Acne is common in teenagers, but it can become a more persistent problem for adults. Dermatologist Dr. Sanna Ronkainen discusses how we treat adult acne and ways to protect your skin.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Sanna Ronkainen, a general dermatologist at MedStar Washington Hospital Center. Thank you for joining us, Dr. Ronkainen. Dr. Ronkainen: Thank you for having me. Host: Today we’re discussing acne, a common problem that’s often associated with teens but affects many adults, as well. Dr. Ronkainen, could start by discussing the reason adults develop acne? Dr. Ronkainen: Absolutely. So, for some adults that I see, their acne is carried on from their teenage years into their young adulthood. So, I see a lot of patients in their early 20s who are still struggling with acne. However, acne, particularly of the face, chest and back, can also linger or become a more persistent problem in women who are in their late 20s, 30s or 40s or even later than that because of the hormonal component of acne. Patients also come in reporting acne when they have inflammatory bumps or acne-like lesions on the body, which sometimes can be related to folliculitis, which is an infection of the hair follicles, which usually happens on areas of the skin that are covered by clothes, such as the buttocks or the thighs. So, we see a variety of different reasons that adults get acne. Host: Do certain demographics, such as race and gender, make a person more at risk for developing acne? Dr. Ronkainen: I think that gender, particularly females, in the kind of 20s, 40s range, tend to have more of a hormonal component of their acne, so definitely we see that patient population a lot in our dermatology clinics. Host: We know the face is a common area that people get acne, but where else can people get acne? Dr. Ronkainen: Classic acne tends to affect the face, chest and back. However, if it’s severe, it can also affect the shoulders. And, as I discussed earlier, folliculitis can affect the buttocks or other areas such as the thighs. Host: What treatment options are available for adults with acne? Dr. Ronkainen: So, even just starting at the local pharmacy, there are a lot of over the counter options for acne and there are many different ingredients that patients can experiment with. Benzoyl peroxide is a classic treatment for acne that really targets the bacteria that grows on the skin. There’s also salicylic acid, glycolic acid or sulphur washes it; work to more exfoliate the skin, help clear the pores that way. These are available over the counter in various products, however, they can be coupled very nicely with prescription products such as topical antibiotics or topical retinoids. These can also be accompanied by oral medications if the acne is deemed to be more severe. Host: How long does it typically take a patient to treat their acne? Dr. Ronkainen: Acne can be really frustrating to treat and, especially when patients are coming in to see me, they want results pretty quick. And, it’s frustrating to tell them that it takes up to three months to really see if a certain new acne regimen is going to work for them. So, I usually tell people that we should start seeing some improvement by the first month, but really by three months we should know if this treatment regimen is really working for them or if we need to change it up a little bit. Host: What are some tips people can follow to help them prevent or treat acne? Dr. Ronkainen: To prevent or treat acne at home, it’s very important to be mindful of what you’re putting on your skin every day. Number one, you need to make sure that the products that you’re using on your skin are not blocking your pores. And so, the products you would be looking for to be using are labeled non-comedogenic, meaning they don’t cause acne. Also, while at home, you can start out with some gentle cleansers and gentle topical treatments that are available over the counter and incorporate those into your daily regimen. Host: Why is MedStar Washington Hospital Center the best place to seek care for acne? Dr. Ronkainen: 353 Washington Hospital Center dermatologists have a wide breadth of experience in treating acne and all types of skin cancer in patients of all ages. So, we really have the dermatologists who work well with the patient to find a regimen that works for them, whether it is just topicals or if we need to go to more aggressive therapy such as oral antibiotics, anti-hormonal therapies, or Isotretinoin, also known as Accutane. Host: Could you share a story where a patient overcame acne after visiting you at MedStar Washington Hospital Center? Dr. Ronkainen: Absolutely. We see acne patients every day in our clinic and there’s nothing more satisfying than having a patient come back in three months, after you started them on a regimen, and have them just have a visible happiness on how well that they’re doing and the improvements that they’ve seen. Host:  Is there anything in people’s diets that could influence their risk of developing acne? Dr. Ronkainen: You know, this topic comes up a lot in my appointments with my patients. And, the only study that we have that has shown a correlation between a certain dietary component and increased development of acne, is skim milk. I don’t think we know exactly why that is, considering as compared to patients who drank regular or whole fat milk and there was no evidence of increased acne in that patient population. So, that’s the only piece of evidence-based medicine that I can point to, to say maybe switch over to the whole fat milk. Host: Some people can be tempted to pop their pimples when they arise. Is this something that’s safe to do? Dr. Ronkainen: As tempting as it is, I do not recommend that my patients pop their own pimples. Breaking the skin can cause more inflammation and can cause more scarring in the long run. Sometimes, if patients have a really deep, painful acne bump, sometimes they can come in to the clinic and have an injection of an anti-inflammatory medication to help soothe that area. However, usually trying to pop the pimple yourself is more trouble than it’s worth and will lead to long-term scarring which tends to be a more frustrating process for patients I see in the long run.  Host: At what point should a patient go to see a dermatologist to treat their acne? Dr. Ronkainen: I think if a patient is not satisfied with how their skin is looking at home, a visit to a dermatologist is an easy choice. We can always talk you through what you’re using as your home regimen - tweak that as well as add in prescription-strength products. So, if you’re at home wondering whether or not you should be seeing a dermatologist, even a one-off consultation certainly wouldn't hurt. Host: Thanks for joining us today, Dr. Ronkainen. Dr. Ronkainen: Thanks 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.

Medical Intel

Adult Acne is Frustrating but Treatable

For many women, breast reconstruction is an important part of the healing process after breast cancer surgery. Plastic surgeon Dr. Kenneth Fan discusses the three reconstruction methods we use and why treatment often depends on patients’ unique expectations, goals, and needs.    TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Ken Fan, a plastic surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Fan. Dr. Fan: Pleasure to be here. Host: Today we’re discussing how breast reconstruction surgery, one that occurs after cancer surgery, works and what patients can expect from it. Dr. Fan, could you begin by explaining why women undergo breast reconstruction surgery after cancer surgery? Dr. Fan: Well, that’s an interesting question. And I think a important point to point out at this juncture is that breast reconstruction after cancer is not cosmetic surgery. It’s a reconstructive procedure and it’s actually mandated by law as a result of the Women’s Health and Cancer Right Act. Therefore, I think it’s important for patients to know that their access to breast reconstruction surgery is not optional. There’s something about breast reconstruction after cancer surgery that really gives patients hope and an opportunity to feel whole again. And we see this in our research. After breast reconstruction, patients who have had reconstruction have the same quality of life as patients who haven’t even had cancer. And this has been shown in large, large series of data. And therefore, I think it’s important for a team of breast surgeons and plastic surgeons to discuss what the right option for breast reconstruction for that patient is. Host: What is your patient population typically like? Dr. Fan: I see patients for breast reconstruction with all sorts of lifestyles and requirements. And therefore, it’s very important for us to have a group discussion on what the best breast reconstruction modality is. For example, some patients have a very active lifestyle and want to get back to work right away. Therefore, we can do certain types of reconstruction that facilitate that. Other patients want this to be the last surgery they go to and really want that home run, so they don’t have any future operations in the future. And so, we also have surgeries for that breast reconstruction patient as well. Host: How does breast reconstruction surgery work? Dr. Fan: That’s a great question. So, globally speaking, there are three main ways that breast reconstruction can occur. The first one is an oncoplastic approach in which the breast surgeon takes out a small tumor and mere rearrange tissue within the breast. The second approach is after mastectomy. And this is usually with a, what we call, prosthetic-based reconstruction. We use an implant, or a temporary device called an expander, to reconstruct a breast mound. The third option is what we call autologous space reconstruction. And in autologous space reconstruction, we use patients own tissues, either from the abdomen or from the back, to reconstruct a breast. Host: Following breast cancer surgery, how long does it typically take women before they have a breast reconstruction surgery? Dr. Fan: So that’s a great question. Breast reconstruction can generally be done in the same operating room visit as the cancer surgery. However, there’s some rare cases in which patients will need what we call a delayed type of reconstruction. However, it’s important for patients to come see us before surgery and we can explore all the options together. Host: How close can you get to making a breast look the way it did prior to surgery? Dr. Fan: Depending on the cancer characteristics and the cancer excision, we can come pretty close. I think for patients and for us surgeons, our greatest hope is that patients, while clothed, can have the appearance of not having had breast cancer. And that is our ultimate goal. And, I think more often than not, we achieve this goal. However, if the patient were to look in the mirror unclothed, there are certain scars that would give away the fact that they had breast reconstruction. Host: Is there anything women must do prior to breast reconstruction surgery? Dr. Fan: Not necessarily. What’s important is to have a group discussion on what the best modality is for that patient. We practice a patient-centered approach, so we go through all the options and really discuss with the patients what is the best modality to make sure that they are happy with their surgery. Host: Is there any new, exciting research related to breast reconstruction surgery? Dr. Fan: At MedStar, we are constantly looking at how we can do things better. In particular, a lot of our research focuses on complications after breast surgery and improving the patient experience after breast surgery. Our second main point of research is improving the patient experience after surgery. In particularly, we are looking at use of enhanced recovery after surgery, short for ERAS protocol. This protocol, we have found, has decreased the amount of narcotic usage significantly that patients have to take after surgery. Patients find themselves walking post-op day 1 or 2 after a major operation and are leaving the hospital sooner. So much so that they are surprised at even how well they’re doing themselves.   Host: Why is MedStar Washington Hospital Center the best place to seek care for breast reconstruction surgery? Dr. Fan: I think it’s important for patients to know, for perspective patients to know, that at MedStar Washington Hospital Center we’re focused, not just on disease, but on the patients themselves. We focus on the patients’ needs through a multidisciplinary approach and really engage patients to help understand their expectations and desires. This makes us such a special place as providers are constantly collaborating together to come up with the best solution for our patients. Host: Thanks for joining us today, Dr. Fan. Dr. Fan: 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.

Breast Reconstruction After Breast Cancer Surgery

About 800,000 Americans have a heart attack each year—and younger women account for nearly one-third of them, according to a recent study. Dr. Patrick Bering discusses what’s causing this rise in heart attacks.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Patrick Bering, a cardiologist at MedStar Washington Hospital Center. Thank you for joining us, Dr. Bering. Dr. Bering: Thank you so much for having me. It’s a pleasure. Host: According to a 2018 study, younger women are having more heart attacks. In fact, they’re accounting for nearly one third of all female heart attacks in recent years. Today we’re going to discuss why this is, and ways women can prevent heart attacks. Dr. Bering, could you begin by explaining why we’re seeing this rise in heart attacks among young women? Dr. Bering: Absolutely. This is definitely an alarming trend that’s seen nationwide. One of the reasons why we think we’re seeing more young women hospitalized with heart attacks is that there has been an increase in the cardiovascular risk factors among young adult women. Among these would be things like high blood pressure, diabetes, obesity, smoking and poor lifestyle, including poor diet and low physical activity levels. Host: And is this something you’re seeing only in young women or young men as well? Dr. Bering: We see premature heart disease both in young men and young women. Unfortunately, we have been seeing a trend for increased hospitalizations for heart attacks in young women more so than young men. There may be some additional risk factors that young women have. And, when I say young women, I mean women and young adults, so between the ages of 35 and 55. And these can include women who have conditions such as polycystic ovarian syndrome, premature menopause or a history of preeclampsia during pregnancy. Host: Are there certain demographics of young women that you’re seeing more than others? Dr. Bering: That’s an interesting question and one that we’re still gathering information about. It seems to be important where you live from a socioeconomic perspective. In that way, your neighborhood may actually be a risk factor, positive or negative, for your development of heart disease. We do see a high amount of premature heart disease in African American women, which is a concern for us and we aim to combat this from many different facets, aiming at preventing the risk factors for heart disease. Or, if they develop, to try to optimize them to prevent any long-term consequences to cardiovascular health. Host: Are there symptoms or warning signs of heart attacks that people should be aware of? Dr. Bering: Definitely. You hear about classic symptoms which include pressure on the chest or some people describe it as an elephant sitting on the chest. These classic symptoms are more common in men. Unfortunately for women, the symptoms may be more atypical. They can include things like heartburn, fatigue, shortness of breath, low energy, acid reflux, nausea. Because women have more atypical symptoms of heart disease, they may be less likely to seek medical attention at the time that they’re experiencing something like a heart attack. Host: Could you expand on some of the symptoms young women may have? Dr. Bering: Certainly. As I said, this can be confusing, even for the healthcare community, at times. Since young women or even women post-menopause are more likely to have atypical symptoms that may be gastrointestinal, it has to be in context with the rest of their symptoms and well-being. If there’s been a change in their ability to do physical activity or exercise, that goes along with symptoms of heartburn or nausea, low energy or fatigue - those combinations are more worrisome than if it’s just heartburn after they’ve had, say, a spicy or acidic meal. Host: Is there any point at which somebody should definitely see a doctor? Dr. Bering: Absolutely. If someone is having significant shortness of breath or decreased energy, intractable nausea, or heartburn that doesn’t get better with usual methods such as an antacid, they should seek medical attention, especially if they have a history of premature heart disease in their family or if they have risk factors for heart disease that we described before - high blood pressure, diabetes, obesity, poor diet, poor physical activity, high cholesterol.  Host: What can young people do to prevent heart disease? Dr. Bering: That’s a great question and one of our most important ones. At an individual level, young people can be aware of their health, in a way that prevents the development of risk factors for heart disease. That generally goes along five different related and intertwined steps to positive health. Those include things like healthy diet, regular physical exercise, control of blood pressure, control of weight and focusing on positive stress and mental health in their life. Even things like getting 7 to 8 hours of sleep per night is a very important step of focusing on your overall health. Host: Could you explain how regular doctor checkups could go a long way in young people preventing heart disease? Dr. Bering: Definitely. For young people, even though many of us feel well or healthy, or we may have a lack of medical problems, some of the risk factors for heart disease may actually be silent. Many people don’t FEEL that they have high blood pressure and instead, they discover it later in life once some of the consequences of high blood pressure have accumulated over time in the body. A regular checkup with your primary care health provider every year is an important way for you to have a dialogue and positive relationship with the health care community. We, in health care, are very excited about seeing patients where we can make positive influences to prevent disease. And, in fact, that seems to be one of our...or actually, our MOST successful strategy, when we are combating disease. Host: Why is MedStar Washington Hospital Center the best place to seek care for heart disease? Dr. Bering: At MedStar, we’re so proud to serve our community and we’re lucky that we have passionate healthcare providers that can focus on a variety of issues related to your cardiovascular health. In one sense, we have great primary care physicians, as well as cardiologists, who are focused on the prevention of heart disease. In another sense, if you are unfortunate enough to develop cardiovascular disease or the risk factors for it, we have a team of experts that are able to provide you with comprehensive, expert care in order to manage your conditions optimally in a strong dialogue with you. We like to make our care patient-centered so that everything is focused on goals that we can achieve with the patient themselves. Host: Could you share a story in which a young patient received optimal care for heart disease at MedStar Washington Hospital Center? Dr. Bering: Absolutely. I’ve recently had the privilege of taking care of a young woman who had initially thought that she had symptoms of acid reflux. As it turned out, this was actually a heart attack in its beginning stages. Since she presented with atypical symptoms, our emergency room physicians were keen enough to look for a cardiac cause and discovered the early signs of the heart attack. When she came under my care, I was able to get her the appropriate procedure that she needed in order to open up a blocked blood vessel supplying blood to her heart muscle. In that sense, we were able to successfully handle her care, both from the moment she hit the door in the emergency room to the point of discharge with minimal heart damage and overall good heart function. Host: Thanks for joining us today, Dr. Bering. Dr. Bering: It’s been a pleasure. Thank you again. Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Why Younger Women Are Having Heart Attacks and Tips to Prevent Them

Some of the most unexpected injuries in medicine are due to orthopaedic trauma, which involves problems related to bones, joints, and soft tissues. Discover what some of the most common orthopaedic trauma injuries are and how we treat 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: We’re speaking with Dr. Robert Golden, Chief of Orthopaedic Trauma Surgery at MedStar Washington Hospital Center. Thanks for joining us, Dr. Golden. Dr. Golden: Thanks a lot for having me. Host: Today we’re discussing common orthopaedic trauma injuries which commonly affect bones, joints, ligaments, tendons and muscles, and how we diagnose and treat them at MedStar Washington Hospital Center. Dr. Golden, could you begin by explaining why orthopaedic trauma injuries generally occur? Dr. Golden: Sure. They can occur from multiple different kinds of mechanisms, the most common being falls and motor vehicle crashes. But we also see a large number of injuries from bicycle related injuries, scooter related injuries. We also, in this area, see a fair number of gunshot wounds.  Host: What are some of the most common orthopaedic injuries that you see? Dr. Golden: A lot of them depend on how the person was injured. We do see a fair amount of injuries from pedestrians being struck by cars. They tend to get injuries to their legs and lower extremities. A lot of people who just fall, and they can hurt anything including ankles and lower extremities, but then they also tend to have a lot of wrist injuries and shoulder injuries from falling and putting their arms out to protect them. Host: And could you explain, giving specifics, some of those injuries? Dr. Golden: Sure. A very common mechanism when you fall and you put your arm out is that you break what’s called your distal radius, which is just the bone at the end of your arm right before your wrist. It’s a very common injury in older people as well as in younger people when they suffer a high energy fall. Some of the injuries from the pedestrians being hit by cars involve what’s called a tibial plateau, which is the top part of your tibia, right below your knee. You can imagine the bumper of the car striking you on the side and that bumper is right about the level of your knee, so a lot of people get injuries that way. Once it gets a little warmer and people go back to motorcycles or riding bicycles, then you start to see a little more high energy injuries, especially from the motorcycles and those can involve injuries to your femur or your thigh bone. And, the higher energy crashes with motorcycles, and with cars, then you can get some of the pelvis injuries that people see. The other thing we’ll see is we’ll get patients referred in who have had complications from fractures that they’ve had in the past. Sometimes the fractures just don’t heal and then that’s called a nonunion. Sometimes they heal but they heal in a crooked position. So, we’ll also treat those patients. And, if they haven’t healed, a lot of times you need to figure out why that is. Sometimes that’s because the bone simply doesn’t have enough blood supply to it. Sometimes it’s because the patient doesn’t have the components necessary to actually heal that, be it enough vitamin D in their system or other reasons that can prevent bone healing. So, oftentimes we’ll have to take them back to the operating room and do other procedures to try to get them to heal, including taking some bone from another part of their body and bringing it into the area where it hasn’t healed. If they’ve healed but it healed crookedly, called a malunion, sometimes we’ll even have to re-break the bone or cut it at the area where it’s crooked - sometimes that can be done as a single procedure. Sometimes we have to put on different kinds of apparatus that go on the outside of the bone and interface with a computer program so that we can control how the bone is manipulated over time and we’ll slowly restore them back to a straight position to get them to heal. The other thing we’ll often see as orthopaedic traumatologists is we also specialize in bone infections, so we’ll get patients referred in who have had bone infections for lots of different reasons, sometimes as a result of trauma but sometimes just as a result of getting an infection, so we’ll treat those as well. Oftentimes, that requires a surgery to open up the bone, get out as much of the infection as possible so that then antibiotics can be used to control the infection for long-term cure. Host: Could you discuss common treatments for these injuries and how they work? Dr. Golden: Sure. A lot of the injuries depend on where in the bone it’s broken. Injuries that occur close to the joints, which are called periarticular injuries, generally require plates and screws to fix them so that you can align the bone, make sure the joint is re-aligned back as perfectly as possible. And then that’s held in place with small metal plates that are held on to the bone with screws. That allows the bone to stay in the proper position and then it heals around it, so the plates are functioned like scaffolding and hold everything in the right spot and then it’s still up to the person to actually heal the bone. If you break some of the long bones, like your tibia or your femur, then sometimes we’ll put rods into them. Those go on the inside of the bone and, like the plates, they form a scaffolding, but these...the bone heals around them, so they’re totally contained within the bone itself. Host: And what kind of recoveries can these patients expect? Dr. Golden: Some of it depends on what’s injured. In general, bones take about 12 weeks or 3 months to heal. Some of the injuries, the hardware that we put in is strong enough to support their weight. If that’s the case, we’ll get them up as soon as possible right after the surgery and get them moving to minimize their stiffness that they might get, minimize the amount of muscle loss that they may have from not being able to move around. Some of the injuries, you just simply can’t do that. Some of the plates and screws that we put in have to get very close to the joints in order to get the joint perfect and those aren’t strong enough sometimes to support the person’s weight. If that’s the case, then they may have to have a period of not putting weight on that limb, using crutches or a walker or sometimes even a wheelchair, until that bone heals strongly enough that then they can start putting weight back on it. Oftentimes, if that’s the case, then we’ll have the physical therapists involved to try to minimize their stiffness and minimize any sort of muscle loss they may have from not using that limb. A lot of times we get other services involved, as well, to try to maximize their recovery, minimize the impact onto their life. Unfortunately, a lot of these people weren’t expecting anything to happen that morning and leave for a normal morning and then they have a huge life interruption from these traumas. So, it’s a little bit different that going in for an elective surgery when you know when it’s going to happen and you can plan for it. So, often we have to have a lot of social work involvement to help them in terms of planning for disability insurance and time off of work until they can be strong enough to get back to their occupations. Host: Do you have any tips to help people prevent these injuries? Dr. Golden: A lot of them, it’s just being careful with what you’re doing, especially with the motorcycles and bicycle crashes, and sort of knowing your limits. Unfortunately, sometimes it is just a random occurrence that happens. You can’t do anything about it if you’re driving down the street and somebody runs through a red light and hits you. You had nothing to do with that but, unfortunately, you still have to deal with the consequences of it. Host: Are there certain patient populations you see the most with orthopaedic trauma injuries? Dr. Golden: Orthopaedic trauma tends to be what’s called a bi-modal distribution most of the time, meaning that we see a lot of younger people in their late teens and twenties, then we see a lot of older people. Those injuries occur for different reasons. The young people tend to be doing the more high energy, risky sort of things - riding motorcycles, riding bicycles, doing things fast with high energy. The older people just lose their balance and have less stability in their bones. So, when they fall, they may break their hip, when, if you fell, you would just get right back up and be fine. Host: Why is MedStar Washington Hospital Center the best place to seek care for orthopaedic trauma injuries? Dr. Golden: Well, we have a full staff of orthopaedic traumatologists here. There’s two of us who specialize...orthopaedic trauma and that’s pretty much exclusively what we treat. But we also are supported by a full orthopaedic department that has specialists in all the other disciplines. So, sometimes if you have a injury to the bone and the ligaments, we’ll take care of some of the bony issues, and then some of the sports medicine people will take care of some of the ligament injuries or the hand people will take care of those specific injuries. We are also plugged in to the MedStar trauma service network here with the trauma team that can provide a multidisciplinary approach to make sure that any other injuries you may have that don’t relate to orthopaedics - injuries to internal organs or other body parts - can be managed, as well. Host: Could you share a story in which a patient received optimal care for orthopaedic trauma injury at MedStar Washington Hospital Center? Dr. Golden: Sure. We’ve had tons of patients come through since I’ve been here and a lot of them have multiple injuries. I just saw a guy who we treated seven years ago now was just coming back essentially to get a checkup. But he had injured both of his limbs, again this was a motorcycle crash, both of his lower legs, both of his feet, some of them were open fractures, meaning the bone had come out through the skin. He also had a bunch of injuries to internal organs. So, he came in, was treated by the general surgery trauma team to stabilize all his internal organ injuries. We then treated his bones. He needed several surgeries to try to minimize any risk of infection and prevent that from happening. We then stabilized his bones with the plates and screws and rods. And then the plastic surgery team provided flap coverage to get that covered as well. One of our more well-known instances of treating patients has been both with the Congressional baseball shooting, prior to that the Navy yard shooting. We had victims of those shootings here, as well, and that was truly an interdisciplinary exercise where there were the general surgery trauma team was involved, vascular surgery teams were involved, we were involved - and all that care came together at the specific times when it was appropriate to make sure that we first saved the lives, then, eventually, got everything fixed and back to function and, you know, getting back in to life. Host: Do you have any advice for what patients can do before EMS arrives? Dr. Golden: Well, a lot of it is just staying calm and keeping the limbs that you think are injured still. Sometimes that involves you just staying still and not moving around. If there’s other things available to help with that - and that can be as simple as finding some cardboard and rolling it up to form sort of a make-shift splint, or sometimes even newspapers are enough, just to help keep everything still - generally that’ll make it feel more comfortable because if the bones aren’t moving around where they're not supposed to, it will hurt less. That could also help prevent some of the associated injuries to the soft tissues around the bones that can be injured if the bone is moving abnormally. So, that may help the person who is hurt, in terms of just pain control, as well as trying to prevent some of the issues to the skin and the soft tissues. Sometimes, if it’s an open fracture and there’s actually bleeding from the wound, you can just put some pressure on the area where it’s bleeding and that will help minimize that as well, until an EMS professional arrives.  Host: Thanks for joining us today, Dr. Golden. Dr. Golden: My pleasure. Thanks 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.

4 Common Orthopaedic Trauma Injuries and How We Treat Them

Deep Vein Thrombosis (DVT), a condition in which blood clots form in the deep veins, affects as many as 900,000 Americans each year and can cause symptoms such as pain while walking and a burning sensation in the legs. Learn who’s most at risk of developing DVT and common treatment options.    TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Steven Abramowitz, a vascular surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Abramowitz. Dr. Abramowitz: Thank you for having me. Host: Today we’re discussing deep vein thrombosis, or DVT, a condition where a blood clot forms in one or more deep veins in your body. Dr. Abramowitz, could you begin by discussing how these blood clots form and where they typically arise? Dr. Abramowitz: Sure. So, in our body, our veins are responsible for bringing blood back into our heart. Arteries take it away, veins bring it back. And, when we think of the veins in our body, there are veins that are superficial, or near the skin, and veins that are deep that run down near our bones or with our arteries. These deep veins - you could think of them, if you’re in the DC area, as our big roads - let’s say the New Hampshire’s or the Pennsylvania Avenues or the Georgia’s. And, some of our superficial veins are more like our side streets - like a T street or a U street. And, everything drains into these deep veins. But, sometimes there can be a traffic jam, and that traffic jam, in the case of our blood vessels, is a blood clot. And that blood clot can occur anywhere these deep veins are - in the arms, in the legs, essentially anywhere that you may name a deep vein. And what we find is that, depending upon where the clot is, it can lead to a variety of different symptoms. And, if that clot breaks free, it can travel back to the heart, where all the blood from our veins goes originally. And that can result in a pulmonary embolism, which can be a fatal condition. Host: And what are some of the common symptoms of DVT? Dr. Abramowitz: Most commonly, people who have DVT in the lower extremities, will experience swelling, pain when walking, a hot burning sensation as their leg gets warm or engorged and full of blood. And those typically are the most common complaints that people have. Host: Who is most at risk of developing DVT? Dr. Abramowitz: Anybody can fall victim to deep vein thrombosis. And really, it depends on what’s going on with someone else’s health. So, for example, there are plenty of patients that we treat here at MedStar Washington Hospital Center who are younger, maybe they’re in their teens, and the first time that they know they have a clotting disorder or a blood disorder that may make them more likely to make blood clots, would be the presentation with a DVT in one of their legs. Other times, patients who have had surgery or other conditions that make them less mobile or engaging in activity in their lives could be victims of DVT, as well. And, it can also be something that we find in hospitalized patients, people who are immobile in a hospital bed for extended periods of time. So really, it’s a condition that can affect anybody of any given age. Host: How is DVT diagnosed? Dr. Abramowitz: For the most part, it’s both a clinical diagnosis and a confirmation with ultrasound. And we use ultrasound as a simple way of diagnosing the presence of clot within the deep veins. And this is done, again, as a very quick test without radiation exposure, or dye, and it’s a simple procedure that we can do, even at the bedside, for someone who’s in the hospital. Host: What treatment options are available for DVT? Dr. Abramowitz: Right now, for patients who have deep vein thrombosis, we currently offer two therapies. First, most patients with deep vein thrombosis, will be treated with something that’s called an anticoagulation agent. In basic terms, it’s a blood thinner. And the reason we put somebody on a blood thinner is not that it actually gets rid of the blood clot, but that it makes it less likely for more blood clot to form because our bodies have the natural ability to break down clot over time. But for some patients who have extensive clot or a lot of clot throughout the vein, let’s say in a leg, we can actually go in with a wire and a small catheter, which is like a plastic tube or a hose, and we can give the medication directly into the clot, to make that clot go away faster for those patients, as well. Host: And, how fast is faster for those blood clots, typically? Dr. Abramowitz: Well, if we’re performing a procedure on a patient, usually we can get that clot away in a single session. For patients who have to have blood thinners, sometimes it can take the body up to 3 to 6 months to dissolve the clot on its own. Host: Is there anything people can do to prevent DVT? Dr. Abramowitz: For patients who are sick or at risk for DVT, meaning they’re not moving around a lot or they already have something else in their body that’s making them feel inflamed or more likely to develop a blood clot, those patients can both get up and walk and move around. If they can’t do that, engage in exercises so that they’re activating those muscles in their legs and circulating blood. For patients who are, let’s say younger, and they have a blood condition making them more likely for DVT, again, moving around is really important. And, a lot of times we talk about blood clots in a setting of travel or prolonged travel. So, if you’re getting on a plane, I always tell patients not to have that 2 or 3 glasses of wine and pass out, make sure you get up and walk every hour or so. And, if you’re in the hospital, or you’re in a sedentary job, or it could be you’re sitting at a desk, make sure you stand up and walk, too. Host: Why is MedStar Washington Hospital Center the best place to receive treatment for DVT? Dr. Abramowitz: Well, one of the great things we have here at MedStar Washington Hospital Center is an interdisciplinary approach to the management of deep vein thrombosis. People who have DVT, not only do they have symptoms now, but they can have symptoms in the future, too, because as the body breaks down that clot, it causes swelling and inflammation in the same way as if you were to get a sprained ankle - you’d have swelling and inflammation. And, that swelling and inflammation can lead to scarring of those veins. So, the deep veins - maybe they’re a four-lane highway before your blood clot, but afterwards they’re a two-lane highway. And that can lead to swelling and that sort of congested traffic for a long period of time. At Washington Hospital Center we offer all of the new therapeutic interventions for deep vein thrombosis management. Anything from sucking out the clot, which is called mechanical thrombectomy, to dissolving the clot rapidly, which we call pharmacomechanical thrombolysis, which is essentially like a little machine that injects that clot busting medication in and sucks the clot out. And, we also put those catheters in and leave them in overnight to slowly dissolve a clot that may have been around for a longer period of time. So, we have the tools to treat your DVT and, also then, take care of you because the DVT is a symptom of something else, most likely. Maybe you have something wrong with your veins that we can diagnose and treat with a stent. Maybe you have another underlying condition, like a blood disorder, or you’re sick with something else so the DVT is the first thing we diagnose. So, when you come to Washington Hospital Center with a DVT, it’s not just about treating your clot. It’s about making sure we understood why it happened. And, we have every single surgical and medical sub-specialty service you could want here to help you deal with that process. Host: How often can DVT be a gateway to other conditions? Dr. Abramowitz: Well, the DVT is a condition in and of itself, but you have to ask yourself why it happened. And, for a lot of patients, sometimes the first sign that they may have cancer, for example, is the blood clot. And so, they need to be screened for conditions that would make their blood more likely to clot. Or, for someone who’s younger, if they have a blood clot, it may be a sign that they’re actually more likely to have a genetic condition. So, anytime someone has a DVT, it always prompts us to ask the question, “Why did this happen?” and “What can we do to figure out, for THIS patient in particular, what led to this state of being?” So, I’d say 80 percent of the time someone has a DVT we’re able to figure out the reason why, be it another medical condition, an anatomic predisposition, meaning there’s something in their body maybe compressing a vein, or we find out that they have a genetic condition that’s related to their blood in and of itself. Host: What are the risks of leaving DVT untreated? Dr. Abramowitz: That’s a great question. So, really it depends upon where in the body the DVT is. For the most part, blood clots below the hip, those being in the top part of the leg or the bottom part of the leg, they tend to result in swelling in the short term, but don’t necessarily result in long-term damage to the leg that would cause wounds to form or prolonged swelling in the future. But what we find is blood clots that are above the hip or above your groin that affect the veins in your belly and in your pelvis. Those can lead to long-term drainage problems from the leg and that can result in long-term swelling or even wound-care formation. And we call that post thrombotic syndrome. So, it’s really important for us to identify the extent of the blood clot and where exactly in the body it is so that we can predict what someone’s risk is in the future for developing problems as a result of their DVT. Host: Thank you for joining us today, Dr. Abramowitz. Dr. Abramowitz: My pleasure. Thanks 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.

DVT: How We Treat These Blood Clots and Tips to Prevent Them

BPH, or an enlarged prostate, affects about 50 percent of men between the ages of 50 and 60, causing symptoms ranging from frequent urination to a weak urine stream. Dr. Daniel Marchalik discusses GreenLight laser surgery, a minimally invasive treatment for BPH.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Daniel Marchalik, the Director of Ambulatory Urologic Surgery at MedStar Washington Hospital Center. Thank you for joining us, Dr. Marchalik. Dr. Marchalik: Thanks so much. Happy to be here. Host: Today we’re discussing a newer treatment for benign prostatic hyperplasia, or BPH, which often is referred to as an enlarged prostate. This treatment is called greenlight laser surgery. Dr. Marchalik, could start by explaining what greenlight laser surgery is and how it works? Dr. Marchalik: Yeah, of course. So, as a lot of listeners know, BPH is a really common issue. In fact, we know that half of all men in their 6th decade of life have signs of an enlarged prostate. And so, as a result, this is something that we have to deal with very often and treat very, very often. And there are different ways of treating BPH. Traditionally, BPH has been treated surgically by shaving the prostate down using an electrode that can actually shave it from the inside. Recently, in the past 5 to 10 years, we’ve started to use something called the greenlight laser to do a photo-vaporization of the prostate. Now what that means is that we use a laser to actually vaporize the prostate tissue. The greenlight laser is a really interesting device because the laser itself is absorbed by the hemoglobin molecules - those are the red cells...red blood cells. What that allows us to do is to actually make the tissue vaporize without causing as much bleeding as other ways of treating BPH. Host: What’s the process in which you diagnose a patient with BPH, or enlarged prostate, and who are the best candidates for greenlight laser surgery? Dr. Marchalik: The diagnosis is really usually made by symptoms. So, when somebody comes in and they complain of having difficulty urinating, waking up at night to urinate, feeling like their stream has gotten weaker, feeling like they’re always rushing to the bathroom - basically, like the guys in the commercial who are going to the baseball game and they always have to sit on the aisle because they need to know where the bathroom is at all times. Or, the guys that are running in and out of meetings because they feel like they’re just not going to make it through the whole meeting without peeing. Those are the symptoms that we tend to see with BPH. Now, we do questionnaires to try to get an objective measure of exactly how much this is bothering them. We can also measure the flow of their urine to see how strong their stream is. And, if we then diagnose them with issues urinating, we then go on and measure the size of their prostate to objectively demonstrate that it is enlarged and sometimes even look inside the prostate using a small camera called a cystoscope. Every patient is obviously going to be different. But, the general approach is to first establish what the symptoms are that the patient is experiencing, and then to get some objective data, like the size of the prostate and the way that the prostate looks. Host: What is recovery typically like following greenlight laser surgery? Dr. Marchalik: The big difference between a greenlight laser surgery and the traditional surgery called a TURP, a transurethral resection of the prostate, which is the way that prostates used to be treated more in the past and still are treated today, is that the greenlight laser surgery could be done as an outpatient, meaning it’s in and out surgery. The big difference there is that you don’t have to spend the night in the hospital. And, that means that the recovery tends to be a little bit smoother. Generally, patients who undergo a greenlight laser photo-vaporization of the prostate get sent home with a catheter that they can either remove themselves the next day or come back in to the hospital and we can remove it for them. Most patients will immediately see a difference in their stream. What I mean by that is that patients who have really struggled to try to push the urine out or felt like their urine just doesn’t tend to flow the way that it used to when they were younger, will often experience the return of that type of force right away, and so they might be able to see the results immediately. Now, of course, because they had the surgery and because their prostate was shaved down, that means that they need to abstain from things like heavy lifting and exercise, cycling, for the next four weeks or so to prevent them from developing bleeding from that raw area in the prostate. Host: Are there any risks involved with greenlight laser surgery? Dr. Marchalik: Of course. As with any surgery, there are inherent risks associated with anesthesia. But for the surgery itself, there are some things that tend to be risks for the procedure. For example, about three-quarters of guys who undergo this procedure will develop something called retrograde ejaculation. It means that when they ejaculate, nothing comes out or less comes out. Now, it doesn’t change their ability to have erections. It doesn’t change their ability to have an orgasm. But it does change the actual experience because there is no ejaculate. About 3 to 5 percent of guys can develop some leakage. It’s called incontinence, meaning when they sneeze or cough or do strenuous activity, some urine might leak out. For a lot of guys, it’s just a few drops and it tends to be transient, meaning it goes away after a few weeks. But there’s a small subgroup of guys that can develop a more long-lasting issue with the urinary leakage. Of course, there’s always a risk that the procedure doesn’t actually help someone, meaning even though we shave the prostate down, they have some underlying problems with their bladder that prevent their bladder from squeezing as well as it should. And in those cases, the procedure might help them but maybe not as much as we would hope that it would. Host: When speaking of risks,  is there usually any hesitancy from patients and how do you walk them through, you know, why maybe they shouldn't be hesitant? Dr. Marchalik: It’s funny that you use the word “hesitancy” because urinary hesitancy is why the guys come to see me in the first place. But, I think that’s a good question. And, I think that as with any surgery, you have to remember that each individual patient is going to be different. There are people for whom this surgery is not ideal. For example, if somebody comes to me and they say, “I want a procedure for my BPH, but we want to have some more children.” And, for a patient like this, this is not a good procedure because the retrograde ejaculation certainly puts you at risk of not being able to have children anymore. Now, there are people that say, “Hey, I really want a procedure, but I can’t go under anesthesia. I’m scared of anesthesia. This is not something that I’m willing to do.” This is not a good procedure for them because this does require anesthesia. There are other people that come to me and they’ll say, “What type of procedure can I do that I know is going to last more than a few months or that has a lot of research behind it?” And then we talk about this procedure because I think this is a very good option for them. There are things that give people pause. For example, the retrograde ejaculation and the risk...the need to have a catheter for one day afterwards. But a lot of times, when we actually talk through this, this is not something that is an issue for most people that I see. Host: What makes greenlight laser surgery superior t o other treatment options? Dr. Marchalik:  The biggest advantage that I see for a greenlight laser TURP is the fact that this could be done as an outpatient, meaning a patient gets to go home at the end of the procedure and spend the night at home versus the hospital.  However, we still see the same benefits with greenlight laser TURPs as we see with regular TURPs, meaning we still see the same effectiveness of the procedure. Guys get the same urinary function that they have with the regular TURP with this greenlight laser TURP. They have the same side effect profile as a regular TURP. And, the same risk of having to need a surgery down the line. So, by that I mean that it is really a comparable procedure, just as good, but the risks are lower and there’s no need to spend the night in the hospital. Host: Is there anything patients should do beforehand to prepare for greenlight laser surgery? Dr. Marchalik: There’s nothing that they need to do in particular that’s different from any other surgery. And, of course, those instructions will differ by each individual patient. But usually it means having nothing to eat or drink after midnight and this is the same approach as they would for any other surgery. The big difference is they don’t need to pack a bag to bring with them to spend the night in the hospital. Host: Why is MedStar Washington Hospital Center the best place to receive treatment for BPH through treatments like greenlight laser surgery? Dr. Marchalik: We have a very good interdisciplinary team that discusses each individual patient. And, we have a good track record of performing this surgery that is an advanced greenlight laser surgery, including for some people who have larger prostates. Traditionally, the greenlight laser TURP has been reserved for smaller prostates, but we’ve been doing it with great success on guys with larger prostates and we’ve had really good patient outcomes. And, of course, we are very committed to our patients, which means that we continue to see them in our clinic and to make sure that their results are not just good successes initially but are durable and they maintain the good urinary function throughout the years afterwards. Host: Could you share a story where a patient received an optimal outcome through greenlight laser surgery? Dr. Marchalik: Yeah. I had a patient recently who had been in and out of the emergency room multiple times over the span of several months. He kept having difficulty urinating. It’s called urinary retention, where basically no urine comes out. It could be an extremely uncomfortable and extremely painful condition. So, he kept coming in to the emergency room, would have a catheter placed, the catheter would be removed, he would be OK for a few days, and then it would return. Leading up to it, he’s a guy who was in a lot of business meetings and he said that this was starting to really interfere with his job. He kept having to leave meetings early, he kept interrupting meetings because he had to rush to the bathroom. And, he said his quality of life just wasn’t what it used to be. He underwent this procedure and immediately, the next day when the catheter was removed, he saw a difference. He said that the stream was the way that it used to be when he was in his 20s, which I think is a pretty good endorsement. A few weeks went by and some of the initial urgency that he felt after the procedure, as he was going through the healing phase, went away. I saw him in clinic a few months afterwards and he told me about how he can now sit through a meeting with no problem. He feels like he can go to a baseball game and he can sit through all 9 innings and it’s not a big issue for him which, honestly, I don’t know a lot of guys who could sit through 9 innings without having to go to the bathroom, but I guess he’s not one of them. Host: Thanks for joining us today, Dr. Marchalik. Dr. Marchalik: Thanks so much for having me. 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.

Immediately Relieve BPH Symptoms with Greenlight Laser Surgery

Skin cancer, which often appears as brown or red spots, is the most common type of cancer in America. Dr. Sanna Ronkainen discusses the best ways to prevent it, as well as how we treat it.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Sanna Ronkainen, general dermatologist at MedStar Washington Hospital Center. Thank you for joining us, Dr. Ronkainen. Dr. Ronkainen: Thanks for having me today. Host: Today we’re discussing key ways to prevent skin cancer, which affects millions of Americans each year. Dr. Ronkainen, could you start by discussing the most common types of skin cancer you see? Dr. Ronkainen: Absolutely. So typically, in our dermatology clinic, we see kind of three main types of skin cancer. There are basal cell skin cancer, squamous cell, and then melanoma. There are a few other more rare skin cancer types that we also treat here at this facility. However, those three are kind of the ones that dominate our interest. Host: Could you walk us through what differentiates these common types of skin cancers? Dr. Ronkainen: Absolutely. So, basal cell and squamous cell skin cancers we typically lump under the non-melanoma skin cancer category. And those are usually non-pigmented or non-mole-like skin cancers that can show up, usually on sun-exposed areas, that will show up kind of like a pimple that is just not going to heal or as a rough spot that bleeds easily. These are much more common in our older patient population. Melanoma is well known, I think, to most listeners. It’s a type of skin cancer that is one of the more dangerous types of skin cancers and those typically look like dark spots that come out of the cells that produce pigment called melanocytes.  Host: Could you describe your typical patient population? Dr. Ronkainen: Here at Washington Hospital Center we see patients from all walks of life and from the whole spectrum of ages. For patients who are coming in for skin cancer, we’ve seen everything from teens to people who are elderly. So, you know, it can really be anybody who walks through the door. Often, we’re seeing young people in their 20s for skin cancer screenings because they have a family history of either melanoma or non-melanoma skin cancers and just want to get a physician’s eyes on them to make sure that we don’t see anything concerning. Host: What are some common risk factors for developing skin cancer? Dr. Ronkainen: There are a few main risk factors that we think about when it comes to skin cancer. First and foremost, is UV radiation. Cumulative exposure to the sun or to tanning beds can increase your risk of skin cancers, including the worrisome melanoma type. In addition to that, as patients get older, there’s a higher risk just because of that cumulative damage. Also, if they’re more fair, that’s a risk factor. But I’ve seen skin cancers in our African American patients here in the District of Columbia, so it really can happen across the whole spectrum of how dark your skin is. Also, if you have a family history or a personal history - if you’ve had a skin cancer before - those certainly play a role. And then last, if you have had a history of a medical treatment such as radiation for an underlying cancer or if you have immunosuppression, whether that’s from a transplant or HIV, those can certainly play a role and do increase your risk of all three types of skin cancer, but particularly the squamous cell type. Host: When it comes to preventing skin cancer, what are some key things people can do? Dr. Ronkainen: In preventing skin cancer, sun protection is very important. Staying out of the sun between the harshest hours, between 10 and 2, during the midday is important. Wearing sun protective clothing or getting that sunscreen on can be very helpful. And also, keeping a close eye on your own skin and seeing if there’s a spot that has come up that bleeds easily or is scaly or rough or is growing - those are things to keep an eye out for. Certainly, I love going outside and exercising outside and enjoying the good weather when we have it here in the district, but just being mindful that those UV rays do add up over time is important. Host: And, speaking of sunscreen, there are a lot of options out there. Some people prefer things like all-natural ingredients. What are some important things people should look out for when they’re picking out sunscreen? Dr. Ronkainen: Absolutely. The number of different types of sunscreen has exploded, and every five minutes I’m hearing about a new type of sunscreen that’s come out. When thinking about what type of sunscreen to use, certainly the higher the SPF the better. However, sometimes when you’re using a higher SPF sunscreen it can come out pretty chalky and it can make you look like you’re wearing glue on your face. So, I often say that the best sunscreen that you can put on is the one that you don’t mind putting on. So, certainly testing out some different brands to figure out which ones you like is helpful. But in terms of trying to go towards all-natural ingredients or ingredients that don’t absorb into your skin, I typically tend to recommend sunscreens that have the physical blockers such as zinc or titanium or iron oxide. However, those tend to be a little bit thicker and less cosmetically appealing to patients because they don’t blend in as well as the chemical blockers. Host:  For sunscreen, is there an SPF level that you usually recommend? Dr. Ronkainen:  When I’m talking about sunscreens with my patients, I always recommend that they use an SPF 30 or above every day. And, typically I recommend that patients get that on in the morning as part of the moisturizer that they apply while they’re getting ready. And then, SPF 30 to 50 is typically what I recommend when they’re out being active, on vacation, at the beach, or things like that. Host: Are there symptoms of skin cancer that people should look out for? Dr. Ronkainen: When patients develop a spot that is new, growing, changing, is very sensitive or painful, or bleeds easily - those are signs of skin cancer. Certainly, sometimes patients will come in with a mole that’s just been irritated but rubs on the clothing or gets caught by the razor blade if it’s in the beard area, and we provide reassurance to that, but those red flag symptoms that I mentioned earlier certainly warrant just an extra vigilance of that spot.  Host: What are some common treatment options for people who do develop skin cancer? Dr. Ronkainen: Treatment of skin cancer depends on the subtype of skin cancer and that is a conversation between a patient and a dermatologist. However, typically most of the skin cancers that we’ve discussed today require excision, so cutting the spot out. We either do that as a conventional excision where we cut a little rim of healthy skin around the spot to cut it out completely or we send the patient for a special type of surgery called Mohs surgery. We have a Mohs surgeon here at Washington Hospital Center who is available to do surgeries like that. Very rarely, certain types of skin cancer can be treated with a topical cream. However, that decision needs to be made at the time of diagnosis. Host:  Could you further discuss the topical skin cancer treatment? Dr. Ronkainen:  Sometimes, when a skin cancer affects only the very top layer of skin, a topical cream can be used to treat the area. This is usually done by the patient at home over the span of several weeks, with close follow-up with the dermatologist to ensure that this spot is resolved completely with the topical treatment. Again, it does require that close follow-up to ensure that there’s nothing left over once the area is healed up. Usually, using the topical creams, the area tends to get red and inflamed, which is a sign that the cream is fighting off the skin cancer cells. Sometimes we use creams like that as a preventative measure in patients who have a high risk of skin cancers like the squamous cell-type, who have a lot of the pre-skin cancers, or sun damage, called actinic keratosis. Host: Could you describe what Mohs is? Dr. Ronkainen: So, Mohs surgery is a specialized type of surgery that is done by a dermatologic surgeon where the patient comes in to the clinic and has the cancer cut out with a very narrow margin. They try to spare as much of the healthy skin around the cancer as possible. The patient then waits until the surgeon is able to look at the slides, that are processed in-house, to make sure that the edges of the tissue that was taken out show no signs of skin cancer. If there is still cancer left at the edges of the spot that was taken out, then the surgeon will go back in and take out more of the skin until they know that the entire cancer is out. Sometimes it can take a little bit longer than just doing a general skin cancer surgery. However, it does spare as much of the healthy tissue around the skin cancer as possible to try and minimize any cosmetic defect there. So, it usually takes about a half a day and the patient waits in the clinic between the different stages of the surgery. However, the ultimate cosmetic result is usually very good. Host: Could you discuss the risks of not treating skin cancer? Dr. Ronkainen: Sure. So, for skin cancers like basal cell skin cancer, this seems to be a slow growing skin cancer that grows on the top layer of skin, which patients might be tempted to leave alone without treatment. However, it can cause a lot of discomfort as the spot continues to grow, bleeds easily after even just gently scratching the skin, and can eventually erode in to the tissue under the skin. Sometimes I’ve seen basal cells even go so deep as they go in to bone. However, things like melanoma or squamous cell skin cancer can travel to the lymph nodes and become more widespread and metastatic, which then would require systemic treatment with chemotherapy instead of just having the spot cut out. Host: Why should people who have skin cancer seek treatment at MedStar Washington Hospital Center? Dr. Ronkainen: We do offer comprehensive care for skin cancer here at Washington Hospital Center. It’s nice because we do have a specialized surgeon who does Mohs surgery here. We also have multiple dermatologists who feel comfortable doing general local excisions on kind of more simple skin cancers. So, it’s nice to see your own dermatologist for the procedure, that they initially diagnosed by biopsy. But also, if, unfortunately, you have an aggressive type of skin cancer, such as a more invasive melanoma, we do have the ability to work with our colleagues in general surgery or oncology or radiation oncology to optimize a multidisciplinary form of care. Host:  Could you share a patient story of someone who came in with a minor skin condition, or what they perceived as minor, and ended up needing serious treatment? Dr. Ronkainen: Sure. I’m thinking of one patient in particular who came in for a spot on his back that was just a rough, raised growth that caught easily on his clothes. And on evaluation of that spot, we realized that it was a benign seborrheic keratosis, which is just a benign warty growth that tends to come up with patient’s age. However, when we were examining the patient, we happened to notice a dark spot very close to that that the patient had not noticed because, again, it was on his back so that he couldn’t see it, that ended up being a melanoma. Thankfully, we were able to get a biopsy of the melanoma early enough and we were able to excise it and we were able to treat it completely without it causing him any further grief other than causing a scar from the surgery. But thankfully we caught it early. Host: Thanks for joining us today, Dr. Ronkainen. Dr. Ronkainen: Thanks 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.

Skin Cancer: How We Treat It and How to Prevent It

One of the main concerns for surgical patients is how much pain they will experience after their procedure.  Dr. Kenneth Fan discusses the Enhanced Recovery After Surgery (ERAS) protocol, which not only reduces pain after surgery, but also decreases the use of opioids.    TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Ken Fan, a plastic surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Fan. Dr. Fan: My pleasure. Thanks for having me. Host: Today we’re discussing ways to reduce pain after various types of plastic surgery. Dr. Fan, pain has to be one of the most common fears patients have prior to plastic surgery. Can you explain how much pain patients can expect from surgery? Dr. Fan: Yes. With the enhanced recovery after surgery, multimodality, multidisciplinary protocol, the most important thing is to set the expectation of pain. So, the first part of the series of treatments is the pre-operative assessment of the patient. So, we go through a detailed discussion with how the patient has recovered in previous surgeries and how they tolerate pain. I discuss with them how they can see themselves recover from this particular surgery. This discussion is very important because not all patients perceive pain the same way and not all surgeries have the same amount of pain. Host: How long does recovery normally take after plastic surgery? Dr. Fan: Recovery varies, based on the type of procedure. Some procedures are out-patient, meaning that patients are discharged and go home. Some procedures require a 3 to 4-day in-patient stay. The benefit of using this ERAS multimodal analgesia protocol is that no matter how long the recovery, it’s shortened - patients return back to base-line functioning sooner and have decreased narcotic usage. Host: What kind of treatments do you provide patients to help them deal with pain or discomfort after plastic surgery? Dr. Fan: So, we use a combination of pre-operative non-narcotic medication that decreases the way the nerves fire. So, they don’t fire strongly, and they don’t fire as hard. Intraoperatively we work with our anesthesia colleagues and they provide a lot of medications that decrease nausea and vomiting after surgery and decrease the amount of pain. We also use wide-spread local blocks, meaning we use local anesthesia that also targets the nerves and prevents them from firing. This also decreases pain. After surgery, we usually provide a cocktail of medications that are also non-opioid anesthesia. They also target the way the nerves fire and they subdue everything and decrease the pain levels for patients. And we found with this ERAS protocol after major surgery, patients are only taking 1 to 2 narcotic tabs after surgery. And, this is research that is being published soon. Host: Is this one way that MedStar Washington Hospital Center is trying to decrease narcotic usage in light of the current opioid epidemic? Dr. Fan: Absolutely and thank you for asking. Yes, opioid use across America has reached a tipping point to where it’s been declared a health emergency. And this protocol especially addresses narcotic use across the board. With our research we’ve been able to demonstrate that application of this protocol has reduced opioid use significantly. And this is great because patients are not reliant on narcotic usage. This takes them out of the cycle of pain and opioid dependence that we unfortunately have seen as health care providers. And this also has the additional benefit of just returning patients to baseline and making them feel a lot better. Host: Does pain tolerance vary from person to person? If so, to what extent? Dr. Fan: Absolutely. I think some patients have higher pain tolerances, some patients have lower pain tolerances. Some patients have had extensive history of opioid use. And therefore, it’s up to us, the provider of the patient, before surgery, to have a discussion and so we can better manage their pain after surgery. Host: Could you share a story in which a patient received optimal care for their plastic surgery with minimal pain at MedStar Washington Hospital Center? Dr. Fan: Yes. There’s one patient in particular that comes to mind. This is a patient who has given permission for me to share her story. She previously has had more than six hernia operations. Her most recent one required a prolonged hospital stay, over two weeks, part of which was in the ICU. As you can imagine, she was not excited to come to the hospital after her hernia came back. In fact, she was putting off her surgery since July of 2018 and her hernia, subsequently, got a lot more complicated. But, long story short, because of the collaborations between the general surgeons, the anesthesia providers, and us, the plastic surgeons, we were able to devise a plan that decreased the amount of pain and decreased the amount of surgery that we had to do. She ended up doing great after surgery. She was with this ERAS protocol, was walking postoperative day 1. She said that this was the best she’s ever felt in her 7 previous surgeries and that she was very excited to tell all her friends that MedStar Washington Hospital Center offers this service. Host: Thanks for joining us today, Dr. Fan. Dr. Fan: 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.

Reducing Pain After Surgery with the ERAS Protocol

Tree nuts are filled with high-quality nutrients, such as vitamin E, fiber, and phytochemicals. Dr. Patrick Bering discusses how tree nuts can decrease heart disease risk, particularly in people who have diabetes.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Patrick Bering, a cardiologist at MedStar Washington Hospital Center. Thank you for joining us, Dr. Bering. Dr. Bering: Thank you for having me. It’s a pleasure. Host: Today we’re discussing how eating nuts may lead to lower heart disease risk for people with diabetes. According to one study, people with diabetes who ate at least five small servings of nuts a week were 17% less likely to develop heart disease. Dr. Bering, what do you make of these results? Dr. Bering: These results are very interesting, and they seem to add to our understanding of how diet plays a key role in our risk or avoidance of cardiovascular disease. These studies were observational in nature, meaning that they relied on self-reporting from a group of patients, but they were perspective, enrolling patients at a younger stage in their life and then, following up along with them over time to see whether or not they developed any heart disease. I think that they’re very exciting and add to our understanding of what constitutes a healthy diet, especially for our patients who have already developed diabetes. Host: Why do you think these expanded on our understanding of what we already know? Dr. Bering: Nuts are an interesting topic. There’ve been some health conditions where nuts were thought to be a food to avoid and that’s been debunked with time. That includes things like diverticulosis, which is a condition of your large intestine. One of the cornerstones of a very popular diet that is practiced by people in the Mediterranean region is the Mediterranean Diet. From our observations, populations who eat a Mediterranean diet have a lower incidence of cardiovascular disease. One of the key constituents of the Mediterranean Diet is actually the inclusion of nuts for regular consumption as part of their usual diet. Host: Why are nuts so beneficial to our health? Dr. Bering: Nuts are jam packed with lots of quality nutrients. They have unsaturated fatty acids. They have plant chemicals that are called phytochemicals. They have fiber. Certain vitamins including vitamin E and folic acid. They also have important minerals for our body like calcium, potassium and magnesium. They are really jam packed with all these great nutrients, great nutritional benefit. And, because of that, we get a lot of bang for our buck, so to speak, when we consume nuts. Host: The study’s authors mentioned that tree nuts were especially associated with lower heart disease risks. What do you think makes tree nuts particularly beneficial for people with diabetes who want to lower their heart disease risk? Dr. Bering: It’s interesting that this was seen more with tree nuts than other kinds of nuts. It’s important to note that probably one of the most popular nuts, so to speak, is the peanut, which is not a true nut, it’s a legume and it grows underground. Tree nuts grow above ground and they seem to have more of these high-quality nutrients that are beneficial to our health, especially for patients with diabetes. Certain of these minerals, fibers and chemicals are more likely to provide anti-inflammatory effects, and inflammation and diabetes is one of the key driving forces of a lot of the complications in the eye and the kidneys and the vasculature. Host: For people with diabetes who want to lower their heart disease risk, what kind of nuts do you recommend? Dr. Bering: That’s a great question. There are so many good ones out there. I think almonds are a great one, cashews, pistachios, walnuts, pine nuts or hazelnuts. And, you can get very creative in the ways that you incorporate these into your diet. My wife, who is a dietician and provides my expert advice at home, will often incorporate nuts either into our breakfast with some yogurt or will add it to a salad as a way to provide some extra texture, crunch and flavor to something that we’re eating. I think there are many great examples of recipes out there, especially with the internet, where you can see how incorporating these into your diet can be helpful. Another thing is that they’re also easy to transport and so they’re a good snack on the go if you’re a little bit hungry and a much healthier option than more food of convenience or junk food. Host: Are there any potential downsides for people with diabetes when they start incorporating nuts into their diets? Dr. Bering: It is important to recognize things like portion of nuts is, as well as what salt content they may have. For example, a usual guideline is that one serving of nuts is about a third of a cup. And, if you eat much more than that, you can actually be eating too many nuts. So, you want to make sure that portion control is an important part of your diet. Secondly, some nuts come pre-salted or pre-flavored and many of these flavorings contain salt in them. For patients with diabetes who may have other problems with their kidneys or their heart disease, it’s important to note the salt content and to prefer buying nuts that are unsalted. If you want to add additional flavor to your nuts down the line, you can often use a unsalted preparation in order to give them extra flavor. Host: Nuts have been shown to lower high blood pressure. What is it about nuts that lowers high blood pressure? Dr. Bering: That’s still something that’s under a little bit of some investigation, but it seems to be partly the anti-inflammatory effects, there inclusion of unsaturated fatty acids and, most importantly, probably the potassium content. A diet that’s rich in potassium is often one that is very useful at controlling high blood pressure. Potassium is a key component in our diet at making sure that we control blood pressure. Host: What other diet tips should people with diabetes follow to prevent heart disease? Dr. Bering: As we talked about before, I think portion control is a very big issue. Many of our portions that we receive outside the home or that we see in advertisements are much too large for what we should actually be consuming. And so, following recommendations, either on the American Heart Association website or the CDC, as far as what a certain portion of different nutrients is, can be very important. As I said before, an optimal portion of nuts when consumed a few days a week or, in this study, up to five days a week, is about a third of a cup. Additionally, a great thing to keep in mind and very simple is that ultra-processed foods - and, what I mean by that is foods that don’t look like anything that occurs in nature - those are foods that often have the worst health effects. Those are foods that have a lot of sugar-enriched sweetening or artificial sweeteners and colors and those are often the foods that lead to adverse cardiovascular health or obesity-related illnesses, such as diabetes or high cholesterol. Host: Why is MedStar Washington Hospital Center the best place to seek care for heart disease? Dr. Bering: We have a very comprehensive and passionate team that loves to serve their community here in the DMV. We have experts in every level of care, from primary care to preventative care as well as to emergency care, if you happen to have the misfortune of suffering from cardiovascular disease. I’m very honored to work with my colleagues, who inspire me every day. But, most inspiring to all of us is our interactions with the patients whom we serve. Host: Could you share a story where a patient with diabetes started following a healthier diet and experienced a decrease in their heart disease risk factors? Dr. Bering: Yes. Interestingly, I recently had the pleasure of taking care of a young man who was obese and had high blood pressure and diabetes, both of which were more recently diagnosed. He unfortunately came to the hospital with a small heart attack. But, after treating the heart attack, he made really positive health changes in his life. He started doing a cardiac rehab program, exercising on a regular basis, and made positive dietary changes, cutting out a lot of the food of convenience - things like fast foods or snacks that are not natural and are these ultra-processed foods. Since then, he’s lost a good deal of weight, says that he’s much happier and has improved energy and overall quality of life. He’s made great progress and it’s a nice journey to go on with him together, to help support him and his improved cardiovascular health.  Host: Thanks for joining us today, Dr. Bering. Dr. Bering: Thank you. I appreciate it. 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.

Nuts Can Lower Heart Disease Risk for Diabetics

Riding an electric scooter is fun and convenient. But it’s important to be careful, as accidents can result in serious injuries, such as fractures to the lower and upper extremities. Dr. Robert Golden discusses how we treat these injuries, as well as tips for riding safely.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Robert Golden, Chief of Orthopaedic Trauma Surgery at MedStar Washington Hospital Center. Thank you for joining us, Dr. Golden. Dr. Golden: My pleasure. Thanks for having me. Host: Motorized scooters are a growing form of transportation in the US. You see people riding them all around the streets and in traffic. As a result, injuries are always a possibility. Today we’re going to discuss some of these injuries, plus some key safety tips. Dr. Golden, could you start by explaining some of the most common injuries you see from people riding motorized scooters? Dr. Golden: Well, we’ve seen a fair breadth of different injuries from them. It’s not a typical single pattern that we’ve seen from them, which you see in some other injuries. With the scooters we’ve seen everything from upper extremity injuries to lower extremity injuries and pretty much everything in between. It seems like part of this is probably because of the different mechanisms where you can get injured while on these. Depending on how you get injured and what you were doing at the time, what happened can really change what gets hurt. Host: Can you share some specific examples of some of these injuries? Dr. Golden: Sure. We’ve seen a couple people who have just fallen off of them, from simply not negotiating a curve right or hitting a bump in the street or in the sidewalk. Some of them have had fractures of their upper extremities and to their arms. A couple of them had been open fractures, meaning the bone came out through the skin. A bunch of wrist fractures, as well, for the same reason. The other sort of spectrum that we see from these are when they’re hit by cars. Some of them have had lower extremity injuries, in mostly their legs and their tibias, the bone below your knee and above your ankle. Again, sort of the same kind of mechanism that they’ve either simply hit a bump or didn’t negotiate a turn quite right and just fell off. Or, they get hit by a car, which you can imagine causes a lot more injuries. Some of them simply get on them and don’t realize how fast they’re going. Then, in haste to sort of slow down or to make a turn, kind of jump off of them without really slowing down and realize they’re going pretty fast after they’ve jumped off. Host: Can you think of some of the most frequent treatments you’ve given patients for their scooter-related injuries? Dr. Golden: Sure. Well, a lot of that depends on what’s been injured. Most of them have, or at least a lot of them, I guess, have required surgery for them which generally would then involve realigning the bone and then stabilizing it either with a nail or plates and screws to hold it still and in the right position until the bone can heal. Host: What are some tips you offer patients to help them avoid getting hurt while riding their scooter? Dr. Golden: I think a lot of it is just knowing the capabilities of the scooters themselves and realizing if they’re new to riding these, they’re not exactly the same kind of scooters you were riding when you were little - the little Razor scooters and you would just kind of push them along. Some of them pick up a fair amount of speed - kind of realize that, at that speed, if you hit something or you get thrown off, there’s a good chance that you could injure something. And then, of course, it’s a pretty busy city down here and you always have to watch out for the cars and the pedestrians. Host: Are there certain people you would recommend not to use a motorized scooter? Dr. Golden: I think if you’re careful and know your capabilities, you’d probably be ok. Probably not a great idea for anybody with a history of osteoporosis or issues with their fragile bones to try them out. And, I think if you DO, you should just start off slowly, figure out how fast these go, make sure you can maintain control on them before you really see how fast they can go. Host: Why is MedStar Washington Hospital Center the best place to seek care for any motorized scooter-related injuries? Dr. Golden: Well, we have the MedStar trauma unit here which allows us to provide a comprehensive care from multiple disciplines. So, the orthopaedic surgery teams are involved, the general surgery teams are involved in case they have any other injuries - internal organs, that sort of thing. And, we’re also plugged in with the physical therapists, the occupational therapists, to get people back to their jobs, get back to walking, depending on which injuries they have, as well as the plastic surgery teams because sometimes these injuries, when the bone comes through the skin, creates a defect that needs to be covered. So, fortunately, we have everything all in one place and all the teams are coordinated so whatever injury you have, we can service. Host: Could you share a story in which a patient received optimal care for a motorized scooter-related injury at MedStar Washington Hospital Center? Dr. Golden: Sure. We had one patient who came in - again, same kind of thing - he was riding one of these and fell off of it. Had a fairly complex fracture of his...what’s called his tibial plateau, which is the top part of your tibia, right by your knee. He had to go through several surgeries until that could be stabilized. Eventually, it required some coverage by the plastic surgery team, so they took care of that for him, as well, and, eventually, healed that up. Host: Can you explain what recovery typically is like? Dr. Golden: I mean a lot of it depends on what’s broken. In general, bones take about 3 months to heal, somewhere around 12 weeks. Some bones heal a little faster, some heal a little slower. But, in general, they’re looking at some sort of immobilization. Or, once they’re fixed, the point of fixing them is to get them up so that they can move, minimize any stiffness. Usually there’s a short period of immobilization right after the surgery, just to let the wound settle down. Then that’s followed by getting them up and moving and making sure they don’t get too stiff on the joints near where things were broken. We see them back in the office during the entire time that they’re healing to make sure that everything’s healing appropriately, that it’s staying aligned the way we left it, make sure that there’s no other complications coming up or they’re having difficulty with anything else as a result of these things. Host: Is physical therapy usually a part of recovery?... Dr. Golden: Yeah, often they do get some physical therapy. Some of it depends on where they were injured and what the treatment was. In general, if it’s in the middle of what’s called a long bone, generally your femur or your tibia, and we can put a rod into it to fix it, they can get up very quickly and put weight on it right away and the bone just heals around it. So, some of those people require less intensive physical therapy because they can just kind of get up and start walking around on their own. Some of the people, where it breaks into the joint and it kind of shatters - it doesn’t break in to clean fracture lines - a lot of those people do require a fair amount of physical therapy to get their joints moving again, minimize their stiffness, rebuild the strength that they lose. Host: Thanks for joining us today, Dr. Golden. Dr. Golden: Thanks 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.

Electric Scooter Safety

Blood clots, prior abdominal trauma, or abdominal surgeries can lead to scarring in the iliac veins. Dr. Steven Abramowitz discusses how endovascular iliocaval reconstruction can restore healthy blood flow.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Steven Abramowitz, a vascular surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Abramowitz. Dr. Abramowitz: Thanks for having me. Host: Today we’re discussing endovascular iliocaval reconstruction, a treatment for iliocaval thrombosis and other vascular conditions. Dr. Abramowitz, could you begin by discussing who the best candidates are for endovascular iliocaval reconstructions? Dr. Abramowitz: Sure. It’s a mouthful. Endovascular iliocaval reconstruction is our way of rebuilding the connection in the veins, the structures that bring blood back to your heart. And, when the veins drain from your legs, they merge in your belly, like an upside-down Y and they form one big vein called the inferior vena cava. So, when we say iliocaval, we mean the iliac veins, which drain your legs, and the inferior vena cava, the main vein that they form inside the belly. What can happen is, in certain patients who have had blood clots in the past, or a history of trauma - maybe a gunshot wound to the belly, or even things like radiation therapy for cancer, or prior surgery - scar tissue can form around those veins. And those patients present with significant swelling in their legs and that swelling can also result in significant wound formation in both of the legs, as well. So, what we can do is, in a minimally invasive way, reconstruct the pathway, restoring flow from the legs back up to the heart to alleviate that jam of blood that’s increasing pressure in the veins. Host: Can you explain how endovascular iliocaval reconstruction works? Dr. Abramowitz: Absolutely. So, as I mentioned before, when these veins scar down, or block off and narrow, there’s usually a thin little bit left. And the best example I can give is your veins, normally, are like four-lane highways. But let’s say there’s a massive snowstorm and a snowplow has to get through. And it only puts a small path and it piles up all this snow on the sides of the road. Maybe only a bicyclist can get by, or a single car. And that narrowing, when you think about how blood has to flow, is just too little and so the blood builds up in pressure.  But what we can do is say we find that pathway, where that one snowplow went, and we can use a series of balloons and stents, which are metal tubes like tunnels, and we can expand and push that snow or scar tissue to the side, making sure that you get all four lanes flowing back again, and alleviating any pressure that’s built up in the legs. Host: What is recovery normally like following this procedure? Dr. Abramowitz: Recovery from this procedure is actually pretty easy. For the most part, we’re not making any incisions. So, this surgery is done through punctures, usually behind the knee or in the groin. So, people have some soreness at those puncture sites. The biggest complaint actually is back pain. We don’t really have nerves that tell us our veins are being stretched and so, after this procedure, the most common thing that people experience is a sense of muscle spasm that can last up to 2 to 3 weeks. And that’s really the stretch of that vein sitting in the body. So, you may not feel like you can get comfortable in your chair but you’re not going to feel like you’re in extreme pain. Host: Are there any risks involved with the procedure? Dr. Abramowitz: So, the biggest long-term risk from this procedure is actually tied to what caused the procedure to be needed in the first place. Most people who require iliocaval reconstruction - again, stenting and opening up those veins - had those veins shut down as a result of a blood clot. So, once we open those veins up again, we’ve reestablished a pathway from the legs back up to the heart. And so, it’s really important that people stay on their blood thinners. Now, for a variety of reasons, people can develop scar tissue or other ways that the stents can shut down over time. But the biggest danger is if they shut down suddenly through another new blood clot. And that’s if somebody maybe needs to stop their blood thinner to have another procedure. Or, they stop their blood thinner because they don’t think it’s important anymore. So, the biggest risk that I counsel people about is the risk of future DVT and future pulmonary embolism, or that clot moving back from the legs or from the stents to their heart. Host: Is there anything patients need to do to prepare for surgery? Dr. Abramowitz: No. For the most part, to prepare for this procedure, it’s to make sure that you’re ready for your surgical date - you have someone to come pick you up from the hospital - and you’re prepared to have your medications ready, which include your blood thinner and some pain control for those potential back spasms. Host: Why is this procedure superior to other techniques used to treat similar conditions years ago? Dr. Abramowitz: That’s a great question. I get asked that a lot. The old way of reconnecting these veins was actually to bypass around them. And a bypass in the venous system is a huge surgery. It means making a big incision, all the way from the bottom of your chest all the way down to below your belly button. And then it means opening up both of your groins, taking plastic tubing or a vein from someone who maybe just died recently and donated their veins for use in medical procedures, sewing them all together, closing you back up, and then waiting for you to heal. But not only was that the problem, the blood that flows in your veins doesn’t flow at a very high rate. It flows actually pretty slowly. So, when we talk about blood pressure, most of the time we’re talking about what it is in your arteries, or the pressure at which it comes out of your heart. And that’s 120 millimeters of mercury. So, just remember 120. On the veins, our pressures are much lower and they’re somewhere between 8 and 12 - so, one tenth that of what’s in your arterial system. So, not only did you just have this huge surgery to bring the blood flow back to your heart, with all this plastic tubing or donor vein, but then, on top of that, the blood that moves through it isn’t moving very fast. So, it’s a very big surgery. And, in the past, it wasn’t really worth it because the failure rate was so high. Over time, most of the things that were done from an open surgical standpoint thrombosed, or clotted off. Now that we can do this within the body, in its natural pathway, we find that the patency rate, or our stents staying open (is really what we call patency), is much higher. And 87 percent of people that undergo iliocaval reconstruction have open stents at five years, which is much, much higher than the previous open bypass rates. So, if you had the bypass, it’s a big, open surgical procedure, usually resulting in a hospital stay that’s anywhere from 5 to 7 days, and then there’s recovery time after that. And, as I said before, the likelihood of that bypass staying open is pretty low. Not to mention, once you have all that scar tissue from the bypass, it pretty much eliminates a lot of other surgical options you may have in that area. Whereas, on this endovascular side, we can do things in a minimally invasive way, via some punctures, you can go home the same day, and it doesn’t necessarily limit your options in the future, should, in the small case that you’re that 13 percent your stents don’t stay open at 5 years, they do fail. Host: Why is MedStar Washington Hospital Center the best place for patients to seek an endovascular iliocaval reconstruction? Dr. Abramowitz: Well, there are a lot of great facilities out there that can perform venous stenting. MedStar Washington Hospital Center was one of the first in the country truly performing endovascular iliocaval reconstruction in its entirety. Not only that, we also are engaged in a lot of novel techniques to do this in a way that improve patency and outflow. So, we’re really one of the leaders in this field and we have a lot of new technology that we’re developing, as well as new techniques for patients who may have failed therapy before at other institutions. So, we’re on the forefront of this field and we really do have a comprehensive program in place to care for patients, both before and after their reconstruction. Host: Thank you for joining us today, Dr. Abramowitz. Dr. Abramowitz: My pleasure. Thanks 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.

Endovascular Iliocaval Reconstruction

Each year, more than 500,000 people visit an emergency room because of a kidney stone, which can cause severe kidney pain and blood in the urine. Dr. Daniel Marchalik discusses outpatient tubeless mini PCNL, a minimally invasive procedure for large kidney stones.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Daniel Marchalik, the Director of Ambulatory Urologic Surgery at MedStar Washington Hospital Center. Thank you for joining us today, Dr. Marchalik. Dr. Marchalik: Thanks so much. Happy to be here. Host: Today we’re discussing percutaneous nephrolithotomy, or PCNL, a technique used to remove kidney stones. Dr. Marchalik, could you begin by discussing who would be a candidate for mini PCNLs? Dr. Marchalik: Yeah, so PCNLs are...actually, it’s a very interesting procedure because traditionally we’ve always thought of PCNLs as being a very invasive and a very difficult procedure. But increasingly, what we’re finding is that PCNLs, or the indications for PCNLs, have been expanded. So, anyone who has a large kidney stone - and by that I mean a stone that’s bigger than 1-½ centimeters - is automatically a better candidate for a PCNL than other types of surgery, barring other considerations, of course. But for mini PCNLs specifically, what we’re finding is that patients that have intermediate-sized stones - so maybe a lower pole stone that’s a little bit bigger than a centimeter or other stones that are bigger than a centimeter and a half but maybe less than a full staghorn calculus, which is a stone that occupies the whole kidney - those are the perfect patients. Host: What are some common symptoms people have before they’re diagnosed with kidney stones? Dr. Marchalik: A lot of times people will present with pain in their kidney or in their back. They might feel like they are actually passing a kidney stone, in which case they will have spasms. In fact, people have actually compared kidney stone pain to childbirth. And, they did a study on this and it turns out that passing a kidney stone is as painful as giving birth. It’s one of the few times that guys can actually feel what women go through. Also, sometimes you can present with an infection in the urine or blood in the urine. And, all of those could potentially be caused by kidney stones. Host: How does a mini PCNL operation work and what are its greatest benefits? Dr. Marchalik: So, percutaneous nephrolithotomy - if you actually break the word down, it means that we are going percutaneously through the skin into the kidney. And nephrolithotomy means that we’re taking the stone out of the kidney. So, we put a small opening into the kidney, through the back, and through that opening we’ll put in a scope and a probe that can break the stone up into smaller pieces and actually suction those pieces out. The greatest benefit of the mini PCNL versus a regular PCNL is that with this procedure we still get all the benefits of a PCNL. So, we still can get patients out of the hospital with less stones or no stones at all. We can decrease the number of surgeries that they need to become stone free. But, it’s got some new benefits - meaning, we do it through a small opening so there’s less pain afterwards. We don’t have to leave a tube behind in the back a lot of times. And, a lot of times we can actually send patients out the same day. So, traditionally people would have to stay in the hospital for several days to get this procedure. But now we can actually get patients in and out and still be able to clear way more stone than we would be by other techniques. Host: What can patients expect during recovery? Dr. Marchalik: There are certain things that necessarily will happen whenever you have surgery - so, grogginess after anesthesia. Some people can get nauseous after the anesthesia and that happens with any type of anesthesia that you get for any procedure. With this particular procedure, sometimes patients can have pain in their back where the opening was. And they can see blood in their urine for several days. And, they can feel some discomfort in their stomach or in their back afterwards, and a lot of times that’s actually from a small tube that we call a stent that’s left behind to allow the area to heal. Host: How is the way you perform mini PCNLs compared to traditional PCNLs or similar treatments from years ago? Dr. Marchalik: The main difference here, the thing that really separates mini tubeless PCNL from a regular PCNL, is that we’re doing it through a smaller opening. Before, we would have to put a larger opening to accommodate our large instruments but as we began to miniaturize these instruments, we’ve been able to do this through a much smaller incision. And, as you can imagine, a smaller incision leads to a better recovery, less pain, less discomfort. The biggest difference is - and the biggest barrier to doing PCNLs traditionally - has been the length of stay, meaning you want the benefits of the PCNL to get as much of the stone out as possible, to do it quickly, but you don’t want the longer hospital stay, possibly coming in the day before, possibly staying a day after the procedure. With this procedure, we’re now able to send patients home the same day as the procedure itself. So, we get the benefits of the PCNL but not some of the barriers that we’ve seen in the past. Host: Why is MedStar Washington Hospital Center the best place to receive mini PCNL and similar operations? Dr. Marchalik: I think a lot of it comes down to us having a high volume of this procedure. It’s a procedure we do a lot of and we feel very comfortable doing. We also have a really fantastic interdisciplinary team. So, sometimes we’ll review these images with our interventional radiology partners, if it’s a more complex case. But more importantly, we also think about this holistically. It’s not just a surgery. At the end of the day, we also follow these patients for years after. We make dietary modifications and any type of other changes that we need to make to make sure that we don’t just treat the stone. We treat the patient. And we prevent these stones from coming back in the future. Host: Could you share a story where a patient received optimal care at MedStar Washington Hospital Center through a mini PCNL? Dr. Marchalik: Well, actually I had a really great case recently. This was a patient who had a large stone. It was blocking his kidney, causing a ton of pain in his back, some nausea and other discomfort. And he was really concerned because he thought that he would require multiple surgeries to get rid of the stone. We were able to do a PCNL - a mini tubeless PCNL - on him. He came in for an 8:30 case. He was home by 1 o’clock. No pain. No discomfort. No tubes left behind. I ended up seeing him in my clinic the week after and he reported that he actually had a great postoperative course. He didn’t have any discomfort or pain. No issues with his back. And all the pain that he had before the surgery was now gone. Now, we still have a long road ahead of us. We still have to figure out why it is that he was making stones in the first place, but at least this part is now over. Host: Are there any risks associated with mini PCNLs? Dr. Marchalik: As with any surgery, you have inherent risks associated with the anesthesia itself. And it doesn’t matter what type of surgery it is, anesthesia always poses a risk. But, there are some inherent risks to this procedure itself. Because we’re going through the back, there’s always risk of damage to the organs that are around the kidney. Now, that risk is small. The only time that this could be a little bit more concerning is with stones that are very high up in the kidney, but we take measures to mitigate that risk, as well. The real risk is that we don’t get all the stone out. And sometimes when you have a very large stone, even despite using this technique, not all the stone gets cleared. That being said, this is the procedure that gives you the highest chance of being stone free at the end. But, we still have to remember that, as with any surgery, every case is different. So, you have to always be able to adapt and do what’s right for each individual patient. Host: Thank you for joining us today, Dr. Marchalik. Dr. Marchalik: Thanks so much. Happy to be here. 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.

Mini PCNL: Minimally Invasive Treatment for Large Kidney Stones

Obesity is the number one cause of cardiovascular disease in the U.S. However, new research shows that bariatric surgery can reduce heart attack and stroke risk in patients with obesity and diabetes by 40 percent within five years.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Timothy R. Shope, Chief of Bariatric Surgery at MedStar Washington Hospital Center. Thank you for joining us, Dr. Shope. Dr. Shope: Thanks for allowing me the time to talk to you. Host: Today we’re discussing 2018 research that suggests that bariatric surgery can dramatically lower the risk of strokes and heart attacks in obese patients who have diabetes. Dr. Shope, could you begin by discussing how obesity, diabetes, and the risk of heart attack and stroke are connected? Dr. Shope: Sure. Many of our patients that we see coming to surgery for surgical weight loss purposes do have diabetes as a component of the multiple medical problems that they have. Obesity is becoming more and more common in our society. Diabetes is becoming more and more common in our society. They’re, without question, intertwined. And what we see is, particularly with this research that’s been done recently, patients that are diabetic and obese that have surgery, have a much lower risk of ultimately having a heart attack or stroke than diabetic, obese patients that do not have surgery or manage with medications alone. Host: How can bariatric surgery reduce the risk of stroke and heart attack in a patient with diabetes? Dr. Shope: Bariatric surgery not only helps patients lose weight - pretty simple thing. We put you on the scale - we can tell that you’ve lost weight. But a lot of these patients will have dramatic improvement in their medical problems as well. Specifically, in this case we’re talking about diabetes, patients that undergo particularly the gastric bypass surgery can have rapid improvement in their diabetic profile. We have some patients, not many, but a few a year will actually leave the hospital not taking their diabetic medications - simply checking their sugar and if it is a little bit too high, then they still have the ability to take some of these medications but they’re not taking them on a regular routine basis. The rest of the patients that do go home on their medications, within weeks and months they are dramatically reduced if not off of them. Similar results can be achieved with either the sleeve gastrectomy or the lap band, but usually it’s directly related to the amount of weight that these patients are losing. So with the sleeve gastrectomy, they do lose weight rapidly and often can get down on their dosages or converted from injectable medications to pills or come off all of the above within several months with the sleeve gastrectomy. With the lap band, which takes a little bit longer for patients to lose the weight, they can ultimately, in many cases, get down or off of their medications, particularly if they’ve been recently diagnosed with diabetes. Host: After bariatric surgery, how likely is a patient to resolve or improve their diabetes? Dr. Shope: Well, based on historical information, we know that, particularly, again, with the gastric bypass procedure, upwards of 85 to 90 percent of patients will resolve or substantially improve their use of diabetic medications and essentially not be diabetic any longer. A little bit less of a likelihood if they have a sleeve gastrectomy. And, with the lap band, it’s really only more like 50 to 60 percent of patients will ultimately be able to get off these medications. And again, if we’re talking about making the patient so that they are no longer diabetic from the standpoint of not needing medications and from the laboratory studies that we do to surveil these patients whether or not they’re diabetic - if we can claim that they’re no longer diabetic, the recent paper that we’re talking about today suggests that there’s around a 40 percent reduction in the risk of having a heart attack or stroke. Host: Which patients would you consider ideal to have bariatric surgery, in part to improve their cardiovascular health? Dr. Shope: Well, there are very strict NIH guidelines around these topics. The patients need to have a certain body mass index, or BMI. It’s basically a ratio of our weight to our height. So someone who’s very tall would also have to weigh a lot in order to meet the criteria for surgery. Likewise, someone very short might not have to weigh as much. But if you have a body mass index of greater than 40, or greater than 35 with certain medical problems like diabetes or obstructive sleep apnea or certain severe medical problems from other types of body systems, you might meet the criteria for weight loss surgery. Other ways of looking at this include things like being more than 100 pounds over your ideal body weight. These are some softer ways to look at whether or not someone might meet the criteria for surgery. So, if the patients otherwise meet the criteria for surgery, then all of the medical troubles that they come with, including those for cardiovascular risk, should improve with losing weight. There are some things that we can’t help patients with. For example, there are some downright skinny people that have high blood pressure. So, you may have high blood pressure for other reasons - family history, age, race, gender. These are things that obviously the surgery is not going to change about you. But if we can help you with your weight and that’s what’s maybe making you be hypertensive or making you be on three medications for high blood pressure, then we can hopefully reduce some of that. And again, most patients that are diabetic, with substantial weight loss, will at least improve, if not resolve, their diabetes. Host: Could you share a story of a patient who had bariatric surgery and had a fairly dramatic cardiovascular outcome? Dr. Shope: So, we’ve had many patients definitely improve their diabetic profile, and include their cardiovascular risk as well. It’s hard to prove that any one of our patients did not have a heart attack because of the weight loss and the improvement in their medical problems that they had just because of their surgery. The research that we’re looking at today talks about a population of patients. And, if you look at the population, we can see that there’s reduction in risk for these things. But for the individual patient, I’d love to be able to say that we prevented heart attacks - and we likely have - I just can’t point to a single individual that we know for certain we prevented. What I can tell you is that there have been a number of patients over the years that have dramatically reduced their reliance on diabetic medications and high blood pressure medications, so clearly improving their cardiovascular risk. We’ve had a couple of patients over the years that have even had prior heart attacks that come in for surgery, lose a whole bunch of weight, and their cardiologists are just so happy with the improvement in their cardiac function and their, again, reliance on these medications. Host: Why should somebody with a history of diabetes come to MedStar Washington Hospital Center for bariatric surgery? Dr. Shope: Well, I think bariatric surgery can be part of the treatment for these types of medical problems. In fact, potentially a cure in some patients. If we can get you off of your medications and your lab profile suggests that you’re no longer at risk for diabetes, I would consider that a cure and that’s quite a powerful statement to say that an operation can actually cure a medical problem. That’s not something that’s common at all. I think that, you know, we have experts in the field, we know how to do these operations, we know how to look after patients afterwards. And yes, of course, we’re going to include your diabetologist and your primary care doctor and be certain that the entire patient is taken care of here. But I think that we’ve got, you know, the right team in place at MedStar Washington Hospital Center to take care of this difficult problem. Host: Thanks for joining us today, Dr. Shope. Dr. Shope: 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.

How Bariatric Surgery Reduces Heart Attack and Stroke Risk

Treating cancer on the head or neck can seem intimidating, as people fear surgery could leave unwanted scars around their face. However, with the techniques we use today, people often end up cancer-free with very few changes to their appearance.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Jonathan Giurintano, a head and neck cancer surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Giurintano. Dr. Giurintano: Thank you so much for having me today. Host: Today we’re discussing reconstructive surgery for head and neck cancers. When a patient has cancer in such a visible area of the body, it’s important for them to have options to not only remove the cancer, but also keep them looking like themselves after surgery. Dr. Giurintano, what are some of the more common cancers for which patients might need reconstructive surgery after treatment? Dr. Giurintano: So, while approximately 90 percent of cancers that occur in the head and neck region are a type of cancer called squamous cell carcinoma, this type of cancer can affect multiple areas within the head and neck. Some examples include the tongue, the jaw bones, the palate, the inner surface of the cheeks, the back of the throat, carotid or saliva glands, and the voice box. Oftentimes, the surgery required to remove tumors from these locations results in very large, noticeable defects that affect not only the patient’s physical appearance but oftentimes their ability to speak, breathe or swallow. More recently, legendary Buffalo Bills quarterback Jim Kelly has been in the news for his fight against head and neck cancer. His cancer was a squamous cell carcinoma located in the maxilla, or the upper jaw bone, and he initially underwent treatment consisting of chemotherapy and radiation therapy but unfortunately developed a recurrence of the cancer after his initial treatment. Because of this, surgery was performed to remove the recurrent cancer in his upper jaw bone and the salvage setting. And, in a patient who’s previously had radiation therapy, it’s very difficult for this area to heal after surgery and the result leaves a communication between the mouth and the nose, which can make speech abnormal, as well as swallowing. So, Jim Kelly underwent his surgery in New York by Dr. Mark Urken, who’s one of the most nationally known and most experienced surgeons, using what we call free flaps to reconstruct head and neck defects. So, a free flap is a piece of tissue that’s harvested from an area of the body outside of the head and neck, that often consists of either skin, fascia, muscle, bone, fat or a combination of all of these. And, it’s a piece of tissue that can be harvested with an artery and a vein that can supply blood to this piece of muscle or bone or fat. We can then take that tissue from the leg or the arm or the thigh and then transfer that up into the defect site and use it to reconstruct things like the tongue, the voice box or the jaw bone. Then, using a microscope, under very high magnification, we can actually sew the artery and the vein that are from the flap to an artery and a vein in the neck and that will actually provide that piece of tissue with its own blood supply. This is especially important in head and neck cancers because most of our patients receive radiation therapy as part of their treatment and without a robust, healthy blood supply, most pieces of tissue will die from the radiation therapy. We do know these pieces of tissue have a robust vascular supply and that they can withstand the radiation treatment, leading to very good results in reconstructing the donor site defect. In Mr. Kelly’s case, Dr. Urken performed what’s called a fibula free flap. And that’s when a piece of bone from the lower leg, called the fibula, is harvested with some overlying skin and an artery and a vein and he was actually able to use that bone to recontour the upper jawbone that was missing after the surgery. And he was able to use the skin from the flap to seal the hole in the palate so that Mr. Kelly was able to talk, eat and look normal essentially. In Mr. Kelly’s case, he was then able to have titanium dental implants inserted into that bone so that he could actually have teeth in his upper jaw again. And, if anyone’s seen him in the news lately, they did a fantastic job and he looks almost the exact same as he did before surgery. And, that is really the ultimate goal of cancer and reconstructive surgery nowadays. Host: How do patients feel when they learn that their appearance might be affected by the surgery that will remove their cancer? Dr. Giurintano: So, patients often feel a mixture of emotions. Receiving a diagnosis that you have cancer is very difficult. And, to add on to that diagnosis that you might require major surgery that might result in a physical deformity can be even more devastating to patients. Our facial structure is often a major part of our identity and it can be very psychologically devastating to learn that your visual appearance might be affected. This goes for the voice, as well. We all have unique voices that we can recognize very distinctly. And the possibility that you might lose your own unique voice can be very devastating to patients. In the past, patients would often have these tumors removed without any technology to reconstruct them and this could lead to crippling deformities that were very easily noticeable upon first glance.  And this has a major psychological impact on patients. Some can often lead to depression and anxiety in our cancer patients. And while it’s impossible to perform a surgery that’s completely scar-less, all surgery requires at least an incision, today we have advanced techniques that limit the deformity that’s caused by removing cancers from the head and neck. We also have to give credit to the body itself. The body is pretty incredible in that anytime we take skin from the arm or the leg and we place it into the mouth, the body can actually recognize this change in the environment that the skin is in and it actually begins to change the cell types of that flap. And through a process that we call mucosalization, the flap actually begins to take on the appearance of the native tongue or the native surface of the mouth. In many of these patients, when you see them one or two years down the road, it is actually very difficult to tell which piece of tissue in the mouth came from the arm or the leg. It just looks like normal tissue. Host: Is the reconstruction procedure performed separately from the cancer surgery? Dr. Giurintano: So, we actually work together in what we call a two-team approach so that we can both remove the cancer and reconstruct the defect at the same time. This means that while the ablative, or the cancer removing surgeon, is working in the head and neck to take the cancer out, the reconstructive surgeon is, at the same time, working on the arm or the leg to harvest the flap so that as soon as the cancer is removed and the defect is made, the reconstructive surgeon can then take that flap, remove it from the arm or the leg and begin in-setting it into the defect. So, by doing the cases in this manner, we can typically finish an entire cancer removal and reconstruction in anywhere from 6 to 10 hours. Back whenever these types of surgeries were invented 20 or 30 years ago, the cases could often go over 24 hours. So, it’s actually been a big advance in our medical practice that we can finish these cases generally in under 12 hours. Our goal, essentially, is to limit the time the patient has to spend on the operating table under general anesthesia and to try to get patients back on their feet as quickly as possible after surgery to help quicken the recovery process. Host: What does a patient have to do to prepare for head and neck surgery with a reconstruction? Dr. Giurintano: Most of the preparation, from the patient standpoint, is more mental and emotional. We recommend that they have a good support system in place, whether it’s family or friends, to help them cope with the psychological impact of undergoing a major surgery and a, typically, 7 to 10-day hospitalization. There are some tests that we may perform in our clinic or in the radiology suite before we schedule a patient for a free flap. Nowadays we really try to tailor what type of free flap we are doing individually to each patient. In the past, physicians would often do one flap as their main flap, regardless of what the defect was or what the patient’s lifestyle included. But nowadays, for example, say if a patient of mine was a classically trained pianist and they wanted to continue playing piano after their surgery, I would be very hesitant to take any tissue from around their forearm or wrist. I would not want to interfere with their ability to play the piano at all. So instead I would go to a different donor site, either the side of the body or the leg. I’d take a similar piece of tissue and contour this to match the defect site. Occasionally, some patients require some tests such as angiography. This is a special test performed in the radiology suite to determine if the blood vessels are good enough to support a flap. For the fibula flap, especially - that’s a flap of the bone called the fibula in the lower leg that we often use to reconstruct the jaw- we know that there’s 3 distinct blood vessels that carry blood into the lower part of the leg to supply the foot. By taking the fibula, we have to take one of those blood vessels out to apply the flap, leaving 2 blood vessels to supply the leg. Normal patients - this is not a problem to remove this blood vessel. However, some patients only have 1 or 2 blood vessels supplying the lower leg, not 3. In these cases, it could be potentially disastrous to take the 1 blood vessel that’s supplying the lower leg. So, in this type of flap, we’ll always do a test before to make sure that the blood vessels are sufficient to sustain the flap. But otherwise, typically, we do not have many other special tests that are required before pursuing a major reconstruction.    Host: How long is the recovery time for these patients? Dr. Giurintano: So, in general, our patients who undergo free flap reconstructions generally spend the first two days after surgery in the intensive care unit setting. During this time, it’s not that they’re so sick they require a stay in the intensive care unit. It’s actually that we have to frequently check the blood vessels supplying the flap to ensure that the blood is flowing to the flap and that the flap is getting the nutrients that it needs. Once the first two days have passed, as long as the patient is doing well, they often go to the floor. And from that point on, most patients spend anywhere from 3 to 5 days on the floor, receiving basic medical care as they recover. Oftentimes they’re receiving physical therapy or occupational therapy during this time to recover their strength. And all of the basic preparations for that patient to go home are being arranged. Typically, if all goes well during the surgery and during the hospitalization, most patients spend about 5 to 7 days total in the hospital and then either go home or sometimes go to a lower level of care, such as a rehabilitation facility to help regain their strength before they’re ready to go home. Once at home or in a rehab facility, it still takes a couple of weeks for the patients to completely recover. And, in general, the entire recovery process takes about 4 to 6 weeks total. But, most patients are back swallowing, speaking, and doing normal activities within 2 weeks of surgery.  Host: What additional treatment or care do patients need after reconstructive surgery? Dr. Giurintano: Depending on the complexity of the case and how the hospitalization proceeds, some patients are able to go straight home and essentially require very minimal extra care. Occasionally, patients require the placement of feeding tubes or tracheostomy tubes. Tracheostomy tubes are special breathing tubes that are inserted into the neck that some patients may require because, occasionally, there’s too much swelling or the flap is too bulky inside of the mouth for them to breathe or to swallow well. Generally, this is a short-term procedure that patients do not require permanently, but sometimes this may require some extra care by a home health nurse or at a rehabilitation facility. Occasionally, if patients have trouble swallowing in the post-operative period and we a concerned that they might accidentally aspirate their foods, a tube can be placed into the stomach to help facilitate nutrition while they’re recovering. And, generally, this is also a short-term procedure that most patients are able to have removed after 6 to 8 weeks. Host: How do the surgeons at MedStar Washington Hospital Center help patients achieve the best cancer related outcomes and cosmetic outcomes with these complex procedures? Dr. Giurintano: So, at MedStar Washington Hospital Center, we work together as a team. Our team includes multiple members within the department of otolaryngology head and neck surgery. And this includes both ablative cancer surgeons (so those are surgeons who remove the cancer), reconstructive surgeons (such as myself), as well as facial plastic and reconstructive surgeons (so these are surgeons who are specially trained in cosmetic procedures of the head and neck). In caring for these patients, we, as surgeons, are responsible for the removal and the reconstruction of their cancer and the subsequent defects. But, in treating their cancer, we also share equal responsibility with our colleagues in the departments of radiation oncology and medical oncology. There are some types of head and neck cancer that can be managed through surgery alone, but most patients who have a head and neck cancer will also require either radiation therapy or chemotherapy as part of their treatment algorithm. We actually have a regular meeting at the MedStar Washington Hospital Center where the surgeons (such as myself), the medical oncologists, the radiation oncologists, the speech pathologists, the pathologists and the radiologists all meet to discuss new patients who have been diagnosed with cancer, as well as patients that have recently been treated for their cancers. And, during this meeting, which is what we call a multidisciplinary treatment conference, we are able to actually stage each patient’s cancer. We’re able to decide on a treatment that best suits that patient’s cancer. And, we’re able to put all of the right consults and all of the right steps in order so that patient can begin their treatment as soon as possible. Host: Could you share the story of a patient who had a particularly successful outcome? Dr. Giurintano: Yes. A patient, who had recently had several previous head and neck cancers, presented to the MedStar Washington Hospital Center, in my partner, Dr. Matt Pierce’s, clinic. This patient had previously undergone multiple surgeries and he had essentially received the maximum dose of radiation therapy that the body could receive in that area. And, unfortunately, there was a new cancer that had developed. This was a very devastating diagnosis to him, as he was a cancer survivor already. But, we were able to perform, essentially, a removal of the entire voice box and the entire back wall of the throat and then reconstruct that with tissue from his upper thigh. And, he had an absolutely amazing postoperative course. He was out of the hospital by postoperative day number 7. And this gentleman, who had not swallowed in 6 months, we had just obtained a swallow study to evaluate how the flap had healed, and he was able to swallow again - well - for the first time in 6 months. So, he was a particularly good outcome and we were very pleased with how he healed. Host: Thanks for joining us today, Dr. Giurintano. Dr. Giurintano: It was my pleasure. 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.

Reconstructive Surgery for Head and Neck Cancers

The adrenal glands respond to signals from the nervous system and produce hormones that regulate many of the body’s normal responses. Dr. Erin Felger discusses what happens when a tumor develops on the adrenal glands and how we treat it.   TRANSCRIPT Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: We’re speaking with Dr. Erin Felger, an endocrine surgeon at MedStar Washington Hospital Center. Thanks for joining us, Dr. Felger. Dr. Felger: Thank you for having me. Host: Today we’re discussing adrenal surgery, or procedures to remove the adrenal glands. Dr. Felger, to begin with, what do the adrenal glands do? Dr. Felger: The adrenal glands are located on the kidney. The adrenal glands make different hormones that help regulate different systems in your body. A hormone that everyone is familiar with is adrenaline and that is one of the main hormones that the adrenal gland makes. Host: What symptoms might cause a patient to visit their doctor and ultimately lead to a diagnosis of an adrenal problem? Dr. Felger: Well, it depends if the adrenal tumor is producing hormones or if it is not producing hormones. If it is what we call a functional tumor, the patient may have high blood pressure, headaches, palpitations, skin changes, weight gain, diabetes, fatigue or weakness. If the tumor is not producing hormone, the patient may not have and likely won’t have any symptoms at all.  Host: Why might a patient need to have the adrenal glands removed? Dr. Felger: Usually, we only remove one adrenal gland. It’s very rare to have bilateral tumors that need to be removed from those adrenal glands. One adrenal gland with a tumor usually needs to be removed for one of two reasons, the first being that the tumor is producing hormone and causing the patient to be sick or the tumor is too large in size and needs to be removed because of concern for cancer. Host: How do you advise patients to prepare for adrenal surgery? Dr. Felger: Again, it’s first having a consultation with your surgeon and then following the steps that need to be completed prior to surgery, which usually include labs, EKG, physical, extra imaging and any clearances that need to be had by other physicians. Host: What does recovery entail after a procedure? Dr. Felger: Recovery is very straightforward for adrenal procedures that are done laparoscopically or retroperitoneally. The patient is able to eat and walk and do most regular activities except for heavy lifting. Laparoscopic adrenal surgery is done from the belly side and it includes using a camera and small instruments and small incisions to remove the adrenal gland and the tumor.  Retroperitoneal adrenal surgery uses a camera and small instruments and incisions but is done from the back and not the front. Host: Do patients need additional therapies after surgery? Dr. Felger: It depends on what type of adrenal tumor a patient has. They may need to have follow-up with their endocrinologist to adjust medications. They may need further imaging studies and potentially treatment if they have a cancer. Host: What sort of medications would they patients have to take ongoing? Dr. Felger: Depending on the type of adrenal tumor, some patients may need to take long-term steroids in order to have normal function until their other adrenal gland wakes up. Other patients may need to have further imaging or frequent follow-ups and, potentially, medication if they have a cancer. Host: Could you share a success story of a patient who overcame adrenal issues, thanks in part to surgery? Dr. Felger: Yes. I had one patient who was a young man and he had excessively high blood pressures and was taking multiple medications and it was affecting his activities of daily living. His doctor did a full work up and found an adrenal tumor on one side. He came to see me and I completed the work up and had a good discussion with him about the operation to remove the adrenal tumor. I explained to him that it would hopefully help his high blood pressure but it may not cure it completely. The patient had the operation and he did very well during the surgery and afterwards. When he came back for his postoperative visit, he was doing quite well and he was off all of his blood pressure medications and he was quite thrilled because he was already getting back to his activities of daily living that he had been unable to do prior to the surgery. Host: Why should a patient come to MedStar Washington Hospital Center for their care? Dr. Felger: We have a multidisciplinary approach with our adrenal patients. They can be seen by our endocrinologists as well as have nuclear medicine studies done and then follow-up with the surgical team. We do an excellent volume of adrenal surgery at our institution and we are trained in both laparoscopic and retroperitoneal approaches so we can offer as many options as possible to our patients. Host: Thanks for joining us today, Dr. Felger. Dr. Felger: Thank you again 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.

Adrenal Gland Tumors: Our Team Approach To Treatment

MedStar Washington Hospital Center doctors give you the inside story on advances in medicine and share health and wellness insights.