Hoag Presents "Ask the Doctor" for Fall 2016

Richard S. Blankenbaker, M.D.

Q: What is an optimal blood pressure reading?

A: Treatment of high blood pressure is a very important factor in maintaining your health. Optimal control of your blood pressure will reduce your chance of having a stroke or heart attack or developing congestive heart failure or kidney disease. The Joint National Committee on Hypertension released a set of guidelines for treatment of high blood pressure in 2014; the committee made the following recommendations regarding blood pressure goals:

Age≥60: BP Goal < 150/90

Age<60: BP Goal < 140/90

For patients with Diabetes or Kidney Disease the recommendations are as follow:

Diabetes (any age) < 140/90

Kidney disease (any age) < 140/90

These guidelines were based on a large number of clinical trials with a very high level of evidence. Since the publications of the guidelines, however, new findings based on the “SPRINT” trial, suggests that treatment to a lower goal (Systolic Blood Pressure ≤ 120) in patients with at least one other risk factor for heart disease may provide additional benefits in reducing your risk of heart attack, stroke, and congestive heart failure. This lower blood pressure goal also appeared to benefit the older population in the study (age≥ 75).

Based on this new information, many physicians are recommending more aggressive treatment of high blood pressure than recommended by the national guidelines. These recommendations are general guidelines and may not apply to every patient. I would encourage patients to discuss treatment goals with their physician and determine on an individual basis what their “optimal” blood pressure measurements should be.

By combining a healthy lifestyle (moderate exercise for 30 minutes 3­4 times per week), a low sodium diet (less than 2000 mg of sodium daily), and the right medication, everyone should be able to achieve their “optimal blood pressure.”

Dr. Richard Blankenbaker is a cardiologist at Newport Coast Cardiology, which is located in Hoag Health Center Newport Beach. He can be reached at 949-548-6634.

Nancy Councelbaum, M.D.

Q: What advice for healthy living can you provide to senior patients?

A. The song, “Don’t Worry Be Happy,” often makes people smile. Does this simple phrase provide benefit for healthy aging?

Negative effects of worry and stress can include sleep disturbance, anxiety, depression, weight changes, hypertension, and poor concentration. Happiness may not be so easy to define but is generally felt to be a sense of well-being. Medical studies rely on people to self-report their feeling of happiness. Most of us would suspect that happy people would tend to live longer, provided other factors were equal. Some studies support this but there is also a large study, which followed women in the U.K. that states happiness and well-being do not appear to effect mortality.

In my experience with patients, I have found that living well – at any age – may be more important than living long. Fear of living with memory loss or other disability, such as a stroke, are concerns raised by many individuals. This can certainly affect well-being and happiness. Elderly people who have a sense of purpose appear less likely to die of Alzheimer’s disease and may have protection against strokes. I encourage people to find things that they enjoy and participate in new activities. It might be gardening, volunteering, a new exercise class, an art class, a book club or something else. You are never too old to learn something new.

Nutrition is also an important part of healthy aging. Think of food as medicine. Following a Mediterranean-type diet is a good choice and good medicine. In some studies, the Mediterranean diet has been found to be beneficial for preventing cardiovascular disease and cognitive decline. The diet is characterized by a high intake of olive oil, nuts, vegetables, fruits, legumes, and whole grain cereals; a moderate intake of fish and poultry; and a low intake of dairy products, red meat, processed meat and sweets. Making changes towards a healthy diet and a healthy lifestyle does not have to be complicated and realizing the benefits can be extremely motivating.

Dr. Nancy Councelbaum is an internist at Hoag Medical Group in Irvine – Sand Canyon. She is board certified in internal medicine and geriatrics and has a special interest caring for seniors and providing a team-based approach to care. She can be reached at 949-791-3101.

Paul J. Korc, M.D.

Q: What are risk factors for developing pancreatic cancer?

A: A risk factor is something that increases the chance of developing a disease. Some risk factors can be modified (lifestyle) while some cannot (such as age and family history). Risk factors for pancreatic cancer include:

  • Lifestyle-related factors, such as smoking, alcohol use and a high-fat diet
  • Being overweight or obese
  • Diabetes
  • Chronic inflammation of the pancreas (chronic pancreatitis)
  • Certain types of pancreatic cysts
  • Family history of pancreatic cancer
  • Family history of certain cancer syndromes, including familial breast cancer (BRCA2), Lynch Syndrome, Peutz-Jeghers Syndrome, and Familial Melanoma.
  • Being African-American

Most pancreatic cancer begins in the cells that line the ducts of the pancreas. This type, known as adenocarcinoma or pancreatic exocrine cancer, accounts for 95 percent of pancreatic cancers. Another type of pancreatic cancer, called a Neuroendocrine Tumor, forms in the hormone-producing cells of the pancreas. Rarely, these can produce hormones in excess and cause associated symptoms—for example, an insulinoma produces insulin and can cause hypoglycemia (low blood sugar). Certain types of pancreatic cysts, including MCN and IPMN, are considered pre-cancerous and may need ongoing follow-up or even surgical removal in some cases.

Often, pancreatic cancer does not cause symptoms during its early stages. However, as the disease progresses, symptoms associated with pancreatic disease may develop, such as:

  • Upper abdominal pain
  • Lack of appetite, nausea or vomiting
  • Unexplained weight loss
  • Jaundice (yellowing of the skin and whites of eyes)
  • Dark urine and/or bowel changes such as diarrhea or light-colored stools
  • Itching all over the body

Hoag is one of few institutions in the nation to develop an early detection program for individuals at high risk for pancreatic cancer. Through evaluation and potential detection of a cancer at an early stage, the chances of successful treatment are much higher. Hoag’s Pancreatic Cancer Early Detection Program also provides active surveillance with continued monitoring of at risk individuals. This program can be reached at 949-722-6237(722-6237). In addition, if you are worried you may be experiencing any of the symptoms of pancreatic cancer, it is important to seek proper evaluation and treatment from a health care expert experienced in the diagnosis and treatment of gastrointestinal issues.

Hoag Family Cancer Institute, in collaboration with digestive disorder physician specialists, USC Care Medical Group and USC Norris Comprehensive Cancer Center, provide state-of-the-art complex hepatobiliary and pancreatic cancer care. Hoag’s commitment to accurate diagnosis, combined with progressive therapeutic options enables Hoag patients to achieve some of the highest clinical outcomes in the nation.

Paul Korc, MD, is a Gastroenterologist/Therapeutic Endoscopist at the Hoag Advanced Endoscopy Center. He performs Endoscopic Ultrasound (EUS) and has a particular interest in pancreatic disorders.

Samir Shah, M.D.

Q: Can cataract surgery be performed by laser?

A: Cataract surgery is one of the most common surgeries in the United States, and can be performed both traditionally (by hand) and by laser. Laser cataract surgery has been shown to significantly improve accuracy and precision of corneal incisions and the capsulotomy. Laser cataract surgery is gentler on the eye because less energy is required to remove the cataract compared to traditional cataract surgery. This can help reduce post-operative recovery time.

In order to understand specifically how laser cataract surgery may be beneficial, it’s important to understand what a cataract is and when surgery is typically performed.

A cataract is a clouding of the natural lens of the eye that eventually results in blurry and/or decreased vision. Cataracts require treatment when visual impairment begins to interfere with your daily life such as difficulty seeing street signs, glare, difficulty reading or watching TV. The only way to treat a cataract is through surgery. There are no clinically proven methods to reverse the progression of cataracts.

During cataract surgery, the natural lens of the eye is removed and an artificial lens or an intraocular lens (IOL) is placed in the eye to restore vision. Surgery takes less than half an hour and is usually performed in an outpatient setting. A typical cataract surgery includes the following steps:

  • Anesthesia – Anesthetic eye drops are applied to numb the eye and prevent discomfort.
  • Corneal incisions – Incisions are created in the cornea to provide access to the lens capsule and allow insertion of surgical instruments. Incisions can also be made to reduce astigmatism.
  • Capsulotomy – A circular incision is made on the surface of the bag that houses the lens.
  • Break up and removal of the lens – Phacoemulsification is a method using ultrasound energy to break the lens into tiny fragments that are gently sucked out of the eye.
  • Irrigation and aspiration – After the bulk of the cataract is removed, small remnants of cataract material are aspirated out of the eye.
  • IOL insertion – The IOL is folded and carefully inserted through the capsulotomy opening into the bag where it gently opens and settles into its functional position. Various IOL’s are available including standard monofocal IOL’s as well as premium/lifestyle IOL’s that can significantly reduce or eliminate dependence on glasses and contact lenses.
  • Finalizing the procedure – The incisions are sealed and antibiotic eye drops are applied.

In a traditional surgery, these steps are performed manually with blades and needles by the surgeon. However, in laser cataract surgery, a highly-accurate, computerized laser assists the surgeon in performing some of the critical steps of the procedure. Specifically, corneal and astigmatic incisions, capsulotomy, and the break-up of the lens are all steps that can be performed by laser, making the procedure blade-free! Additionally, the laser provides optical coherence tomography cross-sectional imaging of the eye to help guide your surgery.

Overall, cataract surgery is a highly successful procedure that can restore clear vision. If you have been recently diagnosed with or think you may have cataracts, it is important to schedule a consultation with your ophthalmologist to discuss the best treatment options for you.

Samir A. Shah, M.D., M.S., F.A.C.S. is a board-certified, surgical ophthalmologist with Beach Eye Medical Group in Huntington Beach. Dr. Shah is a Diplomate of the American Board of Ophthalmology, a member of the American Academy of Ophthalmology, the American Society for Cataract and Refractive Surgery, the Cornea Society, and the California Academy of Eye Physicians and Surgeons.

Dr. Anthony Caffarelli

Q: What is a thoracic aortic aneurysm and how do you treat it?

A: A thoracic aortic aneurysm is a bulging, weakened area in the wall of the aorta that results in the aorta enlarging or widening. It is a silent, slow-growing disease that shows no symptoms, and is often only incidentally discovered through imaging exams.

Left untreated or if not followed by a physician, a thoracic aortic aneurysm can result in an aortic dissection – a tear in the aortic wall, potentially diverting blood flow away from vital organs causing stroke, heart attack, kidney damage and other problems.

That is why it is important to know the risk factors and take a proactive role. Talk to your doctor about thoracic aneurysm testing if you have any of the following:

  • Uncontrolled high blood pressure
  • A bicuspid aortic valve
  • Early aortic valve surgery (under the age 70)
  • Certain genetic conditions or connective tissue disorders
  • A parent, sibling, or child who has a thoracic aortic aneurysm or who has experienced a dissection, rupture or unexplained sudden death
  • Trauma to the aorta (like being in a car accident)
  • Smoking
  • Inflammatory processes

If an aneurysm is detected, based on the size, the physician will either recommend preventative surgery or active surveillance to see if it enlarges. Some individuals diagnosed with an aortic aneurysm may not need surgery or surgery right away. However, as an aneurysm grows, the risk for rupture or dissection also increases. Once an aneurysm reaches a certain size in diameter, elective surgery is recommended, since an emergency surgery carries a much greater risk. Some people may live with an aortic aneurysm and never need interventional surgery. If the aneurysm stays small, the chance that it will burst is also small.

With an engaged medical team and proactive planning, the comprehensive Hoag Aortic Center can help save lives before the high risk of rupture or dissection. If you feel you or a loved one may be at risk for thoracic aortic disease, be proactive. Contact Hoag today to discuss the next step at 949-764-5871.

Anthony Caffarelli, M.D. is the Co-Director of Hoag Cardiovascular Surgery and Director of Hoag Aortic Center. Dr. Caffarelli performs hundreds of cardiovascular surgeries every year, specializing in complex aortic procedures including aneurysm, dissections, bicuspid aortic valve disease and valve-sparing root procedures, in addition to coronary artery bypass surgery and valve replacement.