Medical Intel

Chronic pelvic pain can cost women productive time at work and lost opportunities with family and friends. Dr. Vadim Morozov discusses which populations are most at risk for chronic pelvic pain and the personalized treatment options that are available.

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. Vadim Morozov, a gynecologic surgeon at MedStar Washington Hospital Center. Today we're discussing chronic pelvic pain which can be a symptom of a variety of gynecologic disorders. Welcome Dr. Morozov.

Dr. Morozov: Thank you. Glad to be here.

Host: What do you mean when you say chronic pelvic pain?

Dr. Morozov: So, chronic pelvic pain, by definition, a pain in your pelvis that's been there for longer than six months duration. It could be caused by multiple reasons, but most common one in the female population are things like endometriosis, fibroids, scar tissue.

Host: What symptoms might prompt a woman to seek treatment?

Dr. Morozov: So, things like very painful menstruation. Pain with intercourse for, example. Pain with going to the bathroom and just the one that doesn't go away - the one that's not getting better with just something like Motrin or Advil. Those are the conditions that I would suspect that she has something else and needs to be addressed.

Host: When we're talking pain, are you talking a burning sensation or cramping? What are...what are women complaining about?

Dr. Morozov: That's a very interesting question. So, actually women can complain about any type of pain and in the pelvis, it's highly non-specific, meaning you could have a certain condition but the pain could range from, as you mentioned, burning, pinching, to doubled over with stabbing—"I can't even take a breath."

Host: Is it always in the pelvic area or does it radiate?

Dr. Morozov: It does go to other things and other parts of the body. For example, pain with endometriosis' very commonly go down toward the back. It can go down the legs. It can shoot down toward out the stomach or in your buttocks. It's very difficult to pinpoint the location of the pain and the specific cause of the pain in a lot of cases.

Host: Who is most at risk for chronic pelvic pain?

Dr. Morozov: Obviously, uh, women are 95 percent. So, if you look at the all population of chronic pelvic pain, 95 percent of the chronic pelvic pain happens in the female population. We're still unsure why it happens. Males do too, but very unfrequently, as you can, tell from that statistic. If you had endometriosis in your family—if your mother or your sister was affected by endometriosis, you are much higher chance to have an endometriosis and pelvic pain. If you had fibroids in your family, you are at a higher risk of having a fibroid. If you're African American, for example—race plays a specific role. African Americans statistically are three times as likely to have fibroids as white women. Asians, for example, almost unheard of having fibroids on the other hand. So, very specific genetic component that plays a role.

Host: Is there any sort of genetic testing or any testing that can help determine a woman's risk?

Dr. Morozov: Unfortunately not. There are multiple companies that are trying to get commercial testing on the market. So far, we do not have anything that can predict a risk of developing endometriosis. Or even a chronic pelvic pain for the condition. The interesting thing about chronic pelvic pain and endometriosis or fibroids is that you could have endometriosis and not have pelvic pain. And almost the opposite is true. You can have the most severe pelvic pain and then, when we investigate, you will have very minimal or very mild endometriosis. So, there is no direct correlation between the cause and effect.

Host: Once a cause is defined, if a cause can be defined for chronic pelvic pain, what are some of the treatment options that are available?

Dr. Morozov: We usually start with discussing what causes the pain, as you said, right? So, if we can identify that, let's say, it's a fibroid, for example, or endometriosis or pelvic scar tissue (adhesive disease), usually we try some medical intervention in the beginning. Maybe some sort of a non-steroid anti-inflammatory, otherwise known as Advil, Motrin, and Ibuprofen. Maybe we try to have some sort of a physical therapy intervention. In my experience, in the majority of cases, that doesn't work. Very few times it actually will make women asymptomatic, meaning she's happy with that treatment and done. The next step would be the surgical intervention.

So surgical intervention, nowadays in 21st century, we truly believe it needs to be done minimally invasive, laparoscopic way, meaning small, tiny, less-than-an-inch incisions in the belly with one of them in the belly button. Go home the same day within 2-4 hours. Very quick recovery time. Almost no blood loss. Having said that, the surgery just the first step in the long way to recovery. So, identifying and treating the cause of the pelvic pain, let's say an endometriosis or whatever, will not make you pain free unfortunately. And that's a very complicated topic and people wrote books and chapters and actually I wrote some chapters and research and that. You will need to do a lot of other things on top of the surgery, meaning we will have to suppress your hormonal fluctuation one way or the other. The fewer menstrual periods you have as a woman, the shorter they are, the better your chance of not having the recurrence of endometriosis. Pelvic physical therapy would be the next step. There is a highly interesting phenomenon that's called central sensitization and to explain it in the lay terms, this is where your central nervous system gets used to the pain over many, many years. And technically speaking, no matter what we do in your pelvis, you still feel the pain. So, we'll have to address that problem. So, it's a multi-specialty approach before we can get patient to the level where she can function comfortably.

Host: If a woman, say, doesn't have severe symptoms or has just gotten used to living with them, is there a risk for leaving chronic pelvic pain untreated?

Dr. Morozov: Not the pelvic pain. Now obviously, the chronic pelvic pain is, puts the huge burden on society. The estimate that it costs several billion dollars a year for economy from lost wages, lost time from work, lost...lost time from spending with your family and kids. Endometriosis, for example, left untreated, could become severe enough and could affect other organs next to it—so it could affect your bowel, it could affect a kidney. And I have dealt with cases before where the endometriosis was bad enough that the kidney almost died off because it was obscured in the outflow. So, eventually, it can get you in trouble.

Host: Have you had any women come in with chronic pelvic pain who just had a very severe condition and you were able to help them and get them back to a functional level?

Dr. Morozov: Absolutely. That's what we do. I mean, the worst endometriosis - although some expert will debate - is called a stage 4 endometriosis - was severe. And we do surgery, we restore the anatomy, we remove the endometriosis that affects the organ. And, they seem to be doing great. They're fully functional, they still have pain here and there, but at least we can get them to the point where they can function on an everyday basis and have a normal life.

Host: Do you have any one patient that stands out in particular who was maybe very severe and has done really well?

Dr. Morozov: Yeah, we have, just recently - about a month ago - I did a surgery on a patient and she's great, she feels absolutely phenomenal.

Host: Are there any environmental factors associated with the risk of endometriosis or other chronic pelvic pain?

Dr. Morozov: Absolutely. There's been a lot of research done on the environmental factors in endometriosis. One of them is well known, organa pollutants or organa phosphorus components that exist everywhere. Actually, very common product on the market is a sunscreen that has them. And I'm not abdicating, I'm not saying don't use sunscreens, but we have to be cognizant about what we buy and use. There's been studies saying that the specific components that are used in the industry actually produce both to develop an endometriosis.

Host: Are you conducting any research, you or your colleagues, regarding chronic pelvic pain that women in the community should know about?

Dr. Morozov: Not currently. I mean, I've been involved in the research for chronic pelvic pain and endometriosis. The problem with the research in this arena is that it's hard, as I mentioned before, to correlate the extent of a disease with the sensation of pain. Multiple commercial companies been in the market trying to develop some sort of the either medication or pain control, endometriosis control or fibroid control drugs and some of them are successful, majority are not. So, it's a tricky area of research.

Host: What innovations in chronic pelvic pain do you hope to see in 10 to 20 years?

Dr. Morozov: So, there is some research right now that I find very fascinating. There's a company that's testing the RNA fragments, which is a blood sample, and actually they claim they can get yours out of your saliva, so it's just a little swab out of the mouth. And they are saying that if you can analyze, sort of fragments of RNA, which is nucleic acid in your blood, they can predict whether you have an endometriosis or not. So that would be very useful diagnostic tool which we don't have right now at all. As I said, the only way to diagnose endometriosis is to perform the surgery, which, of course, carries the risk of any surgery. Bleeding, infection, you name it, damage to the surrounding organs. If we can have a test, either by blood drawing or by swabbing the mouth and sending it to the lab, tells you as a patient and me as a physician that you have a certain degree of, you know, sensitivity that that will be the endometriosis. What is more important, that test would be absolutely phenomenal to see the progression after the treatment. So, let's say we do the surgery and then we test that patient six months to a year later and see if that test becomes negative. That would be even better application.

Host: Why is MedStar Washington Hospital Center the best place for a woman to come for chronic pelvic pain care?

Dr. Morozov: Because we have the best interdisciplinary team on the East Coast. I mean, our Center for National Advanced Pelvic Surgery has multiple specialists that deal with nothing else but with chronic pelvic pain, fibroids, endometriosis. We have multiple fellowship-trained urogynecologists. We have a urologist that works with us with interest in woman health. So, this is a place where, if you have a problem, you would expect that they will be detected and solved.

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

Dr. Morozov: 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.

Many people use health and fitness apps to set exercise and dietary goals, but these apps can also help diagnose and manage heart conditions. Dr. Allen Taylor, Chief of Cardiology at the MedStar Heart and Vascular Institute, discusses the evolving role of health and fitness apps in heart care.

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. Allen J. Taylor, Chief of Cardiology at MedStar Heart and Vascular Institute and MedStar Washington Hospital Center. Today we're talking about the future of wearables as they relate to heart health. In 2017, Apple launched the Apple Heart Study App which is intended to pair with the Apple Watch's heart rate sensor to notify patients of irregular heart rhythm activity. This is a next step in technology that may help patients and cardiologists monitor and manage heart conditions outside the clinical setting as well as an opportunity to develop more personalized treatment plans based on a continuous flow of data. Dr. Taylor, how do the cardiologists at MedStar Washington Hospital Center currently use data from smartphone or device apps to help patients achieve better heart health?

Dr. Taylor: These apps are really the way of the future, aren't they? Everyone has a smartphone, everyone is tied to their digital life, and so we're using this in several different ways. The first way is to simply monitor fitness. And the second way is to, in fact, monitor illness. So, for instance for monitoring fitness, you've seen people who may have little step monitors or activity monitors that they wear on their wrist as part of a phone or as part of a separate app. And those can be used to set goals or daily targets and really motivate activity. And I think they're really quite useful. And we can use them to help set fitness goals - how many steps a patient should take or how much activity time they should have.

The second way we're using these is, in fact, to monitor illness. And this is something, I think, that's really very exciting. This could include things like monitoring heart rhythms, monitoring patient's fluid status if they have weak heart muscles, or using it to monitor important numbers like blood pressure through wired applications. And, in terms of the heart rhythm, you know, we have patients that are currently monitoring their abnormal heart rhythms using their iPhones and detecting when they're in or out of certain abnormal heart rhythms like atrial fibrillation, or monitoring for changes in heart rate that might signify or indicate an abnormal heart rhythm. In today's pacemakers, they're all wired with these special apps to monitor fluid status. So, even before patients can feel the effects of rising or fluid retention, they can get a warning from their pacemaker to tell them that they're retaining fluid.

And with blood pressure being such an important number these days, trying to get everyone to optimal blood pressure below 130 over 80, we're finding that those home blood pressure monitoring is more important than even the numbers we get in the clinic. We really rely on patients monitoring their blood pressure because their most accurate blood pressure is the one in their home, the one they live with day-to-day. Not the one that when they come to the clinic every 6-months or every 12-months. And now these blood pressure cuffs are connected by Bluetooth to phones, and we get a nice record of what their home blood pressures have been. It's very helpful to monitoring and tailoring therapy to get the right level of blood pressure control. So, we use these devices not just to monitor and set fitness goals but really to truly monitor illness.

Host: What concerns do you have regarding the use of apps for heart health care?

Dr. Taylor: You know, as we move into this digital age, we are all just aware of having our digital lives out there and exposed, and there's definitely a balance of risk and benefit. For instance, we're using remote monitoring for pacemaker devices and it creates convenience and we think better outcomes. But there is risk entailed. And so, we've got to acknowledge and identify the risk and do all we can to mitigate it. You know, HIPPA or that privacy act that relates to health information, tells us that privacy is very important. And as our digital lives are increasing, so comes more risk with those opportunities. A few things I would advise, though. The first is to make sure that when patients are communicating with their healthcare providers, they're using secure portals. There can be a lot of sensitive information which can be sent across public means of communication and so use those secure portals to communicate. People should always be careful with their own devices—update the software, make sure the security patches are in place and be careful with the apps you're downloading to make sure that they're truly secure. And then lastly, it'll be heartening, I think, for folks to know that device manufacturers are aware of this. And they're learning and are increasingly attentive to the risks of their apps or devices for hacking and data breaches. And so, security there is something which they're helping with, as well. And in the end, I think, it will be a shared responsibility of all of us individuals to have our devices secure, the devices we're given to be, have optimal security and the healthcare providers for interacting with to respect that data and to manage it in a secure as possible way. But I think, in the end, we see the tremendous opportunity before us to leverage this digital age for better health and the risks, I think we can understand, and it will all work together to make everything as safe as possible.

Host: What do you think the future holds as far as using medically-centered apps, such as the Apple Heart Study app, to provide ongoing patient care outside the cardiologist's office?

Dr. Taylor: Yeah, I think the potential is, I won't say limitless, but I think it's enormous. Promises for diagnosis, for example, linking this data to portals so we can see what patients are doing, see their activity levels, see what's happening to their fluid status if they have heart failure, their heart rate status if they have heart rhythm problems, and really, to track their success. Personalized coaching is really out there with these devices. For example, there's devices that will give personalized coaching on diet, if you're importing your diet, what you're taking in, or setting exercise targets and encouraging and coaching. And lastly, in heart rhythm problems we're seeing really great applications, for atrial fibrillation for example, for detecting atrial fibrillation. And when we detect atrial fibrillation, we're treating patients differently. We're using blood thinners and proper treatments to prevent problems from occurring. So, I think really the promise is on not just diagnosis of heart problems but the management of heart problems. Because, let's face it, you go to a doctor twice a year. And there's a lot of time when other stuff is happening, and it really provides a more complete picture of what's happening to folks as they live their lives. So, these apps have an important opportunity for us to really give us a full picture of our health lives and also connect it to make better diagnoses and to get the right treatments.

Host: Why is MedStar Washington Hospital Center the best place to find technological innovations in heart health care?

Dr. Taylor: MedStar's truly committed to innovations. So much so, we have an institute for innovations called MI2, the MedStar Institute for Innovation. And, in fact, they themselves are developing apps to help patients take better care of themselves and to help us take better care of them. Always seeking ways to leverage our modern digital world for, you know, better and more efficient care. So, I think it's an exciting time. I think all of us, we're all people too. We have these same devices, use fitness monitors, and it's exciting to talk to patients about this to encourage them to use these devices or to use them in different ways. Or, to tell them what's out there, for fitness, for diagnosing heart rhythm problems or for monitoring their care. So, it's an exciting time of empowerment in healthcare. And these apps, and this new digital world we live in, are helping with that.

Host: Could you share some success stories from your patient population?

Dr. Taylor: Oh, I have so many success stories from this digital world, provide a few ideas. One, I have a patient who really diagnosed his own atrial fibrillation. And he was monitoring when it was occurring and found that it was, he was very accurate in detection and, he then was so proactive, he sought out and found the types of treatments that he wanted. And, once he had those treatments in place, he monitored how successful it was and it turned out to be very successful. So, he really found and treated his atrial fibrillation through a digital app.

I have another patient that I recently saw, and she came to me and she said, "You know, I'm really working on getting more fit. And I think I am. But when I start to exercise I notice all of a sudden my heart rate is 150." And she said, "Here, let me show you." And she brought out her phone, and she showed me her heart rate graph while she was exercising. And, lo and behold, at occasional times during her exercise, her heart rate jumped to 150 and stayed there, in a very unusual way. And, in fact, that made the diagnosis of an abnormal heart rhythm, that we were able to successfully treat with a very simple medication and she's doing much better. And now she's monitoring if she's having any recurrences and she is not.

And then, I'll give a third example of an app that's called Image Share that let's doctors use their smartphones to rapidly transmit data in a secure way about heart attack patients to decrease the time to treatment, and that's an app to increase communication among healthcare professionals in the crisis of taking care of a heart attack. So, some really, really good success stories - really empowered patients, knowledgeable patients, and then apps in a health system to really lead to more efficient and better outcomes.

Host: Thanks for joining us today Dr. Taylor

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.

A paraesophageal hernia can have symptoms as simple as acid reflux or feeling bloated after a small meal—or no signs at all. Dr. John Lazar, Director of Thoracic Robotics, discusses how we diagnose and treat paraesophageal hernias.

TRANSCRIPT

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

Host: Thanks for joining us today. We're speaking with Dr. John Lazar, Director of Thoracic Robotics at MedStar Washington Hospital Center. Today we're discussing benign esophageal diseases, a group of non-cancerous disorders in the esophagus, which is the tube that connects the throat to the stomach. Dr. Lazar, what are some of the benign esophageal diseases you see most often in your patient population?

Dr. Lazar: I would say that the most common benign disease that we see is something called the paraesophageal hernia. And what that is, is that over time, the diaphragm weakens and the stomach starts to track up into the chest. Um, and it can be quite uncomfortable at certain points which is generally when people start seeing us.

Host: What are some of the common symptoms of paraesophageal hernias?

Dr. Lazar: So, the most common one is reflux, meaning that you have this taste of acid coming up into your mouth or sometimes it causes you to cough. Other ones are after eating a small meal you feel very bloated. Sometimes it even causes you to actually have to vomit in order to feel better. This is something that happens gradually over time, so a lot of times, people don't realize they even have these problems until someone points it out to them. Other issues with the esophagus which are less common is something called acalasia, which is the inability for the lower part of the esophagus that is connected to the stomach to open up all the way. So, food actually sits there at the end of the esophagus and usually you have to wash it down with a glass of water or unfortunately, even then, sometimes things come back up.

Host: So, they sound like pretty similar symptoms to other disorders. How common are these esophageal diseases?

Dr. Lazar: So, I would say that achalasia is probably very small, in the single digits, if you took the population as a whole. Or I would say that paraesophageal hernias are probably around 10 to 15 percent of the population. And most of the time they're asymptomatic, meaning no one has any symptoms and they're only...only found incidentally, meaning you went in for a chest x-ray or something else was bothering you and they did a CT scan and they ended up finding some of these things. I think when you've had long standing gastroesophageal reflux, it's time to talk to your doctor about maybe even getting screened when a...with a EGD by a gastroenterologist, just to make sure that there's no permanent damage done to the esophagus. I think if you're in the category of, "Oh, you know, this happens every year, once a year," you're probably OK, but if it's happening more and more often, then you really should talk to your doctor about getting screened.

Host: Are there certain groups of people who are more at risk, say men or women?

Dr. Lazar: So, generally people who have increased abdominal pressure, so that would be people who are overweight, uh, sometimes women who've had multiple babies, and over time, the diaphragm weakens. It's...it's kind of hard to predict who will or who will not have it.

Host: In terms of treatment, what are some of the most common first-line treatments for these disorders?

Dr. Lazar: Sure. So, basically the only treatment is for the symptoms, unless you fix the problem. So, a lot of times people will take antacids, over-the-counter or prescribed by a gastroenterologist or a primary care physician. But if you want definitive therapy from it, surgery's the only cure.

Host: Is there an issue with people taking antacids and things like that long-term as opposed to having surgery?

Dr. Lazar: Yeah, so there's a growing debate as to whether a certain type of drug called proton pump inhibitors, or PPIs, also has long-term damage to other organs and that's an area in which people are looking into but it's become very popular in the news and so a lot of patients have been talking to their doctors about whether or not surgery's right for them.

Host: Could you explain what a PPI is for individuals who might not know?

Dr. Lazar: So, a proton pump inhibitor works on suppressing the acid on a molecular signaling level and so therefore people have less symptoms from reflux because the pills tell the body to make less acid.

Host: When a person does need surgery, what are some of the more common procedures that are done?

Dr. Lazar: So, if we're talking about a paraesophageal hernia, generally paraesophageal hernia repair involves pre-operative testing with an esophagram, which is drinking of contrast, and then they get x-rays that shows how the contrast goes down. The other common test is a CT scan of the chest, which is about a ten-second test. And then the other test can be something called manometry, which tests how well the esophagus squeezes food down the length of the esophagus.

Host: So they've run through all of these tests...and then, once they go in for treatment, what...are you doing a...an open surgery with these folks, if it's necessary...minimally invasive? What does that look like?

Dr. Lazar: So, almost all surgeons are doing minimally invasive paraesophageal hernia repairs. In the old days we would generally go through the left chest, which was a very painful procedure. Now we're doing it minimally invasively through the abdomen where there's less nerve endings and, uh, they're able to go home much sooner. We do it robotically. Patients are brought to the operating room. They're put to sleep. They'll have five ports about the width of my index finger. And then we will use the robot, which is completely controlled by the surgeon, to then bring down the stomach back into the abdomen, take down all the scar tissue that was holding it in there, and then close the opening that's in the diaphragm that...where the stomach was going in.

Host: Could you talk a little bit about the recovery from that type of procedure?

Dr. Lazar: Sure. So, the great advantage of robotic surgery or any kind of minimally invasive surgery for paraesophageal hernia, is that generally people go home anywhere from one to three days afterwards, uh, depending on the surgeon's preference. So, generally they have less pain, they're able to eat and drink much quicker, and so there's really no reason to keep them in the hospital. Uh, they still take about seven to ten days to really get back on their feet once they're home.

Host: What is the risk of not seeking treatment for long-term symptoms?

Dr. Lazar: So, I think that there's a group of people who are very scared of surgery, and rightly so, who have paraesophageal hernias. Unfortunately sometimes the stomach can twist along the esophagus and cut off the blood supply, and therefore, it becomes a surgical emergency to reduce the stomach and get it back down and there's a risk of the stomach becoming what we call ischemic, or there's no blood supply to it. Uh, and that...that can be life or death in some cases. In the past we had talked about only treating symptomatic paraesophageal hernias, but there's growing evidence because of this that maybe we should start taking care of these patients earlier when the hernias are smaller and they're actually in better health.

Host: What are some of the emerging technologies or procedures that you're using at MedStar Washington Hospital Center?

Dr. Lazar: So, I would say that the biggest technology that's really catching on both nationally here and that we brought to the Washington Hospital Center is...is robotic technology. And, in most senses, this is robotic assisted technology, so the surgeon still remains completely in control of what's going on. The robot is there just to enhance visualization, enhance their ability to operate within a confined space, and to basically make it a smoother operation for the surgeon.

Host: Have you had any patients in the past who have had severe hernias who you were able to help with this type of surgery?

Dr. Lazar: Sure. So, I think, in a lot of senses, because of the enhanced visualization, we've been able to do a better operation than we would open in the abdomen, and in some cases, just as good as we would have done through the chest but with much smaller incisions and therefore better recovery because we're able to take down all the scar tissue that basically keeps it up there. We're able to reduce, you know, the stomach back in to the abdomen or in to the belly area and then close these large defects. Because we have wristed instruments, we're able to then suture in a much better way or close the defects in the diaphragm and then make sure that the patients reestablish the normal anatomy.

Host: So, in...in doing so, in reestablishing that anatomy, is there a follow-up procedure that these patients will have to have?

Dr. Lazar: No. Generally, once the surgery is performed, and then they're able to get out of the hospital in a couple days, uh, we follow them along, at least a couple weeks, and we'll see them back yearly just to make sure that everything's OK. But generally speaking, uh, there's no other procedure that's usually required afterwards.

Host: Why is MedStar Washington Hospital Center the best place to go for treatment of hernias and other benign esophageal diseases?

Dr. Lazar: Well, we have a team of specialists in thoracic surgery who are very dedicated to understanding esophageal disease. We've all been specially trained in the esophagus. A lot of people get training in a lot of different things. Our passion is, uh, esophageal disease, whether it's cancerous or non-cancerous. And, so therefore, I think that we have a lot of experience and knowledge in identifying esophageal disease and, technically speaking, we've dedicated our lives to...to perfecting it.

Host: Thanks for joining us today.

Dr. Lazar: Thank you.

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

A new procedure can lead to quicker, more effective recovery after ACL repair. Orthopedic Surgeon Dr. Evan Argintar explains how internal bracing works and who can benefit from the procedure.

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. Evan Argintar, assistant director of sports medicine at MedStar Orthopedic Institute at Washington Hospital Center about their exclusive use of internal bracing in ACL repair and reconstruction.

Host: Thanks for joining us today, we're talking to Dr. Evan Argintar an orthopedic surgeon and assistant director of sports medicine at Medstar Orthopedic Institute at MedStar Washington Hospital Center. Welcome, Dr. Argintar.

Dr. Argintar: Thank you for having me.

Host: Today we're talking about internal bracing, which can be used to stabilize a joint and accelerate healing time allowing a patient to resume activity faster. When you say 'internal bracing', what do you mean, and how does that work?

Dr. Argintar: So, traditionally with ligament reconstruction whether that be in the knee or the elbow, we've traditionally used a graft. A graft is another tendon. Sometimes that can be from the person. Sometimes that can be from a cadaver, the most common example in my practice is the ACL. You need to put a new ligament where the old ACL ligament was, and that whole process of maturation can take anywhere from eight to ten months and that requires the body to do this process called 'sinovialization' which is a fancy way of saying becoming part of the human body. The issue with that process is at about two or three months the ligament you put in there becomes weak, and what we've found is that's the time when it's most likely to fail. And so researchers have developed an internal brace which is nothing more than a really strong suture that's made out of a polyethylene or a plastic that travels with the new ligament, and it gives it stability and allows it to maintain the structural integrity throughout this process of maturation but specifically at the two to three month period when patients are ramping up their rehab but when their ligament might be weakest. So, what we're finding here at Medstar Washington Hospital Center in our research is that patients seem to be doing better, they're having better clinical outcomes and they're more predictable.

Host: When you say it travels with the ligament, what do you mean?

Dr. Argintar: For an ACL, you have to drill tunnels into bone, and so when you create a new ACL, you're putting that new ACL in tunnels into bone where the old ACL ligament was. And so this new internal brace travels right next to the ligament, so it has the same trajectory, and it has the same biomechanical forces on it. if you think about it as sort of a temporary ACL, while the new ACL is maturing, to me in my mind that's how I make sense of it.

Host: That makes sense to me too. You mentioned the ACL. What other parts of the body is this useful for?

Dr. Argintar: We've been using it in elbow reconstruction. Sometimes people can have lateral or even medial elbow instability, and we're finding that whenever you're doing a repair of a ligament, or a reconstruction of a ligament, meaning taking a tendon from somewhere else in the body or taking a cadaver and incorporating it to replace the old one, this gives additional stability, which allows me as an orthopedic surgeon to be potentially more aggressive earlier on with therapy. Which I think helps mobilization, and it allows patients to be more aggressive in their therapy, which I find anecdotally is helping with outcomes.

Host: When you don't use the internal bracing, when you're taking that tendon from somewhere else in the body or from a cadaver which is a donor body, where typically would you take it from? Would it be that same area? Would it be a different limb?

Dr. Argintar: It all depends on the surgery. The most common example would be with an anterior cruciate ligament or ACL reconstruction. Now certainly you can take it from a cadaver and that's the least painful of all options for patients, but traditionally there are two main sources for patients—one is the bone patella bone which is taking a little piece of bone on the knee cap and a little piece of bone on the tibia or the leg bone and the connecting ligament in between. The other option is a hamstring tendon, which can be taken from the front or the back of the knee. Those would be the two most common examples in ACL surgery.

Host: How long has this been available for the ACL, and are people coming and asking you about it?

Dr. Argintar: We've been finding that as word gets out that we're doing more of this internal bracing, people are seeking us out for second and third opinions for ACL reconstructive surgery, and elbow reconstructive surgery, absolutely. We have research pending but not yet published which is demonstrating that this is a safe procedure it's also allowed us to do ligament repair in a setting where traditionally we were unable to repair ligaments—it's that strong. (4:27)

Host: What is the preparation process and what should a patient expect before, during, and after the procedure?

Dr. Argintar: Preparation for ACL surgery is all about the pre-rehabilitation. Sometimes we'll actually send people to physical therapy in order to get their range of motion. What we know for all surgeries is that if you go into a surgery with poor motion you get poor motion afterwards. Most times, I'm able to educate patients on how to get that motion beforehand, so if they're successful with those exercise programs, they are in very good shape for surgery.

Host: Is this something that can be done under general anesthesia or is it local anesthesia?

Dr. Argintar: This is all done with general anesthesia. It's done as an additional component to surgical procedures in the operating room. It doesn't increase the length of the surgery, in fact in some cases it might even make it faster.

Host: You mentioned before that this allows patients to be a bit more aggressive in their therapy and it allows you to get them into that therapy a little bit quicker. Could you talk about that process? What is the traditional trajectory from ACL surgery into therapy as opposed to internal bracing?

Dr. Argintar: So typically with ACL reconstructive surgery, patients will have surgery—for the first ten to fourteen days they worry about nutrition and health hygiene and then about two weeks afterwards they initiate physical therapy. The problem is that therapy can be modified based on how strong you think your repair can be, so as we incorporate these extra elements that improve or increase the strength of a surgical procedure, that will give clinicians more confidence to be more aggressive earlier on. Although me personally I rehab now ACL repairs and ACL reconstructions exactly the same, I think as we collect research moving forward respectively what we're actively doing. In fact, we're one of only three centers to my awareness, in the United States that are collecting this research and doing this type of surgery. Traditionally, ACL reconstructive surgery, the whole rehabilitation, is somewhere between eight and 10 months and is very patient specific. We know that for ACL repair, which is for keeping the ligament and putting it back where it came from, that's a surgery that absolutely requires this internal brace for additional stability. We have found anecdotally that the atrophy of the muscle after surgery is less, and patients get back to sport activities quicker. A perfect example is two firefighters that I recently took care of. I prepared them for the eight to 10 months of rehabilitation, which is a lot of sedentary work for people who very much want and need to be active, need to have rotational stability in their knee, need to put out fires, and everything they need to do that happens in their job every day. I can think of two recent patients who were happy to get back to their job at six months without restriction. And that two months of lack of them doing sedentary work was transforming both to their job and to their mental health, because patients certainly want to get back to normal living, whether it be work or sport.

Host: What sort of research data are you picking up? What does that look like and what is the patient's role in your collection of that data for your research?

Dr. Argintar: So we're looking at research on lots of different levels. One is "is this internal bracing safe?" and the answer is unequivocally 'yes'. Personally, I've done several hundred of these procedures, and my partners have had similar experiences, so we have looked at that data, and it has been submitted and will be ideally published in the next year demonstrating the efficacy and safety of this procedure. Two, we're looking at how this will allow us to repair ACL ligaments in the knee. Again, we have a lot of anecdotal evidence based on over a hundred patients with ACL repair which is a real new aspect of knee sports medicine. Once upon a time people attempted repairs and they were fraught with failure, and for a long time this was sort of ignore as not a possibility. As we learn better about the anatomy of the ACL and we've incorporated these new technologies we have revisited the idea of ACL repair and we have found the success rate has been excellent here.

Host: Why were surgeons having a difficult time repairing the ACL?

Dr. Argintar: It has a lot to do with understanding the anatomy, number one. When people attempted these repairs twenty years ago—what we know now, but what we didn't know then is that the origin where the ACL starts was not as accurate as we understand it now. In fact, the whole way we do ACL reconstructive surgery has really changed over the last five years. It's not uncommon now for me to see patients who had the old gold standard ACL and we unfortunately have to revise them because they don't have the rotational stability. So it's that information all the new research that's come out over the last decade about simply understanding where the ACL starts and where it goes coupled with the evolution of all these minimally invasive ways to incorporate these new interesting technologies that allow for repair this has all culminated to the ability to repair ligaments in a way that we never had the ability to do.

Host: Part of your research is determining whether this is safe, and you're saying that yes it is safe, anecdotally at least. What are some of the safety concerns that individuals have had about this procedure?

Dr. Argintar: So, there are no specific safety concerns. Whenever there are new technologies in place in a knee joint for example or outside of a joint, you want to make sure that the benefits of the device aren't outweighed by the negative aspects of the device. So, as we launch our investigation and this was based on the success of other institutions, even internationally, we have found that this is completely safe. In fact, when I look at my ACLs with and without the internal brace, I need to look at my report to see who has received that brace, because from the outside there's no easy way to determine—it's that similar.

Host: That's a very good sign. What does your patient base or your patient demographic look like for this procedure?

Dr. Argintar: Typically, people who are getting ACL surgery or elbow reconstructive tend to be younger, more active, age to me is not important. Level of activity is. I've certainly done ACL surgery in people who numerically, chronologically perhaps are a little bit older but I meet people who are chronologically old who are more youthful than some of my patients. I would say ACL surgery in general is something that is done for people in their young teens up through their forties but there are certainly outliers on both sides of that bell curve.

Host: Is there anybody who this procedure would not be safe or effective for, in your opinion?

Dr. Argintar: No. This would be safe for anyone who needs this type of surgery. So, we've had patients traveling across the country for this type of treatment, patients regionally from Philadelphia and new York, or west like Colorado, the good news is that the word is out on the street -- people who are wanting to maintain their anatomy, which makes logical sense, people who want to see if they're candidates for ACL repair, are seeking out medical centers like MedStar Washington Hospital Center, where doctors are doing cutting-edge surgery that might obviate the knee for reconstructive, larger surgeries.

Host: Is there anything else that you would want to elaborate on or if somebody's interested in receiving this type of procedure what would be the process for them to get to you?

Dr. Argintar: Certainly, see one of me or my colleagues who specializes in sports medicine here at MedStar Washington Hospital Center. Again, we're one of few centers in the country this is using and researching these technologies to strengthen ACL reconstruction, as well as even do ACL repair, so we're excited to be on the forefront of this new cutting edge sports medicine intervention.

Host: Thank you so much for joining us today, Dr. Argintar.

Dr. Argintar: Thank you for the opportunity.

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.

Partial knee replacements can provide relief from arthritis pain without the long recovery of a total knee replacement. Orthopedic Surgeon Dr. Evan Argintar explains the benefits and who might qualify for the procedure.

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. Evan Argintar an orthopedic surgeon and assistant director of sports medicine at Medstar Orthopedic Institute at Medstar Washington Hospital Center. Today we're discussing an advancement in joint replacement surgery called bioplasty. These procedures preserve as much of the normal joint anatomy as possible. Dr. Argintar, what's the goal of this advancement?

Dr. Evan Argintar: So traditionally the treatment of arthritis has been a big issue and as the Baby Boomers age, we're actually finding that there are not enough orthopedic surgeons to treat the amount of arthritis that is developing in our country. And as people get older the good news is that people want to maintain the quality of their life, the level of activity and the problem traditionally has been that the definitive treatment for arthritis specifically in the knee has been somewhat limited. We used to do knee arthroscopy but appropriately this has come under criticism because it doesn't give a very sustained relief and then the only thing you can do definitively is some element of a knee replacement. There are three parts of the knee. The inside the outside and underneath the kneecap, and a full total knee replacement or total knee arthroplasty replaces all three types. That is a very good procedure that's a fantastic procedure if all three portions of your knee are diseased or arthritic. Because sometimes patients have an isolated medial or lateral portion of their knee which is far worse than the rest we have developed as orthopedic surgeons partial knee replacement, and so the indication for that is very specific and not all patients are candidates for it.

The problem arises when patients have one out of the three compartments extremely arthritic, one completely normal, and one kind of average, and this puts people in a bit of a grey area. Do you do a partial knee replacement and accept that some of that cartilage in the remaining portion of the knee is diseased and potentially pain generating? Maybe. Or do you do a full knee replacement, replace all the bad stuff with all the good stuff? Maybe. The problem with doing the full knee replacement is that in 2017 you have to sacrifice the ligaments on the inside of the knee and you usually have to change the joint line and what that translates to is really a bit of an artificial feeling knee, and one that does have some intrinsic limitations for activity. Certainly, you can walk and move and have pain relief, but the ability to have a sport and to be active and to pursue professions where you need to have that level of comfort and that sense of a normal knee can somewhat be limited or altered. What I've done here at MedStar Washington Hospital Center is incorporate technologies of both partial knee replacement with some of the treatments I've done in isolation in the sports world, cartilage restoration, ligament reconstruction. So once upon a time, for example, if you had medial isolated arthritis on the inside part of your knee without an ACL, you had no option without a knee replacement. Now you can do a partial knee replacement with an ACL reconstruction, and this allows people to maintain their youth and maintain their activity and avoid some of the limitations inherent with a bigger surgery.

Host: What other types of bioplasty surgeries are available?

Dr. Argintar: Another example would be a partial knee replacement on one side of the knee with a transfer of cartilage to the other side of the knee. If you have a pothole in the middle of a normal road, you can do sporty cartilage restoration surgeries to make that pothole complete. Arthritis is the opposite. That's a street that has no more pavement, and that's when you have to repave it with the knee replacement. But again, now as we're fusing the sports medicine with joint reconstruction, we're coming up with novel solutions for people who don't want the inherent limitations with full knee replacement. Patients are not all good candidates for this. We're finding that patients are coming in seeking to see if they are good candidates for this.

Host: Who is a good candidate for a bioplasty surgery?

Dr. Argintar: Candidates are both people who have a combination of the desire to maintain young and youthful coupled with the right type of need. Unfortunately, sometimes I find people who want to maintain their anatomy but at such advanced tricompartment arthritis that my advice to them is let's consider the full knee replacement. However, a lot of times people come in and we find that they are in fact candidates for this novel approach to joint reconstruction. Knee replacement is a great surgery and it has been done historically successfully, but like in all surgeries, we're trying to identify patients who might not be as successful as others and so I would incorporate others to be aware that other surgical interventions exist, and although you might not be a great fit for it, it's worth pursuing and we're happy to have those consultations and oftentimes we recommend that the first opinion is dead on accurate and other times we are able to give different operative options.

Host: Could you talk a little bit about how the prep and the procedure for that vary from the partial knee replacement and some of these other fusion type surgeries?

Dr. Argintar: Well, it's interesting. Even in my training you know 10 years ago, we would do knee arthroscopy with a hope that you could quote unquote clean up the arthritic knee. Everyone with arthritis has a meniscal tear, and the meniscal tear is an easy target. And I spend many hours all day long convincing people that a knee scope to treat a degenerative meniscal tear will not solve their problems. And, unfortunately, I see a lot of unhappy customers coming from other areas around us that do that surgery knee scope with the thought they can clean it up and they come out very unhappy with a lot of pain, and those are often patients who I find are good candidates for a potential partial knee reconstruction or replacement in combination with some other cartilage restorative procedure. There has been some good well known, well publicized articles and major publications—The New York Times—showing that knee arthroscopy may be overused in the setting of arthritis and I would agree with that 100 percent. It's just so very unpredictable, and very often not sustainable, and so although they may have some relief for weeks to months, it doesn't change the quality of their life for any meaningful period. So, I shy away from knee arthroscopy in the setting of arthritis.

Host: If surgeons have practiced the same way for so long, why was there a need to develop something different?

Dr. Argintar: The evolution of my practice was based on a lack of satisfaction for both me seeing patients coming from other places in the area that had unsuccessful knee arthroscopy outcomes coupled with some of my younger patients who although got pain relief from a full knee replacement, never felt great with it, always had some limitations with it, and so I challenged myself, and this is the challenge that has been brought on the shoulders of some of my other colleagues, you know, regionally and throughout the country, to create a solution that is a middle ground between the minimally invasive knee scope and the maximally invasive full knee replacement and I think that we have found something that is relatively unique and novel here.

Host: Do you have any shining patient success stories you could share?

Dr. Argintar: Sure. So, a perfect example of someone who has done quite well is a lady of mine who is quite young. She had a full knee meniscectomy, removal of the knee the meniscus 15 years earlier. We know that after a course of that is full blown arthritis eventually, and she was a victim to that, only 45 very active, working, running around, young children. She was not excited to sacrifice two-thirds of her knee because she had a degenerative medial joint with an ACL tear. So, in this situation, I was able to do an ACL reconstruction, which allowed me to do a successful partial knee replacement. She's been beyond happy, back to work, back to activity, back to being a mom, well she never left being a mom, but she's doing it more comfortably, and she hasn't looked back. You know doing a full knee replacement sometimes you have to do that in the 30s, the 40s. The problem aside from the artificial feeling of it is that twenty years later you have to do another one. Partial knee replacements also don't last forever, but it gives people potentially a long window of feeling more normal when they're younger in their life and wanting to do more activity recreationally, professionally whatever that may be.

Host: How long is recovery for a bioplasty procedure compared to a traditional knee replacement?

Dr. Argintar: I usually tell my patients that a full knee replacement will take about six months whereas a partial knee replacement is more of a four-month recovery. Everyone walks and stands immediately, but because you're doing less surgery, there's less inflammation, less pain, easier to move it, so it's a little bit of an easier recovery

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.

Pituitary tumors are more common than many people realize, with up to 17 percent of people at risk for developing one in their lifetimes. Dr. Susmeeta T. Sharma, Director of Pituitary Endocrinology, discusses how our team of experts recognizes and treats pituitary tumors.

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. Sharma: Thank you for having me.

Host: Today we're discussing pituitary tumors, which are much more common than many patients and physicians realize. Dr. Sharma, what types of pituitary tumors do you treat?

Dr. Sharma: So, one of the most common functional pituitary tumors would be a prolactin-secreting pituitary tumor. So, prolactin is a hormone that the normal pituitary gland makes that's involved in the development of breast mammary glands and milk production in females, and so when a tumor is making prolactin, that excess prolactin in females can lead to irregular menstrual cycles, can lead to breast milk production, feeling of breast engorgement, breast pain. This irregular menstrual cycle and excess prolactin levels can also lead to difficulty or inability to have children, and that's many times how it comes to attention to a physician. In men, it can cause decreased libido and some signs and symptoms of low testosterone, so low energy levels, decreased libido, erectile dysfunction, inability to have children, um, decreased hair growth, some of the symptoms that you see related to low testosterone levels. Given that we don't have the menstrual cycle marker in men, many times the prolactin-secreting tumors in men tend to be larger in size, and so many of them can have headaches and vision changes related to just the size of the pituitary tumor, and so that's how they may manifest to a physician.

Host: How do you determine if the patient's symptoms are caused by a pituitary tumor or another condition?

Dr. Sharma: Right, so some of the symptoms a patient may present with, for example, low energy levels, decreased libido, can be related to various different hormonal disorders, or it may not be related to a hormonal disorder at all, and so the first time, if the patient is presenting with these symptoms, we need to assess the levels of these hormones to see if there is a hormonal disorder there. So, one would measure testosterone, prolactin levels in a woman, FSH, estrogen levels, get a detailed history and exam, and all of that can help detect whether or not there could be a hormonal dysfunction, which can then lead us to assess for a pituitary tumor. So, they may come to us already with a diagnosis of a pituitary tumor where we are trying to see if it's making some hormone, or they may come to us with these symptoms where we are trying to see if there could be hormonal dysfunction, which can then lead us to a diagnosis of a pituitary tumor.

Host: After a patient is diagnosed with a pituitary tumor, what is their next step for getting treatment?

Dr. Sharma: So, yeah, once we have...there might be 2 or 3 steps involved in the diagnosis of a hormonal dysfunction. We may do some initial screening tests, followed by some confirmatory testing, but, yes, once the diagnosis has been made that a person has a functional or a nonfunctional pituitary tumor, then we would go on to treatment. The treatment can vary from just simple observation and monitoring, which would be the case in a nonfunctional small tumor that's not causing any mass effect, to medical treatment, which would be a case in a prolactin-secreting tumor, which we can treat effectively with medication group called dopamine agonist therapy, which are now well-tolerated medications, uh, to surgeries. So, most functional tumors, other than the prolactin-secreting tumor, will require surgery, and any nonfunctioning tumor that's causing mass effect would require surgery. Many of the pituitary tumors after surgery may require further adjunct therapy, uh, so if there is residual hormonal excess or residual tumor, um, they may require radiation therapy for that or adjunct medications for further hormonal control.

Host: How common are prolactin-secreting pituitary tumors?

Dr. Sharma: So, pituitary tumors in general, I think, they are underrecognized. If you look at the studies done for diagnosing pituitary tumors, the data that comes available comes from either radiological studies, so MRIs that are done in the general population, or autopsy studies, so done after the death of a person, and so, uh, the data coming from there shows that among the population, about anywhere from 10 to 20% of the individuals, depending on the study you look at, can have a pituitary tumor, and in some it may be causing hormonal excess or hormonal dysfunction; in others it may be not. Among those pituitary tumors, about 40 to 50% are actually gonna be a prolactin-secreting pituitary tumor, so I always say, when I'm talking to a group of people, that if we are about 100 people sitting in that room, about 10 to 15 of us could have a pituitary tumor, and out of that about 5 to 6 could have a prolactin-secreting tumor, and that's how common it can be.

Host: What surgical options are available for individuals with prolactin-secreting pituitary gland tumors?

Dr. Sharma: So, for a prolactin-secreting tumor I would say about 80 to 90% of the time we are able to manage that medically. The time that we need a surgery for a prolactin-secreting tumor would be A) if it has gone undiagnosed for a long period of time and it has become really large, and then it bleeds into itself, so as the tumor grows the blood supply sometimes is not able to keep up with itself and it may bleed suddenly into the tumor, which is what we call pituitary apoplexy and, if that happens, that's a surgical emergency. The patient can develop sudden-onset hormonal deficiency, sudden-onset vision changes, sudden severe headaches, and so that is definitely a time when they would need pituitary surgery. Other times a prolactin-secreting tumor may need surgery is if the patient is not able to tolerate the medications, so most of the time these medications are well tolerated, but occasionally the patient may develop gastrointestinal side effects, dizziness, or...and is just not able to tolerate the medication. In those cases, one may need surgery. Uh, another scenario would be although the majority of these tumors do respond to this group of medication called dopamine agonists, there are a small percentage which are resistant to the medication, so resistant prolactinomas. If a tumor is growing or the prolactin levels are increasing while being on an optimal dose of the medication, then that would be another case where we would need surgical intervention.

Host: Are there any life-threatening complications associated with prolactin-secreting tumors?

Dr. Sharma: Uh, so, it…from the prolactin itself, the high prolactin levels may not be life threatening, but from the pituitary tumor, as the tumor grows, you can have hormonal deficiencies, so the hormonal deficiency that can be life threatening is a cortisol deficiency, so again, in the scenario where it's very large, and over time the patient develops, from mass effect of the tumor, loss of pituitary cell function that makes ACTH, which then leads to cortisol production, they can have cortisol deficiency, and cortisol is a life-sustaining hormone. The same way, you can have TSH or thyroid-stimulating hormone deficiency, which then leads to thyroid hormone deficiency. And, again, those are both two life-sustaining hormones, and if that goes undetected, one can have serious consequences.

Host: Is the physiological response to starting therapy gradual, or is it a big shift for patients?

Dr. Sharma: These tumors are very...if they're going to respond, they're very responsive to the medications where the prolactin levels start to decreasing within days, and so even in patients where you actually have the tumor compressing on the eye nerve and causing vision changes, you can...and the medication will start making a difference right away, and as long as they are compliant with the medication and we are titrating up the dose to get the prolactin levels normal, uh, the tumor size will also respond in most cases.

Host: What about some of the more rare tumor types you treat?

Dr. Sharma: Other functional tumors that are more rare, it can be a growth hormone-secreting tumor, so that's called acromegaly or gigantism, so if the growth hormone-secreting tumor occurs in a child who is still growing and their growth plates have not fused, uh, they can become really tall and that's why the disorder is then called gigantism. On the other hand, if the growth hormone excess happens as an adult, you have a condition called acromegaly, and so these patients have a change in facial features. The facial features become really coarse. They will have change in...increase in ring size, increase in shoe size, they develop these enlarged hands and feet. They can also develop high blood pressure and have an effect on their heart, so the heart gets enlarged, uh, which can then make them prone to developing arrhythmias or irregular heart rhythms. Um, they can have increased chances of polyps in the colon and the intestine, and so although not clearly established, they can be at an increased risk of colon cancer. They can develop sleep apnea, they can develop carpal tunnel syndrome and then they can also develop pre-diabetes and diabetes, so many comorbidities can be associated with a growth hormone-secreting disorder. So, when that presents, the treatment for that functional pituitary tumor is surgery. One does want to make sure that they don't have other hormonal deficiencies or hormonal excess. Sometimes, these tumors can be co-secretors, so they can secrete more than one pituitary hormone, but after that initial hormonal evaluation the treatment is gonna be surgery. Many times, because these growth hormone-secreting tumors are large, because the presentation can be subtle and the transformation in the clinical features can be gradual, they do often get detected in a larger size, so as a macroadenoma, and so many times they require adjunct treatment after surgery in the form of medical therapies or radiation therapy. So, we actually had a patient, a young male, who presented to his dental surgeon for jaw surgery, and so basically his main complaint was that he's lost his smile. And so, he ultimately ended up having a growth hormone-secreting disorder, and exposure to these high growth hormone levels had led to protrusion of his jaw such that when he smiled, only his lower teeth were visible and his upper teeth were no longer visible, so that's why he said he lost his smile. But, an astute dental surgeon at MedStar Washington Hospital Center, while looking at his dental x-rays, saw that the bone where the pituitary gland sits, that sella, that looked enlarged, and so he referred the patient to us for evaluation, and for sure he had a pituitary tumor about a centimeter and a half that was making growth hormone. He's now status post-surgery for the pituitary tumor and his growth hormone levels are much lower now, but he's requiring adjunct treatment with a medication that is a once a month injection.

Host: In adults, are the physical changes gradual or sudden?

Dr. Sharma: Yeah, no, these...most of these changes in an adult will be very subtle and so, many times they get overlooked, especially if you are seeing the person every day, the changes in facial features can be very subtle. Many times, the change in ring size or shoe size, um, a patient or a person may attribute it to gaining weight or fluid retention, things like that, or just aging process and it may not get detected. I have had people whose shoe size has changed from an 8 to an 11 before it gets diagnosed so no, it doesn't happen overnight. It's a gradual process. Many times, um, we ask people to bring out their driver's license or other prior photographs to actually compare how they have changed. Many times, it takes for a visit to a relative who has not seen you for a year, and they comment that you look different and sometimes that can lead to an evaluation, but many times it can be because they have developed high blood pressure or a heart issue or a diabetes that then leads to being seen by a physician and that leads to further evaluation, so the presentation can be at various different points.

Host: So, for these patients, is medication management a more likely treatment option than surgery?

Dr. Sharma: For most functional tumors, it will be surgery as first-line treatment. The only medical treatable pituitary tumor is prolactinoma, but many times medical therapy is needed as an adjunct, even after surgery has been done, and so you need to look at various different treatment modalities, with the goal being to optimize hormone levels and make sure that the tumor is either completely gone or, um, the residual tumor is...remains stable over time, and so it would be a mix of different treatment modalities.

Host: Why is MedStar Washington Hospital Center the place to go for pituitary tumor care?

Dr. Sharma: So, I think whenever we think of a pituitary tumors, it's important to remember that not one physician can treat all pituitary tumors. The pituitary tumors involve hormonal dysfunction, which needs an endocrinologist, who is...has expertise in the evaluation of pituitary disorders. You need an experienced neurosurgeon as most functional tumors and many nonfunctional tumors require surgical treatment. You need a neuro-ophthalmologist who is experienced in recognizing the visual field defects that can go with pituitary tumor disorders. You need improved MRI techniques and a good neuroradiologist to detect these pituitary tumors. And you need state of the art radiation therapy, stereotactic radiosurgery modalities, as another treatment option to be available. And then you need a team that is keeping in mind and discussing the treatment plan with each other and coming up with a treatment plan that's best optimized for the patient instead of just giving a one-sided recommendation. So, the reason I think a pituitary center is really important, rather than just going to a physician, is because we are looking at the patient as a whole and coming up with a multidisciplinary team approach for these pituitary tumors.

Host: Is there anything patients can do to prevent pituitary tumors?

Dr. Sharma: So, yeah, we don't completely...there are certain hereditary disorders where you...that are associated with pituitary tumors, and if...those are very rare, um, most commonly multiple endocrine neoplasia, and if that runs in the family, then that could be something that you need screening for, but otherwise it's not completely understood what causes pituitary tumors. That's another area of research. We are developing more and more mutations, but those are not specific for a pituitary tumor and not everybody with that mutation is going to have pituitary tumors, so we are still at a learning stage for that and nothing in particular that one can do to decrease their risk of pituitary tumors because primarily we don't completely understand why they develop. One of the most common questions that patients ask me is that they had a very stressful period where they were leading a very stressful life, and that by increasing their cortisol levels, did that cause Cushing's or any other form of pituitary tumors, and no, we do not think that, at least as of now we don't have any current evidence to suggest that. Uh, so the main thing that one can do is to be in tune with your own body, to recognize any new symptoms that one may be developing and make sure you're following up with your physician as many times they may detect if there is any evidence of any pituitary disorder and then, if needed, refer to an endocrinologist or a pituitary specialist.

Host: Are certain patient populations more at risk than others?

Dr. Sharma: Oh, so yes, uh, age-wise there is. But also, there are certain pituitary tumors which tend to occur in a younger age group or in more in females versus males. For example, Cushing's disease, which is a tumor, where the tumor makes ACTH, which then causes cortisol excess - that tends to be more common in young females compared to males, so there are certain gender predilections in some of the pituitary tumors, but not always.

Host: Thanks for joining us today Dr. Sharma.

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.

Learn the facts surrounding urinary tract infections in women, including symptoms to watch for and common myths about treatment.