Medical Intel

Due to advances in imaging scans, kidney cancer often is detected by chance and early in the disease process. Dr. Ross Krasnow discusses minimally invasive robotic surgery and other treatment options for localized kidney cancer.

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 talking to Dr. Ross Krasnow, a urologist who specializes in urologic oncology at MedStar Washington Hospital Center. Welcome, Dr. Krasnow.

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

Host: Today we're talking about management options for localized kidney cancer and, in particular, the minimally invasive surgery options available to some patients. Dr. Krasnow, what do you mean when you say localized kidney cancer?

Dr. Krasnow: So, localized kidney cancer is cancer that originates from the kidney but is confined to within the kidney or the fat surrounding the kidney or adjacent structures surrounding the kidney. It can also be in some of the lymph nodes, but it has not yet spread to far away lymph nodes and other organs that are not directly touching the kidney.

Host: How common is kidney cancer, in general, and then how common is localized kidney cancer?

Dr. Krasnow: So, kidney cancer is the seventh most common cancer generally, in men and in women. When it presents, most of the time it is localized at the time of presentation. And that's really because of a stage migration that's occurred over the years. The kidney lies in the back of the body, and as you can imagine, before we had advanced imaging, it was only picked up when it became symptomatic and at that point it was very large, it would cause pain, it would cause blood in the urine, and it had often already spread at the time of presentation. Now there's been a stage migration and what that means is often it is picked up incidentally. A patient has imaging such as an ultrasound or a cat scan for another purpose. They have gallstones, they have vague pain, they have indigestion. And they end up getting some sort of imaging and that imaging just happens to show a small renal mass. More and more we're picking this up when it's asymptomatic and confined to the kidney, and it's easier to treat.

Host: So, an individual could come in thinking that maybe they're just having some back pain and they get an MRI for example, and it turns out that it's cancer. What is somebody's reaction to something like that?

Dr. Krasnow: Just to be clear, often when they get that MRI for back pain, the pain is not even related to the cancer; it's completely unrelated. I think most patients, when they learn that they have a renal mass, are very nervous. And I hope that when I see them and talk to them I can reassure them that they're going to be fine, most all of the time. Especially when these tumors are small. They're very easy to manage and very rarely life-threatening until they get to a certain size or demonstrate evidence of spread.

Host: So, does kidney cancer tend to strike certain individuals or certain demographics of people more often than others?

Dr. Krasnow: It's actually quite sporadic. There's a slightly increased risk in patients who are smokers, patients who are obese and have diabetes. Certainly, there's an increased risk in more unusual patient populations such as those with certain genetic predispositions or those on dialysis. But I would say, for the most part, the vast majority of patients I see it in, it's completely sporadic.

Host: So, if an individual is diagnosed with a localized kidney cancer - so that fairly contained cancer - what types of treatment might a doctor recommend? Um, you know, traditionally they talk about active surveillance, they talk about radiofrequency. Can you talk about those common types a little bit, and then some of those minimally invasive options?

Dr. Krasnow: When I first see a patient that comes to me with a renal mass, I'm actually reluctant to call it a cancer right away. And that's because one third, one out of three patients with a small renal mass less than, say, three or four cm, don't actually have cancer. They just have a growth on the kidney. The other two thirds of those patients do have a cancer, but it actually tends to not be very aggressive, and these cancers are not very aggressive until they're over, say, three or four centimeters. Once I frame it like that, patients are immediately reassured. And then I talk about some of the management options. Active surveillance is a great option for certain patients. Even renal masses less than three cm have almost no metastatic potential. And that ultimately is what we worry about, not actually having a tumor on the kidney but having a tumor on the kidney that has the potential to spread. Knowing that allows us to offer active surveillance for patients. That means that we watch the mass every, say, three to six months for some time, maybe extend that out to every year, and if the tumor doesn't seem to be growing, we may not need to treat them at all. This is a really great option for patients who are older, have a lot of other medical problems, or, for whatever reason, are reluctant to have surgery. Maybe they have just one kidney, and were very concerned about preserving their kidney function. When the tumors are over three or four cm, I do tend to recommend some form of treatment, although that's not always the case. And, of course, it's not realistic to watch tumors in patients who are very young. You're not going to watch a tumor in a thirty-year-old for forty years.

So, when we talk about the treatment options, again, there are many. One is often we don't even have to biopsy these masses but sometimes we do biopsy them to confirm that they're a cancer. The treatment options from the least invasive to the most invasive, would be having our colleagues in radiology simply put a needle in it, and through that needle they can burn or freeze the mass. That is called radiofrequency ablation when you burn it or cryoablation when you freeze it. Again, that's a great option for patients who are older, have some other medical problems. It's also a great option for tumors that are small and in a location where the damage from freezing it or burning it would be confined to just the cancer and not damage other structures that are nearby. The long-term results of cryoablation and radiofrequency ablation are not as clear. The short-term results show very good efficacy, maybe just a little bit less than radical surgery—but not by much. There are certainly situations where ablative techniques are not appropriate. If the tumor is large, is in the middle of the kidney close to blood vessels, close to adjacent organs such as the pancreas, the duodenum, the liver, if it's close to where the urine collects in the kidney - those techniques aren't controlled enough. So, at that point, we do recommend radical surgery. Also, patients who want the most effective treatment, the gold standard, we recommend radical surgery. Most often for a small renal mass that is a partial nephrectomy. So, that's removing the part of the kidney that has the cancer in it while leaving the rest of the healthy kidney behind. In the past, we did too many radical nephrectomies. That's when we remove the whole kidney for small renal masses. It was really unnecessary. While effective as a cancer therapy, it hurt patients in terms of their renal function, and we really concentrate on maximizing and preserving renal function now.

Host: When you have those treatments such as radiofrequency or cryoablation, those very focused and targeted type therapies, do you also have to undergo chemo or radiation, or any other subsequent treatment?

Dr. Krasnow: It actually is one of the few cancers that doesn't respond well to chemotherapy at all. And agents for the management of kidney cancer tend to work on the immune system. They also tend to be reserved for patients with metastatic disease or disease that's already spread. Radiotherapy is ok for kidney cancer. The problem is that it damages the rest of the kidney. So, for localized kidney cancer, chemotherapy and radiotherapy are not…are not needed and they're not great options.

Host: So, what about something like immunotherapy? That's…that's becoming more and more common for so many types of cancers. Could you talk about that a little?

Dr. Krasnow: Yes. So, immunotherapy for kidney cancer has made a lot of waves lately as second line therapy for patients with metastatic disease who have failed first line therapy. There are investigational studies looking at it for localized kidney cancer. Those would be patients who have a very large mass that may not be able to be treated surgically, and you may consider giving them some sort of therapy before surgery to see if you can shrink it to the point where surgery is a viable option. The other space that it's being looked at is in patients with high-risk localized cancer, so they had surgery but the tumor appeared very aggressive, and the risk of recurrence is high. In that…those are patients you may consider giving an agent such as an immunotherapy agent right after surgery, even if they don't have evidence of metastatic disease. Those two settings are completely investigational right now and are not the standard of care.

Host: Let's go back and talk about those surgical options. So, could you elaborate a little bit further on partial nephrectomy?

Dr. Krasnow: So, partial nephrectomy is when we remove the part of the kidney that just has the cancer in it, leaving the rest of the healthy kidney behind. This is in order to preserve renal function and also to maximize cancer control, arguably better than the ablative techniques, such as cryoablation and radiofrequency ablation. The great progress that we've made in partial nephrectomy is that we're now able to do it in a minimally invasive fashion, specifically using robotic laparoscopy. This allows us to make small keyhole incisions, get to the kidney, remove the part of the kidney that has the cancer in it using excellent visualization that the robotic optics provides for us, and then reconstruct the kidney afterwards, to close up all the vessels, and to close up where the urine drains out, in order to achieve a good outcome for the patient. And we can now approach the kidney from the front or from the back, which is helpful for patients who have a tumor in the back of the kidney or for patients who have had prior abdominal surgery where the abdominal cavity may be very scarred and adhesed. Both of these techniques are also extremely good for patients with obesity, because otherwise an open incision would be very large, painful, and lead to a longer recovery.

Host: So, when you're talking keyhole incisions, about what size is that? Could you give a visual?

Dr. Krasnow: The incisions are between half and one centimeter.

Host: And how does that work when you're going in through such a small incision - how are you able to remove part of an organ?

Dr. Krasnow: So, we have a camera that has 3-dimensional vision. When we're doing the surgery, we can actually get depth perception. And, the instruments we place are wristed, so we get more dexterity than we would otherwise through what we would call straight laparoscopy. The last option for localized cancer, when we can't spare the kidney, we do have to often remove the whole kidney, and maybe remove some of the lymph nodes around the kidney, and we've also made advances in minimally invasive techniques for more advanced localized kidney cancer. When kidney cancer that's localized is very advanced, it can even extend into big vessels within the body, and traditionally that type of surgery would be approached open in order to perform a vascular operation where you're not only removing the kidney, but you're removing tumor that's within blood vessels. This can now be done oftentimes using the robotic platform as well. So, whereas patients would be staying in the hospital for a week or two after surgery with a prolonged convalescence, they can go home in a day or two with very little blood loss.

Host: So, when you approach a patient who you've determined needs surgery for their kidney cancer and you say, "We're gonna offer you this robotic treatment method," what's their reaction, or what questions do they usually have?

Dr. Krasnow: Most patients are just interested in how long they're going to be in the hospital for and how long it's going to take them to recover. And also, they want a treatment option that's going to offer the best chance at cure. And I tell them that the robotic partial nephrectomy or a minimally invasive radical nephrectomy is the best way to achieve cure but also provides them to have a fairly rapid recovery.

Host: What does that recovery time look like in comparison to that traditional open surgery?

Dr. Krasnow: So, the traditional open surgery, in order to get to the kidney, we would have to make a very large incision in the front or the side of the patient, have to go through many layers of muscle, and sew that back together. Patients after were extremely sore, they would have difficulty walking and breathing afterwards because of the soreness. Also, during the surgery there was an increased risk for blood loss and other complications. Because we're making small keyhole incisions, the patients have very controllable pain after surgery. They can restart their diet much earlier, the next day really. Most patients can go home one or two days after surgery compared to staying in the hospital for a week or longer, and they can get back to work much quicker.

Host: What sort of, uh, restrictions at home or restrictions at work would an individual have after that minimally invasive surgery?

Dr. Krasnow: So, after surgery, actually the day after surgery, we want them up walking, moving around, sitting, eating, trying to get back to as much normal functioning as possible. The only thing I ask the patients not to do for a few weeks after surgery is to avoid really heavy straining, heavy lifting, running, strenuous exercise, swimming - things like that, but for the most part they can go about their day when they get home.

Host: What are some of those other benefits for the patients or for their caregivers to minimally invasive surgery?

Dr. Krasnow: For some people, cosmesis matters. And the small incisions are much more cosmetically pleasing than the large incisions we made in the past. So, for certain patients who are looking to go swimming that summer and want to wear a swimsuit, you can hardly ever tell that they had surgery. I think that technology is even going to get better.

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

Dr. Krasnow: 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.

Birth control can come in many forms—but men's options can be more limited. Dr. Krishnan Venkatesan discusses how a vasectomy can be a solution for men who want effective birth control while maintaining sexual function and the ability to orgasm.

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. Krishnan Venkatesan, Director of Urologic Reconstruction at MedStar Washington Hospital Center. Welcome, Dr. Venkatesan.

Dr. Krishnan Venkatesan: Hi. Thank you for having me.

Host: Today we're discussing vasectomy, a birth control procedure for men that prevents their partners from becoming pregnant without affecting natural sexual function. Dr. Venkatesan, is vasectomy a popular birth control option for men and their partners?

Dr. Venkatesan: Yeah, I would say so. Vasectomy is effective for birth control because it really allows a non-invasive way to cut off the sperm from being delivered into a partner that could cause conception, but it doesn't interfere with erectile function, sensation, orgasm or ejaculation. So, essentially sex should still feel and be the same but without the concerns for pregnancy.

Host: Approximately how many vasectomies are performed at MedStar Washington Hospital Center each year?

Dr. Venkatesan: I'd say probably between fifty to a hundred vasectomies, at least, per year between myself and my colleagues.

Host: Why do you feel that so many couples or so many men chose to undergo vasectomy?

Dr. Venkatesan: I think vasectomy is a popular option and a good option because it's relatively non-invasive, it's an outpatient procedure and has a quick recovery. And, it allows patients to stop using other forms of birth control, whether it's oral contraceptive pills or condoms, and it's certainly easier for men to undergo this than for women to have a tubal ligation. And so, it basically allows for natural sexual function without the risks of conception.

Host: Could you describe your patient population for vasectomy - are they older, younger or who is a good candidate?

Dr. Venkatesan: Any man, really, is a good candidate but typically our patients are those who are in their 30s or 40s, sometimes in their early 50s, who have children, who have had some time to give this some thought and, for the most part, these are men who are in stable relationships and have had a shared discussion and a shared decision making with their partner before they come in to discuss or commit to vasectomy. Occasionally, we do have men who are not in a relationship but are fathers of children or who have decided they do not want to have any children and, after giving it a lot of thought, they come in for counseling about vasectomy and may decide to proceed with that.

Host: Are there any factors that might make a man ineligible for vasectomy?

Dr. Venkatesan: Patients that may not be good candidates for vasectomy are generally those who may have had prior surgery on their testicles, either to bring an undescended testicle down during childhood or maybe some surgery on their spermatic cord or even prior hernia surgery, where it may be just more difficult to identify the vas deferens and may make them more prone to having the procedure fail or have a complication.

Host: So, just like any reproductive issue or reproductive procedure, there is an abundance of incorrect information online about vasectomy. Do your patients or their partners express any fear or anxiety about the procedure?

Dr. Venkatesan: Yeah, and I think that's natural and completely reasonable to have those anxieties. The biggest concerns men have, of course, are that this may affect their other sexual function, including erectile function and the ability to orgasm or to enjoy sex the same way and whether they will still be able to ejaculate after vasectomy. And, generally we're able to assuage all those fears by explaining that this really should not affect erectile function and men will still ejaculate because most of the fluid that comes out with orgasm or with ejaculation is actually made downstream in the prostate. The only difference is that the semen won't contain any actual sperm that can cause conception.

Host: This sounds like a very safe procedure. Are there any risks involved with vasectomy?

Dr. Venkatesan: Yes, there are. And, of course, any procedure has its risks. The main risks here would include general risks of any surgery, like infection and bleeding and injuring other structures that are nearby the vas deferens, including the artery to the testicle and the vein coming from the testicle, as well as some nerves that travel along the spermatic cord, which could result in chronic pain in the testicle, although that risk is very low. And the main other risk really would be the risk of remaining fertile if the two ends of the vas deferens somehow remain connected or find their way back to each other and get reconnected.

Host: Could you describe how the vasectomy procedure is performed?

Dr. Venkatesan: Yeah, absolutely. Basically, each testicle, after it makes a sperm, delivers that through a tube called the vas deferens. That travels up the scrotum on each side into the groin and then makes kind of a hairpin turn and goes back behind the bladder to join the urethra, which is how men are able to urinate and ejaculate through the same pipe. What we do in vasectomy is basically find the vas deferens at the top of the scrotum on each side, bring it out through a small nick in the skin or through a small spread incision to open the skin, and cut out a small segment, burn each side of the tube on the inside, and then tie off each end and fold them away from each other and, basically, put them back into the scrotum but in different tissue layers, all to help minimize the risk of the tubes reconnecting.

Host: With all of the steps of this procedure, is vasectomy permanent?

Dr. Venkatesan: Yes, and that's an important point. I'm glad you brought it up. I always counsel all my patients that, for all intents and purposes, vasectomy is intended to be permanent. Now, technically, it can be reversed. And, there are specific surgeons who have microsurgical training who can do the vasectomy reversal but it's also important for patients to know that the success rates for that reversal are variable and, from a practical matter, it's usually not covered by insurance.

Host: How long does recovery take and are there any restrictions for having sex or using the bathroom?

Dr. Venkatesan: Yes. So, because there's constant sperm production, there's already gonna be sperm downstream from where we cut the vas deferens. So, men need to be counseled that they are not immediately sterile when they go home that day. So, typically, immediately after the procedure, I will ask my patients to refrain from sexual intercourse or any ejaculation for two weeks. And, after that, they need to continue using contraception, in any other form, whether it's condoms or with the oral contraceptives with their partner but continue to have sexual intercourse. After 8 weeks, we'll see the patient back in the office to ensure they've healed up okay and, at that time, we'll have them give a semen sample to make sure that the sperm count is zero. Once the sperm count is zero, then they're okay to stop using other forms of contraception. The recovery from the procedure itself is pretty easy. Usually, we'll do it later in the week so that guys can recover over the weekend. We don't have them take any significant activity restrictions, but they may be a little bit sore for a few days. But usually by one to two weeks after the procedure, they're able to resume all their normal activities.

Host: When you hear about people having vasectomies, like on sitcoms or in books, you always have this mental image of a man sitting there with frozen vegetable on his private area. What do you typically give for men for pain management or inflammation management afterward?

Dr. Venkatesan: We usually do send patients home with some pain medications. It really depends on, subjectively, what the patient thinks they may need. Quite often, even some extra strength Tylenol or Ibuprofen may be sufficient, but if the patient requires more pain medication, we're certainly not averse to giving them a prescription for a narcotic pain medication. And aside from taking it easy for the first few days, we also do recommend that they can put some ice packs or frozen vegetable packs on their incisions until everything is starting to feel more comfortable.

Host: Now, on the flip side, is there anything a patient has to do to prepare to have a vasectomy?

Dr. Venkatesan: Not really. Similar to any other surgery, they should make sure they talk to their urologist beforehand in the office and get all their questions answered. I often will encourage patients to bring their partner along because it's always good to have a second set of ears, and partners tend to have different insights than men, and collectively, you may remember more from the conversation than one person alone. But, physically speaking, there's no specific preparation that is required.

Host: Can you think of any standout patients who particularly benefited from having a vasectomy?

Dr. Venkatesan: All of them. And, it really depends on their goal but, for the most part, because there's a very specific goal with regards to achieving sterility, most of our patients have been very happy with the results. I will say that probably the better example cases are the cases where the female partner may have a difficult time taking oral contraceptives or may have some other medical conditions that prevent tubal ligation. And, in those cases, then this really allows them to enjoy a full quality of life and takes some strain off the partner, in addition to the patient themselves.

Host: Why should a patient choose to come to MedStar Washington Hospital Center for vasectomy when they could really go to any hospital?

Dr. Venkatesan: So, I think Washington Hospital Center is a great place to choose to have vasectomy, mainly because of the surgeons we have here who are very experienced in doing it and because, I think, we all do a good job at counseling our patients and answering their questions beforehand, and meeting their expectations with regards to the procedure and everything before and afterwards. And, I will say that traditionally vasectomy is usually done in the office but here we do, quite often, offer our patients to have it done under anesthesia, depending on their comfort level. And, quite often the patients will select to have that done just so they can be more comfortable during and after the surgery.

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

Dr. Venkatesan: My pleasure.

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.

New technology and guidelines allow us to use PET-CT scans to locate cancer earlier than ever before, with faster scans and less radiation. Dr. Carlos Garcia explains what this means for patients and how we continue to stay ahead of the curve in this area of testing.

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 talking to Dr. Carlos Garcia, Medical Director of Nuclear Medicine at MedStar Washington Hospital Center. Welcome, Dr. Garcia.

Dr. Carlos Garcia: Hi. Thank you for having me.

Host: Today we're talking about advances in PET CT technology. Dr. Garcia, what is PET CT technology and when is it used?

Dr. Garcia: So, PET CT technology is a combination of anatomic and functional imaging. We use the anatomy from the CT portion of the exam and the self-function or the live cell portion of the exam from the PET CT exam. We use it mainly for oncologic imaging. It can be used for other purposes as well, but right now the mainstay, the gold standard, for cancer imaging is PET CT imaging.

Host: How has PET CT scanning technology improved in the last 10-15 years?

Dr. Garcia: It's improved by leaps and bounds, actually. So, in 2006, the new kid on the block was time-of-flight PET CT imaging, which was the most advanced cancer imaging tool at that point in time. Now that's evolved as technology does into digital imaging. So, analog vs digital imaging.

Host: So, why should a patient come to MedStar Washington Hospital Center for a PET CT scan?

Dr. Garcia: We've been very fortunate in the past to, in 2006, to have the first, the most advanced machines in the region. It was called the Time of Flight PET scan, which was the upgrade from, you know, analog imaging from way before 2006, and for many years we were the only ones that had that type of imaging. And now, as of August this year, we have a digital PET scanner, so it's the step up from the Time of Flight. It's the most advanced PET CT unit available in the world right now and we are very fortunate to, once again, be one of the first in the region to actually have this kind of technology. When you compare it to the Time of Flight PET scan that we had prior to the one we have right now, it's basically comparing a flat screen TV to a State-of-the-Art 4K curved screen. You're talking about night and day when it comes to resolution. Images are 10 times, you know, as crisp as compared to what they were before, that everybody, you know, joked around they were a little fuzzy. Now, the lesion detection has increased. The size of the lesion can be much smaller and still be detected. The amount of time it takes to acquire the images has been cut back almost by 50 percent and the dose that we give the patient in order to obtain these higher-quality images can also, in some cases, be cut back as far as 50 percent as well. So, from a patient point of view, they get a much more reliable scan and half the amount of time with half the radiation exposure, and these are all valid concerns to the patient, you know, because coming to the hospital, you know, you can have a PET scan anywhere. You can have any kind of exam anywhere - it's the experience you get from, you know, the center, the staff, the amount of time, the comfortability you experience. All those things put together makes it a much better experience to have a higher quality machine in the hands of somebody with much more experience. The result of that has been increase in detectability, increase in being able to see lesions that were too small to be seen before. And, that leads to early detection, early treatment application and, you know, being able to catch a disease when it's still a time when something can be done about it.

Host: What sort of research are you working on right now for PET CT scanning, and what do you see coming down the road, either at MedStar Washington Hospital Center or nationally?

Dr. Garcia: So, there's a ton of research being done at all levels with PET CT imaging and cancer applications. There's many novel tracers, or let's say substances, that the body produces that are getting linked to radiation and injected into the body and seeing exactly where it will go, known places that you know or known organs that you know it will go to, places that it would take up normally and now it takes up abnormally, and that gives us information. Here at the hospital, we are considered a thyroid/cancer center of excellence, so a lot of the research that we do will be related to imaging with radioactive iodine. There's many different types; used some for therapy, some for imaging and in our case, we use it to be able to see lesions that are not taken up by the normal exams we do, the normal iodine scans that we do, and sometimes these tumors, in thyroid cancer specifically, may stop working the way they do and they don't take up iodine. So, we do PET imaging in those particular cases, and that's actually a proved indication, a reimbursed indication, for patients that are iodine-negative and that still have blood markers that show that there is still cancer and in those cases that's an indication.

Host: When you're talking about radioactive iodine, how is that being introduced into a patient's body and what does that look like for thyroid cancer?

Dr. Garcia: So, in thyroid cancer patients we rely on the fact that the body does essentially one thing with iodine. When you eat it in your normal diet, the iodine gets absorbed, it goes straight to your thyroid gland, and your thyroid gland uses iodine to make thyroid hormone. The body can't tell the difference between radioactive iodine or normal iodine or between different types of radioactive iodine. So, nine out of 10 times it is introduced as a pill. The body thinks it's just normal iodine and it'll take it to wherever there is thyroid tissue. If there's a little bit of thyroid tissue left behind after the surgery, which happens 99 percent of the time, it will absorb the iodine because it still, you know, retains its function. So, the same thing will happen if the cancer has spread to other parts of the body and wherever the cancer cells have gone and attached themselves to, it is still thyroid cells now growing on, for example, a lung, a bone, you know, or in your brain. It's still thyroid cells so they retain that function of taking up iodine. So, the body absorbs the pill it took and it'll circulate through the blood and it'll find the thyroid cells. And the thyroid cells will latch onto it, look at the iodine, try to make thyroid hormone out of it, but we've altered it chemically to get essentially stuck inside the cell and not be able to be metabolized further. All of this translates to being able to see it on images. Wherever the iodine has been absorbed it will show up on the images and that gives us an idea of the degree of spread throughout the body.

Host: Interesting. So, the difference between the PET CT and the regular CT scan is that ability to really track that cancer throughout the entire body. How does that benefit patients, especially in the situation of thyroid cancer, and then how is that helpful for the physician team to treat them?

Dr. Garcia: Not only does it track where it has gone throughout the body because CT exams can show you, as well, irregularities in anatomy, differences in what, you know, patterns are supposed to look like in every part of the body. It will show you where there are cells that are still alive. Sometimes it takes longer for a change to happen on a CT scan, based on the therapy that was applied, then it will take with the level of metabolic function of a cell. Sometimes you can have a tumor that'll shrink a little bit on the scan when you compare one scan before and after the therapy and when you look at the PET scan it'll show that there was a very active lesion and then it's completely inactive. It's essentially gone, although there's only been a small shrinkage of the tumor on the CT scan. So, it's very complimentary to the anatomy that would be shown on a CT scan. This helps physicians to monitor a treatment response. And many, many - even research studies - will take into account the degree of metabolic activity and the change before and after the therapy to see if the treatment is working and should continue or if the treatment is not working and they should switch gears altogether and try something different. It's called the metabolic response to therapy. In thyroid cancer, we use it in those cases in which we know there's thyroid tissue still in the body because it's producing a protein that shows up in the blood, that's only made by thyroid cells. Sometimes these thyroid cells lose their function to capture the iodine and makes a iodine scan basically not the right study to be able to monitor the response. So, you have to migrate over to the basics of the cell function, which is to take up glucose, for example. So, it will still, it still might be able to take up glucose even though it won't take up iodine and that is still very, very helpful to know whether or not this patient would benefit from being treated with radioactive iodine or if they need to be treated with another form of therapy, based on the examination - the PET CT exam.

Host: So, a very technical and very advanced way to get back to the basics of what the cancer does.

Dr. Garcia: That's nuclear medicine, in essence. We rely 100 percent on physiology, which is the normal function of the body. The kidney has a normal function, the brain has a normal function - and when they deviate from that normal function, they stop using the materials or the substances in your blood that they normally would. If you can attach radiation to that substance and then you see that it doesn't go into the liver when it should, that gives us information - we know what that means. So, you're basically relying on the body doing what it's supposed to do, and variations of that function will translate into disease entities, into diagnosis that we can establish. So, we trick the body into doing what it would normally do - it doesn't know it's doing it - and we can see it all on images.

Host: What sort research are you and your and your colleagues working on right now in the field of PET CT?

Dr. Garcia: Right now, we are working mostly in thyroid cancer research. We are looking into how much iodine is absorbed in individual tumors. In the past the fact that it showed up on the scan at all was very productive, but what we need to see is how much radiation is being delivered to each individual lesion. And that will make a difference. So, it's very important to figure out - this is the ongoing research for us - to figure out how much radiation actually gets delivered in a particular lesion. And that will sometimes answer the question of how come we gave the same radiation level to two different patients and it didn't quite work the same way. And we need to figure out how much is absorbed in each piece of tissue, if you will, that is malignant, and that way, if we know that, then we can start tailoring lesion radiation delivery more so than patient radiation delivery. We will go, I mean, we treat the patient as a whole, of course, you know…but we will go after targeting specific lesions and making sure that that lesion receives as much radiation as possible. We're very happy to not have repeat customers, you know, and that's kind of our goal, I mean, like we'll try to get it all on the first try and if not, leave as little behind as possible if we have to do it again.

Host: Thank you for joining us today.

Dr. Garcia: Ah, it was a pleasure. 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.

Missing teeth is never easy. It can cause some people to feel uncomfortable smiling for pictures, while others experience difficulty eating. Discover why Dr. Ravi Agarwal says dental implants can be the perfect solution.

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. Ravi Agarwal, an oral and maxillofacial surgeon and the residency program director for the Department of Oral and Maxillofacial Surgery at MedStar Washington Hospital Center. Welcome, Dr. Agarwal.

Dr. Ravi Agarwal: Thanks for having me here today.

Host: Today we're discussing dental implants which help support dental prosthetics such as bridges, crowns and dentures. Dr. Agarwal, could you explain what a dental implant is?

Dr. Agarwal: Sure. The dental implant is essentially an artificial tooth root in the shape of a metal screw. These screws are surgically anchored to the bone and, once anchored, the body will grow bone on to them and stabilize them. Once that fusion happens, these posts then can be used by your dentist to make supporting teeth such as crowns, bridges and dentures. This is currently the best long-term solution that we have today for tooth replacement. Overall, our success rates are 95 percent, especially when a patient sees a surgical specialist for placement.

Host: So, this sounds like something a patient might see a dentist for instead of coming to the hospital center. Could you explain why that's a better idea for people who need dental implants?

Dr. Agarwal: Correct. Most of the patients who come to see us start with their dentist because it is a team effort for a patient to have a tooth replacement. However, most commonly a dental implant is a surgical procedure, so you want to see a surgeon who's specialized in training to take care of all the surgical aspects of placements of dental implants. However, it is a team effort and once the surgery's done and healed, the patient would then return to their dentist to have the prosthetic made.

Host: What are some of the most common dental implants that your patients need?

Dr. Agarwal: The need for dental implant varies amongst the population. In general, any patient who wishes to replace a tooth can be a candidate for a dental implant. Generally, the most common patients that we see are those requesting a single tooth replacement. This can be a patient who's missing a front tooth affecting their smile. This could be a patient who's missing a back tooth affecting the way they eat. However, as the baby boomer generation continues to grow, we're starting to see a larger population requiring replacement of all their teeth. Most of these patients may have already been in dentures or they have a failing dentition. So, failing dentition is patients who have had a long history of dental work. They've had a lot of work done to their teeth. Their fillings or crowns are starting to fail, and it really becomes more and more expensive to repair all these things and it gets to a point where they may be better off considering replacing all of those teeth. So, our team has an excellent reputation in this area to help patients with solutions to replace either one of their teeth or all of their teeth. In the end, we work with all of our patients and their dentists to help come up with surgical solutions.

Host: So, you mentioned the baby boomers. Could you describe your patient population for dental implants?

Dr. Agarwal: Yeah. As I mentioned, we see a variety of different needs that come through our department and our clinic. I have maturing teenagers who are naturally missing some of their front teeth that we'll replace implants for them. And I also have a 75-year-old patient who's had a denture for 15 years and says, "Hey, I really want to taste my food better. I want to eat better. I want to chew better. I want to smile better." So, our dental implant team can help manage all of them with some of the best experience in the region.

Host: What does a patient have to do to prepare for getting a dental implant?

Dr. Agarwal: There's not a lot to prepare. Most of the patients - we generally request that they have a dental provider. As I mentioned earlier, this is a team effort. You can consider a dental implant like a foundation. I need an architect to tell me how they want the tooth designed so that I can lay the foundation in the correct place. So, most of our patients, we'll require that they're working with a dental provider. Otherwise, if they're missing a tooth or a tooth is failing, the best thing to do is have a consultation with us because there's not much more preparation before that.

Host: The day of an appointment, do they have to do anything differently - maybe change their eating or medication?

Dr. Agarwal: Well, the day of the procedure...usually we'll see the patient prior for consultation to determine what their medical conditions are, what medication is taken - any of that can affect the surgery. So, if someone's on blood thinners, we may require them to stop or discontinue it for a few days during the surgery. And occasionally we start patients on antibiotics or mouth rinses. Usually we'll work these things out during a consultation appointment.

Host: Could you describe the process of creating and then placing that dental implant?

Dr. Agarwal: So, very simply, placing a dental implant is a short office procedure. An incision is made in the gums to access the bone. We use specialized equipment to create space in the bone for us to anchor the screw that we put in. We then will suture the gums with dissolvable stitches. And most of these procedures, for example a single tooth implant, can be as short as 30 minutes in the office.

Host: It sounds like a very painful procedure. How do you keep your patients comfortable getting them in there, making sure that they're nice and calm when they go in? And then how do you keep them comfortable and pain free during?

Dr. Agarwal: You know, surprisingly, this is a very common concern amongst the patients who come to see us. Dentistry, in general, has always been thought as a painful...but nowadays our techniques and local anesthesia have really improved, the office environment has really improved. For most patients, we see them first for consultation. At that time, you really get to develop a relationship with a patient - explain to them what the expectations are. However, anxiety is still a concern and, since we are oral and maxillofacial surgery specialists, we have the ability to offer pain, anxiety reducing techniques, such as office anesthesia. Most dental providers cannot provide this same service, so this is another reason that a patient may want to come see our team, is that we can also provide office sedation for these surgical procedures.

Host: What is the recovery period after receiving a dental implant?

Dr. Agarwal: Very similar to having a tooth removed. Most patients will be uncomfortable for a few days, most often requiring over-the-counter pain medications. Depending on the procedure, they may have a little bit of swelling, which mostly resolves after 3 to 5 days. We ask them to modify their diet, avoiding hard, crunchy foods. And, we also put an emphasis on oral hygiene, that brushing their teeth and we prescribe oftentimes antibiotics and antibiotic mouth rinses. So, for the most part, you know, for procedures done at the end of the week, most patients can return to doing most of their daily activities through the weekend.

Host: One thing I would be concerned with is would I be able to drink coffee or hot beverages or eat right away after I got my implant.

Dr. Agarwal: Sure. The day of the procedure we generally ask everyone to take it easy, possibly more of a soft, mushier diet, considerations to avoid extremes of temperature, but there would be no harm in someone having a warm tea or warm coffee.

Host: Why should a patient choose a dental implant instead of another treatment option?

Dr. Agarwal: Over the years, there have been a lot of methods to provide tooth replacement, but the dental implant is the one that is...generally has a high success rate. It's a treatment that, if done well and done properly, can be there for a lifetime. The other number one reason to have a dental implant is that as you lose teeth, you start to lose the supporting bone. It's just a natural process that the body has. By placing a dental implant, it stimulates the bone and the patient will lose a lot less bone.

Host: Do you have any treatment success stories regarding dental implants from your practice?

Dr. Agarwal: Well, every patient who comes to us and gets a tooth replaced is a success story for us. However, there is one gentleman that comes to my mind. There was a patient we treated who had sustained a fall while he was on vacation and he suffered a significant amount of trauma to his face, breaking some of his bones in the face, but also losing some of his front teeth. He was initially treated outside, at the hospital where he was on vacation, but once he came back to the D.C. area, he came to see our team to help reconstruct his jaw and his teeth. When I first started seeing him, I could tell he was a little dejected and had a little bit less motivation about his smile and his mouth, and you could tell, even when he was with his wife, that he was just sensitive about the topic. We worked with him. We got him in touch with a dental provider to help him restore the teeth. And our team ended up doing it first - a reconstructive procedure for his jaw bone. But once that was done, we replaced all his top teeth that he had lost, and the ones that were failing, with dental implants. Once we did that surgery and anchored that teeth that same day for him, I remember seeing him the following week and thought this was a completely different person. I'd never seen anyone talk so much. He was chatting with all our team members. He was just so excited. He was telling us how he was looking forward to seeing his grandkids. And it really, at that point, gave him a new lease on life with something sometimes we think as such a simple procedure.

Host: Why is MedStar Washington Hospital Center the best place to receive a dental implant?

Dr. Agarwal: So, our dental implant program is one of the earliest centers in the country that dedicates one and a half days a week to dental implant related procedures. One of the unique aspects of our program is that every patient gets both a surgical and prosthetic consultation. As an oral maxillofacial surgeon, we concentrate on doing the surgical procedures. However, having a prosthodontist, who is an individual who specializes in complex dental prosthetics, as a consultant has only enhanced our ability to provide the best care to our patients. For example, our program has key opinion leaders in the field of dental implants who actually go out and train and teach other practitioners around the country, who then use our protocols developed at MedStar Washington Hospital Center. We're on the cutting edge of digital technology, having virtual implant planning, in-house 3D printing for surgical guides and even an implant navigation equipment. All of these technologies have allowed us to reduce treatment time, minimize errors and provide temporary teeth on the same day as the dental implant surgery. Even with all of this technology, I think the biggest reason to choose our team is the ability to provide all this advanced care at a reduced cost.

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

Dr. Agarwal: 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 pelvic pain to fertility problems, endometriosis can affect women's quality of life and relationships. Discover which treatment options Dr. Vadim Morozov says can reduce symptoms, and what to expect during recovery.

TRANSCRIPT

Host: Thanks for joining us today. We're speaking with Dr. Vadim Morozov, a gynecologic surgeon at MedStar Washington Hospital Center. Today we're discussing endometriosis, a gynecologic condition that affects more than 11 percent of women between 15 and 44 in the U.S. Welcome, Dr. Morozov.

Dr. Vadim Morozov: Thank you for having me.

Host: Could you start by telling us what is endometriosis?

Dr. Morozov: Endometriosis is a disease where endometrium, which is normally growing on the wall of the uterus and inside the uterus, starts growing outside of the uterus on the surface of your intestines and the surface of your bladder, all around the pelvic organs in the areas. And, as a result of that problematic growth, you start having pain and symptoms associated with it.

Host: What are the most common symptoms of endometriosis?

Dr. Morozov: Most common ones would be very difficult menstrual periods, cramping, severe pain with that. Pain with sexual intercourse. Pain when you go to the bathroom, having the bowel movements or when you're urinating. Those are the top four that comes to mind when we're talking about endometriosis. Pain perception is individualized, obviously, right? So, as you know, one person hits the finger and barely notices, and the other person hits the finger with the same strength and like, you know, 'I'm dying, that's it, call the ambulance.' So, having said that, it obviously depends on the patient, her perception of the pain, support structure that she has, and her goals in life.

Host: How is endometriosis diagnosed?

Dr. Morozov: Unfortunately, the only way to diagnose endometriosis nowadays is by laparoscopy. We can make a presumptive diagnosis that the patient might have an endometriosis just by symptoms of what she's describing and the physical examination. But to be 100 percent sure, usually we have to look and see the lesions of endometriosis and even better to biopsy those lesions and send them to pathology to tell us that, 'yes, it is exactly endometriosis.'

Host: Are there any genetic or environmental components associated with the risk factors for endometriosis?

Dr. Morozov: There are some. We know, for example, that if you have a mother or a sister or an aunt with endometriosis, you as a patient are at higher risk of developing endometriosis. There are some studies also saying that the environmental factors such as organic pollutants that we have in the atmosphere also affect the development of endometriosis. Um, but there are no conclusive results yet that can pinpoint us with 100 percent accuracy.

Host: Can endometriosis go away on its own?

Dr. Morozov: That's a very interesting question. The short answer is probably no. Um, you might be asymptomatic, meaning you don't as a patient don't have much of the symptoms related to endometriosis. But if you have them, highly unlikely that the disease will resolve and go away on its own.

Host: What are the treatments for endometriosis?

Dr. Morozov: Normally if we diagnose somebody with endometriosis, it's not unreasonable to start some sort of a medical treatment, such as non-steroidal anti-inflammatory, birth control pills. There are some other medications that are a little 'heavy drugs' as we call them - anything that controls hormonal fluctuations in your body - usually is the first line of treatment. In my experience, most patients don't do too well on those, um, medications. And inevitably ends up with a surgery. Um, so the gold standard would be something like minimally invasive surgery by laparoscopy, with small, tiny, less than an inch incisions that made in the belly, and then the endometriosis diagnosed and removed at the same time.

Host: Are there any risks for a woman's health long term if she doesn't get her endometriosis treated?

Dr. Morozov: There are. Endometriosis, to a certain extent, is almost like cancer. Obviously, it doesn't kill you but it tends to spread in the abdomen and in the pelvis in a similar way. It can actually involve and invade your bowels, it can invade your bladder, it can invade other structures and organs that are in the pelvis. So, technically, if you leave severe endometriosis untreated, you are at risk of developing complications related to it.

Host: Can endometriosis affect fertility?

Dr. Morozov: Yes. Technically we're saying that endometriosis does not cause infertility, but rather it causes what we call a subfertility, meaning if you're a woman with endometriosis, for you it is going to be much harder to get pregnant than for a woman who doesn't have it. The reason being is because endometriosis creates the inflammatory environment in the abdomen and pelvis. Your pelvic organ is constantly in the state on inflammation that lowers the chances of becoming pregnant.

Host: Does all of that inflammation and all of that scar tissue and so forth that happens with endometriosis increase cancer risk or anything like that for women?

Dr. Morozov: There's been some association between endometriosis and endometrioid type ovarian cancer. There is no direct correlation, but some researchers are looking that they, some particular endometriomas, which is a chocolate-filled cyst of the ovary, can lead potentially to endometrioid-type cancer.

Host: Have you seen any exciting research that has you excited for women's health in the future?

Dr. Morozov: There are a couple of good areas of research in endometriosis. One of them is to develop markers of endometriosis that allows us diagnosis without doing the surgery. So, the markers are done from drawing the blood from the patient or even the saliva test that goes to the laboratory and tells you as a patient and me as a physician that there's a good chance that you might have a disease. It's in the research phase right now but the results, at least preliminary results, are looking very promising. The other field of interesting research is to develop better laparoscopic visualization tools. Very often we go into laparoscopy with a small camera is placed in the abdomen and pelvis and we don't see anything or maybe we miss a lesion because our eyes are not trained to recognize highly specific lesions in the pelvis. So, some companies are working on the, what's called filters, that allow a better visualization of endometriotic implants during laparoscopic surgery.

Host: Are there any questions that a woman should ask when she goes to her doctor? What does she need to know to take care of herself going forward after she's received treatment?

Dr. Morozov: Well, one thing is, what's the long-term prognosis? What kind of endometriosis I have. Is it the mild disease that's easily treated or versus a severe disease that involves surrounding organs such as rectum, bowel or bladder or anything else? The next question the woman should ask, depending on her fertility age, will it affect my fertility? Can I get pregnant? Can I get pregnant on my own or do I need to go to see an infertility specialist for this? The next question would be, in 10 or 15 years when I'm done with my childbearing, what are the options for me as far as having a definitive surgical management of this condition? So those are something that every woman diagnosed with endometriosis should keep in mind.

Host: What is recovery like for women after undergoing surgery for endometriosis?

Dr. Morozov: Usually it takes about 6 months to feel better. So, within the couple first months, you're sore with the surgery itself. After that time the surgical pain starts going away and you're feeling great. But it still lingers for some time. So, within the 6 months period we expect to see a result of the pain improvement and the symptoms related to endometriosis improvement. How long does it last as recovery depends. I've seen patients that are very good and for years don't have any symptoms and then sort of slowly starts coming back. And I've seen the patients who recur within 3 to 6 months after surgery. Unfortunately, it's unpredictable.

Host: Can a woman expect to become pain-free eventually, after she has treatment for endometriosis?

Dr. Morozov: Very tricky question. The answer is, depends on the conditions and the extent of the disease. Very often, by the time we see those women, the disease is severe enough that it's near impossible to make them completely pain-free. And I try to have a very honest discussion with my patients in anticipation of whatever treatment options we choose, saying the goal of, whether we do surgery or anything else, the goal is not to make you 100 percent pain-free. The goal of everything we do is to bring it to the point where you can function normally every day. You're probably going to have pain here and there, but that pain shouldn't be debilitating. You shouldn't be missing school or work because of the pain. In my experience, it's near impossible to make a woman diagnosed with endometriosis 100 percent pain-free.

Host: Why should a woman come to MedStar Washington Hospital Center for endometriosis care?

Dr. Morozov: Well, we are the largest and probably the best equipped group on the east coast, mid-Atlantic. We have multiple fellowship trained specialists that deal with nothing else but endometriosis and pelvic pain. Our group at the National Center for Advanced Pelvic Surgery have multiple urogynecologists and the specifically trained female urologists that deal with the conditions of the pelvic pain and of the reproductive disorders.

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

Dr. Morozov: My pleasure. Thank you for having me.

Chronic obstructive pulmonary disease, or COPD, has skyrocketed over the past 35 years. Dr. Matthew Schreiber discusses what it means for D.C., and how you can be as healthy as possible if you have the 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 talking to Dr. Matthew Schreiber, associate director of the Medical ICU and an attending physician in Pulmonary Disease/Critical Care Medicine at MedStar Washington Hospital Center. Welcome, Dr. Schreiber.

Dr. Schreiber: Well, thank you for having me.

Host: Today we're talking about a September 2017 report that showed that the number of Americans who died from chronic respiratory diseases, particularly chronic obstructive pulmonary disease known as COPD, skyrocketed over the past 35 years. In 2014, 53 people out of every 100,000 died of a chronic respiratory illness, up from 41 in 1980, a 31% spike. 85% of those deaths were from COPD, which is now the third leading cause of death in the U.S. Dr. Schreiber, how does Washington, DC compare to the national rates of chronic respiratory diseases and COPD?

Dr. Schreiber: Well, Washington DC, if you were to just look at it as a city, it's doing great. The CDC and the NIH did a report starting in 2011 that talks about state by state, how much COPD is there, and I think when you're talking about chronic respiratory diseases, COPD is really kinda the marker for what you're talking about. There are a ton of different things that are chronic diseases in the lung, but the biggest bulk of them is going to be COPD, and even if someone had asthma their whole life, they can later have COPD, because of the chronic nature of that destructive disease. Coming back to what you asked, DC is ranking in with only 4.6% of its residents having COPD and that's actually pretty darned good, if you look at our neighboring states. It's 5.9% in MD; 6.1% in VA; and 8.9% in WV. If you dive into the data a little bit deeper though, DC is a tale of two cities. There are a number of things that the CDC and the NIH found had associations with being diagnosed with COPD, and what they found was that in Washington, you had 2.1% of white respondents saying they had COPD, but up to 6.7% in the African American population, and they didn't report on other ethnic backgrounds. So, 4.6 sounds awfully nice, it's at the low end of the national levels, but then when you start breaking that down, there are definitely some groups in our district who are suffering from this condition, uh, at higher than average levels for the nation. If you look at people who are unable to work, and this might be because of their lung disease, but, of course, being unemployed can have any number of reasons—19.9% of folks that were unable to work reported being diagnosed with COPD. If you had less than a high school education, 9.6%. Nearly 1 out of 10 people with less than a high school education had been diagnosed with COPD, and age was a big factor. If you looked at folks 18-44, it's down to 2.2%, but once you're over 75, almost 10. So, even though you could say we're doing great, being at the low end of the national level, we've got some work to do.

Host: Why would there be such disparity between the education and the types of work that people are doing? Is there some kind of a cause environmentally?

Dr. Schreiber: COPD is a condition that no one can say they know absolutely what causes it. There's a number of theories behind it. What I can tell you is COPD is exactly what the name says. It's chronic, so once you have it, you have it. It doesn't get cured, it doesn't go away, it might not progress very fast, but you have it, and it's all about obstruction. The 'O' in the name says the whole thing. People with COPD have trouble moving the air in and out of their chest. And so, if you can't move the air out, and you're trying to do some activity or exercise, the faster you're breathing, the more air that you're breathing in that you can't then get out, and you get short of breath. And it's pulmonary disease, lung disease. So, if you look at it as a pure aspect like that, this could be caused by inhaling something that can damage your lungs over and over again. Cigarettes are the model example for that, and in truth, this seems like common knowledge to a lot of people now, it's new. We didn't have studies that showed cigarettes caused things like lung cancer until the 1950s. And we didn't have a surgeon general's warning about the damages of smoking until the 1960s and 70s, so progress has been made. But you've got a lot of history in the United States with tobacco use and tobacco exposure, and a lot of science going into cigarettes since the early 1900s, that have done its job, so to speak, on getting people to use cigarettes, and the consequences of that use, that we're only now seeing. When you think about other types of inhaled irritants, different jobs can cause different problems. I ask in my clinic all the time, 'What kind of work have you done through your whole life?' And people will focus on the things they might have enjoyed or liked and then I always come back, 'Did you ever do anything that was around smoke, around fires, around a lot of chemicals, around inhaled irritants where you had to wear a mask, or maybe wish you had worn a mask?' And people will think about what they did earlier in their life. And the lungs are remarkable things. We have "extra," so to speak, that when you look at the lifelong duration of how much lung function you have and when it would have to get low enough to cause symptoms, we're all, for the most part, born with enough lung and develop enough into our late teens early twenties that we can all fortunately die of something else before our lungs become an issue. But when you have these exposures or even some people who just have genetics that predisposes their lungs to dropping off function faster than the average person, when you get to later in life, you start to have this obstruction and then these symptoms, and that's where people come in and we make this diagnosis.

Host: What can a person do to reduce their risk for COPD?

Dr. Schreiber: Quit smoking. That's clearly from a research based standpoint, the thing that can have the greatest impact on reducing your risk. If you have a strong family history, you know, 'both my parents and one of my brothers has been diagnosed with COPD.' If that's your story, you can talk to your professionals in your clinics and your primary care, uh, centers to say, 'Is there anything that I should be tested for because it seems like everyone in my family is getting COPD or getting it at a young age,' or 'I have a non-smoker in my family who's been told they have COPD.' They're a deficiency; something called alpha-1 antitrypsin. Incredibly rare disease, but important enough because of how it gets passed along in families that it's something you can consider having testing for if it seems like there's a higher than average risk for COPD in your family. Um, if you are in a career path or a job that gives you a lot of, what we call occupational lung exposure - you're around something where you're just breathing in things that seem to irritate you all the time, or, you know, in the back of your head, you're just saying 'Gosh, I'm breathing a lot of this stuff,' it's…it's worth it to come talk to your primary care physician or if you have a pulmonologist you can see otherwise, to talk about your risks and being tested. The American Academy of Family Practitioners recommends that anyone who has ever smoked, meaning 100 cigarettes in their life, so the, 'Well, I only have a cigarette or two if I'm out on the weekends at the bar,' well that only takes two years of weekends before you've had a hundred cigarettes.

Host: That's five packs.

Dr. Schreiber: There ya go! And a cough should be tested because we want to catch people early in COPD so we can both manage their symptoms and encourage them to make lifestyle changes that will hopefully not let the disease progress.

Host: So, you talked about some disparities in education and across the work force. Who's most at risk for developing chronic respiratory diseases and COPD?

Dr. Schreiber: The research shows that far and away the most at risk are still going to be the smokers. Now the question is, who becomes the smokers? There are a number of scholars that have looked into the impacts of tobacco on public health. So, they point out that there's a disproportionate, meaning a lot more than you'd expect, of advertising for tobacco products in poor neighborhoods. Their arguments that things like menthol cigarettes are targeted at particular socioeconomic or racial backgrounds and advertising has been done in a way to actually target different groups. Now, these are all theories. I…I can't overtly say there's proof, but, I think if you walk around a neighborhood that may be lower on the socioeconomic scale, and walk around a very affluent neighborhood, you will notice there are more billboards in some than others, that there are more advertisements on your corner store for cigarettes than in others, and in fact, this has gotten to the point where laws had to be passed about advertising cigarettes in certain proximities to schools and daycares, because of how it seems that there's not only this risk of socioeconomics and education having to do with developing COPD and as a proxy of that, maybe using tobacco products, but also the way that marketing is being applied because of how those populations are vulnerable when more people may have this condition and smoking and you add fuel to the fire. So, it is a bigger question of social structure than I think I could ever answer, but there are a lot of people very interested in why these disparities are there.

Host: If a person has smoked in the past and they quit, maybe they quit ten years ago, or they used to work in a chemical plant or a place where they're exposed to smoke, is there anything particular that they can do to either be screened or to reduce the effects of that damage?

Dr. Schreiber: Being screened, absolutely. The only way to diagnose COPD is with something called spirometry. It's a breathing test. It's looking for that obstruction. We have someone basically blow into a tube connected to a small computer, and we see how much air came out and how much came out in the very first second. Because someone with COPD, they can get all the air out, they just can't do it quickly, and if I asked you to blow out for the six seconds it takes for that test and you have normal lungs, it's hard. Like at the end you're really trying to push out that last bit. People that have obstructions, I've read results from these tests and they're still breathing out at 13, 14, 15 seconds because that's how long it takes to get the air out because of the slowness of it. You can't diagnose COPD with a cat scan, an x-ray, a stethoscope, a physical exam, a history – unfortunately, that still happens all the time. In the NIH/CDC data talking about COPD in all these different states, DC for example - three out of ten people reported never having had spirometry, yet were given a diagnosis of COPD. I would bet they probably have it based on the symptoms they had, but there are other things that could be going on and getting tested with spirometry, which can be done in the clinic, you don't necessarily have to get what we call full pulmonary function tests which are done in the hospital, um, not as an admitted patient, but just in…in our hospital facilities, to get some of that answered. And a number of primary care clinics can do spirometry in the office. Um, we can do it in our pulmonary clinic, if that's all the information we need. Or we can send people for additional testing with full pulmonary function tests. What can somebody do to slow the effects? That's the tough part. There was a…a landmark study that gets talked about all the time in healthcare where a group of researchers developed a diagram showing the natural history of what happens to lungs. It's called the Fletcher Peto Curve. And, what they showed is that for a person with no lung disease, we have our best lungs at about 20-25 years old. And then it's literally all downhill from there. For somebody who has vulnerable lungs and has that bit of damage happening from smoking or whatever their particular cause is, if they can get away from that or quit smoking or get rid of that damaging effect, their lungs never grow back. The lungs aren't like skin and muscle and bones. You kinda have what you have after the age of 25, but the rate of decline slows down. And so, you ask…started off this conversation saying, 'Where is this large uptick in COPD coming from?' It's coming from us finally recognizing what's been going in a lot of people for probably the last twenty or thirty years. If you look at that Fletcher Peto graph and you say, 'Well ok, if a 50-yr. old quits smoking at age 50, they might not get bad enough lungs to have symptoms until they're 75.' It doesn't mean they didn't have COPD at 50, just wasn't causing them disability where they actually might have gone in and gotten tested for it. If you have someone who's 73 and maybe has no symptoms because they're one of those people that you've met that smoked their whole lives and did fine, then in 2 years later they start having lung problems, they had COPD all along. It's just they got so close to that symptom marker that now, you know, a year after they quit, they're on oxygen or can't go up the three steps to go in their house, and in truth, that's the scary thing. I don't understand the response sometimes from patients but they'll say something like, 'Well, I'm not worried because this family member, uh, did well with this or did well with that, and so I'm not worried about smoking.' But it's not about necessarily the death with COPD, it's the disability. Losing your independence and…and I've met people in my clinic who literally get short of breath eating. Taking a shower leaves them winded, and that's the kind of life changing event that is so horrible about COPD, that it takes away your freedom. And, people surveyed in DC talking about how COPD has affected them, almost 2/3 said they have some kind of exercise limitation because of breathing, and that's why we need people to get checked early, to hopefully get them to either start medication to prevent flare-ups and exacerbations or maintain their symptoms under control, or to make lifestyle changes that might slow the progression.

Host: How do you go about addressing that risk with your patients?

Dr. Schreiber: I spend a lot of the time counseling smoking cessation, and encouraging activity, referring people to something called Pulmonary Rehabilitation, which is different from just physical therapy because they'll have respiratory therapists and people that are trained on ways you can manage your breathing a little bit better and how to push your limits but not get exhausted, to still make progress. We talk about nutrition, and keeping people physically fit and being preventative, like getting vaccinations where they're appropriate. Um, so there's a lot of things when someone has COPD that we can offer them or counsel them to try to keep them as healthy as possible. Medications have been shown to help when you have COPD. And, it's an interesting split to me and…and I say this to my patients in the clinic all the time - you wouldn't wait until you're having a heart attack or a stroke to start taking your blood pressure medicine, even though you feel fine. For some reason with inhalers people say, 'Well, I'm breathing ok so why am I taking this inhaler every day?' But these are preventive medicines, and if I can stop you from having a flare-up this year, which then will affect your lung function next year, that's a win. And so, the things that we prescribe in the pulmonary clinic are not always just to make you feel better, they're also to prevent you from falling apart in some way, because nature is still going to cause those lungs to decline a bit, but if I can NOT have you in an urgent care or hospital with something that's gonna make it decline even faster, to then keep you independent and doing things, even though you quote 'feel like you're breathing ok,' then I'm doing my job. Taking a pill for folks just seems to be simpler than using an inhaler, and granted, there's a lot more coordination going on with using an inhaler, and a lot of people use them wrong, and there's no point in medicating the back of your throat when we need it to get it down into your lungs. But, it's another task in the day that takes a few more seconds than just swallowing something with water and, you know, it's something that I think when you look at a patient and they're using an inhaler, there might be social or, you know, other biases where you look at them and say, 'Oh, you're doing that, as compared to just discretely swallowing a pill with a glass of water.' And so, I think a lot goes into it. Um, it also comes back to that idea of 'well why am I taking this medicine if it's not making me feel better?' And, with the way that our society, uh, has a healthy and appropriate fear of heart disease and strokes and diabetes and hypertension, um, medications for those, I think, are something people buy into and I don't think we're there yet with breathing disorders to say, 'This is something that you really should do and here are the risks and here are the dangers and here's why.' I think, in some ways, that's a…a blessing, that this is a new enough common disease, so to speak, that we've only been dealing with this for forty or fifty years, um, that people don't have a hundred years of being afraid of heart attacks and strokes the way that, uh, they don't necessarily have that fear with COPD, but it means we've got a lot of catching up to do really quickly.

Host: Thank you for joining us today, Dr. Schreiber.

Dr. Schreiber: No, it's been my pleasure. 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.

ICU delirium is a state of agitation or confusion that can affect as many as 80 percent of patients who are admitted to the intensive care unit. Dr. Matthew Schreiber explains this condition and how we reduce the risk for our patients.

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 talking to Dr. Matthew Schreiber, associate director of the Medical ICU and an attending physician in Pulmonary Disease/Critical Care Medicine at MedStar Washington Hospital Center. Welcome, Dr. Schreiber.

Dr. Matthew Schreiber: Thank you for having me.

Host: Today we're talking about ICU delirium, a sudden and intense confusion that can include hallucinations, delusions, and paranoia. So, Dr. Schreiber, what can cause ICU delirium?

Dr. Schreiber: What can cause it is really the focus of a lot of research right now and the list of things is very, very long. We know that medications have an association with delirium. Some of the things that historically have been used in the ICU to help treat a patient also have risks that are now being identified, like delirium. Additionally, the ICU as an environment itself can lend to having delirium because imagine in your normal job, or your normal life, with a newborn child or something else, if you become sleep deprived, the next day you're a little bit foggy and a little bit less focused, and imagine dealing with night after night of a twenty-four-hour lights on, beeping environment where things are happening because they need to happen to treat somebody. After days of that, it also impacts a patient's mental status and can lead to delirium. On top of that, delirium is really a very specific disease. It's not dementia, it's not pain, it's not agitation -- those things might look really similar, but what delirium is, is it's an end organ failure, meaning the brain, in response to other things going on. And we don't have a model to say A causes B, but we know delirium happens based on a diagnostic criteria—a series of questions and kind of a test, if you will, to say if someone's delirious or not. But we can't necessarily chalk it up to 'if we could just do this one thing we'd be able to get rid of it.' It's a…it's a sign of a disease, but it is its own condition and its own disease and its own thing on its own.

Host: That's fascinating. So, the brain can actually die from overstimulation?

Dr. Schreiber: It's interesting that you put it that way, 'cause that's somewhat of what's being shown in some research. If you parallel this to something like sepsis. Sepsis is the whole body responding to an infection in one place. So, lots of people get urinary tract infections, but some people, their body's inflammation and that's the body's response to it, they end up septic from that same urinary tract infection. The brain sees all the same blood as everywhere else in the body, so even though somebody might have low blood pressure or troubles breathing because of an infection down in their lower extremities or again, that urine, the lungs were an innocent victim. Here the brain is an innocent victim to whatever the illness is because of all the things circulating around in the body causing end organ damage. To come back to what you said about the brain dying, there actually are some studies coming out of Vanderbilt where they've done MRIs on people who were diagnosed as having delirium during an ICU stay. Six months later the brain actually looks different when compared to people who were just as sick but for whatever reason their body didn't end up having delirium, so something physical is happening there.

Host: So, we're talking visual, and auditory and physiological symptoms. What would be some of the indications that a person has delirium as opposed to another condition?

Dr. Schreiber: So, it's important to point out that those kinds of things you brought up are what a lot of people think of when they think of delirium, but delirium really is more nuanced than that. It's got a couple of clinical tests that can be done at the bed side to help make the diagnosis, but they're all consistent in what they are. Delirium is a condition that waxes and wanes, meaning it comes and goes. Dementia is something that comes on and gradually happens over years and doesn't necessarily just get better. Delirium is something that can be there at 6 AM, and gone at noon and back again at 7 PM and gone at 2 AM and so the ongoing fluctuations like that are a key component. The second part is inattention. The patient just can't maintain focus. And so, we test that by seeing if they can just do something that we're asking them to do, uh, ten times. You know, some of them being in the affirmative, meaning do it, and some of them not, meaning we say something and they're not supposed to do it, but if they can't maintain focus for those, that's inattention, and that's the second component. And the last part is disorganized thinking. You might just call it confusion. But the way that we test for this when it comes to disorganized thinking is we ask questions to a patient that really should have no question of what's right and wrong. Things like, is ice cream cold? Is a mouse bigger than a giraffe? Can you hit a nail with a hammer? And when somebody has delirium, questions like that still become difficult for them to answer even though they sound like something anyone should be able to get right. Really, it's hard to tell without actually doing the test. There are people who can be completely oriented, can tell you the date, where they are, their name and be delirious. And there are people who can be disoriented or have dementia or have changes in their ability to respond because of a stroke and not be delirious. So, it really does come back to those key things of waxing and waning mental status, so it's changing throughout the day, inattention, and disorganized thinking.

Host: So, it sounds like different populations of people, different conditions for which they're hospitalized in the ICU, can cause varying levels of delirium symptoms. Is there a particular risk factor an individual might have that would make, say me as opposed to you, more susceptible?

Dr. Schreiber: That has been shown. So, the older a person gets, the more likely they are to have delirium. The more ill the person is when they first come into the hospital, the more likely they are to have delirium. People that have a history of dependencies on different chemical substances, whether it's things like alcohol or illicit drugs or even prescription medications, are more likely to have delirium. Whether if any one of those things is the absolute risk or not, hard to say. But it's something we really should be looking for in every patient. It's also important to say this is not just an ICU thing. It's where a lot of it happens, in fact eight out of 10 people who end up on a breathing machine will have delirium at some point in their hospital stay. But half the people who never end up on a breathing machine can still be that way, and even just regular admissions to the hospital, what we call the medical/surgical floors or wards—up to a quarter of those people will have delirium during their stay, at some point.

Host: So, this is a fairly common thing. How many cases would you estimate that you see at MedStar Washington Hospital Center in a year?

Dr. Schreiber: Hundreds. I think the better way to put it is how many people every day do we see having delirium? We…we make it part of our rounds. It's something that the nurses do every single shift, is do a test - we call it a Cam ICU, confusion and agitation method in the ICU, to look at that series of questions. Has their mental status changed? We ask people, to basically squeeze my hand or blink your eyes or stick out your tongue. Whatever they can do when I say the letter A, and then I spell out 'save a heart,' and heart is spelled wrong, it's s a v e a h a a r t, and if they get more than two of those wrong, then we move on to disorganized thinking and ask them those simple yes, no questions, and can they follow a command. And if they can't follow two separate commands and answer questions without more than two errors altogether, that's delirium. We check every patient in the ICU every single day, and when we find it, then that can actually change our plan of care. Do we need to be more aggressive getting rid of a sedative? Do we need to change that to something else, even if it, you know, we're not sure it's going to be as effective to help maintain a level of comfort. Or, is it a sign that something's going wrong? You know, when a patient's in the hospital and has a fever, everyone says "oh, we need to figure out why that patient has a fever." If someone was normal yesterday and delirious today, that's another sign that the brain is raising a red flag maybe something's going on and that might be the first sign of an infection or a complication.

Host: Is this something that patients have ever brought up in themselves and say, you know, "doctor, I just don't feel right?" Or is this something that family members can also watch out for? Or caregivers? What's their role?

Dr. Schreiber: The patient's usually not aware because it's affecting their brain and so that level of noticing 'hey, I'm different' is one of the risk factors of the condition. Family see it, they just not necessarily know what to call it. Why is my loved one not themselves? Why did they act like they didn't know who I was? And the worry is, is this dementia? Is this permanent? Is—have they had a stroke? Is there something going on? Is it any number of things? They don't necessarily come up and say, 'I think my loved one's delirious.' But when we get those kind of questions, like 'she was talking out of her mind this morning' or 'she couldn't remember something I said to her fifteen minutes ago' or something like that, those are red flags to that disorganized thinking.

Host: Is there anything that a patient or a family member can do to decrease the risk for delirium?

Dr. Schreiber: Absolutely. Being a familiar face, being able to redirect, being able to anchor that patient in what's going on and help them stay focused, has been shown to help. Having things like the whiteboards in our rooms that have today's date and today's nurse and today's information, help reorient the patient. Having things on the television in the room that have current, redirecting kind of issues. Not necessarily dramatic things you might see on the news, but things that let people know of what's going on now have been shown to help. And also, letting people get the rest they need. You know, we do have an open ICU that allows visiting hours around the clock. But our goal is to let patients sleep at night and stay awake during the day. During the day, we try to be aggressive with pushing things forward as much as the patient can do and so family members can help by being encouraging for that. Helping keep the patient's spirits up and when the patient's saying things like "I just don't know if I can do physical therapy today," to ask them, "Are you sure? How about a little, but can we help you? Can we cheer you on?" You know, this is really gonna help you out by staying purposeful and active and moving forward because early mobilization and activity's also been shown to reduce delirium.

Host: Interesting. So, walking or getting up and participating in PT?

Dr. Schreiber: Absolutely, and not just with the physical therapist. One of the things that we've been doing here for almost two years now in the medical ICUs is rolling out a bundle of things to help control, manage, and prevent delirium. This is called the ABCDEF bundle. It stands for assessing and addressing pain, because that's important. When a patient is 'quote un quote' agitated, maybe it's because they're hurting, and if we can control that pain syndrome instead of just using something like a sedative, or an antipsychotic or something to calm them down, you might actually get two birds with that one stone, and reduce their risk, and help that issue. The B is for both the spontaneous awakening and breathing trial. So, people that are on a vent—mechanical ventilation, a breathing machine for life support - to every single day see, can they breathe on their own? And, if they're really sick, they're going to declare that they can't because they'll breathe fast, and you can tell within a minute. But maybe they can, because if they can breathe on their own on that machine with some settings being changed, maybe they're ready for that to come off and you get rid of another risk factor for delirium. The awakening trial is not just saying, let's turn down any pain or sedative medications to see where we can get the patient awake and comfortable, but literally every single day to push stop on those machines and see if the patient needs it.

That's been studied, and by always trying to adjust to just enough for the patient what they need was considered standard of care. By doing that but also once a day pushing pause on the machines, cut the number of days of continuous medications like that, cut the number of days on the vent, shortened the ICU stay, and did nothing to raise mortality or patient harm, and so the fear of 'Well, I can't push stop on this medicines that going through this IV pump, the patient will hurt themselves,' never has actually been shown. In fact, continuing it longer seems to be what hurts people. The C is the choice in those medications. Things called benzodiazepines. At home, people might know this as Xanax, is one of those examples. Ativan is another example. That family of medicines has the most research behind it to lead to delirium than anything else we know. In fact, one study showed a direct relationship of the dose that you get of medicines in this family to having delirium within a day, and it doesn't seem like much but relatively low doses ended up having a hundred percent of people having delirium that day, so we try to avoid those whenever we can. Sometimes they're needed. We use benzodiazepines when someone is seizing. We use them when someone's in alcohol withdrawal. But, a lot of times you can find something else. The D is for delirium. To check it, because if you don't look for it, you're not going to find it. And that's that test we call a Cam ICU. The E is early mobilization activity, which might be physical therapy, but our nurses are fantastic. You know, we can sit somebody on the edge of the bed, let them use those core muscles to dangle their feet. We can move people to a chair because the sitting position uses different muscles than laying in bed, and we walk people. And we walk people. You know, we get a physical therapist, a nurse, another nurse to help, if needed, and even if someone is still on a ventilator, still on a breathing machine, still on life support, we can walk them in the unit if they're able, but we won't know if we don't check to see what they can do. And the F is family engagement and involvement. Because it is important for family members to help us help that patient in a way that we can't. As much as I might like my patients, I will never be that familiar face that they've known for years and years and years, at least I hope that I'm never that face. And that's something we can't reproduce. And so, we do try to invite families to rounds every day. If they can't be there, we try to call them every day, and we really do try to encourage that engagement with the patient to help them move along.

Host: Is there a risk for untreated delirium, or if somebody has it, can it resolve on its own?

Dr. Schreiber: Most of the time patients, as they get better clinically, as whatever got them sick in the first place gets better, they'll start to improve. There are long term risks here though. Being delirious on its own, even when you, what we call, adjust for other things, meaning you're doing statistics to say how much does this cause that or associate with that, and you say 'well, I'm going to take two people who are just as sick and one's delirious and one's not, how does, how does this outcome change,' delirium's been shown to increase mortality at six months. If it's its own process being on its own, it's more likely to kill you, which is why it's so important to try to prevent it with those other things like getting out of bed, and less days on the vent and less sedation. I mentioned the MRI studies a little bit earlier, that there's something physically different happening in the brain and so, long term, patients that have had delirium tend to have more cognitive issues and functional issues and it can be something simple like more often saying 'I was going to tell you something. I just can't remember what that was', but it can be life changing if now they can't go back to work. And icudelirium.org is a fantastic website for both patients and practicing clinicians and family members and everyone else to see testimonials from patients and caregivers and hospital professionals all talking about the long-term outcomes of this condition. It can be life altering and the worst part is, if no one was ever able to say 'hey, you had this while you're in the hospital' because there are plenty of places that don't check for it every day. Even in our institution, I can't tell you that every single unit, every single nurse, every single day, checks for this. Then they go home and wonder 'why am I different?' And we have a long way to go to help support people at the back end of their illness, at the back end of the ICU after they've left, to try to give them every opportunity to get back to being themselves.

Host: That's really a lovely statement, I think, because yeah, I mean it's traumatic enough being in the hospital, let alone being in the ICU after a traumatic event. Is there a certain subset, say accident victims or surgery, you know, people that had complications with surgery, that you see delirium in more often or a certain age group?

Dr. Schreiber: The older you are, the more likely you are to become delirious. As far as the disease itself, I think the literature is just not there yet from the research. It has been shown in burn ICUs, cardiac ICUs, surgical ICUs, medical ICUs, it doesn't discriminate. What we do know is it happens far more often if you are on a breathing machine, and that's probably a mix of both - that means you're sicker because if you're on a form of life support to help you breathe, that's pretty bad. But also, what does oxygen do to you and your brain? If you've ever been unfortunate enough to have a family member in a neonatal ICU or if you've ever worked near one of those, you know that they, as…as early and aggressively as possible, try to have that baby off of oxygen because of how it can affect your eyes and other things. We always try to use it as little as possible but it has things that cause inflammation, it's one of the effects, so could the vent itself do some of this? We don't know. The research isn't there yet. People who are septic - there's some studies that say there might be more delirium in that because of the way the whole body can become inflamed, including the brain, when the body is dealing with an infection and becoming septic. But if there is one disease to do it, I don't think we have that answer yet.

Host: Have you ever seen a very severe case of delirium turn around and what was that process like?

Dr. Schreiber: I have. I, I can distinctly remember a patient who, you'd walk past the room and looked like a normal guy. Sitting in the chair awake, watching tv, and then you'd talk to him, and you'd hear from the nurse, 'Well, overnight we had to, you know, give him something because he was agitated, or we had to calm him down,' you know, even if it wasn't with the medicines. So, right there you have waxing and waning mental status. And then you'd ask questions and he would give answers that just seemed a little off, and so you'd take the next step and ask him to squeeze your fingers when you say the letter a for all those letters, and get that wrong, and then ask him these disorganized think questions and get that wrong. And then something would come out and he, he was scared because that's what he saw and that's what he believed was going on, and you would never know this if you didn't ask the right questions because he would talk to you like everything's fine, until you got into what he was perceiving and seeing. And, you know, he acted like he was actually handling it ok, and it's not a big deal but then you realize he's delirious and that visual hallucination was one of the things his delirium was manifesting. He ended up doing well. He left the hospital. I saw him in the clinic months later and he was trying to go back to work. He ran his own business and said he was having some trouble doing the books, so to speak, but for as close as he came to death with what brought him in, it was a remarkable improvement, just not all the way to as good as you wish you could get if you survived a life-threatening illness.

Host: Thank you for joining us today, Dr. Schreiber.

Dr. Schreiber: Oh, it's been my pleasure! 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.

Some pituitary tumors need immediate treatment, while others may benefit from a wait-and-see approach. Dr. Susmeeta Sharma discusses the different types of pituitary tumors and how we care for them.

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. Susmeeta T. Sharma, director of pituitary endocrinology at MedStar Washington Hospital Center. Welcome, Dr. Sharma.

Dr. Susmeeta T. Sharma: Thank you for having me.

Host: Pituitary tumors often cause no symptoms, but when they do, the symptoms typically are vague and easily can be mistaken for other less serious conditions. Pituitary tumors may be functional, which means they secrete excess hormones, or non-functional, which means they do not secrete excess hormones. Dr. Sharma, when symptoms occur, what do patients typically experience?

Dr. Sharma: The symptoms of pituitary tumor kind of depend on the size of the tumor and whether it's a functional tumor, what hormone it's making, is it causing any hormone deficiency. So, I always think that in order to understand what symptoms a pituitary tumor can cause you have to understand the basic physiology and anatomy of a pituitary gland. So, the pituitary gland is a pea-sized gland located at the base of the brain. And I think of it as a conductor of an orchestra. It basically makes a bunch of different hormones, which then regulate other endocrine glands in the body to make other hormones. So, for example, it makes TSH (thyroid stimulating hormone) which then acts on the thyroid gland to make thyroid hormones. It makes ACTH (adrenocorticotropic hormone) which then acts on the adrenal glands to make...regulate cortisone production. It makes prolactin which acts at the level of the breast for development of the mammary glands and milk production. It makes FSH and LH which are gonadotropins which act on the gonads, ovaries, and testes to make female and male gonadal hormones, testosterone and estrogen. And then it also makes growth hormone which really acts on the entire bodies involved in growth, especially in children during puberty, achieving, uh, their full height potential.

So, it's a really important gland and any small, uh, dysfunction, whether it's related to an inflammatory disorder or a tumor that's causing compression - any of that can lead to either hypofunction of one of these hormones or increased function of one of these hormones. A pituitary tumor has the potential to make any of these hormones. So, it's...if it's a functional pituitary tumor, it can cause symptoms related to excess prolactin, which will then be breast milk production or irregular menstrual cycles or infertility in a female. In a male it may be even harder to detect because of the lack of the menstrual irregularity as a symptom so while they may present with is decreased libido. And later on, as the tumor grows, it may cause symptoms related to the size of the tumor, so headaches and vision problems. So, it all depends on the kind of hormone that the pituitary tumor is making. Another example would be if it's making ACTH which is then leading to excess cortisone production that can lead to a patient gaining a lot of weight, muscle weakness, fractures, diabetes, high blood pressure, developing purple stretch marks on their body. So, a variety of symptoms that could be related to excess production of a particular hormone in the body. Uh, so that would come from hormonal excess. But then you could have symptoms related to hormonal deficiencies. So, if the tumor is large enough that it's compressing normal pituitary cells, you could have a low cortisol state, a low growth hormone state, a low thyroid hormone state, which can then lead to other symptoms of their own. And lastly, like I mentioned earlier, from the size of the tumor. Even if it's not producing any hormone, as the tumor grows, by the size of the tumor, it can cause headaches to the patient and also, in the space where the pituitary gland is located, it's a very tight space and it's very close to the optic nerve or the optic chiasm, and those are fibers that control our vision, especially our peripheral vision, and so, as the tumor grows, it can compress on these nerve fibers, leading to vision problems - double vision, loss of peripheral vision - it may manifest as that. Many times though it may be the patient may not have any symptom at all and it may get detected on an MRI done for other reasons - for example, for headaches, for...which are...may or may not be related to the pituitary tumor. So, the presentation can really be varied and depends on how big the tumor is and if it's making any particular hormone.

Host: When symptoms arise, is treatment urgent, or do the tumors grow slowly?

Dr. Sharma: The majority of these tumors are slow growing tumors. These are benign tumors, not cancers. Often, patients may hear a diagnosis of brain tumor but this is very different from other tumors that arise in the brain and that have a much higher malignant or a cancerous potential. So, pituitary cancer is very rare and so these are mostly benign tumors. Benign in the sense of them being cancerous but not benign in some of the effects that they can cause if they go undetected. But most of the time, yes, given the fact that these are slow growing tumors, the symptoms often develop gradually. Uh, many times these symptoms can be non-specific so a patient may just have some fatigue and some inability to lose some weight and that could even be a symptom for a hormonal disorder. So, um, sometimes the presentation may be very obvious, very florid, and we may even walk into a room and see a clinical appearance of a patient and think that, "Oh, this patient has to have a pituitary hormonal disorder" while other times it may need a much more lengthy interview in the clinic and exam and for the blood test before a diagnosis can be made.

Host: What are some of those immediate symptoms that would cause you to think a patient you're visiting with has a pituitary issue?

Dr. Sharma: Um, so, in particular in women, if they have irregular menstrual cycles and there is breast milk production and they have not had a baby and so that would be a situation where there has to be a prolactin elevation in the majority of the cases. Uh, that may or may not be related to a pituitary tumor; that there are other disorders that can cause a prolactin elevation. But that definitely means that they need to be evaluated by an endocrinologist and need to be tested to see if there is a pituitary disorder there. So that would be one example. Other times, especially in conditions where the pituitary tumor makes growth hormone or the hormone ACTH (adrenocorticotropic hormone) which then leads to cortisol excess—those two particular hormonal disorders can often present very floridly, where the clinical appearance can be very dramatic and easy to detect if it has gone undetected for quite a period of time. So, for example, a growth hormone secreting tumor or excess growth hormone leads to enlarged, fleshy hands and feet. The patient would complain of change in ring size, change in shoe size. They would have changing facial features, coarsening facial features over time that one can detect on...while examining or looking at the patient. Another example would be Cushing's Syndrome, or excess cortisol in the body. In that, also you have a change in facial features, rounding of face, a reddening of face which we call plethora, excess fat positioned on the upper back of the body in the base of the neck area where...near the clavicles. And so all of that can make us at least suspect that this patient could have Cushing's, and then those patients would need to be screened for that disorder.

Host: What are some of the common diagnostic tests when a doctor suspects a pituitary disorder?

Dr. Sharma: If we suspect that a patient has pituitary disorder, sometimes the clinical presentation is so florid that we may want to test for a particular hormone and other times we may need to test for all of the pituitary hormones. And again, anytime I am thinking of a pituitary tumor, I need to make sure both that A) the tumor is not making any excess hormones, so those would be blood and urine tests to start off with for these particular various hormones and then I also need to make sure that it is not deficient. Many times, the blood and urine tests may not itself be sufficient for the diagnosis - that would be the initial screen, followed by some more dynamic testing that may need to be done to confirm that their patient has a particular hormonal deficiency or hormonal excess. And then again, we need to have sophisticated MRI to be able to detect the full location of the tumor, and then you need to collaborate with the neuropthamologist to make sure we are looking at any possible visual deficits related to the pituitary tumor. So definitely a team work - you need the endocrinologist to be able to assess for these hormonal deficiencies and hormonal excess disorders, you need the neuropthamologist and the neuroradiologist to look at...um, visualize the tumor on the MRI and assess if there are any visual field deficits related to the tumor, and then we need, of course, the neurosurgeon if surgical treatment is indicated.

Host: What is the approximate size of the pituitary gland?

Dr. Sharma: In a three-dimensional structure, the height of a normal pituitary gland is around 6 millimeters in size so, overall again, yeah, the pituitary gland is about the size of a pea. And then, any time there's a tumor within it—so just a few millimeters above is the optic chiasm and so any time the tumor is growing there is a potential of that gland with the tumor encroaching onto the eye nerves, especially if the tumor is greater than a centimeter, which is what we call a macroadenoma while in the centimeter. When the pituitary tumor is less than a centimeter it's called a microadenoma.

Host: How big are the tumors that you're taking care of in these patients?

Dr. Sharma: So, very variable. So microadenomas, may come to our attention two ways. It might just be that in this era of MRIs, an MRI is done for other reasons and we find a small tumor now. Once the tumor is found, you do want to make sure that it's not making any hormones and then you have to follow it once a year, at least, to make sure that it's not growing significantly in size that it needs surgical attention, just based on the size of the tumor. Otherwise, it may be that it's a small tumor but it's making a particular hormone so mostly functional tumors can get detected at a smaller stage just because of...they're causing much more symptoms to the patient from the hormonal excess related to them. And so functional tumors may get detected at a size when they're less than a centimeter. Non-functional tumors though, most of the time if they've not been incidentally detected on an MRI, would be greater than a centimeter. So, we have had tumors that are 5 to 6 centimeters, especially many times in patients who have not sought medical attention or have not been seeing physicians regularly. Um, other times the tumor could be very large but it's just that the patient has not paid attention to the visual field deficit that it may be causing. So, they just get used to not being able to see peripherally and that can be very dangerous, especially if they're out there driving with the visual defect. So, as an example, we had a young male with a prolactin secreting tumor. And so, this tumor was about 5 centimeters in size. And, these are slow growing tumors so it was probably present for several years but a prolactin secreting tumor in the male, all it was doing in his case was lowering his testosterone levels and thereby probably causing decreased libido but it had to grow to that big a size and to finally, during a testing for a DMV related driver's license, he failed his vision exam and that's how his visual field loss initially came to attention.

Host: Is a functional or a non-functional tumor more dangerous?

Dr. Sharma: A non-functional tumor, whether or not it needs immediate attention, would depend on the size of the tumor and what mass effects it's causing. But definitely a functional tumor always needs attention. So, I'm not sure if one is more serious than the other but definitely a functional tumor always needs attention immediately. And so, uh, most functional tumors, actually the first line of treatment would be surgery. The only functional tumor that can be purely treated medically in the majority of the cases is a prolactin secreting tumor. So, although there are medications available for treating various different functional tumors, in prolactin secreting tumors using medications that are available are so effective that we can actually shrink the pituitary tumor and normalize the prolactin levels with medications alone and they don't need surgery. And, in fact, outcomes from medical treatment can even supersede what we can achieve surgically and so that is why an endocrinological evaluation is really important for pituitary tumors because we want to make sure that we assess whether or not surgery is indicated and also make sure we're not missing these, this particular kind of tumor—the prolactin secreting tumor—where we can make a difference medically instead of the patient having to undergo any unnecessary surgery.

Host: When a patient requires surgery, is there a minimally invasive option?

Dr. Sharma: Surgical techniques for pituitary tumors have really advanced. And the majority of the pituitary tumors can be safely resected through the transsphenoidal route. So, we have an endoscopic or a microscopic approach and it depends on the size and location of the tumor when the pituitary surgeon decides which approach to take, but they're all being done minimally invasively now. And so, this would be a route either under the lips sublingually or trans nasal so through the nasal passage, through the sphenoid sinus and then through the base of the sella, which is what we call where a pituitary gland is located. So, that would be a minimally invasive approach. Patients are usually in the hospital for 2 to 3 days after surgery and are able to leave so compared to the earlier times where you would actually have to cut open the skull and then approach a large pituitary tumor. So even tumors of the size of 5 to 6 centimeters can be safely removed through this route these days.

Host: Is there any scarring related to the surgery?

Dr. Sharma: So, no actual visible scarring. Many times, in the path that the surgeons take, you may have some superficial nerve fibers that are affected and so people may have temporary, um, either altered or loss of taste or smell sensation. They're definitely going through the sinus so sometime you can have sinus-related issues but those are usually temporary and there's, uh, no visible scarring. You can't really tell that the patient has had surgery, in fact.

Host: Why is MedStar Washington Hospital Center the place for people to seek care?

Dr. Sharma: Oh, I think what we provide is a multidisciplinary team approach. It's really important to see a patient and treat them as an individual and see what would be the best treatment option for them. So, any time I think of a pituitary tumor, I think what it needs is a team and not just a single physician operating in isolation. So, you need an endocrinologist to evaluate the hormonal excess or deficiency related to the pituitary tumor. You need a neuroradiologist to properly evaluate the tumor and make sure they're using up to the mark MRI techniques and developing newer localization techniques for that. A majority of the tumors do need to be surgically removed so we definitely need an experienced neurosurgeon. Not every neurosurgeon is doing the number of transsphenoidal surgeries I feel that are necessary to develop the expertise, so it's really important to have an experienced neurosurgeon who does a lot of these. And we are lucky to have Dr. Edward Aulisi as one of our neurosurgeons here. And so, an experienced neurosurgeon and then an experienced neuro-opthamologist to look at visual field deficits related to it. And then as an adjunct treatment, other than surgery and medical therapy, you may also need radiation therapy for the pituitary tumor. So, we have focused stereotactic radius surgery options available at MedStar Washington Hospital Center as well. So, having it all under one roof helps because we all are communicating and trying to develop a treatment plan that is best for the patient...that's optimal for the patient.

Host: Are you currently doing any research on pituitary tumors that you'd like to share with people in the community?

Dr. Sharma: So, we are starting the research process. We do have Dr. Joseph Verbalis, who's at our counterpart institute which is Georgetown University Hospital, where he's already doing a lot of research on posterior pituitary and sodium disorders. And then Washington Hospital Center - we are developing other research programs to look at the path of physiology of tumors so what leads...for different patient populations to develop various kinds of pituitary tumors. We are working with our pathology department to try and see what molecular markers we can identify to better, um, identify what treatment option would be better for a particular patient based on those molecular markers. And then, of course, devising better, more refined surgical techniques for making these surgeries possible in a minimally invasive manner.

Host: Thank you for joining us today, Dr. Sharma.

Dr. Sharma: 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.

Lifestyle modifications are key to treating hypertension, especially for people at high risk. Dr. Valeriani Bead discusses who is at risk and which treatments are most effective.

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 expertise in nuclear cardiology and echocardiography. Welcome, Dr. Bead.

Dr. Valeriani Bead: Thank you for having me.

Host: Today we're discussing how the 2018 hypertension or high blood pressure guidelines apply to African Americans, the elderly and other at-risk populations. The guidelines lower the target rate of a healthy blood pressure for average risk individuals, thereby increasing the number of U.S. adults who are considered to have hypertension. Dr. Bead, what is the optimal blood pressure target for a person at average risk for hypertension under the new guidelines?

Dr. Bead: Well, you mentioned that the new guidelines that were just released in November 2017 - well, these were the most recent guidelines in almost fourteen years that were published - and they were treating high blood pressure in adults and they're really the first guidelines that we've had that's based on extensive research, using the highest quality clinical research and drug trials. And, based on these new guidelines, really the goal blood pressure is anything less than 120/80 millimeters of mercury. And really where the controversy started is now stage 1 hypertension is considered in individuals who present to their healthcare provider's office with a blood pressure of 130/80 millimeters of mercury. Well, what that means is that more American adults will be told they have high blood pressure because of these newest thresholds. And those who are already being treated will need to really talk with their healthcare providers about whether or not their target blood pressure readings need to be adjusted. And, in some cases, whether or not lifestyle changes and their medication will need to be intensified.

Host: What are some of the symptoms of hypertension?

Dr. Bead: The most common symptoms we experience, which is scary, are none. Some people don't even know it. They don't feel it. Which is just fascinating. Outside of that, the most common symptom is headache, fatigue, dizziness, lethargy and at times, but not quite often, they can get chest pain and shortness of breath.

Host: When it comes to hypertension, African Americans are at greater risk, in general, than other nationalities. Why is that?

Dr. Bead: Well, in the United States, in any decade of life, African Americans have a higher prevalence of hypertension than that of Hispanic Americans, whites, Native Americans and really any other subgroup defined by race and ethnicity. And the ideology remains obscure and we really don't know. But, we do know that hypertension control rates are lower for blacks. That also hypertension, when it's diagnosed, is more severe and that sometimes the medicines we use to treat high blood pressure are less effective at controlling blood pressure. And with all this, the morbidity and mortality attributed to hypertension is more common in blacks than it is in white Americans and any other ethnic group - which is why identifying and treating hypertension can have such a significant impact on health and morbidity in the African American community, which is why it should be identified much earlier.

Host: When we're thinking about high blood pressure, regardless of nationality, the risk increases as we age. Could you explain why older adults are at a greater risk than younger adults?

Dr. Bead: That's a very good question because there really is an extremely high prevalence of hypertension in older adults. And, hypertension is not only a leading cause of preventable morbidity and mortality, but, more importantly, it's under-recognized and it's considered a major contributing factor to premature disability and why many elderly adults get institutionalized, such as nursing homes. And, it is worthy to note that after the age of 69, the prevalence of hypertension rises to greater than 50 percent. And so, it's linear with age. Now, the exact cause is unknown, but we have postulated that as we get older our blood vessels do get stiffer and then that can lead to elevated blood pressure. But, I've got to tell you that that's not entirely elucidated and a lot more research is warranted to help figure that out.

Host: So, we've talked about African Americans. We've talked about older adults. Are there other patient populations who are at increased risk for hypertension?

Dr. Bead: More often times than not, in my clinic practice, I see pregnant women who come in with elevated blood pressure and that is certainly a population that cardiologists, in general, need to be aware of. Because, blood pressure, while it usually declines during the first trimester of pregnancy, it can slowly rise in either the second or third trimester of pregnancy. And we usually need to be aware of those mothers who have newly diagnosed hypertension, or whether or not they have incident hypertension during clinical conditions such as something called preeclampsia, which is a dangerous form of hypertension, that leads to increased protein and other consequences with the mother's health. And the reason that this really is important for us to identify earlier is because we have found out through research studies that mothers who are diagnosed with high blood pressure during pregnancy eventually have high blood pressure later on in life. And so, it's important to identify it earlier so that we can treat it and have it under control.

Host: These women who are diagnosed during pregnancy with high blood pressure, what are some of the risks for them and for, perhaps, their babies if they don't get that treated?

Dr. Bead: The most important risk we always worry about is the health of the mother and the baby. With high blood pressure, that can put the baby at risk. With high blood pressure, that can put the mother at risk and lead to bad consequences such as congestive heart failure. And so, there are actually very serious consequences to worry about if blood pressure is not controlled during pregnancy.

Host: And, if we take a step back and think about all these other individuals - African Americans, older adults, adults of any age, really, who don't take care of their hypertension - what are some of the risks for them if they don't seek treatment?

Dr. Bead: Not to be too grim, the risks for uncontrolled high blood pressure are significant. Meaning, with uncontrolled high blood pressure, it can lead to strokes, heart attacks, abnormal heart rhythms, congestive heart failure, kidney problems, and death. This is typically something that happens over time, which is why you may sometimes hear hypertension referred to as "the silent killer." Meaning, hypertension can be prevented. And usually, when you have consequences related to hypertension such as the ones I just mentioned, it's something that could have been identified much sooner and treated earlier, without the bad consequences.

Host: The 2018 guidelines lower that target rate of a healthy blood pressure for average risk individuals. What does that mean for lowering the blood pressure targets for high risk individuals?

Dr. Bead: The implications are essentially the same. To identify high blood pressure individuals, whether they have it average or high risk, it really helps us treat it earlier and potentially reduce future cardiovascular events.

Host: How can high risk patients proactively manage their blood pressure?

Dr. Bead: The lifestyle measures can be effective in treating hypertension. So, there is something called the DASH lifestyle eating plan and the DASH diet stands for Dietary Approaches to Stopping Hypertension. and that has been a long term, randomized clinical trial that actually shows that following this eating program, which reduces the amount of salt in our diet, can reduce the blood pressure by an average of 10 to 15 points. And, using that, in combination with restricting dietary sodium and increasing dietary potassium, can really result in a good effect on the blood pressure. So, in addition to that, weight reduction, regular aerobic activity, not smoking, and limiting alcohol really also go a long way in terms of managing blood pressure.

Host: When those lifestyle methods aren't enough, what treatment options are available for patients with high blood pressure?

Dr. Bead: So, first line treatment will always be lifestyle changes, such as the ones I've mentioned. And then we can go on to second line treatment which usually includes prescribed medications, and sometimes it may require starting two medications at the same time in order to achieve that goal blood pressure of less than 120/80 millimeters of mercury. Also, ruling out any other potential causes such as obstructive sleep apnea, which is when someone doesn't get enough oxygen when they sleep, can really go a long way in terms of keeping the blood pressure under control and treating that. And, in extreme cases, for patients who have something called resistant high blood pressure, which is basically blood pressure that is difficult to control, we have invasive procedures that are available but that's something for another discussion.

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

Dr. Bead: This is my favorite part! I love my practice and, I've only been doing this for about 8 years. And, I'll never forget one of my first patients, who I met about 7-½ years ago. She was a middle-aged woman who I initially met during a normal EKG. And, at the time, she was dealing with high blood pressure, requiring at least 3 or 4 different medications. She was morbidly obese, and she had problems with arthritis. And, we did a comprehensive cardiovascular workup. And, it turned out that her heart status was actually pretty good. And so, we adjusted some of her medications and, with time, nothing really changed. And at one of her follow-up visits, I sat down with her and looked her in the eye and basically, with as much encouragement as I could, I asked her...that she just has to start moving. Literally, to start doing 2 minutes a day and then, after that, doing 5 minutes a day and then, after that, getting up to about 30 minutes a day. And, I kid you not, when I saw her back in a 6-month follow-up visit, she had lost 50 pounds just by walking. And, she was motivated enough to start changing her lifestyle in terms of what she ate. She followed the DASH eating program and joined a gym and lost another 50 pounds, to the point that her blood pressure was actually too low, and we actually stopped the majority of her medications to the point that she was on one low dose medication to keep her blood pressure under control. And also, she didn't have any more knee problems. So, she was able to share that success story with me and she spread it to her family, and she's also been able to do some exercise programs at the local YMCA. And, she's happy and she's here to tell the story and she actually had a poster that she shared with me. And it's something that I share with my other patients as well.

Host: What was the poster that she shared with you, if you don't mind sharing with us?

Dr. Bead: It was a before and after of herself and basically, it showed pictures of her when she was at her highest weight. It showed pictures of her when she started walking. And it showed current pictures of her at her current weight. Because she had lost over a hundred pounds just by moving and watching her salt intake. So, all of the poster of her - really a before and after. I mean, the picture was worth a thousand words just to see how she transformed by making literally small steps.

Host: That was really amazing and I'm sure that's really inspirational for a lot of your other patients and maybe even for you every day to remind yourself to get in there and do your exercise and just keep going forward. Why is MedStar Heart and Vascular Institute the best place for people at high risk for hypertension to seek care?

Dr. Bead: Because the MedStar Heart and Vascular Institute really offers comprehensive, state-of-the-art care. And the compassionate environment that is patient centered and really evidence based. And what I really like about MedStar Heart and Vascular Institute is there really is a physician for every type of patient and for every type of medical illness that hits our door. So, there is something for everyone.

Host: 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.

The effects of traumatic injury can linger long after initial recovery. Dr. Jack Sava explains why trauma is a disease and should be treated as such.

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. Jack Sava, chief of trauma at Medstar Washington Hospital Center about visualizing trauma as a disease in itself.

Host: Thanks for joining us. We're talking to Dr. Jack Sava, chief of trauma at Medstar Washington Hospital Center. Welcome, Dr. Sava.

Dr. Jack Sava: Well thank you, I'm happy to be here.

Host: Thinking about trauma as a disease in itself, could you explain what you mean by that?

Dr. Sava: Well, it's interesting to think about injury and how is injury similar or different to something like a heart attack or cancer or stroke or asthma and so forth, and many people today I had somebody tell me a week ago that injury is not a disease really, it's something that happens. And i think that's the general perception, and you might ask well why does it matter? Why are we talking about the words? And the reason it matters is because it turns out that looking at injury or trauma as a disease is very helpful and makes a lot of sense and leads us to a lot of sensible policies and a lot of sensible practices. So why is it a disease? Well, trauma, like heart disease has risk factors. It's related to poverty, substance abuse, mental illness and many, many other things in the same way that hardening of the arteries is related to smoking and diabetes, etc. so really even though you might think because it's behavioral, it's different, the idea of risk factors leading to illness is really the same. It also has an acute phase where there's an event kind of like a heart attack, and that requires some time in the hospital. And then it also has this long tail end, just like other diseases where you have to recover, the recovery is slow, the recovery may not be complete, it may impact your quality of life forever, it may impact your family, and then even more so you're going to be at risk for recurrence, so if you have a tumor removed from your stomach, you're always going to have to worry about recurrence of that, and we've found that in many of our patients who've had an injury, they're at higher risk for having another injury than other people are, especially whatever led them to that injury, whether it's their driving habits or their substance abuse problem, or their tendency toward bad luck. If none of those things have been fixed, then they're at risk for having it happen again.

Host: It's sort of an umbrella term too, so like mental health would cover a huge spectrum of diseases, is the same true for trauma?

Dr. Sava: Yea, trauma is an unfortunate term in some ways, because it's been borrowed by so many people in so many ways, so a lot of people use the term to refer to an emotional trauma, like a bad divorce. And a bad divorce is a very bad thing, but it's not the sense in which I use the word trauma, that's why I sometimes use the word injury instead. That one's also tricky but, it's really not that complicated in principle, I think most of us know what a physical injury is. It's when an external force causes damage to the tissues of your body, that's the sort of theoretical definition. What does it mean practically? It means violent injury, like shootings and stabbings, it means vehicular injury like car crashes and motorcycle crashes and bicycle crashes. One of the most important things it means is falls. That could be a fall from three stories or it can mean an elderly person tipping over out of their wheelchair. That is a huge cause of injury in America. It can include intentional self-harm, a suicide and suicide attempts, and it can include workplace injury, and that's a big problem also.

Host: So why the shift in mindset from trauma is the thing that happens to you to trauma is a disease? When did that occur and how is that impacting your practice now?

Dr. Sava: Well, it's interesting. Maybe 30 years ago, people started looking at trauma through that lens and immediately a bunch of really profound things became apparent. If you look at injury or trauma and you put it side by side with other diseases, you see some very interesting things. The most obvious way that you might think to grade the importance of a disease would be is it a common cause of death? And so that's why something like heart disease usually comes out on the top of that list. Because you think about it that everybody whose heart eventually stops beating has a heart problem, so a lot of people in their 90s who eventually their heart gives out, they get put in that category, and so a lot of people have a quote cause of death that's heart disease. But the center for disease control started asking the question what actually kills young people? Or what kills people at different ages. And when you look at that data it's fascinating because it turns out it's all trauma. What kills people in their first second, third, fourth, fifth decades of life is injury, and if you look in your own family, and ask well what took a young person away from my family, you know, most of the time those answers are that somebody got hit by a car, somebody dove into a swimming pool, they're traumatic incidents. So, the CDC developed a new term, a new metric, to describe the importance of diseases, rather than what's the number one cause of death, they started asking, or in addition to that, they started asking what are the important causing of lost life years in America? And that was a radical change when they started asking that question, because again the answer is trauma. So, if you want to know what takes away American life years, whether it's the tragic car crashes or the falls, or the people who die in war time, whether it's America or worldwide, injury and trauma are the most important cause, and they really eclipse everything else.

Host: So, given the impetus of trauma and traumatic events on our health as a nation what's next in research and what's next in treatment?

Dr. Sava: When we started thinking about trauma as a disease and started thinking about how can we impact that like we impact other diseases, we realized a couple of things about trauma and about death from injury, and one of them is that people who die from injury, one of the ways they die is instantly at the moment of their injury. So, if somebody has a horrific car crash, they'd probably die in milliseconds or seconds. So, we have to think about how do we prevent that death? And that's led to a whole growing field of inquiry about injury prevention, and that takes a lot of forms as well, making cars safer making drivers safer, preventing distracted driving. Workplace safety, helmet use, traffic safety all these things can be very effective in preventing the initial injury in the first place, which you can imagine is the best way to prevent death from it. The most important next time of death for an injured patient is in the initial period, what we typically call the golden hour. And what happens during that period is people might be unable to breathe because they're injured so badly, and more commonly they're bleeding to death. So, a lot of stopping trauma deaths has to do with creating systems that can prevent people from bleeding to death, and that starts with people on scene whether they're professionals or just civilian bystanders, knowing how to stop bleeding there, and then it continues through having protocols with the paramedics and the EMTs for stopping bleeding. Protocols that get patients to the hospital really quickly, and then having dedicated trauma centers where there are whole teams of people who are in the hospital 24/7 with expertise and experience in stopping bleeding, both immediately with the right type of pressure, and also with complicated operations. So, for us, that means in many cases on the average Saturday night people come to us and they come through the door of our trauma center, and they might have major surgery on their chest and abdomen to control catastrophic bleeding within 90 seconds of arrival. So how do you do that? Well, obviously, that doesn't happen by rolling into a local, local sleepy hospital and starting to get on the phone to call people to leave the dinner table to come in, that's not going to work. You have to have all these resources, all this readiness, that means surgeons, emergency room physicians, trauma room nurses, blood bank, operating room personnel, anesthesiologists, and on and on. All these people have to be there and have to be either at the door when the patient comes in or ready to be there in a few seconds.

Host: How do you work with the EMS teams so that they're aware they should bring those trauma patients to Medstar Washington Hospital Center and perhaps not another facility without a trauma center?

Dr. Sava: Well, fortunately over the last couple decades, emergency medical services in most metropolitan areas have developed protocols that they know in advance what kind of injury is going to go where. And what that means is that most cities in America, since trauma was identified as an important disease and in most cities in America if you stub your toe, you're going to go to a local ER, if you're shot in the chest, you're going to go to a trauma center. So in other words, there's field triage where the paramedics, EMTs can look at a patient and either by the story of what happened (hundred mile an hour car crash) or by the patient's vital signs, or by their judgement, they can pick the right patients and bring them to a trauma center, and it works out much better when critical patients go straight to a trauma center. And that was a bit of a hurdle you can imagine getting people to understand that the sickest patient doesn't necessarily go to the closest emergency room, that it might actually be better to bypass them and go to the right emergency room rather than the closest one.

You know, we talk a lot in talking about diseases about death and mortality rates and causes of death. It's important with trauma and injury to recognize that for every patient who dies with injury there are many, many lives irrevocably changed. There's a whole ocean of suffering that exists for every patient that actually dies. This can take the form of physical disability, but also post-traumatic stress disorder, and depression, and many other consequences of injury. People often after serious injury, have to develop a completely different conception of their body integrity, they can have lost limbs, they can have lost functions, and these things can obviously snowball, especially if not given the proper care, into a patient losing their job, becoming depressed, their relationships falling apart, or they quit school, that makes the depression worse. And even the emotional problems can in turn make the physical problems like pain worse, so it's very easy to enter into a downward spiral. So even patients who aren't in the data set of patients who died are often the ones who are suffering their whole life and so we need to have systems in place and resources for those people, because it's easier to simply talk about mortality rates, often that's where we focus

Host: How do you triage those individuals who are going to need that extra care even that emotional support after they leave the trauma center?

Dr. Sava: well we screen people in the hospital and we screen people on subsequent visits for post-traumatic stress disorder. I think that there's still a long way to go in American trauma care to help people, especially people without resources, with the emotional fallout of injury. I think that the care of mental illness for people with no resources, generally speaking, with or without injury, is an opportunity in America and a place where we can make a lot of progress.

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