette use is that many people see this as a healthy alternative to smoking cigarettes. Among a lot of vape users a common phrase that you'll hear is, "Oh, it's just water vapor. It's safe" which we're finding to be untrue. There was a big article that was published on CNN as the FDA released the results of an initial study showing that, just over the past year, that the use of vaping among high schoolers has increased nearly 80 percent and among middle schoolers, the use of vaping has increased almost 50 percent. One in five high schoolers has vaped and this is just a really, really shocking number. The reason this is so concerning to head and neck cancer surgeons, such as myself, is that we know that most patients who vape do not only limit their use of nicotine products to vaping itself. Many of these patients often go on to use traditional tobacco cigarettes or other tobacco products in order to fulfill the desire for nicotine, which is the addictive substance that's often present in the vape liquid. And, any potential benefit that one might have seen from vaping rather than smoking quickly disappears whenever you're both vaping and smoking cigarettes in order to get the nicotine effect.

Host: How do you address the health hazards of vaping with your patients?

Dr. Giurintano: So, one of the things I like to do is I actually like to explain to the patient how a vape pen or an electronic cigarette works. So, located within that vape pen or that e-cigarette, there's one or two lithium ion batteries that powers separate heating wires that are composed of a heavy metal that then evaporate a flavored liquid which most oftentimes contains nicotine. And, the carrier substance for this nicotine typically consists of the chemicals glycerin or propylene glycol. We know that these are not inherently dangerous substances themselves. However, whenever you are evaporating these substances such as nicotine, glycerin or propylene glycol, we do know that more harmful or possible carcinogenic side molecules can be released. One of the most concerning things about the vape usage is that the FDA only began to regulate the vape industry in 2016. And today, there's over 7000 different types of flavorings which have been described in the liquids. The majority of these flavorings are used in the food industry. However, they were only truly developed for oral consumption, not for vaporization. So, the long-term effects of taking these substances that are typically meant for oral consumption and converting them into a vaporized form that's then inhaled into the oral cavity and into the lungs, is largely unknown at this point. A few of these substances have been studied in the past and have been shown to cause severe inflammation of the bronchi and of the lungs. And, it is assumed that these chemicals that are irritating to the bronchi and the lungs, could also have an irritant effect to the mucosa of the upper aerodigestive tract as well. The American Head and Neck Society, so this is the society of head and neck cancer surgeons across the United States, recently issued a statement stating that 'given the lack of clear scientific evidence regarding the safety and effectiveness of e-cigarettes for the sensation of, as well as the bystander risk of e-cigarette emission, the American Head and Neck Society does not endorse the use of, e-cigarettes as a safer alternative to traditional tobacco cigarettes.' The H & S agreed that e-cigarette emissions are not simply harmless water vapor, as they are often promoted and advertised. And this organization further expressed the concern that e-cigarettes represent a viable potential for harm to both individual health and environmental pollution. We're still in the process scientifically investigating these vape and e-cigarette devices to help provide a clearer understanding of what the risks and/or benefits are of using vape or e-cigarettes and the indications for or against their use.

Host: What are the long-term oral health implications for patients who vape?

Dr. Giurintano: Well, we're not 100 percent sure at this point what the 20- or 30-year health implications will be for patients who vape. We do know that there are substances within the vapor that's inhaled that harbor carcinogenic potential. We know that studies have shown that these typically are in much lower quantities than the chemicals produced in traditional cigarette smoking. However, we have yet to see what the long-term effects of regular application of these chemicals to the lining of the upper air digestive tract might cause. The biggest thing we do know is that most e-cigarette or vape users do not exclusively use vape devices in order to obtain nicotine and that many of them will also smoke traditional cigarettes, as well. And for these patients, they are at risk for the typical long-term complications seen in most cigarette smokers, including periodontal disease and increased rates of cavity of the oral cancer, voice box, and lungs.

Host: Thanks for joining us today, Dr. Giurintano.

Dr. Giurintano: Thank you so much for having me.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Multiple ankle sprains can lead to chronic ankle pain for some patients. Dr. Ali Rahnama explains how minimally invasive surgery can help these patients avoid much larger procedures in the future.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We're speaking with Dr. Ali Rahnama, a foot and ankle surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Rahnama.

Dr. Rahnama: Thank you for having me.

Host: Today we're discussing chronic ankle pain after a sprain and what could be going on inside the foot and ankle. Dr. Rahnama, many of us have experienced an ankle sprain. How many would you say you treat in a year?

Dr. Rahnama: I would say it really depends on the time of year, especially as we get closer to the winter months. Sometimes I may see as many as 4 to 5 of these a week, sometimes even more.

Host: Student athletes and leisure athletes are at risk of sprains. Are there other groups of people who are susceptible?

Dr. Rahnama: While it's true that typically we do see a lot of athletes with sprains because of the increased level of activity that they engage in on a day to day, we do see them in various patient populations and even non-athletes, particularly as we get closer in to the winter months. Slip and falls, especially in cities like Washington where people use a lot of mass transit and are walking outside on the sidewalk. We, a lot of times, see people slip on little patches of ice and things like that, and injure themselves and get sprains and even sometimes fractures.

Host: How do you determine whether an ankle sprain is mild, moderate, or severe?

Dr. Rahnama: I typically look at three things. I want to see how much tenderness there is, swelling, bruising, that kind of thing, the patient's ability to bear weight or not be able to bear weight. Those are typically how I determine how bad the injury is.

Host: How long should a patient expect to fully recover from a mild or moderate ankle sprain?

Dr. Rahnama: Typically, a mild to moderate ankle sprain, I would expect to clear up in the ballpark of about 2 to 4 weeks, depending on how bad the injury is and exactly what part of the ankle they've injured. Typically, the lateral ankle ligaments are the ones that are affected more commonly. Those would be the ankle ligaments on the outside, as opposed to the inside ligaments.

Host: How long should a patient expect to recover from a severe ankle sprain?

Dr. Rahnama: Severe ankle sprains can take anywhere from up to 6 weeks to even up to 12 weeks to heal, depending on the injury.

Host: Is there anything special that an individual would have to do when they're taking care of a severe ankle sprain?

Dr. Rahnama: Typically, with a severe ankle sprain, I would say it's important for them to initially have a period of immobilization, rest, where they can ice it and elevate it and stay off it. And then, it's really important for them to get with a physical therapy colleague of ours that I'll very often send my patients to, who will work with them on proprioceptive exercises and strengthening exercises, to help get them to strengthen the tendons and muscles in and around the foot and ankle to help the patient avoid having a similar injury again in the future.

Host: Of course, spraining an ankle is painful, but how long does the pain typically last before it's considered "chronic?"

Dr. Rahnama: The chronicity of the sprain isn't just based on how long it takes for them to heal. It really has to do with how many spraining incidents they've had total. So, if I have a patient who comes to me for an acute sprain, meaning that they recently had one and so they've decided to present for care, or somebody sent them to me for evaluation, the first thing I want to make sure and ask them is that have they had similar incidences in the past that maybe they didn't see somebody for and that maybe healed on their own and that now they're noticing a pattern, where they had an initial sprain, sometimes even up to years ago, and as time has gone on, they, every so often depending on what they're doing, particularly if they're active, if they continue to have more and more of these incidences - and, so then, that's when I start to think that it's something chronic because there's multiple episodes of it.

Host: So, it's just being more and more susceptible to sprains?

Dr. Rahnama: Exactly right.

Host: What's the standard first-line treatment for a sprain?

Dr. Rahnama: So, I would divide it into three things. One, I would say resting and protecting the ankle with a brace or boot, sometimes even a splint. And then second, I would follow that with resting range of motion, strength and stability exercises. And finally, maintenance exercises that would slowly get them back to more intense physical activity and for them to be able to engage in sports that would need sharp cutting, like tennis or basketball, for example.

Host: At what point do you typically recommend surgery for an individual with chronic sprains?

Dr. Rahnama: Well, first I'd like to emphasize that, even as a foot and ankle surgeon, the vast majority of sprains are treated nonoperatively. Only in the setting where a patient has not healed for more than 6 or 8 to 12 weeks and they've oftentimes had multiple incidences of sprains, will I start to think of surgery for correction of it. The surgical procedure is actually quite simple for a straight-forward, isolated, chronic lateral ankle tear, or laxity. We make a small incision, and oftentimes we'll try minimally invasive techniques where we can make small, few-millimeter stab incisions and enter the joint and evaluate for any type of synovitic or pre-arthritic tissue, debride that. Debridement is when we use a shaver and the guidance of the camera, once we've gotten into the joint, to essentially just clean up and take out any of that arthritic or inflammatory tissue that doesn't belong into the joint. And then we can even do our lateral ankle repair through those same incisions so that we don't have to make any large incisions and open the patient up. It's fairly straight-forward surgery. So, they actually did studies where they split two groups of surgeons up who had never done minimally invasive surgery before. And, in the first group, they had the surgeons do video games. And then, they had the other group not do anything at all. And, then they trained all...both groups at the same time in minimally invasive surgery and arthroscopic or laparoscopic surgery. And the group that had had the video game training before the surgical training actually got it a lot faster and did much better. So, if you've got a kid at home who's good with video games, he may be good with minimally invasive techniques someday.

Host: When it comes to foot and ankle surgery, why is minimally invasive surgery a good approach?

Dr. Rahnama: Minimally invasive surgery is good for patients for a number of reasons. But, probably the most important things are many times patients undergoing minimally invasive surgery get back to doing what they want to do a lot sooner. There are much smaller incisions that need the body to heal them. And so, overall, they tend to have better outcomes, is what we found.

Host: Have you ever had a patient come in thinking they had sprained their ankle, but it was actually something else?

Dr. Rahnama: So, that's a great question. We actually see this quite often where somebody will come in with the complaint of a sprain, or what they think to be a sprain, that's not getting any better and it doesn't really fit the description of what we would like to see for classifying it as chronic ankle sprainers. And, that's really when we start to think about, 'what else could this be, masking itself as an ankle sprain?' Things like osteochondral defects of the talus, meaning an injury to the cartilaginous surface of one of the bones in the ankle, can cause pain, especially if there's loose pieces of cartilage from that injury that are now in the joint. Those oftentimes can mask themselves with the same symptoms or similar symptoms as an ankle sprain. Also, tendon injuries can also mask themselves as sprains, where it may really be a tendon tear or even a rupture and the patient comes to us with an ankle sprain that's just not healing. And so, those would definitely be a couple of things that we see fairly often that patients think are ankle sprains but they're not. And, obviously, the last thing would be fractures, particularly if the patient was seen in an environment...because a lot of times, primary care offices don't have X-ray available and so the patient is sent to us with a sprain. And, one of the first things that I'll do, if the patient doesn't already have one, is obtain an X-ray to make sure they don't have any fractures anywhere.

Host: What can people do to reduce the risk of ankle sprains?

Dr. Rahnama: I would say it's really important for people to keep in to consideration the type of shoes that they wear and particularly be mindful of the type of activity they're trying to engage in. Runners, a lot of times here in the city particularly, it's best for them to try to avoid, especially in the colder months, the wet months, avoid trying to go out for a run right after a snow or the rain. And, in the summer months, when we're out on trails and things like that, really make sure you know the terrain that you are about to go out for a run in, for example, or embark on any type of physical activity, so that you don't find yourself with any surprises.

So, what I would say is that, particularly in the winter months, if you're a runner, make sure you have the appropriate shoe gear. Make sure your laces are tied nice and snug. And, maybe avoid the day right after a snow storm. Make sure you know the environment that you're going to be running in so that you can avoid little slicks of ice and the really wet, deep puddles. Those are really where we see the biggest problems or people will say, "I slipped on a patch of ice," or "I went off the curb and it was just too wet, and I slipped and I sprained my ankle," or sometimes even worse. And in the spring and the summer months trail runners - I know that's very popular these days - familiarize yourself with the terrain that you are about to go on a nice run for. Make sure you understand where there might be a ditch or a hole that you might want to avoid. So, before we go full speed ahead it's nice to pause and try to really familiarize yourself with our environment.

Host: How do you recommend that patients prepare for foot or ankle surgery?

Dr. Rahnama: I strongly believe an informed patient can help the surgeon help them by developing protocols that are specific for them and their needs. If they feel they don't have the upper body strength, for example, to stay on crutches and remain non-weight-bearing, they should share that with their doctor - and so that we can work with our physical therapy colleagues to help them gain the upper body strength, for example, to then get them ready for lower extremity surgery so that they can stay off of it. It's not just about doing our portion of the procedure and then having patients go out and be on their own. We want to avoid that as much as possible. So, certainly in my exam, I try to assess the patient's whole body to make sure that they have that ability, if they're overweight, or have other things that impede them to remain non-weight-bearing, I definitely try to address that. But, we definitely want to encourage our patients to be forthcoming with any reservations or any concerns that they might have so that they can help us help them.

Host: What does recovery after surgery entail?

Dr. Rahnama: Typically, a period of non-weight-bearing for 2 to 3 weeks. And I will say that these protocols vary sometimes between surgeons. But there is research now that shows that the quality of new collagen that your body puts down when repairing ligaments depends on the stress being put on them. This is very similar to what we've known for a very long time about bone healing and bone turnover in your body. The stress of gravity and the stress of weight bearing actually helps your body heal it the way that it should be healed. And so, after a short period of non-weight-bearing, and making sure that our incisions are healed, I get my patients to therapy as soon as I can right after that to make sure that they engage them with a week to two of fairly aggressive, non-weight-bearing exercises. And then, in under a month typically, I will try to get my patients weight bearing again, again with the help of our physical therapy colleagues, to get them back on their feet and to make sure they have the best outcomes possible.

Host: What are some of those exercises that your patients are participating in during that initial couple of weeks and then the following month?

Dr. Rahnama: So, a lot of them might be resistance exercises, proprioceptive exercises, exercises that really strengthen the muscles, the tissues around the foot and the ankle and to really be able to support the repair that we've done. So, collagen are the little building blocks of ligaments and connective tissues in our body. And so, anytime you have an injury to the soft tissues and ligaments included in that, collagen is what your body uses to help repair things.

Host: Could you tell us about a patient who had foot or ankle surgery after a bad sprain and was able to return to an active lifestyle?

Dr. Rahnama: I had a college athlete in her twenties last year who had been spraining since she could remember and now it was getting to the point that, even with the best wrapping by her trainers, she couldn't do what she wanted to do. So, she came and saw us. Obviously, being an athlete, she had some great trainers and therapists trying to rehab her with no good results. So, we proceeded to surgically fix the ankle ligaments, utilizing a minimally invasive technique and arthroscopy, where we make small incisions, just millimeters wide, and place a small camera into the joint and use that to help guide our repair. Surgery went as planned and we proceeded to use her training team again to help us get her back. And, she was back training in under two months, without restrictions. Now, she's an extreme case of very aggressive rehab, but the point is that it can be done and there's no reason to think that even the most physically demanding athletes can't get back on their feet and get back to doing what they love.

Host: I know a lot of folks can be kind of stubborn when it comes to thinking about surgery. What are some of the reasons that you would give patients if they're hesitant to come have surgery because they don't want to take time off their activities?

Dr. Rahnama: That's a great question. The one thing that I would emphasize is that a small problem, if not addressed by the right specialist, can a lot of times turn in to a much larger problem down the road that the patient then can't avoid having taken care of. If a patient doesn't see somebody for a chronic ankle sprain and thinks that this is something that they don't want to have addressed, the reality is if they DO have it addressed and they have a small procedure now, that may help them avoid a much larger procedure, such as the need for a total joint replacement or joint fusion even, later on in the future as they get older.

Host: Why should someone with chronic ankle pain or a bad sprain speak to a surgeon at MedStar Washington Hospital Center?

Dr. Rahnama: We're here to help and make sure our patients and individuals suffering from foot and ankle conditions can get back to life and do the things they love and be active. And so, that's what we do every day, and we just want to make sure the local public knows we're here, and if they need us, we're happy to help.

Host: Thanks for joining us today, Dr. Rahnama.

Dr. Rahnama: Thank you so much for having me.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

One way to protect your heart is to choose the right diet. Discover why Dr. Allen J. Taylor believes the Mediterranean Diet—which relies on foods such as fruits, vegetables and white meat—is the best for preventing heart disease.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We're speaking with Dr. Allen J. Taylor, Chair of Cardiology at MedStar Heart and Vascular Institute. Welcome, Dr. Taylor.

Dr. Allen J. Taylor: Thank you.

Host: Today we're discussing diet choices for heart health, specifically the Mediterranean Diet. With so many ideas online and from well-meaning friends and family, it can be tough to make the best food and beverage choices for on-going heart health. Dr. Taylor, patients hear the recommendation to eat a healthy diet all the time. What does that really mean?

Dr. Taylor: Yeah, everyone's an expert on their own diet, aren't they? We've long known that (quote) "healthy diets" - and those are typically defined, from a heart perspective, as diets that are low in fat, high in fruits and vegetables - tend to be seen more frequently in patients who don't suffer from heart disease. On the converse, people that eat poor diets are more likely to have heart disease. And that is true. The question is, where is diet science going? And in 2018, what's the best diet to prevent heart disease? And that's where there've been changes.

Host: What questions do your patients often ask about how their diets relate to their heart health?

Dr. Taylor: When you talk to patients about diet, there's usually two things. The first is controlling body weight. And then the second is about controlling specific health problems, such as their blood pressure or their diabetes or their cholesterol. And as you tailor diets to different patients, it often has to be highly customized to the health problems that they have. But overall, it's about reducing heart risk. And, it can get very confusing to think, "Oh, I have to avoid salt and I have to avoid fat and I can't eat sugar because of my diabetes." And the question is, "What can I eat?" And patients get confused. And they get so confused, they can't make good food choices and they give up. And they eat things which aren't good for their health. So, how do you bring it all together? There's so many diets - there's fad diets, the keto diets, the low carb diets, Atkins diets, South Beach - it's all over the place these days. And today...tomorrow there'll be another one. The optimal diet from a heart perspective is one, if you were going to design it, is one that makes good metabolic sense and has been tested. Tested and proven to reduce heart disease risk. Now, when it comes to weight loss, that's a simple thing. It's about calorie balance. It's calories in and calories out. One reason people gain weight as they age is because, they don't realize it, with every decade they age their daily calorie requirements go down about a hundred kilocalories. Now, the average 20-year-old can probably eat 2,000 or 2,200 calories a day. The average 60-year-old has to eat 400 calories less a day just to stay in balance, 1,700 or 1,800 calories. If you're eating like you did when you were 20 or 22, you're gaining weight. So, calorie balance is the most important thing from a weight perspective. But then it's about what goes in to those calories; what's making up those calories - how much is fat, how much is sugar, how much is protein? It's hard to eat like that. It's hard to eat...how much protein am I going to eat today? How much sugar should I eat today? And, some people can do that. What I try to do with my patients is to make it as simple as possible and to use the best evidence-based diet as possible because we're trying to reduce the risk for heart disease. And today, that diet is the Mediterranean Diet.

Host: What about the Mediterranean Diet makes it so heart healthy and so, quote/unquote, "easy to follow?"

Dr. Taylor: Well, the first thing about a Mediterranean Diet, and it's just simply a name for it, but it's really a style of eating, it's food choices. And, it has been rigorously studied, both in people with known heart disease and without known heart disease. Very important study, published about five years ago now, was a study called the PREDIMED study. And, it was a study of about 7,500 individuals who were either asked to eat a Mediterranean Diet or an otherwise really high-quality American diet. The American diet was things like using low fat dairy products, saying that things like pasta and rice were ok, and fruits and vegetables are encouraged, and lean fish and seafood are also okay. That sounds pretty good, doesn't it? It's pretty much what a lot of us eat. What was interesting is that the Mediterranean Diet is different than that. It's a diet that's, again, rich in fruits and vegetables but includes fish. It includes beans. White meats, such as chicken. Wine is okay with meals and that's often a good selling point for the diet. And then it can include nuts and supplementation with olive oil - olive oil to cook or even olive oil to simply add to your food, like put it on top of salads. When those two diets - this really good quality American diet and the Mediterranean Diet - were compared, Mediterranean Diet won, hands down. There was nearly a 20 percent lower risk for heart events in people who ate the Mediterranean Diet. There was a 30 percent reduction in heart disease risk in the patients that ate the Mediterranean Diet. So, that's a large reduction - 30 percent risk - that's the same risk reduction seen with taking cholesterol pills, for example. So, very impactful. The thing about the Mediterranean Diet that I like in particular - while those are the things you should eat, and again, to repeat them, fresh fruits and vegetables, fish, white meat, beans, nuts are okay, wine is okay, and olive oil supplementation - it discourages certain things like soda drinks, commercial baked goods and sweets, spread fats and red meats. And what I like about it in particular is it doesn't say you can never have those things. It's about how frequently. For instance, most of those things should be fewer than one serving per day. And commercial baked goods, less than three servings per week. And so, when you stand in the line at your favorite coffee shop, what you're tempted with while you're waiting is nothing but commercial baked goods and sweets. And it's okay to have one once in a while. Not every day, if you're going to eat the Mediterranean Diet. And, I ask my patients, is that worth a 30 percent reduction in your risk for heart disease? And most become very interested in this type of diet because it's about the food choices you make. And it's not like you can never do certain things because look, eating's supposed to be fun and eating is a part of life many times a day. It's a social function; it's what we enjoy. And so, the Mediterranean Diet, I think, can be compatible with a very healthy diet, a very heart healthy diet, but also one you can sustain. The problem with many of the fad diets is they're great for a week or a month and people will often lose weight and that entices them into it, but frankly, we don't know the safety of those diets. We don't know if they're heart safe. We don't know what it does to their cholesterol and their blood pressures. In the end, that's the most important thing. So, if you really want to follow an evidence-based diet, a diet that's been proven to work, to reduce heart risk, it's the Mediterranean Diet.

Host: When you give that example, what do you say to those patients who say, "Well, if it's similar to taking a pill, I'll just take a pill and still enjoy my cheeseburgers."

Dr. Taylor: That's great. Well, I say, "You know what? This was in addition to people taking pills." So, this doesn't replace pills and lowering cholesterol is not the goal of this diet. It's about lowering heart risk. So, if you have a cholesterol problem, you probably will need a pill. If you have a blood pressure problem, you probably will need a pill. But this diet reduces heart risk. And it's the types of food you're eating and the types of foods you're not eating that is driving it. So, it's the diet that, from my viewpoint, we should be following for heart risk in this country. To come back to the diet that it was compared to, it was the previously recommended diet by the American Heart Association. So, those recommendations - and if you grew up through the '80s and the '90s, you were told, "avoid fat, avoid red meat, and the rest is gonna be fine." Now, I'm summarizing, but that was what people were trying to avoid. And what do they substitute? They substituted sweets and baked goods and pasta, which are great, but small amounts. And, the Mediterranean Diet is by far a better diet from a heart risk perspective.

Host: What about those trendy diets like Atkins or like keto. What do you say when folks are wanting to try those types of diets?

Dr. Taylor: The goal of those diets is usually weight loss, and they do work in the short term. You can eat a ketogenic diet, and that's a fancy term for a diet that is simply carbohydrate poor. So, it takes rice and breads and sweets out of the diet and focuses on vegetables and meats. And so, it's a high protein diet. And in the short term, people will lose some water weight and they'll lose water weight very quickly. Then it tails off. And, what the evidence is, is that, in the end, if you eat simply a calorie-restricted diet versus a ketogenic diet, the weight loss is the same. So, there's no specific advantage of eating a ketogenic diet, when you look at 6 and 12 months out. What we're talking about with things like the Mediterranean Diet is a diet that is more about prevention of heart disease. It's not about weight. So, if you want to lose weight, it's really about ins and outs - how many calories you're taking in; how many calories you're burning. Oftentimes patients aren't quite aware. They've got a certain pattern of eating and often there's some overeating. And, you've got to measure it. There's some great health apps like MyFitnessPal. It's a free app and you put in all your foods. It tells you exactly what you're eating and how many calories. And there's other ones as well. That's important - to measure where you are and how much you're eating. And it'll tell you how much protein and fat and sugars you're eating. And again, if you want to lose weight, you've got to measure your ins and monitor your outs. More exercise, less eating. It's the only way to lose weight in a stable, long-term way. But from a heart risk perspective, it's about the types of foods you're eating. And, the best diet now is the Mediterranean Diet. That diet is better than the best American diet, 30 percent better for heart risk. It's an easy sell.

Host: So, when you're thinking about all these diets - you have paleo and you have keto and you have Atkins and they have all these flashy names - well, Mediterranean Diet just sounds very fancy and complicated. How do you break that down for people so it's something relevant to them that they can really do?

Dr. Taylor: Yeah, it can sound exotic and it isn't and that shouldn't scare anybody away. It's actually just a diet that changes the quantities of things you eat to one, things that are healthier and away from things we're probably eating too much of. And nothing in this diet is not freely available to people on a daily basis. So, it's about the quantities. And the thing I love about this diet is that it's...you don't have to go to the Mediterranean to eat it. And you don't have to eat foods you don't like. It's about the choices you make. So it's about eating lean meats, fruits and vegetables. It's about eliminating sodas and baked goods and sweets. And the occasional red meat is okay. And people that like red meat will find that really comforting and think that they can really sustain this.

Host: What questions should patients ask their doctor if they're considering trying one of these newer, trendier diets or going on to the Mediterranean Diet?

Dr. Taylor: I think it's important to talk about the goals of the diet and what the risks are or unknown risks are. If the goal of the diet is weight loss, the answer is simple. You've really just got to do it a calorie restriction and more activity. It's hard work. It's slow going. The fad diets - you'll lose a little more weight quickly, but it's a fake-out—it's usually water. If the goals are other things like you want to improve your blood pressure, well, there are blood pressure improvement diets, such as the DASH diet. It restricts sodium, it supplements potassium, magnesium. It'll lower your blood pressure. So, if you're worried about your blood pressure, you'd like to avoid meds, there's a diet out there for you. Similarly, for cholesterol. You can lower your cholesterol with a diet - somewhat. Restrict fats, eat lean meats. But by and large, cholesterol is pretty unresponsive to diet. And so, we usually use medicines for cholesterol. So as you talk about what diet to eat and fad diets, define your goals. Is it weight loss? Then the answer is ins and outs. And, if it's a specific health problem, that is a little bit more of an in-depth discussion because there are some diets that are proven to work - the DASH diet is the best example. But I choose, typically, to focus on the global risk for heart disease because, no doubt, the most effective diet is this Mediterranean Diet. We'll treat the blood pressure and cholesterol with other ways, but reducing heart risk is so important and the Mediterranean Diet is very effective.

Host: Could you share a success story from your practice about changing their eating habits and reducing their heart attack risk?

Dr. Taylor: Yeah, I can share a few. One is simply weight loss and have had many patients and I'll describe one that, you know, everyone walks in with their smart phone and they think they're all app'ed up. And, many patients have turned on to these apps like MyFitnessPal. And I've had patients come in and they've shown me exactly what they've eaten and how they've changed what they eat. They found foods that they thought they liked but really are quite unhealthy for them - they have a lot of sodium or a lot of calories. And, have changed their diet and have lost weight. And that's really gratifying. And they've done that simply by more monitoring - and these apps, these health aids can really help. The Mediterranean Diet is a different story. And, a week doesn't go by where I'm in the hospital talking to some patient, and it's usually the wife that's asking the diet question, about how to change a diet to reduce the risk of a future heart event. And, I try to be very optimistic in talking about the Mediterranean Diet - that it is a lifestyle diet. There's nothing you can't do, but it's about food selections and these days, you know, we're fortunate that the access to fresh foods and to healthy foods can be made without a lot of sacrifice. And so, it's about shifting the types of foods you eat and usually the wine's a big seller. People don't mind a glass of wine with dinner, and that's in this diet as well. So, people want to know what they can do that's active to improve their health and eating is such an important part of life. You want to know that you're eating a diet that's not just you enjoy but that is healthy for you. So, I think the Mediterranean Diet is really worth a look. You can find simple information online. And even, you know, you can find the study I referenced - the PREDIMED studies - free online. You can go and look that up. And, it's got the diet simply laid out. So, you can really start to look at the foods you're eating and choose the right ones. I think diet is an important discussion to have with your doctor, and it's not a quick discussion. You've really got to define the goals and then make a commitment toward changing diet that you can sustain. And, if you can outline a way forward. And I'll even give patients a copy of the study and a page that summarizes the diet so they can ... somebody can look and say, "I can do that. I like that food. Ah, I'll just have that once a week. I'll skip it three times a week." They sound like they can be successful, and they are. And it's nice to see that people can make sustainable changes that you know reduce their heart risk.

Host: Thanks for joining us today, Dr. Taylor.

Dr. Taylor: Thank you very much.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

In the past, the only way to treat aortic stenosis was to perform open-heart surgery—a very invasive procedure. Discover how TAVR, a new minimally invasive surgery, can replace a heart valve without surgery, allowing patients to recover faster.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We're speaking with Dr. Toby Rogers, an interventional cardiologist at MedStar Washington Hospital Center. Thanks for joining us, Dr. Rogers.

Dr. Rogers: It's great to be here.

Host: Today we're discussing high, medium and low risk transcatheter aortic valve replacement, or TAVR. Dr. Rogers, could you start by discussing what TAVR is?

Dr. Rogers: That's a great question, and a lot of patients are quite confused by this terminology. So, aortic stenosis is a condition that is very common, particularly in older patients. And, it's caused by a narrowing or blockage of the main heart valve through which blood flows from the heart to the rest of the body. And, as that gets progressively tighter with time and with age, patients can start to get very symptomatic, particularly when they're trying to be active. So, they get very short of breath, they can get dizzy, they can even get chest pain when they're trying to be active, even just walking across the room. And, historically, the only way to fix this problem was to do open-heart surgery and literally stop the heart from beating, cut out the old valve, and surgically sew in a new valve. But you can imagine, open-heart surgery is a big deal and it's very stressful on the body and, the older you are, the more stressful a big surgery is. And so, TAVR is an amazing new technology that over the last decade has revolutionized cardiac surgery, in that we can now replace that heart valve through a little tiny catheter in the groin, with the heart still beating - in fact, with the patient awake. We don't even have to put the patient asleep. And, we can replace the heart valve and improve the blood flow to the rest of the body.

Host: What do you mean when you say high, medium and low risk TAVR?

Dr. Rogers: So, again, this is a concept that we use very freely in medicine, but patients often get confused by that. And, what we're actually saying is, 'What would the risk be for that patient to undergo the old fashioned open-heart surgery?" Meaning, if they were to have open-heart surgery tomorrow, would that be a low risk procedure, an intermediate risk procedure or would it be a very high-risk procedure. And that's not really determined by the heart at all. It's often determined by other medical problems they have. And obviously, older patients are more likely to have more than one medical problem. So, if you have trouble with the kidneys, if you have trouble with your lungs, if you have trouble with your liver - then all of those things will make a big procedure, or a big surgery, more high risk. And so, for every patient that comes along with aortic stenosis, we make an assessment based on a whole barrage of tests, looking at all the different organs in the body, as well as the heart, to say, "What would your risk of surgery be?" And that, then, helps us judge whether the open-heart surgery is the best treatment for them or if, in fact, they'd be better to have a procedure like TAVR, which is less invasive.

Host: Who would you consider to be an optimal candidate for TAVR?

Dr. Rogers: Well, certainly anyone who is very high risk for surgery. So, if undergoing open-heart surgery would be very high risk, and there would be a risk of not making it through the procedure, then clearly those are patients who should have less invasive procedure. And certainly, that's the way TAVR started. It was really only available to patients who were so high risk that they just couldn't have surgery. But then, as we've gotten more comfortable with the technology, and we've gotten more data for the technology and as we've run clinical trials - very rigorous clinical trials - across the US and across the world, we've actually demonstrated that TAVR's actually a very good option for anyone with aortic stenosis. And, I think within the next 12 months, we'll expect that the FDA will approve TAVR so that we can offer it to anyone with aortic stenosis. So, for sure if you're high risk, but the truth is, moving forwards and in years to come, I suspect that TAVR will be the first line treatment for anyone with this condition.

Host: You mentioned inserting the catheter through their groin and replacing the artery that way. Could you describe how TAVR is performed?

Dr. Rogers: Yes. So, of course, each procedure is slightly different for different patients. But, a typical TAVR is performed with a patient under conscious sedation. By that we mean we give you some medication to make you relaxed, make you a little bit sleepy, but you're breathing for yourself, you're not on a ventilator and, in fact, some of these patients even sort of, you know, are able to talk to us and are fairly awake during the procedure. And that has a lot of advantages because putting a patient on a ventilator and breathing for them with a mechanical ventilator under general anesthetic increases the risk of the procedure. There's more risk of picking up a chest infection, needing to be in hospital longer after their procedure, whereas if it's all done under conscious sedation and with local anesthetic, then patients bounce back much faster and are able to get up and about much faster and that speeds up the recovery. So that's the first step - it's done under conscious sedation. And then, what we actually do, is we take the heart valve, the new heart valve, and we crimp it down or we'll crush it down onto a catheter. So, we squeeze it down so it's small enough to now go through the artery and the groin. We all have big arteries that go from the heart all the way down through the belly, down the legs, and so, we actually access one of those arteries and thread the catheter, with the new valve on it, all the way from the artery in the groin, all the way up to the heart and then position it inside the heart using x-rays and ultrasound so that we know we're in the right place. And then, we open up the new heart valve inside the old one and "Hey, Presto" - you have a new heart valve.

Host: What does a patient have to do then to prepare for the procedure?

Dr. Rogers: So, I think we have a great team here that really guide the patients through the whole process, right from the very first contact, through all the testing to work out whether TAVR is the right treatment for them, all the way through the procedure. So, there are a lot of steps to this. This is not just a sort of come in and have the procedure and go home the next day. We always see patients beforehand. We usually bring patients in for a day or two several weeks in advance of the procedure to do all the tests we need to do to make sure that we know everything we need to know about this patient before we embark on the procedure. And then if we're talking specifically on the (sort of the) day of the procedure, we usually ask people to come in the night before or very early in the morning. There's a whole series of tests that we do - blood tests, to make sure that there's...nothing's cropped up in the meantime. And then, the procedure itself takes 3, 4 hours. And then, the patients typically go to either the cardiac ICU overnight or increasingly, actually, just go back to the normal ward, just to be monitored by the nurses there. And then we try and get people up and about the next day, and the average hospital stay for this procedure now is 2 or 3 days. So, actually, we've gone from a process where open-heart surgery patients would be in hospital for a week or more to a process where people are having heart valve replacement and they're out, sometimes the day after the procedure, which, I think, is a revolution in this treatment.

Host: What are the benefits of TAVR compared to traditional open-heart surgery?

Dr. Rogers: Ok, so the first benefit is that some patients simply can't have open-heart surgery. They're too sick. They have too many other medical problems that would make the procedure too high-risk. And therefore, surgery just isn't an option for them. Whereas, we're able to perform TAVR safely in those patients because it's less invasive. For the more general population, TAVR has the clear advantage that recovery is faster. Patients, after surgery, often have longer hospital stays. They end up staying in hospital for a week or so after the procedure. The complications are more common after surgery because it is just a bigger procedure and a bigger stress on the body. TAVR patients, in contrast, tend to go home within 2 or 3 days of the procedure and the recovery after they get home is much faster because they don't have to deal with the surgical wound, the incision, and all of the problems you can get related to having just had a much bigger procedure. And so, in terms of getting back to normal daily activities, getting back to work, TAVR allows for much faster recovery.

Host: And the recovery process - how does that look for patients?

Dr. Rogers: So, the great advantage - and I think I've highlighted it a little bit already - the great advantage to this procedure is it's not surgery and it doesn't require cutting the chest open, it doesn't require general anesthesia. And so, the great advantage of TAVR is the recovery. Patient's bounce back and recover from this procedure must faster because it's just less stressful on the body. Now, that being said, it's still heart surgery, we're still replacing a heart valve, and so I always try and temper patient's expectations and say that, "You're gonna have to take it a little bit slow here at first." But, it depends. Someone who is in their 60s is going to recover from a big procedure like this much faster than someone who is in their 90s. And so, every patient is a little different. But certainly, the whole goal of doing this procedure is to get someone back to their normal activities, not just what they were like before they had the procedure but what they were like before they had symptoms from the aortic stenosis. So, back to being active, back to playing sports, whatever they want to do.

Host: Could you share the story of a patient who had a particularly successful outcome with TAVR?

Dr. Rogers: Sure. So, one patient, he'd had open-heart surgery to replace the same valve about 10 years or so ago. And, that had been a great success. He felt wonderful afterwards. But, the truth is, prosthetic heart valves don't last a lifetime. And so, his "new" heart valve started to get tight and he a started to get those same symptoms again. And he was very, very worried about the prospect of having to have open-heart surgery again. He felt like he had done it once; he did not want to go there again. So, when he found out that there was an alternative to avoid having to have open-heart surgery again, he jumped at it. And, he came in the hospital, we did the procedure the same day, we got a great result with the new valve, and he actually went home, I think, the day after the procedure. Now, not everyone goes home so soon but, for him, the difference experienced from the first surgery, where he was in hospital for a week, to going home, literally, 24 hours after his procedure, I think, that's really remarkable. And certainly, he was overjoyed by the result he got.

Host: Why is MedStar Washington Hospital Center the best place for patients to come for TAVR?

Dr. Rogers: I think that one of the strengths we have is that we've been part of the whole TAVR program since it very first took off. The very first procedure was done in France in 2002, and TAVR came to the US in around 2007, and MedStar was part of the first wave of hospitals to perform this procedure. And, we have performed almost 2,000 of these procedures now. We have a great deal of experience with all the different types of technologies which are out there to treat this. It's not just one valve available. Now we have a whole series of different types of valves, which are...different patients need different valves. And, we're also very active in research. So, not only do we have access to all of our past experience in research, but we also have access to all of the new technologies. So, when a new valve is made available, we're one of the first hospitals to get access to it to offer that to our patients.

Host: Thanks for joining us today, Dr. Rogers.

Dr. Rogers: Thank you for your time.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Relaxing is important an important part of life—especially for the heart. In fact, when the heart has difficulty relaxing between beats, people can develop diastolic heart failure, a serious functional condition. Discover which treatment options can help.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We're speaking with Dr. Valeriani Bead, a board-certified cardiologist at the MedStar Heart and Vascular Institute, with extensive experience in nuclear cardiology and echocardiography. Welcome, Dr. Bead.

Dr. Valeriani Bead: Thank you for having me. I'm really happy to be here.

Host: Today we're discussing diastolic heart failure which occurs when the left ventricle or the lower left chamber of the heart can't properly fill with blood. Dr. Bead, is diastolic heart failure a common heart condition?

Dr. Bead: Yes. But first we need to understand what diastolic heart failure is. In simple terms, it's defined as an abnormality of the diastolic filling, or what we call the relaxation, of the left side of the heart, despite the fact that the heart pumping function is normal. And usually it occurs when the ability of the left side of the heart...when it can't really accept blood or it's impaired. And this can lead to a higher pressure inside the heart. Then, that can lead to fluid build-up in the lungs and also to the rest of the body. Now, to answer your question, diastolic heart failure is quite common, and it's thought to be as prevalent as 20 to 70 percent in some patient populations and is thought to be responsible for about two-thirds of the incidence of congestive heart failure that we see in general.

Host: What are some of the main symptoms of diastolic heart failure?

Dr. Bead: Some of the most common symptoms that we experience with diastolic heart failure are shortness of breath, fatigue, lightheadedness or fainting, and sometimes even an irregular or abnormal heartbeat.

Host: How is this condition diagnosed?

Dr. Bead: Typically, we diagnose diastolic heart failure by good, comprehensive history and physical exam. And then, based on that, we may order some imaging tests called an echocardiogram, which is a sonogram of the heart. This is often combined with the stress tests to show how blood is flowing in the heart during exercise. Finally, we may do additional blood tests or even an invasive procedure called a cardiac catheterization, which is when a thin tube is inserted into the heart in order to see how the heart is functioning and to determine whether or not there are any blockages in the arteries.

Host: Could you tell us a little bit about your patient population for diastolic heart failure?

Dr. Bead: So, the most common individuals we see, those at highest risk for diastolic heart failure, is the older population, so typically individuals over 65 years old and those who have high blood pressure. Sometimes those who have problems with their heart valves, particularly the aortic valve, and typically when that valve is narrowed or doesn't open well. We also see the diabetics and people who have clogged arteries, and, for unclear reasons, you see it more common in women.

Host: Once you've diagnosed an individual with diastolic heart failure, what treatment options are available for them?

Dr. Bead: We always start off with lifestyle modifications, which include smoking cessation, increasing physical activity, and dietary changes. Next, we offer treatment to address the stiffening of the heart and that typically includes controlling the blood pressure, controlling the diabetes, and also, if they have high cholesterol, we also treat that. And some of the medications we use may include a class of medication called beta blockers, which are used to slow the heart rate in order to allow it to function better. We also use medications called calcium channel blockers, which help reduce the stiffness of the heart. Other medications include diuretics that help reduce the fluid accumulation. And, if those are not sufficient, sometimes we offer an invasive procedure called a cardiac catheterization or even surgery to fix any blockages or narrowings in the blood vessels.

Host: What are some of the risks if a patient doesn't receive treatment for diastolic heart failure?

Dr. Bead: Now that's a great question because, the main risk we worry about, if a patient doesn't receive treatment for diastolic heart failure, is death. The other risk we worry about is congestive heart failure, which is when an individual has a sensation that they can't breathe, and they have evidence of fluid overload. Other things we may see are abnormal heart rhythms called atrial fibrillation. Other things that we may see are passing out, also called syncope.

Host: Is there anything that patients can do to reduce their risk of diastolic heart failure?

Dr. Bead: Yes. The most important thing patients can do to reduce their risk of diastolic heart failure is to keep their blood pressure under control, to control their diabetes or their blood sugars, and to control their cholesterol. And, of course, I mentioned lifestyle changes. So, meaning making sure they don't smoke, they stay active, and they eat a heart healthy diet.

Host: Could you explain how diabetes is related to diastolic heart failure?

Dr. Bead: Diabetes affects every organ in the body. And in fact, in cardiology, we consider diabetes 'heart disease' until proven otherwise. Although the ideology is unclear, diabetes is thought to lead to direct stiffening of the heart, either by having too much glucose in the system or by causing premature stiffening of the blood vessels surrounding the heart and, thereby, stiffening the heart itself.

Host: When you said that, it made me think of a 'starch,' like you would put in your clothing to make it stiffer.

Dr. Bead: You know what!? That's an amazing analogy! Yeah! Cause that's basically what it does. When you have all this excess glucose in the circulation. It's basically, because it can literally surround cells and kind of 'coat' them so they don't function so well, and they can become stiff like a starch. Yeah, like starch.

Host: Could you share a treatment success story from your practice?

Dr. Bead: This is always my favorite part! I love talking about my patients because they're so amazing. There was one middle-aged lady who came to me as a consult from her primary care physician. Initially, it was a semi-urgent consult because the EKG, the electrocardiogram, was abnormal and showed, an abnormal rhythm that was initially concerning for atrial fibrillation when, in fact, she had a lot of skipped beats. When I saw the patient, she was complaining mostly of shortness of breath and the inability to do her Zumba exercises. Oh, she loved to exercise about three days a week. But then she started noticing that her legs were more swollen. She got tired easier. She had a 'flooded' sensation in her heart and she really couldn't do her usual activity of daily living. And, I did a good exam. Her lungs were clear. Her heart actually sounded pretty good, with the exception of some skipped beats. But she did have some swelling in her legs and her blood pressure was quite elevated. And so, based on that, we talked, we adjusted her medication in order to get her blood pressure under better control. I prescribed a diuretic in order to reduce the fluid on her legs. And then we discussed her lifestyle changes such as reducing the sodium from her diet. When we saw her back within a couple of weeks, I had her get an echocardiogram or a sonogram of her heart which showed that her heart was strong but, using certain diagnostic techniques, we could tell that her heart was a bit stiff and it was also thickened from long-standing high blood pressure. So, we were very vigilant in terms of getting her blood pressure under good control. We were able to keep the fluid off. She was...did her part by making the lifestyle changes that she wanted to. And then, within about 6-8 weeks, she was back to doing her Zumba classes with no restrictions. And then, when I see her back every 6 months, she's actually to the point that she's helping teach the Zumba classes, which is always awesome.

Host: Why is MedStar Heart and Vascular Institute the best place for patients to seek care for diastolic heart failure?

Dr. Bead: The MedStar Heart and Vascular Institute, really is the best place for general cardiology patients, but, in particular, for patients who have specific diagnoses, such as diastolic heart failure, because it offers comprehensive, state-of-the-art care in a compassionate environment that is patient-centered and evidence based.

Host: Well, thanks for joining us today, Dr. Bead.

Dr. Bead: Thank you for having me.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Artery buildups serve as silent danger signs of a heart attack. Discover how a coronary calcium score calculates patients' risk by measuring the amount of calcium in their arteries through the use of a computed tomography (CT) scan.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We're speaking with Dr. Allen J. Taylor, Chair of Cardiology at MedStar Heart and Vascular Institute. Welcome, Dr. Taylor.

Dr. Allen J. Taylor: Thank you.

Host: Today we're discussing coronary calcium scoring, which is a non-invasive heart scan that a cardiologist can use to help calculate a patient's risk for coronary artery disease or atherosclerosis. Dr. Taylor, what are you looking for in a patient's heart when you perform coronary calcium scoring?

Dr. Taylor: Great question. This is a very simple test that very accurately and easily detects the beginnings of atherosclerosis or what otherwise people call (quote) "hardening of the arteries." It's that development of plaque, cholesterol buildups and other things that are filling up the arteries as we age. And so, when we're doing coronary calcium scoring, we're looking for little pieces of calcium, like in your bones, but that are in the arteries and it shouldn't be there. And it's a marker for these buildups that we can easily detect and measure and through that, evaluate a patient's risk for heart disease.

Host: How does the calcium end up there when it's not supposed to be there?

Dr. Taylor: The calcium comes because the arteries are becoming damaged from the buildups and as they heal, the body naturally lays down some calcium. So, it's part of these plaques or buildups and it's the one that we can detect with x-rays because x-rays detect bone, and this is basically bone in your arteries—little pieces of calcium. So, it's easily detected with a simple scan, a CT scan, that we call a coronary calcium scan.

Host: Are there certain populations of patients who are at increased risk for high levels of coronary calcium?

Dr. Taylor: It's interesting because simply by aging, that's your major risk. Now, some people with high cholesterol or high blood pressure or diabetes or smokers - they may develop calcium in their heart arteries at a faster rate. But, just because you don't have those things, doesn't mean you're not developing buildups; it doesn't mean you don't have coronary calcium. And the challenge is that by measuring those risk factors, we can detect somewhat of a patient's risk for heart disease, but it's only part of the story. And, the important thing about calcium scoring is that it tells us more of the story. It adds to what we already know about a patient and helps us to determine who really is at risk for heart disease.

Host: Is there anything that a patient has to do to prepare for this type of scoring test?

Dr. Taylor: The beautiful thing about this is it's a very simple test. It's done using a CAT scanner or CT scanner, but it uses very low doses of radiation. There's no needle. There's no medicines. All the patient does is lay down, get hooked up to a few electrocardiogram electrodes, and hold their breath for about 15 seconds. Within 5 minutes, they're done, and the scan is complete.

Host: Now why does the patient have to hold their breath while they're getting this test?

Dr. Taylor: The reason that you have to hold your breath is because if the heart is moving when you breathe, it'll blur the images. So, it's done during a breath hold. But, the breath hold is very short. The scans are very fast. And, virtually all patients can tolerate the scan. The scanners are very wide profile, there's not a lot of claustrophobia or that feeling of being closed in by the scanner tube. And the radiation levels, which is previously or often a concern, are very, very low. They're really like a couple of mammograms worth of radiation exposure. So, it's a very simple test and actually they're also very inexpensive. Most health systems will do these tests for under a hundred dollars, if insurance doesn't cover it. And many insurance payers will actually cover the test.

Host: What happens next if a patient's scan shows high levels of coronary calcium?

Dr. Taylor: Right. If you find calcium, what does it mean? It means you're at increased risk for heart disease. By the converse, if you don't find calcium, it means you're at low risk for heart disease. So, it really puts a lot of clarity on who is and who's not at risk. So, when you detect coronary calcium, there's certain things you're going to do. The most obvious things are live a better lifestyle since lifestyle changes are so important to heart disease risk. Eat a better diet, exercise more, get good rest, avoid stress, for example. And then, other health habits, like don't smoke, make sure your cholesterol is well controlled, make sure your blood pressure is well controlled. Maybe you'll need a cholesterol medicine to control your risk. Maybe you'll need aspirin to control your risk. With this information, you can make the right lifestyle changes. And also make sure you're on the right treatments to optimize reducing the risk for heart disease. Because, remember - heart disease is still the number one killer in this country.

Host: If those lifestyle changes don't work, what treatment options are available to take care of that coronary calcium buildup?

Dr. Taylor: A common question we get is "Can you remove the calcium?" And, you can't. But remember, if there's calcium there, there's plaque or other buildups. And it's that other parts of the buildups we're trying to treat by treating cholesterol, for example. Mostly we can show that we can stabilize the plaques, for instance, by lowering cholesterol a lot using very simple cholesterol medications that are very safe and very effective. But, some other choices might be there for patients, like do they or don't they take an aspirin a day, for example, or what blood pressure targets should they be looking for? Or, maybe they've been avoiding diabetes treatments and they should get on treatments. Or, what types of diabetes treatments? So, with your doctor, there's many healthcare choices that can be made to reduce the risk for heart disease. But, that's the connection. You get the test, you clarify your risk, and then you treat the risk using those other interventions - lifestyle and then targeted treatments for certain heart risk factors.

Host: You've given us a lot of really good reasons to get this test and then to seek treatment after. But what if a patient doesn't seek treatment? What are some of the risks to their health?

Dr. Taylor: Well, one thing we know is that many patients fear heart disease but may not have to fear it at all because, if you have no calcium in your arteries, the evidence shows the risk for heart disease over the next 10 years is extremely low, like .1 percent per year, one in a thousand. Very low. Now, if a patient does have coronary calcium and doesn't seek treatment, that would not be the outcome we would want because anytime you do a test, you want to use that test to make better health choices. And, the evidence shows that, in fact, that is what happens. So, when people get this test, they're more likely to get appropriate cholesterol medication, for example. They're more likely to take appropriate measures, like taking aspirin. And, they're also more likely to make other healthy lifestyle choices. So, I think the test has some great utility to help both patients and doctors more carefully identify risk and then respond in the right way. And, the evidence suggests that that's actually what happens.

Host: Could you tell us about a patient who came in for a coronary calcium scoring test - maybe found that they had some calcium and made some changes to their life or were able to reduce their heart disease risk?

Dr. Taylor: Oh sure. I can tell you stories on both sides of the story. A friend of mine, he's in is early 50s and has a family history of heart disease, has always worried that something inside of him is not...won't be right, that genetics have led to him to have risk for heart disease. But he lives a healthy lifestyle, doesn't have any risk factors. He got a scan - there was no calcium. So, he has been reassured that, in fact, whatever it was that led his loved one - it was one of his parents - to have heart disease, he, at least at this point in his life, doesn't appear to have it. And it's a pretty good time to screen, as people turn middle-aged, 50 to 60. That's when heart disease risk really goes up and we can detect calcium, if it's present, and how much. On the other side of the story, many, many successful stories that show how this test can be well utilized. For example, a woman who was also middle-aged, in her 50s, and she had been worried about her heart health and didn't have a lot of risk factors. Not a smoker, good cholesterol. And, in fact, she has very high levels of coronary calcium. And, she's way above average for age and that says that her risk is much higher than it should be. So, what did we do? Well, she's now on a cholesterol medicine - her cholesterol wasn't bad, now it's perfect. And, not all healthy people should take aspirin, but her risk is high enough with this that we have, in fact, placed her on aspirin - carefully, because aspirin can cause bleeding, so you only want to use aspirin when patients have risk for heart disease. So, her treatments have been changed. Now, she's still active and she's still eating well. She was always doing those things. But now we've gone from the normal lifestyle changes to, in fact, a very proactive approach to reduce her risk and hopefully that risk is being optimized.

Host: What would you say to a patient who feels like maybe this isn't for them or they don't need this type of test?

Dr. Taylor: The interesting thing about calcium testing is that we can only predict, with heart risk factors, about a third, meaning a minority, of actually how much buildup is actually there. You only know by looking. You know, they've said 'a picture says a thousand words?' That's the case with this. By doing this very simple test, you can get a complete view of heart risk within 5 minutes, and it's something that no other test can provide.

Host: What makes the program here at MedStar Heart and Vascular Institute so unique for patients who have coronary artery calcium buildup?

Dr. Taylor: In the mid-Atlantic, MedStar Heart and Vascular Institute has been doing calcium scanning longer than anybody. And, many of our doctors, myself included, have conducted some of the seminal research, the important research, that's shown the value of this test. And we provide this as a low-cost health service. So, even if patients' insurance won't provide it, we so strongly believe that this is the best test that a patient, age 50 and above, could take to really know their heart risk, that we provide this at very low cost. So, we believe in the test. We think it's very important. And we provide that care so that no patient shouldn't have the benefit of a coronary calcium scan.

Host: Thanks for joining us today, Dr. Taylor.

Dr. Taylor: Thank you so much.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

People who are concerned about their thyroid health may turn to supplements. But thyroid supplements can cause the very problems they're supposed to correct.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. In today's episode, we talk to Dr. Kenneth Burman, Director of Endocrinology at MedStar Washington Hospital Center about thyroid supplements. The thyroid is a tiny organ that's involved in regulating several major bodily functions including breathing, heart rate and body temperature. Over-the-counter thyroid supplements may seem like a good idea to someone who believes they may have a thyroid condition. But thyroid supplements actually can cause problems with the thyroid and we may not know exactly what's in them.

Host: Dr. Burman, thanks for joining us.

Dr. Kenneth Burman: Sure. Thank you for the invitation.

Host: You bet. So, over-the-counter thyroid supplements—helpful or dangerous? Tell us about that topic.

Dr. Burman: Sure, be glad to. Over-the-counter supplements for the thyroid come into various categories. So, one type of supplement would be iodine or iodine containing substances. Another type would be substances that contain one type of thyroid hormone, or thyroid hormone analog. There are other ones that are much less well characterized, and we'll focus on the iodine and the thyroid containing supplements. So, iodine is an interesting substance. It is required for the synthesis of thyroid hormone synthesis and also required for secretion of thyroid hormone. And, thyroid hormones, which are abbreviated T-4 and T-3, contain about 68 percent iodine. So normal iodine in a diet, minimum daily requirement is about 150 micrograms per day and some substances that we use in medicine such as IVP dyes or cat scans contain thousands of micrograms of iodine per day. Supplements can vary over-the-counter and are not necessarily regulated as to how much iodine they contain. So, if a supplement contains something close to the minimum daily requirement (about 150 micrograms) that should be fine and maybe even beneficial. But many of the supplements are not quantitated in terms of iodine, but also contain iodine that is very high in thousands of micrograms in a tablet. And if you take one a day, that would be thousands of micrograms a day.

So, what are the effects of iodine on the thyroid gland? They're multiple. For a short period of time iodine in these concentrations will lower thyroid hormone secretion so we actually use supplements to very hyperthyroid people under very controlled circumstances. But that control of thyroid synthesis only occurs for 10-14 days approximately, and after that time, they escape from that effect and the iodine fuels worsening hyperthyroidism. Normal people may or may not have those reactions but those are possible, especially in the large percentage of patients in the population that have autoimmune thyroid disease and may not even know it. So, in summary, with regard to iodine, large amounts of iodine should be avoided by normal people and anyone with thyroid disease, a normal amount of iodine, a minimum daily requirement, is reasonable; and everyone, but especially people with a family history or known history of thyroid disease should avoid large amounts of iodine. With regard to thyroid hormone analogs, one of my former fellows and now colleague, Vick Burnett who is the head of endocrinology at Mayo Clinic, Jacksonville, did a nice study that he published of looking at supplements and measuring thyroid hormone in them. And it turned out, that of the 10 or 20 supplements that he looked at, almost all of them had a significant amount of thyroid hormone in them, even if they didn't put that on the label. So, thyroid hormone itself, given to a normal person, can cause hyperthyroidism, which may be associated with a fast heart rate, palpitation, bone loss, and even more severe problems such as atrial fibrillation and should be avoided. And that these thyroid hormone analogs are difficult to identify in these supplements unless you specifically look for them. And it's not just the standard hormones of T-4 and T-3 but there are various analogs of thyroid hormone that can cause similar problems that are not necessarily quantitated in these supplements.

Host: When we talk about over-the-counter supplements, are these people who self-diagnose themselves and then they just go out and they get the supplements?

Dr. Burman: Either because they are self-diagnosing themselves but perhaps, more commonly, they're using it as health food or health additives to try to make them feel better or have more vigor. Of course, regular vitamins are key, and everyone should have adequate amounts of regular vitamins but iodine in excess, or thyroid hormone in excess, in any of these supplements should be avoided. And, of course, the FDA does not regulate supplements like they regulate medications.

Host: So, we don't even know what's in them necessarily.

Dr. Burman: Correct. So, this study by Dr. Burnett, it was unknown or unidentified exactly what the contents were and he was very surprised that it turned out to be significant amounts of thyroid hormone in many cases.

Host: So, for the most part, would you recommend people do not take them then or do consider them?

Dr. Burman: We would recommend that, in general, patients with any known thyroid disease not take supplements, and even normal individuals should ask their physicians to examine whether those particular supplements may contain thyroid hormone.

Host: What can happen if you take supplements and you don't have a problem?

Dr. Burman: If you take supplements and you don't have an endogenous thyroid problem, there could be enough thyroid hormone in them to cause overactive thyroid activity, just as if you had bona fide hypothyroidism. That can result in atrial fibrillation, heart irregularities, bone loss, and other significant problems.

Host: What other tips do we have on this topic? Anything else we need to share that people need to be aware of?

Dr. Burman: Yeah, it's always of interest that people wonder where iodine comes from and in food, etc. in our normal American diet. So, I frequently ask the medical students "What's the most common source of iodine in the American diet?" and they always, unanimously say, "salt." But it turns out salt doesn't contain that much iodine. That rather, it's processed foods that contain iodine as a preservative—bread and pastries, to name one large source of iodine. And then another source of iodine that relates to health food is kelp. Kelp is seaweed which, of course, no matter how it's prepared, has a large amount of iodine in it that can cause the problems of over or under activity.

Host: Great. Well, thank you for joining us on the show today and I appreciate everybody listening and hopefully you found this information helpful. Thanks again.

Dr. Burman: Thank you.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Why are more people younger than 50 developing colorectal cancer? Dr. Brian Bello discusses the disturbing trend.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thank you for joining us today. We're talking with Dr. Brian Bello, a colorectal surgeon at MedStar Washington Hospital Center. Welcome, Dr. Bello.

Dr Bello: Thank you.

Host: Today we're talking about why more younger patients are dying of colorectal cancer. Once considered an older person's disease, patients in their 30s and even 20s are being diagnosed with colorectal cancer, which is baffling the medical community. A 2017 study found that, after years of decreasing mortality rates, colorectal cancer deaths in adults age 20 to 55 increased 1 percent per year from 2004 to 2014. Dr. Bello, what do you think caused this seemingly sudden spike in colorectal cancer deaths?

Dr Bello: That's a tough question to answer. Many people have been looking at this. The answer is really unclear. We think it's probably a combination of factors. I think if we look at the population now compared to 15 years ago - the population is more obese, that's probably the driving factor. Patients diets are different than they were 15 years ago. People may not be exercising as much. And then there's maybe genetic factors that we quite don't understand. But we are looking at this very closely, but I think the number one issue is probably diet and weight.

Host: Is this something that you're seeing in patients locally in the Washington DC area?

Dr Bello: Well, certainly people now are asking about it. Many patients come in and have read about this New York Times study and ask do they need a colonoscopy or they have friends that have recently been diagnosed with colon cancer and they are asking if they need one. So, certainly more people are asking about it. I think the key take-home lessons are people need to be educated about what signs and symptoms to look out for. So, if young people are experiencing abdominal pain that's chronic, that doesn't go away, or if they have rectal bleeding or unexplained anemia or weight loss, providers should be more willing to provide or give education about a colonoscopy.

Host: What do you mean by unexplained anemia?

Dr Bello: Yeah, usually this blood work is done by a primary care physician and it's usually a yearly blood work laboratory value that can be checked. If a patient's blood count is lower than normal and there's not a good reason for it, then we need to investigate other causes of the blood loss.

Host: How has the increase in colon cancer changed the screening recommendation?

Dr Bello: Currently we're not changing our screening recommendations. Usually the screening for Americans is everybody over the age of 50 needs a colonoscopy, which is the gold standard for colon cancer screening. For younger patients, as I mentioned earlier, we look for signs and symptoms. If they have concerning things that are chronic, then we recommend a colonoscopy. If we started screening earlier, that would probably mean more unnecessary tests - tests that are very costly and these tests that we do aren't without risk. We do the CT scans for many reasons, and sometimes we'll pick up things that are of benign cause, meaning that there's nothing really to worry about but that usually prompts more tests which mean that patients are paying maybe more money, and these things are clinically relevant, meaning that you could find like a cyst in your liver and then we do additional tests and you really didn't need to look at that at all. So, we try to avoid unnecessary tests just because they're costly and could provide risk to the patient. In today's field of medicine, we're trying to be more cost efficient, cost effective. So, right now we haven't changed our screening recommendation - we're just looking for signs and symptoms - if these younger patients have those, then we recommend a colonoscopy.

Host: How can a young adult patient determine whether they're at risk for developing colorectal cancer early in life?

Dr Bello: So, one thing that we always look for in these patients are a good family history. So if a patient has any family history of colon cancer in their family, especially relatives that were diagnosed at age 50 or younger, we're more likely to recommend a colonoscopy. And again, those signs and symptoms that I had mentioned already - bleeding, abdominal pain, weight loss - those are the things we look out for.

Host: What can patients can to reduce their risk of developing colorectal cancer?

Dr Bello: Yeah, we always recommend a healthy lifestyle. Number one is definitely watch what you eat. So, we try to encourage people to eat a high-fiber diet, try to avoid fatty food, avoid fried food. In addition, we recommend that people exercise. Also, we recommend no smoking and try to avoid a lot of alcohol use.

Host: How does smoking and alcohol use affect the colon?

Dr Bello: So, that's a good question. It's unclear but we know that people that smoke more are at significantly increased risk of many different things - heart problems, stroke - but specifically for colon cancer we find that there's an increased risk. It's an unclear connection. It might have to do with some weird effect that smoking has with the bacteria in the colon or the lining of the colon. It's unclear. But we just know that from studies there's an association with it.

Host: What makes MedStar Washington Hospital Center the best place to seek screening and treatment for colorectal cancer?

Dr Bello: Well, here at MedStar Washington Hospital Center, we have a multidisciplinary team. That means we have experts in different fields - like surgeons, gastroenterologists, medical oncologists, pathologists, radiologists - that all see a lot of colon cancer and rectal cancer. So, we just do a lot of high volume. We do this day in and day out and we're just specifically looking at colon cancer. Because of that I think we see better results and better outcomes for patients. Another thing we do at MedStar Washington Hospital Center is we promote the use of laparoscopic surgery. So that is surgery that we use very small incisions to do major, complex abdominal surgeries in. So we can do, for example, a colon resection with 3 or 4 very small incisions, and when we do this, patients tend to do a lot better. They have less wound complications, we can feed those patients earlier, and they tend to get out of the hospital much faster. So that is another thing we do at Hospital Center that makes it a great place to go for your colon cancer surgery.

Host: What is a colon resection?

Dr Bello: So, a colon resection is a surgery where we remove part of the colon and the fatty tissue surrounding the colon. Usually treatments for colon cancer or other colon problems. So, the old fashioned incisions usually were anywhere from your sternum to your pubic bone. But usually now we can do them with some stab incisions, which are about a centimeter and maybe one other incision that's maybe 4 or 5 centimeters, where we pull out that part of the colon.

Host: Are you currently doing any research on colorectal cancer that you'd like people in the community to know about?

Dr Bello: Yes, I have research interests in colon cancer, specifically about screening, which we're talking about today. Specifically, we've been looking at why people aren't getting their colon cancer screening. So, again, everybody over age 50 should have some sort of colon cancer screening, whether that be the gold standard with the colonoscopy or some sort of stool test. It should be done. But for some reason people aren't getting them done. Approximately 40% of patients across the U.S. and in DC don't get the appropriate colon cancer screening. So, we've done some surveys to find out why. The number one reason why people don't get colon cancer screening is that they felt that they weren't educated about it, they didn't know about it, their primary care physician didn't tell them about it. Those are the driving factors, but we've also found things like people were worried about the bowel preparation they have to do before a colonoscopy or they were worried about procedural risks or they just didn't like talking about their GI system.

Host: How do all of the surgeons and physicians work together to provide a team approach to care for colorectal cancer?

Dr Bello: So, usually when somebody is diagnosed with colon cancer, we present each of these cases at a multidisciplinary tumor board. We review the CT scan images, the biopsies, and we come up with an individualized treatment plan for the patient. And that's when everybody can chime in and give their recommendations and we come up with one plan for each individual patient.

Host: Could you share some screening or treatment success stories from your young adult patient population?

Dr Bello: I was involved in the treatment team of a young 20 something year old gentleman. He had some routine blood work done, which showed anemia. His primary care physician recommended that he get a colonoscopy. Unfortunately, that colonoscopy showed multiple large polyps throughout his colon and many of the biopsies showed that these polyps had pre-cancerous cells in them. So then he was referred to me and then I recommended that he undergo a colon resection and we did that. We did that with small incisions called laparoscopic surgery. He did great post-op and now he's on a very good surveillance plan where we're doing routine colonoscopies. He did great. If he doesn't get that blood work or if he doesn't get a colonoscopy, these polyps would have likely have turned in to cancer by now and then a lot more difficult to treat. Thankfully, we caught them early, and we did his surgery early, and now he's doing great.

Host: In those younger patients, where they have unusual lab testing, is surgery usually the best option to treat them?

Dr Bello: Oh, hopefully, if the lesions are small, like if they're just polyps, we can remove those with a colonoscopy. Only if these polyps grow very large or they are cancerous do we recommend surgery. The goal of the colonoscopy is to find these polyps and to remove them at the same time.

Host: So the colonoscopy can serve both as a screening tool and as a preventive measure?

Dr Bello: Yeah, what's really good about colon cancer screening is, if you get a colonoscopy, we're able to find these polyps before they turn into cancer - that's the key.

Host: Thanks for joining us today, Dr. Bello.

Dr Bello: Thank you very much.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Thoracic surgery has come a long way in the last century. Dr. John Lazar discusses how patients in Washington, D.C., can benefit from safer, more precise surgeries with faster recovery through minimally invasive robotic technology.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We're speaking with Dr. John Lazar, Director of Thoracic Robotics at MedStar Washington Hospital Center. We're discussing robotic surgery, a minimally invasive technique, which increasingly is being used for esophageal, lung, and other thoracic conditions. Dr. Lazar, what do you mean when you say robotic thoracic surgery?

Dr. John Lazar: So, basically, we mean we're doing minimally invasive surgery and it's robotically assisted, meaning the surgeon is in total control of the robot. Nothing is automated, and yet we're taking advantage of robotic technology, which would be 3-D visualization, uh, removal of any tremor, and basically being able to manipulate the robot in small, hard to reach areas.

Host: When you say removal of tremor, is that from the physician's hand?

Dr. Lazar: not necessarily the way you would think about a tremor, but for every three motions I make, the robot will make one. So, it sort of stabilizes the hand - there's no big lunging motions - so we call it stabilization.

Host: What are some of the more common thoracic procedures that are performed with robotic surgery?

Dr. Lazar: So, when we think about robotic surgery, we think about three main areas, one of which is the lung. Uh, the other one is called the mediastinum, which is the central part of the chest - the soft tissue's there, which includes the thymus. And the other part is the esophagus as well as the stomach.

Host: Are you treating conditions that are just cancer or what sort of conditions are you looking for?

Dr. Lazar: So, we treat conditions that are both cancerous or malignant as well as benign, meaning non-cancerous. Um, non-cancerous conditions are especially prominent in the esophagus - such things as paraesophageal hernias, where the stomach actually over time goes up into the chest. Uh, we also treat things like lung cancer. There are some benign diseases of the mediastinum which we also treat, but they have to be treated with excision. And, that's pretty much it when it comes to the robot.

Host: So, what are some of the patient benefits that people can expect when they get a robotic surgery as opposed to a traditional surgery?

Dr. Lazar: So, traditional surgery we're talking about usually a large incision, something anywhere from six inches to twelve inches. Uh, when we talk about robotic surgery, we call it port-based surgery. It's minimally invasive and instead of the instruments kind of grinding back and forth, they go through a port and so there's only one small area where the port is touching the skin, and so generally we find that there's less pain afterwards. People are able to get back to their daily lives quicker. So, in terms of comparison in after-care for robotic surgery versus open surgery, uh, most people who have open surgery are in the ICU anywhere from one to three days, maybe sometimes five days, whereas most patients who get robotic surgery do not need to go to the ICU and therefore, they're up and out of bed and walking around the floors much quicker and the tubes - there's usually a tube after surgery - that can come out. And I tell most of my patients that they're in the hospital three to five days. Everybody's a little bit different, but that's about it. Um, most people are walking - they're walking up the stairs - they're eating, they're drinking. Uh, they're usually...their biggest complaint is they're a little bit sore, but nothing compared to open surgery. There's less narcotic use, uh, for minimally invasive and robotic surgery and they're usually 90 percent better by ten to fourteen days after surgery. That's not out of the hospital - that's after surgery itself.

Host: How do patient outcomes with robotic surgery compare to those of traditional surgery?

Dr. Lazar: So, robotic patients are minimally invasive patients. So, generally speaking, if you're able to get a minimally invasive procedure, meaning smaller incisions, patients usually do better quicker. Over the long term, they do just about the same. But the idea that robotic surgery is just another type of minimally invasive surgery, the advantages being more for the surgeon and less from the patient when we talk about things like VATs or laparoscopic surgery which are other types of minimally invasive surgery. For the surgeon, we're able to get into smaller places, we're able to visualize things in 3-D as opposed to just on a flat screen TV, which is the way we do it in traditional minimally invasive. And this allows us to do more highly technical procedures in a smaller space. So, in comparison to open surgery, I think where robotics has really helped the patient is getting them a better...technically a better operation, whether it's cancer operation or whether it's for something like paraesophageal hernia, and I think that's because the surgeons can see better. They are not constrained by stiff instruments like you have in VATs and laparoscopic surgery. In robotic surgery there's...the wrists are able to flex just like your own wrists and we're able to see things that we normally couldn't see and therefore we're able to do better operations. You're better to see the margins, and I think that that plays a big role in the post-operative care.

Host: Why is MedStar Washington Hospital Center the best place to seek thoracic surgery from a robotic or a minimally invasive standpoint?

Dr. Lazar: I would say that the group of surgeons across multiple disciplines are outstanding here - and that's one of the major reasons why I came to join the thoracic team. They have a great deal of experience. They've been doing this for many years. They have gone through their learning curves already, and they're able to offer patients an advanced level of robotic care at the cutting edge. Robotics is being employed by a lot of different specialties, not just thoracic. So, ENT is doing some cancer operations, uh, for tonsils and tongue-based cancers. Gynecology, urology are using it a lot as well for both malignant and non-cancerous procedures.

Host: Thinking about those patients as you were talking, have you had any outstanding or really interesting patients that you could talk about in generalities?

Dr. Lazar: There was an example of a young man who was, uh, working at home, felt his, uh, back sort of twinge, didn't think anything of it. And then a week later went to his primary care physician who got a chest x-ray and saw that there was a mass along the left side of his chest. It led to a cat scan and showed a mass. His other surgeon was gonna do a large open procedure. Uh, luckily for him, they didn't accept his insurance and so he came to me as a second referral. And, uh, we were able to do it minimally invasively. It turned out to be a benign cyst that was growing along his major artery called the aorta. We were able to do the surgery safely and he went home the next day and so far has not had any other issues and went back to work within two weeks.

Host: You mentioned that your patient had had back problems, and that's what prompted him to see his doctor. What are some of the other symptoms that patients often notice before they get to you?

Dr. Lazar: I would say that pain is usually the number one, um, issue that patients have when it comes to the esophagus or the stomach. There's usually things like nausea, bloating, indigestion, reflux - those types of things. Also, weight loss can be a big part of it. Fatigue.

Host: Tell me a little bit about your patient population. Are you seeing mostly older folks or what does that look like?

Dr. Lazar: So, I think, you know, being in the D.C. area, you see a lot of different people that you normally wouldn't see. It's a...it's a much different population, probably because so many people move here from different parts of the country. So, we see people from 16-years-old to, you know, people in their 90s. And they have a variety of different issues. Um, some are cancerous and some are not. Um, so there's... it's really hard to pinpoint it on one thing, which is one of the nice things about practicing here at the...the hospital center is...is you do see a large variety of people.

Host: Who's at risk for these types of conditions?

Dr. Lazar: So, I would say that the youngest people that we usually see are in their 30s but it goes all the way up in to the 90s, especially for the benign esophageal. This can happen to anybody at any age because it's just a weakening of the muscle lining.

Host: Is surgery the first line of defense, or the first treatment for these types of conditions or do you typically try another therapy first?

Dr. Lazar: So, when you're talking about non-cancerous things, obviously people try to avoid surgery at all costs. But usually once the symptoms become impinging on their quality of life, they generally seek surgical opinion. They're not necessarily sold on surgery at that point but they at least want to keep their options open, especially if medical therapy tends to get more and more expensive, such as anti-acid medications and things like that.

Host: Do your patients typically have to see their primary care doctor first or can they refer right to you?

Dr. Lazar: It depends. Some people come right in to the emergency room, and if that happens, then it kind of bypasses the primary care but I think if they have a primary care, they should see their primary care first and get properly worked up. Most conditions are not surgical.

Host: Are you or your colleagues participating or conducting any research right now on thoracic surgery field that you'd want people to know about?

Dr. Lazar: Um, we are looking to become one of the first centers to robotically repair something called tracheobronchial malacia, which is a weakening of the trachea which is the windpipe that connects your mouth to your lungs. And basically, if it loses its integrity and it just starts to collapse, it can be very difficult and easily winded. In the old days we didn't really have a lot for this, but now we can buttress it and sort of reinforce that integrity of the trachea and allows them to have a much better quality of life and not feel continuously short of breath.

Host: Thanks for joining us today, Dr. Lazar.

Dr. Lazar: Thank you.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.