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  • January 14, 2022

    By Allison Larson, MD

    Whether you’re a winter sports enthusiast or spend the season curled up by the fireplace, the low humidity, bitter winds, and dry indoor heat that accompany cold weather can deplete your skin’s natural moisture. Dry skin is not only painful, uncomfortable, and irritating; it also can lead to skin conditions such as eczema, which results in itchy, red, bumpy skin patches. 


    Follow these six tips to prevent and treat skin damage caused by winter dryness.


    1. Do: Wear sunscreen all year long.

    UV rays can easily penetrate cloudy skies to dry out exposed skin. And when the sun is shining, snow and ice reflect its rays, increasing UV exposure. 


    Getting a sunburn can cause severe dryness, premature aging of the skin, and skin cancer. Snow or shine, apply sunscreen before participating in any outdoor activity during the winter—especially if you take a tropical vacation to escape the cold; your skin is less accustomed to sunlight and more likely to burn quickly.


    The American Academy of Dermatology (AAD) recommends sunscreen that offers protection against both UVA and UVB rays, and offers a sun protection factor (SPF) of at least 30.


    That being said, if you are considering laser skin treatments to reduce wrinkles, hair, blemishes, or acne scars, winter is a better time to receive these procedures. Sun exposure shortly after a treatment increases the risk of hyperpigmentation (darkening of the skin), and people are less likely to spend time outside during the winter.


    Related reading: 7 Simple Ways to Protect Your Skin in the Sun

    2. Do: Skip products with drying ingredients.

    Soaps or facial products you use in warm weather with no issues may irritate your skin during colder seasons. This is because they contain ingredients that can cause dryness, but the effects aren’t noticeable until they’re worsened by the dry winter climate.

    You may need to take a break from:

    • Anti-acne medications containing benzoyl peroxide or salicylic acid
    • Antibacterial and detergent-based soap
    • Anything containing fragrance, from soap to hand sanitizer

    Hand washing and the use of hand sanitizer, which contains a high level of skin-drying alcohol, cannot be avoided; we need to maintain good hand hygiene to stop the spread of germs. If your job or lifestyle requires frequent hand washing or sanitizing, routinely apply hand cream throughout the day as well.


    During the COVID-19 pandemic, I have seen a lot of people develop hand dermatitis—a condition with itchy, burning skin that can swell and blister—due to constant hand washing. Sometimes the fix is as simple as changing the soap they're using. Sensitive-skin soap is the best product for dry skin; it typically foams up less but still cleans the skin efficiently.


    3. Do: Pay closer attention to thick skin.

    Areas of thin skin, such as the face and backs of your hands, are usually exposed to the wind and sun the most. It’s easy to tell when they start drying out. But the thick skin on your palms and bottoms of your feet is also prone to dryness—and tends to receive less attention.


    When thick skin gets dry, fissures form. You’ll see the surface turn white and scaly; then deep, linear cracks will appear. It isn’t as pliable as thin skin. When you’re constantly on your feet or using your hands to work, cook, and everything in between, dry thick skin cracks instead of flexing with your movements. 


    To soften cracked skin, gently massage a heavy-duty moisturizer—such as Vaseline—into the affected area once or twice a day. You can also talk with your doctor about using a skin-safe adhesive to close the fissures and help them heal faster.


    Related reading:  Follow these 5 Tips for Healthy Skin

    4. Don’t believe the myth that drinking more water will fix dry skin.

    Contrary to popular belief, the amount of water or fluids you drink does not play a major role in skin hydration—unless you’re severely dehydrated. In the winter, especially, dry skin is caused by external elements; it should be treated from the outside as well. 


    The best way to keep skin hydrated and healthy is to apply fragrance-free cream or ointment—not lotion—to damp skin after a shower or bath.
    Some people need additional moisturizers for their hands, legs, or other areas prone to dryness.

    While some lotions are made better than others, most are a combination of water and powder that evaporates quickly. Creams and ointments work better because they contain ingredients that can help rebuild your skin barrier. 

    Look for products with ceramide, a fatty acid that helps rebuild the fat and protein barrier that holds your skin cells together. The AAD also recommends moisturizing ingredients such as:

    • Dimethicone
    • Glycerin
    • Jojoba oil
    • Lanolin
    • Mineral oil
    • Petrolatum
    • Shea butter

    For severely dry skin, you can try a “wet wrap” technique:

    1. Rinse a pair of tight-fitting pajamas in warm water and wring them out so they’re damp, not wet.
    2. Apply cream or ointment to your skin.
    3. Put on the damp pajamas, followed by a pair of dry pajamas, and wear the ensemble for several hours.

    Dampness makes your skin more permeable and better able to absorb hydrating products. If the wet wrap or over-the-counter products aren’t working for you, talk with a dermatologist about prescription skin hydration options. 

    Drinking more water isn’t the answer to dry winter skin. The best solution is to apply fragrance-free cream or ointment directly to damp skin. Get more cold weather #SkinCareTips from a dermatologist in this blog: https://bit.ly/3KbVUA1.
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    5. Don’t confuse skin conditions with dryness.

    Skin conditions are often mistaken for dry skin because peeling or flaking are common symptoms. Redness of the skin or itching in addition to dryness and flaking indicates a skin condition that may need more than an over-the-counter moisturizer.


    Skin cells are anchored together by a lipid and protein layer (like a brick and mortar wall). With very dry skin, the seal on this wall or barrier is not fully intact and water evaporates out of the skin’s surface. The skin will become itchy and red in addition to scaly or flaky. If you experience these symptoms, visit with a dermatologist.

    6. Don’t wait for symptoms to take care of dry skin.

    Be proactive—the best way to maintain moisture is to apply hydrating creams and ointments directly to your skin on a regular basis. Start by applying them as part of your morning routine. Once you get used to that, add a nighttime application. And carry a container of it when you’re on the go or keep it in an easily accessible location at work.

     

    You can’t avoid dry air, but you can take precautions to reduce its harsh effects on your skin. If over-the-counter products don’t seem to help, our dermatologists can provide an individualized treatment plan. Hydrated skin is healthy skin!


    Does your skin get drier as the air gets colder?

    Our dermatologists can help.

    Call 202-877-DOCS (3627) or Request an Appointment

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  • June 15, 2021

    By Ivanesa Pardo, MD

    The muscles of the abdominal wall —the core muscles— wrap in strong layers around the body’s midsection. These vital muscles support the upper body, enable bending and twisting, and help power the arms and legs. They also serve to structurally contain the internal organs.

    A hole —or hernia— can occur at or near natural weak points in these core muscles. When a hole forms in the muscle mass, fatty tissue or a portion of an organ may begin to push through that gap, migrating between the abdominal wall and skin and often creating a visible bulge.

    A hernia may appear suddenly or gradually over time. Some types are:

    • Inguinal hernia, which occurs within the muscles of the groin
    • Umbilical hernia, occurring near the navel
    • Hiatal hernia, developing within the diaphragm
    • Incisional hernia, which can appear at the site of a prior surgery

    Depending on size and location, hernias may cause varying levels of discomfort. A small opening that allows some fatty tissue to penetrate may cause no symptoms at all. A larger hole may permit a more substantial portion of internal organ—for example, part of the small or large intestines, bladder, or ovaries—to migrate, triggering pain and other medical issues.

    In extreme cases, as an organ is forced through the gap, it can become strangulated—its blood supply so restricted that the organ may begin to die. Most serious cases of hernia warrant medical attention well before they reach this life-threatening stage.

    With minimally invasive robotic hernia repair, most patients return home the same day, with fewer complications and a speedier recovery. Dr. Ivanesa Pardo explains. https://bit.ly/2Ts3YqK via @MedStarWHC
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    Risk Factors for Hernia

    The biggest risk factor for a hernia is simply age. Over decades, it’s normal for muscle tone to diminish and for weakened areas to become increasingly prone to herniation.

    In addition, certain medical conditions can encourage hernia development. For example, a serious respiratory condition that causes chronic coughing, such as COPD, can cause recurring force within the belly that results in herniation.

    Strenuous activity is also a risk factor—particularly in extreme athletic endeavors, or among weight lifters, or warehouse and construction workers, who routinely lift heavy loads.

    Men can be especially susceptible to inguinal hernias due to a small hole that exists naturally within their groin muscles, allowing blood vessels to reach the testicles. The abdominal wall within the inguinal area can weaken with age, also creating the potential for hernia.

    As a result of the strain placed on a woman’s abdomen, pregnancy may also create a tear in the abdominal wall; however, the developing baby typically provides a somewhat protective barrier between the tear and a woman’s internal organs.

    Among these other risk factors, obesity can also increase the likelihood of hernia, and of its recurrence post-surgery. For this reason, weight loss is often recommended prior to a hernia procedure.

    Diagnosing and Treating Hernia

    Hernia symptoms can vary, depending on where the hernia is located. For example:

    • An abdominal hernia typically appears as a visible bulge that may or may not be painful for the patient.
    • In the case of inguinal hernia, one patient may complain of a mass in the groin area that doesn’t hurt at all, while another may experience pain with no visible cause.
    • Occurring within the chest, a hiatal hernia often presents as a digestive issue like reflux or as dysphagia—difficulty or discomfort swallowing. Hiatal hernia may decrease respiratory capacity as well.

    In order to make a clear and accurate diagnosis of hernia, we conduct a physical examination and review the patient’s medical history, including reports of pain, bulging, or discomfort. If hernia is suspected but is possibly too minimal to detect easily, or if a patient’s abdomen is very large, an ultrasound or CT scan can help confirm the diagnosis.

    Once confirmed, surgical treatment of hernia is generally the best course of treatment. This approach has evolved considerably from the days when surgical repair required very large incisions and a complicated healing process. Beginning in the 1980s, laparoscopic—or “belly button”—surgery launched the age of minimally invasive procedures, with reduced incision size making same-day surgery and speedier healing possible.

    Today, the game-changer in hernia repair is robotic surgery.

    Like laparoscopic procedures, robotic hernia surgery utilizes thin instruments passed into the body via very small incisions, as tiny on-board cameras and lights provide clear views of the area to be repaired. But robotic surgery offers additional advantages over traditional laparoscopy:

    • The instruments used for robotic hernia surgery are smaller and even more maneuverable, reducing tissue damage and blood loss and promoting faster recovery. For many patients, smaller incisions mean less post-surgical pain as well.
    • The robotic system’s dual cameras deliver a true 3D view, allowing more comprehensive examination of the damaged area.
    • As a natural extension of arm and hand movement, surgeons find the robotics console quite intuitive to use. As a pianist, I compare operating the console to playing the piano—it feels instinctive.

    Minimally invasive robotics can be used to manage even severe or complex repairs that would have required open surgery just a few years ago. With these tools, we can confidently and effectively repair hernia damage, and tailor and apply a superior grade of supportive mesh to strengthen the affected area.

    The vast majority of hernia surgeries are very successful. In just two to three percent of repair procedures, hernia may recur. This may be due to insufficient time allowed for healing or to the patient’s overall health—hernia can sometimes return for smokers (who do not heal as well as non-smokers) and for obese patients.

    Recovering from Hernia Surgery

    Most patients return home the same day as their hernia surgery. They may experience some soreness for a few days; medication is prescribed when needed, but patients often find that over-the-counter pain relievers are enough to manage their temporary discomfort.

    The most critical element of a strong recovery is time allowed for thorough healing.

    Most surgical patients can begin a return to light activity within a week or so, when residual soreness from their procedure subsides. Intense core exercises and heavy lifting must be avoided for at least six weeks; however, with their surgeon’s approval, patients can generally take walks, cycle without resistance, and even jog lightly during the six-week recovery period.

    Protecting the surgical repair and giving it time to heal, as well as carefully managing weight and tobacco usage, can give the hernia patient their best chance for a complete and healthy recovery.


    Feeling an abdominal lump?

    Our specialists can help.

    Call 202-788-0402 or Request an Appointment

  • June 11, 2021

    By Stephen Peterson, MD, Psychiatry

    For most doctors and other providers, 2020 was a year to end all years.

    In early 2020, we began to hear of a novel virus more lethal than the flu, emerging in China.

    In a few short months, medical care was radically transformed. We began to shelter in place, practice social distancing, wear facial masks, and frequently wash our hands. Rounding in the hospital and communing with colleagues stopped; meetings and grand rounds were canceled or went online. Office visits became televisits, elective surgeries were canceled, hospital units morphed into COVID-19 patient care. Doctors stopped seeing patients who were afraid to come to hospitals, lest they be exposed to the virus.

    Healthcare workers had to learn how to protect themselves from the illness as they rendered care, especially since the virus infects not only the lungs, but many other organ systems. For much of healthcare in America, PPE supplies became limited in some areas, and therapies were not defined.

    But this disaster year was continuous, with more facets. Unhealed racial wounds ripped open, as confrontation occurred between police and citizens. Civil unrest and protests erupted across America.

    During the summer, a heat wave settled in the southern U.S. Wildfires erupted on the West Coast, due to drought conditions and high winds with low humidity. Many lost lives to the fires, and others their homes and livelihoods. More hurricanes arose in the tropics this year than ever before, and five struck the Louisiana coast.

    Our usual social interactions contracted from many to just a few. A striking shift occurred in our socializing, from every day enjoyable communing, to sudden lonely isolation.

    Not surprisingly, doctors, indeed everyone in healthcare, have been stressed to the max. The mental fallout will be huge and long-lasting. Even after single disasters, we know that mental health has the biggest impact, is the most pervasive, and is long-lasting.

    A recent study reported in The Washington Post showed one-third of physicians surveyed felt hopeless, one-fifth sought mental health support, and one-fifth reported increased use of medication, illicit medication, or alcohol. Almost three-fourths of doctors have had financial loss. Older doctors are retiring early, as the risk for them to catch COVID-19 is high, and they find telemedicine less than satisfactory. Sadly, doctor suicides are now at the highest, and we know physicians usually succeed on the first try, for obvious reasons.

    How can we better cope with our current situation?

    Try to:

    • prioritize your personal needs for yourself and your family
    • seek out others to be with
    • get your house in order (one room at a time)
    • get regular exercise, and if you need motivation, read the book, “Younger Next Year”
    • take short trips to places you have always wanted to go
    • read books you have always wanted to read
    • get active in causes that you love and believe in
    • look for seniors and others who are lonely, to befriend, and make a new friend
    • see a mental health provider if you have too much trouble with anxiety, depression, guilt, or interpersonal friction, even if it is via telehealth
    • get together with colleagues in a group for support; one of us can help facilitate
    • not forget that if you are burned out, your work as a doctor makes a real difference for everyone, giving them relief, support, and hope

    The author gratefully acknowledges adopting a conceptual framework and facts about disasters, in a lecture by Josh Morgenstein, MD, and Kerri Palamara, MD, online by American College of Physicians.

  • June 10, 2021

    By Harjit K. Chahal, MD

    The internal carotid arteries are among the most critical blood vessels in the body. Located on both sides of the neck, they deliver oxygen to the brain.

    But that critical function may be affected by carotid artery stenosis, a narrowing of the arteries caused by plaque. Plaque is a waxy substance that can build within blood vessels just like rust can collect inside a water pipe.

    As the layer of plaque within a blood vessel thickens over time, bits of it may break loose and reduce or block blood flow. Without a steady supply of oxygenated blood, brain tissue begins to die—a dangerous path to stroke, the fourth leading cause of death in the U.S. Plaque in the carotid arteries is, in fact, responsible for up to 20 percent of strokes.

    Perhaps most alarmingly, plaque buildup often occurs without symptoms. It can progress silently for years—then suddenly become a stroke emergency.

    Who tends to experience plaque buildup? What are the risks?

    Harjit K. Chahal, MD, Cardiology: Atherosclerosis—fatty and inflammatory plaque buildup—is a natural process that begins early in life. Studies of young military recruits have shown that it can start in the late teens to early 20s, even among fit and active young people.

    Depending on where the plaque forms, atherosclerosis can eventually become catastrophic. Besides stroke, it can cause complications if it blocks or narrows the arteries that feed the heart muscle (triggering heart attack) or lower legs (resulting in lack of blood flow there as well).

    Bianca M. Cutler, CRNP, Vascular Surgery: Risks for atherosclerosis can include certain risk factors we can’t control—for example, some patients are genetically predisposed to plaque buildup, or tend to build it faster.

    But more controllable risk factors include high blood pressure (or hypertension) and high cholesterol (hyperlipidemia). Diabetes can also be a factor as it increases the risk of both high blood pressure and high cholesterol. We can help decrease the odds of a patient developing carotid artery disease if we can prevent and control these other conditions through regular medical care.

    Certain lifestyle factors, of course, can influence plaque build-up as well. Poor diet, lack of exercise, and excess weight can negatively impact blood pressure and cholesterol, and use of tobacco can increase both blood pressure and inflammation—all of which accelerate plaque development.

    Dr. Chahal: The more we study atherosclerosis, the more we recognize and acknowledge the role of inflammation as a precursor to carotid artery disease. For example, we know that people with chronic inflammatory disorders like HIV or lupus are at higher risk. These connections are the subject of much current medical research.

    How does a plaque blockage occur? What happens when it does?

    Dr. Chahal: The carotid arteries run from the chest to the head, on either side of the neck. Each artery bifurcates—branches into an internal and an external artery—near the jaw; the internal one is responsible for supplying blood flow to the brain. These bifurcated vessels can be at higher risk for dangerous plaque buildup because blood flow naturally becomes more turbulent at the point of bifurcation.

    Bianca: Plaque within carotid arteries typically builds without any symptoms or obvious signs. For many, carotid artery disease in a patient only manifests when obstructed blood flow causes a stroke, or a mini-stroke—also known as a transient ischemic attack or TIA.

    In a stroke, brain tissue dies. In a TIA, the interruption to blood flow may spur symptoms similar to a major stroke, but symptoms often resolve within seconds or minutes. A TIA is a warning sign that a major stroke may be imminent.

    Is there a screening process to detect arterial blockage?

    Bianca: Unlike colon or breast cancer, regular screening for plaque buildup is not recommended for everyone. Our strategy primarily focuses on identifying and reducing risk.

    We do encourage screening for patients with multiple potential risk factors—for example, a smoker with high blood pressure or high cholesterol, plus a personal or family history of ischemic stroke before age 60.

    If a patient does have such risk factors, we evaluate for a carotid bruit [broo-EE], a type of murmur that can be heard via stethoscope as the blood pumps through the arteries. A bruit alone does not confirm artery disease—but, combined with other risk factors, it can be an important indicator that further evaluation or imaging is needed.

    Dr. Chahal: The choice to screen is decided on a case-by-case basis and involves both patient and provider. When screening is indicated, we look for evidence of atherosclerosis throughout the body.

    People with coronary or peripheral artery disease are certainly at risk of having carotid artery disease as well, and it’s quite reasonable to screen those patients. In addition, in our practice, we also screen anyone with a history of heart attack.

    Bianca: Initial screening is done via ultrasound, which is non-invasive and painless. If the results show narrowing within certain criteria, we order CT imaging or carotid angiography, both of which combine X-ray with dye contrast. CT imaging delivers a more detailed view within the body. Angiography lets us clearly visualize the arteries.

    Strokes are the fourth leading cause of death in the U.S.—and plaque in the carotid arteries can cause up to 20 percent of all strokes. Dr. Harjit Chahal and Bianca Cutler, FNP-C, explain why prevention is so important. https://bit.ly/3pBDhLY via @MedStarWHC
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    How do you help patients manage carotid artery disease?

    Dr. Chahal: We consider our first task to be education and disease prevention. We counsel our patients to recognize signs and symptoms of stroke and to understand the importance of getting emergency care if they think they’re experiencing one.

    We also devote considerable time and effort to managing each patient’s controllable risk factors, such as cholesterol, blood pressure, diabetes, and smoking. With appropriate medication and risk factor optimization, the potential for stroke can be reduced to less than one percent.

    Bianca: The steps we take can be dramatically effective for patients who are compliant, committed, and invested in their health.

    Statin medication for high cholesterol or hyperlipidemia is one staple of treatment. Statins primarily work in the liver to lower total cholesterol. Interestingly, some recent studies have shown that they may also work in the arteries to smooth and stabilize existing plaque, making it less likely to break off and travel to the brain. So, I will often recommend use of a statin in the setting of carotid artery stenosis, even when cholesterol is at a healthy level.

    We may also prescribe antiplatelet drugs that prevent clotting around the narrowed plaque areas within a blood vessel. We typically recommend a daily aspirin and, if narrowing is fairly progressed, the addition of a prescription drug such as Plavix.

    When is surgery called for?

    Bianca: Many patients do well with drug therapy and lifestyle modifications—especially when narrowing of one or more carotid arteries is discovered early. In more extreme cases, when medication alone is not effective, our team can perform a surgical procedure to remove the plaque.

    But, because this is a serious surgery that can itself carry a small risk of stroke, we generally wait until an artery is narrowed approximately 70 percent or more in men, and at least 75 percent in women. Of course, our decision to recommend surgery may vary depending on other carefully considered factors, such as the patient’s advanced age, other medical conditions, and so forth.

    Dr. Chahal: The reason for this difference is that men have historically fared better with the procedure. That may be due to a number of genetic or physiological variables. Women tend to be smaller in stature than men, with smaller arteries that can make the surgical removal of plaque a bit more complex.

    The goal of surgical intervention is revascularization—increasing the blood supply to the brain. But because we’re placing instruments within the artery itself, we must be very careful not to dislodge any plaque or microemboli during the procedure. Today, surgeons are increasingly more experienced in removing blockage even from very tiny blood vessels.

    What procedures are used to treat carotid artery disease at MedStar Washington Hospital Center?

    Bianca: We are equipped to perform several different procedures that will effectively increase blood flow and decrease plaque burden within the carotid arteries.

    In carotid endarterectomy (CEA), the surgeon makes an incision in the neck, opens the diseased artery, and removes the plaque causing the blockage. This takes about two to four hours and patients are generally discharged the next day.

    Angioplasty and stenting is a minimally invasive approach used when a blockage is too difficult to treat via CEA or when a patient has other issues that make surgery risky. The doctor inserts a catheter—a thin, flexible tube—through a blood vessel in the patient’s arm, groin, or neck, and guides it to the site of the blockage. There, a balloon at the end of the catheter is inflated to widen the artery, and a stent is inserted—a small wire mesh tube that acts as a scaffold to keep the artery open.

    Transcarotid artery revascularization (TCAR), is the newest and most advanced procedure, in which we briefly reverse the direction of blood flow during surgery. If blood is moving away from the brain, clots or loose plaque are much less likely to reach it. With this minimally invasive method, there’s less of a chance that a patient might experience complications. TCAR generally requires an overnight stay.

    MedStar Washington Hospital Center has an abundance of experts that collaborate across a wide range of specialties. For example, Dr. Chahal and I team to share essential patient data and documentation quickly and can consult together to deliver a comprehensive, holistic approach to our patients’ diagnoses and treatment of arterial disease.

    Dr. Chahal: Our team of experts works together cohesively across the areas of internal medicine, neurology, cardiology, vascular rehab, medicine, and sometimes interventional radiology.

    And our Vascular Center is one of the busiest in the Washington, D.C., region. We perform a high volume of procedures to treat carotid artery disease, so we are experienced with the many possible ways that it can present.

    What do you recommend to help people avoid plaque buildup and carotid artery disease?

    Dr. Chahal: A good program of diet and exercise is 80 percent effective in preventing carotid artery disease.

    We recommend that patients maintain a healthy weight, get regular physical activity, consider adopting a Mediterranean diet, practice proper glucose control, avoid tobacco in all forms, and effectively manage their blood pressure.

    Bianca: And, of course, regular checkups with a healthcare professional are vital to help patients stay aware of potential warning signs, for this or any other disease.


    Plaque can build up quietly.

    Know your risk factors.

    Call 202-788-0574 or Request an Appointment

  • June 08, 2021

    By Elspeth Cameron Ritchie, MD

    Through the centuries, how individuals respond and react to trauma has been well documented in historical records as well as in literature ranging from Homer’s 8th-century Iliad to the writings of Shakespeare and Dickens. In the modern age, we understand well that anyone may be subject to experience a genuine—and valid—physical or psychological response to a traumatic event.

    Particularly well recognized over the years were the stressful effects of battle on soldiers of war. In 1980, researchers who were engaged in psychiatric work with Vietnam veterans coined the term post-traumatic stress disorder, or PTSD. They noted that many former soldiers appeared well-adjusted when they returned home from battle, yet, perhaps even years later, they began to display symptoms of stress. Hence, the title post-traumatic stress disorder: intense or disturbing stress occurring sometime after trauma is experienced.

    What Is Trauma?

    PTSD is associated with events that are traumatic—extremely stressful and out-of-the-ordinary: war, torture, violent crime, large natural disasters, or man-made disasters like car accidents or plane crashes. Although more normal life events such as death, divorce, or financial challenges can add stress, they do not typically bring on PTSD. However, these losses can certainly cause grief and depression.

    But what qualifies as “traumatic”? Because we all respond to stress differently, the reality of trauma can vary from individual to individual. One person may experience an event as traumatic; in another person, it might trigger a less complex form of stress.

    Most people who experience trauma will not develop PTSD—yet some do. Each individual processes stress through the filters of their own unique personality and experience, so reactions to stress can vary widely from person to person. For example, being in close proximity to the World Trade Center on 9/11 was undoubtedly traumatic. But might that stress potentially be the same for a person who saw those events happening live on TV? Or for an individual who repeatedly watched replays of the disaster? Or for someone who lost a loved one that day?

    PTSD Symptoms

    Post-traumatic stress disorder can trigger very real, even debilitating symptoms in an affected individual. It may cause that person to:

    • Re-experience trauma in flashbacks or recurrent dreams
    • Avoid reminders of the event, such as a particular location, or TV news coverage or conversation about it
    • Feel emotionally numb, with difficulty connecting to others or recalling details of the trauma
    • Exhibit hyper-vigilance—for example, repeatedly check the house for intruders, or sleep with a weapon
    • Experience sleep, memory, and concentration problems
    • Show uncharacteristic irritability or be quick to anger
    • Self-medicate with drugs or alcohol
    • Experience an exaggerated startle response—for example, in reaction to loud noises

    I had my own experience with the latter on Independence Day. Recently back from Army duty in Somalia, I heard what I thought was gunfire and instinctively dropped to the floor. Then I realized that the noise was simply coming from fireworks. Fortunately, I had this reaction only once. PTSD becomes a concern when multiple symptoms last for longer than a month.

    PTSD is very sensitive to triggers—an ambulance siren, a loud noise, even a smell. It’s also common for symptoms of PTSD to recur periodically; battle veterans who’ve been symptomless for decades may suddenly experience new onset. For example, many Vietnam vets have reached the age where they are retiring, perhaps their health has declined a bit, or perhaps they’ve lost a spouse or some friends. Add 50th-anniversary news coverage of the war and images of battle, and the sudden stress it generates may be surprising.

    A person suffering from PTSD may not even realize that he or she is in trouble. Instead, warning signs are often reported by someone close to the patient. It’s also important to note that anxiety, depression, and PTSD are very similar and can be interconnected; so, a clear clinical diagnosis by a trained medical professional is therefore imperative.

    The best way to manage stress levels in our lives is to understand the warning signs—and take action when we notice them in ourselves or in others. Learn more from Dr. Ritchie. https://bit.ly/3cpDYmq via @MedStarWHC
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    PTSD Treatment

    When symptoms impair someone’s ability to work or have a successful home life, it’s time to intervene and start treatment for this disorder, in the form of medication, therapy, or other interventions.

    • We know that medication works well, especially when anxiety and depression are involved; however, not everyone is receptive to medication.
    • Useful therapy focuses very much on the present, and what the patient can do, right now, to reduce stress day by day.
    • Other interventions may include activities like meditation, yoga, or exercise that deliver a soothing or relaxing effect—maybe something as simple as a daily walk at lunch to enjoy the fresh air. Finding a quiet environment and taking 10 deep breaths can have a dramatic, positive effect on state of mind.

    I tell all my patients: find something healthy you love to do, and do more of it.

    Can PTSD be prevented or avoided?

    It’s anticipated that soldiers may experience a level of trauma in their role, so today we train them to be prepared. Certain occupations—medical first responders and other jobs in which PTSD is a real possibility—can do well to follow the military’s example in preparing for stress-inducing situations.

    What we can all do is be aware of and attuned to recognizing the signs of trauma or stress in ourselves and others, and act quickly when things seem amiss.

    PTSD and COVID-19

    Will the coronavirus pandemic trigger PTSD to some degree in all of us?

    Throughout the pandemic, the presence of COVID-19 has been a source of stress. But each person has, of course, experienced that stress in his or her own way.

    Many have sheltered in place as directed and, while perceiving COVID-19 as a threat, may have had no direct personal experience with it. Others, like those living in harder-hit areas such as New York City, may have experienced the death of a loved one or a more heightened level of fear and tension due to the greater incidence of infection in their environment.

    The most common stressor resulting from this pandemic, one we’ve all felt to some degree, has been fear—15 months fearing contagion from an invisible force. Everyone we encounter could potentially infect us with a life-threatening virus—and, conversely, each of us could be a potential threat to someone else. As a population, we’ve been forced to be very isolated, separating from others and avoiding touching, hugging, or shaking hands.

    Now, with the success of vaccines and with infection declining across the U.S., we’re all beginning to get out and about. But for some, the prospect of being around others again is causing another type of stress—reunion anxiety. Are we ready to take off our masks and be with people again? For many, the answer may be “not yet.”

    And, although the situation is much improved in this country, we’ve seen a surge of infections in countries like India, which can also compound feelings of stress, especially for those with ties to those areas.

    And then there are the “long-haul” COVID-19 survivors. Many of them feel unique forms of post-illness stress—especially patients with lingering and disconcerting aftereffects such as fatigue or brain fog. Many others feel the stress of anger, wondering, “How could this happen here? Why weren’t we better protected?”

    Health crises are, by their nature, stress-inducing—but, for most of us, the COVID-19 pandemic will not cause lingering stress in the form of PTSD. We should, however, keep a watchful eye on our first responders and on frontline workers such as emergency medicine and critical care providers. Depending on their working environment and how much support they’ve received during the pandemic, they may be at higher risk for lingering symptoms.

    The final chapters of the pandemic are yet to be written, but I expect that our learnings will parallel those of our 9/11 experience: the closer you were to ground zero, the more likely you may be to experience some level of post-traumatic difficulty.

    Stay Alert to Warning Signs

    So remember: Most people who experience a psychological trauma will not develop PTSD. But for the small percentage who will, it can be frightening, overwhelming, and very disruptive.

    Probably our best approach to managing stress levels in our lives is to understand PTSD symptoms and warning signs—and take action when we notice them in ourselves or in others. The more attentive we are to such changes and signals—especially those that linger for longer than a month—the greater success we’ll have at counteracting them.


    Feeling frequent stress?

    Reach out for help.

    Call 202-788-0402 or Request an Appointment

  • June 05, 2021

    By MedStar Team

    As an academic healthcare system, we have a large number of trainees (including students, residents and fellows) as part of our internal teams and research population. In addition, MedStar Health includes a dedicated cohort of investigators focused on research of education in healthcare and learning in clinical settings. As researchers, it is important to consider the requirements of the Common Rule and ethical guidance for the protection of research participants when designing and conducting research involving Human Subjects. Trainees may be part of a research participant population and may provide valuable data on field-specific research as learners. In order to protect trainees that are also research participants, it is important to be aware of aspects of recruitment, consent and the conduct of research that can impact study participation in additional to protections for their safety and privacy.

    One concern for trainees as research participants is the potential for coercion or undue influence. Some have referred to trainees as “captive participants” that may be in a dependent or restricted relationship with a researcher. In this context, the participants ability to consent may be compromised by vulnerability to the power of the researchers if the research also serves in some supervisory capacity over the trainee. Consider the power dynamic between trainees and their program director, preceptors, attending, or professors. This dynamic could also be extended to employees that may serve as research participants if the researcher is in a supervisory role, either directly or indirectly, for the employees.

    This dynamic can create unintended pressure for potential participants and may result in individuals agreeing to participate in research when they would otherwise decline consent or to continue when they would otherwise withdraw consent.  In one publication, the authors state that 10-25% of university students report feeling coerced to participate in research and 33% report they would feel coerced if asked to participate in their own professor’s research (Leentjens & Levenson, 2013). Some incentives to research participation (ex.: extra credit for course work, required course credit, promise of letters of reference or excessive research stipends) may also lead trainees to agree to research participation when they would otherwise decline.

    Researchers should also consider the generalizability of research conducted with only trainees as participants. Results from these studies may not generalize to the larger population.   Even generalization within student populations may be difficult and may be influenced by incentives to participate. For example, if students receive extra credit for research participation this may serve as a self-selecting element for students with lower scores or those that need the extra credit to improve to the next grade (improve from an C to a B average).

    The Common Rule does not provide special protections for students or trainees as it does for children, pregnant women or prisoners. However, it does state “The IRB should be particularly cognizant of the special problems of research that involves a category of subjects who are vulnerable to coercion or undue influence, such as children, prisoners, individuals with impaired decision-making capacity, or economically or educationally disadvantaged persons.”  While students, trainees and employees are not specifically mentioned as potentially vulnerable to coercion or undue influence in the regulations it is important to understand the dynamic that can exist between researchers and potential research participants based on relationships outside of the research context. Researchers should consider these dynamics when developing research protocols and build in protections to avoid. It is best whenever possible to avoid even the proception of coercion or undue influence in research.

    Below are some recommendations for Participant Safeguards that should be considered when designing research protocols. While this is a good start for items to consider this is not an exhaustive list.

    • Ensure that students / trainees are essential to the research population, not just a convenient sample for the research team.
    • Engage multiple researchers/staff for consent process. This allows for removal of direct relationship between one professor / supervisor / mentor & students / trainees as part of the consent process.
    • Have an explicit and stated process in the protocol for voluntary/informed consent.
    • Ensure that there are explicit protections for the privacy of data. Consider what demographic information is required for the research. In small programs, it may be easy for professors to identify students / trainees based on the broadest of demographic information. Is this information necessary? If yes can some researchers be blinded to some of the data so that they are not aware of participation of individuals they supervise?
    • All research involving human subjects must have IRB approval

     

    Please contact the MedStar Health Research Institute, Office of Research Integrity for additional guidance.

     

     

    Reference

    Leentjens, A. F. G., & Levenson, J. L. (2013). Ethical issues concerning the recruitment of university students as research subjects. Journal of Psychosomatic Research, 75(4), 394–398. https://doi.org/10.1016/j.jpsychores.2013.03.007

  • June 05, 2021

    By MedStar Team

    Each year, MedStar Health associates have the opportunity to win a John L. Green Generation of Leadership Scholarship. The scholarship is for five MedStar Health associates, each equaling up to $3,500. Recipients of the scholarship may use funds for tuition and/or fees for the current academic semester for the upcoming academic semester.

    Established in 2003, the John L. Green Generation of Leadership Scholarship awards academic scholarships to highly-motivated, MedStar associates who strive to advance their leadership career in health care. 

    The scholarship is reserved for exceptional individuals who share Green’s traits of excellence, leadership, and commitment to the vision, mission, and values of MedStar Health. This targeted scholarship reflects Green’s commitment to increasing minority representation in leadership positions in health care.

    We are pleased to share that Gebremedhin Melaku, Senior Coronary Imaging Research Analyst, MedStar Health Research Institute is one of the 2021 John L. Green Scholarship recipients.

    Gebremedhin Melaku, is a physician from Ethiopia. He was born in very small village called Qunzila, 30 miles northwest of Bahir Dar along the shore of Lake Tana, source of the Blue Nile river. He received his medical degree at University of Gondar and attended Ob-Gyn residency at Addis Ababa University. He worked as a lecturer at the University of Gondar and later as Maternal Child health/Prevention of mother to child transmission of HIV Advisor for three different international organizations.

    He joined Medstar Health as a Clinical Research Associate and was promoted to Research Analyst within three months of joining. He is currently working as a lead on clinical trials based on angiography, physiologic parameters such as Quantitative Flow Ratio (QFR) and vFFR (vessel Fractional Flow Reserve). He has authored/co-authored 20+ publications in his professional career.

    He is currently seeking his master’s degree in data science/Analytics at Kansas State University. He decided to join the program after he completed a certificate program of “python for Data Science” online and found out how powerful python is in the field of Research, Analytics, Machine Learning and Visualizations.

    The John L. Green Generation of Leadership Scholarship honors the late John L. Green, executive vice president, Corporate Services. From 1983 to 2002, Green held executive leadership roles at Medlantic Health Care Group and MedStar Health, as well as on the Morgan State University Board of Regents in Baltimore. He served as chairman of the Morgan State University board from 1990 to 1995. The scholarship is funded entirely by a grant from the MedStar Health Board of Directors to commemorate Green’s contributions and his legacy of excellence.